You’ve heard the conventional wisdom: obesity leads to diabetes, heart disease, etc.
Me, I think obesity may be the cause of things like arthritis from the excess weight on joints, but if you’ve read the sidebar here, you know that I actually think that obesity is also a symptom, and what causes it is what causes diabetes and heart disease (among others): the Western diet. And our diet’s influence on inflammation probably contributes to things like arthritis as well!
But I’ve also been noodling something in my head for a while now. What to make of people whose excess weight winds up being hundreds of pounds or more?
And why aren’t many of these morbidly obese folks diabetic?
This is over-simplistic, but if diabetes is essentially excess blood glucose, then a real difference between the overweight type 2 diabetic and the morbidly obese person is that the former’s fat cells are apparently incapable of taking up excess glucose, whereas the morbidly obese person’s fat cells are able to take and take. Curiously, both are likely insulin resistant and have other metabolic syndrome markers.
Why does this matter? Because a very important question is the role of sugar intake regarding high blood sugar and heart disease. Of course, there are other potential culprits, like fructose, excessive omega 6s, etc. But it seems pretty clear that caring about blood sugar levels is important, whether or not you’re diabetic.
Usefulness of checking blood glucose levels
One of my regular go-to blogs is Dr. Davis’ Heart Scan Blog, and this is a regular topic for him. He recently convinced me of the usefulness of testing my blood sugar after a meal even though I’m not diabetic:
Blood sugar after eating (“postprandial”) is the best index of carbohydrate metabolism we have (not fasting blood sugar). It also provides an indirect gauge of small LDL. Checking your blood sugar (glucose) has become an easy and relatively inexpensive tool that just about anybody can incorporate into health habits. More often than not, it can also provide you with some unexpected insights about your response to diet.
If you’re not a diabetic, why bother checking blood sugar? New studies have documented the increased likelihood of cardiovascular events with increased postprandial blood sugars well below the ranges regarded as diabetic. A blood sugar level of 140 mg/dl after a meal carries 30-60% increased (relative) risk for heart attack and other events. The increase in risk begins at even lower levels, perhaps 110 mg/dl or lower after-eating.
My fasting blood sugar level? Around 90. My blood sugar one hour after chicken salad with an olive oil vinaigrette? About 90. My blood sugar one hour after a Big Mac, fries, and Diet Coke? About 150. Yikes!! Yeah, that diet soda is a big win, eh?
[You'd have thought that seeing that would have gotten me off the processed carbs right away, but alas, it actually took me nearly a month (those carb cravings really do a number on me).]
I’m actually pretty psyched about continuing to test *my* response to carbs in my diet (mostly non-sugar, non-wheat carbs). Part of this is probably my inner sugar addict, but part of it is reading folks like Stephan Guyenet and considering that many populations have done fine on some starches, so going ultra low-carb may not be necessary (or at least as a permanent solution).
Obesity as a defense against high blood glucose
Anyways, all this is a preamble to a interesting comment from Stan I read over on Dr. Davis’ blog on blood sugar, diabetes, and morbid obesity.
Dr. Davis had written:
A subset of people with lipoprotein(a) can have wildly increased blood sugars despite their slender build and high aerobic exercise habits.
Stan’s response (emphasis mine):
It is interesting that you confirm that thin slender people which you identify as “Lp(a)” types are so much less tolerant against high refined carbohydrates!
In my subjective observation some of the most robust people on the standard (high carb medium fat) diet are of heavy set build ( Kapha/Phlegmatic).
They are able to easily increase their adipose tissue which probably is their main defense against high blood glucose.
This protection comes at the price of putting up weight, sometimes a lot of weight. In some rare cases their body weight can grow above 500lb before this protection mechanism stops, their adipose tissue stops expanding, and then - and only then - they get diabetes! Not before, not while their fatty tissue is still growing!
In my personal opinion the only difference between the heavy set type people and us (“ascetic” body types) is that our adipose tissue is for some reason (genetic?) incapable of growing beyond a minimum (in my case I was only able to put up ~10lb extra at most) therefore our fatty tissue is not able to scoop up as much excessive glucose out of our bloodstream as their therefore we get diabetes, on a very high refined carb diet, earlier and more severe than them.
Perhaps it’s just me, but I’m surprised that so few seem to consider this possibility. Maybe it’s “well, duh, of course,” like of course this happens. But I’m not so sure.
Implications for the obese
It’d seem to me that if people really made more of this connection, then a focus on maintaining reasonable blood sugar levels would be a critical tactic for weight loss and prevention of disease. And if that were so, then industrial food products full of sugar would be even more problematic — especially if they are diet foods!
If the overweight non-diabetic paid attention to their blood sugar levels, then perhaps weight loss shakes full of sugar (have you looked at the labels for Optifast?), weight loss cookies (blech), rice cakes, 100-calorie snack packs of Oreos and so on wouldn’t be part of anyone’s weight loss plan — even one that was based on the concept of glycemic index/load.
Of course, this isn’t really a big surprise. There is still an argument as far as the right diet for diabetics who absolutely need to maintain good blood sugar control!
For the non-diabetics, one way of looking at it is perhaps the morbidly obese have a genetic advantage. If we were living 10,000 years ago in times of scarcity, maybe this response to high blood sugar would be a good thing. But now, these genes in this environment seem to be just bad news. As Dr. Sharma says: “the obesity epidemic is simply the natural response to our unnatural environment.”
Matt Metzgar has an interesting take on this: maybe our environment has us in a state of perpetual winter metabolism:
In modern times, people can get trapped in a permanent winter metabolism due to lack of sun exposure and lack of plant food in their diet. What is supposed to be a transient state of the metabolism for a few months becomes a permanent condition.
Perhaps it’s just me, but the more I read, the more I firmly believe that the response to obesity needs to be a lot more sophisticated than just “eat less, move more.”
More of that later in a followup post, but for now, I think a good approach would include:
1) Reducing carbs, especially sugar and refined grains. I am not convinced ketosis is necessary, but you probably want to go low enough that you aren’t carb dependent (which means you’re body is making good use of fatty acids instead of carbs, you don’t get light-headed or ravenous between meals, etc.). I’m also not convinced that you need to go full-on paleo and avoid all grains (though the Weston Price folks may be onto something).
2) Eating a whole food diet, including protein, veggies, and a good dose of healthy fat at each meal (keeping omega 6s as low as possible, which means avoiding most vegetable oils). I also like full-fat dairy from grass-fed cows.
3) Considering some supplementation. It’s better to get micronutrients from food or nature, but that’s getting harder with our industrial food system. And it looks like a number of these micronutrients are essential for a healthy metabolism. For me, the contenders are vitamin D, magnesium, omega 3, and iodine.
4) Healing the liver and gut. For the liver, this’d involve avoiding things like alcohol and fructose (probably fruit too); for the gut, it’d involve strategies for repopulating the gut with healthy bacteria.
5) Stopping the chronic cardio! Exercise is important for health, but it may need to come later after some level of weight loss depending on where one starts. I like the idea of low level aerobics and a small amount of weight and high-intensity training.
Of course, I’m not a doctor, nor do I play one on TV (sorry, dated reference); this is just my current thinking. More to come later. For a more sophisticated take, I encourage you to check out Stephan Guyenet’s thoughts here or Kurt Harris’ approach here.
Weight Maven is written by Beth Mazur. Beth believes that obesity is more symptom than cause and that the real problem is our Western diet -- especially sugar, refined grains, and industrial oils. Beth writes about nutrition, ancestral health, & food policy. And cats! 
You mention that the Weston Price folks may be onto something. But they ONLY recommend whole grains, which they have you soak, sprout, or ferment to neutralize phytic acid and enzyme inhibitors. If you are not going to do these steps, then grains are not in their diet.
I had only meant to suggest that for folks who really are reluctant to go full-on paleo and omit grains, there may be a way to include them if you don’t mind some extra effort.
That said, I do think WAPF folks are like paleo/primal folks; some are more strict than others. And some of them think a little phytic acid isn’t such a big deal if you just decide you want oatmeal one morning and you don’t have any soaked.