The Great Debate: Medicine or Surgery

What Is Best for the Patient With Type 2 Diabetes?

David Lautz, MD; Florencia Halperin, MD; Ann Goebel-Fabbri, PHD; Allison B. Goldfine, MD


Diabetes Care. 2011;34(3):763-770. 

In This Article

Advanced Nonsurgical Management of Weight and Type 2 Diabetes

Patients with type 2 diabetes have difficulty losing weight and maintaining weight loss. Pharmacologic management of diabetes remains controversial, both from the perspective of the best medications to prescribe and the optimal glycemic targets. Many new classes of drugs have been Food and Drug Administration approved for the management of type 2 diabetes on the basis of glucose-lowering properties. Although many diabetes medications are associated with weight gain, including insulin, sulfonylureas, and thiazolidinediones, more recently approved medications are weight neutral (dipeptidyl peptidase-4 inhibitors or bile acid sequestrants) or promote weight loss (GLP-1 analogs and amylin analogs). However, the long-term risks of newer agents remain less certain, and these agents are considered tier 2 in consensus algorithms.[55]

Nonsurgical behavioral approaches to weight loss have been studied for decades. Most evidence supports the effectiveness of combining moderate dietary changes and increased physical activity—an approach referred to as a "lifestyle intervention"—for achieving modest weight loss and maintaining weight improvements over time. Long-term evidence is now available supporting the power of lifestyle interventions to prevent the onset of type 2 diabetes in high-risk populations;[56] however, patients already diagnosed with diabetes may have a harder time achieving and maintaining weight loss than patients without diabetes.[57] The LookAHEAD trial (Action for Health in Diabetes) is a large-scale, multicenter clinical trial investigating the impact of lifestyle intervention on cardiac outcomes in more than 5,000 patients with type 2 diabetes. Four-year follow-up data from LookAHEAD support the successful impact of lifestyle interventions in achieving weight loss and improved glycemic control in type 2 diabetic patients.[58] Participants in the lifestyle arm initially lost an average of 8.6% of their initial weight and experienced a mean decrease in glycohemoglobin from 7.3 to 6.6% during their first year of LookAHEAD. After 4 years, 6.2% weight reduction was sustained in the lifestyle group compared with only 0.9% reduction in the control group; glycohemoglobin was reduced 0.4% in the lifestyle group compared with 0.09% in the control group. Lifestyle participants showed sustained improvements in blood pressure, cholesterol, and physical fitness. Current results of LookAHEAD[58] and other studies already support the use of lifestyle interventions to improve overall health and wellness of patients with diabetes.

The best weight loss outcomes result from interventions that include multidisciplinary teams with behavioral modification components, frequent contact individually or in group programs, and administration of long-term support. Substantial funding is needed to carry out these interventions in research or clinical care settings. Private insurance reimbursement for such programs may become more widely available now that Medicare recognizes obesity as a chronic disease. Thus, insurance-billable, cost-effective multidisciplinary approaches are emerging in clinical practice that target both diabetes and weight management. One such example is the Why WAIT (Weight Achievement and Intensive Treatment) program, which consists of 12 weekly group sessions led by nutrition, exercise physiology, mental health, and diabetes care providers, followed by monthly support aimed at long-term maintenance of weight loss and diabetes control.[59] Unfortunately, on a national level, few patients participate in these types of intensive medical management programs.


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