Lowering the Curtain

Systematically Preventing Obesity and Diabetes Care

Two ideas are hard to miss at the annual Scientific Sessions of the American Diabetes Association. One is that it’s getting harder to treat and prevent diabetes adequately without treating obesity. Second is that health systems can’t handle this reality. They are systematically preventing adequate obesity and diabetes care.

Distinct but Overlapping Diseases

Let’s get one thing straight. Obesity and diabetes are two different diseases, though they overlap considerably. It’s not uncommon for untreated obesity to cause type 2 diabetes. There’s even research at the ADA meeting to suggest that obesity in adolescence raises the risk for type 1 diabetes in adulthood. Inbar Zucker et al simultaneously published this finding in Diabetologia.

So diabetes can be a complication of obesity. Likewise, obesity can be a complication of diabetes. In fact, John Malone and Barbara Hansen have argued here that diabetes and obesity are linked only because diabetes causes obesity. But let’s set that argument aside for now and grant that both views about the direction of causality are reasonable suppositions.

What is becoming ever clearer, though, is that treating obesity can be essential for preventing or putting diabetes into remission.

A 60% Reduction in T2D Risk

In a post-hoc analysis, Tim Garvey and colleagues found that treatment of overweight and obesity with semaglutide 2.4 mg (Wegovy) reduced the risk of developing type 2 diabetes by 60 percent. Garvey presented this as a late-breaking abstract at the ADA meeting. This is consistent with previous findings that liraglutide can dramatically reduce the risk of type 2 diabetes.

Furthermore, bariatric surgery can be one of the most reliable ways to put type 2 diabetes into remission. So plainly, for folks with both obesity and type 2 diabetes, treating obesity is a key part of preventing and treating diabetes. In fact, on Sunday at the meeting, Ildiko Lingvay and Jeffrey Mechanick debated whether weight management or glucose control should be the primary target for type 2 diabetes care. In the end, they seemed to agree that neither end point is sufficient by itself and thus weight management or obesity care is an essential part of the picture.

Systemic Bias Preventing Obesity Care

Unfortunately, though, health systems – and especially payers – are slow to catch up. They still put roadblocks in the way of adequate obesity care. It’s not unusual for health insurance to deny coverage for obesity meds simply because they don’t want to pay. They might call them “vanity” drugs – as if good health is a vanity.

All of this stems from obsolete thinking that obesity is a problem of bad behavior, instead of accepting the truth that it is a problem of physiology maladapted to our environment. This is, even today, the prevalent bias about obesity.

So health systems seize upon it, systematically preventing adequate obesity and diabetes care. They draw an artificial curtain between the two. Inevitably, this is changing. But that change is coming at such a slow pace that many people are suffering needlessly.

Click here, here, and here for more on the growing overlap between obesity and diabetes care.

Lowering the Curtain, painting by Edgar Degas / WikiArt

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June 6, 2022