and depending on how one views obesity either treats those with disease as gluttons who have absolutely no self-control (so medication is the only solution - and why bother recommending lifestyle changes since there's not a chance those gluttons would follow it) - or - the other extreme (the RFK position - stop giving them the easy way out - force them to make lifestyle changes.
The reality is that T2 diabetes is, almost certainly, many many different diseases - which have both different configurations of causes/predispositions and many different models for treatment.
Unfortunately, virtually all doctors in the US pay lip service to lifestyle changes (largely following the ADA guidelines which don't come close to a diet low enough in in carbs to control diabetes) and then shovel medicine at it. From my perspective - as a general concept - that model is no better and perhaps worse than the RFK model.
Fun facts: There are two people in my immediate household who have T2 diabetes.
Both are around 5'2. Both both are over 65. Both are treated by the same doctor.
The weight of one varies between 165 and 185 - the weight of the other varies between 110 and 120.
One is/has been on Jardiance, Januvia, 2Kg/day of Metformin, statins and blood pressure medication; the other takes 500g-1Kg/day of Metformin.
The most recent A1C for one is 8.3, and for the other 6.2.
One has a single ancestor with T2 Diabetes. For the other every single descendent of one grandparent has developed diabetes once they hit about 65.
If you were to try to assign each of those 4 variables to one or the other of the two people in my household, based on common prejudices, very few would get it right.
My spouse is between 110 and 120. She has a single ancestor with T2 diabetes. While on Jardiance, Januvia and Metformin, her A1c was 8.3, and she takes statins, and blood pressure medication.
My grandfather, mother, uncle, three cousins and I all have diabetes. Our weights range from a BMI of below 18.5 (underweight) to 30.2 (obese). Most are in the "low-normal" range. The only medication I take for diabetes is Metformin. Until I had COVID, I took 500 grams/day and my A1C was around 6.0, sometimes lower. Post COVID I take 1000 grams of Metformin and my A1C has averaged higher than before COVID. I don't take statins or blood pressure medication. My blood pressure is normal. My cholesterol runs high, but the ratio for total cholesterol to LDL falls below what is normally considered normal (meaning a lower risk of heart risk). But more on that below.
Diabetes is also viewed as universally a major cardiac risk - significant enough that doctors are threatened with being downgraded by their insurance companies if they don't automatically put their diabetic patients on statins and blood pressure medication, regardless of an individualized assessment of risk.
My doctor has been pushing statins at me for quite a while. I have zero history of heart disease (even with so many ancestors with diabetes). A risk calculation on any of the risk calculators available that does not automatically insist that anyone with diabetes needs to be on a statin puts my personal risk at the level that the doctor should start a conversation with me about statins. BUT - that's not how it works in our country. Individual assessments of risk are banned, once you have diabetes. (I don't like the risk profile of statins unless I am at significant risk for heart disease - and my doctor has never been willing to discuss the matter with me without using the "but you have diabetes" justification as a trump card so I've had to do my own evaluation using the tools available on line.)
I finally got a cardiac calcification score to get him off my back. I have zero cardiac artery calcification. Taking diabetes into account - WITHOUT FACTORING IN the actual status of my arteries puts my heart at slightly older than my chronological age. Taking my diabetes AND the actual status of my arteries into account, my heart is 14 years younger than my chronological age.
So much for diabetes being a slam dunk for heart disease. The upside may be that my doctor may start doing individual risk assessments. Nah, he was shocked, but I'm sure it will take more than one exception to shake him up.
So - I'm not mad at there being voices that challenge the mantra that all diabetics ate themselves into this, and have such poor self-control that we ought to just throw medication at them. But - the other extreme isn't good either. Our little n=2 family includes two very different forms of the disease, two very different responses to diet, two very different responses to medication, and at least somewhat different impact on cardiac health. I'm sure there are many more, and doctors who treat all of us the same are doing a disservice.
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