Von Noorden suggested that obesity and diabetes are different consequences of the same underlying defects in the mechanisms that regulate carbohydrate and fat metabolism. In severe diabetes (Type 1), he noted, the patients are unable either to utilize blood sugar as a source of energy or to convert it into fat and store it. This is why the body allows the blood sugar to overflow into the urine, which is a last resort since it wastes potentially valuable fuel. The result is glycosuria, the primary symptom of diabetes. These diabetics must be incapable of storing or maintaining fat, von Noorden noted, because they eventually become emaciated and waste away. In obese patients, on the other hand, the ability to utilize blood sugar is impaired, but not the ability of the body to convert blood sugar into fat and store it. “Obese individuals of this type have already an altered metabolism for sugar,” von Noorden wrote, “but instead of excreting the sugar in the urine, they transfer it to the fat-producing parts of the body, whose tissues are still well prepared to receive it.” As the ability to burn blood sugar for energy further deteriorates and “the storage of the carbohydrates in the fat masses [also suffers] a moderate and gradually progressing impairment,” sugar appears in the urine, and the patient becomes noticeably diabetic. Using the modern terminology, this is the route from obesity to Type 2 diabetes. “The connection between diabetes and obesity,” as von Noorden put it, “ceases in the light of my theory to be any longer an enigmatical relation, and becomes a necessary consequence of the relationship discovered in the last few years between carbohydrate transformation and formation of fat.”

After the discovery of insulin in 1921, the potential role of insulin as a fattening hormone would become a long-running controversy. Those physicians who believed, as Louis Newburgh did without reservation, that obesity was an eating disorder, rejected the idea that insulin could fatten humans, if for no other reason than that this suggested the existence of a defective hormonal mechanism that could lead to obesity. The evidence, however, suggested exactly that. When insulin was injected into diabetic dogs in the laboratory, or diabetic human patients in the clinic, they put on weight and body fat. As early as 1923, clinicians were reporting that they had successfully used insulin to fatten chronically underweight children—patients who would be diagnosed today as anorexic—and to increase their appetite in the process.