Source / Disclosures
Lingfei I et al. Balancing the Evidence – Should Obesity Be the Primary Goal of Treatment in Type 2 Diabetes. Presented in: Scientific Sessions of the American Diabetes Association; 3-7 June 2022; New Orleans (mixed meeting).
Lingvay reports serving on the advisory committees of Altimmune, AstraZeneca, Bayer, Boehringer Ingelheim, Click, Eli Lilly, Intercept, Janssen Pharma, Mannkind, Medscape, Novo Nordisk, Sanofi, TARGET PharmaSolutions, Valeritas and Zealand Pharma; As a consultant to Novo Nordisk and received research support from Merck, Mylan, Novo Nordisk and Sanofi. Mechanic report serving on an advisory committee to L-Nutra Inc. and Twin Health, and in the speakers’ office at Abbott Nutrition.
NEW ORLEANS — There is no one answer when it comes to setting the primary goal of treating type 2 diabetes, two speakers said during a discussion at the American Diabetes Association Scientific Sessions.
Promoting weight loss to improve health outcomes for people with type 2 diabetes is one of the goals emphasized in the 2022 ADA Standard of Care. Ildiku Lingfai, MD, MPH, MSCSObesity should be the primary goal for treating type 2 diabetes; However, providers should focus on the individual’s phenotype and fat distribution rather than on BMI.
“When you think of people with type 2 diabetes, the majority will have lipopathy,” Lingvay said during the show. “How do you recognize them? Look at your patient in person. Where is their fat? How much do they have?”
Lingvay added that weight loss should be a goal in conjunction with other viable disease goals, something he echoes. Jeffrey I Mechanics, M.D.MD, professor of medicine and medical director of the Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart and director of metabolic support in the division of endocrinology, diabetes, and orthopedics at the Icahn School of Medicine at Mount Sinai. Mechanics said he agreed with Lingvay that obesity should be a primary goal for most people with type 2 diabetes, but goals can vary based on an individual’s profile. Although glycemic control is not sufficient on its own, it should be another primary goal that is considered by caregivers.
“There are several primary goals that are prioritized based on relative risk, logistical ease, cost and individual factors,” Mechanics said during the presentation. “Primary goals can be addressed concurrently, not necessarily sequentially and not necessarily mutually exclusive.”
Focus on obesity phenotype
Lingvay said obesity should be the primary goal for treating type 2 diabetes, but that providers should avoid using BMI to determine the disease.
“It’s all about the amount, quality and location of the fat,” Lingvay said. “I prefer to avoid the term obesity not only because our patients don’t like it, but because it is so intricately linked to BMI that it creates a problem when it comes to diagnosis.”
Plenty of evidence supports the essential role of losing weight in improving blood sugar, reducing the risk of complications related to diabetes, and reducing the risk of other obesity-related diseases. In data from the Diabetes Prevention Program, participants reduced their risk of developing diabetes by 16% for every 1 kilogram of body weight lost. Results from the Diabetes Remission Clinical Trial revealed that most participants who achieved a weight loss of 10 kg or more also reached type 2 diabetes remission, defined as having an HbA1c of less than 6.5% without diabetes medications.
“The amount of weight loss matters, because the amount of weight loss correlates with the effect on blood sugar,” Lingvay said. “The benefits of weight loss appear across the dysglycemia continuum.”
The amount of weight loss is critical to maximizing benefits for people with diabetes. It will bring most of the benefits, Lingfei said, including remission of diabetes and reduced risk of dyslipidemia, hypertension, nonalcoholic fatty liver disease, heart failure and cardiovascular disease. However, there is no single target that individual patients hit. Lingvay noted that the ADA standard of care emphasizes exit with an individual goal based on risk, duration of illness, comorbidities, life expectancy, patient preference, and more.
A weight loss of 15% cannot be achieved with lifestyle intervention alone. Data from multiple studies has shown that bariatric surgery is associated with more than 15% weight loss. In addition, trial data showed that drug treatments, such as semaglutide (Ozempic, Novo Nordisk) and tirzepatide (Mounjaro, Eli Lilly), have allowed some people with diabetes to lose weight by 15% or more.
Providers need to identify the type 2 diabetes subtype for each patient to know the treatment goal for priority setting. For most people, a weight-focused approach with a body weight loss of 15% or more works best. However, people with diabetes and CVD may benefit most from a heart-focused approach with proven cardioprotective agents, and people with isolated hyperglycaemia may benefit better from a glucose-centric approach with an HbA1c target of less than 7%.
Lingvay said there are potential drawbacks to weight loss, such as gallbladder disease, sarcopenia, bone loss, surgical complications, cost and adverse events from medication, but the benefits of improved metabolic control, mechanics, and quality of life always outweigh the negatives.
“The benefits are so overwhelming, unless you can manage the drawbacks, I see no reason not to,” Lingvay said. “Even in people with type 1 diabetes, if they have lipopathy, they will benefit from weight loss.”
HbA1c is among several primary treatment targets
Mechanics said the primary goals in type 2 diabetes should not be conflicting. The best way to manage the disease is to take an approach that optimizes the benefits for the individual patient.
“Glucose control is a necessary primary goal, but it is not sufficient in patients with type 2 diabetes to prevent the development and progression of complications,” Mechanics said.
According to Mechanics, identifying obesity as the only primary goal of type 2 diabetes care is wrong for several reasons. He pointed out that obesity is accurately determined by body mass index. Adverse metabolic effects and beta cell defects require comprehensive care; Not all people with type 2 diabetes are obese either; Obesity and hyperglycemia are not opposing clinical goals for the prevention of cardiac metabolism; Nor did the evidence mention the absolute superiority of weight control over glycemic control in type 2 diabetes.
Targeting hyperglycemia may be best for some patients, including those with severe hyperglycemia, mild obesity, or those at greater risk of developing hyperglycemia-related complications than obesity-related complications. A 3D model of cardiovascular-based chronic disease prevention was first published in Journal of the American College of Cardiology In 2020, hyperglycaemia should be prioritized over obesity as a primary target in patients with stage 3 or 4 chronic disease caused by dysglycemia, severe hyperglycaemia, and those with lower stage of chronic disease based on obesity And those with a higher stage of cardiovascular disease – Mechanics said it was a chronic disease.
“This will require thinking on your part as healthcare professionals to not just accept that high blood sugar means that this is how a patient will be classified,” Mechanic said. “Do a deeper research into your patient to identify the different triggers and how they are prioritized.”
According to Mechanics, controlling hyperglycemia is good in terms of reducing microvascular complications and the CV of diabetes. The ADA Standards of Care includes a section of glycemic goals for people with diabetes, with a scale included to help providers set a glycemic goal based on an individual’s profile.
Mechanic agreed with Lingvay that weight control is the most important part of treating type 2 diabetes for most patients with this disease and should be the primary goal for many. However, he added that focusing solely on weight control is not a practical approach.
“Glucose control is also important, particularly for mitigating the progression of chronic disease caused by dysglycemia,” Mechanic said. Both views represent valid interventions according to the cardiovascular model. Both opinions are valid. Obesity and glycemic control are critical components of comprehensive care for people with type 2 diabetes. It is the timing and severity of the intervention, the individual scenarios and other factors that influence this.”
Mechanics said future discussions about treatment goals for type 2 diabetes should focus on legalizing risks, prioritizing relevant outcomes, and designing evidence-based strategies and tactics to improve outcomes within a comprehensive preventive care plan.