Preventing Diabetes Through Sustainable Weight Loss
By Julia Kenney
While diabetes and prediabetes treatments have traditionally focused on managing your glucose, recent research highlights the importance of weight loss in type 2 diabetes prevention, management, and remission.
For people with diabetes, managing glucose levels is top of mind. Avoiding highs and lows and doing your best to stay in range throughout the day can be difficult, but what if it is not all about glucose? Researchers are beginning to advocate for a more weight-centric approach to type 2 diabetes treatment that prioritizes weight management, in addition to glucose control, in treating diabetes. This approach could help improve long-term health outcomes and support people in achieving type 2 remission.
What is the connection between weight management and diabetes?
Type 2 diabetes and obesity are closely linked. Of the over 463 million people with type 2 diabetes globally, around 90% either have excess weight (a BMI greater 25 kg/m2) or obesity (a BMI greater 30 kg/m2). Both diabetes and obesity are metabolic diseases caused by a series of genetic, social, behavioral, and environmental factors. Because these causes are closely linked and the two conditions frequently overlap, experts continue to debate whether obesity causes diabetes or vice versa.
While the exact relationship between diabetes and obesity is uncertain, experts have linked the two by looking at the effects of excess fat in the liver and pancreas. Fat build-up in the liver and pancreas is exacerbated by obesity and has been shown to predict the development of type 2 diabetes. The extent to which fat builds up in the liver and pancreas is largely determined by a person’s genetics, but weight management can help decrease fat build-up in these parts of the body and ultimately reduce a person’s risk for type 2 diabetes.
Look here to learn more about the relationship between diabetes and obesity.
What is a “weight-centric” approach to diabetes and who is it for?
Dr. Ildiko Lingvay, an endocrinologist from UT Southwestern Medical Center, discussed the difference between a weight-centric and glucose-centric approach to diabetes at the EASD 2021 virtual conference. “Our current approach to treating type 2 diabetes is singularly centered around lowering glucose with the purpose of preventing diabetes-related complications,” she said.
Dr. Lingvay recommends this glucose-centered approach for people whose diabetes is driven by beta-cell dysfunction (which is when the cells in your pancreas that make insulin, called beta-cells, stop working properly). This most commonly describes people with type 1 diabetes but can also occur in some individuals with type 2. However, for those with diabetes that is driven by obesity or excess weight, Lingvay advocates for treatments to address the main driver of the disease – weight.
A weight-centric approach sets health goals focused on weight loss rather than glucose targets. For example, in addition to health goals related to improving A1C and Time in Range (TIR), treatment decisions would be based on achieving weight management goals as well. This approach may also benefit those at risk for developing prediabetes or type 2 diabetes.
Which weight loss interventions can help treat diabetes?
Dr. Priya Sumithran, an endocrinologist at the University of Melbourne, spoke to the effectiveness of different weight management strategies in treating diabetes at the conference. Dr. Sumithran explained that the impact and purpose of weight management strategies largely depends on when they are implemented in a person’s diabetes progression.
A person with excess weight who has prediabetes could completely avoid a diabetes diagnosis by focusing on weight management strategies. For someone with diabetes and excess weight, weight management strategies could help prevent long term health complications like heart and kidney disease. Overall, Dr. Sumithran explains that a weight loss of at least 10% could even help people achieve remission, and it could prevent serious complications or a diabetes diagnosis altogether.
Dr. Sumithran describes the following weight management strategies and how they can help treat or prevent diabetes:
Lifestyle – Changes in diet and exercise can help people with excess weight and diabetes manage their disease and even achieve remission. In a two-year study on dietary interventions and weight management in people with type 2 diabetes, 70% of participants who lost at least 15 kilograms achieved diabetes remission compared to 28.8% of participants who lost between 5 and 10 kilograms. The wealth of research on dietary interventions in those with type 2 demonstrates that weight management through lifestyle changes can help manage your diabetes. However, achieving and maintaining a high level of weight loss through lifestyle changes alone can be difficult.
Medications – New FDA approved medications have been designed to reduce a person’s appetite and can have significant, long-term weight management benefits for people with diabetes and obesity. One of these medications, semaglutide, is a GLP-1 receptor agonist – a class of glucose-lowering medications shown to support weight loss. In the recently published STEP 2 trial studying the use of Wegovy (a 2.4 mg dose of semaglutide) in people with excess weight and type 2 diabetes, nearly half (45.6%) of participants achieved weight loss of at least 10% of their body weight, and just over a quarter (25.8%) achieved weight loss of at least 15%.
Tirzepatide is another medication that can help with weight management in people with type 2 diabetes and excess weight. According to the SURPASS trials studying the effectiveness of the drug, 43% of people using tirzepatide achieved a weight loss of at least 15%. Learn more about tirzepatide here.
Surgical – Bariatric surgery may also be able to help people with diabetes lose weight, keep it off, and avoid health complications, however the ADA recommends that this intervention should really only be considered for those with a BMI greater than 35 kg/m2 whose diabetes or other lifestyle comorbidities are unable to be managed with lifestyle changes or medication. In a study of over 13,000 people with type 2 diabetes, those who had bariatric surgery had a 40% lower risk of developing heart disease than those who did not. Like any procedure, there are physical, mental, and financial factors to consider before undergoing bariatric surgery. It can also be inaccessible to many people with diabetes due to high costs and coverage barriers. Learn more about weight management surgeries here.
What about type 1 diabetes?
Weight management is not unique to people with type 2 diabetes. According to recent data, 29.7% of people with type 1 in the US have excess weight and 21.6% have obesity. Dr. Bart Van der Schueren, an endocrinologist with the University of Leuven in Belgium, describes obesity care for people with type 1 diabetes as a “two-way road filled with potholes” because of the unique challenges these individuals face.
It’s a two-way road because of the “bi-directional” relationship between type 1 diabetes and obesity. As described in the image below, insulin therapy can lead to weight gain. Weight gain can lead to obesity which worsens type 1 outcomes by increasing insulin resistance (this is called the accelerator hypothesis). The “potholes” are what he describes as the main drivers of weight gain in people with type 1 diabetes, including:
Intensive insulin therapy – Insulin can lead to weight gain in some people with type 1 diabetes. Because people with type 1 need insulin to survive, this barrier can make weight management a difficult task.
Risk of hypoglycemia – The health consequences of low glucose levels can be severe. To avoid hypoglycemia, people with type 1 diabetes may eat more often or exercise less, which can make weight management difficult.
Genetics – Genetics plays a large role in weight management and the onset of obesity for all people, regardless of whether or not they have diabetes. Depending on a person’s genetics and family history with obesity, it may be more difficult for them to manage their weight.
While managing glucose levels will always be important for all people with diabetes, “The treatment of obesity is the future of diabetes treatment,” according to Dr. Lingvay.
Weight management can help prevent and treat type 2 diabetes and can even lead to remission. That said, we acknowledge that weight management can be difficult. Talk with your healthcare team to determine your treatment plan and how to set manageable and achievable weight management goals.
To learn more about weight management in diabetes, read our article “How to Lose Weight and Keep it Off.”