Dr Priya Sumithran
Weight loss of 15% or more should be the focus of a weight-centric primary treatment goal for managing type 2 diabetes, according to Australian experts
The proposed obesity-first strategy for managing T2D was presented at this week’s Annual Meeting of the European Association for the Study of Diabetes (EASD) and published in The Lancet.
The authors, including endocrinologist Dr Priya Sumithran, who leads the Obesity Research Group at the University of Melbourne, say that weight loss has benefits that go beyond the potential to slow progress and even reverse many cases of T2D and reduce complications.
Such an approach would have the added benefit of addressing other obesity-related complications, such as fatty liver, obstructive sleep apnoea, osteoarthritis, high blood pressure and an elevated blood fats profile, thus having a much greater impact on the person’s overall health than just managing blood sugar alone, the authors note.
“The time is right to consider the addition of substantial (ie, double-digit %) weight loss as a principal target for the treatment of many patients with type 2 diabetes,” they write.
“This approach would address the pathophysiology of the disease process for type 2 diabetes; recognise adipose tissue pathology as a key underlying driver of the continuum of obesity, type 2 diabetes, and cardiovascular disease; and reap metabolic benefits far beyond blood sugar control. Such a change in treatment goals would recognise obesity as a disease with reversible complications and require a shift in clinical care.”
The paper presents the evidence of the benefits of weight loss in T2D management such as seen in the DiRECT trial which assessed an intensive lifestyle intervention in patients with overweight or obesity and T2D of less than 6 years’ duration. It showed remission of T2D at two years in 70% of those who lost 15kg or more (with an average baseline weight of 100kg).
Studies of obesity (bariatric) surgery have also shown both immediate and sustained benefits to patients with T2D and obesity – reducing the need for glucose lowering drugs within days of surgery and improving multiple indicators of health for the long-term.
The authors also discuss pharmacological treatments including GLP-1 receptor agonists, which are approved by some regulatory authorities for chronic weight management.
Studies of drugs such as semaglutide and tirzepatide have reported that 15% of bodyweight can be readily lost in more than 25% of participants with T2D, and near normalisation of blood sugar control in most participants.
Insulin resistance and body fat
Co-author Dr Ildiko Lingvay of the University of Texas Southwestern Medical Center said that most patients with type 2 diabetes will have one or more features of insulin resistance, meaning their T2D is likely driven by increasing body fat.
“Key features that identify people in whom increasing body fat is a key mechanistic contributor to type 2 diabetes are the presence of central adiposity (fat around the waist), increased waist circumference, multiple skin tags, high blood pressure, and fatty liver disease,” he said.
“In this population, we propose a treatment goal of total weight loss of at least 15%, with the intention of not merely improving blood sugar control, but rather as the most effective way to disrupt the core pathophysiology of type 2 diabetes and thus change its course in the long term and prevent its associated metabolic complications.”
The authors outline important considerations when redefining treatment goals for patients with T2D to focus on sustained weight loss. Firstly, the initiative should be driven by updating treatment guidelines to include substantial, sustained weight loss as a primary treatment target for patients with T2D.
Health systems should focus on the upstream benefits of reducing obesity in preventing or controlling T2D, rather than the higher costs of treating someone with advancing T2D and the cluster of complications that can come with the condition.
“Also vital is that medical practice management should refocus to effectively incorporate weight management for patients with type 2 diabetes,“ said Dr Lingvay.
“Health-care providers, especially those managing people with diabetes routinely, should be trained and become experienced in all aspects of obesity management. Support staff should be trained to support patients through their weight-loss journeys, and practices should consider the need for specialised staff to deliver the educational component of the new treatment strategies that are proposed.”