The development of glucagon-like peptide-1 (GLP-1) receptor agonists and combination gastric inhibitor polypeptide (GIP)/GLP-1 receptor agonists have transformed weight management. But while these agents can produce a dramatic loss of 35% or more of body weight, they are not the answer for everyone with type 2 diabetes and excess adipose tissue.
“Obesity is a complex and challenging condition,” said Dina Griauzde, MD, MSc, Assistant Professor of Internal Medicine, University of Michigan Medical School; Research Director, Michigan Medicine Weight Navigation Program, Elizabeth Weiser Caswell Diabetes Institute; and Medical Director, MOVE! Medication Program, Veterans Administration Ann Arbor Healthcare System. “Our patients have different problems, and not all have access to the latest and most effective treatments due to cost and insurance.”
Dr. Griauzde explored multiple approaches to managing adiposity during Incorporating New Weight Management Strategies for Obesity into Type 2 Diabetes Care—Medical Management and Surgery on Sunday, June 5. The session was livestreamed can be viewed on-demand by registered meeting participants at ADA2022.org. If you haven’t registered for the 82nd Scientific Sessions, register today to access the valuable meeting content.
Most type 2 diabetes complications are related to excess adiposity, Dr. Griauzde said. Body mass index (BMI) is an imperfect measure, and metabolic dysfunction occurs across the BMI spectrum.
“What matters is where the fat is stored,” she explained. “Visceral versus subcutaneous fat is the key driver to metabolic dysfunction. The presence of central adiposity should move us to prioritize weight management in the treatment of type 2 diabetes.”
There are direct correlations between greater weight loss and greater benefits in type 2 diabetes, Dr. Griauzde noted. Losing 2%-5% of body weight can reduce blood glucose and blood pressure. Losing 4%-10% improves mobility, mood, fertility, and lipids while reducing health care costs. Losing more than 10% can result in type 2 diabetes control with the use of fewer or no medications, reduced cardiovascular events and mortality, and improved quality of life.
Low-calorie and low-carbohydrate diets can be similarly effective in weight loss, though most individuals eventually regain weight. Many type 2 diabetes medications can be used to improve weight management. Naltrexone/bupropion, liraglutide, phentermine/topiramate, and semaglutide have been approved by the U.S. Food and Drug Administration for weight loss. Tirzepatide, the first dual GLP/GLP-1 receptor agonist, is even more effective, but has not yet been approved for weight loss.
“Despite the availability of effective agents, fewer than 2% of patients who need weight loss medications actually get them prescribed,” Dr. Griauzde said. “It is not enough to have them FDA-approved. We have to get them into practice with providers who are trained in weight management and comfortable with the wide array of treatment options.”
Bariatric surgery is another option. Surgery produces more total weight loss and more durable weight loss than other treatments, said Kristina Lewis, MD, MPH, SM, Associate Professor of Epidemiology and Prevention, Wake Forest University School of Medicine. About two-thirds of patients see their hypertension, dyslipidemia, obstructive sleep apnea, and other obesity-related conditions improve or resolve following bariatric surgery.
A1C drops a median of 2% following bariatric surgery compared to 0.5% for medical and lifestyle approaches. Up to 63% of type 2 diabetes patients remain in remission five years after surgery.
“Bariatric surgery is expensive but highly cost-effective,” Dr. Lewis said. “We see between $6,000 and $12,000 per quality adjusted life year (QALY) with bariatric surgery versus more than $40,000 per QALY for intensive medical therapy for glycemic control.”
It is not yet clear how surgery compares to the current GLP-1 receptor agonist and dual GIP/GLP-1 receptor agonist approaches.
“Some of the advantages for surgery may erode with these newer medications,” she said.
The key to successful weight management is recognizing and treating obesity as a chronic disease, not as an individual failing.
“There is a huge problem with stigma, both in the clinic and in the hospital,” said Jackie Boucher, MS, RDN, President, Children’s HeartLink. “Talking about weight can be a very emotional topic, very personal. We have to think about stigma and our own attitudes. When it comes to weight management, not everything is under the individual’s control.”
Most patients who undergo bariatric surgery self-refer, she continued. Many clinicians, both primary care and diabetes-specific providers, are reluctant to suggest, or even discuss, bariatric surgery.
“We need to understand patient preferences, experiences, and goals,” Boucher said. “And like so much in health care, obesity treatment requires a team approach. Use your team to make management easier and individualize therapy.”