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8. Obesity Management for the Treatment of Type 2 Diabetes: Standards of Medical Care in Diabetes—2020

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8. Obesity Management for the Treatment of Type 2 Diabetes: Standards of Medical Care in Diabetes—2020 Diabetes Care Volume 43, Supplement 1, January 2020 S89 This article includes updates in the form of annotations as of June 2020. See pages S92 and S93. 8. Obesity Management for the American Diabetes Association Treatment of Type 2 Diabetes: Standards of Medical Care in Diabetesd2020 Diabetes Care 2020;43(Suppl. 1):S89–S97 | https://doi.org/10.2337/dc20-S008 8. OBESITY MANAGEMENT FOR THE TREATMENT OF TYPE 2 DIABETES 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 guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsi- ble 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/dc20-SINT). Readers who wish to comment 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 beneficial in the 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 glycemiccontrolandtoreducethe needforglucose-lowering medications (6–8).Small studies have demonstrated that in patients with type 2 diabetes and obesity, more extreme dietary energy restriction with very low-calorie diets can reduce A1C to ,6.5% (48 mmol/mol) and fasting glucose to ,126 mg/dL (7.0 mmol/L) in the absence of pharmacologic therapy or ongoing procedures (10,18,19). The goal of this section is to provide evidence-based recommendations for weight-loss therapy, including diet, behavioral, pharmacologic, and surgical interventions, for obesity management as treatment for hyperglycemia in type 2 diabetes. ASSESSMENT Recommendations 8.1 Measure height and weight and calculate BMI at annual visits or more frequently. E Suggested citation: American Diabetes Associa- 8.2 Based on clinical considerations, such as the presence of comorbid heart tion. 8. Obesity management for the treatment failure or significant unexplained weight gain or loss, weight may need to be of type 2 diabetes: Standards of Medical Care in d monitored and evaluated more frequently. B If deterioration of medical status Diabetes 2020. Diabetes Care 2020;43(Suppl. 1): S89–S97 (https://doi.org/10.2337/dc20-s008) is associated with significant weight gain or loss, inpatient evaluation should fi © 2019 by the American Diabetes Association. be considered, speci cally focused on the association between medication Readers may use this article as long as the work use, food intake, and glycemic status. E is properly cited, the use is educational and not 8.3 For patients with a high level of weight-related distress, special accommo- for profit, and the work is not altered. More infor- dations should be made to ensure privacy during weighing. E mation is available at http://www.diabetesjournals .org/content/license. S90 Obesity Management for the Treatment of Type 2 Diabetes Diabetes Care Volume 43, Supplement 1, January 2020 Height and weight should be mea- DIET, PHYSICAL ACTIVITY, AND 8.10 To achieve weight loss of .5%, sured and used to calculate BMI at an- BEHAVIORAL THERAPY short-term (3-month) interven- nual visits or more frequently when Recommendations tions that use very low-calorie appropriate (20). BMI can be calcu- 8.4 Diet, physical activity, and be- diets (#800 kcal/day) and meal lated manually as weight divided by havioral therapy designed to replacements may be prescribed the square of height in meters (kg/m2) achieve and maintain $5% for carefully selected patients by or electronically using the electronic weight loss is recommended trained practitioners in medical medical record or other resources (20). for patients with type 2 diabetes care settings with close medical Clinical considerations, such as the who have overweight or obesity monitoring. To maintain weight presence of comorbid heart failure and are ready to achieve weight loss, such programs must incor- or unexplained weight change, may fi porate long-term comprehensive warrant more frequent weight mea- loss. Greater bene ts in control weight-maintenance counseling. B surement and evaluation (21,22). of diabetes and cardiovascular When weighing is questioned or re- risk factors may be gained from Among patients with both type 2 diabe- fused, the practitioner should query even greater weight loss. B tes and overweight or obesity who also for concerns, and the need for weight 8.5 Such interventions should be $ have inadequate glycemic, blood pres- monitoring should be explained as a high intensity ( 16 sessions in 6 sure, and lipid control and/or other part of the medical evaluation process months) and focus on dietary obesity-related medical conditions, life- that helps to inform treatment deci- changes, physical activity, and be- style changes that result in modest and sions (23,24). If patients report or havioral strategies to achieve a sustained weight loss produce clinically exhibit a high level of weight-related 500–750 kcal/day energy deficit. A meaningful reductions in blood glucose, distress, special accommodations should 8.6 Individual’smotivation,lifecircum- A1C, and triglycerides (6–8). Greater be made to ensure privacy during weigh- stances, and willingness to make weight loss produces even greater ben- ing. Once calculated, BMI should be clas- lifestyle changes to achieve weight efits, including reductions in blood pres- sified to determine the presence of loss should be assessed along with sure, improvements in LDL and HDL overweight or obesity, discussed with medical status when weight loss cholesterol, and reductions in the need the patient, and documented in the interventions are undertaken. C for medications to control blood glucose, patient record. In Asian Americans, the 8.7 As all energy-deficit food intake blood pressure, and lipids (6–8,28), and BMI cut points to define overweight and will result in weight loss, eating may result in achievement of glycemic obesity are lower than in other popu- plans should be individualized to goals in the absence of glucose-lowering lations (Table 8.1) (25,26). Providers meet the patient’sprotein,fat, agent use in some patients (29,30). For should advise patients with over- and carbohydrate needs while a more detailed discussion of lifestyle weight or obesity that, in general, still promoting weight loss. A management approaches and recom- higher BMIs increase the risk of car- 8.8 Food availability should be que- mendations see Section 5 “Facilitating diovascular disease and all-cause mor- ried, as well as other cultural Behavior Change and Well-being to Im- tality, as well as other adverse health circumstances that could affect prove Health Outcomes” (https://doi and quality of life outcomes. Providers dietary patterns. C .org/10.2337/dc20-S005). For a detailed should assess each patient’sreadi- 8.9 For patients who achieve short- discussion of nutrition interventions ness to engage in behavioral changes term weight-loss goals, long-term please also refer to “Nutrition Therapy for weight loss and jointly deter- ($1 year) weight maintenance for Adults with Diabetes or Prediabe- mine weight-loss goals and patient- programs are recommended when tes: A Consensus Report” (https://doi appropriate intervention strategies (27). available. Such programs should .org/10.2337/dci19-0014). Strategies may include dietary changes, at minimum provide monthly con- physical activity, behavioral therapy, tact, as well as encourage ongo- Look AHEAD Trial pharmacologic therapy, and metabolic ing monitoring of body weight Although the Action for Health in Di- surgery (Table 8.1). The latter two (weeklyormorefrequently)and abetes (Look AHEAD) trial did not show that an intensive lifestyle interven- strategies may be prescribed for care- other self-monitoring strategies, fully selected patients as adjuncts to tion reduced cardiovascular events including high levels of physical diet, physical activity, and behavioral in adults with type 2 diabetes and over- activity (200–300 min/week). A therapy. weight or obesity (31), it did show the Table 8.1—Treatment options for overweight and obesity in type 2 diabetes BMI category (kg/m2) Treatment 25.0–26.9 (or 23.0–24.9*) 27.0–29.9 (or 25.0–27.4*) $30.0 (or $27.5*) Diet, physical activity, and behavioral therapy ††† Pharmacotherapy †† Metabolic surgery † *Recommended cut points for Asian American individuals (expert opinion). †Treatment may be indicated for select motivated patients. care.diabetesjournals.org S91 feasibility of achieving and maintaining practitioners, with close patient moni- PHARMACOTHERAPY fi long-term weight loss in patients with toring, can be bene cial. Within the in- Recommendations type 2 diabetes. In the Look AHEAD tensive lifestyle intervention group of the 8.11 When choosing glucose-lowering intensive lifestyle intervention group, Look AHEAD trial, for example, use of a medications for patients with mean weight loss was 4.7% at 8 years partial meal replacement plan was as- type 2 diabetes and overweight (32). Approximately 50% of intensive sociated with improvements in diet or obesity, consider a medica- lifestyle intervention participants lost quality (38). The diet choice should be tion’s effect on weight. B and maintained $5% of their initial based on the patient’s health status and 8.12 Whenever possible, minimize body weight, and 27% lost and main- preferences, including a determination medications for comorbid con- tained $10% of their initial body weight of food availability and other cultural ditions that are associated with at 8 years (32).
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