Obesity and diabetes are significant public health concerns globally and in the United States. ‘Diabesity’ is a term used to describe the combination of adverse health effects of obesity and diabetes on individuals. In the recently concluded Pri-Med East Conference, 2022, in Boston, Nicholas Pennings, DO, Campbell University School of Osteopathic Medicine, Lillington, NC, and Jennifer Green, MD, Professor of Medicine Department of Medicine, Division of Endocrinology, Duke University Medical Center, Durham, NC, discussed the management of obesity, therapeutic inertia, 6 A’s of behavior change, and how the clinicians can reframe their mindset to treat obesity.
Obesity increases the risks for people with diabetes
About 60%-80% of people with diabetes also have obesity (Body Mass Index ≥30). Obesity greatly increases mortality risk, diabetes progression, and related complications among people with diabetes.
Benefits of weight loss in people with diabetes
The benefits of weight loss among people with diabetes are well documented. Prior studies have reported that participants with diabetes who lost ≥10% of their body weight showed cardiovascular and mortality benefits. Additional benefits include reduced need for diabetes medications, fewer hospitalizations, improved sexual functioning, and decreased waist circumference.
Weight loss has the potential to improve other comorbidities as well. These include improved lipid profile, improved blood pressure control, reduced cancer, reduced severity of sleep apnea, improved management of urinary incontinence, reduced knee pain in osteoarthritis, and reduced frequency and severity of gastroesophageal reflux disease.
Challenges of lifestyle modifications
Lifestyle modifications alone are insufficient for weight loss. Research has shown that modifications to diet and activity typically reduce weight by 5% to 10%. Lifestyle changes take time to start and maintain. As weight loss occurs, the body makes it more challenging to continue losing weight and works to regain it.
Existence of therapeutic inertia around treating obesity
Therapeutic inertia is a significant barrier in the management of obesity. According to the American Diabetes Association, “therapeutic inertia is a lack of timely adjustment to therapy when a patient’s treatment goals are not met.”
Some of the causes of this therapeutic inertia around obesity include clinicians being busy treating other critical chronic diseases, lack of penalty for neglecting to treat obesity, clinicians lacking comfort prescribing weight loss interventions, and patient misconceptions and lack of awareness around pharmacologic treatment (such that weight loss medicine are ineffective, unsafe and is not a long-term solution).
Sometimes the clinicians are also biased towards patients with obesity, believing them to be lazy, undisciplined, and unlikely to adhere to recommended changes and view them as a “waste of time.”
Treatment approach for obesity
The speakers highlighted that patient-provider communications about a patient’s weight should be patient-centric, empathetic, non-judgemental, performed using appropriate terminology, focused on health rather than weight, focused on shared decision-making, and providing practical options to assist with weight loss. For patients with a Body Mass Index (BMI) ≥27 with diabetes and/or other weight-related comorbidities or a BMI ≥30 without comorbidities, anti-obesity medications should be prescribed as an adjunct to lifestyle therapy. Clinicians should adjust their treatment plan if patients on anti-obesity medications aren’t achieving 5% weight loss after 12 weeks. If patients are at maximum dose and not meeting goals, one should change medication, the speakers highlighted. However, if all fails bariatric surgery, endoscopic procedures, and non-surgical intervention should be considered.
The 6 A’s for behavior change in weight management
The speakers discussed the 6 A’s clinicians should keep in mind to underline behavior change in weight management. These include:
- Ask – asking permission to discuss the patient’s weight and preferred terms;
- Assess – assessing patients for obesity with metabolic risk factors and patients’ readiness and ability to make changes at this time;
- Advise – advising patients of the health benefits of weight loss and lifestyle change;
- Agree- agreeing with patients on the measurable and achievable goal that will lead to health benefits;
- Assist- assisting patients in creating a management strategy that leverages the entire care, such as referrals to dietitians, social workers, obesity medicine providers, etc.;
- Arrange- arranging follow-up to create a structure for accountability and feedback on progress.
Reframing our mindset to treat obesity as a chronic disease
The speakers concluded their talk by emphasizing the need to reframe our mindset in treating obesity as a chronic condition. Obesity should be treated as a chronic health issue that requires long-term care. Multiple anti-obesity drugs and interventions can be used long-term and have been proven to help sustain weight loss better than lifestyle changes alone.