I. More than half of overweight or obese diabetics in China
Surveys have shown that the prevalence of type 2 diabetes in China has been rising from the 1980s to the present.
Figure 1. Diabetes prevalence in China from 1980 to 2013
The 2013 edition of the China Type 2 Diabetes Guidelines states that compared to Caucasians, Chinese people are less obese, and the distribution of body fat tends to accumulate in the abdominal cavity, making them more likely to develop abdominal obesity. (The 2013 version of China’s type 2 diabetes prevention and treatment guidelines defines generalized obesity: BMI ≥ 28 kg/m2; abdominal obesity: waist circumference ≥ 90 cm in men and waist circumference ≥ 85 cm in women.)
Second, diabetes starts because of obesity and ends because of obesity
A study published by JAMA in 2013 showed that as BMI increased, the prevalence of diabetes in China increased accordingly.
Figure 2. obesity is positively correlated with the prevalence of diabetes
In addition, increased waist circumference was significantly associated with insulin resistance; and a survey of 3,381 Chinese elderly people found that the prevalence of diabetes was significantly higher in those with abdominal obesity than in those with non-abdominal obesity. However, not only does it affect the incidence rate, but it is also more difficult for obese type 2 diabetic patients to meet the blood glucose control standards.
A number of studies have shown that weight control is beneficial for achieving blood glucose standards.
Analyses have shown that the benefit of a 5 kg weight loss is comparable to that of any FDA-approved oral hypoglycemic agent.
Figure 3. Systematic review analysis of 10 studies
WhyWAIT, a 12-week multidisciplinary program initiated by the Joslin Diabetes Center, showed that weight control as a management goal was more effective in controlling patient glycemia, reducing health care costs, and improving patient quality of life than the traditional HbA1c-based goal.
Table 1. Comparison of two diabetes management models
The 2013 CDS guidelines for the prevention and treatment of diabetes in China state that obesity is significantly associated with an increased risk of developing type 2 diabetes and cardiovascular lesions, and that a comprehensive treatment strategy for type 2 diabetes should include weight control; the 2016 AACE guidelines for diabetes management also recommend managing overweight/obese patients with a focus on complications.
Figure 4. 2016 AACE guidelines recommended management steps
Fourth, several ways to control weight
1. lifestyle is easy to know and hard to do
Studies have shown that lifestyle enhancement can significantly improve sleep apnea, relieve diabetes and reduce disease activity, and diet and exercise are the basic means of weight reduction, but most patients have difficulty adhering to them.
2. Drug therapy balances safety and effectiveness
Table 2. 2013 Edition of the Chinese Guidelines for the Prevention and Treatment of Type 2 Diabetes, the efficacy of commonly used oral medications for glucose lowering and weight reduction
(1) Metformin
The 2013 edition of the Chinese Diabetes Prevention and Control Guidelines states that metformin is effective in reducing HbA1c without increasing weight or risk of diabetes. The meta-analysis also showed that metformin combined with insulin can lower glucose, reduce weight and save insulin dose more significantly compared with insulin alone. Chinese expert consensus also recommends the combination of insulin and metformin: the combination of the two can further improve glycemic control and reduce insulin dosage, as well as reduce weight gain caused by insulin therapy.
(2) Alpha-glucosidase inhibitors
The MARCH study compared the effect of acarbose and metformin on weight control. After 24 and 48 weeks of treatment, there was a significant difference in weight loss between the two groups, with acarbose being more effective than metformin.
Figure 5. Acarbose outperforms metformed metformin for weight loss
Other studies have similarly shown that acarbose 100 mg significantly reduced body weight in Chinese patients with type 2 diabetes.
(3) GLP-1 receptor agonists
These drugs act on the brain to promote satiety, reduce appetite, accelerate energy expenditure and reduce fat synthesis; they also act on the stomach through the vagus nerve pathway to slow gastric emptying. Long-term clinical application studies have shown that liraglutide is highly effective in “controlling” sugar and reducing body weight and waist circumference at the same time.
Figure 6. 2 year results of liraglutide use
(4) SGLT2 inhibitor
A randomized, double-blind, 24-week controlled study showed that initial single-agent SGLT2 inhibitors were effective in reducing glucose and weight loss. 2016 ADA Medical Standards for the Management of Diabetes added a new section on obesity, in which orlistat is the first drug available for the pharmacological management of obesity. The results of a 1-year study showed that orlistat combined with metformin was more effective in reducing patient body mass, HbA1c and FBG than metformin alone, with a good synergistic glucose-lowering effect.
Table 3. Effect of orlistat + metformin compared with placebo + metformin for glycemic and weight control
3. strict indications for bariatric surgery
The 2016 AACE/ACE Clinical Practice Guidelines for the Comprehensive Management of Obese Patients recommends that patients whose quality of life is greatly affected and patients with a BMI of 30 kg/m2 – 34.9 kg/m2 combined with diabetes or metabolic syndrome may be considered for bariatric surgery if the individual so desires.The STAMPED study randomized 150 patients with type 2 diabetes into two groups. Intensive drug therapy alone, intensive drug therapy + bariatric surgery, and the results showed that the surgery was effective in reducing glucose and weight.
Summary
The incidence of diabetes is increasing, and obesity and diabetes interact and are closely related. The treatment of diabetes, blood glucose standards at the same time, weight control can not be delayed!