Belly fat and type 2 diabetes: your personal fat threshold

We all know somebody carrying a fair amount of weight with impeccable blood tests, and somebody slim with type 2 diabetes. It seems to make no sense. It does, and understanding it completely changes what you should be measuring.

It is not how much fat you have: it is where it is

Fat stored under the skin — thighs, hips, arms — is relatively harmless metabolically. It is a safe warehouse, and making room there is exactly what your body prefers.

The problem appears when that warehouse fills up. Then the surplus fat has to go somewhere else, and it goes where it should not: inside the abdomen, around the organs, and above all inside the liver and the pancreas.

The personal fat threshold

Here is the idea that explains the paradox we opened with, and we owe it to Professor Roy Taylor of Newcastle.

That is why, in my practice, I have seen people develop diabetes at 78 kg and others not develop it at 110. It is not the norm, but it happens, and it is not unfairness or bad luck: their warehouses have different capacities.

And from this comes a practical conclusion that turns a lot of frustration on its head: you do not need to reach a "normal" weight from a chart. You need to get below your threshold. For many people that happens considerably sooner than they feared.

How liver fat causes diabetes

The mechanism, in two steps, without jargon:

Step 1 — the liver. Filling with fat, it stops responding properly to insulin. Part of its job is to release glucose when you have not eaten for hours; with fat inside, it releases it when there is no need. That is why your glucose is high when you wake up, having eaten nothing. Many people think that value comes from dinner. It comes from their liver.

Step 2 — the pancreas. The saturated liver sends fat out to the rest of the body, pancreas included. And a pancreas with fat inside stops producing insulin properly: the mechanisms directing how it is made get switched off.

The two cycles feed each other. Hence the name of the hypothesis: the twin cycles.

And now the hopeful part

If that is the mechanism, removing the fat should reverse it. And that is exactly what was found.

In the Counterpoint study, 11 people with type 2 diabetes followed a 600 kcal a day diet for eight weeks, under medical supervision. The liver's handling of glucose returned to normal within seven days, and pancreatic cell function recovered substantially over those eight weeks.

This is not something to do on your own, least of all if you take insulin or sulfonylureas.

Seven days. It is among the first things to improve, long before the scales give you anything serious to celebrate.

Measure your waist, not just your weight

The scales add up muscle, water and fat, and tell you nothing about where it is. The tape measure tells you what matters.

How to measure it properly: standing, with no clothing over the area, the tape midway between the lowest rib and the top of the hip bone (or at the navel, but always in the same place), at the end of a normal breath out, without pulling tight and without holding your stomach in. Always at the same time of day, ideally first thing in the morning.

What reduces visceral fat

• A sustained calorie deficit. There is no shortcut. Visceral fat is, however, among the first to go: it responds before hip fat does.
• Enough protein and resistance work. So that what you lose is fat and not muscle. Losing muscle worsens your glucose handling.
• Cut liquid sugar and alcohol. They go straight to the liver and are the fastest route to storing fat where it should not be.
• Sleep. Short sleep is associated with more abdominal fat.
• No exercise "burns off the belly". Sit-ups do not reduce the fat on top of them. It goes with your overall balance.

What you can do this week

1. Measure your waist and write it down with the date.
2. Look at your ALT on your last blood test: if it is raised and you do not drink, there is probably fatty liver — and that is reversible.
3. Cut liquid sugar. Just that.
4. Measure again in four weeks. Do not weigh yourself daily: weigh once a week and measure once a month.

And if you want to know how much fat you need to lose for your diabetes to go into remission, the answer has concrete numbers in can type 2 diabetes be reversed?.