May 2025 Newsletter

In this issue:

  • Community Artwork

  • Evidence-Based Archives

  • Find us on Instagram!

Community Artwork

This month, MSSI is proud to feature a moving original submission by April Ascher (she/her)!

Original artwork may be submitted to the MSSI newsletter to be considered for publication. Submissions are reviewed on a monthly basis. All forms of artwork are welcome! We look forward to receiving your work!

Evidence-Based Archives

MSSI is excited to present another installment of “Evidence-Based Archives,” our monthly column highlighting and summarizing seminal research in the field of size-inclusive healthcare. In this section, we hope to celebrate our scholars, empower each other with knowledge, and stock up on citations for the next time we’re called upon to justify size-inclusive healthcare in the classroom, clinic or wards!

Content warning: Medicalized fatphobia, ob*sity, anti-fat language

Disclaimer: We use the terms “ob*sity” and “overw*ight” in our summaries when it is otherwise impossible to accurately describe findings from certain studies, due to the language and descriptors chosen by researchers. We acknowledge the inaccuracies and harms that these labels have perpetuated in medicine and society. Please keep your mental health in mind when reading, and feel free to reach out to us with any feedback or suggestions at any time!

This month’s highlight:

Diabetes management (Type 2 in particular) is arguably one of the greatest movers and shakers of medical practice. For better or worse, most medical providers have advice to offer their patients who are living with T2DM, and while information access can be a good thing, it also means that generalizations and stereotypes surrounding diabetes counseling/treatment are rampant.

Generalizations are commonplace in medicine, passed along from well-meaning attendings to residents and medical students. Yet whether because of oversimplification or the not-so-subtle influence of the diet industry in healthcare, many common diabetes recommendations can also feel fat-phobic, unintentionally promote shameful/avoidant food behaviors, and worse of all, be based in very limited evidence!

This month, MSSI hopes to highlight some medical oversimplifications surrounding Type 2 diabetes and additional evidence/recommendations to consider the next time you are approaching counseling and treatment for this condition. As a brief disclaimer, this is a HUGE topic that cannot possibly be covered in a short article! We will provide links and resources to follow up if you want to further explore, and please write in and provide feedback if we missed something that you think would be great to address — it might even get featured in our next article!

Oversimplification #1: Weight loss is the most effective way to treat type 2 diabetes

  • Research repeatedly demonstrates that weight loss via a diet and exercise approach is ineffective in the long term. (1, 2)

  • Researchers have identified weight-stigma as a significant factor worsening everything from medication adherence to long-term health outcomes for individuals diagnosed with Type 2 diabetes. (3)

  • Weight-loss research does not control for the impact of lifestyle modifications that may otherwise be impacting health. (4, 5)

Practice recommendation: Encourage health-supporting behaviors that genuinely promote and support long-term wellbeing and happiness. Refrain from suggesting that weight loss is a prerequisite to pursuing or achieving a meaningful, well-rounded, and “healthy” life. Suggestions for health-supportive, weight-inclusive diabetes practices include challenging weight-stigma, engaging in joyful movement, spending time with supportive loved ones, going to therapy, and fueling your body. Additionally, consider de-stigmatizing the role of medications in supporting overall health. An un-medicated body is not “better” than a medicated one (we are all only temporarily able-bodied, after all!) 

Oversimplification #2: Pre-diabetes 

Diabetes is technically a risk factor, not a disease — most folks with HbA1C > 6.5% are asymptomatic (6.5 was defined to be the cutoff based only on projected likelihood of developing symptomatic retinopathy). That’s why practice guidelines for successful diabetes management don’t advocate for the reduction of HbA1C to below 6.5, but maintenance of the value to somewhere between 7-8%, with additional nuance based on an individual’s overall state of health and projected lifespan. Managing diabetes can play a role in supporting overall health. But pre-diabetes management (managing a risk factor for developing a risk factor) is actually more controversial.

  • “Pre-diabetes” is a diagnostic category created in 2010 by the American Diabetes Association by lowering the cutoff for “impaired glucose tolerance.” This was done, theoretically out of consideration that “early detection” could reduce diabetes-associated morbidity and mortality. However, the lower cutoff was controversial and contested by multiple professional groups, including the World Health Organization, because the change created a large, poorly defined patient group that included low-risk individuals unlikely to benefit from medical intervention. (6) The change also made it such that the prevalence of “impaired glucose tolerance” in the population doubled, fueling concerns for rising rates of glucose intolerance in the US despite the fact that the rate at which diabetes is being diagnosed in the US population has been declining since 2009. (7,8)

  • 2/3 (66%) of people diagnosed with pre-diabetes remained non-diabetic at the 10-year mark. (6)

  • There is some evidence that initiating medication (such as with metformin) in the setting of prediabetes can delay the development of diabetes by ~2years, but it has NOT been shown to prevent the development of diabetes. (6) It has definitely increased profits for drug companies, though!

  • “Pre-diabetes” diagnoses in otherwise healthy individuals (and widening disease definitions in general) have been demonstrated to contribute to stress-related conditions and an overburdened medical system. (9)

Practice recommendation: Older adults (age > 65) do not need to be medically treated for pre-diabetes, a recommendation that is also supported by AAFP practice guidelines (9). When discussing a diagnosis of pre-diabetes in any age group, consider including some of the above context (including actual risk of progression to diabetes).

Oversimplification #3: If you have diabetes, you shouldn’t eat carbs

Anyone who’s trained in an inpatient unit has “carb-controlled diet” and “insulin sliding-scale” drilled into their brain as must-have items on the plans for patients with diagnosed diabetes. Unsurprisingly, this philosophy carries over to the outpatient setting, where carbohydrate restriction is the most commonly cited piece of advice for managing diabetes (and more recently, pre-diabetes). Carbohydrate restriction may make sense in the short term to lower blood glucose levels, but:

  • Low carbohydrate diets have not been shown to reliably impact measures of glucose tolerance in the long-run. (10)

  • Dietary guidelines framed as restriction are more likely to promote disordered eating behaviors and damage rapport between patients and providers. Unsurprisingly, they are also are less likely to be observed. 

  • Other ways of managing a meal’s immediate glycemic impact (for patients with severe diabetes) include consuming protein and veggies before or alongside the carbohydrate part of a meal, or going on a gentle post-meal walk to aid digestion. (11, 12)

Practice recommendation: Encourage patients to fuel their bodies with a wide variety of foods and to explore tastes/flavors/textures outside their comfort zone. All foods are important and play a role in supporting our mental/emotional/social/physical health, so try to include protein, fruit/veg, AND carbs in most meals! Health-supporting meals can be created in the context of any cultural practice or tradition. 

  1. Fildes A, Charlton J, Rudisill C, Littlejohns P, Prevost AT, Gulliford MC. Probability of an Obese Person Attaining Normal Body Weight: Cohort Study Using Electronic Health Records. Am J Public Health. 2015 Sep;105(9):e54-9. doi: 10.2105/AJPH.2015.302773. Epub 2015 Jul 16. PMID: 26180980; PMCID: PMC4539812.

  2. Nordmo M, Danielsen YS, Nordmo M. The challenge of keeping it off, a descriptive systematic review of high-quality, follow-up studies of obesity treatments. Obes Rev. 2020 Jan;21(1):e12949.

  3. Potter L, Wallston K, Trief P, Ulbrecht J, Juth V, Smyth J. Attributing discrimination to weight: associations with well-being, self-care, and disease status in patients with type 2 diabetes mellitus. J Behav Med. 2015 Dec;38(6):863-75. doi: 10.1007/s10865-015-9655-0. Epub 2015 Jul 2. PMID: 26133488; PMCID: PMC4628883.

  4. Aphramor L. Validity of claims made in weight management research: a narrative review of dietetic articles. Nutr J. 2010 Jul 20;9:30.

  5. Rothblum E.D. Slim chance for permanent weight loss. Archives of Scientific Psychology. 2018;6(1):63–69.

  6. Yudkin JS, Montori VM. The epidemic of pre-diabetes: the medicine and the politics. BMJ. 2014 Jul 15;349:g4485. doi: 10.1136/bmj.g4485. Erratum in: BMJ. 2014;349:g4683. PMID: 25028385; PMCID: PMC4707710. 

  7. https://archive.cdc.gov/www_cdc_gov/diabetes/library/reports/reportcard/national-state-diabetes-trends.html

  8. https://archive.cdc.gov/www_cdc_gov/diabetes/research/reports/cdc-research-20yr-report.html

  9. https://www.aafp.org/pubs/afp/issues/2021/1200/p649.html

  10. Landry MJ, Crimarco A, Gardner CD. Benefits of Low Carbohydrate Diets: a Settled Question or Still Controversial? Curr Obes Rep. 2021 Sep;10(3):409-422. doi: 10.1007/s13679-021-00451-z. Epub 2021 Jul 23. PMID: 34297345; PMCID: PMC9621749.

  11. Kubota S, Liu Y, Iizuka K, Kuwata H, Seino Y, Yabe D. A Review of Recent Findings on Meal Sequence: An Attractive Dietary Approach to Prevention and Management of Type 2 Diabetes. Nutrients. 2020 Aug 19;12(9):2502. doi: 10.3390/nu12092502. PMID: 32825124; PMCID: PMC7551485.

  12. Engeroff T, Groneberg DA, Wilke J. After Dinner Rest a While, After Supper Walk a Mile? A Systematic Review with Meta-analysis on the Acute Postprandial Glycemic Response to Exercise Before and After Meal Ingestion in Healthy Subjects and Patients with Impaired Glucose Tolerance. Sports Med. 2023 Apr;53(4):849-869. doi: 10.1007/s40279-022-01808-7. Epub 2023 Jan 30. PMID: 36715875; PMCID: PMC10036272.

Thoughts?

We are open to feedback and interested in the lived experiences of our MSSI members. Have you referenced this article in your clinical work, used it to guide patient counseling, or used it to communicate with your colleagues? How did it go? 

Feel free to share your stories, reflections, expertise, and advice using the links below. With your permission, we may publish reflections in future installments of this column.

If you have a favorite article you’d like us to highlight in our next installment, feel free to submit it for consideration, also by using the link below! We look forward to hearing from you!

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This newsletter was authored by MSSI members Sophie Lalonde-Bester (University of Alberta) and Jay Liu (Stanford University).