Section 2.2 Metabolic Complications

Key Points

  • Obesity is associated with higher risks of prediabetes and type 2 diabetes (T2D)
  • Weight loss with lifestyle therapy, pharmacotherapy, or bariatric surgery
    • Reduces the risk of progression to T2D
    • Improves glycemic control in patients with T2D
    • Improves features of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH)

AACE/ACE Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity Recommendations1

Prediabetes and Metabolic Syndrome

  • R30. Patients with overweight or obesity and with either metabolic syndrome or prediabetes, or patients identified to be at high risk of T2D based on validated risk-staging paradigms, should be treated with lifestyle therapy that includes a reduced-calorie healthy meal plan and a physical activity program incorporating both aerobic and resistance exercise to prevent progression to diabetes. The weight-loss goal should be 10%.
  • R31. Medication-assisted weight loss employing phentermine/topiramate ER, liraglutide 3 mg, or orlistat should be considered in patients at risk for future T2D and should be used when needed to achieve 10% weight loss in conjunction with lifestyle therapy.
  • R32. Diabetes medications including metformin, acarbose, and thiazolidinediones can be considered in selected high-risk patients with prediabetes who are not successfully treated with lifestyle and weight-loss medications and who remain glucose intolerant.

Type 2 Diabetes

  • R33. Patients with overweight or obesity and T2D should be treated with lifestyle therapy to achieve 5% to 15% weight loss or more as needed to achieve targeted lowering of A1C. Weight-loss therapy should be considered regardless of the duration or severity of T2D, both in newly diagnosed patients and in patients with longer-term disease on multiple diabetes medications.
  • R34. Weight-loss medications should be considered as an adjunct to lifestyle therapy in all patients with T2D as needed for weight loss sufficient to improve glycemic control, lipids, and blood pressure.
  • R35. Patients with obesity (BMI ≥ 30 kg/m2) and diabetes who have failed to achieve targeted clinical outcomes following treatment with lifestyle therapy and weight-loss medications may be considered for bariatric surgery, preferably Roux-en-Y gastric bypass, sleeve gastrectomy, or biliopancreatic diversion.
  • R36. Diabetes medications that are associated with modest weight loss or are weight-neutral are preferable in patients with obesity and T2D, although clinicians should not refrain from insulin or other medications when needed to achieve A1C targets.

Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis

  • R45. Patients with overweight or obesity and NAFLD should be primarily managed with lifestyle interventions, involving calorie restriction and moderate-to-vigorous physical activity, targeting 4% to10% weight loss (a range over which there is a dose-dependent beneficial effect on hepatic steatosis).
  • R46. Weight loss as high as 10% to 40% may be required to decrease hepatic inflammation, hepatocellular injury, and fibrosis. In this regard, weight loss assisted by orlistat, liraglutide, and bariatric surgery may be effective.
  • R47. A Mediterranean dietary pattern or meal plan can have a beneficial effect on hepatic steatosis independent of weight loss.

Reference

  1. Garvey WT, Mechanick JL, Brett EM, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity. Endocr Pract. 2016;22(suppl 3);1-205.