Overweight and obesity are defined as abnormal or excessive fat accumulation that may impair health.¹ There is a recognized close association between obesity and type 2 diabetes termed as ‘diabesity’. Moreover, these two co-morbidities are strongly inter-linked and reduction of bodyweight improves control of diabetes and associated mortality and morbidity. Treatment of obesity in the diabetic patients becomes complex as some of the anti- diabetics may lead to weight gain. Likewise Diabetes treatment doses not give optimum glycemic control in obese patients. Bariatric surgery is currently the most effective anti-obesity treatment and causes long-term remission of diabetes, but surgery has a high cost and associated complications.²

Moreover, patients with Type 2 diabetes are at risk of increasing weight, insulin resistance, with requirement of further amplification of glycemic treatment. In overweight and obese patients with type 2 diabetes, modest and sustained weight loss has been shown to improve glycemic control and to reduce the need for glucose-lowering medications.³

For this review, the evidence for pharmacological management and surgery to manage obesity in Type 2 Diabetes will be reviewed. This will be carried out through literature search and systematic review assessment on obesity treatment in patients with type 2 diabetes with patient relevant outcomes.

It is hypothesized that pharmacological management and surgery are useful interventions to treat obesity for better outcomes among patients with Type 2 Diabetes.

This literature based research took place in 2017 in Pakistan as fulfillment of Diploma in Diabetes through University of South Wales. To review and find evidence as per set hypothesis studies using RCT published between 1995 till to date with inclusion of patients who are obese with type 2 diabetes were explored. Finally two studies using pharmacological interventions and two studies using surgical interventions were selected and results briefly described below in Table 1.

The above studies that looked separately in to pharmacological and surgical interventions in obese patients with type 2 diabetes have shown that maintained weight reduction is an independent parameter for better outcomes.

Pharmacological management with widely used medicines like sibutramine and Orlistat in obesity is associated with improvements in metabolic and glycemic control through meaningful maintenance of weight loss.⁴ However, the more significant weight loss was observed with moderate calorie restriction, while these medicines are well tolerated.

Regarding Surgical Interventions, Dixon et al.,⁵ and Kashyap et al.,⁶ suggested that surgical therapy achieves remission of type 2 diabetes through better weight reduction and Bariatric surgery provides robust glycemic control when comparing with intensive medical therapy at 2 years. Moreover, it is also observed that regardless of similar reduction in weight as sleeve gastrectomy, gastric bypass is beneficial in restoring pancreatic β-cell function truncal fat reduction and consequently reverses the fundamental deficiencies in diabetes.

Looking at the results of above studies and other such similar researches, it is evident that obesity management not only favors to reduce diabetes progression, but also useful to manage glycemic control and substantial reduction in other co-morbidities like hypertension, cardiac disease. Moreover, improvements in glycemia due to weight loss are likely to happen early in the natural history of type 2 diabetes when obesity-associated insulin resistance has caused reversible β-cell dysfunction but insulin secretory capacity remains relatively preserved.⁷

A recent study by Davies et al.,⁸ reported tremendous efficacy of Liraglutide and results showed, significant reductions in mean waist circumference and BMI with liraglutide (3.0 mg) and liraglutide (1.8 mg) compared with placebo. Moreover, Liraglutide (3.0 mg) was associated with significantly better glycemic control compared with placebo in terms of change in HbA1c level. . In addition, more participants treated with liraglutide (3.0 mg) and liraglutide (1.8 mg) than placebo reduced their net use of oral hypoglycemic agents after 56 weeks. This evidence is quite convincing, however, the choices of pharmacological agents to treat obesity are still limited.

According to Sims et al⁹  that as compare to medical therapy alone, recent clinical trials have shown that RYGB or bilio-pancreatic diversion resulted in better glucose control. Likewise, RYGB achieved glycemic control in significantly more patients,¹⁰ and sleeve gastrectomy resolved the diabetic state more effectively.¹¹

As we know that hallmarks of Type 2 diabetes are insulin resistance and obesity are the major causes of this condition. While central or abdominal obesity a factual dilemma, it is also evident that links between Obesity and diabetes are well established and interventions like diet, physical activity, pharmacological and bariatric/metabolic surgical measures are conjunctive treatment measures to manage diabetes in obese patients.

1. Behavior change strategies should be used to bring constant, sustained and long term weight loss in obese diabetics and life style measures should also be prioritized as 1^st line intervention as per guidelines.
2. Follow up care should be stringent with team based approach in diabetes management.
3. The recommendations from recent NICE/ADA should be adopted while managing patients.

None.

The author declares there are no conflicts of interest.

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