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Big v. Small —

October 23, 2013

Weight LossFat HealthFat ScienceExerciseFat NewsWeight Loss SurgeryDiet Talk

Trigger warning: Discussion of traditional diabetes treatment (aka weight loss) and weight loss surgery.

If I asked you to imagine someone with Type 2 diabetes (T2D), who do you see?

If you’re a biotech news site covering T2D developments, you see this.


If you’re the New York Times reporting on the dangers of childhood T2D, you profile someone like this:

Diabetes Stereotype 3

If you’re a panic blogger, you portray T2D like this:

Diabetes Stereotype 2

Because when we think diabetes, we have to be sure that this is the image we see:

Diabetes Stereotype

And God forbid you should confuse Type 2 with Type 1, lest your body become your face:

Faces of Diabetes

We have been trained to think of T2D as a consequence of obesity: you’re a gluttonous sloth, you get really fat, you get diabetes.

Meanwhile, we ignore all the other factors that contribute to T2D. As the NYT article put it:

Type 2 is thought to be brought on by obesity and inactivity in people who have a genetic predisposition to develop the disease when they gain weight. And they may also have an inborn tendency to put on weight… Doctors began noticing an alarming increase in Type 2 cases in children in the 1990s, especially among blacks and Hispanics from poorer families. The problem had started even earlier in American Indians, who have had sharp increases in obesity in recent years.

BMI is definitely correlated with T2D, but not in a straightforward way. For instance, one study that compared diabetics by race and gender found that the correlation between BMI and T2D was counterintuitive (PDF). The incidence of T2D among obese people (~0.3%) was comparable among all groups, but far higher among Blacks at lower weights.

TableAs the authors explain:

Although the interaction between race and BMI implies a relative decrease in the risk of diabetes associated with higher levels of BMI in blacks, black subjects still experienced a higher risk of diabetes at most levels of BMI. This could be due to the effect of BMI overwhelming the effect of race at higher levels of BMI or to higher levels of BMI having a greater relative impact on diabetes risk among whites.

What researchers tend to ignore is the fact that poverty may be a leading cause of T2D, and can double, or even triple, a person’s risk of developing diabetesRace is certainly correlated with poverty in this country, especially. In fact, poverty increases the risk of T2D even in countries with universal healthcare. We can then point to the effects of stress on T2D and the fact that stress management improves glycemic control.

All of this is not to dismiss the connection between diabetes and BMI, but to explain how complicated and interconnected these symptoms are. I also want to point out that the experts on diabetes, like the American Diabetes Association, point out that in studies of diabetes treatment, the role of weight is not necessarily the linear path we’ve been taught to believe. As one 35-year longitudinal study in the journal Diabetes Care found, “The fact that the individuals treated with insulin had greater weight gain despite worse glycemic control is consistent with the hypothesis that insulin causes weight gain.”

The research community has a vastly different view of weight and diabetes than the lay community. For example, the National Institutes of Health does not advise diabetics to shed massive quantities of weight on its official T2D page:

Set a reasonable weight-loss goal, such as losing 1 pound a week. Aim for a long-term goal of losing 5 to 7 percent of your total body weight. To estimate this amount in pounds, find the weight closest to yours on the chart below. Follow the row across to see how many pounds you need to lose.

The chart provided suggests that the long-term goal for a 350 pound person lose between 18 and 25 pounds.

That’s it.

The nation’s foremost medical research institution advises people that if you weigh 350 pounds, then in order to control your diabetes, you should try to get your weight between 325 and 332 pounds. Does that sound like panic over obesity driving T2D?

Yesterday, a new study came out concluding that BMI shouldn’t even be considered as part of the key eligibility criteria for bariatric surgery any more.

They found that a simple 4-variable prediction rule can be used to predict 10-year mortality in obese individuals eligible for bariatric surgery, with the 4 variables being age, sex, smoking, and diabetes. Although BMI was significantly related to mortality, its inclusion in the model did not improve its accuracy.

How’s that for counterintuitive?

The authors said, “Our results challenge conventional wisdom emphasizing the importance of BMI as a prognostic indicator for mortality in individuals eligible for bariatric surgery and, of equal import, the practice of using BMI as a surrogate for long-term prognosis.”

In other words, forget everything you know about obesity and diabetes. You can’t predict good or poor health by sight, and you certainly can’t spot a diabetic by sight either. This is why I hope that we will replace all of the aforementioned images of fat diabetics with a new, streamlined, realistic image: this guy…

The 67th Annual Tony Awards - Arrivals

This is Tom Hanks, the beloved actor, and he announced on David Letterman that he has Type 2 diabetes.

And it is, by far, one of the best, most intelligent discussions of diabetes that I have seen on TV in a long time.

Hanks explains that his doctor told him “You know those high blood sugar numbers you’ve been dealing with since you were 36? Well, you’ve graduated. You’ve got Type 2 diabetes young man.” When the audience responds with gasps of shock, he reassures them, “Well, it’s controllable.”

Letterman jumps in at this point and says, “Through diet, mostly, and exercise.” He then explains that he has also struggled with high blood sugar and had to go on a special diet.

Then Hanks shares what may be the greatest doctor/patient interaction ever:

My doctor said, look, if you can weigh as much as you weighed in high school you will essentially be completely healthy, will not have type 2 diabetes. And then I said to her, “Well, I’m going to have type 2 diabetes because there is no way I can weigh as much as I did in high school.”

When Letterman asks him how much he weighed, Hanks says 96 pounds, although I can’t tell how facetious he’s being. But the fact is, Hanks was an incredibly thin actor from the beginning.

Bosom Buddies

All of this is GREAT INFORMATION. Hanks is dead on that T2D is controllable and Letterman is dead on that diet and exercise are key. Couple this with Hanks’ amusing apathy toward his doctor’s weight loss advice, and you’ve got a late night Health At Every Size® infomercial.

If that were the end of this story, I’d be grateful for what Hanks is doing, but it gets better.

In The Guardian, Hanks explains what he believes pushed him from high blood sugar to T2D.

The actor – who lost 13kg (two stone) for Philadelphia and 25kg for Castaway, and gained 13kg for A League of Their Own – said that “may have had something to do” with his having type 2 diabetes, “because you eat so much bad food and you don’t get any exercise when you’re heavy”.

But Hanks said he had had the symptoms for 20 years. “I think I was genetically inclined to get it and I think it goes back to a lifestyle I’ve been leading since I was probably seven, as opposed to 36.”

Now, I disagree that you “don’t get any exercise when you’re heavy,” but the fact that Hanks went from active to sedentary, from healthy diet to unhealthy diet, to gain weight for roles would certainly take its toll.

Hanks was first diagnosed with high blood sugar back in 1992, when he was 36. That was the year two of his popular films were released: A League of Their Own and Sleepless in Seattle. Comparing his body in both films shows the difference that his 30 pound weight gain had in the former.

Hanksnuits blanches a` Seattle

Hanks also went from 225 pounds to 170 pounds during the filming of Cast Away. After his announcement on Letterman, CBS News did a piece on whether these weight changes could have contributed to his diabetes. Dr. Holly Philips explained, “In dramatic weight gain and dramatic weight loss, the equilibrium of the body is just completely off. So that might predispose him to developing type 2 diabetes later.”

Although these two fluctuations were significant, we’ve seen smaller fluctuations in weight throughout Hanks’ career, as I’ve outlined below:

Tom Hanks RetrospectiveThis brings me to the one correlation with T2D that the medical community tends to ignore with fatties: weight cycling.

A great paper that explains how weight cycling, or yo yo dieting, contributes to diabetes and other metabolic disorders calls it the “Repeated Overshoot Theory.” In a nutshell, when you engage in weight loss behaviors your metabolic profile improves, as your blood pressure and cholesterol drop, while your insulin sensitivity improves. But if those weight loss behaviors are unsustainable (as most are), then when you put the weight back on, then your blood pressure and cholesterol rise and you become more insulin resistant. Each time you lose, then gain, is a cycle, and each cycle puts more stress on your system, making your bad blood pressure and cholesterol worse and makes you even more insulin resistant.

But setting aside the theory, even weight loss evangelists like Walter Willett, who try to disprove the dangers of weight cycling, admit that weight cycling is strongly associated with long-term weight gain. If their theory is correct, then the weight gain itself is still contributing to worsening metabolic health. So whatever way you look at it, fluctuating weight is bad for you, whether you’re Tom Hanks or Joe Schmo.

The key to health is not obsessing over your weight, but in making permanent lifestyle changes regardless of how it affects your weight. If Tom Hanks wants to control his diabetes, then he just needs follow the diabetic diet and get some exercise, regardless of whether it makes him the same size he was when he threatened to beat up the Fonz with kung fu.

And the same goes for EVERYONE who wants to control their blood sugar: diet and exercise will have a profoundly positive impact on your health whether it makes you look like this or not.

"Splash" Tom Hanks © 1984 Buena Vista Pictures ** I.V.

10 Comments leave one →
  1. October 23, 2013 3:47 pm

    I was having a self-pity moment (okay, that “moment” has lasted all afternoon) because I saw a picture of myself, crossing the finish line of a 5k I had just completed.

    I didn’t see the finish line. I didn’t remember the sounds of cheers from total strangers as I, and others, completed our 5k.

    No, I saw the double chin, the sweaty hair, and this enormous roll of fat.

    You’re absolutely right. Get on the diabetic diet, get exercise and stop worrying about what you may look like or what you could look like. Just… make like a Nike ad and do it.

    Now I hope I remember this tomorrow especially if that pity party is still going on.

    • October 24, 2013 11:28 am

      Serious congrats on completing that run. (Also, has Nike ever shown anyone in their ads being athletic but not skinny? Maybe you should pop them a note and ask them when they’re going to join the 21st Cenutry… 😉 )

      • October 24, 2013 11:32 am


        Ms_Xeno? I needed that! Thank you!!!

      • October 24, 2013 3:13 pm

        That’s a good point. I have a friend who in the past couple of years has started doing 5Ks and when I said something to my dad about it, he kept repeating her name to make sure we were talking about the same person, since he deemed her too fat, too nonathletic, too something to do 5Ks. I called him out on his bigotry.

        RogueGirl, you’re awesome. I have tried to run, but I get severe monkey brain where I just go from thought to thought and I always end up very, very angry. I detest listening to music on headphones, but I’ve recently started trying to listen to podcasts to see if that will keep me distracted enough to stop thinking. My husband’s brain goes blank when he runs or walks and I’m so jealous that I’m not wired that way.

        • Nof permalink
          October 28, 2013 12:10 pm

          Always glad to hear I’m not the only angry runner. I’m not sure why my brain takes running as an opportunity to indulge in revenge fantasies, but I do wish it would knock it off.

          • October 28, 2013 12:23 pm

            As a gardener, I find revenge fantasies work best on the points of a large pitchfork being jabbed (hard) into a stubborn clot of mud, weeds, and rocks. Hey, a workout’s a workout, right? :p

  2. vesta44 permalink
    October 23, 2013 9:21 pm

    DH has type 2 diabetes, and has had it for 19 years now. He was diagnosed at his separation physical from the Navy (he was be retiring after 20 years). Now, being in the Navy, he had to meet certain physical requirements, which necessitated him dieting once a year, when he had to meet the Navy’s weight requirement. That alone could have contributed to his diagnosis, even though he wasn’t fat (even 5 lbs over the weight limit meant dieting). But when you also take into consideration that both his parents had type 2 diabetes, as do 4 of his 6 brothers, I don’t see how he could have not ended up with T2D, no matter how he ate, how much exercise he did, etc.
    We have found that the fewer carbs he eats, the easier it is to control his blood glucose and the less insulin he needs – he’s only been on insulin for the last 4 years, so he controlled it pretty well for the first 15 years with diet, exercise, and oral medication. It also helps that his job requires him to do a lot of walking 4 to 5 days a week – that 10,000 steps that’s recommended? He exceeds that by probably 50,000 steps a day, at least 4 days a week. We’ve also found that exercise after a meal will help lower his blood glucose.
    The odd thing is that people would look at him and say he “ate his way” to diabetes, but our barber also has T2D. They would never say that our barber had “eaten his way” to T2D because he’s thin. The cognitive dissonance between those two views is astounding.

  3. October 24, 2013 3:02 pm

    Reblogged this on Sly Fawkes and commented:
    I have been working with the geriatric population since 1988. I have actually seen more thin to average size type II diabetics than heavy type II diabetics.
    This is one of those diseases that becomes more likely as a person ages. The fatphobia in our current medical system means that larger people who may happen to be at risk aren’t getting the treatment they need because they’re ashamed to seek treatment. It also means that the disease may be being missed in people with smaller body types, because “only fatties get type II diabetes.”
    Fat hate is helping no-one of any size.

  4. Elizabeth permalink
    October 25, 2013 4:45 pm

    I see everyone suggesting the diabetic diet — any dissenters? My RN husband said the recommended caloric intake for the diabetic diet is 1800 calories, which I think is the minimum required to prevent starvation in the opinion of the WHO. It’s very hard to get adequate nutrition on 1800 calories a day.

    • Laura permalink
      October 25, 2013 11:15 pm

      I don’t think that’s what is meant by the “diabetic diet,” which I believe is far more about what choices of foods one makes than calorie counting. I once lost weight on Weight Watchers while “spending” half my Points on chocolate. That no doubt contributed to my development of T2D. Diabetic diet is more about avoiding big carb-loading and ensuring adequate protein, fiber, etc; choosing complex carbs rather than simple and highly-processed carbs; stuff like that.

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