▎WuXi AppTec content team editor
With changes in lifestyle and diet, overweight (24.0 kg/m2≤ body mass index [BMI]
More than half of China's 18-year-olds ≥ are overweight or obese. In addition, overweight and obesity are important risk factors for the development of type 2 diabetes. People with type 2 diabetes are often overweight and obese, and obesity further increases the risk of cardiovascular disease in patients with type 2 diabetes.
And now coincides with the Spring Festival holiday, the so-called "every festival fat three pounds", the number on the scale has made you can't bear to look directly? In order to make themselves healthier after the holiday, everyone including people who are overweight or obese and related chronic diseases (including diabetes) need to hurry up and manage their weight now. Below we will provide a detailed introduction to weight management in people with type 2 diabetes who are overweight or obese, and some of the recommendations also apply to the general population.
Image source: 123RF
What are the benefits of proper weight loss?
Epidemiological data show that according to the diagnostic standards of China and the World Health Organization (WHO), the proportion of Chinese adults with diabetes combined with overweight, obesity and central obesity (which can be judged by waist circumference, male waist circumference ≥90 cm, female waist circumference ≥85 cm) is 41%, 24.3%, 45.4%, 43.8%, 11.8% and 65.8%, respectively. Appropriate weight loss (such as 5%~15%) can not only effectively reduce glycosylated hemoglobin (HbA1c) in patients with type 2 diabetes, reduce the type or dose of hypoglycemic drugs, improve blood pressure, blood lipids and even cardiovascular outcomes, but also achieve diabetes remission in some patients.
What are the goals and principles of weight loss?
The short-term weight loss goal of overweight and obese diabetic patients is 5%~10% of weight loss in 3 months to 6 months; Some patients can set more stringent weight loss goals (such as 10%~15%). For patients who have achieved their short-term goals, a long-term (≥1 year) comprehensive weight loss plan should be further developed.
Weight management in patients with diabetes should follow the principle of individualization, that is, comprehensive consideration according to the patient's age, course of disease, life expectancy, and severity of complications or comorbidities.
3 categories of bariatric treatment strategies
Weight management strategies for adults with type 2 diabetes who are overweight and obese include lifestyle interventions, the use of hypoglycemic or weight-loss drugs with weight-loss effects, and metabolic surgery.
1. Lifestyle interventions
Lifestyle interventions are the basic treatment and mainly include reasonable diet, increased physical activity, and correction of behaviors and habits that cause excessive or insufficient energy intake.
A reasonable weight loss diet should be based on ensuring the balance of dietary nutrients on the basis of an average reduction of 500 kcal~750 kcal in total daily calorie intake, adjusted according to the individual's baseline weight. It is recommended to develop an individualized diet plan based on individual metabolic characteristics and preferences under the guidance of a dietitian.
The effect of increased physical activity on weight loss depends on the manner, intensity, timing, frequency, and total amount of exercise. Approximately 300 minutes of moderate-intensity endurance activity per week or 150 minutes of higher-intensity exercise significantly reduces visceral fat and prevents weight regain after weight loss. People with type 2 diabetes who are overweight or obese are advised to use a combination of aerobic exercise and resistance training.
At least 150 minutes (more than 30 minutes per day) of moderate-intensity aerobic exercise (equivalent to walking at a speed of 5 km/h~6 km/h) per week at the beginning of weight loss, and moderate-intensity aerobic exercise of 200 min~300 minutes per week during the weight loss maintenance period; Combined with resistance training 2 ~ 3 times a week (non-continuous), each time 15 min ~ 20 min, resistance training is mainly compound movements (squats, deadlifts, bench press), 8 times ~ 12 times / group, high load, low times, low number of sets and low load, high times, high number of sets combined resistance training, can maximize the effect of "muscle gain and fat reduction".
In addition, all people with type 2 diabetes who are overweight or obese are encouraged to increase non-exercise, active recreational activities to reduce sedentary behavior.
Second, use hypoglycemic drugs or weight loss drugs that have both weight loss effects
1. General principles of drug treatment:
Patients with overweight and obese type 2 diabetes should consider the impact of drugs on weight and minimize weight gain.
For patients with type 2 diabetes with a BMI ≥ 27 kg/m2, drugs such as glucagon-like peptide-1 receptor agonists (GLP-1RA) can be used in addition to lifestyle interventions.
For diabetic obese patients who need to use insulin therapy, it is recommended to use one or more other hypoglycemic drugs that can reduce weight, or choose basal insulin and GLP-1RA in combination to enhance the hypoglycemic effect while avoiding adverse reactions such as weight gain and hypoglycemia caused by insulin therapy.
If the weight control is still not ideal after fully adjusting the hypoglycemic regimen, the adjuvant use of weight loss drugs can be considered; If the goal of 5% weight loss is not achieved within 3 months of full dose weight loss drugs, the weight loss drugs should be discontinued and the patient reassessed.
2. Weight loss and glucose lowering drugs:
Hypoglycemic drugs with weight-reducing effects include: metformin, α-glycosidase inhibitor (AGI), sodium-glucose co-transporter 2 inhibitor (SGLT2i), GLP-1RA. While these drugs effectively play a hypoglycemic and hypoglycemic effect, they can reduce weight to varying degrees, and some drugs can also bring cardiovascular and renal benefits.
▲ Characteristics of metformin, GLP-1RA, SGLT2i, AGI drugs (Image source: Reference [3])
2. Weight Loss Drugs:
These drugs are only used as an adjunct to lifestyle interventions for weight loss in patients with type 2 diabetes. At present, the only approved weight loss drug in China is orlistat (lipase inhibitor), however, the gastrointestinal adverse effects of the drug (steatorrhea, etc.) limit the widespread use of the drug. GLP-1RA liraglutide 3.0 mg/day and semeglutide 2.4 mg/week have been officially approved as weight loss drugs in many countries internationally, in addition, GLP-1RA benaglutide, liraglutide and semeglutide are also conducting phase 3 clinical trials in China, submitting applications for relevant indications to observe their weight loss efficacy and safety in overweight or obese adults in China.
3. Metabolic surgery
Obese adults with type 2 diabetes should adopt lifestyle and medication as much as possible, and metabolic surgery may be considered for those who still have poor blood glucose control. Compared with intensive lifestyle intervention and hypoglycemic drug treatment, metabolic surgery can reduce weight and blood glucose more effectively, improve metabolic indexes such as blood lipids and blood pressure, reduce the risk of diabetic macrovascular and microvascular complications, and reduce the occurrence of obesity-related tumors.
For severely obese patients with type 2 diabetes, metabolic surgery is currently the only intervention that can achieve short- and long-term weight loss. Metabolic surgery requires multidisciplinary collaboration and management before, during, and after surgery. Patients after metabolic surgery should regularly monitor micronutrients and assess nutritional status. Lifestyle intervention alone can achieve an HbA1c ≤ of 6.5% and a fasting blood glucose ≤ of 5.6 mmol/L, which can be regarded as remission of type 2 diabetes.
Metabolic surgery includes laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, and biliopancreatic diversion duodenal transposition.
Laparoscopic sleeve gastrectomy: after this procedure, the average 2-year response rate for patients with type 2 diabetes is 70%. According to the Chinese Guidelines for the Prevention and Treatment of Type 2 Diabetes (2020 Edition), this surgical therapy is the preferred surgical treatment for moderate to severe obesity with type 2 diabetes.
Gastric bypass: This procedure is more complicated, traumatic, high complication rate, postoperative monitoring and nutrient supplementation, for patients with relatively long duration of type 2 diabetes and more weight loss. After 5 years of follow-up, the remission rate of patients with type 2 diabetes can reach 83% after treatment with this therapy.
Biliary and pancreatic bypass: Although the surgical therapy has a good weight loss effect, the remission rate of type 2 diabetes can reach 95%, but the surgical operation is extremely complex, the complications and mortality are high, and it is easy to have vitamins, trace elements, nutrients (especially protein) deficiency, and the nutritional metabolism disorder must be strictly monitored after surgery and supplemented. For severely obese patients with type 2 diabetes with a BMI of ≥ 50 kg/m2, biliopancreatic diversion duodenal transposition is an option.
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