Weight Management + Type 2 Diabetes: Using Compassion, Medicine and Surgery
A panel of experts discussed the barriers to weight loss for people with type 2 diabetes and how providers can help patients achieve their weight goals.
Presentation: Incorporating New Weight Management Strategies for Obesity into Type 2 Diabetes Care—Medical Management and Surgery
Speakers at this ADA Scientific Sessions presentation included: Jackie Boucher, MS, RDN (Children’s HeartLink), Dina Griauzde, MD, MSC (University of Michigan), Kristina Lewis, MD, MPH, SM (Wake Forest University School of Medicine)
Research shows visceral fat accumulation—the fat that gathers around your abdominal organs—drives metabolic dysfunction, shedding light on the connection between obesity and type 2 diabetes. A first-line therapy for obesity and type 2 diabetes is weight management.
Weight loss has shown several benefits for people with type 2 diabetes (T2D):
- Reduced blood glucose levels and overall glycemic control
- Improved ovulatory function
- Reduced cardiovascular events and mortality
- Improved quality of life (mobility, mood, etc.)
- Reduced liver fat
Why aren’t more people with T2D losing weight?
Patients are all unique, including in their needs and preferences, yet many treatments have a one-size fits all approach. People with diabetes (PWD) need personalized treatment plans.
In addition to individual preferences, other barriers to weight loss include:
- Insufficient resources for patients
- Lack of support for patients
- Lack of provider training in obesity medicine
- High costs of weight management medicines or lack of coverage by insurance
- Weight bias and stigmas
How should providers help PWD with weight loss?
Discussing weight can be an uncomfortable topic. Registered dietitian nutritionist Jackie Boucher said patients may hesitate to discuss weight loss due to stigmas, but providers can help by initiating the conversations without judgement and with compassion.
Boucher proposed providers use the five As to initiate conversations with patients:
- Ask permission to discuss weight in a nonjudgmental way
- Assess their story: look at their body mass index (BMI), weight loss drivers and complications
- Advise on management: discuss health risks of obesity, benefits of weight loss and long-term strategy
- Agree on goals: set realistic weight loss goals, behavioral changes, SMART goals and specific details of treatment options
- Assist with drivers and barriers: identify/address possible barriers, provide resources and identify appropriate follow-ups
In addition to having conversations with patients about weight loss, Boucher emphasized it should be a team approach. Obesity and weight loss teams should consist of:
- Registered dietitian nutritionists (RDN)
- Nurse practitioner/physician assistant
- Primary care physician or endocrinologist
- Exercise physiologist
It’s important to recognize and treat obesity as a chronic disease and ask the patient for permission to offer advice and help treat the disease in an unbiased manner.
What treatment options are available for weight loss?
“No one size fits all eating patterns” Dina Griauzde said. There are several eating patterns that people with T2D can try for weight loss. These eating patterns must be calorically restricted to be effective in treating obesity. The two most recommended eating patterns were caloric restriction and carbohydrate restriction.
Weight-management medications (WMM) are available, yet few are prescribed. Why aren’t weight loss medications used?
- Lack of provider comfort/familiarity with WMMs
- Negative patient track record of prior weight loss medications
- Patient’s fear of side effects
- Low belief in WMM efficacy and benefits
- Poor insurance coverage
New medications like semaglutide and Mounjaro (tirzepatide) show promising weight loss benefits for people with T2D, but many individuals still have concerns regarding accessibility and affordability.
Why should people with diabetes (PWD) consider bariatric surgery?
- Results in more total weight loss
- More durable
- Improves glycemic control
- Operations are now laparoscopic, with smaller incisions making them safer
- Low mortality rate (0.1-0.5 percent)
- Can lead to T2D remission
According to Kristina Lewis, weight loss from bariatric surgery can increase skeletal muscle, improving insulin sensitivity and contributing to T2D remission. The rate of remission five years post-surgery is 30-63 percent. People with type 1 diabetes (T1D) who live with obesity can also achieve benefits from surgery but are at higher risk for diabetic ketoacidosis (DKA).
Who should consider surgery? PWD who have a BMI of 30-35 and have inadequate glycemic control are eligible for surgery.
Less than 1 percent of eligible patients undergo bariatric surgery. Lewis attributes this to patient preference, but also acknowledges the pre-operative requirements could be a limiting factor.
People wanting the procedure have to undergo a long list of examinations and doctor visits that can be burdensome for patients.
Achieving Weight Loss Goals
Providers have several tools to offer patients to help with weight loss, yet they are being underutilized. To help PWD achieve their weight loss goals, Griauzde argued there needs to be a new system of care utilizing evidence-based obesity treatments that is actually implemented into clinical practice. Most importantly, patients need advocacy to ensure equal access to all available treatment options.