Which Came First, the Diabetes or the Fat?
November 7, 2021 2:41 PM   Subscribe

In a recent toss-aside on the Web, someone wrote, "Mom, you didn't get diabetes because you got fat, you got fat because you have diabetes. It's a metabolic disorder." As an obese diabetic man, I blinked ... hard ... and went, "What?" Can someone with more medical knowledge than I please explain this to me? Is this true? I always thought my progression from prediabetes to diabetes was because of weight gain.
posted by MollyRealized to Health & Fitness (25 answers total) 8 users marked this as a favorite
I have had pre-diabetes and now diabetes, ongoing for the last 10 years or so. Been to at least 3 diabetic counselors, and taken the classes (due to moving around). For myself, I have noticed that when I follow the carb counting method, or the plate method, etc., as well as exercising after eating, which lowers your blood sugar, I can get my A1C from an all-time high of 8.2 once, down to about 5.6 last Spring. I take Metformin, extended release, 500 mg per tablet. I was taking 4, but since my A1C was so low, my NP lowered it to 3 per day.

Due to stress and life, I found myself craving more carbs in September, oh, just a little of this or that won't hurt me, and it has been a while since I've seen the nutritionist. Let myself slide, now my weight has creeped back up. I have an A1C check appt in December, and know it will be worse than last Spring. I am so po'd at myself, because I know with good diet and exercise practices, I can control it to the point of being almost non-existent, with the help of Metformin. I also had a work colleague, years ago, who'd been living overseas in a place where fatty foods and little vegetables were prominent, and he was in sorry shape when he got home. He started going out canoeing, walking, watching his diet, etc. and got it down to the point where his doctors were amazed at his progress.

I'm not sure if it's the same for everyone. I used to have low blood sugar, years ago, and was weighing my food portions on a scale to make sure I ate ENOUGH food. Now that I am almost 58, its the other way around, sadly. Recently, I got some chia seeds, as fiber plays a huge role in all of this, along with lots of veggies. I had fallen into the trap of too much sugary and rich desserts, eating snacks because I felt I deserved them, etc. I am lucky to have a good medical practice where they will work with me and help me, without being condescending. So I guess I don't have a medical degree, but it IS hard to lose weight when you have insulin resistance, because the glucose can't get into your cells, it just floats around in your blood stream causing damage, and Metformin somehow opens the "door" to those cells and lets it in, so you get more energy and might eat less. Does that make sense to you?
posted by Marie Mon Dieu at 3:27 PM on November 7, 2021

I am not in medicine, nor am I a scientist, just a fellow diabetic. The answer is... complicated. It's a bit like the chicken and the egg.

Type 2 diabetes (T2D) is characterized by 2 things: deficiency in the pancreas beta-cells to secret insulin, and target tissue insulin resistance, generally seen as a result of hyperglycemia, but the two conditions reinforce each other, resulting in a cascade worsening of both.

Fat is a consequence of having more nutrients the body needs, which is extracted and results in hyperglycemia, which the body struggles to correct by turning the extra glucose into fat (intermediate steps: glucose -> glycogen, glycogen + insulin = fatty acids, fatty acids -> adipose tissue = fat) but if you have hyperglycemia for too long, your body's "neutral" gets altered and you got T2D.

Rather than say one caused the other, they are BOTH consequences of over-nutrient. :)
posted by kschang at 3:42 PM on November 7, 2021 [1 favorite]

The book Fat Chance has this as its central premise.

Dr. Lustig suggests that we're all eating high-sugar foods, our insulin spikes, and the insulin signals fat storage. Ultimately, the 24-hour-a-day seven-days-a-week high insulin levels will lead to resistance (some parts of your own body will ignore hormones, like adapting to drugs), which will lead to higher insulin levels to keep the signalling system "working". Which means more and more insulin, more and more fat storage, more and more hunger, with the proper signals being ignored. (Hunger itself was other hormones, but you get the idea.)

He essentially believes it's not children's fault they're getting fat, they have a hormonal problem caused by poisonous food. Some have brain tumors, sure, but most of them (us) are just insulin resistant.

Along with the fatness comes the pancreatic and liver damage. Insulin is also part of packing fat into liver for safe keeping (eventually leading to fatty liver, which is partially what A1C is checking for).

As a fat person who has also improved his liver test results by "losing weight", I believe this. I believe fatness is a symptom of organ damage. Really, what I did was cut sugar and improved both problems.

On the other side of the coin, type-1 diabetics can lose weight by not taking all their insulin. A risky behavior, but they want to be thin. Obviously, before insulin, children wasted away with no fat at all.
posted by Snijglau at 3:43 PM on November 7, 2021 [2 favorites]

If you do a little research into the term "metabolic syndrome" I think you'll find your answers.
posted by superelastic at 3:53 PM on November 7, 2021 [1 favorite]

This TED Talk by Peter Attia discusses this.
posted by 10ch at 7:19 PM on November 7, 2021 [1 favorite]

Whether obesity causes diabetes, or whether diabetes causes obesity, or whether both are consequences of a common cause, doesn't change the fact that intermittent fasting has been demonstrated as useful for correcting both in people able to tolerate it.

Personally I'm more inclined to believe that obesity per se is not the causal factor, on the grounds that all the study results I've looked at show improvement in diabetes markers after beginning an IF regimen that are much faster than the associated reduction of obesity.

I have had morbid obesity (BMI > 40) for about thirty out of the past sixty years, and obesity (BMI > 30) for forty. I do not have and to the best of my knowledge have never had diabetes, but my daughter has type 1 so I have ready access to finger prick glucometers and experience with continuous glucose monitoring devices. I have worn Abbott's FreeStyle Libre sensors at various times in the past to monitor how the way I eat affects my blood glucose level over time, both when experimenting with IF and not. Every time I've done this I have seen an unambiguous downward trend in average daily BGL over the course of the first two weeks of the IF regimen, after which it stabilizes at the lower level.

My current IF regimen has been working very well for me for about three months now and is something I feel very good about the prospect of being able to sustain indefinitely. I would certainly rather do so than live with the same challenges as my younger brother, whose obesity is even more extreme than mine and who does have type 2 diabetes.

I am in no way trying to say that IF is that One Weird Trick that would fix everything for everybody if only they'd give it a go, just reporting what's been working for me. Happy to discuss further over memail or email with anybody who would like to compare notes.
posted by flabdablet at 10:01 PM on November 7, 2021 [1 favorite]

Assuming you have Type 2 diabetes, your progression from pre-diabetes to diabetes WAS caused by weight gain, in the sense that you took in more glucose than you needed and your insulin sensitivity reached a point where it couldn't cope and you became diabetic (welcome to the team, brother).

However, one of the major problems with pre-diabetes is that it makes you hungry, because your cells aren't getting the energy they should, so you eat more, which exacerbates the problem and hastens the drop into diabetes. But type 2 diabetes in and of itself doesn't make you fat in the first place.

To be very clear:
You don't develop type 2 diabetes, then get fat.
You get fat, then you develop type 2 diabetes.

Any other explanation is - at best - talking about rare cases, compared to the tidal wave of type 2 diabetes cases in the Western world that are caused by obesity.

Whilst there is no guarantee that being obese will cause type 2 diabetes, the overwhelming majority of people who get type 2 diabetes are grossly overweight and have been for some time. Diabetes is a fat disease; people with low body fat virtually never develop type 2 diabetes (relative to the numbers of obese people who do; I'm not saying its impossible or doesn't ever happen, but the stats are indisputable: being really fat is the single biggest risk factor for getting diabetes).

So as regards "you didn't get diabetes because you got fat, you got fat because you have diabetes", I'm sorry to say that that is functionally nonsense, and a clear misunderstanding of the mechanisms at work. If you don't get fat, your chances of getting type 2 diabetes are extremely low (think, less than 0.1% low).

Now, once you HAVE diabetes it can be more difficult to lose weight because your cells aren't getting the energy and the energy is therefore more likely to be stored as fat, so you're both struggling to have the energy to exercise, and you're hungry because your cells want energy. That's the diabetic trap. But to reiterate, you don't get diabetes and then get fat. You get diabetes and then maybe get fatter, if you don't heed the warning and change your diet and exercise choices.
posted by underclocked at 11:21 PM on November 7, 2021 [2 favorites]

The usual obesity first, glucose dysregulation second progression is also completely consistent with obesity and diabetes being normally-successive symptoms of the same underlying condition.

You don't develop type 2 diabetes, then get fat.

I have a friend who did exactly that. He didn't start getting anywhere near seriously fat until after the insulin injections he'd been prescribed to treat his type 2 diabetes messed with his appetite.
posted by flabdablet at 2:39 AM on November 8, 2021

the overwhelming majority of people who get type 2 diabetes are grossly overweight and have been for some time

It is also the case that the majority of people who have had obesity for some time do not get type 2 diabetes.

Obesity is a risk factor for type 2. That means only that there is a correlation between the two, not that either causes the other, and that of these two conditions obesity is the more obvious.

As an aside, I have strong objections to the commonly used language patterns around obesity. I am not defined by my body fat percentage. Obesity is a condition I have, not a thing that I am.

I particularly object to the choice of pejoratives such as "grossly" as intensifiers for "overweight" or "obese". If you are disgusted by the fact that I carry much more weight than my insurer would prefer me to, it would be polite of you to keep that to yourself.
posted by flabdablet at 3:07 AM on November 8, 2021 [28 favorites]

Intermittent fasting seems to be a powerful tool (from a nephrologist treating patients with kidney problems caused by diabetes). This was a very compelling presentation, but I'm no expert.
posted by superelastic at 4:26 AM on November 8, 2021

Obesity and diabetes are correlated. In most cases, people realise they are obese before they realise they have Type II diabetes, but that does not necessarily mean that obesity causes type II diabetes. For example, they may both have a different common cause (or set of causes). We don't know yet.

Type I diabetes is considered an autoimmune disease not believed to be caused by obesity. But people with type I diabetes are increasingly likely to be obese, relative to the general population. This is considered likely to be a result of the way in which their diabetes is managed and the different insulin profile they have over time compared to people who have a pancreas that can make insulin naturally.

Lots of things around obesity and diabetes are affected by both a limited current understanding of the mechanisms involved, and people's pre-existing views about obesity. Given that the vast majority of obese people can lose weight over the short term (3 months), but cannot maintain that over the long term (5 years) I think it makes most sense to look at diabetes management as a separate problem which may require changes to diet, medication, exercise etc, and track the impact of those changes on the relevant diabetes markers. Leave your weight to do what it's going to do as a result, and just wear clothes that fit.
posted by plonkee at 4:45 AM on November 8, 2021 [2 favorites]

You don't develop type 2 diabetes, then get fat.
You get fat, then you develop type 2 diabetes.

My body is on a quest to prove you wrong. While I could be fitter, I am not overweight, never mind obese. Every time I change doctors it's a toss up between them being concerned about my A1C and dismissing it because of my weight. Like someone else said, we know obesity is a risk factor for type II diabetes. But suggesting it's causitive for a prerequisite does no one any good, just more fat shaming and obstacles to care.
posted by hoyland at 4:55 AM on November 8, 2021 [1 favorite]

Dr Fung (in the video) is my MIL’s nephrologist. When she moved in with us 6 years ago we thought she would be on dialysis within 2 years. She’s lost 100+ lbs and is off insulin. IF was only *one* thing she did, though. She has had a lot of medication changes, treatment for an injury and an ulcer, and a number of lifestyle changes. She saw 4 specialists. So just pointing out that treating diabetes is complex. Lately she’s gotten one of the skin blood sugar trackers and it’s informing our whole family about our diet together.

I really do think the science is out a bit on which comes first. If you look at childhood ACE scores they correlate strongly with diabetes. We know trauma changes the brain and hormones, as does stress.
posted by warriorqueen at 4:55 AM on November 8, 2021 [4 favorites]

I particularly object to the choice of pejoratives such as "grossly" as intensifiers for "overweight" or "obese".

Maybe you know this already, but "gross" in this sense means large and has nothing to do with the currently more common meaning of "disgusting." It's probably a good idea to drop it as a modifier because of the confusion, but I wouldn't assume perjorative intent.
posted by FencingGal at 5:59 AM on November 8, 2021 [10 favorites]

"gross" in this sense means large and has nothing to do with the currently more common meaning of "disgusting."

"Nothing to do with" is, I think, naive at best.

Lots of words exhibit meaning drift over time but "gross" has had unambiguous connotations of disgust for at least as long as I've been alive. It absolutely does read as pejorative when used as an intensifier and should be avoided on that basis when talking about obesity.

"Gross negligence", "gross indecency", "gross error" - these are all applications where the pejorative and hugeness connotations work together appropriately. But there is no excuse at all for using "gross" in a way that tips yet another little bucket of contempt onto those of us who live with a condition so notoriously resistant to long term mitigation. And no, living with obesity yourself doesn't give you an out; internalized body shaming is the most damaging kind of all.
posted by flabdablet at 6:32 AM on November 8, 2021 [14 favorites]

For example, they may both have a different common cause (or set of causes). We don't know yet.

If Jason Fung is to be believed, the common cause is that some people simply need much more time spent with an empty stomach than others in order to stay healthy; in particular, much more time than most people raised in affluent industrialized cultures are typically habituated to.

I'm nearly sixty years old, raised in Breakfast Lunch and Dinner 1960s Australia, and I still have a lot of difficulty with misinterpreting the bodily sensations from a digestive system that's physically ready to process a full meal as urgent alarms meaning that I must eat something now or that it is objectively time to eat something now.

What we learn about ourselves as small children really does shape us for life, and it's been taking a lot of work to learn that all those sensations I've hitherto lumped together and labelled as "hunger", from simple craving for a sweet biscuit up to and including those associated with not having consumed anything but water for weeks at a stretch, are not only much more nuanced than I've noticed before but can be experienced other than as forms of suffering.

Over the last three months in particular, I've been making a deliberate, focused practice of sitting with those sensations and paying very close attention to them rather than seeking to distract myself from them, while reminding myself that all they are is information and that there are ways to interpret that information that do not call for immediate action. I am already feeling this CAN != MUST distinction starting to become habitual; one lives in hope.

CAN = MUST is of course the Technological Imperative, responsible for the relentless perpetuation of the upgrade treadmill and all its associated waste on a cultural level. Lately I've been learning that it's a principle every bit as bad for my personal health as it is for the planet's.

But holy shit is this stuff time-consuming. If I still needed to be gainfully employed there is no way I'd be able to find the time and attention required. Getting lean again is essentially my whole career right now.
posted by flabdablet at 8:15 AM on November 8, 2021 [6 favorites]

apologies flabdablet, I appear to have hit a nerve without intending to. FencingGal is correct, I meant "grossly" in the sense of "large", not as a pejorative. This may be a cultural difference; here in the UK it's perfectly common to use "grossly" in this sense, as in "grossly unfair", "a gross overreaction", "grossly mistaken", and so on but of course that may be different in other English-speaking places.

If it helps, I was clinically obese for a long time, which is one of the primary causes of my type 2 diabetes. I'm not criticising people who are obese, nor in any way calling them disgusting. I know what's it's like to be stared at, both metaphorically and literally, and I will not do to others what was done to me.

The point I was trying to make was that, statistically speaking, if you are significantly overweight, your chances of getting type 2 diabetes are significantly increased. It is the single most accurate predictor - not guarantor - of type 2 diabetes. Of course it is possible, as with your friend, for people who are not visibly overweight to develop type 2 diabetes, but that doesn't change the fact that the single largest risk factor for, and best predictor of, type 2 diabetes is excess body fat. I'm not judging anyone for that, but the OP asked and I have tried to answer using valid statistical facts and some elementary medical knowledge of our shared condition.

You are not in anyway obliged to agree with my opinion, but I hope that puts your mind at ease a little as regards my intentions.
posted by underclocked at 8:23 AM on November 8, 2021 [1 favorite]

One final point and I'll bow out; been taking up more than enough of the air in here already.

The idea that obesity and diabetes are fundamentally different kinds of thing, where diabetes is some kind of punishment to be inflicted on people so irresponsible that they "don't heed the warning" of their obesity, while the obesity itself is held to be some other kind of thing brought on by "diet and exercise choices"? That right there is nothing more nor less than body shaming. It might be internalized body shaming, but it's body shaming all the same and it needs to go away. It doesn't help. In fact it actively impedes the pursuit of good health by promoting chronic emotional stress in those of us with obesity.

The simple fact is that most people who don't have obesity, which includes most of the medical professionals and other assorted highly paid consultants who have taken it upon themselves to tut tut at us for our "irresponsible choices" for all of our lives, have no clue about how much time, effort and attention it takes to keep a body that runs to fat under any kind of control. To frame obesity as a consequence of "choices" is a toxic cultural trope that trivializes and denies that effort.

If you think topping out at 166kg was something I chose to do, ask yourself how much worse all the other options would have to look in order for somebody to choose to put their spine and knees and ankles through that kind of grinding daily torture.

As an affluent retired white man I now have the total luxury of having the time and energy available to get on top of this thing, and it's only because I now have a completely passive income and kids who will very soon be mature enough to look after themselves that I can reasonably expect to be able to maintain the work and attention required for the rest of my life. Most obese people are nowhere near as lucky, and framing their obesity as if it were a simple matter of "choices" is grossly unfair.
posted by flabdablet at 9:30 AM on November 8, 2021 [10 favorites]

I was around 150 lbs/5’6”/US size 8 when I developed T2D. I have lost about 10 lbs since then by cutting carbs, but i was not particularly fat. My dietician made me upset by telling me most of her patients were twice my age and twice my size, and wasn’t it unfair that I came down with it? Implying that it was somehow fair or deserved that fat people would get this stupid disease that sucks. I know she was trying to be nice and sympathetic to me, but it really rubbed me the wrong way.

Everyone in my mother’s family has diabetes and all but one of them is very skinny, probably more like 100-115 lbs at a similar height to me.

I’d like to know where the <0.1% chance number came from.
posted by music for skeletons at 11:04 AM on November 8, 2021 [5 favorites]

I've lost around 35 pounds, just calorie counting, not really restricting what type of foods I eat and my A1C has dropped below pre-diabetic in that year. But I've always been overweight and still am. So yeah it's complicated.
posted by 922257033c4a0f3cecdbd819a46d626999d1af4a at 11:39 AM on November 8, 2021

I wonder why it is that there are some people who can eat complete meals, and then still eat a full slice of chocolate cake. And others who can't. Most blame it on gluttony, but I wonder what the science is behind it. Both my kids were eaters, stout kids who've grown up to big teenagers (ie 6ft, and 200lbs). Both are super active (water polo, rugby, hockey). As compared to some of their friends, also active but are lean. These kids I've known all their lives. At 4 and 5, my kids would polish off 2 hot dogs, and the leaner ones would eat 3 bites and declare done. Now some of those lean ones outeat my kids, and still stay lean.

Its all so complex.

I also know far too many who don't get healthcare, because they are so ashamed of their fat. I'm fat. I hate diabetic appointments. I know how to eat. I don't need someone to tell me to eat off a small plate.
posted by Ftsqg at 12:29 PM on November 8, 2021

music for skeletons, forgive me, I typed that incorrectly. It should read "less than 1%".

That figure is based on the fact that, using England as an example, an estimated 7.4% of the population has type 2 diabetes, of which 90% of cases have body weight as a signifiant contributing factor. 10% do not, primarily made up of gestational diabetes and adult onset diabetes. That means that in the general population, 0.74% of people have type 2 diabetes where weight is not a contributing factor, hence less than 1%. Stats are from gov.uk here.

From the same source, for the same time period, 62% of the population was overweight, including just under 25% who were obese. If diabetes was a significant contributing factor to weight gain, one would expect a lot more than 7.4% of the population to have diabetes. So to answer the OP's question: whilst it is nuanced and there are lots of caveats, generally speaking you get diabetes because of weight gain (amongst other contributing factors), not the other way around.

There are lots and lots of peer-reviewed, scientific studies and stats from reputable bodies around the world that come to the same general conclusion.

I am not judging, criticising, or body shaming people for being overweight. As I said, I was obese for years, and I know what it's like to be treated poorly because of it. Lots of people gain weight, and struggle to lose it again, for lots of reasons, a lot of which have nothing to do with willpower or "choice". I'm sorry that some people think that what I've said is in some way aimed at them, or is in some way an attack on people struggling with their weight. It is not.

But the OP asked a question, and the uncontroversial medical science and statistics says that in the majority of cases people get overweight, then they get diabetes, not the other way around.
posted by underclocked at 12:38 PM on November 8, 2021 [1 favorite]

From the same source, page 10:
Diabetes prevalence among adults who are obese

Analysis of combined Health Survey for England (HSE) data from 2010-12 show that 12.4% of people aged 18 years and over with obesity have diagnosed diabetes, five times that of people of a healthy weight. (Table 1)

Table 1: Doctor diagnosed diabetes prevalence by weight status and gender for adults aged 18 years and over 2010-12, England
       Underweight   Healthy weight   Overweight   Obese
Female     1.9%           1.9%           4.3%      10.7%
Male       0.0%           3.3%           6.0%      14.6%
Total      1.3%           2.4%           5.2%      12.4%
So if excess body fat causes diabetes, surely it is odd that it is failing to do so for 87.6% of people with obesity.

If obesity causes diabetes, how does intermittent fasting trigger very rapid improvements in blood glucose control well before it has yielded significant reductions in obesity? Increased exercise does this too, even more strongly. How?

It is transparently clear to me that there is a range of underlying metabolic dysregulations that contribute to obesity, a minority of which also culminate in diabetes, and many of which are improved by interventions such as caloric restriction, carbohydrate restriction, intermittent fasting and increased regular physical movement.

Again, it is uncontroversial that if you have obesity you are more at risk of going on to develop diabetes than if you do not have obesity, but this would be true regardless of whether the obesity caused the diabetes (which it is clearly not doing in the overwhelming majority of cases) or whether obesity and diabetes were successive effects of underlying metabolic dysregulations.

It is also uncontroversial that knowing of this increased risk might well make it worthwhile to devote time and attention and energy and money and pain toward the kinds of intervention known to be effective against both obesity and type 2 diabetes. But evidence that the diabetes occurs because of the obesity simply does not appear in the data, regardless of the post hoc ergo propter hoc interpretation that the quoted source puts on it and regardless of the fact that this causation is apparently a matter of "common sense".

I'm also quite convinced that this particular "common sense" has a great deal to do with the advertising industry having systematically skewed public opinion toward fatness being inherently shameful and reflective of a lack of moral fortitude since the advent of "diets" as a saleable commodity.
posted by flabdablet at 2:01 PM on November 8, 2021 [1 favorite]

None of which goes against what I said. Weight is a significant contributory factor. I have never said it was the sole cause.

But regardless, the fact remains: whilst types 2 diabetes can be part of the reason for weight gain, that only happens AFTER you become diabetic. The most significant contributory factor in GETTING type 2 diabetes is weight gain. There are other factors such as ethnicity, smoking, genetic predisposition, etc. But 90% of people who get type 2 diabetics have weight gain as a contributory factor, and that is what the OP is asking about.

I am not trying to have an argument, cause offence, hurt anyone's feelings, criticise anyone, fat shame people, or in any way upset anyone. The medical science and the stats are what they, and I'm not blaming anyone for anything, I'm just answering the OPs question as they requested.

And to paraphrase you earlier, flabdablet, I've taken up enough air and it's time I let other people offer an answer.
posted by underclocked at 2:18 PM on November 8, 2021 [1 favorite]

I agree that 90% of people who get type 2 diabetes have weight gain as a comorbidity. I see no justification for calling it a "contributory factor", which seems to me to be the essence of the issue raised in the quote that prompted the question: "Mom, you didn't get diabetes because you got fat, you got fat because you have diabetes. It's a metabolic disorder."

It seems to me that the somewhat poetic expansion of the meaning of "diabetes" here to refer to the metabolic disorder that causes both obesity and loss of blood glucose control is a perfectly cromulent rhetorical move, even though it can also result in misinterpreting the first sentence, taken out of context, as a strong claim about a reversal of causation rather than a softening-up for a point about a common underlying disorder.

That rhetorical move looks completely justified to me, given how far the Overton window on this issue has clearly been shoved in the obesity-causes-everything-terrible direction over the last fifty years. Lots and lots and lots of people are fully convinced that in order to regain blood glucose level control they must first face the completely daunting proposition of dealing with their obesity, and this is simply not the case.

It is possible - common, even - for type 2 diabetes to be kept in check without having any lasting success at getting weight gain under control first, and the fact that many of the interventions more commonly used to control weight gain also work to a greater or lesser extent against type 2 doesn't alter that fact.
posted by flabdablet at 2:37 PM on November 8, 2021 [5 favorites]

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