It's estimated that 60% of type-2 diabetics would no longer be affected if they simply lost weight and got down to a healthy BMI.
Obese Type-2s should really be called "Type F" because it's not fair to people who didn't self-inflict their condition.
Obese Type-2s should really be called "Type F" because it's not fair to people who didn't self-inflict their condition.
If you want to be unbanned you're welcome to email us at hn@ycombinator.com and promise not to do this any more.
It's actually a fairly complicated and can be quite difficult for people to break out of, even people who desperately want to change. When people follow the standard guidelines (which are beginning, slowly, to change) to avoid fat and reduce calories, they end up feeling hungry all the time, and have to white knuckle their way through. This is not a state that people can maintain long-term.
Starvation studies from the University of Minnesota have been described this way: "During the semi-starvation phase the changes were dramatic. Beyond the gaunt appearance of the men, there were significant decreases in their strength and stamina, body temperature, heart rate and sex drive. The psychological effects were significant as well. Hunger made the men obsessed with food. They would dream and fantasize about food, read and talk about food and savor the two meals a day they were given. They reported fatigue, irritability, depression and apathy. Interestingly, the men also reported decreases in mental ability, although mental testing of the men did not support this belief."
In addition, there is evidence that the body begins to reduce energy output in response to reduced energy input, thus making the advice every overweight person hears from nearly every source to "eat less and move more" a load of nonsense. That can work short-term, but the combination of reduced energy output and constant hunger make that recipe very ineffective long-term.
There is even more to complicate the story (e.g. it is common for overweight people to feel hungry even with massive amounts of energy stored in fat due to some of the effects of what's now being called variously, metabolic syndrome, syndrome X and diabesity).
In short, when people become overweight, which is a progressive condition of insulin resistance that grows slowly over time, or in other words and emergent hormonal dysfunction because of diet, they cannot "eat less and move more." To that extent it is not self-inflicted especially since millions of Americans are doing exactly that as told by their doctors and it is having no effect.
The only way to really change body composition long-term, is to change diet in a way that is at odds with what doctors learned twenty years ago in the two days they studied nutrition in medical school, which, as it turns out, is wrong.
Those people were actually starving. Their fat stores had dropped to 4% or less, which is very dangerous when not on a strictly controlled and supervised diet. People with normal or above normal stores of body fat can be hungry and malnourished, but will not be starving (in the medical sense of the word, which is what the Minnesota experiment was testing).
> In addition, there is evidence that the body begins to reduce energy output in response to reduced energy input, thus making the advice every overweight person hears from nearly every source to "eat less and move more" a load of nonsense. That can work short-term, but the combination of reduced energy output and constant hunger make that recipe very ineffective long-term.
I would like to see this in reputable studies, because everything I have read on the subject rejects the hypothesis that there is a physiological change in energy usage as a result of lowered intake. In fact, it a) doesn't make any sense since fat is supposed to be a store of energy for lean times and b) if the body could function at its current level on less energy, it would.
On the starvation study it's merely one example that highlights how calorie restriction affects people. Yes, it's an extreme version, but it is different only in degree from any other calorie restriction, and when people try to reduce by X calories, it's probably a linear effect; more restriction, more of these effects. Oddly though, fasting tends not to have these effects, it's only in sustained calorie restriction, so fasting in various forms is one of the tools people can use to lose weight.
As for the lowered energy output Jason Fung wrote (pg. 53 of the Obesity Code, "One major problem is that the basal metabolic rate does not stay stable. Decreased caloric intake can decrease basal metabolic rate by up to 40 percent. We shall see that increased caloric intake can increase it by 50%."
If you want to learn more here are some sources:
Jason Fung - The Obesity Code: http://www.amazon.com/gp/product/B01C6D0LCK/ref=dp-kindle-re...
Robert Lustig on sugar: https://www.youtube.com/watch?v=dBnniua6-oM
and also here: https://www.youtube.com/watch?v=nxyxcTZccsE
Peter Attia on ketosis and fat: https://www.youtube.com/watch?v=NqwvcrA7oe8
Reversal of diabetes by diet, also Jason Fung: https://www.youtube.com/watch?v=mAwgdX5VxGc
No dude, you are ignoring the fact that these people did not have ample fat stores. It is completely unreasonable to expect that obese people would behave the same while restricting calories than people who are already borderline starving (4% BF). These aren't effects of caloric intake restriction, they are effects of caloric restriction in general, which is a state obese people are not, have not been in for years and will not be in for years.
> One major problem is that the basal metabolic rate does not stay stable. Decreased caloric intake can decrease basal metabolic rate by up to 40 percent
This is basically unrelated to your statements about insulin though, so don't conflate the two. This statement does not support the idea that obese people cannot harvest energy from their fat stores, it supports the idea that you get less energy output from less energy input which is almost tautologically true.
I don't think I am ignoring it. You seem to be asserting that their issues with calorie restriction were lack of body fat. There is no evidence for that I am aware of. A simple rejoinder based on anyone's experience, do fat people get hungry? If they do, why? They have all that energy available. But I don't need to rely on arguments like that, since in the vast corpus of research on this at this point, it's pretty well established that calorie restriction by itself (even with exercise) does not work long-term. The failure rate is astronomical and it is in part due to what plain old calorie restriction as we've been told to do it does to metabolic energy and also due to the psychology of hunger. Also, and this is very important, a full fast does not have these effects according to the evidence. People can totally abstain from food for very long periods of time (depending on body fat), with very little hunger. It is smaller scale calorie reductions, without breaks (like the breaks intermittent fasting provides) and without much dietary fat since fat is highly satiating, that cause these reactions to calorie restriction.
> "This is basically unrelated to your statements about insulin though, so don't conflate the two."
Again, I'm not. I was responding to the request for a source on the idea of energy output reduction in response to lower calories. I'm not claiming there is a link between energy output reduction and insulin.
Fat people can get energy from fat stores, just not in the way we are typically told. If it was impossible to get energy from fat no one would ever lose weight, which is trivially and obviously not true.
No I'm asserting that what happens to people's bodies at 4% body fat when in severe caloric restriction is very different than what happens to people's bodies at 40% body fat with severe caloric restriction, and so we can't apply the metabolic damage/starvation models to fat people. Fat people just need to eat less, and the issue basically comes down to compliance. How do we get people to stay on a healthy diet long term?
> do fat people get hungry? If they do, why?
Because, as even you have shown, hunger is not a reflection of your bodies actual caloric needs, it's hugely a reflection of blood sugar levels, among other htings. Given enough time (in the order of magnitude of minutes to hours) in an obese but otherwise healthy person fats will be broken down and blood glucose will increase and hunger will decrease. It's getting through that period that is a mental compliance issue, but not otherwise physiologically challenging.
> The failure rate is astronomical
Again, this is a compliance issue. People absolutely lose weight on caloric restriction, and starvation issues like low metabolism do not become an issue until you are very low body fat. You simply do not see obese people going into so-called "starvation mode." In fact there are a few cases, though admittedly not many, of obese people that abstain entirely from eating for months at a time without long term "metabolic damage."
> People can totally abstain from food for very long periods of time (depending on body fat), with very little hunger.
I think we basically agree, then, that it's mostly a compliance issue and not an issue of caloric restriction working or not, and also that hunger is not a reflection of the body's actual metabolic state (especially in obese people).
> Fat people can get energy from fat stores, just not in the way we are typically told.
Fat people get energy from fat stores in the same way skinny people do. Very skinny people on severe caloric restriction are not a good model for the general population.
On oversimplification, but the crux of the issue. The astronomical failure rate is because of compliance. The prescription you seem to be suggest is "comply more! comply better!" but the biology of this is exactly why it fails so often. The type of food you eat is what sets you up for sustainable long-term success or its opposite. What you wave away with a wash of the hand--compliance--is the reason people fail and more willpower is not the issue and not a solution. It's a dysfunction of the hormones brought on by high insulin resistance brought on by excessive sugar and flour, which becomes a hunger trap, unless you add fat to your diet, which is exactly what people are told not to do. So, I do think hunger tends to differ when you suffer from fatty liver disease and insulin resistance. People can endure calorie restriction and lose weight for a while doing low-fat but they do not stay on it. Saying that people should just comply more is like telling someone with sleep apnea to sleep better. They need a different intervention.
edit--A failure rate of 80-90% is not an anomaly, it's a colossal failure. It's not something to be overcome, it's an indication of wrongness. By asking for more compliance you are asking people to fight their biology and they will lose this fight. Instead the intervention should be to employ their biology as their ally, and lose weight more easily and without much hunger and that's possible. It's just not helpful to tell people to eat less. We've been telling them that for forty years.
(Side note. The 4% bodyfat in the UofM study you mention is an assumption of yours, and not the starting weight of the people in the study. I think you're unfairly dismissing the study and presenting it as if it's a binary condition between starving/not starving, and that may be a thing, but it's not certain that it is. I'm merely cautiously using it as evidence that calorie restriction is difficult (actually more than difficult) to maintain, which anyway we all know from experience. It would be good to explore other studies on the topic). Intermittent fasting, for example, is vastly easier than consistent calorie restriction, and you're consuming the same number of calories as calorie restriction (if you design it right). That's not a matter of willpower, that's a different intervention).
Unfortunately I don't have time to continue the conversation, but take the time to explore some of the links I posted (there are tons more)--they go into way, way more detail and make the argument better than I have.
You've offered introducing fats as a way to stave off hunger (aka increasing satiety) but introducing fats are far from the only way to increase satiety. Introducing fiber, for instance, is another way.
You also seem to be in favor of a ketogenic diet. Let me say that I totally believe that a keto diet is a great way to eat healthily and boost compliance for some people. Others have a really hard time tolerating large amounts of fat, and so we still need to find alternative solutions for them.
I agree that simply telling people to have more willpower is not the solution, but I think it's important to recognize that the diet is not causing physiological damage to the vast majority of people (it's not the insulin spike in and of itself that causes damage, it's what happens after that, ie: more food intake). So maybe we can attack this from the pure will power front and leave the diet alone (or maybe not, but let's be deliberate about what we are doing).
Regardless, the UofM study is heavily discredited and I still maintain that it is not relevant to what you are arguing either way: the study is designed to study extreme starvation and famine. Brink of death type stuff. Obese people who feel hungry are not that. We know this because if you don't feed them they don't die.
FWIW I actually have read/watched all the links you've posted (I had before this conversation as they are all relatively well known), and I still hold by all my points.
This is still talking about near starvation mode. People who stop menstruating and who grow lanugo are doing stuff that reduces their need for energy.
(I'm not sure it's accurate even for this extreme state though. Re-feeding is risky, but I don't know if "starvation mode" is part of the cause of that risk.)
I don't think there is anyone recommending reducing fats and calories as the only thing. Both of those are positive things to do to your diet, but if taken while ignoring the rest of the actual "standard guidelines" (which include eating more fiber and fruits and veggies), then yes, you are basically simply reducing calories (which is good) and increasing glycemic index (which is bad, for some).
> In short, when people become overweight, which is a progressive condition of insulin resistance that grows slowly over time, or in other words and emergent hormonal dysfunction because of diet, they cannot "eat less and move more."
I don't believe this is true but would be interested in seeing a study.
> To that extent it is not self-inflicted especially since millions of Americans are doing exactly that as told by their doctors and it is having no effect...The only way to really change body composition long-term, is to change diet in a way that is at odds with what doctors learned twenty years ago in the two days they studied nutrition in medical school, which, as it turns out, is wrong.
People have success with every kind of diet program, and it's a bit of a strawman to argue that the medical profession is advocating a diet that is only low in fat, but still high in sugar (which is what produces the results you're talking about). In fact, millions of Americans are following only a small portion of their doctors' advice (ie: lowering fats) which has the effect of lowering satiety, increasing overall glycemic index of their consumption (while ignoring the advice that they should eat more fiber and less sugar). There is no doctor out there recommending that as long as you eliminate bacon you can drink all the gatorade you want.
Let me repeat: There are zero (0) medical professionals advocating for a high sugar diet. The "high carb" part of the recommended diet is meant to come from vegetables and whole grains (which contain a fair amount of fiber).
There isn't any evidence I'm aware of showing people eating a calorically balanced, low fat, high carb, low sugar, moderate fiber, micronutritionally balanced diet and having diabetes. I understand that's more complex that saying "low fat/high carb" but again, there aren't doctors out there recommending cutting out fats and subsisting on sugar. So yes, it's a complete and total straw man, but when you only consider large macronutrient groups and ignore the rest of nutrition it's easy to see why that seems ignorable.
That's true as far as it goes, but the internal fight inside the medical research community was whether it was fat or sugar that was the culprit in a host of physical problems. Fat won in a slam dunk, even though it turns out to be wrong. Doctors are largely not researchers, and they are taught what was the conventional wisdom. There is no suggestion of malice, just bad (or at least overturned, but it was actually bad in this case) research that has been promulgated in the medical community. A lot of doctors think fat is bad and pay less attention to sugar.
The Guardian recently wrote about this: http://www.theguardian.com/society/2016/apr/07/the-sugar-con...
So, it's not bullshit to say a lot of doctors don't understand the nutrition.
OK, later! :)
The idea that you can isolate it down to fat vs. carbs is "not even wrong." It doesn't ask the right questions, and ignores many other confounding factors. I don't really want to keep restating this point.
There are healthy high fat diets. There are healthy low fat diets.
I was not ignoring your argument but rather pointing out that there is data showing a correlation between doctors advocating low fat/high carb and obesity in America.
Now, what is a straw-man is to put forth a theoretical/never seen in reality diet and claim that no one has ever gotten fat eating it. Sorry, but an extrapolation from a population of zero to 350 million is a bit much for me.
I think the one point we do agree on is that this is a complex issue. So, you can blame fat people for not listening to their doctors, doctors for not checking the research or food companies for bastardizing what doctors actually recommended to sell low fat/high sugar food and label it "healthy." But it's quite obvious that the advice doctors have been giving for the past few decades has not had the intended effect.
> data showing a correlation between doctors advocating low fat/high carb and obesity in America
No there isn't because no doctor advocates that without the other nuances I provided in my post. I still feel like you are ignoring my posts, because my last post was literally entirely devoted to addressing this nuance. The simple fact is that there is not a large group of people eating according to the medical communities recommendations who are obese. The rise of obesity in America is people largely ignoring medical recommendations. Yes, low fat was in fad for a while, but there is plenty of evidence that a low fat diet can be healthy, and that a high fat diet can be healthy, so, as I've repeatedly said, it depends.
> I think the one point we do agree on is that this is a complex issue.
100%
> But it's quite obvious that the advice doctors have been giving for the past few decades has not had the intended effect.
When you radically simplify their advice, sure. When you actually follow what is recommended, no not really.
Also, no one gets cured of diabetes type 2, you just control your blood glucose levels better and in effect alleviate the symptoms of diabetes, but you still have diabetes. If you think you don't, do a glucose tolerance test (i.e. drink a sweet drink and measure your blood glucose 1 hr later) and you will find that your glucose tolerance is still compromised no matter how well you managed to control your glucose levels by avoiding eating high glycemic food for life.
A team from Newcastle University, UK, has shown that Type 2 diabetes is caused by fat accumulating in the pancreas -- and that losing less than one gram of that fat through weight loss reverses the diabetes. "So if you ask how much weight you need to lose to make your diabetes go away, the answer is one gram! But that gram needs to be fat from the pancreas. At present the only way we have to achieve this is by calorie restriction by any means -- whether by diet or an operation."
That may not have been T2DM. One of the things research has revealed over the past 30 or so years is that there are far more manifestations of diabetes than the old two-mode model though. Incidentally, that is one reason the types were renamed "Type 1" and "Type 2", to acknowledge that there are likely more types. There is a particular subtype known as Latent Autoimmune Diabetes in Adults (LADA), which some researchers have named "Type 1.5" because it shows signs of both T1DM and T2DM. It initially presents as T2DM, though, so people are often misdiagnosed at first. This manifestation has only been known for about 20 years, though, so it isn't surprising.
> Also, no one gets cured of diabetes type 2, you just control your blood glucose levels better and in effect alleviate the symptoms of diabetes, but you still have diabetes. If you think you don't, do a glucose tolerance test (i.e. drink a sweet drink and measure your blood glucose 1 hr later) and you will find that your glucose tolerance is still compromised no matter how well you managed to control your glucose levels by avoiding eating high glycemic food for life.
This is flat-out contradicted by Dr. Taylor's research. He is demonstrating that patients on a hypocaloric diet, either from bariatric surgery or just a medically-supervised diet, can (and in many cases do) regain normal glucose control after about 10% loss of body weight. I personally went from borderline diabetic to normal glucose control (I can pass an OGTT) after a four-month, 35lb weight loss. I changed nothing about my diet except amount of consumption.
Yep. The inheritance in families with monogenic diabetes and high incidence in certain ethnic groups make this pretty clear.
But no, let's shame everyone who is fat for being overindulgent.
Maybe having diabetes wouldn't be stigmatized so much if so many Type-1s didn't participate in it as well.
(Non-diabetic here, I have no dog in this fight.)
Considering MonadQueen said "* 60%* of type-2 diabetics" and "Obese Type-2s" (emphasis mine) I wonder where you got the idea that she as "completely ignoring" anything.
> But no, let's shame everyone who is fat for being overindulgent.
When and why did telling fat people that being fat hurts their health become "shaming"? Why does telling someone that always jump to a presumption of moral judgment?
The accusation was that these cases are self-inflicted. It's WAY more complicated than that.
Accounts for about 10 extra pounds on a normal-sized human. Didn't stop me from losing 35 pounds in four months when I was 100 pounds overweight.
> PCOS
Same as above, assuming PCOS is a cause and not an effect. There seems to be some debate on that in the Ob-Gyn community.
> Cushing's syndrome
Cushing's is fairly rare, and is usually curable.
> complications of depression
Yes, depression is a big psychological cause of overeating. Been there. Disentangling the depression from the food is part of the therapy, though. Particularly since it becomes a self-reinforcing cycle where depression begets comfort eating which begets more depression.
> The accusation was that these cases are self-inflicted. It's WAY more complicated than that.
Always self-inflicted? No. More complicated? Yes.
However, except in rare circumstances every underlying condition is treatable or curable. There are synthetic hormones for hypothyroidism. There are cortisol blockers, surgeries, and other treatments for Cushing's. PCOS is incurable but treatable, ironically considering the subject by weight loss. Depression is treatable, though it can be a struggle.
Obesity may not be self-inflicted in all cases, but it is almost always resolvable. I'm resolving it, despite having two of the things you listed. You can't just throw your hands up and complain about "conditions" as an excuse to not do anything about the problem. Hell, everything you listed has potentially serious problems if untreated even if it doesn't cause weight gain.
What about being ugly, does that hurt your dating options?
Like being fat, both are things you can improve/fix with enough work.
Do you have any evidence that it's most?
>let's shame everyone who is fat for being overindulgent.
Being overweight is tied to many diseases, and costs me a lot of money in health care costs. I have a say in this.
The beautiful thing about figuring out a treatment is that it'll help you if you're Type-2 diabetic and should ease your suffering from the disease regardless of your fitness level.
I didn't say they didn't. The OP said "most" people who get type 2 aren't fat. I merely asked for any evidence.
Edit: OP didn't actually say that.
But:
>Just look at family and ethnic correlation.
"People of different racial and ethnic groups are more likely to develop type 2 diabetes, heart disease, and stroke. African Americans, Mexican Americans, American Indians, Native Hawaiians, Pacific Islanders and Asian Americans have a higher risk for these deadly diseases. This is partly because these populations are more likely to be overweight, have high blood pressure and have type 2 diabetes. - See more at: http://www.diabetes.org/are-you-at-risk/lower-your-risk/nonm...
I'd say "family" is much the same, since eating habits are learned at home.
I realize not everyone with Type-2 can help it. I also realize there are many overweight people who can.
Just look at family and ethnic correlation. (rare) Monogenic diabetes is even hereditary!
If you have a say in this you might want to look at effective ways to push your message.
We know from lots of research that merely yelling "GO FOR A JOG FATTY" does nothing to help fat people lose weight, and probably makes things harder for them.
While some people respond to a pat in the back, others respond to a kick in the butt.
Sources? That'd be some weird research.
Regardless, it isn't my job to "fix" overweight people. They are welcome to their indulgences. I just do want to pay for the ill effects of bad habits. I have a feeling if they were on the hook for related costs, we'd have a different looking society.
It's like we live in a world where all of the inner aisles of the grocery store are stuffed with $3 liters of Vodka and the outer aisles $20 20oz bottles of water and then blame and ridicule people for boozing...
It's not your job to make judgemental comments on every single thread that mentions weight, but you never fail to do so.