Diabesity – T2D 18

posted in: Diabetes, Health and Nutrition | 35

The term diabesity is the unification of the words ‘diabetes’, referring to type 2, and ‘obesity’. It is a wonderful word because it is at once able to convey that they are truly one and the same disease. It is incredibly descriptive and evocative in the same way as the word ‘bromance’.

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High schoolers? Right…..

Strange as it may now sound, physicians did not always recognize this seemingly obvious and basic connection between type 2 diabetes and obesity. Let’s go back in time to the year 1990. Grunge was taking over the music scene. Fanny packs were growing in popularity (gasp!) and not the sole domain of the middle-aged dad tourist. The mid 20’s actors of the hit TV show Beverly Hills 90210, pretending to be high school students, were totally fly not just sad replicas of cool.

The obesity epidemic had only just gotten underway in the late 1970s and was not the public health disaster it is today. Type 2 diabetes barely scratched the surface as a public health concern. AIDS was the hot topic of the day. And type 2 diabetes and obesity were not considered diseases that were related in any way. Indeed, the 1990 Report of the Dietary Guidelines Advisory Committee issued by the US Department of Agriculture allowed that some weight gain after the age of 35 is consistent with good health.

Walter Willett, now Professor of Nutrition at Harvard’s School of Public Heath was one of the first researchers to identify the strong and consistent relationship between weight gain and type 2 diabetes. But it was certainly not an easy sell to a skeptical medical profession. “We had a hard time getting the first paper published showing that even slight overweight greatly increased the risk of diabetes,” Willett said. “They didn’t believe it.”

In 1990, Dr. Willett and colleagues reported that weight gain after age 18 was the major determinant of type 2 diabetes. A weight gain of 20-35 kg (44-77 pounds) increased the risk of type 2 diabetes 11,300%. More than 35 kg (77 pounds) weight gain increased the risk by 17,300%! Even smaller amounts of weight gain could raise the risk significantly.

The Body Mass Index (BMI) is a standardized measurement of weight. It is calculated by the following formula:

BMI = Weight (kg)/ Height2 (m2)

A BMI less than 18.5 is considered underweight. BMI 18.6 – 24.9 is considered normal weight, and BMI over 25 is considered overweight. Women with a BMI of 23-23.9 compared to less than 22 have a 360% higher risk of type 2 diabetes. This is all the more stunning, since that BMI is well within the normal range.

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Walter Willett

By 1995, these insights were extended and refined. Weight gain of only 5.0-7.9 kg (11-17.5 pounds) increased the risk of type 2 diabetes by 90%, and weight gain of 8.0-10.9 kg (17.5 – 24 pounds) increased the risk by 270%. By contrast, weight loss decreased risk by over 50%. This established the uniquely intricate relationship between weight gain and type 2 diabetes. But far more sinister, this excess weight also increased the risk of death.

Dr. Frank Speizer established the original Nurses’ Health Study (NHS) in 1976 as one of the largest investigations into risk factors for cardiovascular disease and cancer. This was a large-scale, long-term epidemiological study of 121,700 female nurses from around the Boston area.

Dr. Willett continued with the Nurses’ Health Study II, which collected yearly data on an additional 116,000 female nurses since 1989. At the start all were relatively healthy, but over time, many developed chronic diseases such as diabetes and heart disease. By looking back at the collected data, some idea of the risk factors for these diseases emerged.

By 2001, Dr. Willett and his long-time Harvard collaborator Dr. F. Hu showed that, once again, the single most important risk factor for the development of type 2 diabetes was obesity. But other lifestyle variables were also important. By incorporating simple lifestyle measures that included maintaining a normal weight, regular physical exercise, no smoking and a ‘healthy’ diet could prevent a stunning 91% of type 2 diabetes. The ‘healthy’ diet here was defined as a diet high in cereal fiber, high in polyunsaturated fats, low in trans-fat and low in glycemic load.

Glycemic load is a measure of how high blood glucose rises after eating certain foods. It is calculated by multiplying the glycemic index with the grams of carbohydrate in a standard serving of food. Generally, foods high in sugar and refined carbohydrates are high in glycemic load. Dietary fats, since they raise blood glucose minimally, have very low glycemic loads. This ‘healthy diet’ was not the low-fat diet recommended by all the medical associations around the world at the time. Indeed, one of the components of this ‘healthy’ diet was more fats of the right kind. This diet was about reducing sugar and refined carbohydrates, not fat.

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Heart attack in a snack.

But it was difficult to sway a skeptical 1990 medical establishment about this critical distinction. We were in the middle of a frenzied low-fat obsession. Dietary fat was evil. Dietary fat was a mass murderer. Dietary fat was vile. The term healthy fats did not exist. It was an oxymoron, like a jumbo shrimp. Fat laden avocados? A heart attack in a fruit. Fat laden nuts? A heart attack in a snack. Olive oil? Liquid heart attacks.

Fats were going to clog our arteries, weren’t they? Most people believed that the evidence was conclusive. But it was only an illusion. Dr. Zoë Harcombe reviewed all the data available at the time the low fat guidelines in the United States and United Kingdom were introduced in the early 1980s. No proof had ever existed that dietary fat worsened cardiovascular disease. The ‘evidence’ for the low fat guidelines was simply a great work of fiction.

In the midst of the low-fat maelstrom, suggesting that refined grains and sugars were the problem rather than dietary fat was simply heretical. Coming from the very heart of the medical establishment, this was high treason from a favored professor prince of Harvard. But the truth could not be concealed forever.

In 2001, Dr. Hu writes, “The public generally does not recognize the connection between overweight or obesity and diabetes. Thus, greater efforts at education are needed”. At least this much has been accomplished. The general public understands clearly that obesity is the main underlying issue behind type 2 diabetes. But the problem wasn’t simply obesity. Rather, it was abdominal obesity.

Fat Distribution

In 2012, Dr. Michael Mosley was a TOFI. A what? Not tofu, the delicious Asian soy delicacy. TOFI stands for Thin on the Outside, Fat on the Inside. Dr. Mosley is a medical doctor, BBC journalist, documentary maker, and international best-selling author. And, in his mid-50s, he was also a ticking time bomb.Dr. Michael Mosley

He was not particularly overweight, weighing 187 pounds, standing 5 feet 11 inches with a waist of 36 inches. This gives a body mass index (BMI) of 26.1, just barely in the overweight range. By most standard measurements, he was considered just fine. He felt just fine, with perhaps just a little bit of weight carried around the mid-section from being ‘middle-aged’.

However, BMI is not the best indicator of type 2 diabetes risk. The waist circumference, a measure of body fat distribution around the trunk is a far better predictor of type 2 diabetes. Filming a health show for the BBC, Mosley had a magnetic resonance imaging (MRI) body scan. To his shock and consternation, his organs were literally swimming in fat. To look at him, you would not have guessed it because most of it was hidden inside his abdomen.

Eighteen months later, during a visit to his GP, routine screening blood tests revealed type 2 diabetes. Devastated, Dr. Mosley says, “I had assumed I was healthy and suddenly I was discovering I wasn’t, and had to take this visceral fat situation seriously.” Visceral fat accumulates around the intra-abdominal organs such as the liver, kidneys and intestines, and can be detected by an increased waist size, or an increased waist/hip ratio. This pattern of obesity where most of the fat is carried around the abdomen is called central obesity or central adiposity. In contrast, subcutaneous fat is the fat deposit directly under the skin.

The different fat distribution explains how roughly 30% of obese adults are metabolically normal. These ‘healthy fat’ people carry more subcutaneous fat, not the more dangerous visceral fat. On the other hand, some normal weight persons show the same metabolic abnormalities as that in obesity, because of excessive visceral fat.thindiabetics

Type 2 diabetes is diagnosed at all BMI following a normal distribution with no distinct subpopulation of ‘thin’ diabetics. A full 36% of newly diagnosed diabetics have a normal BMI <25. The core clinical component is not total fat, but visceral or intra-organic fat.

Sophisticated measurements of insulin resistance, such as the Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) correlate better to the waist-to-hip ratio and waist circumference rather than the BMI. Independent of total weight, central obesity is highly correlated to metabolic abnormalities, increased cardiac risk and progression to type 2 diabetes, even independently of total weight. Reducing visceral fat in the Diabetes Prevention Program also successfully reduced the risk of progression of type 2 diabetes.waisttoheight

Subcutaneous fat, on the other hand, shows little correlation to insulin resistance, type 2 diabetes or heart disease. Even more telling, the surgical removal, via liposuction of almost 10 kg of subcutaneous fat brought no significant metabolic benefits whatsoever.

The waist to height ratio (WHR) is a simple measure of central adiposity calculated by comparing waist circumference to height. This WHR is far more predictive of years of life lost than BMI. Optimally, your waist circumference should be less than half your height. For example, an average man standing five foot ten inches (70 inches) should strive to maintain a waist size of thirty-five inches or less. As central obesity increases, years of life lost skyrockets.

There is a distinction even between types of visceral fat. Fat found inside the organs, such as that within the liver and pancreas is distinctly more dangerous than fat found around the organs, called the omental fat. Intra-organic fat increases the risk for the metabolic complications of obesity, including type 2 diabetes, NASH, and cardiovascular disease. On the other hand, surgical removal of omental fat does not result in any metabolic improvement.

Fat within the liver, called intrahepatic fat, plays a crucial role in the development of insulin resistance. Central obesity tracks very closely with intrahepatic fat content. Fat within the pancreas also plays a leading role in type 2 diabetes.

So, what drives fat deposition into the organs? The master hormone insulin plays the starring role.

 

35 Responses

  1. Before I read it here a while back .. height to waist ratio .. I can’t recall ever seeing or hearing or reading about it.

    It seems that BMI is all the Insurance / Medical Professionals care about these days.

    To that point .. TOFI .. lol .. well I guess it’s time someone gets this out to th industry .. I won’t hold my breathe though .. they seem hell bent on strict enforcement of the BMI standard.

    • As a side note .. how can being skinner than 0.5 h2w ratio take YLL (aka .. years off your life)?

      Seems it must calculate in the sickly with the healthy .. and being more of the emaceated being terminally ill folks. Just a guess.

    • BMI is the easiest to measure that’s why

      Even waist to hip ratio takes effort as you have to relax properly and use a pliable measure. It isn’t your pants size at The Gap.

    • WHR is more commonly used as an abbreviation of Waist-to-Hip Ratio, which I believe the author meant.

  2. Thank you Dr. Fung! You have done it again…not only my favorite medical teacher, but my favorite author?

  3. I’m someone who WAS TOFI and seriously insulin resistant from a very young age. I eventually became obese in my mid-30’s after monkeying around with my hormones to treat PCOS–due to IR. I think there is a great assumption that obesity causes diabetes/insulin resistance, but not much attention to the possibility that it’s the other way around–insulin resistance (essentially an early stage of diabetes) may be the cause of weight gain.

    That’s why the usual medical prescription for Type II–“if you’d “just” lose some weight”–tends to be pretty ineffective. I even had an endocrinologist tell my daughter who inherited my IR/PCOS that the best way to treat it was “to lose weight”. She was telling this to my 85 lb 13 year old daughter without an ounce of fat on her body. Physician’s’ knee jerk reaction to IR is “lose weight” instead of understanding that the IR must be addressed.

    • Jan–“lose weight” seems to be the only band-aid in the doctor’s box any more. Broke your arm? Lose weight. Failing eyesight? Lose weight. Balance problems? Lose weight. Bipolar? Lose weight. HIV+? Lose weight. High cholesterol? Take this statin and lose weight. On and on it goes like this.

      • Well — it may be the greatest lifestyle risk factor right now …

        • No, because even Dr. Fung says that 30% of obese people are metabollically normal – they don’t have diabetes. You can be fat and be relatively healthy. Conversely, you can be skinny and insulin resistant. High insulin levels is the greatest danger we face.

      • Getting rid of the hormonally active body fat is key to better health.

        The problem is that few doctors know how to explain HOW to get rid of that fat.

        And, that problem is exacerbated by the fact that individual behavior change is extremely difficult for most people.

        One of the beauties of Dr. Fung’s approach to the problem is the pure simplicity of the fasting approach.
        Not only does it work, but it saves time!!!

  4. Terri Iverson

    After reading the above article (sent as a link from a friend). I understand that this is the CAUSE of TOKI, and the hormone insulin is the star, but why is there not a further link that gives reference to working on a reversal to this deadly abdominal obesity?

    • There are a lot of articles about intermittent fasting and food choices on this sight. They are loaded with information that will answer your question.

  5. sten bjorsell

    BMI adds both good and bad fats, plus muscles(!) altogether, similar to the more common crazy measure “total cholesterol”, which adds good and bad cholesterol together to a new super measure that corresponds to debit and credit being added together, with same sign! It is like spending 10 dollars and earning 10 dollars and get a “score” of 20 instead of being broke! We need a lot more thinking doctors that dare to think and speak, like Jason Fung does. People that dare to ditch meaningless measures because “they are easy to measure”, or “established”. Too many doctors seemingly are like the man looking for a lost key under the streetlight. When asked where he lost it he points out in the dark, adding, but I cannot see anything there, so I look here. Yet doctors are well supported in their chases with phantom numbers by benevolent pharma companies providing “helpful guidelines” of how many statins any such (phantom) high cholesterol number qualifies for, irrespective of if good HDL is sky high and LDL particle size is large and beneficial instead of small and causing stiff arteries with high blood pressure. And the important size of the LDL particles is usually safely locked way out in the dark, well away from lights! (A test we have to send away for..)

  6. Back in the 90s I think we all understood that heart disease was linked to body fat, however, the solution was (and still is in many doctor’s minds) Low calorie, low fat, get off the couch and run around fatty.

    I remember trying to be on the carbohydrates addicts diet at the time, like all diets it worked for a while, but problem was they told you not to eat fat and that you should eat three meals a day. I remember having to remove egg yokes from one of the recipes and the reward meal could be whatever you wanted, so I ate bread. On top of this I had a gym membership, would ride my bicycle and roller-blade regularly. I was also doing activities , such as volley ball and softball, with my church singles group.

    I became disillusioned with this diet when my weight plateaued and the authors later retracted their statements on the reward meal. Also, having to do recipes all the time was not what I wanted to have to do all the time, I wanted simple meals. The recipes required exotic indigence you usually don’t use for cooking. Little did I know if I just didn’t eat two meals out of the day I would have been better off. I remember though missing a meal simply because I didn’t want to bother with these low-carb, low-fat recipes in the book. If only I did that more often.

  7. George Henderson

    Brilliant Jason. Agree with everything except tofu being delicious.
    Conn and Newburg discovered the connection between overweight and T2DM and their reversibility in 1939-1942. The reversibility of diabetes by weight loss was the criteria by which they distinguished juvenile diabetes from adult onset.

  8. charles grashow

    “The waist to height ratio (WHR) is a simple measure of central adiposity calculated by comparing waist circumference to height. This WHR is far more predictive of years of life lost than BMI. Optimally, your waist circumference should be less than half your height. For example, an average man standing five foot ten inches (70 inches) should strive to maintain a waist size of thirty-five inches or less. As central obesity increases, years of life lost skyrockets.”

    Jimmy Moore should start saving for his funeral

  9. Dr. Fung have you seen this?

    http://www.ncbi.nlm.nih.gov/pubmedhealth/behindtheheadlines/news/2016-05-11-bmi-categories-may-need-adjusting-argue-researchers-/

    In a huge study of over 120,000 people, the researchers gathered people from Copenhagen, Denmark, recruiting people from 1976 to 2013. They were then separately compared to those who were recruited in the 70s, 90s, and 00s. Surprisingly, the BMI linked with the lowest risk of having died from any cause was 23.7 in the 70s, 24.6 in the 90s, and 27 from 2003-2013. Due to the results of this study, the researchers are arguing that BMI categories may need adjusting.

    Thoughts?

  10. Cheryl McMaster

    Good morning (my) Dr Fung, really enjoyed the interview with Dr Mercola cant wait to purchase you book,
    regards

  11. Dr. Hugo Werner Galvez B.

    Dr. FUNG, what do you know about the super starch of (which Dr. Petter Attia and Dr. Volek comment in their websites and or videos) in relation to diabetes and or keeping a ketogenic state that benefit very sensitive people to carbohydrates or with very stabilised insulin resistance syndrome. (http://eatingacademy.com/sports-and-nutrition/introduction-to-superstarch-part-i (https://vimeo.com/51891286) ( http://education.uconn.edu/2012/12/03/atkins-foundation-grant-fuels-studies-low-carb-diets/) (https://www.generationucan.com/ucanrun/benefits/) (Watch “Dr. Jeff Volek – Low Carb Tips to Improve for Energy & Performance” on YouTube https://youtu.be/CjDfJCa8biI )

  12. Dear Jason Fung
    Hello
    I am your fan, I am from China.
    After using your recommended intermittent fasting diet, I quickly

    suffered a rash.
    I see a lot of people on the Internet are fasting or using

    ketogenic diet, their body appeared on the rash.
    At present, my body rash has lasted about 2 weeks.
    Did you have an good solution.

    thank you very much.

  13. hi please help i am currently on a long fast been fasting for 3 days feel great. when will i know that i have to eat. i feel great but i feel weird just in concept and I am worried about nutrients and passing out or something i feel better than i ever have how am i supposed to get my nutrients if i fast for lets say 20 days surely thats a bit unhealthy. i feel like i can and i back everything dr fung is saying but there is not much information about extended fasts on the internet all of them say consult a doctor for longer fasts. i am an obese 22 year old man without any other conditions and my bloods are all good. definitely have some insulin resistance, my parents have diabetes and pre diabetes. please can i have some advice on longer fasts i don’t really have the resources to go to a doctor for this fast. so speaking generally would help me. thank you

  14. Dr. Fung,

    Just buying your book now. Two suggestions:

    I would definitely buy an audiobook version on Audible. I listen to books more than I read these days. I’m sure you’d increase the range of people who benefit from your book and sell more too (including to people who already bought the Kindle or paper versions; Kindle in particular has sync between it and the Audible version and that’s really nice).

    Any chance you could do an Audible version or one done?

    Second thing, why don’t you include a picture/text ad and/or prominent link (such as in the site menu) to your book?

    Cheers,

    Christoph

  15. Doc, sorry My Question is Out of Topic, If my last meal of the day is at 5 pm, then I exercise hard (HIIT maybe) to deplete glycogen until my Glycogen “let say empty or almost empty”, then I dont eat anything ( or I eat small amount protein but no carb to prevent muscle loss), then go to sleep, and next day, break my fast around 1 pm.
    My goal is I want to burn fat immediately (because no glycogen after exercise). The Theory is if your glycogen empty or almost empty before Fasting, you can start burn Fat immediately compare to wait glycogen empty 10 to 12 hour than you can start burn fat. Is it ok Doc? I ask anyone, many concern the muscle loss after exercise, but if I ate small and complete protein to prevent muscle loss, is it ok?

    Thanks Doc

  16. Hi there– I am a new Obsesity Code/Dr Fung fan. I started following the book’s recommendations with a daily fast of about 16 hours (43 days ago). I am loving it and cannot imagine going back to old habits. My main reason for getting on board is to avoid a T2 diabetes diagnosis, the 9.6 lbs lost is a wonderful surprise bonus! I tell everyone I know about your book! Reading all past blogs and looking forward to new blogs.
    Thank you–for putting together this website!

  17. […] normaali paino vapauta insuliiniresistenssin vaaroista. Tämän sai tuta tunnettu TV-lääkäri Michael Mosley. Hänen painoindeksinsä oli vain hieman normaalia korkeampi. Silti hän sairastui reilu […]

  18. Interesting, the waist to height ratio shows me as much healthier than the traditional BMI. My waist to height is 0.52, but my BMI is 28, which is considered overweight. I have a classic hourglass figure with roomy hips and large breasts so I guess that means I can carry extra weight and still have the ‘right’ waist.

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