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Sustained weight loss of ≥5% of initial body weight can improve glycemic control and cardiovascular risk factors.
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In people with diabetes and obesity, weight loss and A1C lowering can be achieved with healthy behaviour interventions as the cornerstone of treatment. Weight management medications can improve glycemic and metabolic control in people with diabetes and obesity.
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Bariatric surgery may be considered appropriate for people with diabetes and obesity.
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When selecting the most appropriate antihyperglycemic agent(s) for a person with diabetes, the effect on body weight should be considered.
Key Messages for People with Diabetes
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When you have diabetes, having overweight or obesity increases your risk for complications.
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Healthy behaviour modifications, including regular physical activity and eating well can help with your blood glucose control and reduce your risk for other health problems associated with diabetes.
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Your diabetes health-care team can help you with weight management. For some people with diabetes, weight management medications and bariatric surgery may be helpful.
Introduction
Obesity is a chronic health problem that is often progressive and difficult to treat. An estimated 80% to 90% of people with type 2 diabetes have overweight or obesity (
). In addition, intensive insulin therapy and some antihyperglycemic medications are associated with weight gain which, in turn, leads to obesity-related comorbid conditions (
UK Prospective Diabetes Study (UKPDS) Group Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33).
). The relationship between increasing body fat accumulation and adverse health outcomes exists throughout the range of overweight and obesity in men and women of all age groups (
). Weight loss has been shown to improve glycemic control by increasing insulin sensitivity and glucose uptake and diminishing hepatic glucose output (
Health Canada guidelines recommend that the initial assessment of people with diabetes should include the following measurements: height, weight, calculation of body mass index (BMI) (kg/m2) and waist circumference (WC) (
Expert Panel on Detection Evaluation, Treatment of High Blood Cholesterol in Adults
Executive summary of the third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel III).
). Table 2 lists National Cholesterol and Education Program Adult Treatment Panel III (NCEP-ATP III) WC values. The International Diabetes Federation (IDF) has proposed population specific WC cut-off values; however, these guidelines have not been fully validated against the development of clinical events (
WC cut-offs may be lower in some populations (e.g. older individuals, Asian population [see Table 3]), especially in the presence of the metabolic syndrome (such as hypertriglyceridemia).
Increased WC can also be a marker for increased risk, even in persons with healthy weight.
Risk of developing health problems
Men ≥102 cm
Increased
Women ≥88 cm
Increased
WC, waist circumference.
* WC cut-offs may be lower in some populations (e.g. older individuals, Asian population [see Table 3]), especially in the presence of the metabolic syndrome (such as hypertriglyceridemia).
† Increased WC can also be a marker for increased risk, even in persons with healthy weight.
In people with diabetes and overweight or obesity, the reasons for the previous or current positive energy balance can often be identified. People with diabetes often take medications that are associated with weight gain; these include antihyperglycemic, antihypertensive, pain relief and antidepressant agents (
). Assessing psychological aspects of eating behaviours, such as emotional eating, binge eating, attention deficit and hyperactivity disorder (ADHD), and depression, is also relevant in determining reasons for weight gain (
Exercise capacity and cardiovascular/metabolic characteristics of overweight and obese individuals with type 2 diabetes: The Look AHEAD clinical trial.
The goals of therapy for people with diabetes and overweight or obesity are to achieve optimal glycemic and metabolic control and, ultimately, improve quality of life, morbidity and mortality. Attaining and maintaining a healthy body weight, and preventing weight regain, are key components of optimizing glycemic control in people with diabetes. Often people with obesity and diabetes have greater difficulty with achieving weight loss compared to people with obesity but without diabetes (
). Health-care providers should attempt to minimize use of weight-inducing agents without compromising glycemic control, or switch the person with diabetes to agents not associated with weight gain (
For many people with diabetes, prevention of further weight gain is a realistic and sustainable target. A modest weight loss of 5% to 10% of initial body weight can improve insulin sensitivity, glycemic control and blood pressure. Greater amounts of weight loss may be needed to improve OSA and dyslipidemia (
). A negative energy balance of approximately 500 kcal/day is needed to achieve this weight loss. Metabolic and physiologic adaptations following weight loss can promote weight regain and make sustained weight loss challenging (
). Adjustment of the caloric deficit may be required as weight loss progresses. In addition, as individuals lose weight, adjustment in antihyperglycemic medications may be required to avoid hypoglycemia (
Surgically and conservatively treated obese patients differ in psychological factors, regardless of body mass index or obesity-related co-morbidities: A comparison between groups and an analysis of predictors.
The National Institutes of Health (NIH)-sponsored multicentre Look AHEAD (Action for Health in Diabetes) trial, investigated the effects of lifestyle intervention on changes in weight, fitness and cardiovascular (CV) risk factors and events in people with type 2 diabetes (
Look AHEAD Research Group Long-term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus: Four-year results of the Look AHEAD trial.
). This provided evidence that lifestyle changes can have a positive impact on weight change, fitness level and a decrease in medications, along with a small decrease in glycated hemoglobin (A1C) and other health benefits (
The American Diabetes Association (ADA) has been actively involved in the development and dissemination of diabetes care standards, guidelines, and related documents for many years.
). Interventions that combine dietary modification, increased and regular physical activity and behaviour therapy are the most effective at improving health outcomes (
Dietary plans for people with diabetes should be evidence based and nutritionally adequate to ensure optimal health. Specific dietary recommendations for weight loss can be found in the Nutrition Therapy chapter, p. S64. Moderate carbohydrate reduction has been beneficial in people with diabetes, demonstrating improvements in high density lipoprotein (HDL) and triglycerides, blood glucose stability, and reductions in diabetes medication requirements (
People with obesity and diabetes benefit from advice by qualified professionals on appropriate serving sizes, caloric and carbohydrate intake and how to select nutrient-rich meals, as demonstrated by the Look AHEAD Study (
Look AHEAD Research Group Long-term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus: Four-year results of the Look AHEAD trial.
The effect of antihyperglycemic medication on body weight varies by class of medication. Some antihyperglycemic medications are associated with weight gain (insulin, insulin secretagogues, thiazolidinediones), and the magnitude of weight gain can vary from 4 to 9 kg or more (
New insulin glargine 300 units/mL versus glargine 100 units/mL in people with type 1 diabetes: A randomized, phase 3a, open-label clinical trial (EDITION 4).
Patient-level meta-analysis of the EDITION 1, 2 and 3 studies: Glycaemic control and hypoglycaemia with new insulin glargine 300 U/ml versus glargine 100 U/ml in people with type 2 diabetes.
). People with type 1 diabetes may have a tendency toward slightly higher body weight with use of neutral protamine Hagedorn (NPH) insulin compared to long-acting basal insulin analogues (
Insulin detemir used in basal-bolus therapy in people with type 1 diabetes is associated with a lower risk of nocturnal hypoglycaemia and less weight gain over 12 months in comparison to NPH insulin.
) (Table 5). When used to treat people with overweight or obesity and type 2 diabetes, both have been demonstrated to improve glycemic control and to reduce the doses of antihyperglycemic agents that promote weight gain (
). For people with type 2 diabetes or prediabetes, pharmacotherapy is indicated for chronic weight management with a BMI ≥27.0 kg/m2, in whom healthy behaviour interventions have been unsuccessful or insufficient for improvement in health. Clinical trials with weight loss agents have confirmed a smaller degree of weight loss in people with diabetes compared to people with obesity without diabetes (
Effect of orlistat on glycaemic control in overweight and obese patients with type 2 diabetes mellitus: A systematic review and meta-analysis of randomized controlled trials.
Liraglutide is a GLP-1 receptor agonist, which acts to increase satiety and decrease hunger in the brain. While most of the blood glucose lowering benefits of liraglutide are seen at 1.8 mg per day, there is an additional dose dependent weight loss effect up to 3.0 mg per day (
). Liraglutide is indicated at 1.2 or 1.8 mg per day for the treatment of type 2 diabetes, and at 3.0 mg per day for weight management in people with (
). In people with type 2 diabetes, liraglutide 3.0 mg is effective to facilitate weight loss in addition to improving glycemic control and metabolic parameters, in combination with a lifestyle modification program (
One-year sustained glycemic control and weight reduction in type 2 diabetes after addition of liraglutide to metformin followed by insulin detemir according to HbA1c target.
) (see Reducing the Risk of Developing Diabetes chapter, p. S20). Gastrointestinal side effects, including nausea, are generally transient in nature. Gallbladder disease and acute pancreatitis are rare potential complications of treatment (
Pharmacotherapy directed at weight management has not been adequately studied in people with type 1 diabetes.
Bariatric Surgery
Bariatric surgery is a therapeutic option in the management of people with type 2 diabetes and obesity. “Bariatric surgery” is the preferred term over “metabolic surgery”, as the benefits encompass metabolic, mechanical and psychological improvements. These procedures can result in sustained weight loss and significant improvements in obesity-related comorbidities, including control or remission of type 2 diabetes. Surgery is a treatment option for people with BMI ≥40.0 kg/m2 or with BMI 35.0 to 39.9 kg/m2 in the presence of comorbidities, such as type 2 diabetes, who have demonstrated an inability to achieve weight loss maintenance following an adequate trial of healthy behaviour interventions and/or pharmacotherapy. Evaluation for candidacy and appropriateness for surgical procedures includes assessment by an interdisciplinary team with medical, surgical, psychiatric and nutritional expertise (
Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient-2013 update: Cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery.
). The benefits and risks of bariatric surgery must be carefully considered for each individual, and candidates must be prepared to comply with lifelong medical surveillance.
Commonly performed bariatric surgeries include Roux-en-Y gastric bypass (RYGB) (Figure 2), sleeve gastrectomy (Figure 1), and biliopancreatic diversion with or without duodenal switch (BPD/BPD-DS) (Figure 3). These procedures lead to sustained weight loss and improvements in or remission of type 2 diabetes (
). The likelihood of improvement in control or remission of type 2 diabetes is higher with Roux-en-Y gastric bypass surgery, sleeve gastrectomy or BPD compared to gastric banding (
Bariatric-metabolic surgery versus conventional medical treatment in obese patients with type 2 diabetes: 5 year follow-up of an open-label, single-centre, randomised controlled trial.
). The gastric band has largely been abandoned in North America due to less sustained weight loss and metabolic benefits, and high surgical complication rates necessitating band removal (
Figure 1Gastric sleeve. A longitudinal (sleeve) resection of the stomach reduces the functional capacity of the stomach and eliminates the ghrelin-rich gastric fundus
Figure 2Roux-en-Y gastric bypass. A surgical stapler is used to create a small gastric pouch. Ingested food bypasses ~95% of the stomach, the entire duodenum and a portion of the jejunum
Figure 3Biliopancreatic diversion with duodenal switch. The stomach and small intestine are surgically reduced so that nutrients are absorbed only in a 50-cm “common limb”
Predictors of likelihood of remission of type 2 diabetes after bariatric surgery include higher preoperative serum C-peptide, younger age, shorter duration of diabetes and lack of need for insulin therapy preoperatively (
). People who experience remission of type 2 diabetes with bariatric surgery may experience recurrence of diabetes years later; thus, life-long monitoring and screening for recurrence is important (
). Evidence of the risks and outcomes of bariatric metabolic surgery in people with type 2 diabetes and BMI between 30 to 35 kg/m2 is very limited and cannot be recommended at this time.
Bariatric surgery can prevent the development and progression of albuminuria (
For people with overweight or obesity who have or are at risk for diabetes, an interprofessional weight management program is recommended to prevent weight gain and improve CV risk factors [Grade A, Level 1A (
Look AHEAD Research Group Long-term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus: Four-year results of the Look AHEAD trial.
Weight management medication may be considered in people with diabetes and overweight or obesity to promote weight loss and improved glycemic control [Grade A, Level 1A (
In adults with type 2 diabetes and overweight or obesity, the effect of antihyperglycemic agents on body weight should be considered when selecting pharmacotherapy [Grade D, Consensus].
4.
Bariatric surgery may be considered for selected adults with type 2 diabetes and obesity with BMI ≥35.0 when healthy behaviour interventions with or without weight management medication(s) are inadequate in achieving target glycemic control or healthy weight goals [Grade A, Level 1A (
*Excluded based on: population, intervention/exposure, comparator/control or study design.
From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(6): e1000097. doi:10.1371/journal.pmed1000097 (
Dr. Wharton reports personal fees from Novo Nordisk, Janssen, Lilly, Merck, and Valeant, outside the submitted work. Dr. Lau reports grants and personal fees from AstraZeneca, Boehringer Ingelheim, and Novo Nordisk; and personal fees from Valeant, Amgen, Merck, Janssen, Eli Lilly, Sanofi, and SHIRE, outside the submitted work. Dr. Pedersen reports personal fees and non-financial support from Novo Nordisk, personal fees and non-financial support from Janssen, grants, personal fees and non-financial support from Eli Lilly, personal fees from Merck, personal fees and non-financial support from Valeant, grants, personal fees and non-financial support from Astra Zeneca, grants and personal fees from Abbott, grants and personal fees from Boehringer Ingelheim, grants and personal fees from Sanofi, personal fees from Prometic, and personal fees from Pfizer, outside the submitted work. Dr. Sharma reports personal fees from Novo Nordisk, Valeant, Merck, and Berlin Chemie, outside the submitted work.
Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33).
Expert Panel on Detection Evaluation, Treatment of High Blood Cholesterol in Adults
Executive summary of the third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel III).
Exercise capacity and cardiovascular/metabolic characteristics of overweight and obese individuals with type 2 diabetes: The Look AHEAD clinical trial.
Surgically and conservatively treated obese patients differ in psychological factors, regardless of body mass index or obesity-related co-morbidities: A comparison between groups and an analysis of predictors.
Long-term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus: Four-year results of the Look AHEAD trial.
The American Diabetes Association (ADA) has been actively involved in the development and dissemination of diabetes care standards, guidelines, and related documents for many years.
New insulin glargine 300 units/mL versus glargine 100 units/mL in people with type 1 diabetes: A randomized, phase 3a, open-label clinical trial (EDITION 4).
Patient-level meta-analysis of the EDITION 1, 2 and 3 studies: Glycaemic control and hypoglycaemia with new insulin glargine 300 U/ml versus glargine 100 U/ml in people with type 2 diabetes.
Insulin detemir used in basal-bolus therapy in people with type 1 diabetes is associated with a lower risk of nocturnal hypoglycaemia and less weight gain over 12 months in comparison to NPH insulin.
Effect of orlistat on glycaemic control in overweight and obese patients with type 2 diabetes mellitus: A systematic review and meta-analysis of randomized controlled trials.
One-year sustained glycemic control and weight reduction in type 2 diabetes after addition of liraglutide to metformin followed by insulin detemir according to HbA1c target.
Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient-2013 update: Cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery.
Bariatric-metabolic surgery versus conventional medical treatment in obese patients with type 2 diabetes: 5 year follow-up of an open-label, single-centre, randomised controlled trial.
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