Management of obesity by dietary, pharmacologic, and surgical intervention can provide very positive results.
Obesity management can help delay the progression from prediabetes to type 2 diabetes and helps with glycemic control in type 2 diabetes, which helps reduce the medication burden. Studies have shown that patients with obesity and type 2 diabetes can lower A1C to less than 6.5% and fasting glucose to less than 126 mg/dL by doing extreme dietary restrictions with a low calorie diet. The goal of this study is to provide evidence-based recommendations for dietary, pharmacologic, and surgical interventions in patients with obesity and type 2 diabetes.
Studies recommend that greater than 5% weight loss should be prescribed to patients with type 2 who have excess weight or obesity by doing diet control and physical activity. The diet, physical, and behavioral changes should achieve a 500-750 kcal/day energy deficit. It is recommended to individualize the diet for every patient to achieve effective weight loss. Weight maintenance programs can help encourage ongoing maintenance of body weight by continuing to consume a reduced-calorie diet and participating in a high level of physical activity (200-300 min/week). Modest and sustained weight loss has shown to reduce blood glucose, A1C, and triglycerides, and an even greater reduction in weight has shown great benefit in reduction of blood pressure, improvement of LDL and HDL cholesterol, and reduction of the need for medication for blood glucose control.
The Look AHEAD trial participants had a mean weight loss of 4.7% at 8 years. About 50% of participants lost ≥ 5% and 27% participants lost ≥ 10% of their initial body weight at 8 years. It was found that participants in the intensive lifestyle group required fewer glucose, blood pressure and lipid-lowering medications. However, the Look AHEAD trial did not show any reduction in cardiovascular events with intensive lifestyle interventions in adults with type 2 diabetes who had excess weight or obesity. Intensive lifestyle interventions include ≥ 16 sessions in 6 months that are focused on diet and physical activity to achieve 500-700 kcal/day energy deficit. Secondary analyses of the Look AHEAD trial did show other benefits of weight loss such as an improvement in mobility, physical as well as sexual function, and overall improvement in quality of life.
Studies recommend that weight loss can be attained with an approximate consumption of 1200-1500 kcal/day for women and 1500-1800 kcal/day for men depending on individual’s baseline body weight. According to the AHEAD trial, use of a partial meal replacement plan prescribed by trained practitioners was associated with improvements in diet quality. Individuals are recommended to have diet choice based on their health status and preferences.
In terms of pharmacotherapy, a meta analysis of 227 patients in a randomized controlled trial showed that patients with obesity can benefit from the same types of treatment as patients with type 2 diabetes who have normal weight. It is recommended that whenever possible, medications for glucose control should be chosen to induce weight loss or be weight neutral for patients with excess weight or obesity and type 2 diabetes. Some of the medications that promote weight loss include metformin, a-glucosidase inhibitors, sodium- glucose cotransporter 2 inhibitors, glucagon-like peptide 1 agonists, and amylin mimetics. Dipeptidyl peptidase 4 inhibitors have weight neutral effects.
Some weight loss medications approved by the U.S Food and Drug Administration can also be used for both short-term and long-term weight management. For short-term weight loss, phentermine can be used in adjunct with lifestyle and behavioral interventions. There are five weight loss medications that can be used for long-term use for patients with BMI≥ 27 kg/m2 with one or more comorbid conditions and by patients with BMI≥ 30 kg/m2 who are motivated to lose weight. These medications include Orlistat, Lorcaserin, Qsymia, Contrave, and Saxenda.
Furthermore, metabolic surgery can be considered as one of the options for individuals with BMI≥40 kg/m2 regardless of the level of glycemic control and in candidates with BMI of 35.0-39.9 kg/m2 when hyperglycemia cannot be controlled despite medical and lifestyle therapy. Some of the surgery options include gastrointestinal operations, including partial gastrectomies and bariatric procedures. Compared to medical and lifestyle interventions, numerous clinical trials show that metabolic surgery achieves superior glycemic control, improvement in quality of life, reduction in cardiovascular and cancer risk as well as reduction in overall mortality in patients with excess weight and obesity in patients who have diabetes. Metabolic surgeries can be costly, and have many risks associated with them, including vitamin and mineral deficiencies, anemia, osteoporosis, dumping syndrome, and severe hypoglycemia.
- Intensive lifestyle modifications leading to weight loss in patients with excess weight or obesity require fewer glucose, blood pressure and lipid-lowering medications.
- When choosing glucose-lowering medications for patients with type 2 diabetes who have excess weight or obesity, medications that promote weight loss or that are weight neutral are recommended.
- Metabolic surgery can help achieve superior glycemic control compared to medical and lifestyle interventions in patients with type 2 diabetes who have excess weight or obesity.
Obesity Management for the Treatment of Type 2 Diabetes: Standards of Medical Care in Diabetes- 2018. Diabetes Care. 2018; 41:S65-S72.
Vidhi Patel, Pharm. D. Candidate 2018, LECOM School of Pharmacy