Bigger Hammer —
Trigger warning for clinical discussions of weight loss.
The following is an open letter from my friend Laurie, the Nurse Practitioner/Diabetes Educator who helped me respond to Dr. Peter in this exhaustive post. Whereas I am just a schmuck blogger studying obesity and health issues as a hobby, Laurie has over 20 years of experience working with, and treating, patients with type 2 diabetes. She is in the process of creating her own blog, but in the interim I asked if she would respond directly to Dr. Peter’s comments on my post and she kindly obliged.
It seems obvious that you genuinely care about your patients and do want to help them. I would like to help you to do that. I know that it also seems like a very simple equation to lose weight: eat less and exercise more. As a person who started out at 12 pounds and has struggled with weight issues all my life, I want to assure you that it is not that easy.
The body is a wonderful machine and can do many things to prevent starvation. Even with small weight loss, leptin goes down and ghrelin goes up, and persists at a year or more. If it were that easy, there would not be a $60 billion dollar weight loss industry.
What is most disturbing to me about what you have written is that you assume that if someone has not lost weight, they are “non-compliant.” I have lost over 1,000 pounds in my life, yet have never been a “normal” weight. I did a webinar on this subject that is just over an hour long. If you are interested in listening to it let me know.
With as much stigma, health issues, discrimination surrounding obesity, I can assure you that desire for weight loss is strong. Recently, there was a large meta-analysis representing 80 studies and over 80,000 people which suggests that if all you do is tell someone to lose weight, they will fail. The best case scenario is that after two years the people who followed through on their behavior changes lost 8-10 kg (17-22 pounds).
When you look out the window the world looks flat. Imagine the difficulty Christopher Columbus had convincing everyone the world was round. Just because we have always thought obesity caused insulin resistance does not make it true. Obesity has become a scarlet letter, while insulin resistance is under Harry Potter’s invisible cloak. In order to really evaluate for insulin resistance you have to do an insulin clamp study that is very cumbersome, invasive and expensive, which is why it is only used in research settings.
In the early 80s I was literally laughed at when I said insulin resistance comes before diabetes. Before that, the experts said diabetes causes insulin resistance. Insulin is an anabolic hormone: it turns sugar to triglyceride, and then to fat. It also prevents the breakdown of fat, which would then be turned to sugar for use as fuel. Without insulin you will literally starve to death no matter how much you eat.
If you are insulin resistant you have extra insulin turning extra sugar into extra fat. Insulin also has a direct stimulatory effect on the brain causing hunger. So even though high weight can be an indicator of insulin resistance, I firmly believe insulin resistance comes first.
Next time you are really hungry try to not eat, or else eat a bucket of celery and fill your stomach. You can do that a day or two, a week or two, a month or two, but imagine living like that for the rest of your life. When we do things that make insulin resistance worse, such as give someone a steroid, it often causes weight gain due to increased hunger. When we do things that make insulin resistance better, such as prescribe Byetta, weight loss occurs.
If you lose weight unintentionally, such as with cancer, you do not get the benefits correlated with weight loss. If you gain weight intentionally like a sumo wrestler, you don’t have increased insulin resistance. If you surgically remove fat, even if it is the “bad” abdominal fat, you do not get the benefit.
The reason that it looks like weight loss helps and weight gain harms is that the same things that make insulin resistance better or worse also cause the weight gain or loss. We have a lot of genes identified that are associated with insulin resistance and weight. Adoptive children match their biological parent much better than their adoptive parent. The weight of identical twins are identical whether they grew up together or not.
Just suppose for a minute that insulin resistance is truly, strongly genetic, and that someone is trying really hard to lose weight. What do you suppose you are doing to them when you call them a liar or non-compliant? Do you suppose they would keep coming back and be more motivated to engage in healthy behavior?
When a respected physician tells his patient that all they have to do is eat 200 fewer calories a day to lose weight and it does not happen, what really happens is that they feel like a failure and throw in the towel. It is extremely de-motivating. Many fat people don’t go to the doctor precisely because of the wide-spread assumption that fat patients are non-compliant (PDF).
My own mother died at 58. She had not gone to the doctor for fear of being bashed every time about her weight. At the same weight, her sister is still alive today at 81 because she has been treating her metabolic syndrome. Believe me, I’m familiar with the consequences some people have from excess weight. But this is an “association” not a causal relationship.
Male pattern baldness is also associated with cardiovascular disease, but that does not mean that if you grow hair the problem is fixed. I do not need to be told each and every time I go to the doctor that I am a miserable failure. As a nurse practitioner and diabetes educator for over 20 years, I spend a lot of time repairing the damage done by doctors who think they are helping someone by ripping away any motivation they have left.
I know it sounds like a bunch of “Freethinking Fatties” aren’t trying, but in reality they have realized that diets don’t work, that weight cycling is harmful, and that they are healthier for focusing on behavior, rather than the scale. It is not that they just don’t care.
The actual benefit of improved insulin resistance comes from healthy behavior with or without weight loss. I have no problem with a physician asking me if I have healthy behaviors. But even if it is all the patient’s fault, would it be so harmful to focus on what they did right?
Even a very basic motivational skills handbook can tell you that you catch more flies with honey than vinegar. I beg you to try this approach: rather than focusing on the scale, focus on the pedometer. I guarantee you will see not only healthier, but happier patients. I am sure your patients are not losing more than the national average of 17 to 22 pounds, so what do you have to lose?
One final question: who lived longest Jack LaLanne, George Burns, or Bob Hope? Both George (100) and Bob (100) lived longer than Jack (97). Being happy is vital for health and longevity too.
I would love to discuss this with you further. I can even send you my PowerPoint and then discuss it if you would like. Just let me know.