Obesity is a major risk factor for type 2 diabetes. Obese persons are six times more likely to develop type 2 diabetes, while the risk is 2.4 times higher for the overweight, as per a study published last year in Diabetologia.¹ The word “diabesity” coined by Dr Ethan Sims aptly illustrates the inseparable association between the two. Obesity has redefine been linked to insulin resistance and predisposes to metabolic abnormalities.² 

India too is not untouched by this and the twin epidemics of diabetes and obesity have gained strong foothold in the country.

While weight reduction is an integral part of the management of type 2 diabetes, the focus has been on achieving optimum glycemic control with anti-diabetic drugs being the mainstay of treatment. But now marking a major shift in approach to type 2 diabetes management, experts from the US, Australia, Brazil, Ireland and the UK have recommended that obesity should be the primary focus of diabetes management and control of blood sugar should take second place to it. ³ 

Randomised controlled trial like the DiRECT, Look AHEAD have demonstrated the beneficial effects of weight loss on achieving remission, partial or complete, in patients with type 2 diabetes. A weight loss of more than 15% has been reported with anti-diabetic drugs like semaglutide and tirzepatide. Similarly, >15% weight loss has been seen to exhibit mortality benefits in bariatric surgery patients, irrespective of the surgical approach used.

The predominant type 2 diabetes phenotype should determine the main treatment goal for the patient. Weight management as the primary goal is best suited to those persons (young and newly diagnosed) in whom the primary pathophysiological driver of diabetes is insulin resistance (adiposity-related diabetes). 

The other two phenotypes that have been described are diabetes with CVD, where atherosclerosis and inflammation are the key drivers of disease pathophysiology and isolated hyperglycemia with beta-cell dysfunction as the main pathophysiological driver. The diabetes treatment target is cardiocentric and glucocentric, respectively in these two phenotypes. This does not mean that weight loss has a positive effect on only the adiposity-related diabetes. Weight loss also improves cardiovascular risk factors in most patients with type 2 diabetes such as dyslipidemia, hypertension. Hence, weight management is a pertinent goal for diabetes with CVD and isolated hyperglycemia. 

The experts recommend a treatment goal of total weight loss of at least 15% and maintaining it, as the initial treatment goal for those patients with type 2 diabetes, who show features of increased adiposity such as increased waist circumference, acanthosis nigricans, multiple skin tags, hypertension, hypertriglyceridaemia, non-alcoholic fatty liver disease, PCOS, etc. They say that “weight loss of at least 15% has a greater likelihood of disrupting the disease course of type 2 diabetes than does a smaller loss”.

According to the experts, “the shift in emphasis to prioritise weight loss is important as a proactive approach to addressing a key driver of the disease process of type 2 diabetes that will have benefits well beyond lowering glucose alone”. 

It’s time to reset the goals of treatment for most patients with type 2 diabetes and also redefine the primary treatment approach to achieve these goals. Management of obesity with substantial weight loss should be the main focus for most patients with type 2 diabetes to achieve the desired glycemic targets. As an added advantage, this would prevent other metabolic complications as well. Even persons with long standing type 2 diabetes can benefit from this weight-centric approach.

The recommendations are published in The Lancet and were also presented at the virtual European Association for the Study of Diabetes (EASD) conference.

Reference

1. Theresia M Schnurr, et al. Obesity, unfavourable lifestyle and genetic risk of type 2 diabetes: a case-cohort study. Diabetologia. 2020;63(7):1324-1332. 
2. Chawla R, et al. Medical Management of Diabesity. J Assoc Physicians India. 2019 Dec;67(12):52-56. 
3. Lingvay I, et al. Obesity management as a primary treatment goal for type 2 diabetes: time to reframe the conversation. Lancet. 2021 Sep 30;S0140-6736(21)01919-X.