"Using Weight as Our Main Marker of Health Isn't Working."

Welcome to Burnt Toast! This is the podcast about about diet culture, fatphobia, parenting, and health. I’m Virginia Sole-Smith.Today’s conversation is with Gregory Dodell, MD, a weight-inclusive endocrinologist in New York City, better known as @everything_endocrine or “that one good diabetes doctor!” on Instagram. I know so many of you have questions about weight and diabetes, and a newsletter essay on these issues is forthcoming! But in the meantime, I’m delighted to bring you this conversation with Dr. Dodell, which challenges so many of our assumptions about carbs, weight and diabetes risk. If you enjoy this episode, please subscribe, rate and review us in your podcast player! And subscribe to the Burnt Toast newsletter for episode transcripts, reported essays, and more. (Here’s a 20% discount if you’d like to go paid!)VirginiaI am delighted today to be chatting with Dr. Gregory Dodell, who is an endocrinologist in New York City. Welcome!GregThanks for having me on.VirginiaI’m really excited to have you here. I think I get a question about diabetes about once a week. It comes up in a lot of different ways, from parents, from people worried about their own health or a parent’s health. It also comes up a lot from trolls, right? It’s the argument that they think you can’t fight back on. We’ll be having this very nuanced conversation about the relationship between weight and health and why it’s so important to separate weight from health, and someone will throw in, “But what about diabetes?” It feels like this third rail. Like, okay, people can be healthy at any size, but maybe not with diabetes. So, why don’t we start there? Why is diabetes so inextricably linked to weight and our collective understanding of this condition?GregYeah, it’s tough to tease out. It’s tough to answer, just because of what we hear in the media and what a lot of doctors probably say in the office. The first thing is, it’s really important to realize that correlation and causation are not the same things. There’s 40 some-odd things that impact blood sugar, just like there are many, many, many things that determine body weight. You can’t just say one causes the other when you look at weight and diabetes. There’s people across the size spectrum that have diabetes. I see people in my office across the BMI spectrum—of course, BMI is not a useful indicator of health—but just to put it in context. Not everyone who has a higher BMI has diabetes and there are many people with a “normal” BMI that have diabetes. A lot of the research doesn’t control for things like weight stigma, access to healthy food, stress levels, sleep—real behaviors that impact these things. So that’s really what I would say: Let’s focus on the behaviors. Let’s really look at the research critically, like a lot of people in the field are thankfully starting to do, to tease out the relationship and see. There may not be anything there and there may be something there. Even if there is, we need to treat people and focus on behaviors and things that we can do to improve health. Focusing on weight as a main marker of health just isn’t working.VirginiaRight, because we don’t have effective and safe ways for most people to lose weight. So prescribing that and zeroing in on that as the entire treatment plan is underserving people. And I’m glad you highlighted the stigma piece, too, because I think that’s difficult to tease out for folks. It’s not like researchers are acknowledging this bias as they’re doing the studies. Because this has been so baked into our culture for so long, a lot of researchers who are studying these questions are starting from the premise that there’s a causal relationship without the data to support that. GregRight. When you start with a research study and a protocol, you have to look at all the factors that impact all the different variables. I think, if you come into a study with a preconceived notion that weight is what’s gonna cause this, and you’re not controlling for other variables, it’s not a good study. Every research paper, or a lot of them, start outs by acknowledging we’re in this epidemic of people gaining weight. It’s an assumed thing, leading into this conclusion without really looking at all the other variables.VirginiaIt also means that if they are able to document any weight loss in the study, and they see that people’s numbers got better, they’ll say, well, the weight loss caused that improvement, without asking what else changed for people? Did they change behaviors? And what if it’s the behaviors that cause the improvement?GregTotally. And there is that great review paper that just came out that was like 250 reference articles documenting very clearly that independent of weight loss, increases in activity improve health and diabetes and cardiovascular function, all those things. So that has to be taken into account.VirginiaSo, obviously, you are somewhat unusual in your field, because you are taking a weight-inclusive approach to diabetes management and prevention. That is not the typical encounter that people have in an endocrinologist’s office. What does that look like for your patients? What are you doing differently from your colleagues?GregYeah, I’m not sure that I’m doing anything differently with regard to how I treat diabetes. I’m using blood sugar and other data points to treat overall health. I just take weight out of the equation. People may lose weight with behavior changes and with medications. They also may gain weight. If someone has uncontrolled diabetes and their blood sugar is really high and we work together with behaviors and medication to help control the blood sugar, they may start retaining muscle and gaining muscle and holding on to calories. Because what happens is if the blood sugar is really high, your body starts burning muscle and fat to create energy. So the weight may change in either direction. I think that’s why focusing on weight is not really that helpful. We should focus on the behaviors and we should focus on blood sugar and cholesterol and blood pressure, things like that. VirginiaAre patients surprised when you don’t focus on weight?GregTotally. I do get referrals from people that just know that that’s my approach. But I have a lot of patients that come in not knowing that. And when I say, “Well, I’m not going to focus on your weight, I’m going to focus on these other variables, and these behaviors and use the medication accordingly,” I think people are pleasantly surprised. Some of them just don’t say anything. They’re just surprised and maybe speechless. A lot of people come in saying, “I know, I need to lose weight. I’m working on it,” just because that’s what they’re expecting me to say.VirginiaThey’re used to doctors starting there. GregThe patients that are speechless when I say that—I wonder if they walk out shaking their head, like, “Who is this guy? He’s not gonna tell me to lose weight?” Like, in a bad way? Or if they’re like, “Wow, that was kind of interesting.” I don’t know.VirginiaYeah, I bet for a lot of them it’s pretty refreshing if they’re used to going to the doctor and having weight be this problem to solve. I mean, speaking from personal experience, whenever I find a doctor who doesn’t do that it’s a real ray of sunshine in my life. Of course, it does run so counter to people’s expectations, it can also be a little unsettlingGregYeah. Because obviously a lot of people want to lose weight. Statistics are out there, like 70% of women and 50% of men. They may be looking to the doctor to help them accomplish that objective. So it may be counter to their expectations and also desires.VirginiaWas this something you gradually started doing over the course of your years in practice? Talk a little bit about your evolution on this because I’m assuming this wasn’t how you learned it in medical school? GregNo. You know my wife, Alexis Conason at the Anti-Diet Plan. We had very similar trainings, we actually trained in the same hospital right out of our doctoral programs. She was in the bariatric surgery world and then went into private practice and started hearing from her clients all the stigma, avoiding doctors, and all this stuff. And thankfully  she came across this HAES movement and started learning about and slowly  telling me about it. It took me a while just because, I’ll admit, I’m just so entrenched in my training and what I’m reading from the medical community, it was really hard to break free from that. Like she would joke years ago and be like, “I think you’re almost there, but you’re not 100% HAES. I’m not sure I can send people to you.” But then I read her book, one of the first drafts, and I was like, “Whoa.” Like, I got it. I had that epiphany. I read it and the research studies, and I was like, “Okay, I can do this.”VirginiaThat’s awesome. So now we just need you to get all the other doctors to be on the same page with us.GregYeah, maybe I’m overly optimistic, but across the communities of medical professionals everyone is acknowledging that weight stigma is very problematic. There’s a big conference going on this week and stigma is a huge part of it. You know, people first language, all this kind of stuff. The problem is they are still thinking in terms of needing to help these people with their disease, versus not focusing on that. Let’s focus on behaviors because people are and can be possibly healthy across the size spectrum. So using different language is nice. And yes, trying not to stigmatize people is obviously a good goal, but let’s just take it out of the equation and then you definitely won’t stigmatize any.VirginiaRight. You need to recognize that you can say you don’t want to stigmatize people, but if you are still saying that their body size is wrong and needs to change, then you are inherently perpetuating stigma. There’s a tension there. I’ve seen that shift as well. Ten years ago, when I was interviewing doctors, they had never even heard of weight stigma. And that’s definitely shifted. But yeah, there’s still there’s still a little a little more pushing we have to do. The other stuff that comes up for folks around diabetes that I’m sure you hear all the time is the food anxieties, the feeling that diabetes means you can’t ever eat carbohydrates. Or even if you’re at risk for diabetes, that you shouldn’t eat carbohydrates. So can you drill into that relationship a little bit for us between carbs and blood sugar? How do you think about this?GregI think it’s very problematic to tell people you can’t eat a major food group. I have a couple patients out of thousands who can just not eat carbs but it’s unlikely and it’s not sustainable. I think the yo-yo dieting, the weight cycling, all those things are more problematic in the long term. The way I approach it is by saying what a lot of very good dietitians say, which is: Have the carbs but paired with proteins and fats, and that will help the absorption. And also, from an intuitive eating standpoint, check in with yourself after you have those things, a couple hours later, how do you feel? How’s your blood sugar? How do you feel when your sugar is high? And really key in and if you’re not feeling well, or you’re tired, or you’re more thirsty when your blood sugar is high, then that’s something to kind of take notice of and really have that conversation with yourself. So that’s my approach. Certainly people that are on insulin for type one diabetes, or even type two diabetes, can use medications to fit into your nutritional eating pattern and activity. We’re fortunate enough to have medications that we can use, so that you don’t have to change your life in order to manage diabetes, and you don’t have to sacrifice quality of life to do so and to be healthy.VirginiaThat’s an interesting shift. There’s often a mindset of, you have to be doing everything you can to avoid or minimize medication use, even if that means restricting your life in major ways, right? Because somehow it’s a failure, if you just can’t eat quote perfectly enough and avoid the need for medication. So, I like that you’re clearly taking a lot of the shame out of it and prioritizing people’s lifestyles along with their health.Greg,It goes hand in hand, right? So if someone’s really stressed because they’re at a party, and everyone else is having cupcakes, or pizza, and they’re like, “Oh, I can’t eat this, because my blood sugar is gonna go high” or, “The doctor said I can’t do that.” That creates stress, which, will probably also increase blood sugar. And then later on most likely this restrictive thing is going to be like, go and have the cupcake or pizza and maybe more. So, I would say, if it’s in front of you, try it, see if you’re enjoying it. And we can adjust the medication. I don’t want you to feel the stress around living your life and feeling that you can’t have or do something.VirginiaThat’s a very important mindset shift for us to make around this. I think one of the really tough things with type two diabetes in particular, is that people feel this sense of failure, that the sense of like, “I did this,” particularly folks in larger bodies. I did this because I couldn’t lose the weight. And there’s that whole cultural narrative of blaming people for this condition. So yeah, I don’t know if you want to speak to that a little bit because I think that’s a lot of what needs to get undone here.GregTotally, yes.  So much of type two diabetes, or a big proportion of it, is genetic. Then there are other variables that cause blood sugar to go up, whether it’s stress, not getting enough sleep, certain medications raise blood sugar, so there’s a lot of different variables. It’s clearly not just what someone’s eating, or how much they’re moving, or how little they’re moving. There are a lot of things in life and with regard to health that we can’t control. And if it does happen, let’s figure out how to work together to control it and make sure that the quality of life is good, and that the health is as good as it possibly can be.VirginiaWe need to take it out of this sense of personal failure, which just speaks to this idea that we have to earn the right to health care. That only good people deserve these things is such a problematic concept, and really goes against what health care is supposed to do.GregRight, and there’s a huge overlap between diabetes and depression and anxiety. I think taking the shame out of it is a good first step. Acknowledge that a lot of this may have nothing to do with what you did or should have done. Okay, we’re in the present moment, let’s treat it the best we can. What happened in the past, whatever it is, It’s not your fault. It’s genetic. Blame whoever, doesn’t really matter. Like, let’s just take care of it.VirginiaAs you’re talking about behavior changes, which can be a really important tool for managing diabetes and health in general, I think we should talk about the fact that there’s a risk there of that becoming shame-based as well. Doctors prescribing very unrealistic goals for people in terms of the behavior changes they want made. Like, if you’re depressed, it’s hard to exercise regularly. Even if it would be helpful, there’s just these different barriers in people’s lives to achieving the kind of behaviors that doctors might be looking for. So I’m curious how you approach that with your patients to get over the shame. GregSo much about exercise has been linked with negative feelings, doing it just to lose weight—like “no pain, no gain.” With regard to movement, just saying, “What do you like to do?” Do you like to dance? Do you think you could try a yoga class or a spin class? Or, hey, could you just walk for five minutes? Let’s come up with something a little bit above and beyond what you’re doing now, something that you’re gonna enjoy and that’s gonna feel good. So that’s one thing I try to talk about. And then, being realistic and talking about what the access to food is. If someone’s working two jobs, you know they work all day, and they don’t have time for lunch. Just trying to figure out their life is as an individual. Because making population based recommendations, when we all live very different lives, it’s just not realistic. Saying, Oh, you need to diet and exercise, that just means nothing.VirginiaRight. And it can just make people feel very defeated. I remember when I was pretty newly postpartum, maybe six months after my second daughter was born, the doctor I was seeing at the time was pretty weight-focused. She was like, “Well, when my kids were that little, I would walk for an hour a day with them strapped in the stroller.” And I just remember this sense of failure because I knew I couldn’t achieve that. I was like, “Well, my older child has school, and I’m working, and my baby’s not sleeping through the night, and I’m really too tired to walk.” There was such a different way that we could have approached that conversation. If she had started with, “Well, what do you like? What is your time like?” As opposed to, “Why aren’t you doing this thing that worked for me?” Which was frustrating.GregYeah, and I don’t know if that’s training—like if we should be better at motivational interviewing—or if it’s just the structure of the system, that we’re so short on time, It’s easy to be like, “Oh you should diet and exercise.” We’re just clicking away on our little box of the electronic medical record. There’s so many assumptions that are made about people’s lives and not taking the time or having the time to dissect what’s going on in someone’s day-to-day life that’s impacting their health, or could be impacting their health.VirginiaAbsolutely. So the last thing I wanted to talk about is kids. I know you treat adults, but diabetes concerns come up so much for parents. If they have a family history of diabetes or if they have a kid in a bigger body, it’s often one of the first things the pediatrician starts talking to them about. It’s very tied to all this rhetoric about the “childhood obesity epidemic.” What’s your advice for parents? How should they be thinking about this issue if it’s a concern in their family?GregFocusing on making sure the child is getting good sources of nutrition, whatever that may mean, fruits and vegetables, things like that. Coming from a standpoint of not a restrictive eating pattern, but trying to add in certain foods that we know are healthy. Not having things that are off limits or limiting things because in the long run that can be detrimental. Just trying to find ways, the same way with adults, to move, sleep, stress management, all those kinds of things. Focusing on weight specifically with kids is very, very problematic. I’ve had people message me on on Instagram who have diabetes, and they tell me stories of when they went to the pediatrician that they held up like a regular soda on a diet soda and said, “Regular soda? You’re never gonna drink this again.” And threw it in the trash. Seven years old and then goes on to like a 20 year eating disorder. So I think it’s very, very important to not focus on body weight with kids. Just getting kids to find behaviors that we know will serve them long term is important. Body shaming them is probably the worst thing that you could do for a kid.VirginiaI mean, it’s striking me that the advice you’re giving is what I would hope that any parents would be doing: Encouraging exposure to vegetables and finding movement you love. The problem really comes when we only talk about these things because we’re worried about your body size or because we’re worried about your disease risk. That’s underserving all kids. And it’s likely to make the child who is getting that message feel really stigmatized and shamed, as opposed to this just being a part of life for them.GregWhatever their body size is, everyone could benefit from these healthy behaviors. And that should be the same approach with kids.Butter For Your Burnt ToastVirginiaAlright, so we wrap up the episode by giving some recommendations of things we are loving. This can be a book, product you’re loving, an experience you’ve had recently,  any recommendation you’ve got for us.GregI’ll shamelessly just say I love Alexis Conason’s book, Diet Free Revolution. I can’t say without blushing because I feel ridiculous, but whatever.VirginiaThat’s a great recommendation! And of course, you’re always allowed to promote your wife’s book.My recommendation is a podcast my four year old is obsessed with called Julie’s Library, which is Julie Andrews reading kids books. It’s quite magical, if you grew up as a Mary Poppins fan, as I did. They apparently made 20 episodes in 2020, but I completely missed it then. But we’ve just found it and my four year old is in love with it. Julie brings on really wonderful children’s authors like Jacqueline Woodsonq to read their books and chat. It’s a very Mr. Rogers vibe. It’s very low key, very soothing. And I’m finding it’s helping us a lot when she gets home from school because, I don’t know about you, but my kids come home from school in horrible moods, and everybody’s grouchy and screaming. It’s my least favorite part of the day, to be honest. That transition out of schoolwork mode into family mode is very fraught. We put on this podcast and she eats her snack and listens. She’s like, “I need Julie, don’t I?” It just kind of chills her out and I want to recommend it. Anywhere you get your podcasts, there’s 21 episodes. I hope they make more. When you look at the reviews, there’s all these parents being like, “Please, Julie make more episodes.” It’s kind of like preschool or hypnosis. It’s really great.GregSo awesome. Perfect. We all need it.VirginiaWell, Dr. Dodell, tell listeners where they can find more of your work. I will link to your Instagram because people need to see you dancing on Fridays.GregOh my goodness, yeah. So I’m @everything_endocrine on Instagram. Twitter, I don’t use that much, but I am on there at @DodellMD. And my practice website is Central Park Endocrinology.VirginiaAwesome. Well, thank you so much for being here. This was a great conversation.The Burnt Toast Podcast is produced and hosted by me, Virginia Sole-Smith. You can follow me on Instagram or Twitter.Burnt Toast transcripts and essays are edited and formatted by Corinne Fay, who runs @SellTradePlus, an Instagram account where you can buy and sell plus size clothing.The Burnt Toast logo is by Deanna Lowe.Our theme music is by Jeff Bailey and Chris Maxwell.Tommy Harron is our audio engineer.Thanks for listening and for supporting independent anti diet journalism! This is a public episode. If you’d like to discuss this with other subscribers or get access to bonus episodes, visit virginiasolesmith.substack.com/subscribe