Double-digit weight loss suggested as the primary target in managing type 2 diabetes

By Dr Emily Lathlean MB BS, FRACGP
Obesity management should become the primary focus for management of type 2 diabetes, a group of international specialists has proposed.

In their review article, published in The Lancet, the specialists highlighted the shared key pathophysiological mechanisms of both obesity and type 2 diabetes and the ability of weight loss to reverse the underlying metabolic abnormalities of type 2 diabetes. They reviewed current evidence supporting weight loss in managing type 2 diabetes and proposed a new therapeutic framework incorporating sustained weight loss as a primary treatment goal in type 2 diabetes, as opposed to the current sole focus on glycaemic control.

The framework outlined primary and secondary treatment goals for type 2 diabetes by prevailing disease phenotype: adiposity-related diabetes, diabetes with cardiovascular disease (CVD) and isolated hyperglycaemia.

The authors proposed that use of proven cardioprotective agents and an HbA1c of less than 7% should be the targets for those with phenotypes of diabetes with CVD and isolated hyperglycaemia, respectively. They estimated that adiposity-related diabetes accounted for 40% to 70% of patients with type 2 diabetes, with insulin resistance being the primary physiological driver. For this phenotype, the framework suggested a greater than 15% weight-loss target.

‘Sustained weight loss of 15% body weight has a major impact on type 2 diabetes progression and can even result in diabetes remission, particularly in people with a relatively recent diagnosis (within six years),’ said Dr Priya Sumithran, one of the article authors and an endocrinologist and researcher in Melbourne.

Dr Sumithran, who leads the Obesity Research Group at the University of Melbourne and is Head of Obesity Medicine at Austin Health, said that, ‘this approach would have the added benefit of addressing other obesity-related complications, thus having a greater impact on the person’s overall health than managing blood glucose alone.’

The authors recognised the various barriers to achieving and maintaining significant weight loss and discussed emerging pharmacotherapies for obesity and the substantial evidence for the use of bariatric surgery in patients with obesity and type 2 diabetes.

They called for treatment guidelines to be updated to include emerging evidence for remission of type 2 diabetes after double-digit weight loss and the benefits of substantial and sustained weight loss as a primary treatment target for patients with type 2 diabetes.

‘Effectively incorporating this change in the management of type 2 diabetes will require support and resources for healthcare providers and patients,’ Dr Sumithran told Medicine Today.
Lancet 2021; https://doi.org/10.1016/S0140-6736(21)01919-X.