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Why we need to rethink our attitude to diabetes

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Why we need to rethink our attitude to diabetes
Award-winning journalist and Sunday Times bestselling author Gary Taubes argues that we need to reassess our attitude towards diabetes and its treatment
The history that emerged in my research for Rethinking Diabetes serves as a cautionary tale, a case study in the medicalisation of modern life and one that is particularly relevant today. As the pharmaceutical industry develops more effective treatments for chronic, progressive conditions—obesity, now, being among the most controversial—medical associations become ever more likely to consider them diseases, beyond the control of the patients themselves. Physicians, in turn, become increasingly comfortable prescribing lifelong drug therapy as treatment. While physicians will be aware of the potential for side effects and long-term complications, the unvoiced assumption is that, given time, new drugs or drug variants will be developed and the patients can always switch or add a new drug as necessary. The clear immediate benefits outweigh concerns about future risks. 
"The history that emerged in my research serves as a cautionary tale"
As I write this, a new class of drugs has recently been shown to be remarkably effective at inducing weight loss in those who are overweight or obese. Based on a hormone secreted from the gut known as glucagon-like peptide 1(GLP1)and originally developed and approved for type 2 diabetes, these drugs have been described as “game-changers” and “‘the’ transformative breakthrough” in obesity therapy. The scenario is not all that different from the introduction of insulin therapy a century earlier. Indeed, as the journal Nature reported, when the results of the first clinical trials testing these drugs for obesity were announced at a conference in November 2022, “sustained applause echoed through the room ‘like…at a Broadway show.’ ”
The parallels with insulin therapy are clear: as with insulin, these new drugs have to be injected (although those days may already be over), albeit once a week rather than daily. As with insulin for type 1 diabetes, they almost assuredly will have to be taken for life. They don’t cure the state of obesity, they only reduce the symptom of excess weight so long as the medication is taken regularly. Those who go off the drugs, for whatever reason—cost, intolerable side effects, health concerns for mother and fetus during pregnancy, lack of availability—will apparently gain back much to all of the weight they had lost. 

The implications of medical treatment

Very similar decisions are being made now by physicians about their patients with obesity and by those individuals themselves as were made a century ago with insulin therapy for diabetes. The issue in this case, though, is not life and death, as it was then and is still with type 1 diabetes, but quality of life, which can seem of almost equal importance to many who are burdened with obesity. In January 2023, the American Academy of Pediatrics published guidelines suggesting that physicians should consider obese patients as young as twelve—children—as candidates for the use of these drugs, assuming, again, that they will be taken for a lifetime. 
As with insulin and diabetes, the new drugs are already changing the discourse, the dialectic process, on obesity from diet vs disease to drug vs disease. The drugs, as The Wall Street Journal put it, are “ripping up long-held beliefs that diet, exercise and willpower are the way to weight loss.” A likely scenario is that in just the next few years, millions to tens of millions of individuals struggling with obesity will be using a new class of pharmaceutical therapy, committed to it for life, as the medical community struggles to understand and manage whatever long-term risks accompany the very clear benefits of the present. These risks are, by definition, unknowable and may take years to decades to manifest themselves. As with insulin, diet, and diabetes, whatever mistaken assumptions are embraced as this process plays out may likely haunt medical practice, and so the health and well-being of patients, for generations. 
"My ultimate goal is to make the patient’s work easier, to improve their ability to control their disease"
Living with diabetes is often described as self-care, more so than medical care. The diabetic patient has to do the hard work of keeping the disease under control. To do so successfully, though, the patient must have the support and understanding of their physician along the way. My ultimate goal is to make the patient’s work easier, to improve their ability to control their disease, while giving their physicians, diabetes educators, and dietitians the understanding necessary to offer informed encouragement and assistance. This comes, however, with a caveat: what I write here is supported by the work of many diabetes researchers and specialists, but their voices do not carry the authority of a consensus. Hence, for individuals struggling to achieve optimal control of their disease, I cannot overemphasise the value of working with a physician—and there are now many of them— who understands the science and the therapeutic implications of carbohydrate-restricted diets and can therefore help minimise any risks. 
Rethinking diabetes cover
Extract taken from Rethinking Diabetes by Gary Taubes (Granta Books, £16.99)
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