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Bigger Hammer —

April 4, 2012
by

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.

Dr. Peter,

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.

Laurie

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38 Comments leave one →
  1. April 4, 2012 10:33 am

    This is great Laurie. The shaming some doctors engage in is, to me, nothing less than a form of social control. They may think they are concerned about their patients’ health, but knowing what we know about what weight bias and shaming does to people’s health, it’s actually only contributing to marginalizing people who are already stigmatized and marginalized.

  2. vesta44 permalink
    April 4, 2012 11:14 am

    Wonderful post, Laurie. This is something all doctors who shame/blame their fat patients need to read. Maybe then they would be able to concentrate on health instead of conflating weight with health.

  3. Mulberry permalink
    April 4, 2012 11:37 am

    “It also prevents the breakdown of fat, which would then be turned to sugar for use as fuel.”

    Am I misreading something here? I thought insulin helps the conversion of fat to energy, and it’s insulin *resistance* that throws the process off.

    Good article, thank you for writing it. I think citations wouldn help, not that fat-haters ever believe them.
    It would be great if more doctors could distinguish between non-compliant patients and non-compliant bodies.

    • Mulberry permalink
      April 4, 2012 11:38 am

      Sorry, that should be “citations WOULD help”

  4. nycivan permalink
    April 4, 2012 11:39 am

    I expect more deflecting and blaming by the good doctor.

    I hope the good doctor can put aside his bias and look at the facts. This would mean that he admits to himself that most everything he has learned about this is wrong and he has contributed to a lot of suffering unnecessarily.

    I hope he surprises us. I think it is more likely that we can use this exchange to illustrate how difficult it is for a severely biased person to let go of the bias.

    Come on Doc, you can still be an arrogant MD, even if you embrace an iota of humility about this bias you hold that prevents you from being a more prolific healer.

    I’m rooting for you to choose to expand your ability to help folks like me instead of continuing to very cleverly defending your bias and holding on hard to that flat globe of the earth.

    Come on Doc, it there is a nicer, more compassionate world than the one you live in right now.

  5. JeninCanada permalink
    April 4, 2012 6:38 pm

    Great post, Laurie, thank you!

  6. April 5, 2012 9:57 pm

    LaLanne, Burns and Hope. Name some long lived fat people.

    • April 5, 2012 10:17 pm

      Ned Beatty (squeal like a pig, boy!) is 75. Sydney Greenstreet, the classic fat man baddy, lived to be 75. Marlon Brando, frequently mocked for the weight he gained as he aged, lived to be 80. Alfred Hitchcock was 80. James Earl Jones is 81. Burl Ives was 86. Ernest Borgnine (crystal balls!) is 95 and still masturbating.

      Peace,
      Shannon

      • April 6, 2012 12:31 pm

        None made it to 90 and Borgine is no longer fat and none of them were morbidly obese. Like John Candy dead at 43, Chris Farley dead at age 33, Luther Vandross, Pavarotti Divine was 42 in 1988 when he died in his sleep from sleep apnea caused by obesity.

        DeLuise died at age 75. He was hospitalized at the time, suffering from kidney failure and respiratory problems due to complications from obesity, diabetes and high blood pressure.

        Nell Carter died young

        Aretha Frankin was on death’s doorstep until she lose weight.

        Leslie West lost his lost his leg to diabetes now he lost weight. That was his wake up call.

        Fat people lose weight less for vanity reasons and more for health reasons.

        Totie Fields died at age 48 from the complications of obesity. Phyliss Diller is still vibrant as is Betty White.

        Victor Bueno dead at 43.

        Fatty Arbuckle dead at 46

        Lou Costello age 52

        Israel Kamakawiwo’ole. dead at age 38

        Mama Cass dead at age 32

        Shall I go on?

        • vesta44 permalink
          April 6, 2012 12:45 pm

          MD – I’m 58 and far from being dead – my numbers that doctors like to look at and say are indicative of health are all in the normal range and have been for the whole 35 years that I’ve been morbidly obese. ALL of my grandparents were morbidly obese – both of my grandmothers were 86 when they died, my grandfather was 90 (the other grandfather was an alcoholic and died in his 50s from cirrhosis of the liver, had nothing to do with his weight, had everything to do with the fact that he drank like a fucking fish for over 30 years). My mother was obese, she died at the age of 76 after fighting ovarian cancer for ten fucking years (how long would she have survived it if she had been thin?). My great-aunts were morbidly obese and they were all in their 80s when they died. I have an aunt that has had several heart attacks and a couple of strokes and is in the overweight range – she’s still alive and is 80 – her doctor told her she wouldn’t have survived ANY of that if she hadn’t had some meat on her bones to draw on while she was ill and couldn’t eat.
          So, your point is? For every fat person that has died at a young age, we can give examples of fat people that have lived well into their 80s and 90s. STFU and go away, asshole.

        • April 6, 2012 1:04 pm

          How many of them (like Chris Farley) were heavy drug or alcohol users? How many of those actors and actresses were lifetime dieters, or used amphetamines to lose weight? Totie Fields lost almost 70 pounds before her death. Pavarotti died of pancreatic cancer.

          Davy Jones just died at 66 of a heart attack, and height has a “significant inverse relation” with cardiovascular disease (PDF).

          And for every fat person you can name, I can name five thin people who died young because of various lifestyle choices, which don’t get commented on.

          I have now deleted two comments of yours that kicked off with insults and name-calling. I’m done tolerating trolls, so either get your shit together or earn yourself an insta-perma-ban.

          Peace,
          Shannon

          • April 7, 2012 3:45 am

            Cass Elliot (she hated the name “Mama Cass”) also lost about 75 pounds prior to her death (intentionally). She was well known to have been on multiple extreme crash diets from the time she was very young. She was also a notorious substance abuser and already had had one (unintentional) OD three years earlier; in fact, even the people in her life who gave her the most shit about her weight initially assumed she’d overdosed on heroin, which she’d been addicted to on and off for about seven years.

          • The Real Cie permalink
            April 9, 2012 2:12 pm

            You make a good point, Shannon. A lot of the “fatties who died young because of their fatness” had lost large amounts of weight before they died. Yo yo dieting is far more unhealthy than being heavy is on its own.

        • The Real Cie permalink
          April 9, 2012 2:10 pm

          Mama Cass had a heart condition. This, not her size, is what killed her. I had a great grandmother who weighed 300 pounds and lived to 80. It wasn’t her size that killed her, it was a very aggressive form of leukemia. The fact that she was fat may have allowed her to live longer. The cancer took a year to kill her. By the time she died, she had lost more than 200 pounds. A smaller person would have been dead much sooner.

    • April 5, 2012 10:21 pm

      Listen you pathetic piece of shit, we have a simple rule in this community and that’s don’t be an asshole. If you want to ask questions, you ask questions, but if you insult or degrade anyone here without cause. I’m calling you a piece of shit because you threw the first shot, but I’m not willing to let the kind of shit you wrote stand. If you can’t disagree without acting like a 12-year-old brat, then I will make the executive decision to ban your ass.

      We invite dissension, not disrespect. So learn to play nice or fuck the fuck off.

      Peace,
      Shannon

  7. LittleBigGirl permalink
    April 6, 2012 1:59 am

    Wow this post gave me a lot to think about, and research. I have PCOS but I have never heard of Byetta. All the books I’ve read (there aren’t nearly enough out there) about “managing” PCOS depressed me because they all had a special diet plan and talked about “good” and “bad” food. I also got the impression that there isn’t much you can really do about it. I am disappointed that my doctor has diagnosed me with PCOS but hasn’t made any suggestions about how to deal with my insulin resistance. Laurie, do you have any further resources?
    Also thank you Shannon for a) letting Laurie post this and b) cutting the troll comment that I *so* did not need to get triggered by today.

  8. April 6, 2012 12:47 pm

    Borgnine is still very muscular. He had a gut on him. He was never really obese unlike Dan Blocker dead at 43.

    John “Sergeant Shultz” Banner dead at 63.

    http://www.sciencedaily.com/releases/2009/03/090319224823.htm

    The Oxford University research found that moderate obesity, which is now common, reduces life expectancy by about 3 years, and that severe obesity, which is still uncommon, can shorten a person’s life by 10 years. This 10 year loss is equal to the effects of lifelong smoking.

    The analysis brought together data from 57 long-term research studies mostly based in Europe or North America. People were followed for an average of 10 to 15 years, during which 100,000 died, making it the largest ever investigation of how obesity affects mortality. It was coordinated by the Clinical Trial Service Unit (CTSU) in Oxford and the results are published online today (18 March) in The Lancet.

    The studies used body mass index (BMI) to assess obesity. BMI is calculated by dividing a person’s weight in kilograms (kg) by the square of their height in metres (m). If a person has a BMI of 30 to 35, then they are moderately obese; if they have a BMI of 40 to 50, they are severely obese. Though not perfect, BMI is useful for assessing the extent to which fatty tissue causes ill health.

    Among the 900,000 men and women in the study, mortality was lowest in those who had a BMI of 23 to 24. This means that if a person were 1.70m (5 feet 7 inches) tall, for example, his or her optimum weight would be about 70kg (154 pounds or 11 stone).

    • April 6, 2012 1:05 pm

      Ah, so you’ve given Ernest Borgnine a DXA scan and know how his fat to muscle ratio?

      Shut the fuck up and get the fuck out, you have no clue what you’re talking about

      Peace,
      Shannon

    • The Real Cie permalink
      April 9, 2012 2:15 pm

      Dan Blocker died of a pulmonary embolism following surgery. This can happen to a person of any size. Pulmonary emboli do not seek out the obese.
      I’m only saying this for the purpose of providing information to others who may read here. I don’t actually care to answer you. You’ve shown yourself to be a troll and are therefore not worthy of an answer.

  9. April 6, 2012 12:58 pm

    Facts are stubborn things. Ain’t that right Shannon?

    • April 6, 2012 1:07 pm

      MD,
      Here’s the comment I deleted: “Why don;t you sick fucks prove science wrong and call MIT and put your money where your gluttonous lying mouths are?”

      There’s nothing factual about this comment, you’re just being a hateful troll, and if you pull this shit again, I’m banning you. Period.

      Peace,
      Shannon

      • April 6, 2012 2:36 pm

        I move that there should be a shortcut to the asshole rule, because frankly, I don’t like having to wait for four or five people to call asshole – during however many hours that is, there’s still hateful and triggering shit defacing this page.

        MD, that isn’t a fact, it’s your own bigoted opinion, so go suck your own dick, given that’s the only way you’ll ever get laid. Go die.

        • April 6, 2012 9:54 pm

          Done and done.

          Peace,
          Shannon

        • The Real Cie permalink
          April 9, 2012 2:17 pm

          Now, now. He’d have to get a big microscope to find something that small!
          >;-)

      • Kala permalink
        April 6, 2012 3:57 pm

        I didn’t realize that proving science wrong entailed a call to MIT. *facepalm*

  10. Fab@54 permalink
    April 6, 2012 3:40 pm

    First of all, I think it’s very important for certain fools who insist on listing all the fatties who died “young” to limit those listed who’ve died recently.
    I don’t want to hear about some fat actor who died young back in the 1960’s or earlier. Medical treatments for *ALL* major diseases have come a huge, huge distance in the last 40 years. That is a fact.
    My grandmother was fat, (but not considered obese) and she had diabetes too. Diabetes was not aggressively or as successfully treated as it is now a days. What came first, her fatness or her diabetes? Don’t know, because most people didn’t have any sort of early detection going for them back then- they found out they had it only when symptoms already progressed to dangerous and unmanageable levels.
    My grandmother lost her leg just below the knee, and half of her other foot due to late diagnosis, limited treatments and management of diabetes at that time. She was in her mid-60’s when the first amputation was done. Yet she STILL lived to 77 years old and died in 1965. She also didn’t die of diabetes, either.
    It is also important to eliminate those fat folks who died young that partake in hard drug and alcohol use for many years – (as Shannon pointed out). Chris Farley didn’t die because he was fat, he died because he excessively abused hard drugs and alcohol known for damaging the heart. Being very fat may have indeed exaggerated his problems, but it didn’t CAUSE them. For every fat drug and /or alcohol abuser who’s died young, I can name at least three thin ones who also died young…. that argument is seriously flawed.
    Eh, what’s the point, “MD” is just a troll and has no inclination to open his mind to any other perspective anyhow. Whatever we say is just words wasted on a sad and twisted person.

  11. April 6, 2012 10:12 pm

    Proof by deletion? Is that your game Shannon? You are a pathetic loser. That would be OK but you are taking people down with you. Hurry up and die.

  12. April 7, 2012 3:18 am

    I realize Dr. Trollface McNadblister has already been cordially invited to fuck off, but for anyone who’s lurking, take it from someone who has seen over 150,000 medical records in her lifetime: Fat old people — even VERY fat old people — are not rarities at all. Just last night, I had back to back reports on women 88 and 89 years old, who were described by the doctor as “morbidly obese.” And neither one was a wealthy celebrity, either.

    And speaking of those wealthy celebrities, especially those whose livelihood depends almost umbilically on thinness, they not only have motivation to try very risky and expensive experimental treatments, but they have unlimited access to those treatments. They can get off-label drugs the rest of us can’t. They can be sure that if they get, say, bio-identical hormones, they will get the ones that actually work, they don’t have to play drug lottery with their money and time. They have access to the very best surgeons and state of the art facilities if they want WLS. If they lose weight, even if they keep it off (and most of them won’t, even with everything working in their favor), they are hardly role models for the rest of us.

    Any doctor who tells a patient xe has to lose a third or half or, gods help us, three-fourths of their body weight in order to improve their health is STUPID. Because you might as well tell me I have to have a million dollars in the bank free and clear. And come to think of it, the million dollars would probably do me a lot more good.

    • The Real Cie permalink
      April 9, 2012 2:25 pm

      I work with old people of all sizes, and yes, I’ve seen many a large one. Most of the so called “diseases of obesity” are actually diseases of aging. We all end up with one or more of these problems as we age.
      As a large person, everyone expects me to have type II diabetes, hypertension, heart disease, and arthritis. My blood sugar is steady as can be–I take it sometimes just for shits and grins while I’m at work. I don’t have heart disease now but I keep an eye on it because it runs in my family. I don’t have arthritis now but almost everyone gets it to some degree while they age. I do have mild hypertension, but this runs in my family and I take medication for it. I don’t want to end up like my dad, who was not obese, and who had a major hemorrhagic stroke at 68 because of undiagnosed hypertension and arterial disease.
      By the way, if you figure out how to get a million dollars in the bank free and clear, please tell me how to do it because I could use that money for my fat old age! I’m likely to live a fairly long time–the women on both sides of my family live into their 80’s and 90’s, regardless of their size.

  13. nycivan permalink
    April 7, 2012 11:30 pm

    this was a very difficult thread to follow (emotionally) It just hit so close to home about how hurtful and hateful the energy out there is. I find myself more fragile than I have been in a long time and I am glad that there are badass fatties around here to call those hateful and hurtful out.

    But these two were talking about us dying and threatening these painful deaths as retribution for my sloth, greed and laziness. The degree of hate and the snide way in which it was doled out here by these two hateful individuals.

    and that hatred lives out there… outside of my bedroom, my house. And it has overshadowed every breath, every interaction, every choice I have ever made. This hateful energy has made my failures more painful and it has diminished the goodness of every victory.

    I wish I could stand strong with all of you and overtly confront these haters but I am defeated and I have no more fight in me. Some of the comments in this thread I had to skim because I couldn’t deal with the hate. I ask myself if my existence as is so repulsive that I deserve to die a painful horrible early death?

    I am glad that there are those out there that can stand in the cross fire and go to war. Right now I am having a hard enough time getting 30 minutes of movement in each day which I really want to do.

  14. vesta44 permalink
    April 8, 2012 12:51 am

    nycivan – you do what you can do, and right now, if all you can do is take care of yourself, then that’s what you do. Don’t worry about confronting the haters or going to war if you don’t have the strength for it. Self care comes first. Just remember that everything the haters have to say says more about them than it says about us – it shows how petty and small they really are, that they would wish death on people who have done nothing to them. Those kinds of people aren’t even worth fighting with, really, they’re more like gnats to be shooed away and ignored. They’re insignificant and that’s why they’re so hateful to those they see as inferior to themselves, but they just show their inferiority by their hatefulness.

  15. Fab@54 permalink
    April 10, 2012 9:06 am

    “On Monday, Mark Lenzi, the last American male diver to win Olympic gold, died at the age of 43 in Greenville, N.C.”

    I have a feeling, just a feeling, mind you – that this person was in pretty darn good shape physically. Not an ounce of fat on him, and by all accounts (so far) not a drug user nor abuser. He has been busy coaching prospective Olympic divers since his wins in the Olympics. But there he is, gone at 43. RIP Mark.

  16. April 16, 2012 7:58 am

    I already called on MIT [well not specifically]

    http://fivehundredpoundpeeps.blogspot.com/2011/02/letter-to-obesity-researchers.html

    Too bad that person probably just wants to abuse fat people.

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