Source: Przemyslaw Koch/123RF

How do you feel about fat?

Visualize a woman with . Do you assume she eats all day and never gets off the couch? Picture a man with obesity. Do you think of him as lazy and unsuccessful? Are you secretly (or not so secretly) critical of those you love who have obesity? Do you yourself live with obesity, self-judgment, and ?

When we see an obese woman eating cake, we judge her for making irresponsible choices and may even be disgusted by her behavior. When we see a slim man eating cake, we may admire or even him. “He’s so lucky—he can eat whatever he wants.”

The false belief that excess body fat is caused by eating too many calories and not getting enough exercise gives society a logical reason to blame obese individuals for their sorry plight. If obesity is due to gluttony and sloth, then those with obesity must lack the insight and/or self-discipline to control their weight. If only they would simply eat less and exercise more, their bodies would return to normal.

Yet there are plenty of clues that overweight people are fundamentally different—and always will be.

Curiosity to the rescue

Nobody wants to be obese, so most people with obesity try hard to lose weight their whole lives—unfortunately many of them without sustainable success.

If we are to make progress on this painful and serious epidemic, we will need to turn to the most powerful tool known to the medical profession: intellectual curiosity.

Isn’t it interesting that obesity was quite uncommon until recent decades?

Why do some inactive over-eaters become obese while others seem to be able to “get away” with gluttony and laziness?

Why is it that even some very physically active people gain too much fat?

How come there are no obese wild animals? Even during times when food supply is abundant? Even in the case of sedentary animals like sloths? As science journalist Gary Taubes writes in Good Calories, Bad Calories: wild animals don’t become obese and diabetic in the presence of too much food, rather, they flourish and multiply (2007: Knopf).

Why can some people eat one cookie and walk away while others can’t stop until the whole package is gone?

Isn’t it interesting that some people enjoy remarkably stable weight from day to day, wearing the same size for years, while others’ weights are so unpredictable that they have to keep several sizes of clothes in their closet?

Obesity is a disorder

Obesity isn’t just a number on a scale—it's associated with a whole host of serious chronic diseases, including type 2 diabetes, heart disease, fatty liver, , and even certain forms of cancer.

Yes, obese people are at higher risk for medical problems, but this doesn’t mean obesity CAUSES those problems. As Dr. John Schoonbee writes: “even though umbrellas are strongly associated with rain, they do not cause rain!” We now understand that obesity is usually an external, visible clue to an internal, invisible metabolic disorder called insulin resistance.

Insulin resistance now affects more than 50% of Americans, yet most don’t realize they have it, because most physicians don’t test for it. In people with insulin resistance, insulin levels tend to run too high. When insulin is low, our bodies burn stored fat for energy; when insulin is high, our bodies store excess calories from food (even fat-free food) as body fat. Most people think of insulin as a simple blood sugar regulator, but in actuality, insulin is a master growth hormone that controls the metabolism of nearly every cell in the body. This explains why problems with insulin signaling can have profound effects not only on our fat tissue but on every organ from the heart to the brain and beyond.

Obesity is just one possible manifestation of this silent metabolic killer.

What causes insulin resistance?

Insulin resistance is primarily the result of years of eating ultra-processed foods loaded with refined carbohydrates and vegetable oils that our bodies simply aren’t designed to handle: sugar, flour, fruit juice, cereal, and foods made with soybean oil and other unnatural fats. Unfortunately, for complicated political reasons, many of these same products are officially recommended in our U.S. Dietary Guidelines, so we’ve been taught to include them in a healthy . These modern non-foods, which have only been widely available to human beings for a handful of decades, contribute to unnaturally high insulin levels, oxidation, and inflammation, which slowly destroy cells from the inside out.

There is a genetic component as well, which may help to explain why some people become obese while others don’t. The most likely explanation is that our respond differently to modern processed foods. Some of us will become obese, others will develop heart disease, and still others will fall prey to Alzheimer’s Disease. Due to a phenomenon called , our vulnerabilities are magnified with each passing generation. The problem is now so baked into our civilization that there are babies born with insulin resistance and toddlers who already have obesity and even type 2 diabetes.

Real hope for obesity

The bad news is that insulin resistance is a permanent problem that requires lifelong .

The good news is that insulin resistance is preventable and treatable if you understand its root causes.

While there are many ways to lose weight, many of them are unsustainable because they involve a degree of superhuman discipline not required by metabolically healthy people—excessive exercise, severe caloric restriction, or extreme avoidance of dietary fat. These draconian strategies can also worsen underlying metabolic and psychological damage, making it increasingly more difficult to lose weight with each attempt (Fung 2016: Greystone).

The combination of irresponsible, unscientific dietary guidelines and ineffective, unsustainable weight loss advice has led many with obesity to feel demoralized and hopeless. All our lives, we’ve been told to eating ancient, nutrient-rich, satisfying whole foods like red meat and eggs, which are virtually carbohydrate-free, non-addictive, and naturally gentle on our insulin signaling system. Instead, public health authorities have advised all of us, regardless of our metabolic state, to consume flours, cereals, juices, and non-fat dairy products that spike blood sugar and/or insulin levels. Insulin spikes turn on fat storage, turn off fat burning, trigger release of stress hormones, and raise appetite, creating a vicious cycle of cravings and weight gain in susceptible individuals.

For people with insulin resistance, healthy weight management isn’t simply about eating less and exercising more; it’s about finding natural, sustainable ways to lower insulin levels. Helpful strategies include whole foods diets, low carbohydrate diets, diets, zero-carb carnivore diets, intermittent fasting, strength training, or some combination of these.

Managing insulin resistance and obesity requires lifelong diligence, commitment, understanding, patience, strength of character, and support. The ultra-processed foods that got us into this predicament are intensely flavorful, addictive, cheap, convenient, and have wormed their way into every part of our culture and environment. It is easy to judge people with obesity for continuing to eat processed foods, but the truth is that people of all shapes and sizes need to eliminate these addictive substances from their diets in order to be healthy.

Are you fat on the inside?

When a 50-year old man with obesity dies from a heart attack we think of it as his own fault for overeating himself to death. When a 50-year old active man of normal weight dies from a heart attack, we are shocked, mystified and feel his life was unfairly cut short—“but he was so healthy!”

Of course, BOTH men were unhealthy— or they wouldn’t have died of a heart attack.

The one benefit obesity provides is a visible clue on the outside that something is wrong on the inside. If you think you’re healthy simply because you don’t have excess body fat and your doctor told you that you don’t have diabetes or high cholesterol, you’re making a dangerous assumption. It is possible for slender folk to have insulin resistance and even for fit athletes to develop insulin resistance, particularly as they get older. Studies have shown that people with this phenomenon-- sometimes referred to as "TOFI" (Thin Outside Fat Inside) or "MONW" (Metabolically Obese Normal Weight")-- have measurable signs of metabolic and cardiac dysfunction.

Many athletes believe they can get away with consuming high-glucose processed foods like corn flakes, smoothies, and energy bars, but as renowned South African exercise physiologist Professor Tim Noakes wrote in the British Journal of Sports Medicine: “You cannot outrun a bad diet.” This is why it’s so important for people of every age, , and fitness level to learn how to get tested for insulin resistance.

Be the change you wish to see in the world

You may not be able to change your feelings, but you can practice changing your thoughts. Next time you see a person with obesity—whether across the street or in the mirror—remember that obesity is a devastating, lifelong, metabolic disorder caused by a worldwide, multi-generational food science experiment gone horribly wrong.

Keep in mind that none of us knows where someone else with obesity may be on their journey. The person you see who currently weighs 275 pounds may have weighed 325 pounds last year. The person you see may have the wrong information, tried many times to lose weight, and decided to take a break or even give up. The person you see may have all the right information but decided it’s too much work to fight obesity or chooses not to prioritize their weight or health at this time for whatever reason—that’s their prerogative—it’s their body.

Stay focused on your own health—because it is YOUR metabolism that deserves your full .

Additional Resources

It is my hope that more clinicians will adopt new ways of approaching obesity that address root causes. I share some suggestions for health care professionals in my companion post Changing How Doctors View Obesity.

I discuss my thoughts about why women gain weight more easily than men and share my personal history with weight management and fat shaming in this podcast conversation with Daisy Brackenhall: Keto Woman #41 with Dr. Georgia Ede.