Managing obesity in people with type 2 diabetes

By 2050, the cost to the NHS of overweight- and obesity-related morbidity is estimated to be £9.7 billion, with wider society costs reaching almost £50 billion.4 Pathophysiology of obesity and T2DM The mechanisms linking obesity and T2DM are complex and still being understood, but likely involve a combination of: * adipose tissue release of excess circulating fatty acids, glycerol, hormones and pro-inflammatory cytokines, impairing cellular insulin signalling and increasing insulin resistance5 * chronically raised lipid levels leading to impaired islet beta-cell function and lower levels of insulin production.6 An approach to the patient with obesity and diabetes An individual with T2DM and obesity may present to a range of specialties. Clinical assessment Detailed history taking and evaluation is described elsewhere.11 Aspects to consider include: * age of onset of excess weight * where onset was as a young child, whether other traits are present suggestive of genetic syndromes * family history of obesity and its pattern, especially if severe obesity is dichotomously present with normal weight * pattern of weight gain, noting periods of acceleration or weight loss and their relation to health or life events * intake of alcohol or other highly calorific liquids * success and failure of previous attempts at losing weight.11 National Institute for Health and Care Excellence (NICE) guidelines (CG189) also provide further advice on the assessment of obesity.12 During examination of a person with diabetes and obesity, aspects to consider include cardiovascular risk, secondary obesity (including genetic causes and endocrinopathies such as Cushing's syndrome) and sequelae (eg osteoarthritis and sleep apnoea). The Look AHEAD Trial compared a 4-year intensive programme (including lifestyle counsellor, dietary interventions, portioncontrolled meal plans, physical activity and behavioural modification techniques) with a diabetes support/education (DSE) group and usual medical care.13 The intensive intervention group showed mean weight loss at 1 year of -8.6% versus -0.7% in the DSE group. A systematic review and metanalysis of 621 studies with 135,246 patients undergoing a range of bariatric procedures reported an overall weight loss of 38.5 kg or 55.9% excess body weight loss.20 78.1% of diabetic patients reached remission and a further 8.5% had an improvement in their diabetic control.