Diabetes and me: Wrestling with the causes of diabetes

In Diabetes and Me, RNZ's Megan Whelan shares her journey of learning to live with type 2 diabetes.

It's not a particularly productive question, but it's the one that plagues me: How much is this my own fault?

If I hadn't eaten those cheeseburgers, would I be here? If the sport that spoke to me was marathon running and not yoga, might my pancreas have been in better shape?

I try to resist being that person who talks about my diet all the time because, my God, those people are boring, but I also can't help it. How to best eat for this condition, and the many hours of exercise I do, and how many grams of protein is in an egg (about six) occupies a pretty large part of my brain space.

And so I feel myself turning into a person I would have avoided a few months ago - and asking questions that I know I won't like the answers to.

To get some good answers, I spoke to Dr Jeremy Krebs, an endocrinologist. Endocrinology is the specialty of "glands and hormones" and diabetes is one of the areas endocrinologists study. He did a doctorate at the UK's prestigious Cambridge University investigating obesity, and he's now a consultant in Wellington, and researches nutrition, obesity and diabetes. So, a very good person to talk to, and - I promise, I wasn't trying to get some free medical advice.

Here's our conversation (edited for length and clarity, and to cut a massive discussion about exercise, which is a whole other column).

Megan: I think prior to my diagnosis, if someone had said "hormones" to me, I probably would have thought of progesterone and estrogen and maybe cortisol if I was having a good day. But there are so many, and they're so important, right?

Jeremy: The key one here is obviously insulin and that comes from the pancreas. But when you're thinking about type 2 diabetes, there are many, many different organs and hormones that are involved in the process, and there are many many different versions of it. And so not everybody with type 2 diabetes is the same, whereas type 1 diabetes, which is fundamentally about the failure of the beta cells in the pancreas because of an autoimmune process, is a much more homogeneous condition.

And that's partly what makes type 2 diabetes such a harder beast for people to get their head around. And I mean people in the broader sense, both people with diabetes, but also health professionals and people trying to, you know, find solutions and help and support because there's no one size fits all.

Megan: So, then, what is type 2 diabetes?

Jeremy: The simple version is that diabetes, by definition, is an increase in blood glucose, or blood sugar.

Blood sugar is controlled by two key hormones, the most important being insulin and the other being its counterpart or its counter-hormone, glucagon. The balance of glucose in the body is determined by how good your pancreas is at making insulin, and secondly, how good your tissues are (your liver and your muscle and other tissues in your body) - how good they are at responding to insulin and taking up and storing and using glucose.

So there's two main sides to the equation and type 2 diabetes is where you get a problem, usually on both sides of the equation, but one may dominate the other. So what I mean by that is, if your body becomes resistant to the action of insulin, which is something we generally see as people gain weight, then your pancreas can respond to that by simply pumping out more and more insulin. And it does. [It] does that incredibly well.

But there comes a point where the pancreas says 'bugger, this, I've had enough of that I'm going on strike,' and that's when it can't keep up with that demand. And that's when your blood sugar starts going up.

There's a researcher by the name of Defronzo, who coined a phrase called the ominous octet. It incorporates all of these sorts of ideas that we're talking about: the various hormones that are involved, but it also incorporates ideas of physical activity or inactivity, and then the other key thing which we haven't touched on yet, which is genetics and the role of family history and genes in terms of who might develop diabetes.

So we often think about some of these risk factors in terms of what is modifiable and what's not modifiable, and clearly your genes are not modifiable. There are modifiable things which can influence ... your chance of getting diabetes or your journey with diabetes.

Megan: In my journey I've kind of been swinging wildly between 'you're such a piece of shit, this is your own fault. You absolutely should have known that this was going to happen', it's in my family, I had allowed myself to become inactive, and I have a really stressful job and would come home every night and get takeaways because it's easier than cooking. I look back now and think 'how the hell did you let it get like this?'

And I guess one of the reasons I want to do this whole column is so someone like you can say "well, because you're a human being and that's what happens and it's not your own fault," but also it kind of is my own fault and maybe the ominous octet is a really nice way to do it. Maybe there's bits of it that were my own fault and bits of it that aren't my fault?

Jeremy: There is no question that there are things we have conscious control over and that we can influence, but there's a heck of a lot we don't. Appetite is an incredibly subtle thing. How does anyone maintain a vaguely constant weight in the world that we live in? It's a miracle, frankly.

When we're bombarded with readily available - I used to say cheap, but that's changing - calorie dense, cleverly marketed food that appeals to the palate (because people understand what our tastebuds respond to) and a physical environment that has become less and less demanding for us to do things.

Megan: By doing this column, I'm gonna get some emails that are really, really nasty. What's the best response to those people who will say you should regret every cheeseburger you have eaten?

Jeremy: In a clinical environment that's very much where I start to talk about the genetic side of this and the subtleties of the influence of genes on our appetite regulation. Of course, those people will simply say, 'well, everyone says that, everyone hides behind that, but at end of the day, you know it's still [that] you're still sticking it in your mouth'.

And as you said there are bits of truth to some of that. I wish I hadn't had that 4th glass of red wine last night, but I did. And I had to spend an extra half hour on the treadmill this morning because of it.

But people who would hide behind those sorts of emails to you are lying to themselves, frankly, if they don't think they're not human, and aren't fallible to some of those choices.

Everyone makes choices they know retrospectively weren't the best choices. God, we're human.

Megan: I was doing my grocery order last night and a cauliflower was $7.50 and I thought to myself 'that's a happy meal, that's a combo at a fast food restaurant.' I'm incredibly lucky. I earn a decent amount of money. I don't have kids, so I have disposable income. I can spend $7.50 to buy a cauliflower, but lots of people can't, and that has to be really difficult.

Jeremy: There's no question about it. I was reviewing a paper last night from a group in Auckland and one of the key determinants of both developing diabetes, but also outcomes of diabetes, that overrode ethnicity was deprivation (and we know that ethnicities are a really important factor, which is largely driven by genetics).

You can know till the cows come home what you should be buying in the supermarket. But if the prices keep doing what they're doing at the moment, then you know we're all going to be buying white bread.

Megan: I am aware I am going to anger some people when I ask this, but I watched a talk of yours, and you had a graph of the overwhelming correlation between obesity and type 2 diabetes. And I wonder if there's a disconnect between what we want to believe about weight and what's actually true.

Jeremy: You're right, you will anger a lot of people by that. But there are some truths that you just have to accept. And unfortunately excess fat mass is not healthy. In a number of ways, not just metabolically, in terms of joints, in terms of the hormones of fertility, there's a whole range of stuff.

But turning that into self-blame and self-loathing is not going to achieve anything or help anybody. So if you have to frame it in a way that a person can still live with themselves and make some change which is taking them in a healthier direction, then I'm totally on board with that.

But where you have to be careful is where someone hides behind that and denies some of the harder effects.

Megan: If I had been honest with myself, I knew I wasn't healthy - that is no fault of the people who talk about this, and the really important activism that's happening in that space. But I think the people who think this is all my own fault might miss a point, which is that every experience I've ever had with a GP was negative because of my size. And so of course, I didn't look after myself [by getting help when I need it] because I would have to go to see my GP, who would weigh me and say something and that [made me] felt like shit.

Jeremy: Yep, it's not in any way supporting you.

Megan: So how do we bridge that gap between wanting to help people and not making them feel awful for needing help.

Jeremy: I think in the last 20-plus years of doing this… there will be people that I have met that I've tried to help where I've got it right and it's helped them and there will be people where I've tried to help and for whatever reason for that person, I've got it badly wrong and they've gone away hating me because for whatever reasons we didn't quite manage to get that balance, that connection. It's tricky. It's very emotive.

***

Dr Krebs tells a story that many people will recognise. He was overweight, and a child poked him in the stomach, and said "you're fat". For him, that was the trigger to start running and losing weight.

It feels comforting to me that at least one doctor understands that feeling. I have countless stories like that. Like the time a woman walked past me in the supermarket carpark and said "see, that's why we don't buy chocolate biscuits. You don't want to end up like that." As I type this, I can feel the shame that pricked my cheeks, the tears I fought back that someone could be so casually cruel. But it certainly didn't make me want to don my leggings and hit the treadmill.

The question I want to ask isn't "is it my fault?" It isn't the "is being fat unhealthy" that I asked Dr Krebs, because I couldn't, in the moment, articulate what I meant. It's, did I get diabetes because I am fat, or because my fatness meant I couldn't access the care I needed that would have helped me avoid getting it?

That's a question that's much bigger than me, but it's one worth asking - and I am going to keep asking it in this column.

Diabetes and me will be a weekly column on Wednesday mornings.