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Never Mind Semantics, We Have to Talk About Weight Loss in Diabetes Treatment

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My patients constantly ask me what their A1C and glucose goals should be. Those on continuous glucose monitors often are savvy enough to ask me what their goal should be for a time in target range. These questions tell me that we are, generally, doing a good job educating our patients on these treatment targets. Yet I struggle to remember the last time a patient asked me what their goal weight should be. So my question is, are we losing this aspect of the messaging, or are we not even trying?

 I worry it's the latter: we clinicians fail to bring up obesity. I suspect there are contributing factors: lack of time, fear of offending or antagonizing the patient, or predetermining the patient won't lose the weight or even try to do so. Unfortunately, if we fail to address obesity, then we will fail our patients. Never more so than in 2022, an era when it's clear that weight loss can lead to prevention or remission of Type 2 diabetes and when we have so many tools (bariatric surgery, GLP-1 agonism, and now dual GLP-1/GIP agonism) at our disposal.

Today I attended (virtually) the ENDO 2022 session "Should Weight Management Be a Primary Treatment Goal for Type 2 Diabetes?" a debate between Dr. David Nathan and Dr. Ildiko Lingvay.

Dr. Nathan made the case that weight management should be a primary prevention goal for Type 2 diabetes but not the primary treatment goal. He argued that glycemic control should be the primary treatment goal by citing many of the most famous studies linking improved glycemic control with better outcomes (UKPDS, DCCT, etc.) He also noted that in the Look AHEAD study, which primarily focused on weight loss, there was minimal microvascular complication benefit and none for the cardiovascular. He pointed out the subsequent lack of high-quality evidence supporting weight loss as the primary treatment goal for Type 2 diabetes and the difficulty of achieving and sustaining weight loss.

Dr. Lingvay acknowledged Dr. Nathan's eminence in the science of diabetes prevention and treatment but gamely countered that given Dr. Nathan's documented support for bariatric surgery in a large number of Type 2 diabetes and that they probably agreed more than they disagreed. She cited many studies linking greater weight loss to greater glycemic control (Dr. Nathan's proposed primary treatment) and further cited many studies linking weight loss to improved macrovascular, microvascular, and mortality outcomes.

After listening to both sides, I think they were really having a semantic argument rather than a substantive one (indeed, during the Q&A that followed, an audience member brought up the same point!) Focusing on whether something is the primary treatment ignores the importance of multiple intertwined and supremely important goals for treating Type 2 diabetes: improve glycemic control to reduce current symptoms and prevent long-term complications, weight loss as a critical means to improve glycemic control while reducing medication use and improving health and mortality in areas beyond diabetes, and treatments (e.g., SGLT2-inhibitors, statins) that directly reduce complications of diabetes regardless of glucose. We should discuss weight loss in the same breath as A1C, statin therapy, foot exams, and blood pressure control. It doesn't matter which one comes first — and, most importantly, we need to try!

Dr. Bodnar is employed by VA Ann Arbor Healthcare System. He has no conflicts of interest to report.

Image by Alphavector/Shutterstock

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