Treating Patients with “DIABESITY”: Challenges and Opportunities

A Message from Dr. Christopher Still

Christopher Still, DO, FACN, FACP, Co-Clinical Editor, Bariatric Times; Medical Director for the Center for Nutrition and Weight Management, and Director for Geisinger Obesity Research Institute, Geisinger Medical Center, Danville, Pennsylvania. Dr. Still is also a board member of the Obesity Action Coalition, Tampa, Florida.

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Dear Colleagues,
When patients present with obesity, physicians are faced with both a unique challenge and opportunity in treating not only their obesity, but also their comorbidities, such as type 2 diabetes mellitus (T2DM), obstructive sleep apnea (OSA), hypertension and, most commonly, metabolic syndrome. Metabolic syndrome is defined as having at least three of the following: abdominal obesity, hypertriglyceridemia, low level of high-density lipoproteins, hypertension, and high fasting plasma glucose level. It is associated with an increased risk for development of T2DM and cardiovascular disease. As 90 percent of patients who have T2DM are also overweight,[1–3] it is clear that these two diseases exist in tandem. The treatments too should be complimentary, meaning what is good in improving one disease is also good for the other, but that was not always the case.

Until recently, standard treatment for T2DM were insulin, sulfonylureas, like glipizide (Glucotrol®, Pfizer, Inc., New York, New York), and thiazolidinediones, like pioglitazone (Actos®, Takeda Pharmaceuticals America, Inc., Deerfield, Illinois). While effective in lowering blood sugar, I have found that they also, unfortunately, cause weight gain and fluid retention. Clinically, this is a very frustrating problem for the provider and patient alike.
Fortunately, we have newer medications that treat the T2DM while helping patients with weight loss and or maintenance. This is a huge opportunity and breakthrough in the treatment of both diseases. Metformin (Glucophage®, Bristol-Myers Squibb Company, New York, New York) is an insulin sensitizer that has been around a long time. It works on the liver to help the body be more sensitive –or use insulin more efficiently—so the body doesn’t have to secrete as much in order to control blood sugar. Since insulin is an anabolic hormone, meaning it causes weight gain or retards weight loss, producing less is good. Metformin has also been shown to cause modest weight loss,[4,5] but the exact mechanism is not clearly understood. It is not just the insulin sensitizing effect—the thiazolidinediones are also insulin sensitizers that work on the muscle, however, they tend to cause weight gain.

Recent Endocrine Society Guidelines, titled, Pharmacological management of obesity[6] were developed for clinicians to use a “patient centric” approach to treating a patient with obesity. It lists metformin as the first-line treatment. They also suggest the use of other antidiabetic medications that have additional actions to promote weight loss, such as glucagon-like peptide-1 (GLP-1) analogs or sodium-glucose-linked transporter-2 (SGLT-2) inhibitors, in addition to metformin.

When seeing patients, remember to take a thorough medication history. Many patients I see in clinic with T2DM are on one or more medications. They often know which medication(s) have contributed to their weight gain. My aim is to have patients decrease or stop medications that cause weight gain and prescribe medications mentioned previously that will help with glycemic control and, hopefully, weight loss. While this is a wonderful opportunity, some barriers exist. For instance, some insurers require the patient to be “not well controlled” on one or more of the traditional medications in order for them to cover new medications. The good news is, as stated before, metformin has been around a long time and is generic and relatively inexpensive. The biggest problem with metformin is the potential gastrointestinal upset.

Finally, and I can’t emphasize this enough, although we have newer medications for the treatment of T2DM, the cornerstone treatments remain diet, exercise, and behavior modification. Patients often put more credence in the medications we prescribe, but all medications will work best in combination with a lower glycemic index meal plan and modest exercise. Also, as you all know, the earlier we can intervene with bariatric or “metabolic” surgery, the best chance patients have in remitting their T2DM—not to mention their OSA, fatty liver disease, and other comorbidities. So yes, Raul, even with better medications for the treatment of T2DM, believe it or not, I still think bariatric surgery remains the best long-term treatment option for patients not able to reach their target A1c.

Sincerely,
Christopher Still, DO, FACN, FACP

References
1.    Diabetes UK. Diabetes and obesity rates soar. Diabetes UK 2009. www.diabetes.org.uk/About_us/News_Landing_Page/Diabetes-and-obesity-rates-soar/. Accessed April 22, 2015.
2.    Smyth S, Heron A. Diabetes and obesity: the twin epidemics. Nat Med. 2006;12:75–80.
3.    Norris SL, Zhang X, Avenell A et al. Long-term non-pharmacologic weight loss interventions for adults with type 2 diabetes. Cochrane Database Syst Rev. 2005;2:CD004095.
4.    Diabetes Prevention Program Research Group. Long-term safety, tolerability, and weight loss associated with metformin in the Diabetes Prevention Program Outcomes Study. Diabetes Care. 2012;35:731–737
5.    Seifarth C, Schehler B, Schneider HJ. Effectiveness of metformin on weight loss in non-diabetic individuals with obesity. Exp Clin Endocrinol Diabetes. 2013;121:27–31.
6.    Apovian CM1, Aronne LJ, Bessesen DH, et al. Pharmacological management of obesity: an endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2015;100(2):342–362. Epub 2015 Jan 15.

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