Obesity and Type 2 Diabetes - Health Matters

Obesity and Type 2 Diabetes – Health Matters

this ucsd-tv program is presented by university of california television like what you learn visit our website or follow us on Facebook and Twitter to keep up with the latest programs hi everybody I'm dr. David granite and welcome to health matters it's all many people talk about you can't open a magazine or turn on television without hearing about weight loss and obesity there are shows dedicated to it it's what gyms are for it's why all these places pop up to help you lose weight well why why does it matter if you're overweight are a lot of people overweight what do we know about this what don't we know about this how do we deal with it well we need an expert and we have one right here dr. Alan Saltillo welcome thank you dr. Sol tiel is a professor of medicine here at UC San Diego School of Medicine and he's director of the comprehensive diabetes center here it you know we're gonna I just said you're head of the Diabetes Center but I was talking about obesity we're gonna make that connection in a moment but I think that if we start talking about what's now being called an epidemic of obesity we probably need to define what is obesity well it's a good point David I mean we are indeed in some kind of epidemic and we don't really understand this but since 1980 there's really been almost a doubling of rates of obesity right now in the United States a third of our population is obese and another third is overweight so only a minority of people are actually as a normal weight right now how do we define a normal weight overweight and obesity well we have a lot of ways to do this there's this thing called the body mass index or the BMI which is probably not a great measure of this it's a rough measure a BMI is some kind of a measure of your weight per your height over your height and a BMI of 25 or below is thought to be healthy 25 to 30 is overweight and over 30 years obese I remember when I was learning about some of this there were almost insurance company actuarial tables that you could literally tell by someone's BMI what their expected life spans were yes and those are those are roughly true I mean they're not they're not very exact and I think some of the some of the techniques now are gonna probably be better and more accurate determinations of this you know you can have a bodybuilder with a very high BMI who's very fit so in great shape but in general the implication was that this affected your lifespan you know and that's that's a sobering thought as soon as you step back and start saying that and I think it's true now there are a lot of people think they know a lot about this and one of the quotes I saw that you had which I loved was as much as we know we actually know very little and that scientists are the people who recognize how little we know right that's the one of the great things about being a scientist every day you learn how much you don't know and it is really true and I think it separates us from a lot of people and we're comfortable with understanding that we don't know everything and that's what drives us yeah and the desire to answer the question and to know more about it so so let's let's either either create myths or explode myths or or or confirm it is obesity a lifestyle issue well it's a really tough question and it's kind of coupled to this question of whether or not obesity is really a disease or not and there's controversy about this and you know I come down on the side of thinking it is a disease I've never met anybody in my life yet who wants to be obese I think that the forces that drive us to consume food and then store it as energy are very very powerful and I think that's really what drives the the obesity epidemic I think although I have to say I don't I don't really understand why there's an epidemic there are a lot of factors a lot of people are trying to understand this and work on it you know factors like a sedentary lifestyle that we probably have has probably increased since 1980 the development of the personal computer and television and things like that the availability of food the the processing of food the makeup of food right now is particularly the presence of corn syrup which is high in fructose is probably an issue but there been a lot of other theories about the obesity epidemic a viral origin you know which is not as crazy as it sounds there might be a viral origin there's a lot of talk about something called intestinal dispossess which means they the bacteria in your gut are messed up somehow and it's somehow contributing to it to obesity so there's probably some kind of combination of all these things that's giving rise to this epidemic some of what you said was heresy not so long ago I had dr. McKnight on talking about the microbiome and those changes that was that was craziness you know not so long ago virus craziness but now but that's the part where you talk about how little we know yes exactly and and and what you're studying now so if you don't understand where all this comes from how do you design a plan to help someone right and that's a good question and I think in my view you do it by dissecting the components oh I'm the reductionist as a scientist and I like to try to dissect what the individual components are I think we have to understand when it comes to weight and diabetes to which is connected and we'll talk about hopefully soon is that you know there are powerful you know the that evolution tells us that a famine is just around the corner that so our bodies have not caught up yet with the fact that and are in a modern time famines are pretty much a thing of the past for at least in the Western world and so our but our bodies think there's a famine coming so there are powerful forces that tell us to eat and eat and eat and store that energy in the most efficient way we can which is as fat so we store we eat a lot we store energy as fat assuming that there's a famine just around the corner and we're trying to prepare for ourselves for the famine so these forces are really strong and the question is what are the what are the hormones what are the signals that go on between all the different components of energy metabolism and balance the brain the liver the fat cell the gut the muscle you know all these different factors and tissues talk to each other all the time to try to control energy well the word we use is homeostasis which is kind of the balance of energy use and storage we mentioned earlier that the as the BMI changed your longevity might change the the connection to that is a disease and one of the major diseases when you get overweight is diabetes yes it's the granddaddy of all the complications of obesity first but there are others you know people are low pressure high blood pressure cardiovascular disease asthma not business as well established psoriasis and the big thing that we're learning now is cancer you know there's a big ins a big and a big increase in the incidence of cancer associated with obesity so none of those are good no it's just to put it simply we didn't talk about sleep disorders you know that go on with this as well so let's tackle the big boy on the block and the one that you deal with all the time is is diabetes and first what is the connection and why does that happen and there's more than one type of diabetes so let's see if we can tease all that out and help people understand why these are connected so in terms of diabetes there's two types of diabetes predominantly there other subtypes but they're two types of diabetes type 1 and type 2 and they're different diseases type 1 diabetes is an immune disorder kind of an autoimmune disorder which occurs when the beta cells in your pancreas that make insulin are destroyed so your own body attacks so you can't make enough insulin or any insulin to control your blood sugar and so you are absolutely dependent on exogenously so non injection of insulin and it usually happens to kids weight independent weight independent it usually happens in kids we don't really understand why it happens to some people and not others there is a genetic component that we don't really understand and people on people who have type 1 diabetes must take insulin for the rest of their lives let's pause for just a second and explain what insulin does and what its role is ok that's it that's really good an important question so you know I've worked on insulin since I don't even want to admit trying to understand how it works insulin is the most important hormone in the body that instructs your cells to store energy so it tells it's it's secreted when your blood sugar gets high like after you eat it sends a signal to these cells in the pancreas that beta cells and beta cells and cotton in response to high sugar secrete insulin insulin then travels into the bloodstream and tells your fat cells your muscle cells and liver cells to take up that energy and store it in those cells especially in muscle and fat and tells your liver to stop making its own sugar so if so it tries to reduce the amount of sugar it's a closed-loop system it's really nice and then when the sugar comes down the secretion of insulin is reduced so it goes up after you eat then it comes back down so it's it's important regulatory mechanism and in diabetes it's that whole thing gets screwed alright so in type 1 diabetes you're not making insulin so your blood sugar goes up and you need to exogenously you need to inject insulin and type 2 diabetes what seems to be happening at least initially is that your cells don't respond to insulin as well probably because they've accumulated all this energy because you're over eating or not expending enough energy so insulin is no longer working you develop a problem that we call resistance to insulin and that is really the beginning of a pathway towards diabetes that take to two kinds of diabetes so this is like when I'm talking about kids and they stopped listening to me I mean yeah the cells are no longer listening the signal for mince and exactly how that happens is not clear that's something a lot of us are trying to understand we're trying to understand how it works in the first place and then how it stops working so how does wait now if I lose weight that system gets better if you lose weight early on and type 2 diabetes so when you're first becoming resistant to insulin if you lose weight you'll restore the sensitivity to insulin so it's very interesting it's a dynamic and process so I think about the fat cell the fat cell is the is the cell it stores a lot of this energy as fat and you know it's a really interesting cell we used to think of it as just a Depot to store energy now we know it's an endocrine cell it secretes its own hormones so when the fat cell sees all this energy it sees insulin insulin instructs the fat cell to store this energy it takes it up it's a plastic cell so it gets bigger it gets bigger and bigger and bigger and then when it gets really big it secretes another hormone a hormone that we think of as in a Depot stat like a thermostat the adipocere Mon leptin travels to the brain and tells you two things one is stop eating buddy because you have enough energy so it has this anorexic effect it tells you to stop eating but it also activates the nervous system to come back and send other hormones to your fat cells to tell you to start to use all that energy that you store it so it's like it sticks it these other hormones called adrenaline or epinephrine it's like they stick a needle in that fat cell and they let out some of the air so it's a closed-loop system with insulin leptin and epinephrine and clearly it goes wrong sometimes and then in obesity it's very interesting I think what happens in obesity is that you're bombarding your fat cells with glucose and lipid and other things you're bombarding your fat cell with insulin it's expanding and expanding and finally it says I can't expand anymore there's not room and it says enough nutrients and enough insulin I can't take anymore and so it develops resistance to that insulin and exactly how that happens is what's so interesting and and losing I can get it back so it's not resistance anymore early on losing we can get it back early on so it's not resistant and it does indeed work but of course it's really hard to do it it's really hard to lose weight for a lot of reasons what are those reasons because people people want it this is where it comes but you know that the rubber meets the road well you know this is one of the reasons that I and a lot of other people think that obesity is a disease because again our body really works hard to defend our weight they we are evolution is telling us store energy store energy that famine is coming so our body really still really wants to store it you think about the ancient man in your caveman that getting food each day was their entire jobs all they wanted to do III remember asking one of the guests on the show if we went back in took somebody for a doctor or somebody from 200 years ago and brought him to the president what would they think is the most astonishing thing and I was thinking TV and radio they said the supermarket yes because they didn't have to fight for food right so here we go this is this is new in all of the human history that we don't have to fight for food it's very very new and I think that's the problem our bodies haven't yet caught up with this change in in our environment but evolution still thinks you know that family is coming so what happens is for example and that this has been evaluated over the last 10 or years or so is that if you put people on a diet and this is very well-established now if you put people on a diet of real diet so you really will watch their food intake they they will lose weight but their metabolism which expends that energy will slow down as a consequence to try to defend against that weight loss so your body is fighting you when you're trying to lose weight you know there's basically you know an energy balance there's just two things energy intake and energy expenditure on the calorie of you know calorie is a calorie doesn't matter where it comes from you can't lose weight and you can't gain weight unless energy intake exceeds energy expenditure and you can't lose weight and less expenditure it exceeds intake but it's really hard to lose weight just by increasing energy intake because your energy expenditure will drop as a consequence to defend that way so it sounds like it in forwards to lose weight you need to eat less and exercise more you do well you need to you need to eat less and you need to increase energy expenditure somehow how do you increase it energy so and that's a really good question so probably you know the conventional way is to exercise and exercise account activity accounts for I would say about 20% or so of energy expenditure so it's not the major way that we expend energy which is a surprise I think it is a surprise but it is a controllable way week but it is the one controllable and it influences the other way we expend energy so if you exercise and diet you can lose weight for some reason and you know you I think people who are obese or overweight and try to lose weight though you know my experience is that people who are successful are the ones who are the most obsessive about this and I don't mean in this case obsessive in a good way yeah you know I'm one of those obsessive people about exercise too I mean I think if you if you really obsessively exercise and watch your diet you can lose weight yeah I worked out this morning before we came to this so but you know we've finessed this a little bit by saying diet but but the the there's so many people go how why what should I do what's good you know if I eat ice cream all day is that bad even though it's less calories you know I mean and carbohydrates or proteins and they they there are a million diets out there well this is a controversial area okay so I would say that you know I'm a scientist who who studies energy homeostasis and energy balance and you know I think the first thing that's important to recognize is that there's a physics law called called the first law of thermodynamics and this says that a calorie cannot be destroyed or formed so a calorie is a calorie and you know calorie coming in doesn't matter what that calorie is it's got to be counteracted by calorie going out what's an energy expenditure so when you think about diets it seems that if you if you study all the diets the ones that work are the ones with the calories that come in are less than the color or less portion control some portion control but I would say that you know the the jury's out still I mean I think there are there are different diets that make you feel differently there may be in components of diet that have effects on kind of like drugs can have an effect on craving for food or whether or not you're you sense satiety or whether or not they can activate some process of energy expenditure or change energy storage so it might be that they change the balance a little bit tweak the mechanisms of expenditure of energy or storage so you know I wouldn't say all diets are equal but calories are really important but it's interesting to hear scientists talking about this because you go back to that that sentence we opened with about how much we know and what we don't know and what what I hear you saying is there's a lot about the components of diets that we still don't know and it's empirical and people have to eat so they try whatever that works for them right and they true and they as they should they should try what works for um there's a television show called The Biggest Loser where that you know they they they really push them an exercise they watch what they eat from what you're saying at least that beginning component of it isn't crazy it's the it's the getting obsessed and keeping obsessed about it that because there are a lot of people who when the show is over they gain the weight back yeah and you know you're it's it's very hard to sustain this again your body's working against you you know it wants to lose weight there's all it's also clear that there there are some people predisposed to gain more or less weight the less weight people are probably the abnormal people you know I think that the most people gain weight over their lifetime it's just normal so I think there are some people who don't gain weight at all those are the weird people my dad my dad was one of those people yeah he never gained a pound in his whole life it's sort of exercise are there any other things that energy stores into expert what else can people do right well you know we I mean I would say this is an area where science is really gotten very excited and the research on these other areas of energy expenditure has heated up to to use a pun and the reason I say heated up is that the big thing that people are excited about now is this process called thermogenesis which is the generation of heat in our bodies and we have a process to generate heat we have we have different kinds of fat cells in our body and there are these fat cells called brown fat cells or in some cases beige from fat cells whose job it is to in who have something called uncoupling so they uncouple energy synthesis from heat and they can generate a little bit of heat and we think that if we can just tweak that process a little bit to increase the generation of heat we might be able to increase energy expenditure just a little bit how much of a bang you'll get for that buck in terms of weight loss is not clear yet but it might be that in combination with diet or maybe with the drug that regulates food intake or craving or something I doubt you might be able to really lose weight so the research now is focused on trying to understand how thermogenesis and how the generation of heat and these fat cells is controlled how the how the cells themselves are developed what happens in those cells how they respond to other hormones like epinephrine so without this research we don't go forward and we don't get a better knowledge and understanding what are you working on that you're really excited about right now and what do you need to do more yeah this is you know great question in my lab we're really interested in two things one is the the connection between obesity and diabetes so why does insulin resistance happen in fat cells and liver cells and how does that all happen and what are the processes and the other question is why is it that energy expenditure drops so much and obesity and or in weight loss and how do we try to tweak that and these things are linked and their length because we think and a lot of other people think that one of the ways in which cells cease to respond to insulin ensues as to developing something called inflammation so there's this obesity induces through processes that we don't understand at all really induces a state of inflammation just like you get when you have a wound or when you have arthritis or something like that it's the same kind of a thing you become in your fat cells become inflamed in response to obesity and it's the inflammation that causes you to stop responding to hormones to insulin and maybe also to epinephrine well so you become basically your cells become inflexible now initially this inflammatory response is probably okay you know it's a it's an adaptive response because you're overeating you're storing all this energy and inflammation is helping you deal with all this extra energy but I think it transitions to a maladaptive response just like happens in arthritis where the long-term effects are bad negative so the question is can you use different kinds of anti-inflammatory therapies to to combat weight and diabetes and the idea that inflammation is a final cause that a part of this is not unique in obesity nor arthritis there was just a report schizophrenia may be related to inflammation lots of heart disease and all the other so this is a common unifier what do you need to keep doing this work that we need you to do so that we can get some answers yeah we you know it's it's really interesting I mean we need resources of course that's the obvious thing and we need to get we need to but we need to excite young people into this area of science we think it's really exciting we need to keep our focus on the basic pathways that are involved because we're not going to make any progress unless we really understand how does insulin work how does the fat cell talk to the brain you know how does the liver talk to muscle or core issues about physiology and cell biology and biochemistry and molecular biology before we can go on and really tackle some of these things and the clinic at the same time we need to be aware that we can learn a lot in clinic studies we can now get biopsies from Obispo patients take out their fat cells study all the genes that are changed but we can we can create a biological atlas of the changes in the fat cell that might occur in response to weight loss or drugs or exercise whatever do you think it's science fiction to say that one day we will have the ability to really alter people's metabolism change the way they respond to insulin maybe even affect the immune system I mean is that science fiction or we we looking at the point now where we don't know the date but that's going to be science fact yeah you know I hate that question because all sigh you know all scientists hate this question when when are we going to know ba bla bla and is it real it's it's real I think it's certainly it's a fan it's a fantasy but I think it's a good fantasy and I think we can understand it we are gonna learn a lot more about what we don't know as we go forward I mean if you to ask me something 10 years ago what's the big what are the next big discoveries I would have gotten it wrong probably and but I would not have known about these really cool things that we would have learned in in the future you don't even know what you don't know don't know what you don't know we'll learn what we don't know and then we'll attack those things and then we'll learn more stuff that we don't know so are we crawling walking or running right now I think we're doing all three okay we're doing we just don't know when each those components is coming in in the very short time that we have left people are sitting there they've got to do things today what are the one or two top things you would say to people that they can do in terms of their health weight relationship I I think you know they need to think about calories it's it's it's not fun but I think it's really important I think they need to move around there's it's not just actually it's you know I I'm a strong advocate for exercise and and I'm an I'm an advocate for ritualized exercise so you know pick a time do it every day or every other day but just getting up off your butt and just and moving fitting any kind of movement you know I wear I don't know if you wear a monitor you know and I think these things are mean for me it's just a lot of fun I know I'm gonna do it anyway but yeah I like to you know I like to measure and track things but I think moving and thinking about calories and keeping abreast of all these changes and in terms of the calories do what works for you great advice thank you so much for spending some time with us but more importantly for the work that you're doing in your lab and great science I've been talking with dr. Alan salt eel about really something that is crucial and I hope everybody was listening because you had wanted the world's leading scientists who understands obesity insulin diabetes the best that we have right now telling you that there's a lot we still don't know we need him in his lab we need him doing all this hard work synthesizing this information so that we can learn more that's why we have academic medical centers it's the value of what we do here but if you learn more your health gets better that is the power of knowledge and that's what we do here on health matters we'll see you again next time I'm dr. David granite


  1. Obviously out of date with todays research which says that a calorie is NOT a calorie and exercise and lower calorie diets DONT WORK. you cant exercise your way out of a crap diet full of processed grains fast food and sugar. Eat REAL FOOD and exercise, mainly strength training and NOT endless cardio .

  2. In my experience a calorie is not just a calorie. It matters what good group it came from- fat, carb, sugars? What time of the day was it consumed? High glycemic index foods play a major role in weight gain especially if you tip towards insulin resistance. Eating low glycemic index foods and slight increase of good fats along tapering your calorie intake towards evening play a role in weight loss. Exercise helps more to strengthen the muscles and joints and only contributes about 20% towards weight loss/management.

  3. Anyone tested out the Hybetez Remedy (just search it on google)? We have noticed several amazing things about this popular cholesterol home remedy

  4. Honestly we still have to fight for good quality food. I guess you guys didn't know (but can find this out fairly easily from talking to anthropologists) that people in foraging societies spend/spent less than half the time modern humans living in cities in western societies do in looking for and preparing food. In many ways foraging societies were healthier – not necessarily in terms of acute trauma or infectious diseases, but certainly with respect to chronic diseases. Western societies in most cases have constructed a situation in which it is now challenging to be healthy in the long term, when it comes to our eating habits and activity levels. You have to basically go against the grain entirely in order to be and remain healthy.

  5. Obesity a disease? LOL. Perhaps a diseased society with its priorities upside down, certainly not a disease to cure with pills. I can't believe my tax dollars help spread this ignorance. 🙁

  6. Dafuk. This is extraordinary in its illustration of how so called experts want to continue to bamboozle everyone. Its not difficult. And they're getting nicely paid. Are they REALLY that stupid?

  7. We have decades of evidence that telling people to eat less and exercise more is not helpful. Any diet that involves chronic hunger will ultimately fail. Counting calories doesn't work. Why would you count them? So you eat less and are then hungry? That doesn't work.

    Your body will not burn fat when the blood insulin level is sufficiently high. Eating sugar and carbs and snacking all the time will keep that insulin up so you can't burn fat even if you force yourself to exercise. The answer is to eat less sugar and carbs. Replace them with fat. You will automatically eat less because eating carbs makes you hungry and eating fat makes you feel stuffed. You also need to fast between meals. A big fast that starts 6 hours before you go to sleep and ends in the morning will allow insulin to drop and fat to burn. You might be a little hungry but it is only a few hours per day. Counting calories means you're hungry all the time.

    Check out Effortless Healing by Dr. Mercola.

  8. The body storing fat is not some old primitive evolutionary by product to be despised. It's crucial to our survival. Yes in modern society there is no immediate threat of famine due to modern factory farming and agriculture, but that doesn't mean that in the future the threat could re-appear. People just need to be diciplined and take care of their bodies and stop being fatasses.

  9. Indeed it's sad to see health professionals making fools of themselves.
    However healthy and good for you exercise is the fact remains you can't outrun a bad diet.
    Look at the long-term health of professional athletes and sporting professionals as soon as they stop their sport they develop no end of health problems.
    Saying a calorie is a calorie.may have an element of truth to it but in practice focussing on the caloric value of food misleads people into thinking food quality doesn't count.
    Eating sugary foods that promote addictive behaviours causes greater long term harm than eating the same number of calories of real whole foods the promote satiety and don't create the demand to eat throughout the day.
    It's almost as if these two haven't been paying attention to the Low Carb/Paleo and/or fasting protocols to reversing diabetes.
    Perhaps they should listen to Jason Fung.
    "Insanity: doing the same thing over and over again and expecting different results."
    We've seen the results of the message Dr. Alan Saltiel is promoting over the past 30 years. Repeating the same message only promotes further obesity and more diabetes.

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