Diabetes Guilt

For lots of people the hardest question is, “What are you doing to control your diabetes?” That’s what a leader of some new focus groups tells me.

“If they have type 2 diabetes, they feel guilty about it,” she tells me. “So they won’t open up about their diet, exercise, testing, and how they take their prescribed medication.”

Feeling guilty is bad enough when you done wrong. But when it’s not your fault, it’s doubly awful.

If you have type 2 diabetes, it is not your fault, although it seems that many of us don’t know that. On the other hand, everybody knows that when people get type 1 diabetes it is not their fault. Type 1 diabetes is an autoimmune disease that we still don’t know how to prevent. But much of the world goes around telling us that our type 2 diabetes is “a lifestyle disease.”

That lumps it together with lung cancer from smoking and cirrhosis of the liver from alcoholism. The message – usually hidden but sometimes explicit – is that we are lazy, we eat too much sugar, and especially that we get fat because we stuff our faces with bonbons and jelly beans.

But the numbers just don’t add up. More than one-third of all American adults are overweight. Plus, nearly one-third of us are obese.

Many people think that being heavy causes diabetes. But since a lot more people are overweight or obese than have diabetes, weight can’t be its cause.

Government data show that 34.1 percent of adults are overweight. These people have a body mass index of 25 to 29.9. Another 32.2 percent are obese, meaning a body mass index of more than 30. Together, almost exactly two-thirds of us are carrying more weight around than is good for our health.

By comparison to the two-thirds of Americans who are overweight or obese with a body mass index of 25 or more, 7 percent of us have diabetes. So being heavy can’t be the cause of diabetes. Even when we consider the one-fourth of Americans with pre-diabetes, there’s got to be more to causing diabetes than being well-upholstered.

Still, more than 85 percent of people with diabetes are overweight or obese. That means there must be some connection between diabetes and weight.

While being overweight can’t be the cause of diabetes, weight and diabetes are linked. They probably have a common cause. This strong correlation is why you will often see type 2 diabetes described as a “lifestyle disease.” This implies that diabetes results from a choice, just as other lifestyle choices like cigarette smoking and heavy alcohol consumption lead to other diseases. It’s blame-the-victim time.

Even the government’s Centers for Disease Control and Prevention buys into this argument. “We know obesity causes about two-thirds of diabetes,” the agency told state health agencies in 2005. In fact, no one has ever demonstrated that obesity causes diabetes or even insulin resistance.

On the other hand, maybe insulin resistance or diabetes makes us overweight. That’s certainly possible, but even if it is there has to be something else that causes us to carry more weight than we should.

Type 2 diabetes generally results from the combination of impaired beta cell function and insulin resistance acting on susceptible genes. Why then is there such a large overlap between being heavy and type 2 diabetes?

The answer is slowly coming out of research led by three scientists who worked together for years in Seattle. They are endocrinologists Daniel Porte Jr., M.D., who is now associated with the VA San Diego Health Care System, Michael W. Schwartz, who is now professor of medicine at the University of Washington, and psychologist Stephen Woods, now of the department of psychiatry of the University of Cincinnati.

“It’s complicated,” Dr. Porte tells me, “because everybody who is obese doesn’t have diabetes, and everybody who has diabetes is not obese. So we have been looking at why they tend to overlap.”

The answer, they found, is the beta cells of the pancreas that make and secrete insulin. “If the beta cells are not functioning properly this will tend to lead to diabetes,” he says. “And this will also tend toward an increase in body weight.”

Insulin has two apparently contradictory impacts on your body, Dr. Porte says. “One is that it tends to store fat. When you eat a meal, the calories will be stored so that you will be able to survive between meals. But the insulin also goes to your brain to suppress your eating – so you won’t overeat.”

Obesity too has “a bunch of causes,” Dr. Porte says. “Diabetes and obesity occur together more than you would expect by chance.”

If you have factors in your genes or your environment that would cause obesity, then you would probably become obese, he says, and your diabetes, if any, would be very mild. But if you have factors that tend to damage the beta cells or to produce insulin resistance, then you would get more severe diabetes.

“So you can get varying amounts of diabetes and obesity,” he says. “But they will tend to occur together because of fact that insulin tends to store fat and tells the brain how fat you are, preventing overstorage.”

Does this mean that Dr. Porte would not call diabetes or obesity a lifestyle disease? “In our view obesity is not very often a behavioral disorder,” he replies. “It is a biological disorder, that is an interaction between the biology and the environment.”

“While obesity is a biological disorder,” he continues, “it is sometime amenable to behavioral intervention. But the difficulty occurs when you intervene behaviorally, because that behavior is fighting the biology. That is one of the reasons why it is so hard to regulate your weight. So we need to come up with ways to help people achieve those goals.”

This is not to deny that we can control our diabetes better when we lose weight. I know from my experience of losing a lot of weight during the past year how much better my numbers are and how much better I feel.

Now, we have begun to have drugs to help people with diabetes regulate their weight. Maybe in a few years as more and more of us lose weight, people will stop blaming us for being overweight and stop labeling type 2 diabetes as a lifestyle disease.

This article is based on an earlier version of my article published by HealthCentral.

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