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!)
One of the things I have experienced frequently in my life is being treated with contempt by doctors- I have left doctors offices in tears more times than I can count. Being a trans man, having a history of eating disorders (and osteoporosis because of it), anxiety, and a hereditary nerve condition seems to cause doctors to assume and tell me it’s all in my head. That’s never what you want to hear when you are seeking help!
Your posts are great because they always get me to think… I tend to think obesity is a symptom, and that there is always an underlying issue whether it is physical, psychological or genetic…I don’t have any evidence, but I don’t think that obesity is just one disease that exists in a vacuum…
I’m with you on not checking the ED box anymore…
((hugs)) Reid – I’m so sorry, I can’t imagine how frustrating and painful it must be for you to have to deal with ignorance on so many different levels. Any one of your struggles would be huge and to have all of it together? You are a strong man, hang in there:)
LOVE TED talks. They always make me think.
If all doctors treated patients as a whole, instead of looking only for symptoms leading to a diagnostic, we would all fare better!
I love this Charlotte. Thanks for writing this.
May I add that depression or actually any mental disease should be treated with less contempt. I’m a nurse in a hospital and sometimes I get so frustrated with the harsh judgments made my coworkers (especially doctors and case managers). I have even become more compassionate since I suffered from depression and anxiety last year after a hysterectomy. My worst symptoms lasted only about a month and I bet it wasn’t anything compared to what some poor souls go through, but it stunned me enough that I will never look at depression in the same way. I proudly hold my bottle of Prozac up for all to see. There should be no shame.
I totally agree – thank you for making this point! And I’m so sorry you had such a difficult time after your hysterectomy. It sounds like you learned a lot from the experience though and have used it to help you be more empathetic in your career. (Have I told you I love nurses? My mom is a nurse. Nurses are the best!!)
Obesity is definitely a symptom of a larger problem.
A food industry that doesn’t have the consumer’s well being on the agenda (at all) and a diet industry that relies on a poor food industry to stay flush with funds are two HUGE factors in the “obesity epidemic” and a huge part of that “larger problem”.
Excellent point. There’s definitely a level of corporate complicity not being addressed.
Sob. My medical records say that it is my “obesity” that has caused a misdiagnosis that resulted in an unnecessary and painful surgery that was forced upon me by an aggressive and powerful doctor several years ago. He was wrong, not me. Not my body. My “obesity” had nothing to do with the problem (twisted ovary that was not twisted) and nothing to do with his inability to correctly diagnose the problem. He never admitted his mistake, and was cruel. If only he had the humanity to admit his prejudice led him to make a mistake. (btw, I am not in fact “obese”, just not skinny. I wore a size 14, 5’7″ at the time) All my life Dr’s have been telling me that I need to lose weight. I am very steady in my weight, although heavier than socially desirable. I am SO SICK of the obesity issue. freaking doctors.
Thanks for this article, and the TED link, good stuff.
Oh Cheri, I’m so sorry! That sounds like a nightmare:(
As a physician I absolutely applaud the work of Dr Attia and his humility. I honestly (perhaps my bias) think that it’s a lack of knowledge that leads to the general medical community’s attitude regarding obesity. I wholeheartedly agree that obesity is a symptom, as suggested by Attia and Gary Taubes. Paradigm shifts are difficult for many of us to accept but I hope that as we learn more the community will be willing to consider a change of view. No patient deserves to be judged, no matter the circumstances.
Thank you for your perspective Amanda! And for reminding me about Taubes…
I think this approach is definitely a good one, but just like the black-and-white idea that everyone who is overweight is unhealthy and losing weight will solve all obese people’s health problems, I don’t think it is black and white that obesity is a symptom of a health problem all the time either. Treating overweight and obese patients (and people in general) as human and deserving of respect is a huge challenge for doctors right now- so often, overweight patients don’t get medical care they need. So finding compassion is a big step forward. But lets not jump from one end of the spectrum to the other. Overweight people are all individuals with different realities- I don’t think there will be a one-size-fits-all solution. For some people, obesity is a symptom. But what about the people who eat healthy, generally are healthy and are overweight? Their weight isn’t a symptom. What this article says to me is that doctors are making steps towards seeing overweight patients as people, but they still cannot accept the idea of overweight and healthy. Everyone who is overweight still needs to be “fixed”- only now they should also be pitied. And I’m pretty sure that my overweight co-worker who can out-hike me every day of the week doesn’t want pity or a solution- she just wants people to start seeing her before they see her weight.
Great point! I should have been more specific. I believe that obesity associated with metabolic syndrome, as described by Attia and Taubes, is a symptom of an underlying metabolic derangement not a root cause.
I got distracted in my comment and left it a long time, so I didn’t see your post until after I posted. I wasn’t trying to target you at all
Interesting points Nicole! What I took from the research though was that you CAN be overweight and healthy. It’s the insulin resistance that’s the issue whether you are overweight, underweight or normal weight. Some overweight/obese people have perfect blood work and are still told they’re “sick” – I think this research shows that they’re not. I def agree though that the medical community has a long way to go for treating people as individuals!
This is so, so interesting Charlotte, so glad you shared it.
I once had a doctor tell me I looked pretty normal after I went in for an ED-related evaluation. I was underweight at the time and this was before he even ran any tests. Like, seriously? And don’t even get me started on the condescension I get when I get on scales backwards and ask to not be told my weight. I’ve had doctors hand me a printout about my appointment with my weight on it after I asked them that and then ask if I was getting treatment when I complained.
Just refuse to be weighed at all. The doc does not need to weigh you.
Actually, they do need to weigh you if they are using Electronic Medical Records and prescribing any meds. Because dosing is dependent on weight sometimes and the system will not allow prescriptions without a weight. Whether or not this is a good idea…. don’t get me started .
Yes, that’s what I was told too. My old doc was really understanding and never made me get weighed but since then all my docs have been kind of dogmatic about it, insisting on it and writing it on the top of my chart where I can see it. Sigh. As you guys have seen on this blog, sometimes those doctor visits are the catalyst for a bit of a tail spin after seeing those numbers… I wish there was a better way.
The nurses at my doctor’s office always offer to let people stand on the scale backwards if they choose, and they never say the number out loud. I don’t care one way or the other since I always have a rough idea, but perhaps that’s not a bad suggestion for some people?
Love this and I am going to share this!
I agree it can be a symptom, but {and I mean zero contempt with this next statement} this can not be a blanket “excuse” {for lack of a better term} either. But as a RD and someone with my own eating disorder and part of this medical community we need to approach ppl that are over AND under weight with care and respect. We need to determine WHY they are the size they are whether it be from insulin resistance, depression, eating disorder, or deep seeded issues. It just isn’t fair to say to anyone “do this, eat this way, exercise like this and boom you will be all fixed.” There is no “right” size, as an RD my main priority is to make sure you are healthy, number/lab wise, and comfortable with who you are. Thanks again. This was eye opening.
I don’t think it’s an issue so much of making an “excuse” but rather trying to focus limited resources on what the real health risk is and not wasting time on things that don’t work. I totally agree that there is a lot of improvement to be made in treating ALL patients with kindness and as individuals. I also agree that there is no one-size-fits-all prescription!
This article was in our local paper recently. It deals with how the medical community treats obese patients and how a doctor with a different point of view approaches the issue: http://www.edmontonjournal.com/professor+studies+weight+bias+health+care+system/9115056/story.html.
Very interesting! Thanks for the link!!
This is a tough one. Having watched my obese sister in law cope with endless doctors who aren’t interested in really hearing her health concerns because she’s obese….I can se the complexity of this. Yes being overweight brings so many health issues, but often just losing weight isn’t so simple or even possible without knowing what is brought on by the weight gain and what the weight gain has brought to the picture. Yes, people need to work to take control of their body and health, but I think doctors can do their patients a disservice by blanketing all overweight patients together. The body is a complicated thing…
I would have a lot more respect for Dr. Attia if his “solution” to the declared problem of insulin resistance is, essentially, an extreme Paleo/low carb-high fat diet (http://eatingacademy.com/how-can-i-lose-weight http://eatingacademy.com/nutrition/what-i-actually-eat). His blog is a great example of how you can immerse yourself in and completely understand the science and yet still extrapolate a bit too far. And he makes the same error as every novice dieter – that what worked for him personally is the answer for nearly all individuals.
There is a world of difference between noting that excessively high levels of added sugars cause some very negative physiologic adaptations, and concluding, essentially, that if a lot of sugar is bad, even a little (as is found in fruit and root vegetables) is harmful. His personal diet (the second link above) is so high-fat and low-carb his liver must be working triple-time to keep up both lipolysis and ketone production (the brain can only process sugar or ketones for energy, not fatty acids or amino acids), and, as a physician myself, I am skeptical that most individuals would feel well on it. There are children with refractory epilepsy who have to eat a diet similar to the one he espouses, and I can vouch for both how difficult it is to maintain adherence to it, and how crummy they feel.
Thanks for the links Andrea – I checked out his diet and it seems very similar to Atkins ? I couldn’t eat like that. He has very little fruit and veges. I thought that the sugars in fruit metabolised differently to table sugar ? Or has that since been debunked – I can’t keep up.
Although – I might try that Fat shake but with more fruit 🙂
I had no idea he had a blog!!! (But, duh, of course he would). In the TED talk he specifically says he has no recommendations or solutions at this point and is waiting for the research to “lead” him so this is super interesting. As you probably know, paleo/low-carb has never worked for me. Gonna go pop over to his blog now and check it out. Thank you so much for the links and for letting me know about this! I know nothing of Dr. Attia outside of his TED talk…
I now refuse to admit to a heart condition when seeing a new doctor. They see that on the form and that’s all they think about. I went to a doctor years ago because I’d stubbed my toe and it was swollen and purple and bleeding. He saw “Heart Condition” and that was the only thing he wanted to look at. I’ve lived with it for years and I know when it’s normal (for me) or when it’s acting up and needs to be checked. But what would I know ? Cardiologists are the worst. I had one guy, running 2 hours late, give me a cursory examination, then he started dictating into a hand held gizmo, pausing every now and then to ask “Did you follow that”. His determination was surgery – immediately. I told him that I hoped he had a plan B because plan A certainly wasn’t happening. The look on his face was priceless. He then told me I’d die within 6 weeks if I didn’t. I called his bluff and got a referral to someone else who told me that he didn’t know what the first guy was talking about. Needless to say I’ve not been operated on and am still here 10 years later.
I’m also overweight – guess what they all say about that ! Most doctors see the weight, and the heart and that’s as far as they look. I had one doctor nearly kill me – literally. He thought that because of my weight my tiredness was due to vitamin deficiency. He had me go in every Saturday for a vitamin shot. I went to another doctor who looked beyond the size, ran a blood test and found that I was super high in Potassium. If I’d continued with the vitamin shots there’s a good chance I’d not be here.
I hope more doctors start at least asking questions, instead of making judgements. That would be so nice.
Yes I fully believe obesity is the symptom and not a disease. That’s why I keep telling folks that there will never be a drug to “cure” obesity simply because it’s not the disease itself.
unfortunately, there are many reasons to bring about the symptom and while there are many influences it’s hard to point the finger at a single cause.
Also the example of “eating right” is also something I take exception to. When are we going to learn that healthy eating is about eating in a way that’s best for the ever changing circumstances that influence the dietary demands of the body as well as the mind? It’s so hard to say a food is either healthy or unhealthy because its the circumstance that dictates how well we can use it.
I guess I think obesity is a symptom of unhealthy eating.
I looked at images of the doctor, and in older ones he looked overweight to me.
Always enjoy reading criticisms of doctors 🙁 I’d like to follow some of them in their daily activities and see what kind of standards they live up to!
To be clear, follow the people criticizing doctors.
I think no matter what specialty, doctors tend to see the most obvious (what you indicate in your chart as previous problems) as the culprit regardless of other information. I seriously love my doctors and have the utmost respect for them, so I’m not criticizing them, just making a general observation. When i was 28, 20 weeks pregnant, and newly diagnosed with breast cancer, my oncologist joked that all my symptoms during chemo while pregnant were caused by the pregnancy. My OB did the same, but in reverse. However, even with that I received excellent care because I was well-informed and stuck to my guns when something was wrong. My daughter was born with no complications and my cancer was defeated through chemo and surgery. I am now the second proud survivor out of 5 generations of women effected by ‘female’ cancer (breast and ovarian). I also got a beautiful daughter who counts as the third survivor (or previvor).
To me, the most basic fact that everyone, patients and doctors, need to know is their particular ‘normal’. Any unexplained deviation from normal can be an aberration or a sign of true disease. However, only by carefully evaluating the deviation with an eye towards the body’s natural ‘normal’. If patients can’t get their doctors to work this way, perhaps they should change doctors. A doctor is meant to listen to the patient with an eye for the scientific/medical specialized notions they have, but mostly by listening to their patients doctors can truly discover what ails them.
Great attitude change Doctor. Losing weight really is a two step process of exercise and diet. As for exercise, do both cardio and weight lifting. If you do sets of weight training quick enough, you get the benefit of both.
As for diet, get a good diet program that emphasizes good quality nutrition but is less dense in calories.*
*Source: http://womens-weightloss.com
Good luck.
Not sure how I missed this when you first posted it. Oh, the being fat and healthy issue. My nemesis. Props to the doc for realizing he was being a judgmental ass. I doubt many of them (judgmental asses, not doctors) ever get that far.
I am one of those fat and healthy people that the medical community seems to think are unicorns. At 4’10”, I was a solid 182 in high school. One of the big girls, sure, but not BIG – size 12 or 14. After college I gained quite a bit of weight, and I’ve sense regained all of it with my year of knee hell and surgeries, but even when I lose that weight, I’ll still be seen as fat. Morbidly obese, if you want to get technical about it. (Side note – BMI puts me at overweight at 116 pounds…which is 10-15 pounds LESS than my lean muscle mass currently weighs. If I could magic away every pound of fat on my body, I’d still be only 5 pounds away from being classified as obese. Way to be stupid, medical community.)
I can not tell you how many times I have been tested for diabetes in my life. Because naturally, since I’m fat, anything that remotely falls under a diabetic symptom MUST mean that’s what I’ve got – I even got tested once when I went in for a rash, because it happened to be on my foot and we all know about those diabetic foot issues. (Nope, it was cellulitis, probably from the dorm showers. It spread nicely while I did my fasting bloodwork though. Morons.) I had to diagnose myself with Overactive Bladder Syndrome after years of suffering because having to pee a lot and being fat MUST mean you’re diabetic. (And then when that didn’t pan out, well I “needed to lose weight to take the extra pressure off my bladder. Seriously? I’m getting up to pee 7-8 times a night because I gained 20 pounds two years ago? Riiiight.)
I am really healthy. Prior to my knee injuries/surgeries earlier this year I worked out 10-15 hours a week, though people assume I’m out of shape because of my size. My fasting blood sugar is around 70. My pulse is in the low 70s. My blood pressure is 100/65 on average. Cholesterol is a mere 147. (Compared to my ex, who has a body that could almost be on the cover of Men’s Health and has a bp of 140/something and a cholesterol in the 230s. But I’m the unhealthy one because I’m fat.) If anything I’m a little on the low end for all my stats, always have been. The doctor’s explanation? Well, it’s because I’m young, but eventually my obesity will catch up with me and I’ll see the negative effects and everything will go down the toilet. They’ve been saying that since I was a teen, and I’m 31 now…it sure is taking a long time to catch up.
I tried being in the size acceptance movement, but that tends to swing too far the other direction (sorry, I don’t think you really can be healthy at 500 pounds, or if you can’t walk up a flight of stairs without being winded). So I just tend to go to DOs versus MDs when I can, and fight the good fight one doctor at a time. I can’t wait until I’m 50 and they’re still telling me it’ll catch up some day. Grr.
Oh, and refuse the weigh-ins. True, there are meds that require a weight for dosage but odds are you won’t be on one and if you need to be, they can weigh you then.