Obesity in Type 2 Diabetes

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The MD Magazine Peer Exchange "Improving Management of Type 2 Diabetes Mellitus" features a panel of physician experts discussing current best practices to treating and managing patients with T2DM that generally includes lifestyle modifications as well as medication. The mechanisms of action, patient selection criteria, and side effects for various oral medication classes are included in the discussion.

This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons, and an associate director of Surgical Intensive Care at New York-Presbyterian Hospital.

The panelists are:

• Robert Busch, MD, director of clinical research in the Community Endocrine Group at Albany Medical Faculty Practice in Albany, NY
• Ralph DeFronzo, MD, professor of medicine and chief of the diabetes division at the University of Texas Health Science Center in San Antonio, TX
• Pamela Kushner, MD, clinical professor at UC Irvine Medical Center and director of Kushner Wellness at UC Irvine Medical Center in Los Alamitos, CA
• Jeffrey Miller, MD, professor of medicine and clinical director of the Division of Endocrinology and Diabetes at Jefferson Medical School in Philadelphia, PA

Peter L. Salgo, MD: If somebody is obese, that certainly is a risk factor for increased cardiovascular morbidity. Does that affect how aggressive you’re going to be and how closely you’re going to monitor a diabetic?

Jeffrey Miller, MD: I would say if somebody is obese, they’re at increased risk of cardiovascular disease. We’d like, therefore, to give an agent, which, if anything, is going to be associated with some modest weight loss. Most of the agents—the newer kids on the block, incretins, particularly GLP-1s, SGLT2 inhibitors—are associated with a 10- to 12-pound weight loss, which obviously would improve the metabolic syndrome and minimize some of the cardiovascular disease risk that goes with it.

Peter L. Salgo, MD: If you’re trying to bring into this team the patient, which has real advantages, you’re going to bring in some patients with cognitive impairment. You’re going to bring in some patients who clearly have some DSM (diabetes self-management) issues, as well. So, how do you approach that? Can you trust a patient who has that kind of an issue, and what do you do? How do you get around that?

Pamela Kushner, MD: That’s why you have to approach the patient as a team approach. I’ve always been concerned when patients who are having cognitive issues give themselves insulin injections. You have to have members of the team, everybody identifies that, but what about taking your medications regulatory and recognizing what you eat? That’s why if you’re talking about someone with cognitive issues, it becomes a very important point.

I want to go back to something that Ralph said, because I think it’s so important. Treating a patient early and recognizing that willpower does not work—because of your ominous octet that you’ve displayed so eloquently—helps you understand that you can give that patient certain hints, like get up in 20 minutes, you’ve eaten enough, plan ahead, these type of suggestions—and working with the family.

Peter L. Salgo, MD: Right. But at the end of the day, the patient’s got to do that or the family has got to say, “I recognize where you are, you may not. Put away the pie.”

Pamela Kushner, MD: That’s the team.

Jeffrey Miller, MD: In fact, to follow up on Dr. DeFronzo’s point about weight loss and then re-gain, there was a beautiful article a couple of months ago in the Philadelphia Inquirer that spoke about the boomerang effect, and I believe that’s the nicest, closest analog I’ve heard to weight loss. You may be successful in losing weight, but it’s going to come back again, unfortunately.

Ralph DeFronzo, MD: I think it’s important to recognize there is a small percentage of people, whether it’s 10%, 15%, or 20%, who do lose weight and keep it off on a long-term basis. So, it’s critical that you have a strong lifestyle intervention. But even if you prevent the patient from gaining weight, even if you can just neutralize it, that’s very important. Because the natural history of diabetes is to gain weight. The idea is not to minimize lifestyle intervention. I think the idea is to be realistic in terms of what it’s going to achieve. And, in most patients, you’re probably going to need some help with anti-obesity drugs, with a physical trainer, exercise, and they’re going to need some antidiabetic medications to control their glucose.

Jeffrey Miller, MD: What is the role of bariatric surgery in obesity, Dr. DeFronzo?

Ralph DeFronzo, MD: A very controversial topic. I would say if you really have morbid obesity, then I think the only thing that really works is bariatric surgery. I’m reminded very graphically of a relative of someone who is very important at my university with a son who’s 16 and is clearly massively obese. I’m trying to take a history, and the kid has Pickwickian syndrome and is falling asleep. So I told the mom that the only thing that really would work is bariatric surgery. She became very hysterical and said, “Oh, absolutely no, under no circumstances. There must be some medications.” And I said, “Well, there are, but it’s really not going to, I think, be the end-all.” She said, “Let’s go with the medications.” She called me back about 2 months later—and I’ve been now talking to her like every week—hysterical. Her son died in his sleep.

When you have morbid obesity, the only thing that really, I think, works on a long-term basis is the bariatric surgery. But what do you do with somebody who has a BMI of 30 or 31? Well, if they’ve lost weight, gained weight, lost weight, they’re on three oral agents, and now they’re progressing to insulin therapy, I think that I would strongly consider the bariatric surgery. And then there’s an even grayer zone. What if you still have several choices of oral agents and you’re relatively early in the course? Would you go to the bariatric surgery? Well, I probably wouldn’t, but there might be other physicians who might. So, I think at extremes, you can probably make decisions, but there’s always this big gray zone in between.