8. OBESITY MANAGEMENT for the TREATMENT of TYPE 2 DIABETES Treatment of Type 2 Diabetes (6–17)
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S100 Diabetes Care Volume 44, Supplement 1, January 2021 8. Obesity Management for the American Diabetes Association Treatment of Type 2 Diabetes: Standards of Medical Care in Diabetesd2021 Diabetes Care 2021;44(Suppl. 1):S100–S110 | https://doi.org/10.2337/dc21-S008 The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guide- lines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10 .2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to com- ment on the Standards of Care are invited to do so at professional.diabetes.org/ SOC. There is strong and consistent evidence that obesity management can delay the progression from prediabetes to type 2 diabetes (1–5) and is highly beneficial in the 8. OBESITY MANAGEMENT FOR THE TREATMENT OF TYPE 2 DIABETES treatment of type 2 diabetes (6–17). In patients with type 2 diabetes who also have overweight or obesity, modest and sustained weight loss has been shown to improve glycemic control and reduce the need for glucose-lowering medications (6–8). Several studies have demonstrated that in patients with type 2 diabetes and obesity, more intensive dietary energy restriction with very-low-calorie diets can substantially reduce A1C and fasting glucose and promote sustained diabetes remission through at least 2 years (10,18–21). The goal of this section is to provide evidence-based recommendations for obesity management, including dietary, behavioral, pharma- cologic, and surgical interventions, in patients with type 2 diabetes. This section focuses on obesity management in adults. Further discussion on obesity in older individuals and children can be found in Section 12 “Older Adults” (https://doi.org/10 .2337/dc21-S012) and Section 13 “Children and Adolescents” (https://doi.org/10 .2337/dc21-S013), respectively. Suggested citation: American Diabetes Associa- tion. 8. Obesity management for the treatment ASSESSMENT of type 2 diabetes: Standards of Medical Care in Diabetesd2021. Diabetes Care 2021;44(Suppl. Recommendations 1):S100–S110 8.1 Use patient-centered, nonjudgmental language that fosters collaboration © 2020 by the American Diabetes Association. between patients and providers, including people-first language (e.g., “person Readers may use this article as long as the work is with obesity” rather than “obese person”). E properly cited, the use is educational and not for 8.2 Measure height and weight and calculate BMI at annual visits or more profit, and the work is not altered. More infor- frequently. Assess weight trajectory to inform treatment considerations. E mation is available at https://www.diabetesjournals .org/content/license. care.diabetesjournals.org Obesity Management for the Treatment of Type 2 Diabetes S101 weighing, particularly for those patients 8.3 Based on clinical considerations, macronutrient composition, will who report or exhibit a high level of such as the presence of comorbid result in weight loss. Dietary weight-related distress or dissatisfaction. heart failure or significant unex- recommendations should be in- Scales should be situated in a private area plained weightgain orloss, weight dividualizedtothepatient’spref- or room. Weight should be measured and may need to be monitored and erences and nutritional needs. A reported nonjudgmentally. Care should evaluated more frequently. B If 8.9 Evaluate systemic, structural, and be taken to regard a patient’s weight (and deterioration of medical status is socioeconomic factors that may weight changes) and BMI as sensitive associated with significant weight impact dietary patterns and food health information. Additionally, assessing gain or loss, inpatient evaluation choices, such as food insecurity weight gain pattern and trajectory can should be considered, especially and hunger, access to healthful further inform risk stratificationand treat- focused on associations between food options, cultural circumstan- ment options (30). Providers should ad- ces, and social determinants of medication use, food intake, and vise patients with overweight or obesity health. C glycemic status. E and those with increasing weight trajec- 8.10 For patients who achieve short- 8.4 Accommodations should be made tories that, in general, higher BMIs increase term weight-loss goals, long-term to provide privacy during weighing. E the risk of diabetes, cardiovascular disease, ($1year)weight-maintenance and all-cause mortality, as well as other A patient-centered communication style programs are recommended when adverse healthandqualityoflifeoutcomes. that uses inclusive and nonjudgmental available. Such programs should, Providers should assess readiness to engage language and active listening, elicits pa- at minimum, provide monthly con- in behavioral changes for weight loss and tact and support, recommend on- tient preferences and beliefs, and as- jointly determine behavioral and weight- going monitoring of body weight sesses potential barriers to care should loss goals and patient-appropriate interven- (weekly or more frequently) and be used to optimize patient health out- tion strategies (31). Strategies may include other self-monitoring strategies, comes and health-related quality of life. dietary changes, physical activity, behavioral fi “ and encourage high levels of Use people- rst language (e.g., person therapy, pharmacologic therapy, medical ” “ physical activity (200–300 min/ with obesity rather than obese per- devices, and metabolic surgery (Table ” fi week). A son )toavoidde ning patients by their 8.1). The latter three strategies may be 8.11 Short-term dietary intervention condition (22,23,23a). prescribed for carefully selected patients using structured, very-low-calorie Height and weight should be measured as adjuncts to dietary changes, physical diets (800–1,000 kcal/day) may and used to calculate BMI at annual visits activity, and behavioral counseling. or more frequently when appropriate be prescribed for carefully se- (19). BMI, calculated as weight in kilo- lected patients by trained practi- DIET, PHYSICAL ACTIVITY, AND tioners in medical settings with grams divided by the square of height in BEHAVIORAL THERAPY meters (kg/m2), will be calculated auto- closemonitoring.Long-term,com- matically by most electronic medical re- Recommendations prehensiveweight-maintenance cords. Use BMI to document weight status 8.5 Diet, physical activity, and behav- strategies and counseling should (overweight: BMI 25–29.9 kg/m2; obesity ioral therapy designed to achieve be integrated to maintain weight class I: BMI 30–34.9 kg/m2; obesity class II: and maintain $5% weight loss is loss. B BMI 35–39.9 kg/m2; obesity class III: BMI recommended for most patients 2 with type 2 diabetes who have $40 kg/m ). Note that misclassification Among patients with both type 2 diabe- overweight or obesity and are can occur, particularly in very muscular tes and overweight or obesity who have ready to achieve weight loss. or frail individuals. In some populations, inadequate glycemic,bloodpressure, Greater benefits in control of notably Asian and Asian American pop- and lipid control and/or other obesity- diabetes and cardiovascular risk ulations, the BMI cut points to define related medical conditions, modest and maybegained from even greater overweight and obesity are lower than in sustained weight loss improves glycemic weight loss. B other populations due to differences in control, blood pressure, and lipids and 8.6 Such interventions should in- body composition and cardiometabolic may reduce the need for medications to clude a high frequency of coun- risk (Table 8.1) (24,25). Clinical considera- control these risk factors (6–8,32). seling ($16 sessions in 6 months) tions, such as the presence of comorbid Greater weight loss may produce even and focus on dietary changes, heart failure or unexplained weight change, greater benefits (20,21). For a more de- physical activity, and behavioral may warrant more frequent weight mea- tailed discussion of lifestyle management strategies to achieve a 500–750 surement and evaluation (26,27). If weigh- approaches and recommendations see kcal/day energy deficit. A ing is questioned or refused, the practitioner Section 5 “Facilitating Behavior Change 8.7 An individual’s preferences, mo- should be mindful of possible prior stigma- and Well-being to Improve Health tivation, and life circumstances tizing experiences and query for concerns, Outcomes” (https://doi.org/10.2337/ should beconsidered, along with and the value of weight monitoring should dc21-S005). For a detailed discussion medical status, when weight loss be explained as a part of the medical eval- of nutrition interventions, please also interventions are recommended. C uation process that helps to inform treat- refer to “Nutrition Therapy for Adults 8.8 Behavioral changes that create ment decisions (28,29). Accommodations With Diabetes or Prediabetes: A Con- an energy deficit, regardless of should be made to ensure privacy during sensus Report” (33). S102 Obesity Management for the Treatment