Misconceptions of Type 2 Diabetes: Genetic Links and Weight Management
The Times on Type 2 Diabetes
Part 1 of 2
Blaming the Patient
Well it's about time!
Several articles on diabetes in the New York Times this week noted that type 2 diabetes is not caused by simple sloth and gluttony: it has a strong genetic component. Furthermore, weight loss alone may not make type 2 diabetes go away, because the underlying cause is insufficient insulin as well as insulin resistance.
Some patients have been saying this for years, but then, who listens to patients? The standard dogma spouted by medical professionals continues to be, "Eat less and exercise more. If you can lose weight, sometimes just 5 or 10 pounds, your diabetes will probably go away."
The standard dogma spouted by journalists has been that Americans are eating too much fast food, that this is making them obese, and that the obesity is causing diabetes.
Some writers are calling this idea a meme, or an idea that propagates throughout a culture. Once such an idea becomes entrenched in the public consciousness, it can be very difficult to eradicate, despite evidence that it isn't true.
Even some patients with type 1 diabetes blame those with type 2 for their disease, claiming that type 1s are innocent victims of a genetic disease but type 2 is preventable and type 2 patients "brought it on themselves."
Of course we all know how difficult it is to lose weight, even more so when you're born with "thrifty genes" that mean you need less food than other folks but you've been brought up to clean your plate even when serving sizes are huge. So most type 2 patients never manage the weight loss, especially when they're given drugs like sulfonylureas, insulin, and the glitazones that cause weight gain. But they continue to hope that if they could just get those extra 40 pounds off, they'd be cured. "Next week I'll be really, really good at my diet."
You might think it's good to offer hope to patients. The problem is that if the patients do, in fact, manage to lose weight and their diabetes doesn't go away, they lose their faith in doctors and other medical professionals. Then when another medical decision has to be made, perhaps a life-and-death decision, they may ignore the doctor's advice because they no longer believe the doctor.
The Times reporter Gina Kolata is trying to correct some misconceptions about type 2 diabetes. This is good. And she's laying the blame not on the patients themselves, but on public health propaganda:
"And in part it is the fault of public health campaigns that give the impression that diabetes is a matter of an out-of-control diet and sedentary lifestyle and the most important way to deal with it is to lose weight."
This disconnect between known facts and the perceptions of the public -- and even medical professionals -- is very sad. The knowledge has been out there for years, but no one is listening.
I pointed out in my book The First Year: Type 2 Diabetes, first published in 2001, that type 2 diabetes has a strong genetic component and the weight gain that so many people with type 2 diabetes see may not be their fault.
Many of us have pointed out, as Kolata did in the Times, that not all overweight people have type 2 diabetes, so obviously obesity alone does not cause the disease. Again, no one listened.
Patients have also pointed out that without any change in their diet, they suddenly began to put on weight, especially in their stomach, before they were diagnosed with diabetes, suggesting that some metabolic defect was causing the weight gain, rather than the weight gain causing the metabolic defect. But no one listened. People thought, "Yeah, yeah. They're probably cramming themselves with doughnuts when no one is looking."
Recent research, which I described in this blog in late July, has provided support for the patients' observations. Research showed that the apple shape doesn't cause insulin resistance. Rather, insulin resistance causes the apple shape.
A metabolic defect that shows up years before people are diagnosed with metabolic syndrome or diabetes means that people with this defect are unable to store carbohydrates correctly. Instead the carbohydrates are converted to fat, and this extra fat is deposited in the stomach.
Then this extra fat causes insulin resistance, and in those without the pancreatic reserves to increase their output of insulin, the insulin resistance causes type 2 diabetes.
Thus obesity is associated with type 2 diabetes, and sometimes reducing weight can reduce insulin resistance and improve blood glucose levels. But obesity is not the real cause of type 2 diabetes.
The fact that a prestigious newspaper like the New York Times is trying to spread the word is encouraging. But will it have any effect?
Probably not right away.
Gary Taubes, in an oft-cited article in the Times in 2002 -- What If It's All Been a Big Fat Lie -- argued that the currently popular low-fat diets were not helping people, and might even be causing the "obesity epidemic."
Did anyone listen? Yes, for a few minutes, and then they went back to the old dogma, urging patients and clients to cut back on their fat and eat a lot of "healthy complex carbohydrates."
So I don't imagine the latest Times article is going to turn diabetes care around in a heartbeat. But each little bit helps. Each time someone gives support to the idea that people with type 2 diabetes shouldn't be blamed for "bringing it on themselves" it helps.