What to know about managing weight to prevent type 2 diabetes

A whopping 37 million people in the U.S. have diabetes, and the vast majority—over 90%—have the type 2 variety. These numbers are hardly surprising, given the obesity epidemic and that obesity is a major risk factor for type 2 diabetes. The good news is that weight loss can help improve glycemic control, and care teams have easy access to evidence-based guidelines updated annually by experts.

A synopsis of the most current clinical guidelines, published in JAMA, summarizes the major recommendations put forward by the American Diabetes Association (ADA) earlier this year for managing obesity and weight to treat type 2 diabetes. Read on to learn how the guidelines cover diet, physical activity, behavioral health and pharmacotherapy, as well as metabolic surgery if nonsurgical interventions fail.

The AMA Diabetes Prevention Guide supports physicians and health care organizations in defining and implementing evidence-based diabetes prevention strategies. This comprehensive and customized approach helps clinical practices and health care organizations identify patients with prediabetes and manage the risk of developing type 2 diabetes, including referring patients at risk to a National Diabetes Prevention Program lifestyle-change program based on their individual needs.

The guidelines were developed by the ADA Professional Practice Committee, which was made up of physician, nurse and dietician experts in diabetes care and education. The committee evaluated each through literature searches, as well as input from ADA staff and the medical community at large.

“These ADA guidelines are similar to the 2016 American Association of Clinical Endocrinologists and American College of Endocrinology comprehensive clinical practice guidelines for obesity management,” noted the authors, Adam S. Cifu, MD, Cherry Jiang, MD, and Susan Sam, MD, all of the University of Chicago.

“Diet, physical activity and behavioral therapy should be designed to achieve and maintain at least 5% weight loss,” the authors wrote. “Additional weight loss usually results in further improvements in control of diabetes and cardiovascular risk.”

“Interventions to achieve weight loss should include a high frequency of counseling to achieve a 500- to 750-kcal/d energy deficit,” the authors noted, explaining that a high frequency of counseling is at least 16 sessions in six months.

“Weight loss medications are effective as adjuncts to diet, physical activity and behavioral counseling for selected people with type 2 diabetes and body mass index (BMI) of at least 27,” the authors wrote.

Several are approved by the Food and Drug Administration and associated with at least 5% weight loss. For short-term use, meaning 12 weeks or less, these include phentermine. For longer term use, look to orlistat, extended-release phentermine-topiramate, extended-release naltrexone-bupropion, liraglutide, 3.0 mg and semaglutide, 2.4 mg.

“When selecting glucose-lowering medications for people with type 2 diabetes and overweight or obesity, consider the effect of medications on weight,” they wrote.

For example, metformin, glucagon-like peptide 1 agonists, sodium-glucose cotransporter 2 inhibitors, α-glucosidase inhibitors and amylin mimetics are associated with weight loss. Meanwhile, insulin, insulin secretagogues and thiazolidinediones are associated with weight gain.

For certain patients, “metabolic surgery should be a recommended option to treat type 2 diabetes in those … who do not achieve durable weight loss or improvement in comorbidities with nonsurgical methods,” the authors wrote.

The guidelines’ authors sounded a note of caution, writing that patients with obesity “experience weight bias” to which physicians should be attuned. Ultimately, they wrote, “use of evidence-based guidelines to manage weight in treatment of type 2 diabetes should be associated with improved glycemic control and cardiovascular risk.”

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