Article Analysis: Should Type 2 Diabetes Management Focus on Weight Loss over Blood Sugar?
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Reader Cheryl let me know about an article that truly horrifies me. The title is “Type 2 Diabetes Experts: Weight Loss is (Almost Always) More Important than Glucose Control.” (As usual, I don’t link to articles with harmful content, but provide enough info for it to be found online if someone wishes to do so.)
Before I dive in, a quick reminder that people of all sizes get Type 2 Diabetes and all of those people deserve blame-free, shame-free, future-oriented care.
The article leads with a conference session that was supposed to be a “debate between two experts on the superiority of glucose control versus weight loss for type 2 diabetes” at the Scientific Sessions Diabetes Conference, but explains that “the resulting exchange couldn’t be called a debate at all, because both experts agreed to favor weight loss.”
This is a common issue in these sorts of conferences. There are plenty of experts who could have made this a debate, but that isn’t what they want.
Let’s take a quick look at our “debaters”:
Dr. Jeffrey Mechanick, the doctor who was supposedly representing the blood sugar management side has taken payments from our old friend Novo Nordisk, who have been borrowing every page they can from the Purdue Pharma OxyContin playbook in order to market what they hope will be their new blockbuster weight loss drug Wegovy, which is also marketed as a diabetes drug at a lower dose.
His “opponent” Dr. Ildiko Lingvay, has also taken payments from Novo Nordisk, as well as from Eli Lilly, Zealand Pharma A/S, Janssen Scientific Affairs, Bayer Healthcare Pharmaceuticals, and Boehringer Ingelheim Pharmaceuticals, all of which are developing weight-loss drugs.
The conference was hosted by the American Diabetes Association. One of their three “Founding Pathway” sponsors “who cumulatively have contributed more than $53.6 million” is…Novo Nordisk.
Here we see one of the issues with “news” stories like these. The author is Ross Wollen and his bio for the story says:
Ross Wollen is a Senior Science Journalist at Diabetes Daily. Ross was diagnosed with type 1 diabetes at age 36, and quickly became an active member of the diabetes online community. Before joining Diabetes Daily, Ross was the lead writer/editor of the diabetes website ASweetLife.org. He also works as a food safety consultant. Ross previously worked for over a decade as a chef and craft butcher, mostly in the San Francisco Bay Area. He lives with his wife and children in Maine’s Midcoast region.
I’m not sure about Ross’s knowledge of things like research methods, or his understanding of the complex interplay between the pharmaceutical industry and doctors who are on their payroll. I do know that he failed to disclose any of the financial relationships of these doctors to the companies that profit directly from their recommendation (but hey, so did the New York Times.) He also reports this “debate” as if it is somehow proof that nobody disagrees with this idea (which is absolutely untrue,) and he doesn’t quote anyone who doesn’t agree.
The article explains that:
“The magnitude of this shift in treatment philosophy was significantly underscored by the unveiling of a new draft of guidelines for the treatment of hyperglycemia in type 2 diabetes. This annual consensus report, officially co-authored by the American Diabetes Association and the European Association for the Study of Diabetes, exerts a massive influence on the way that diabetes is treated throughout the world.”
Guess who is a partner of the European Association for the Study of Diabetes…if you guessed Novo Nordisk, you win.
The article also quotes Dr Vanita Aroda who, from 2014-2020 took nearly $400,000 in general payments and research funding, much of it from the weight loss industry including Novo Nordisk
A “centerpiece” of this new strategy will be to update a flowchart for treatment of patients. Per the article
The new flowchart, which audience members were asked not to photograph, will emphasize weight loss to a much greater degree, even including a panel that ranks glucose-lowering drugs by their efficacy for weight loss.
The article explains:
As a result, we might expect that clinicians will begin to turn away from glucose-lowering drugs that are associated with weight gain, including sulfonylureas and insulin.
The article goes on to say that the focus will be on the new drugs manufactured by the companies who give millions to the ADA and to doctors who then become “experts” at conferences and in articles like this (and which this author previously wrote a glowing article about in which he described about 40 pounds as an “almost unbelievable” amount of weight loss.)
In this article Dr. Carol Wysham, MD, who has taken money from Novo Nordisk for “consulting” bemoans the fact that more people aren’t taking their drugs.
In the article, many of the same doctors touting these drugs are recommending “very low-calorie” diets and meal replacement despite a century of data showing a near-total lack of efficacy.
Dr. Linvay (who, recall, is on the payroll of six different weight-loss focused pharmaceutical companies) stressed that BMI is flawed but claimed that it should be replaced with doctors’ “visual examination, coupled with their experience and judgment.” She said, ostensibly with a straight face “For lack of a better measure, I think our clinical evaluation is the best way we can get to a diagnosis.”
So, a supposed health condition that this “expert” is claiming triggers the immediate need for medications that have box warnings (the FDAs strongest warning) for potentially life-threatening side effects has, as its best diagnostic criteria, a (potentially deeply fatphobic) doctor staring at us. That does not have the ring of strong science or ethical, evidence-based medicine.
The article seems to put a lot of faith in the work of Dr. Roy Taylor, who put together a couple studies where a small numbers of people were put on starvation diets for short periods of time. The studies are short-term (ending well before the 2-5 years post-weight loss time period during which the majority of people regain back to or above their baseline in the research from the past one hundred years.) From what I can tell, he seems to be claiming that the lowered glucose response to being starved is some kind of sustainable “diabetes remission.”
Dr. Taylor gets around the fact that people of all sizes develop type 2 diabetes with an idea (that I would describe as bordering on quackery ) that “a person will develop type 2 diabetes when they’ve become too heavy for their own body. It doesn’t matter if their BMI is within the ‘normal’ range. They’ve crossed their personal threshold and become unhealthy.” He doesn’t seem to have any research around the causal mechanism of this, but he seems as unconcerned with that as he is about the long-term outcomes of starving people (which we already have concerning data about.)
Professor Taylor’s website sells a book, shakes, and pre-prepared meals to help people plan and consume 800 calories per day.
This article’s final claim is “Most people with type 2 diabetes can benefit greatly from weight loss, even many of those without obesity. Weight loss drives blood sugar improvements itself, and also may confer comprehensive long-term health benefits.”
The article offers no proof of this. It does not include any studies that actually compare weight-neutral glycemic management to approaches that focus on body size over glycemic management.
It ignores the findings of Tomiyama, Ahlstron, and Mann, which found that
“In correlational analyses, however, we uncovered no clear relationship between weight loss and health outcomes related to hypertension, diabetes or cholesterol, calling into question whether weight change per se had any causal role in the few effects of the diets. Increased exercise, healthier eating, engagement with the health care system, and social support may have played a role instead.”
The article fails to interrogate (or even mention):
The financial relationships of almost everyone involved with the drug companies the article is lobbying for.
The dangerous side effects of the drugs
The lack of long-term efficacy data of the drugs
The short-term nature of the studies upon which these new guidelines rely
One of the ways that weight stigma operates within healthcare is that the weight loss industry (including the pharmaceutical industry) hijacks the concepts of health and healthcare to sell weight-loss interventions that risk fat people’s lives and quality of life, often with insufficient (or no) data on long-term outcomes, and everyone along the way (journal editors, reporters, non-profit organizations etc.) either allows it to happen, or actively aids and abets it (sometimes for profit.)
This certainly seems, to me, to be an example of this.
If you are looking for resources for weight-neutral blood sugar management:
I wrote this piece with the help of weight-neutral endocrinologist Dr. Greg Dodell
There is a HAES Health Sheet that I wrote with Dr. Louise Metz and Tiana Dodson
I have a video workshop with a pay-what-you-can-afford option here.
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More research and resources:
https://haeshealthsheets.com/resources/
*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.
This is my wheelhouse, as close as I can get without actual medical/nutrition degrees. I've been reading studies about diabetes and body weight for over 25 years now, because when I was diagnosed with diabetes I was told that "insulin is only for bad diabetics" and that I "had to be lying" about what I ate because my blood sugars were so high and I was very sick. I got a better doctor, and then started reading research papers and studies. I started a mailing list for diabetics who didn't want to diet-for-weight loss because pop culture insisted you had to lose weight or you would DIE! (People actually called me selfish for refusing to go on a severely restrictive weight loss diet.)
There's been a lot of work since then to find real causes of diabetes, both type 1 and type 2, that don't rely on the lazy "Because you're fat." Until the late '90s, when there was a huge push for weight loss drugs and using BMI as the standard of "weight" and "health," you'd find in a list of symptoms of type 2 diabetes as "unwanted weight gain." They've known for decades that insulin resistance often causes weight gain in people with glucose intolerance. And if you go to the diabetes forum on reddit, you'll see the same story over and over again: "I gained weight, my doctor said I was 'pre-diabetic' and had to lose weight, I lost weight, six months later I was diagnosed with diabetes. How could this happen when I did everything right?" (Because body weight and insulin resistance are a complicated loop, but once you have IR you're on the track to type 2 diabetes no matter how much you weigh.)
They're pretty sure that the plasma C14:0 ceramide (a type of lipid) is one of the root causes of insulin resistance. Exercise independent of weight change can reduce the C14:0 ceramide which in turn can reduce insulin resistance. (There are also believed to be types of insulin resistance caused by antibodies and autoimmune disorders.) Note that the C14:0 ceramine is also indicated in non-alcoholic fatty liver disease.
Saying that even "people who aren't ob*se can benefit from weight loss" is horrific. That's like saying that people with no sign of cardiovascular disease can benefit from shunts (which we now know don't work, either).
The latest "sure cure for fat people" that's really a diabetes drug which is being handed out like candy off-label is terrifying. I'm fully expecting for it to go down like Phen-Fen and Rezulin as drugs promising diabetes cures, health, and thinness and instead causing too early death and disease.
I could blather on for pages but I've hijacked your comment section enough. :)
Thank you for taking time to write this, when I shared it to others, I led with this intro post about my personal experience with 2 practitioners who were both obsessed with weight loss as a front line T2 treatment:
"If you have pre-diabetes or T2, please read this: Some of you know that I've been on a long journey attempting to balance my blood sugar and to limit the progression of T2 diabetes (my mother's side of the family has a history of T2). After years of this, it finally became clear to me that I was dealing with medical fatphobia to the exclusion of actual good medical diagnostic work. I had 2 separate practitioners outline their recommended treatment protocols for me, which I followed obsessively. In both cases, I even lost 10% of my then body weight, which is reputed to create statistically significant improved health markers. Both practitioners treated medication such as metformin as a "failure" of some sort.
Here's the painful truth: those recommended measures, including 3 years eating strict keto, did not produce the promised results, in spite of my weight loss. In one case, this led to a practitioner yelling at me and trying to shame me as she believed I couldn't possibly have followed her directions if I wasn't getting the improved markers she expected.
In the other case, I suffered through medical misdiagnosis as my weight was perceived as the front line cause of all problems--this led to me going years with a worsening gall bladder condition, which resulted in a near emergency surgery to finally remove my gall bladder in May of this year. I cannot even describe to you how much this has improved not just my quality of life, but a sweeping swath of my health markers! (C-Reactive protein dropped from 14.3 to 1.4 within 3 months of the surgery, for instance. It had been high for years.)
At any point when I had what were gall bladder symptoms, my PCP assumed it was weight related and would send me out for things like heart stress tests--and these tests all came back with good results. At that point, because my PCP assumed weight must somehow still be the source of the issue, he would simply stop there, and not pursue any other evidence-based diagnostic work because clearly any symptoms I was having that couldn't be related to weight must be outlier experiences that didn't indicate I had other problems to be pursued. (I had gallbladder symptoms going back to 2017.)
Why does this matter? If you are a person who is pre-diabetic or already has T2, it's critical to know that diet and exercise can only impact 30% of what is behind the tipping point into T2. In fact, genetics makes up a larger proportion of impact, along with social determinants of health. Even stress and insomnia dramatically skew blood sugar levels, which anyone who tests their blood sugar regularly can easily confirm. People who have a trauma background (which can include things like trauma related to growing up in a racist society, for instance) are effectively steeped in stress hormones which can rather permanently alter blood sugar levels skewing toward pre-diabetes and T2. So no, I didn't "eat yourself into T2."
My own PCP, while blinded by his over focus on my weight, even conceded that science doesn't actually know if the endocrine disruption happens first and then causes weight gain, or if it's the other way around. But the public assumption is simply that people eat themselves into T2 and caused this particular health issue themselves--which is not substantiated.
The article suggesting new treatment protocols prioritizing weight loss over blood sugar control that is about to come out or has just been released features a "debate" between doctors and a doctor moderator who are all paid by weight loss industry and NovoNordisk. If you watched "Dope Sick" on Hulu, many of the marketing tactics NovoNordisk has used for GLP-1 agonist drugs are a direct lift from the playbook of oxycontin maker, Purdue Pharma.
One of the greatest problems I see with the coming recommendation that weight loss is more important than blood sugar control is that it completely overlooks evidence-based research and practice, and diverts both medical professionals and their patients from bona-fide treatments. Research already exists that fatness may have a protective effect, and is not clearly correlated with increased risk for cardiovascular issues. In fact, in some overweight people, forcing them to lose weight can increase their risk for cardiovascular events.
Drugs like Ozempic, which may soon be prioritized as front line for T2 treatment are being favored because they may lead to temporary weight loss (ie weight loss that lasts only as long as you are on the medication), but often to the exclusion of quality of life as a significant number of patients report severe nausea and other unpleasant side effects. Additionally, GLP-1 agonists such as Ozempic may confer no other benefits--unlike metformin which can quite effectively control blood sugar, is much cheaper, is often more readily tolerated, and has protective benefits for the cardiovascular and renal (kidney) systems, as well as offering protection benefits against age-related macular degeneration, dementia, and some types of cancer. GLP-1 agonists may lower blood sugar A1C by .66%, while metformin has been shown to lower blood sugar up to 1.5%. (A1C is often expressed with numbers like 5.4, 6.7 etc. so the difference between .66% and 1.5% is pretty important.)
The low side per unit cost of metformin is $.16, while the low side per unit cost of Ozempic is $632. Yes, Ozempic is $631.84 more than metformin, on a per dose basis.
Just like Purdue Pharma created the medical "conditions" that would require oxycontin, it's very hard for me to imagine a world where NovoNordisk is not similarly creating a "need", which will drive a new treatment direction, which will drive sales of Ozempic--all the while lacking sufficient research which would justify such a switch in treatment protocols.
I'm not against anyone who uses GLP-1 agonists because it improves their quality of life and health--but since I have directly been negatively impacted by doctors who were misguided by the over focus on weight to exclusion of all else, I hate to see anything else that might further compromise evidence-based diagnostics and treatments when it comes to T2. If your treatment for T2 begins and ends with, "You're too fat," the need for additional diagnostic work, along with improved treatment protocols becomes irrelevant. This is sloppy medicine at best, and could be deadly at worst.
If you are [in Oregon and] in need of an evidence-based treatment-minded, non-weight-obsessed endocrinologist, please let me know, I would be happy to share the name of my doctor. I had to go to Corvallis to find her, but she is 100% worth the drive. I also have a new PCP who is likewise a breath of fresh air to work with. Finally, the surgeon who removed my gallbladder? He was the first person to order the actual diagnostic work for me, and I would recommend him as well. I will always be grateful that he did not simply tell me my issue was my weight."