Weight Management for Patients with Type 2 Diabetes: Impact of Newer Antidiabetic Therapies on Body Weight.

SUPPORT This article is sponsored by Primary Care Education Consortium and supported by funding from AstraZeneca. and mortality in patients with T2D. Even modest weight loss (~5% of body weight) in overweight or obese patients with T2D has been shown to improve blood glucose control as well as blood pressure and lipid levels, delay progression of diabetes, and reduce the need for glucose-lowering medication. Consequently, guidelines from the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) recommend that weight loss should be considered for any patient with T2D who is overweight or obese. However, patients with diabetes who are overweight or obese often struggle to achieve sustained weight loss with lifestyle modification alone. In the opinion of the author, this is because the body has a goal to return to its maximal weight, and these patients must constantly work against this goal to first reduce and then maintain a lower weight. Maintenance of weight reduction was assessed in the Action for Health in Diabetes (Look AHEAD) study, which compared intensive lifestyle intervention with usual care in a large cohort of overweight and obese patients with T2D. Although weight loss was significantly greater in the group receiving intensive intervention at all time-points up to 8 years, weight loss started to drop off after the first year, even in this group. At 1 year, there was a mean 8.6% reduction from baseline in weight in the intensive lifestyle intervention group, declining to 4.7% at year 8. The tendency for weight regain is likely to be at least partly due to physiological adaptations that favor weight gain in response to a reducedcalorie and reduced-fat diet. Therefore, primary care physicians should consider the psychological implications associated with advising their patients on losing weight and ensure that realistic expectations are set. Physicians should also encourage improved health and lifestyle rather than making weight loss the main focus. Moreover, for many patients with T2D, lifestyle modifications are unlikely to be enough to achieve glycemic targets, and guidelines recommend that pharmacotherapy should also be employed to improve glycemic control. With a wealth of different agents available, it is now possible to tailor therapy to the needs of the individual. This is particuCASE STUDY JB is a 61-year-old, non-Hispanic Caucasian man diagnosed with type 2 diabetes (T2D) in June 2015. His body mass index (BMI) at diagnosis was 31. * To control his blood glucose, JB was prescribed metformin combined with a sulfonylurea, which has reduced his fasting plasma glucose and glycated hemoglobin (HbA1C) levels. He received dietary advice to help him lose weight; however, after initial success, JB has been unable to keep the weight off in the long term. Although he felt well, he also had elevated blood cholesterol and is receiving a statin. In March 2018, JB attended a scheduled clinic appointment. His HbA1C was 7.6% and his BMI was 30.8. JB tells you he has read that some diabetes medicines can cause weight gain, and he is concerned that the drugs he is taking are making it more difficult for him to lose weight. What advice would you give him, and would you make any changes to his diabetes medications?