By Mukaila Kareem
Diabetes may have been defined by water’s chemistry, but it will only be defeated by the fire of metabolic fat burning. Until then, we will keep treating the visible tip while ignoring the mass below.”
Anyone who is familiar with my writing knows that I am a proud physiotherapist. And, as a typical Nigerian, I will invoke a sense of divine intervention here: I stumbled into the profession by accident just a few hours before I submitted my university admission form. Of all the healthcare professions, physiotherapists, along with occupational therapists, are uniquely trained to apply physical agents to treat disease and restore quality of life.
Universally, water and nutrients support the flow of energy that powers life, and they are by far the most obvious physical agents. To illustrate, it takes about 2,000 degrees Celsius to break the bond between hydrogen and oxygen in water, which is why engineers have never been able to generate energy directly from water as they do from fuels. Plants, however, have no trouble breaking water apart to power photosynthesis. And when liquid water is scarce, drought sets in, whether it is the dry season in the tropics or winter in temperate climates. Without sufficient water, photosynthesis stalls and life weakens.
From the period of antiquity to the modern times, our experience with water largely shapes the way we perceive disease, yet it does not always reflect the way nutrients behave in the bloodstream, which itself is about 70 percent water. We often assume that nutrients are inert passengers in the blood, but this is not the case. If they were chemically inactive, the body would never be able to extract their energy to sustain metabolism.
Let us zoom in on the behavior of sugar in water. For centuries, diabetes has been defined as a sugar disease, a name that traces back to the observation that patients’ urine was sweet to the taste. Even today, glucose meters and continuous glucose monitors reinforce this water-based view, reducing diabetes to nothing more than “high blood sugar.” Glucose is water-soluble, while fats are not, and our water-based experience has shaped how we see the condition. But the chemistry of nutrients in water tells a larger story. The solubility properties of nutrients, and the way fats remain invisible in water, shaped the entire way we define and think about type 2 diabetes. The problem is that the definition is incomplete.
Allow me to make a brief digression: Just weeks before I emigrated to the United States, my recruiter strongly advised me to buy a winter coat for the freezing December weather in Detroit. Growing up in the village, the coldest substance I had ever known in the outside weather was hailstones, which we happily scrambled to pick before they melted. In my language, we have a word for hail, yinyin, but we have no word for snow obviously because it never snowed. Therefore, my naive preparation for winter was a thick sweater meant for Nigeria’s harmattan, which was grossly inadequate for freezing snowy December in Detroit. In the same way, medicine has no adequate words for diabetes beyond sugar, because water chemistry made sugar visible while fat remained hidden.
Glucose needs no carrier to move in blood. When its level rises above a threshold, the kidney becomes overwhelmed and glucose spills into the urine. This made diabetes historically recognizable and is why sugar still dominates our definition today. But putting on my physiotherapy hat, we must also account for fats, which are more energy dense than sugar and far from inert as well. It is misleading to pretend that someone with high blood sugar has consumed only sugar, or to ignore the chemical fact that excess glucose is often converted into fat for storage.
When glucose lingers in circulation, its reactive end attaches to proteins, gumming up red blood cells in what we measure as HbA1c, and attacking amino acids in blood vessels, impairing their structure and function. These leave chemical fingerprints that are visible and measurable. Fats behave differently. They are not water-loving, cannot dissolve in blood, and cannot be excreted in urine. Instead, they must be packaged in lipoproteins or carried by albumin. When they accumulate, they lodge silently in arteries, liver, and muscle. Because they cannot be peed out, fats never became part of the historical definition of diabetes. Their invisibility does not mean they are absent.
This medical blind spot comes at a staggering cost. As long as diabetes is treated primarily as a sugar disease, the solutions are designed to control visible glucose. Drugs flatten blood sugar curves while the tripartite of fats such as triglyceride surges, fatty acid overflow, and cholesterol buildup remain in the background. Yet chronically elevated insulin traps both sugar and fat in circulation, even if only sugar is named.
The scale of this problem is striking. About 70 percent of people with type 2 diabetes also live with high blood levels of fats. Seven out of ten patients are not only struggling with sugar but also with fat overload. This hidden nutrient swamp drives heart disease, fatty liver, and kidney failure that cuts lives short.
There is another sobering truth. Pharmacies brim with glucose-lowering medications and cholesterol-lowering statins, but there is no blockbuster drug for high levels of blood fats. Fats stubbornly resist pharmaceutical control. Glucose, by contrast, can never deposit inappropriately. It is limitedly stored as glycogen in liver and muscle or cleared in urine. Fat, however, does deposit. It embeds itself in arteries, liver, pancreas, and visceral stores, silently fueling disease.
This is why every effective modern intervention for type 2 diabetes, whether bariatric surgical gut reduction, appetite suppressant drugs like Ozempic, or SGLT2 inhibitors that cause glucose to be urinated out shows metabolic improvement as fat stores are mobilized. Elevated triglycerides and free fatty acids in the blood are only the tip of the iceberg. Beneath the surface lies visceral fat, packed around organs, releasing fatty acids and inflammatory signals directly into the liver. This hidden depot drives insulin resistance, fatty liver, and cardiovascular disease long before glucose levels rise.
If diabetes is more than a sugar disease, if it is truly an iceberg of fat excess, then our target must be fat. And for that, lifestyle is not an optional add-on. That is why every patient who loses weight shows metabolic improvement. Fat is burned, the swamp drains, and health improves. It is the only potent medicine we have. Physiotherapy is inherently evidence-based. No one needs research dollars to recognize a normal walking pattern, to see when a joint is restricted, or to test the strength of a weak muscle. The goal is always to restore function, or as close to normal as possible. The same principle applies to metabolism: the natural agents of walking and eating remain our most powerful therapy.
Studies show that subsistence farming populations and hunter-gatherers maintain stable weight throughout adulthood, and they are among the most metabolically healthy people on the planet. Raichlen and colleagues showed that Hadza men and women take 11,000 to 18,000 steps daily. Equally important is the other half of the equation of how they eat. In hunter-gatherer societies, meals are irregular and opportunistic, often delayed until after hours of activity. In subsistence farming communities, meals are larger but tied to work cycles, with food eaten after labor, not before. In both cases, eating patterns are aligned with energy use, protecting against the continuous nutrient surplus that defines modern diabetes.
Regular walking clears blood triglycerides and prevents fat from settling on internal organs. Leaving 4–6 hours between meals gives the bloodstream time to drain, switching the body into fat-burning mode and mobilizing storage. No prescription drug comes close to the power of these simple physical agents. Diabetes may have been defined by water’s chemistry, but it will only be defeated by the fire of metabolic fat burning. Until then, we will keep treating the visible tip while ignoring the mass below.
Mukaila Kareem, a doctor of physiotherapy and physical therapy advocate, writes from the USA and can be reached via makkareem5@gmail.com
