The Professional Practice Committee of the American Diabetes Association (ADA) has published the latest recommendations for obesity and weight management for the prevention and treatment of type 2 diabetes. The recommendations are featured in the paper, ‘American Diabetes Association Professional Practice Committee. 8. Obesity and weight management for the prevention and treatment of type 2 diabetes: Standards of Medical Care in Diabetes—2022’, published in Diabetes Care.
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. The specific aim of this paper is to provide evidence-based recommendations for obesity management, including behavioural, pharmacologic and surgical (bariatric) interventions, in adult T2DM patients.
During patient assessments, the recommendations state that person-cantered, non-judgmental language should be used and that the presence of comorbid heart failure or significant unexplained weight gain or loss, weight may need to be monitored and evaluated more frequently. In addition, if a patient’s medical status is associated with significant weight gain or loss, inpatient evaluation should be considered, especially focused on associations between medication use, food intake, and glycaemic status.
The ADA maintains that diet, physical activity and behavioural therapy is recommended to achieve and maintain ≥5% weight loss for most people with type 2 diabetes and overweight or obesity and should include a high frequency of counseling (≥16 sessions in six months), focus on dietary changes, physical activity and behavioural strategies to achieve a 500–750 kcal/day energy deficit. However, a patient’s preferences, motivation and life circumstances should be considered. Interestingly, the paper notes that there is no clear evidence that dietary supplements are effective for weight loss.
Regarding pharmacotherapy, the ADA recommends that the medication’s effect on weight should be considered when choosing glucose-lowering medications for T2DM patients. Research from published clinical trials shows that early responders have improved long-term (typically defined as >5% weight loss after 3 months’ use), conversely, when early use appears ineffective (typically <5% weight loss after 3 months’ use), it is unlikely that continued use will improve weight outcomes. Therefore, it should be recommended to discontinue the medication and consider other treatment options.
Concerning weight loss medical devices - such as implanted gastric balloons, a vagus nerve stimulator and gastric aspiration therapy - given the current high cost, limited insurance coverage, and paucity of data in people with diabetes, there is limited evidence for medical devices for weight loss.
Bariatric and metabolic surgery
The ADA recommends metabolic surgery as an option to treat T2DM in screened surgical candidates with BMI ≥40 kg/m2 (BMI ≥37.5 kg/m2 in Asian Americans) and in adults with BMI 35.0–39.9 kg/m2 (32.5–37.4 kg/m2 in Asian Americans) who do not achieve durable weight loss and improvement in comorbidities (including hyperglycaemia) with non-surgical methods. In addition, Metabolic surgery may be considered as an option to treat type 2 diabetes in adults with BMI 30.0–34.9 kg/m2 (27.5–32.4 kg/m2 in Asian Americans) who do not achieve durable weight loss and improvement in comorbidities (including hyperglycaemia) with non-surgical methods.
The ADA also recommends:
Metabolic surgery should be performed in high-volume centers with multidisciplinary teams knowledgeable about and experienced in the management of obesity, diabetes and gastrointestinal surgery
Potential patients should be evaluated for comorbid psychological conditions and social and situational circumstances that have the potential to interfere with surgery outcomes
Metabolic surgery patients should receive long-term medical and behavioural support and routine monitoring of micronutrient, nutritional and metabolic status.
Metabolic surgery patients should routinely be evaluated to assess the need for ongoing mental health services to help with the adjustment to medical and psychosocial changes after surgery.
Larger and longer-term studies are needed to determine the role of metabolic surgery in T1DM patients
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