Treating Diabetes and Obesity: Complementary Approaches to Care
by Nicholas Pennings, DO, FOMA
Dr. Pennings is Associate Professor and Chair of family medicine at Campbell University School of Osteopathic Medicine (CUSOM), serves as the director of the Campbell University Health Center, and is an Executive Director of Clinical Education for the Obesity Medicine Association (OMA).
Funding: No funding was provided.
Disclosures: The author has no conflicts of interest relevant to the content of this article.
Bariatric Times. 2021;18(11):20
November is National Diabetes Month, a fitting occasion to remind ourselves of the association between obesity and diabetes and to understand the importance of treating obesity first. Obesity and Type 2 diabetes rise and fall together, as we have known for many years, and the number of adults with obesity has increased by more than 200 percent in recent decades. Type 1, or insulin-dependent, diabetes now accounts for only around 10 percent of total diabetes cases, leaving a host of patients whose condition originates not from pancreatic dysfunction, but insulin resistance. Several mechanisms underlie the connection between obesity and lack of response to insulin.
The risk of developing prediabetes and Type 2 diabetes increases as body mass index (BMI) increases. An increase in visceral adipose tissue increases Type 2 diabetes risk, in part because visceral fat itself responds weakly to insulin. Less susceptible to the anti-lipolytic property of insulin than other tissues, this fat becomes a source of lipotoxic circulating free fatty acids, which in turn reduce insulin sensitivity in muscle and liver tissue, limiting glucose disposal after meals.
Moreover, as adipose cells reach and exceed their normal storage capacity, the cells increase production of cytokines, causing inflammation. Increased circulating cytokines, along with increased free fatty acids, contribute to both insulin resistance and beta cell failure, resulting in prediabetes and eventually Type 2 diabetes. These processes also promote further weight gain. There is a powerful feedback loop at work here: overweight leads to insulin resistance, which leads to further overweight, which leads to further insulin resistance.
Therefore, practitioners should focus on obesity treatment when treating patients with Type 2 diabetes and arm themselves with the tools and principles of obesity medicine as a means of preventing Type 2 diabetes.
Two birds, one stone. More than a billion adults worldwide have overweight, at least 300 million of those have the disease of obesity. In the United States, more than 70 percent of adults have overweight, and adults with obesity make up over 40 percent of the population. All these people are at increased risk for prediabetes and Type 2 diabetes. The scope of the problem is daunting, but the good news is that our understanding of the treatment of obesity and diabetes has been refined to a point that we can address both at once.
The Diabetes Prevention Program has found that even a seven percent decrease in body weight was associated with a 58 percent reduction in the risk of developing Type 2 diabetes. A weight loss of 5 to 10 percent improves glycemic control, and a weight loss of 20 percent can potentially reverse Type 2 diabetes. Weight loss can be further aided by treating Type 2 diabetes with medications that promote weight loss, including metformin, GLP-1 agonists, and SGLT2 inhibitors. By treating diabetes with an obesity focus, the clinician can control glucose levels while also treating the underlying pathophysiology of Type 2 diabetes, insulin resistance.
There is no need to exclude weight loss from treatment plans centered on glycemic control. Clinicians now have the means to take out two birds with one stone, slowing the vicious cycle of weight gain and insulin resistance and returning balance to a patient’s body signals.
Bariatric surgery and diabetes. Bariatric surgery is shown to be an effective treatment strategy for both diseases. We most often discuss this intervention in the context of obesity treatment, but it benefits patients with diabetes as well, especially Type 2 diabetes. Five-year outcomes from the STAMPEDE trial show that bariatric surgery is more effective than intensive medical therapy for controlling glucose. The benefits of the surgery seem to extend past caloric restriction and point to improved metabolic function. The International Diabetes Foundation, meanwhile, notes that surgical intervention can be a cost-effective treatment for Type 2 diabetes. Clinicians should investigate treatments like bariatric surgery for patients with obesity and Type 2 diabetes; the link between Type 2 diabetes and obesity goes deep enough that patients could stand to make gains on multiple fronts simultaneously from a single intervention.
Obesity and diabetes resources. The Obesity Medicine Association (OMA) provides several resources to educate healthcare providers on the connection between obesity and adiposity-related diseases like Type 2 diabetes. These resources include specialized continuing education tracks that review the role of weight management in the treatment of diabetes. In addition, practitioners may avail themselves of tools including the Obesity Algorithm® and American Board of Obesity Medicine (ABOM) preparation materials.
Our best evidence at the moment recommends a synergistic form of care in cases of Type 2 diabetes and obesity. These correlated conditions exacerbate each other; when clinicians emphasize principles of obesity medicine in their diabetes treatment plans, they can be confident that their approach gives patients a straight path toward better health.
For more obesity medicine resources or to become an OMA member, visit: https://obesitymedicine.org/.
Category: Medical Methods in Obesity Treatment, Past Articles
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