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.