Oprah, GLP1s and Diabetes Care
Explore how this TV show has highlighted the changing conversation and the unexpected ripple effects towards policy and future funding of diabetes care.
Oprah's recent special program about weight stigma and how GLP1s have personally helped her has been in the news. This TV show’s ripple effect is a helpful way to explore how the use of GLP1s for weight loss is unintentionally changing the conversation, policy, and funding of diabetes care.
What are GLP1s
Glucagon-like peptide-1 (GLP1) agonists are a fantastic class of drugs for people with diabetes. They work in the gut, muscle, and pancreatitis. They slow digestion, inhibit glucagon secretion, and stimulate insulin with a glucose-dependent mechanism. They also increase the effectiveness of existing insulin and send signals to the brain, increasing the sense of fullness. All of this happens without causing low blood sugar. GLP1 medication targets many of the 11 systems Dr. Defronzo identified as a problem for persons with diabetes. This class of drugs has dramatically changed diabetes care. However, the conversation about GLP1s has shifted from diabetes to weight loss.
Weight stigma
It is easy to lose sight of this complicated intersection between diabetes, weight, and politics, which centers on the impact of weight stigma on our overall health. Let’s start by defining weight stigma. Weight stigma generally refers to social disapproval of people of higher weight. While the definition refers to people with a BMI >30, weight stigma impacts people of any size.
Weight stigma is the outcome of weight bias. Weight bias refers to the thoughts about weight, size, and health. If a healthcare professional's thoughts agree that fatness is something that an individual causes because fat people are lazy, gluttonous, and lack willpower and self-discipline, these are biased views. Weight stigma is not new, and weight discrimination is present in the workplace, education, healthcare settings, and society in general.
For example, states like Michigan define weight stigma as a type of discrimination—in other states, including New York. San Francisco; Urbana, Ill.; Binghamton, N.Y.; Madison, Wis.; and Santa Cruz, Calif., prohibit weight bias at work. Washington, D.C., prohibits discrimination based on personal appearance, which could encompass weight. Michigan is the only state that has passed a law to declare weight as a category protected from discrimination. In Washington state, obesity is covered by the state anti-discrimination law. Massachusetts, New York, New Jersey, and Vermont state legislatures are considering legislation prohibiting weight discrimination.1
Weight bias arises from weight-centric training, which reinforces the false belief that weight gain is entirely reversed by voluntary decisions to eat less and exercise more. This view was the dominant one, and it has been codified into public health policies, treatment access, and research. The following article, What is a Weight-Centric Approach to Diabetes Care? can help you explore this topic in more detail.
Because weight and diabetes are now linked, people with diabetes are often told, "If you lose weight, you will not have diabetes." However, weight-cycling, AKA yo-yo dieting, is also associated with type 2 diabetes. When a PWD doesn’t lose weight, they may be encouraged to try harder, delaying care. Additionally, they may be placed on medications that promote weight loss even though current efforts are effectively keeping the A1C at goal. Seeing this connection is how diabetes is linked with weight, and this means weight stigma is part of diabetes care. What is concerning is that weight stigma and yo-yo dieting are positively associated with diabetes.
Oprah’s public life has chronicled her struggle with both of these experiences. Her solution wasn’t to explain how all forms of stigma are oppressive or to point out systems that uphold these ineffective beliefs. Instead, she focused on weight loss, using a tool that has a significant financial burden for people seeking it for weight loss and is literally out of reach due to drug shortages for people who need it to manage their glucose.
The experience of weight stigma causes a decrease in self-care. A systematic review of the literature has demonstrated that the empirical study of this phenomenon is in its infancy (Pearl and Puhl, 2018). However, early findings illustrate a significant detrimental impact on mental (e.g., depression, anxiety, body dissatisfaction) and physical health (e.g., metabolic syndrome, weight cycling) as well as related health behaviors through rejection of dietary advice, binge eating, and exercise avoidance (Ratcliffe and Ellison, 2015; Jackson and Steptoe, 2017; Puhl and Himmelstein, 2018). Research in this field has detailed that shame or stigma cannot motivate individuals to lose weight. Again, many healthcare professionals are unaware of how common microaggressions regarding weight are stigmatizing.
These harmful effects also affect people with type 2 diabetes.
The risks of dieting have been well documented in the 2022 article, The consequences of a weight-centric approach to healthcare: A case for a paradigm shift in how clinicians address body weight. Over time, weight and diabetes stigma begin to be internalized, increasing the risk of clients engaging in disordered or unsustainable eating patterns. Without understanding stigma and oppression, people in diabetes care can unintentionally promote stigmatizing messages about diabetes, and these examples include national guidelines and diabetes prevention campaigns.
Weight stigma, GLP1s, and diabetes
Around 2014, nine years after GLP1s had been available, there was a change in who these medications were targeted to. With FDA approval for weight loss, GLP1s were marketed as the magic bullet for higher-weight individuals with diabetes. Then, in 2020, there was an additional shift in marketing these medications specifically for weight loss. Ragen Christain, a scientific writer and fat advocate, breaks down how this is benefiting drug manufacturers but not people with diabetes.
Why is it essential for diabetes professionals to listen?
The following weight-inclusive advocates have taken their time to provide analyses of weight-loss medication from many perspectives. These are not just for diabetes or health but public policy, research, and medical ethics. Understanding the direct experience of Fat people and the research questioning weight-centric findings allows us to see diabetes from a larger perspective.
Virgie Tovar is a fat weight-inclusive advocate. Virgie has written extensively about this medication and the science behind it. Read her other articles here.
Kate Manne explains how and why it is important to disconnect health from weight. Learn more about Dr. Manne.
Diabetes is the most expensive chronic illness in the United States. Many programs are looking for options to reduce the cost of diabetes. The conversation after the Oprah special argues that weight loss via taking a GLP1 will reduce healthcare costs. This is concerning because the cost of diabetes is not fully covered for most people.
If the reason why GLP1s should be funded is to reduce the financial burden of diabetes care, it should be noted that the American Diabetes Association found that 50-60% of all diabetes outcomes are tied to the Social Determinants of Health.
The Social Determinants of Health focus on five areas: socioeconomic status (education, income, occupation); neighborhood and physical environment (housing, built environment, toxic environmental exposures); food environment (food insecurity, food access); health care (access, affordability, quality); and social context (social cohesion, social capital, social support).
Giving GLP1s medication to everyone does not address the existing SDOHs in our country. Additionally, it is vital to question if it is good to invest $15,000 annually in medication for weight loss when diabetes disproportionately impacts lower-income individuals. "What would happen if people with diabetes were provided with this level of support for housing, medical care, and food?" If your immediate thought was, “That is ridiculous!” Why?
Inclusive Diabetes Care is a weight-inclusive continuing education company.
It offers 12 foundational courses to untangle the many stigmas in diabetes care.
Healthy People 2030 found a disproportionate impact: 28.6 percent of low-income households were food insecure, compared to the national average of 10.5 percent. Food insecurity is linked to poor health outcomes and lower test scores, not to mention the psychological burden, which the Food Dignity Movement, founded by Clancy Harrison, discusses. Clients share that their barriers to eating a 'healthier' diet are more complicated than not knowing what foods to choose.
“I can't afford nutrient-rich foods with my current income."
“I need help getting to the store (due to lack of a car or physical limitations.)”
“If purchased, I cannot prepare the ingredients because of physical limitations due to illness, the demands of caring for others, or existing physical or mental limitations.”
Pointing to the Food As Medicine movement, the most significant barrier centers around cost. In our current political climate, our nation is struggling to invest $50-100 per person with prediabetes to improve their food intake and choices. Why would it pay for weight loss medication? As diabetes professionals, we have to consider how addressing the SDOH, including food insecurity, instead would help more people, including people who have diabetes.
Diabetes care is also about politics. While it is easy to assume poverty is the root cause of health inequity, the connection between poverty, policy, and diabetes is complicated and often racially driven. Heather McGhee, the author of The Sum of Us, explains that racial stereotypes and beliefs drive economic thinking, which hurts everyone. If the diabetes community is not careful, this shifts the focus from helping people with diabetes to weight loss. Inclusive Diabetes Care is centered on the needs of people with diabetes. Without their concerns being fully considered, it becomes another good example of how we will get caught up in a zero-sum game.
Bottom Line: Shifting the focus of GLP1s from diabetes care to weight loss is concerning. It will likely divert funding, resources, and access for people with diabetes. Additionally, it will fail to address the underlying causes of complications associated with diabetes, which are the social determinants of health.
https://www.shrm.org/topics-tools/news/inclusion-equity-diversity/laws-policies-can-counter-weight-discrimination-work#:~:text=Michigan(opens%20in%20a%20new,a%20category%20protected%20from%20discrimination.