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. 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 .OEIYMNGMN O H RAMN FTP DIABETES 2 TYPE OF TREATMENT THE FOR MANAGEMENT OBESITY 8.

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). Participants randomly circumstances that could affect dietary weight gain. E assigned to the intensive lifestyle group patterns (39). 8.13 Weight-loss medications are ef- achieved equivalent risk factor con- Intensive behavioral lifestyle interven- fective as adjuncts to diet, phys- trol but required fewer glucose-, blood tions should include $16 sessions in ical activity, and behavioral pressure–, and lipid-lowering medica- 6 months and focus on dietary changes, counseling for selected patients tions than those randomly assigned physical activity, and behavioral strate- with type 2 diabetes and to standard care. Secondary analyses gies to achieve an ;500–750 kcal/day BMI $27 kg/m2. Potential ben- of the Look AHEAD trial and other large energy deficit. Interventions should be efits must be weighed against cardiovascular outcome studies docu- provided by trained interventionists in potential risks of medications. A ment other benefits of weight loss in either individual or group sessions (34). 8.14 If a patient’s response to weight- patients with type 2 diabetes, includ- Assessing an individual’s motivation level, loss medications is ,5% weight ing improvements in mobility, physical life circumstances, and willingness to im- loss after 3 months or if there and sexual function, and health-related plement lifestyle changes to achieve weight are significant safety or tolera- quality of life (23). A post hoc analysis loss should be considered along with med- bility issues at any time, the of the Look AHEAD study suggests ical status when weight-loss interventions medication should be discon- that heterogeneous treatment effects are recommended and initiated (27). tinued and alternative medica- may have been present. Participants Patients with type 2 diabetes and tions or treatment approaches who had moderately or poorly controlled overweight or obesity who have lost should be considered. A diabetes (A1C $6.8% [51 mmol/mol]) weight during a 6-month intensive be- as well as those with well-controlled havioral lifestyle intervention should be diabetes (A1C ,6.8% [51 mmol/mol]) enrolled in long-term ($1 year) compre- Glucose-Lowering Therapy and good self-reported health were hensive weight-loss maintenance pro- Agents associated with varying degrees foundtohavesignificantly reduced grams that provide at least monthly of weight loss include , cardiovascular events with inten- contact with a trained interventionist a-glucosidase inhibitors, sodium–glucose sive lifestyle intervention during and focus on ongoing monitoring of cotransporter 2 inhibitors, glucagon-like follow-up (33). body weight (weekly or more frequently) peptide 1 receptor agonists, and amylin and/or other self-monitoring strategies mimetics. Dipeptidyl peptidase 4 inhibi- Lifestyle Interventions such as tracking intake, steps, etc.; con- tors are weight neutral. Unlike these Significant weight loss can be attained tinued consumption of a reduced-calorie agents, insulin secretagogues, thiazolidi- with lifestyle programs that achieve a diet; and participation in high levels of nediones, and insulin often cause weight 500–750 kcal/day energy deficit, which in physical activity (200–300 min/week) gain (see Section 9 “Pharmacologic Ap- most cases is approximately 1,200–1,500 (40). Some commercial and proprietary proaches to Glycemic Treatment,” https:// kcal/day for women and 1,500–1,800 weight-loss programs have shown doi.org/10.2337/dc20-s009). kcal/day for men, adjusted for the indi- promising weight-loss results (41). A meta-analysis of 227 randomized vidual’s baseline body weight. Weight When provided by trained practi- controlled trials of glucose-lowering loss of 3–5% is the minimum necessary tioners in medical care settings with treatments in type 2 diabetes found for clinical benefit (20,34). However, close medical monitoring, short-term that A1C changes were not associated weight-loss benefits are progressive; (3-month) interventions that use very with baseline BMI, indicating that pa- more intensive weight-loss goals (.5%, low-calorie diets (defined as #800 tients with obesity can benefit from the .7%, .15%, etc.) may be pursued if kcal/day) and total meal replacements same types of treatments for diabetes as needed to achieve a healthy weight may achieve greater short-term weight normal-weight patients (44). and/or if the patient is more motivated loss (10–15%) than intensive behav- and more intensive goals can be feasibly ioral lifestyle interventions that typically Concomitant Medications and safely attained. achieve 5% weight loss. However, weight Providers should carefully review the Dietary interventions may differ in the regain following the cessation of very patient’s concomitant medications types of foods they restrict (such as high- low-calorie diets is greater than regain and, whenever possible, minimize or fat or high-carbohydrate foods) but are following intensive behavioral lifestyle provide alternatives for medications effective if they create the necessary interventions unless a long-term com- that promote weight gain. Examples of energy deficit (20,35–37). Use of meal prehensive weight-loss maintenance medications associated with weight gain replacement plans prescribed by trained program is provided (42,43). include antipsychotics (e.g., clozapine, S92 Obesity Management for the Treatment of Type 2 Diabetes Diabetes Care Volume 43, Supplement 1, January 2020

olanzapine, risperidone, etc.) and anti- MEDICAL DEVICES FOR WEIGHT conditions and social and situa- depressants (e.g., tricyclic antidepres- LOSS tional circumstances that have sants, selective serotonin reuptake Several minimally invasive medical de- the potential to interfere with inhibitors, and monoamine oxidase vices have been approved by the FDA for surgery outcomes. B inhibitors), glucocorticoids, injectable short-term weight loss (48,49). It remains 8.20 People who undergo metabolic progestins, anticonvulsants includ- to be seen how these are used for obesity surgery should routinely be ing gabapentin, and possibly sedating treatment. Given the high cost, limited evaluated to assess the need antihistamines and anticholinergics (45). insurance coverage, and paucity of data for ongoing mental health serv- in people with diabetes at this time, ices to help with the adjustment Approved Weight-Loss Medications medical devices for weight loss are cur- to medical and psychosocial The U.S. Food and Drug Administration rently not considered to be the standard changes after surgery. C (FDA) has approved medications for both of care for obesity management in peo- short-term and long-term weight man- ple with type 2 diabetes. Several gastrointestinal (GI) operations agement as adjuncts to diet, exercise, including partial gastrectomies and bari- and behavioral therapy. Nearly all FDA- METABOLIC SURGERY atric procedures (40) promote dramatic approved medications for weight loss and durable weight loss and improvement have been shown to improve glycemic Recommendations of type 2 diabetes in many patients. Given control in patients with type 2 diabetes 8.15 Metabolic surgery should be the magnitude and rapidity of the effect of and delay progression to type 2 diabetes recommended as an option to GI surgery on hyperglycemia and exper- in patients at risk (46). and treat type 2 diabetes in imental evidence that rearrangements of other older adrenergic agents are indi- screened surgical candidates GI anatomy similar to those in some $ 2 cated as short-term (#12 weeks) treat- with BMI 40 kg/m (BMI metabolic procedures directly affect glu- $ 2 ment (47). Five weight-loss medications 37.5 kg/m in Asian Americans) cose homeostasis (41), GI interventions – are FDA approved for long-term use andinadultswithBMI35.0 have been suggested as treatments for 2 – 2 (more than a few weeks) by patients 39.9 kg/m (32.5 37.4 kg/m in type 2 diabetes, and in that context they 2 with BMI $27 kg/m with one or more Asian Americans) who do not are termed “metabolic surgery.” achieve durable weight loss obesity-associated comorbid condition A substantial body of evidence has now and improvement in comorbid- (e.g., type 2 diabetes, hypertension, been accumulated, including data from ities (including hyperglycemia) and/or dyslipidemia) who are motivated numerous randomized controlled (non- with nonsurgical methods. A to lose weight (46). Medications approved blinded) clinical trials, demonstrating that 8.16 Metabolic surgery may be con- by the FDA for the treatment of obesity metabolic surgery achieves superior gly- sidered as an option for adults and their key advantages and disadvan- cemic control and reduction of cardiovas- with type 2 diabetes and BMI tages are summarized in Table 8.2. The cular risk factors in patients with type 2 30.0–34.9 kg/m2 (27.5–32.4 rationale for weight-loss medication use diabetes and obesity compared with var- kg/m2 in Asian Americans) who is to help patients to more consistently ious lifestyle/medical interventions (17). do not achieve durable weight adhere to low-calorie diets and to rein- Improvements in microvascular compli- loss and improvement in co- force lifestyle changes. Providers should cations of diabetes, cardiovascular dis- morbidities (including hypergly- be knowledgeable about the product ease, and cancer have been observed cemia) with tested efficacious label and should balance the potential only in nonrandomized observational nonsurgical methods. A benefits of successful weight loss against studies (50–61). Cohort studies attempt- 8.17 Metabolic surgery should be the potential risks of the medication for ing to match surgical and nonsurgical sub- performed in high-volume cen- each patient. These medications are con- jects suggest that the procedure may ters with multidisciplinary teams traindicated in women who are pregnant reduce longer-term mortality (51). knowledgeable about and expe- or actively trying to conceive. Women On the basis of this mounting evi- rienced in the management of of reproductive potential must receive dence, several organizations and gov- diabetes and gastrointestinal counseling regarding the use of reliable ernment agencies have recommended surgery. E methods of contraception. expanding the indications for metabolic 8.18 Long-term lifestyle support and surgery to include patients with type 2 routine monitoring of micronu- fi diabetes who do not achieve durable Assessing Ef cacy and Safety trient and nutritional status Efficacy and safety should be assessed weight loss and improvement in comor- must be provided to patients at least monthly for the first 3 months bidities (including hyperglycemia) with after surgery, according to of treatment. If a patient’s response is reasonable nonsurgical methods at BMIs guidelines for postoperative deemed insufficient (weight loss ,5%) as low as 30 kg/m2 (27.5 kg/m2 for Asian management of metabolic sur- after3monthsoriftherearesignificant Americans) (62–69). Randomized con- gery by national and interna- safety or tolerability issues at any trolled trials have documented diabetes tional professional societies. C time, the medication should be dis- 8.19 People being considered for met- remission during postoperative follow- – continued and alternative medica- abolic surgery should be evalu- up ranging from 1 to 5 years in 30 63% tions or treatment approaches should ated for comorbid psychological of patients with Roux-en-Y gastric bypass be considered. (RYGB), which generally leads to greater care.diabetesjournals.org Table 8.2—Medications approved by the FDA for the treatment of obesity 1-Year (52- or 56-week) mean weight loss (% loss from baseline) National Average Typical adult Average wholesale Drug Acquisition Weight loss maintenance price (30-day Cost (30-day (% loss from Common side effects Possible safety concerns/considerations Medication name dose supply) (108) supply) (109) Treatment arm baseline) (110–115) (110–115) Short-term treatment (£12 weeks) Phentermine (116) 8–37.5 mg q.d.* $5–$56 (37.5 mg $3 (37.5 mg dose) 15 mg q.d.† 6.1 Dry mouth, insomnia, dizziness, c Contraindicated for use in combination with dose) 7.5 mg q.d.† 5.5 irritability, increased BP monoamine oxidase inhibitors PBO 1.2 Long-term treatment (>12 weeks) Lipase inhibitor (3) 60 mg t.i.d. (OTC) $41–$82 $43 120 mg t.i.d.‡ 9.6 , flatulence, fecal c Potential of fat-soluble vitamins 120 mg t.i.d. (Rx) $823 $556 PBO 5.6 urgency, back pain, headache (A, D, E, K) and of certain medications (e.g., cyclosporine, thyroid hormone, anticonvulsants, etc.) c Rare cases of severe liver injury reported c Cholelithiasis c Nephrolithiasis

Selective serotonin (5-HT) 5-HT2C receptor agonist (14)** 10 mg b.i.d. $360 $288 10 mg b.i.d. 4.5 Headache, nausea, dizziness, fatigue, c Serotonin syndrome–like and neuroleptic Lorcaserin XR 20 mg q.d. $360 $287 PBO 1.5 nasopharyngitis, increased BP malignant syndrome–like reactions theoretically possible when coadministered with other serotonergic or antidopaminergic agents c Monitor for depression or suicidal thoughts c Avoid in liver and renal failure Sympathomimetic amine /antiepileptic combination Phentermine/ 7.5 mg/46 mg $223 (7.5 mg/ $178 (7.5 mg/ 15 mg/92 mg q.d.| 9.8 , paresthesia, insomnia, c Birth defects ER (117) q.d.§ 46 mg dose) 46 mg dose) 7.5 mg/46 mg q.d.| 7.8 nasopharyngitis, xerostomia, c Cognitive impairment PBO 1.2 increased BP c Acute angle-closure glaucoma Opioid antagonist/antidepressant combination / 8 mg/90 mg, $334 $268 16 mg/180 mg b.i.d. 5.0 Constipation, nausea, headache, c Contraindicated in patients with uncontrolled ER (15) 2 tablets b.i.d. xerostomia, insomnia hypertension and/or seizure disorders PBO 1.8 c Contraindicated for use with chronic opioid therapy c Acute angle-closure glaucoma Black box warning: c Risk of suicidal behavior/ideation Glucagon-like peptide 1 receptor agonist Liraglutide (16)** 3 mg q.d. $1,497 $1,199 3.0 mg q.d. 6.0 Gastrointestinal side effects common c ?Acute pancreatitis 1.8 mg q.d. 4.7 (nausea, vomiting, ), c Caution when initiating or increasing dose due to injection site reactions potential risk of acute kidney injury PBO 2.0 Black box warning: c Risk of thyroid C-cell tumors All medications are contraindicated in women who are or may become pregnant. Women of reproductive potential must be counseled regarding the use of reliable methods of contraception. Select safety and side effect information is provided; for a comprehensive discussion of safety considerations, please refer to the prescribing information for each agent. b.i.d., twice daily; BP, blood pressure; ER, extended release; MEN 2, multiple endocrine neoplasia syndrome type 2; MTC, medullary thyroid carcinoma; OTC, over the counter; PBO, placebo; q.d., daily; Rx, prescription; t.i.d., three times daily; XR, extended release. *Use lowest effective dose; maximum appropriate dose is 37.5 mg. †Duration of treatment was 28 weeks in a general obese adult population. **Agent has demonstrated cardiovascular safety in a dedicated cardiovascular outcome trial (118,119). ‡Enrolled participants had normal (79%) or impaired (21%) glucose tolerance. §Maximum dose, depending on response, is 15 mg/92 mg q.d. |Approximately 68% of enrolled participants had type 2 diabetes or impaired glucose tolerance. S93 S94 Obesity Management for the Treatment of Type 2 Diabetes Diabetes Care Volume 43, Supplement 1, January 2020

degrees and lengths of remission compared of minimally invasive approaches (lapa- or other mental health conditions should with other bariatric surgeries (17,70). Avail- roscopic surgery), enhanced training and therefore first be assessed by a mental able data suggest an erosion of diabetes credentialing, and involvement of multi- health professional with expertise in remission over time (71): 35–50% or disciplinary teams. Mortality rates with obesity management prior to consider- more of patients who initially achieve metabolic operations are typically 0.1– ation for surgery (107). Surgery should remission of diabetes eventually experi- 0.5%, similar to cholecystectomy or hys- be postponed in patients with alcohol ence recurrence. However, the median terectomy (87–91). Morbidity has also or substance abuse disorders, significant disease-free period among such individ- dramatically declined with laparoscopic depression, suicidal ideation, or other men- uals following RYGB is 8.3 years (72,73). approaches. Major complications rates tal health conditions until these condi- With or without diabetes relapse, the (e.g., venous thromboembolism, need tions have been fully addressed. Individuals majority of patients who undergo sur- for operative reintervention) are 2–6%, with preoperative psychopathology should gery maintain substantial improvement with other minor complications in up to be assessed regularly following metabolic of glycemic control from baseline for 15% (87–96), rates which compare favor- surgery to optimize mental health man- at least 5 years (74,75) to 15 years ably with those for other commonly per- agement and to ensure that psychiatric (51,52,73,76–78). formed elective operations (91). Empirical symptomsdo not interferewith weightloss Exceedingly few presurgical predic- data suggest that proficiency of the and lifestyle changes. tors of success have been identified, operating surgeon is an important but younger age, shorter duration of factor for determining mortality, com- diabetes (e.g., ,8 years) (79), nonuse plications,reoperations,andreadmissions References 1. Knowler WC, Barrett-Connor E, Fowler SE, of insulin, maintenance of weight loss, (97). Accordingly, metabolic surgery should et al.; Diabetes Prevention Program Research and better glycemic control are consis- be performed in high-volume centers with Group. Reduction in the incidence of type 2 tently associated with higher rates of multidisciplinary teams knowledge- diabetes with lifestyle intervention or metfor- diabetes remission and/or lower risk able about and experienced in the man- min. N Engl J Med 2002;346:393–403 of weight regain (51,77,79,80). Greater agement of diabetes and GI surgery. 2. Garvey WT, Ryan DH, Henry R, et al. Pre- vention of type 2 diabetes in subjects with baseline visceral fat area may also help to Longer-term concerns include dump- prediabetes and metabolic syndrome treated predict better postoperative outcomes, ing syndrome (nausea, colic, and diar- with phentermine and topiramate extended especially among Asian American pa- rhea), vitamin and mineral deficiencies, release. Diabetes Care 2014;37:912–921 tients with type 2 diabetes, who typically anemia, osteoporosis, and, rarely, severe 3. Torgerson JS, Hauptman J, Boldrin MN, have more visceral fat compared with hypoglycemia (98). Long-term nutritional Sjostr¨ om¨ L. XENical in the prevention of Diabetes fi in Obese Subjects (XENDOS) study: a randomized Caucasians with diabetes of the same and micronutrient de ciencies and re- study of orlistat as an adjunct to lifestyle changes BMI (81). 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