OK, I’m going to shake things up on this blog for the 2012 New Year!

As diabetes professionals, we all know that people in America really do form specific opinions.......with most being bad and even bordering on ugly…... of those who have type 2 diabetes, especially the type 2’s who are overweight, are on multiple meds, have really high A1c's, have DM-related complications and/or are very 'non-compliant'.

Let’s be honest.  “Opinions” is a rather light word; many people have flat out prejudices against people with T2DM (espcially the subsets listed above) not only in the work place, but also in the family unit, in neighborhoods, schools, churches and even in social gatherings.  

These opinions and prejudices take on many forms, whether they are just in the mind of the beholder, or actually ‘put into action’ (e.g., passed over for a earned job promotion).

This is one of those “hidden topics” that us diabetes professionals avoid talking about.  I’ve never seen it discussed openly and honestly.  The closest blog I’ve read on e-talk was about people with diabetes themselves who experience “shame and self-blame” about their disease (but I'm fairly new to the site).

My objective in starting this blog is to finally have an open, honest and frank discussion about this touchy topic.  The days of sweeping it under the rug because if doesn’t fit nicely into our “professional sensibilities” are gone, I hope!

So here goes: 

What opinions and prejudices (O’s/P’s) do people without diabetes typically form of those who do have T2 and T1, especially the: 

> T2’s who are overweight/obese.....on multiple meds?.....have very high A1c’s?....who

   have DM-related complications?......who are very non-compliant?

2.  Are the O’s/P’s formed of those with T2DM different from those formed of people  

    with T1DM?  If yes, WHAT are the differences?  And WHY the differences?

3.  What O’s/P’s do YOU, as diabetes professionals, have when you FIRST meet a NEW   

    >  Overweight T2?.....T2 on multiple meds?.....T2 with very high A1c?.....T2 with severe

        complications?....T2 who have been very non-compliant?

    > T1DM?

                                                           PLEASE be honest!

 4.  Are ANY of these O’s/P’s valid? 

I truly believe this discussion will help all of us gain a deeper understanding of the REAL DIABETES WORLD we all live and work in.   This will help us serve our patients better.

Mary Ann Hodorowicz, RD, CDE, MBA, Certified Endocrinology Coder
PresentDiabetes Author of MNT and DSMT Reimbursement Audio Lectures

Eat Well, Laugh Often, Love Much

I've been thinking about the questions you pose for a couple of days, and to be honest I'm finding it difficult to formulate a reply. I think in general most people believe that someone causes T2 by being overweight, or by drinking too much soda. In fact, one of my newly diagnosed T2 patients today told me she can't figure out what she did to cause developing diabetes. She never drank soda, she doesn't eat sweets, but she's about 30 pounds overweight. In fact she said that family and friends have been telling her that something she did caused T2 - and I assured her that's not the case.

I've posted about my dislike of the term 'non-compliant' before. Every time I hear that phrase, it makes me cringe. People are compliant to what they want to do - and their goals may not be the same as their health care providers goals. Engaging someone in a conversation about diabetes, how they feel about diabetes, how it affects their life, and what goals they have for diabetes is much more constructive than labeling someone non-compliant.

I'm not sure this gets exactly at your questions Mary Ann, but hopefully it's a start!

Hi Lynn,

From my experience, many people without diabetes tend to form very negative opinions of overwt T2's that they themselves have caused the disease due to their poor eating, overeating, over drinking, not exercising, etc..  

Or, at the very least, they have contributed to their declining condition by: not caring; not taking their disease seriously; not being able to control their temptations (lack of will power), etc.

Do you think some of this spills over to us diabetes professionals?  Have you ever thought: "Yes, one has to inherit the diabetes genes to get diabetes, but something has to "wake up these genes in order to get full blown diabetes"?

Mary Ann Hodorowicz, RD, CDE, MBA, Certified Endocrinology Coder
PresentDiabetes Author of MNT and DSMT Reimbursement Audio Lectures

Eat Well, Laugh Often, Love Much

Hi Lynn, and Others:

Just found this on the Internet (http://forums.webmd.com/3/diet-exchange/forum/1080)

Do you thnk medical providers are biased against the obese?

I have personally experienced a bias and stereotyping in my health care providers.  My (former) endo would routinely tell me that I had diabetes because I was fat and he actually recommended I use the starvation Medifast diet to "fix" my obesity.  I am hardly fat and such naive and offensive comments added to the fire which led me to eventually fire him.  I got diabetes most likely because of genetic reasons.  If I or other patients gain weight, it is most likely due to metabolic problems that results from our condition, not because we are uncontrolled eaters who won't exercise. 

I actually don't think this is about individual bias, I think this is about then entire "establishment."  After all, we now have the ADA and NIH pushing the Diabetes Prevention Program.  Notice the choice of words?  Diabetes is "prevented" by losing weight.  If I look up the antonym (opposite) of "Prevent" what exactly do I see.  That's right "Cause." I think this sort of program while good for managing diabetes is perpetuating a huge lie, suggesting that it prevents or cures diabetes.  It just won't.

The public messages to everyone is that diabetes is caused by excess weight and that people are "choosing" to get diabetes.  It is no surprise that practioners listen to these messages and conclude that patients coming through the door caused their own sorry condition.

This is a very important discussion and I will be interested to read the replies of others.

Brian's comments on weight (read considered fat by others) do seem to be part of the negative bias.

Within this Third World culture it is "common knowledge" that the T2s living here brought this on themselves by allowing themselves to become overweight and or obese.

Current research is now strongly suggesting that obesity is related to and tightly linked  mitochondrial  issues and not related to diet per se.

See: The role of impaired mitochondrial lipid oxidation in obesity.  Biol Res Nurs. 2009 Apr;10(4):356-73. Epub 2009 Feb 3.

I certainly have had some serious "continuing education" reading on the site by Peter (Petro Dobromylskyj) "Hyperlipid :You need to get calories from somewhere, should it be from carbohydrate or fat? "

Much new material to learn.  Peter's review of the above paper is definitely worth a read. 
If you overlook the few personal family related posts, his site is chuck full of extremely valuable insights and reviews.  For example see Metabolic flexibility and the identical twins below:

http://high-fat-nutrition.blogspot.com/2011/11/metabolic-flexibility-and-identical.html

...and why so many obesity studies based on a type of lab mouse are flawed from the start:

http://high-fat-nutrition.blogspot.com/2011/11/lirko-mice-3-mcq.html

On a separate but related note, apparently many U.S. states also mandate limitations on issuing driver's licenses for T1 & T2s using insulin.

While there MAY be some validity with potential hypo events and related cognitive impairment there are multitudes of other medical ailments in the general populations that are not so "regulated" or addressed in such a manner that certainly could impact driving skills and abilities.

As we are pondering leaving Belize after 25 years of living and working here, I need to verify what the state of Michigan laws are on diabetes and how easy it will be to obtain a driver's license.    Likely this will come as no surprise (based on some of my opinions posted here and elsewhere related to DM T1 & T2) that I may be on the "militant" side of things if I have any issues with getting my license.

Especially since I grew up in Europe, attended competition driving schools and was driving on international road racing circuits well before I was old enough to be licensed to drive on public highways.   While still living in the U.S. I still had the competition bug and there was nothing better to relieve the stress of a week at work than strapping myself into my open wheel formula car and hitting the circuit.

Hard to worry about work when you are diving into a tight 60 mph corner on a road racing circuit at an 140 mph approach speed and passing 4 other more timorous drivers in the process.  Of course living to tell about it makes it all the more fun :-).

This is an interesting discussion. I personally have no negative feelings toward anyone with either Type 1 or Type 2 diabetes. I  do my best to help those patients/families/significant others learn how to achieve glycemic control within an individualized realistic plan. I also teach nurses how to assess, care for and teach patients with diabetes with a very positive approach. If a health care professional has a negative view of diabetes (either their own diabetes or diabetes in general) they are not able to be positive in their interactions with patients.
 
I think the relationship of obesity to type 2 diabetes is a complex problem to address. There is no "one size fits all" answer.  The only way to reduce weight is to make significant lifestyle changes...that, as we all know is not easy...and must be fueled by some motivation that is meaningful to the individual. 

The governmental and health insurance industry 's approach to stamp out obesity is often not very subtle.  It may help some individuals become motivated, but it surely also can feel like discrimination to an obese person.  I know also that when an obese person does become motivated to lose weight, he/she may face a strained relationship with friends and family who remain obese.  In some cultures, also, being what might technically be called "obese" is actually looked upon as desirable and beautiful. 

Some doctors, I think, do feel frustrated by patients who are obese because they are prone to so many health problems that can be prevented by weight loss. Most doctors do not have the training or the time to address the issue. it is easier to give a pill.  In a time when doctors may be penalized for not meeting standard of care treatment goals in their patients, doctors feel the pressure of potential negative reviews by the health care payers if they have obese patients with type 2 diabetes.  

First To Brian:

Although I agree with much of what you say, I would like to challenge you just a bit on  your take of "diabetes prevention"......you indicate that the establishment defines "prevention" of diabetes as being almost entirely attributable to weight loss, and point out that this is a falsehood from a number of perspectives. 

But from my understanding....and IF we continue in this great duscussion to use the word "prevention".....a person can forstall, slow down or help mitigate conversion to full blown T2 DM OR mitigate its the exacerbation of T2 DM (e.g., A1c of 6.5% vs. 10%) by incorporating a NUMBER of lifestyle changes: healthy eating, exercise, stress management, etc.  But this DOES open up a whole new can of worms: can these myriad of healthy self-care activities really "prevent" T2DM if one has the genetics for the disease?

To Bruce:   When I opened your hot link on "The role of impaired mitochondrial lipid oxidation in obesity", (thank you for this great info!) the abstract stated:

"The resulting model of obesity is based on a growing body of research demonstrating that altered mitochondrial energy production, particularly in skeletal muscles, is a major anomaly capable of setting off a chain of metabolic events leading to obesity."

I did not access the entire article, so would like to ask you (as you are so well-versed), do these researchers and others postulate then, based on this particular research, that this mitochondrial anomaly dooms obese people to a lifetime of obesity, despite any and all lifestyle changes made in diet, exercise and even alcohol intake to shed body fat?

To come back to the original thread in this discussion about HCP bias (and also public bias) against obese T2s, and T2 pts in general,  my underlying feeling...to be really honest...is that T2's and/or obese people really do have SOME control over there conditions, whether it be some control over their increasing A1c's OR pounds on the scale.  And this is how the bias and judgements and prejudices arise.

The question maybe should be then, in addition to how much bias, is how much control do they have, if any??

Am I wrong?  Am I the only one who feels this way??

Mary Ann Hodorowicz, RD, CDE, MBA, Certified Endocrinology Coder
PresentDiabetes Author of MNT and DSMT Reimbursement Audio Lectures

Eat Well, Laugh Often, Love Much

Hi Mary,

Re: your query "mitochondrial anomaly dooms obese people to a lifetime of obesity, despite any and all lifestyle changes made in diet, exercise and even alcohol intake to shed body fat?"

There seems to be a growing body of evidence that this may be the case.
Here is a link FYI to an interesting post by Dr. Eades yesterday Re: gaining weight over the holiday period as well, that is linked to diet and damaged metabolic systems.

http://www.proteinpower.com/drmike/weight-loss/resolving-to-diet-in-2012/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+drmikenutritionblog+%28The+Blog+of+Michael+R.+Eades%2C+M.D.%29

"MD and I both had our struggles with excess weight starting a few of decades ago.  We were both thin, both ate whatever we wanted, and both never gained weight.  Until, that is, our metabolic systems became damaged.  Once that happened, we ballooned, then lost, then have fought it since.  We both have kept our weight under control for years now with a few exceptions here and there by judiciously following a low-carbohydrate diet.  Since we’ve both stayed pretty much in the normal weight range for at least the last several years, we decided to try an experiment over the holidays.  And not over the entire Thanksgiving to New Year’s stretch but for a fairly short stretch between Dec. 20-Jan 2.  We had planned to make a multi-state trek to visit relatives over this period, so we decided that while we were traveling, we were going to eat like normal Americans just to see what would happen."

The review of the twin study paper that Peter addressed on the HYPERLIPID site looks at the Nature/Nurture issue.   Both apparently eat similar things one gains weight and the other does not.  So not an ingested caloric issue, but linked to damaged metabolic functions that now seemed linked to cell mitochondria.

Makes my head spin... loads more to learn.
While I am too old now to go back to med school (and considered that after returning from Vietnam in the medical corps with the Marines) I am still keen on learning all I can so that when I discuss DM management issues with others needing help/guidance and/or support and education I am as knowledgeable as possible on the current issues.

This field is moving Soooo fast it is understandable why many primary care physicians are often behind the DM management learning curve.  Just no time.

OH I did check on-line and MI has no licensing restrictions for people with DM.
I should have checked before posting my concern. ;-(

Sorry for clouding the issue.

Bruce

these are great questions. After thinking on my opinions and prejudices, I feel like I am a Dr. Jekyl and Mr. Hyde. On one hand I totally understand the difficulty with trying to lose weight especially since excess weight is exacerbated by insulin resistance. But on the other hand diet and exercise can have a huge impact on overall health.

I have T2 diabetes myself, lost 30 pounds, and started exercising. My son encouraged me to join him on a 155 mile bikeride. After training for several months I was able to complete this 2-day ride (100 miles first day and 55 miles on the second day). The amazing results: I am off all medication. My A1c is 5.9%. My HDL cholesterol went up to 74 mg/dl. And I feel better. And as I continue w/ normal weight and moderate exercise, my BG levels remain in the normal range.

So I feel like I need to encourage people in their healthy lifestyle choices. And sometimes when they just want to "take a pill", I do find I get frustrated with them because I know how much better they would feel and how much healthier they would be with these lifestyle changes. And honestly, I think that is why the prejudice occurs.

I practice tolerance and acceptance for all my patients. I know that coersion is an ineffective tool for behavior change. But how can I be sure I am giving the patient the big picture? How do I motivate them to see how important their lifestyle choices are? I have a book titled The Diabeteic Primer 4th Edition that was published in 1930. It is very interesting to see what we knew then compared to now.... One section of the book that was very thought-provoking was that diets were prescribed by doctors and all food was measured in grams and each meal was detailed specifically on types and weight of food to be consumed. It looks SO restrictive compared to our approach today and thankfully we do not have to follow that tight regimen today. But I can't help but wonder if we are losing something by not expecting more personal responsibility.

So you see I am still Dr. Jekyl and Mr. Hyde.

Side note: For me to lose weight successfully, I had to go on a carb-restricted diet (similar to South Beach). Since I've had diabetes, I have had poor success w/ higher-carb diets. I'm wondering if some of those genetic mitochondrial changes are affected by the type of foods that we eat.

Roxy

This is an interesting disscussion on so many levels! I agree with others that many people with T2 have made lifestyle choices that led to their diagnosis. While they most probably have a genetic tendency toward T2, lifestyle choices often play a role in when they actually develop T2, and also how well they are able to manage their BG levels going forward. That's not to say that if you're overweight, you're automatically unhealthy. I've worked with many people who are technically overweight, yet have good BG control, exercise regularly, and maintain healthy cholesterol and blood pressure levels. I actually think a lot of the problem lies in how we define overweight. Do we go by BMI? By the old height/weight tables? If we took body weight out of the equation completely, how would we define health?

Being open and honest, yes, I do honestly believe that the vast majority of T2DM are not only victims of the disease but did indeed have a hand in developing it.  I think that is, really, common sense and even though I want to be as PC as everyone else, there is some truth to my opinion.  T2DM tend to be overweight or obese (remember, the vast majority of lean T2DMs really have LADA).  That comes from overeating and underexercising; whether you ate or drink too much refined sugar, saturated fat or just calories in general, if it accumulates around your stomach, it's proinflammatory and causes insulin resistance.  Also, diets which support gaining significant weight tend to be lower in nutrient status and so patients are nutrient insufficieny or even deficient, which also promotes inflammation and insulin resistance. Patients who haven't exercised since high school are putting their bodies at health risks for loads of medical conditions, including T2DM.   Patients may also have environmental toxins in them, either from the polluted world at large, but also from eating Agri-industry food, and from using chemicals around their homes (pesticides, cleansing agents), or using typical dry cleaners, etc. 

Yes, there is a genetic component, too, but having the gene by no means causes the condition; it just sets one up to develop it if many other factors occur (like poor diet, no exercise, nutrient insufficiencies, etc). 

I appreciate that many people do not know how to eat well and in good proportion to their body needs.  Also, when they start developing blood sugar problems, they are usually told in standard care to either do nothing and wait until they are actually a diabetic to receive medication or told to "lose weight" in their five minute doctor office visit and shoved out the door.  Neither of those are very beneficial for helping to instruct patients on reversing habits and their developing diabetes.  We should teach parents and kids to exercise regularly and eat well and not that much food, and organic foods, and etc.

Obesity is such a complex issue and there is so much new research that pulls in so many directions (mitochonria, gut bacteria, genetics, conflict on which type of diet is best etc...) that there is no simple answer.  I am sure of the fact that we haven't begun to uncover it all scientifically, yet many presume to "know it all".  I for one have had patients who have always maintained an active lifestyle and healthy eating plan even prior to developing BG  and weight issues and yet still struggle with weight mgmt.  Their food logs look a lot better than what I've seen some of their thinner providers eat!  I've had a couple come to me intears because they don't know what else to do and their provider says they need to do more.  I have some other new DX pt's who embrace the new "awareness of what they are eating and make more conscientious choices with excellent results in wt loss, BG and lipid results.  I know thin and obese individuals who don't eat well and have no issues with BG management.  Some have good lipid panels and some don't.  I identify with those struggling.  Being that I am one who was DX'd with DM1 at age 17 and was thin and ate healthy...I almost lived on salads and yogurt.  My mom was a nurse and brough us up on balanced diets with lots of veggies and measured treat allowances.  I never had a sweet tooth.  However, in my mid 20's I began to develop weight issues and continue to struggle.  I eat 1400 calories and about 80 % veggies/fruit average on a daily basis and about 80 - 100 carbs average per day.  I can't loose wt to save my life.  I have been an active walker, like to fish and hike.  I struggle more the older I get.  There is more to this than just eating healthy and everyone who struggles with their body weight is not a slacker.  I of course, like many continue to run up against assumptions and it burns when I do.  I have reached the age that I let it roll off my back and take pride in the fact that I have good numbers, better than some of my providers, with the exception of BMI!  I have no micro or macrovascular complications, other than a mild stable retinopathy which according to my Opthomalogist is impressive for 35 yrs of DM1.  That gets me through the encounters with "stupid" people.  I just hate it when my patients have to endure this and I try to empower them to recognize all the good they have accomplished and to ignore the ingnorance.  I encourage them to focus on their good labs and accept the rest because they've done their best.  I cheerlead cause I don't want them to give up.  We are all made differently and have differing struggles.   Humans just have an inate tendancy to make themselves feel better by sitting in judgement of others.  I do it too however, but generally not on the issue of judging people who struggle with weight.  I do observe DM2's getting a raw deal sometimes.  It's done thoughtlessly because providers only have about 20 minutes to get throught the visit and don't have time to ask questions and more importantly, LISTEN.  Rote, snap comments about a person's obesity do more harm than good however. 

I get frustrated when I see a patient with an A1C of say, 6.8% who says to me, "I don't want to take any medicine", so I tell them how taking a 20 minute walk a day can act just like medication to open up their cells and lower their blood sugar and possible lower their A1C back to normal but they don't do it.  

They don't want to take medicine (who does?) but they don't want to do what may be able to help them avoid taking it either.

It's frustrating.

You bring up a situation where motivational interviewing can help sort things out. I point out the discrepancy in what they say they want (control BG without medication) and ask them how they plan to achieve that goal. What's stopping them from walking? You might be surprised at the replies you get - I know that more times than not, my client brings up something that I never thought about. At least when we point out the discrepancy in their statement, it makes them think about what they truly want.

I like to use the example of going on vacation. Most of don't just wake up one day and say "I"m going on vacation today. I have no idea where I'm going or how I'm going to get there, but I'm heading out the door right now." We plan ahead, research where we want to go, how to get there, make reservations, pack, etc. If PWD clearly state that they want to control BG, or they want to live a healthy life, or they want to avoid amputation (I heard this goal yesterday) then I think we need to ask them questions to get at their specific plans for how they're going to accomplish their goals.