ADA releases 2019 guideline for Obesity Management for Treating Diabetes
American Diabetes Association, ADA has released its position statement for Obesity Management for the Treatment of Type 2 Diabetes: Standards of Medical Care in Diabetes—2019 which has appeared in Diabetes Care.It includes ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care.
There is strong and consistent evidence that obesity management can delay the progression from prediabetes to type 2 diabetes and is beneficial in the treatment of type 2 diabetes . In patients with type 2 diabetes who are overweight or obese, modest and sustained weight loss has been shown to improve glycemic control and to reduce the need for glucose-lowering medications,It is well established thatWeight loss–induced improvements in glycemia are most likely to occur early in the natural history of type 2 diabetes when obesity-associated insulin resistance has caused reversible β-cell dysfunction but insulin secretory capacity remains relatively preserved.
The aim of this position statement is to provide evidence-based recommendations for weight-loss therapy, including diet, behavioral, pharmacologic, and surgical interventions, for obesity management as treatment for hyperglycemia in type 2 diabetes.
Key Recommendations are-
At each patient encounter, BMI should be calculated and documented in the medical record.
DIET, PHYSICAL ACTIVITY, AND BEHAVIORAL THERAPY
Diet, physical activity, and behavioral therapy designed to achieve and maintain >5% weight loss should be prescribed for patients with type 2 diabetes who are overweight or obese and ready to achieve weight loss. A
Such interventions should be high intensity (≥16 sessions in 6 months) and focus on diet, physical activity, and behavioral strategies to achieve a 500–750 kcal/day energy deficit. A
Diets should be individualized, as those that provide the same caloric restriction but differ in protein, carbohydrate, and fat content are equally effective in achieving weight loss. A
For patients who achieve short-term weight-loss goals, long-term (≥1 year) comprehensive weight-maintenance programs should be prescribed. Such programs should provide at least monthly contact and encourage ongoing monitoring of body weight (weekly or more frequently) and/or other self-monitoring strategies, such as tracking intake, steps, etc.; continued consumption of a reduced-calorie diet; and participation in high levels of physical activity (200–300 min/week). A
To achieve weight loss of >5%, short-term (3-month) interventions that use very low-calorie diets (≤800 kcal/day) and total meal replacements may be prescribed for carefully selected patients by trained practitioners in medical care settings with close medical monitoring. To maintain weight loss, such programs must incorporate long-term comprehensive weight-maintenance counseling. B
When choosing glucose-lowering medications for overweight or obese patients with type 2 diabetes, consider their effect on weight. E
Whenever possible, minimize medications for comorbid conditions that are associated with weight gain. E
Weight-loss medications are effective as adjuncts to diet, physical activity, and behavioral counseling for selected patients with type 2 diabetes and BMI ≥27 kg/m2. Potential benefits must be weighed against the potential risks of the medications. A
If a patient's response to weight-loss medications is <5% weight loss after 3 months or if there are significant safety or tolerability issues at any time, the medication should be discontinued and alternative medications or treatment approaches should be considered. A
MEDICAL DEVICES FOR WEIGHT LOSS
- Several minimally invasive medical devices have been recently approved by the FDA for short-term weight loss . It remains to be seen how these are used for obesity treatment.
Metabolic surgery should be recommended as an option to treat type 2 diabetes in appropriate surgical candidates with BMI ≥40 kg/m2 (BMI ≥37.5 kg/m2 in Asian Americans) and in adults with BMI 35.0–39.9 kg/m2 (32.5–37.4 kg/m2 in Asian Americans) who do not achieve durable weight loss and improvement in comorbidities (including hyperglycemia) with reasonable nonsurgical methods. A
Metabolic surgery may be considered as an option for adults with type 2 diabetes and BMI 30.0–34.9 kg/m2 (27.5–32.4 kg/m2 in Asian Americans) who do not achieve durable weight loss and improvement in comorbidities (including hyperglycemia) with reasonable nonsurgical methods. A
Metabolic surgery should be performed in high-volume centers with multidisciplinary teams that understand and are experienced in the management of diabetes and gastrointestinal surgery. C
Long-term lifestyle support and routine monitoring of micronutrient and nutritional status must be provided to patients after surgery, according to guidelines for postoperative management of metabolic surgery by national and international professional societies. C
People presenting for metabolic surgery should receive a comprehensive readiness and mental health assessment. B
People who undergo metabolic surgery should be evaluated to assess the need for ongoing mental health services to help them adjust to medical and psychosocial changes after surgery. C
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