With no scientific evidence whatsoever, the expert panel recommends frequent measurement of weight and BMI , particularly when rapid weight changes or heart failure.
LIFESTYLE INTERVENTIONS.
Evedence-based recommendations are:
- Patients with T2DM and overweight or obesity who want to lose weight benefit in A1c and triglycerides from a diet and exercise program with the aim of losing at least 5%. Larger loses achieve even more benefits (HDL, LDL, reduction in medication for diabetes and CV risk factors).
- Such interventions should be high intensity (>16 sessions in 6 months) and include diet, exercise and behavioural changes to achieve a negative caloric balance of at least 500 Kcal. That was evidenced in the Look Ahead trial.
- Motivation and life circumstances, like culture or food availability, must be taken into account in these interventions.
- Dietary plan must be individualized.
- For those achieving short-term weight lose, a long-term management program that includes monthly contact, weekly weight monitoring and >200 weekly exercise minutes is advisable.
- More intense short-term programs with <800 Kcal or food replacement may be employed inicially by trained professionals in selected patients, always followed by a long-term strategy.
All this looks like science fiction for me. Offering 16 sessions in 6 months to every overweight T2DM patient in my clinical setting is absolutely unachievable, not to mention a monthly long-term program, but it's worth it to know the way things are right done.
PHARMACOTHERAPY.
- When choosing antidiabetic drugs, consider effects on weight. ADA says GLP1-RAs, SGLT2-i and metformin (?) reduce weight, DPP4i are neutral and insulin, secretagogues and TZD increase weight.
- Consider weight effect in drugs used in comorbidities. Antipsychotics, antidepressants, gabapentin or glycocorticoids raise weight.
- If weight lose medications are used, always balance benefit and risk. FDA has approved quite a lot of weight-lose drugs: phentermin (inly <12 weeks), orlistat, lorcaserin, phentermin/topiramate, naltrexone/bupropion and liraglutide. In Spain there are only three: liraglutide, naltrexone/bupropion and orlistat.
- If weight lose drugs are used, discontinue in weight lose <5% or adverse effects.
MEDICAL DEVICES.
There are no clinical data, so they are currently not part of the standard of care in diabetes.
BARIATRIC/METABOLIC SURGERY.
- Patients with BMI >40 and those with BMI 35-40 in whom nonsurgical methods have failed must be considered candidates for bariatric surgery.
- Patients with BMI 30-35 may be considered if other methods have failed.
- Experienced centers and surgeons are preferable, although this is just an expert opinion, i,e, nothing.
- Postoperative surveillance of nutritional deficits is advisable. Dumping syndrome or hypoglycemia are also long-term complications.
- Psychiatric preoperative evaluation is mandatory. Substance abuse, depression, and suicidal ideation must be carefully taken into account before surgery is chosen.
- Psychiatric postoperative surveillance is recommendable, particularly for patients suffering from thea aforementioned conditions.
RCT have shown that MS is superior to medical approach in diabetic and risk factor control. Nonrandomized trials have shown reduction in micro-, macrovascular complications and cancer. Observational studies suggest that MS reduce death rate.
Young age, short duration of diabetes, absence of insulin, weight lose manteinance, and visceral fat are predictors of metabolic success.
Some type 1 morbid obese diabetic patients may benefit from MS, but further data are necessary.
MS is costly, long-term cost-effectiveness is not well established.
Adverse effects have reduced over time. Mortality is 0,1-0,5%, similar to a cholecystectomy. Major complications like pulmonary embolism or reoperation are 2-6%, and minor complications are 15%.
