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What If Obesity Is the Symptom Not the Disease? [The Research Answer to the Question of Whether You Can Be "Healthy Obese"]

Posted Nov 05 2013 2:20am


Dr. Peter Attia, like many new doctors, thought he had this whole healthy living thing figured out. So much so that when a woman came into his ER one night in 2006 with uncontrolled type II diabetes and needed a foot amputation, he had nothing but “bitter contempt” for her, for allowing herself to get that way. “If she’d just watch what she ate and exercised a little she wouldn’t be in this position,” he remembers thinking as he unceremoniously lopped off her limb.

So far, Attia’s story is like so many countless other doctor interactions with obese patients – sad, too common, and not terribly helpful. But then Attia’s story changes from the common narrative, in three important ways.

1. He recognized the unfairness of his attitude, even as he was thinking it.

2. He got metabolic syndrome – a precursor to type II diabetes – himself, just a few years later despite watching what he ate and “exercising four hours a day.” 

3. He questioned the conventional wisdom about obesity, turning the research of it into his life’s work. Which led to a very interesting conclusion.

In regards to the first point, I have to give him mad props. It takes some humility to recognize that you’re being an unsympathetic jerk and to regret it. He wanted to give all his patients the benefit of “non judgement” when it came to their care but it turns out doctors are only human too and end up making biased generalizations, just like the rest of us!

But the second point is where his story, as chronicled in his TED talk (holy crap are those not the best invention ever?), gets interesting. Even though he was a doctor and doing everything “right”, the way he’d been taught in medical school, he developed insulin resistance and then full-blown metabolic  syndrome – scary because it’s a known risk for not just diabetes but heart attacks and early death. He took his diet restriction to “extreme” levels and upped his workouts to four hours per day. (How does a doctor find four hours a day to exercise?) But it wasn’t until he started focusing on his insulin (and cut his exercise way down) that he was able to drop the extra weight and return all his health measures back to normal.

The experience made him wonder if obesity is really a symptom and not a disease, as was so famously decided by the AMA earlier this year. Attia compares it to an epidemic of people banging their shins on coffee tables and getting bruises. “Would we then treat the bruises?” he asks, adding that people could be prescribed pain pills and special creams and makeup to make the bruises more flattering ( hahah !). But of course that would be ridiculous considering the plethora of sharp-edged coffee tables in the world. Rather you would remove some of the coffee tables or teach people how to avoid bumping into them or even provide them with shin guards to prevent the issue from occurring in the first place. Now, trade bruises for obesity and shin-banging (must…not…make…joke…) for insulin resistance.

“Could it be that, in the same way a bruise forms in order to protect the body after an injury, that gaining weight is a coping mechanism for a deeper problem at the cellular level?” Attia asks. “What if we’re fighting the wrong war—fighting the obesity rather than insulin resistance? Even worse, what if blaming the obese means we’re blaming the victims? What if some of our fundamental ideas about obesity are just wrong?” (Emphasis mine.)

So Attia went to the research, both doing his own and studying that of others, to answer these questions by challenging the conventional wisdom. One of the first interesting connections he found answers the often perplexing question of “If obesity is the disease, why are some obese people totally healthy (as defined by health measures like blood pressure, cholesterol, etc)?” Looking at the biomarkers of thousands of people, he discovered that some obese people have insulin resistance, as measured by a blood test, whereas others do not. The obese people with insulin resistance are the ones who get diabetes and have the health risks we typically associate with all obesity. He also found that some normal-to-under weight people also have insulin resistance, whereas others in that same cohort do not. And, the skinny folks with insulin resistance not only had the same health issues and risks as the obese insulin-resistant group but the skinny peoples’ health issues were worse. Yeah, I’ll let that one sink in for a minute.

In addition, he cites a recent a study published in The New England Journal of Medicine   that looked at 5000 people with type II diabetes over 13.5 years. Half were assigned a “lifestyle intervention” that focused on losing weight while half were given “standard diabetes care” including insulin shots and meds. Surprisingly, while the first group did lose weight their incidence of heart attacks, death from cardiovascular causes, and nonfatal strokes was exactly the same as the other group. This discovery actually led the trial to be stopped early. The researchers concluded that the relationship between obesity and health risks was more complicated than previously assumed. Attia thinks it was the untreated insulin resistance in both groups that led to the health problems, regardless of their body weight.

Attia’s theory is that obesity is the body’s way of protecting itself from too much insulin (i.e. the “bruise” created by the coffee table run-in). It led him to focus his research on the theory that it’s insulin resistance that is the real health risk and obesity is the symptom of it, not the other way around.

Insulin is a peptide hormone produced by the pancreas to help cells metabolize glucose (i.e. sugar). It’s a tricky little thing – too little and we all die but too much and… we all die. It’s not a bad hormone and the more sensitive we are to its signalling, the healthier we are. The key is to eat in a way that allows insulin to do its job without going nuts and taking all our cells hostage and demanding peanut butter cups as ransom. (Note: We often hear about needing to keep our blood sugar “stable” – turns out this is kind of bogus as our blood sugar was meant to fluctuate. We just want it to fluctuate in a controlled manner and not a day-after-Halloween-all-the-candy-is-half-off way.)

This fundamental misunderstanding of insulin and its impact on the body has led to some strange solutions in the health and fitness world. For instance a friend (who is smart and kind and healthy) recently posted a recipe from a healthy living site for a breakfast dish made up of quinoa, apple cider, vanilla almond milk and apples. Normally I’d shrug something like this off but it caught my eye because a) um, yum! and b) the healthy living blogger started the post with how she used to eat a bowl of Lucky Charms every morning and then decided the sugar crash wasn’t worth it and had healthified her breakfast to this tasty recipe.

The only problem? It’s really not any healthier. I’m probably oversensitive to this issue as I’m currently limiting my sugar intake to help ameliorate my depression right now but  in many respects it’s worse than her Lucky Charms. This recipe, as written, has nearly 30 grams of sugar WITHOUT the blogger’s suggested added toppings. Add the apple on top and you’re looking at a whopping 53 grams of sugar. For comparison, a bowl of Lucky Charms only has 11. A small Dairy Queen Blizzard has 55. Plus while the 9 grams of protein from the quinoa are nice, the sugar makes this a GI nightmare. I’m not saying you should eat Lucky Charms or ice cream for breakfast but just giving you info to make informed choices. I’ll give her big ups for using whole, natural foods – def. better than the ‘Charms there – but even though the sugar is from natural sources like apple cider, it’s still digested in the body the same way table sugar is.

It’s not my intent to call out this particular blogger (which is why I’m not linking) because this faux health food mistake happens a lot – heck, I’ve done it myself! I think you could modify this breakfast to make it healthier by subbing unsweetened Almond Milk and ditching the cider for water (as the cider, with 27 g sugar and none of the satiating fiber of a whole apple, is the real issue) plus Stevia for sweetness but you’d definitely sacrifice taste and flavor. Or just eat and enjoy the recipe as written but let’s not pretend it’s health food. It’s like those bran muffins we were all excited about in the 00′s but turned out to have more fat, calories and sugar than the white toast we were replacing. (But boy did we poop pretty!)

Which I realize makes me sound like a health pedant and one of *those* super annoying girls on FB who has to go pop holes in everyone’s healthy non-latex party balloons. But Attia’s TED talk is exactly why it’s so important not to discount the effect of sugar when you’re deciding what to eat.

Attia’s TED talk ended on a surprising note – and one that had nothing to do with insulin or research. He ended by apologizing to the diabetic woman whom he had treated with such disdain early in his career. With audible sobs he said, “Sometimes I think back to that night in the ER. I’d say to her, As a doctor I delivered the best clinical care that I could but as a human being I let you down. You didn’t need my judgment and my contempt, you needed my empathy and compassion. But above all else you needed a doctor who was willing to consider that maybe you didn’t let the system down – maybe the system, of which I was a part, let you down. If you’re watching this now I hope you can forgive me.”

Not gonna lie, I had all the tears watching it. As a person who has to ask for forgiveness in a public way on a fairly regular basis, I can appreciate his effort. As a person who hopes desperately that people will forgive me, even when I don’t deserve it, I can sympathize with his pain of the undone unknown. And lastly, as a person who has dealt with more than one medical professional who showed “bitter contempt” for me, I am grateful for his apology, even if it wasn’t meant for me specifically. (I remember one time when I told a doctor I’d been anorexic in the past, he immediately chalked up my current issues – which had nothing to do with my prior EDs – to me being “stupid” and didn’t I know that kids in China were starving for real? What I learned from that experience is that I don’t check the box for eating disorders on intake forms anymore because I don’t want it to color the doctor’s perception of me. And as frustrating as that was, I know it doesn’t even compare to what obese patients sometimes go through – they don’t have the option of simply leaving a box unchecked.)

Attia concluded poignantly, “We can’t keep blaming our overweight and diabetic patients like we have. Most of them want to do the right thing. If obesity is just a proxy for metabolic illness then what good does it do to keep punishing those with the proxy?”

What do you think – is obesity a disease or a symptom? Have you ever been treated with contempt by a doctor? Did you have a fave “health food” that surprised you by how unhealthy it really was?

(I’ve embedded Dr. Attia’s whole TED talk below – it’s worth a whole listen! Huge thanks to the reader who sent me this talk – I love you!)


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