A recent debate at the 2022 American Diabetes Association (ADA) Scientific Sessions highlights the growing focus on obesity as a treatment target for type 2 diabetes, as described in a news release from the American Diabetes Association.
A wide range of studies in recent years have shown the dramatic health benefits that weight loss can have in people with type 2 diabetes and obesity. In people with obesity, bariatric (weight-loss) surgery has been shown to promote remission of both type 2 diabetes and prediabetes — meaning that blood glucose levels are normal without taking any glucose-lowering medications. But bariatric surgery isn’t the only potentially effective option — measures like low-calorie diets and meal replacements have also been shown to promote weight loss and diabetes remission. At the same time, there are new drug treatments for obesity — namely Wegovy (semaglutide) and Saxenda (liraglutide) — that are unprecedented in their effectiveness at leading to weight loss, and are expected to be used much more widely once their manufacturers increase the supply to catch up with the enormous demand for these drugs.
But improved glucose control and diabetes remission aren’t the only potential benefits from weight loss in people with type 2 diabetes and obesity. Studies have shown that weight loss may improve symptoms of diabetic peripheral neuropathy — nerve damage, usually in the legs and feet, that can cause numbness, tingling, or burning sensations. And remission of diabetes following bariatric surgery is linked to a lower risk for cancer.
Weight loss vs. blood glucose management as main treatment target
In the debate at the conference, one expert — Ildiko Lingvay, MD, a professor of medicine at the University of Texas Southwestern Medical Center — argued in favor of making obesity the main treatment target in people with type 2 diabetes and obesity. Another expert — Jeffrey I. Mechanick, MD, a professor of medicine at the Icahn School of Medicine at Mount Sinai — didn’t exactly take an opposing view, but argued in favor of making both weight loss and blood glucose control part of a comprehensive care plan.
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Lingvay argued that instead of focusing on reaching an A1C level (a measure of long-term blood glucose control) of 7% or lower in patients with type 2 diabetes and obesity, doctors should focus their treatment on losing 15% of their body weight. While this target might have seemed out of reach only a few years ago, she noted, there is now evidence showing that this level of weight loss can often be reached through bariatric surgery or newer drug treatments. And this level of weight loss almost always dramatically improves blood glucose control, in addition to improving cardiovascular health.
In addition to promoting insulin resistance — a core element of type 2 diabetes in which cells throughout the body are less responsive to insulin — obesity can also make diabetes worse by contributing to sleep disorders, fatigue, and mental health problems, Lingvay noted. And diabetes itself can contribute to obesity, creating a vicious cycle of weight gain and worse blood glucose control.
As a counterargument, Mechanick noted that while the evidence on weight loss is clear, so is the evidence on the harmful effects of high blood glucose levels — meaning that good blood glucose control remains as important a goal as it ever was. An individualized assessment of risks, he said, should determine whether a doctor prioritizes weight loss, blood glucose control, or another measure like blood pressure as a main target of treatment — while stressing that there doesn’t have to be just one main treatment target or goal.
Rather than focusing on prioritizing any one area of treatment, Mechanick said, discussions on treatment strategies for type 2 diabetes should be centered on how to optimize all of the relevant outcomes for a given person, with an emphasis on long-term preventive health.