adaADA 2018 guidelines (American Diabetes Association, 2018) provide comprehensive evidencebased recommendations on obesity management for T2DM. They stress the value ofeven moderate sustained weight loss of 5-10% in those who are overweight orobese in achieving reductions in Hba1c, TGs and BGL. Further weight loss can even reduce the needfor medication.
They stress that HCP should assess the patient’s readiness tolose weight and jointly with the patient determine goals and an interventionstrategy for weight loss made up from:1. diet, 2. physical activity3. behavioral therapy4. pharmacotherapy 5. metabolic surgeryHowever, they modify this patient centered approach to managementby adding that weight loss medications should only be used in patients who havebeen selected carefully and only them in conjunction with the top 3interventions. PharmacotherapyIn the use of pharmacotherapy are 3 recommendations by ADA: 1.
Choose diabetes medications which are eitherweight neutral or that are associated with weight loss2. Avoid or minimize the use of other medications forcomorbid conditions which are known to cause weight gain. 3. When considering weight loss medications do arisk/benefit analysis Cease if weight loss<5% after 3 months or if there areissues with safety or side effects and consider changing to another medication oranother approach such as surgery. The guidelines conclude by saying the effectiveness of drugtreatment for obesity has been limited by · Low adherence · Modest efficacy· Adverse side effects· Weight regain after ceasing the drugHowever, in my view some of these issues are not such aconcern if the medication being used for weight is also a diabetic medication andis prescribed for a long-term medication with less side effects and betteradherence.
Also, the guidelines pointout that a met analysis looking at 227 RCT found that the efficacy of diabeticmedication on Hba1c was not dependent on baseline BMI. This suggest that obeseand overweight patients almost benefit from antihyperglycemic treatment.(Cai et al.,2016)Word count 321SurgeryHas been shown to beable to achieve significant weight loss and improvements in glycemic control comparableto that achieve by VLCDs even to the stage of remission but with the advantageof weight loss being more sustained.
Improvements in CVD and microvascularcomplications and reductions in mortalityalthough seen or suggested in observational or cohort have not been proven byRCTs(American Diabetes Association, 2018) .However it is expense and not without risk or sideeffect, There a several techniques available. ADA 2018 guidelinesrecommend metabolic surgery as an option where:· BMI >=40 (37.5 Asian) regardless of glycemic control or diabetic medication regime.OR · BMI35-39.9 (32.5-37.
4 Asian) where diabetes poorly controlled on optimal therapy.Consider metabolicsurgery as an option Where control poor control on optimal therapy:· BMI30-34.9 (27.5-32.4 Asian) Some international diabetes organizations have recommended extendingindication further to BMI as low as 30 (27.5 for Asian) where control is inadequate due tothe growing evidence in support of metabolic surgery.(Rubino et al.
,2016)They also recommendthat surgery only be performed in specialized centres with experienced multidisciplinaryteams. Also, these patients need to be provided with of long-term lifestyle supportand routine nutritional monitoring. Full mental health assessment should be doneas part of presurvey assessment to screen for alcohol or drug abuse, depressionother mental health issues which hinder their adjustment.
A 30-63% continued remissionrate has been seen post-surgery over 1-5 years period. Of those who achieveremission 35-50% relapse back to diabetes eventually. Of those patients whoachieved remission following Roux-en-Y gastric bypass the median remission periodwas 8.3 years.
adaADA 2018 guidelines (American Diabetes Association, 2018) provide comprehensive evidencebased recommendations on obesity management for T2DM. They stress the value ofeven moderate sustained weight loss of 5-10% in those who are overweight orobese in achieving reductions in Hba1c, TGs and BGL. Further weight loss can even reduce the needfor medication. They stress that HCP should assess the patient’s readiness tolose weight and jointly with the patient determine goals and an interventionstrategy for weight loss made up from:1. diet, 2.
physical activity3. behavioral therapy4. pharmacotherapy 5. metabolic surgeryHowever, they modify this patient centered approach to managementby adding that weight loss medications should only be used in patients who havebeen selected carefully and only them in conjunction with the top 3interventions. PharmacotherapyIn the use of pharmacotherapy are 3 recommendations by ADA: 1.
Choose diabetes medications which are eitherweight neutral or that are associated with weight loss2. Avoid or minimize the use of other medications forcomorbid conditions which are known to cause weight gain. 3. When considering weight loss medications do arisk/benefit analysis Cease if weight loss<5% after 3 months or if there areissues with safety or side effects and consider changing to another medication oranother approach such as surgery. The guidelines conclude by saying the effectiveness of drugtreatment for obesity has been limited by · Low adherence · Modest efficacy· Adverse side effects· Weight regain after ceasing the drugHowever, in my view some of these issues are not such aconcern if the medication being used for weight is also a diabetic medication andis prescribed for a long-term medication with less side effects and betteradherence. Also, the guidelines pointout that a met analysis looking at 227 RCT found that the efficacy of diabeticmedication on Hba1c was not dependent on baseline BMI. This suggest that obeseand overweight patients almost benefit from antihyperglycemic treatment.
(Cai et al.,2016)Word count 321SurgeryHas been shown to beable to achieve significant weight loss and improvements in glycemic control comparableto that achieve by VLCDs even to the stage of remission but with the advantageof weight loss being more sustained. Improvements in CVD and microvascularcomplications and reductions in mortalityalthough seen or suggested in observational or cohort have not been proven byRCTs(American Diabetes Association, 2018) .However it is expense and not without risk or sideeffect, There a several techniques available. ADA 2018 guidelinesrecommend metabolic surgery as an option where:· BMI >=40 (37.5 Asian) regardless of glycemic control or diabetic medication regime.OR · BMI35-39.
9 (32.5-37.4 Asian) where diabetes poorly controlled on optimal therapy.Consider metabolicsurgery as an option Where control poor control on optimal therapy:· BMI30-34.9 (27.
5-32.4 Asian) Some international diabetes organizations have recommended extendingindication further to BMI as low as 30 (27.5 for Asian) where control is inadequate due tothe growing evidence in support of metabolic surgery.(Rubino et al.
,2016)They also recommendthat surgery only be performed in specialized centres with experienced multidisciplinaryteams. Also, these patients need to be provided with of long-term lifestyle supportand routine nutritional monitoring. Full mental health assessment should be doneas part of presurvey assessment to screen for alcohol or drug abuse, depressionother mental health issues which hinder their adjustment.A 30-63% continued remissionrate has been seen post-surgery over 1-5 years period. Of those who achieveremission 35-50% relapse back to diabetes eventually. Of those patients whoachieved remission following Roux-en-Y gastric bypass the median remission periodwas 8.
3 years.
