Emphasis on Weight Loss in New Type 2 Diabetes Guidance

Miriam E. Tucker

September 26, 2022

STOCKHOLM, Sweden — Weight loss should be a co-primary management goal for type 2 diabetes in adults, according to a new comprehensive joint consensus report from the European Association for the Study of Diabetes (EASD) and the American Diabetes Association (ADA).

And while metformin is still recommended as first-line therapy for patients with type 2 diabetes with no other comorbidities, the statement expands the indications for use of other agents or combinations of agents as initial therapy for subgroups of patients, as part of individualized and patient-centered decision-making.

Last updated in 2019, the new Management of Hyperglycemia in Type 2 Diabetes statement also places increased emphasis on social determinants of health, incorporates recent clinical trial data for cardiovascular and kidney outcomes for sodium–glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) agonists to broaden recommendations for cardiorenal protection, and discusses health behaviors such as sleep and sitting. It also targets a wider audience than in the past by addressing health system organization to optimize delivery of diabetes care.

The new statement was presented during a 90-minute session on September 23 at the European Association for the Study of Diabetes (EASD) 2022 Annual Meeting, with 12 of its 14 European and American authors as presenters. The document was simultaneously published in  Diabetologia and Diabetes Care.

During the discussion, panel member Jennifer Brigitte Green, MD, commented: "Many of these recommendations are not new. They're modest revisions of recommendations that have been in place for years, but we know that actual implementation rates of use of these drugs in patients with established comorbidities are very low."

"I think it's time for communities, healthcare systems, etc, to actually introduce these as expectations of care...to assess quality because unless it's considered formally to be a requirement of care I just don't think we're going to move that needle very much," added Green, who is professor of medicine at Duke University, Durham, North Carolina.

Vanita R. Aroda, MD, of the Division of Endocrinology, Diabetes and Hypertension at Brigham and Women's Hospital, Boston, Massachusetts, commented: "In the past, sometimes these recommendations created fodder for debate, but I don't think this one will. It's just really solidly evidence-based, with the rationales presented throughout, including the figures. I think just having very clear evidence-based directions should support their dissemination and use."

Weight Management Plays a Prominent Role in Treatment

In an interview, writing panel co-chair John B. Buse, MD, PhD, told Medscape Medical News: "We are saying that the four major components of type 2 diabetes care are glycemic management, cardiovascular risk management, weight management, and prevention of end-organ damage, particularly with regard to cardiorenal risk."

"The weight management piece is much more explicit now," said Buse, director of the Diabetes Center at the University of North Carolina, Chapel Hill.    

He noted that recent evidence from the intensive lifestyle trial DiRECT, conducted in the United Kingdom, the bariatric surgery literature, and the emergence of potent weight-loss drugs have meant that "achieving 10% to 15% body weight loss is now possible."

"So, aiming for remission is something that might be attractive to patients and providers. This could be based on weight management, with the [chosen] method based on shared decision-making."

According to the new report, "Weight loss of 5%-10% confers metabolic improvement; weight loss of 10%-15% or more can have a disease-modifying effect and lead to remission of diabetes, defined as normal blood glucose levels for 3 months or more in the absence of pharmacological therapy in a 2021 consensus report."

"Weight loss may exert benefits that extend beyond glycemic management to improve risk factors for cardiometabolic disease and quality of life," it adds.

Individualization Featured Throughout

The report's sections cover principles of care, including the importance of diabetes self-management education and support and avoidance of therapeutic inertia. Detailed guidance addresses therapeutic options including lifestyle, weight management, and pharmacotherapy for treating type 2 diabetes.

Another entire section is devoted to personalizing treatment approaches based on individual characteristics, including new evidence from cardiorenal outcomes studies for SGLT2 inhibitors and GLP-1 agonists that have come out since the last consensus report.

The document advises, "Consider initial combination therapy with glucose-lowering agents, especially in those with high A1c at diagnosis (ie, > 70 mmol/mol [> 8.5%]), in younger people with type 2 diabetes (regardless of A1c), and in those in whom a stepwise approach would delay access to agents that provide cardiorenal protection beyond their glucose-lowering effects."      

Designed to Be Used and User-Friendly

Under "Putting it all together: strategies for implementation," several lists of "practical tips for clinicians" are provided for many of the topics covered.

A series of colorful infographics are included as well, addressing the "decision cycle for person-centered glycemic management in type 2 diabetes," including a chart summarizing characteristics of available glucose-lowering medications, including cardiorenal protection.

Also mentioned is the importance of 24-hour physical behaviors (including sleep, sitting, and sweating) and the impact on cardiometabolic health, use of a "holistic person-centered approach" to type 2 diabetes management, and an algorithm on insulin use.

Buse is a paid consultant for Anji Pharmaceuticals, Boehringer Ingelheim, Eli Lilly, Fortress Biotech, Janssen, Mellitus Health, Moderna, Pendulum Therapeutics, Praetego, ReachMD, Stability Health, and Zealand Pharma. He is a member of the advisory board for Boehringer Ingelheim, Eli Lilly, Mellitus Health, Moderna, Novo Nordisk, Pendulum Therapeutics, Praetego, Stability Health, vTv Therapeutics, and Zealand Pharma. His employer receives research funding from Dexcom, Eli Lilly, NovaTarg, Novo Nordisk, Sanofi, Tolerion, and vTv Therapeutics. He is an investor in Mellitus Health, Pendulum Therapeutics, and PhaseBio.

Green is a consultant for AstraZeneca, Pfizer, Boehringer Ingelheim/Lilly, Bayer, Sanofi, Anji, Vertex/ICON, and Valo. She conducts research at her institution for Boehringer Ingelheim/Lilly, Merck, and Roche.

Aroda has served as a consultant for Applied Therapeutics, Duke, Fractyl, Novo Nordisk, Pfizer, and Sanofi. VRA's spouse is an employee of Janssen and a former employee of Merck. VRA's employer institution has received research funding for her role as investigator for clinical trials by Applied Therapeutics, Medpace, Eli Lilly, Fractyl, Premier, Novo Nordisk, and Sanofi.

EASD 2022 Annual Meeting. Presented on September 23, 2022.

Diabetologia. Published online September 24, 2022. Full text  

Diabetes Care. Published online September 23, 2022. Full text

Miriam E. Tucker is a freelance journalist based in the Washington, DC, area. She is a regular contributor to Medscape, with other work appearing in The Washington Post, NPR's Shots blog, and Diabetes Forecast magazine. She is on Twitter: @MiriamETucker.

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