Q&A: In patients with obesity and type 2 diabetes, OMA advocates to ‘treat obesity first’

The Obesity Medicine Association recently published a new clinical practice statement encouraging clinicians to prioritize the treatment of obesity in patients who also have type 2 diabetes mellitus without acute illness.

In the clinical practice statement (CPS), OMA Chief Science Officer Harold Edward Bays, MD, FOMA, FTOS, FACC, FNLA, FASPC, and colleagues, provide an overview of how obesity may lead to insulin resistance, prediabetes and type 2 diabetes mellitus.

“Patients with or without diabetes mellitus who have acute illnesses should have these illnesses treated acutely (eg, marked hyperglycemia, uncontrolled high blood pressure, severe hypertriglyceridemia, cardiovascular disease or cancer),” they wrote. “However, beyond that, treatment of obesity is the priority for most patients with obesity and T2DM, with optimal therapies providing clinically meaningful weight reduction, therapeutic benefits and/or potential remission of the complications of obesity (ie, T2DM), and improved disease outcomes (eg, cardiovascular disease or cancer).”

Healio spoke with Bays, who is also the medical director and president of the Louisville Metabolic and Atherosclerosis Research Center and clinical associate professor at the University of Louisville School of Medicine, about key takeaways of the CPS, common misconceptions about obesity care and more.

Healio: Can you please discuss the rationale behind “treat obesity first”?

Bays: At least since the 2015 Endocrine Society Clinical Practice Guidelines for Pharmacologic Management for Obesity, when encountering a patient with obesity, a therapeutic priority among many clinicians is weight reduction. In patients without acute complications, the 2023 OMA CPS on Obesity, Diabetes Mellitus and Cardiometabolic Risk furthers this approach by explicitly recommending a “treat obesity first” paradigm for patients with the disease of obesity. Among the more common adiposopathic metabolic complications of obesity include diabetes mellitus, hypertension and dyslipidemia — if such abnormalities are thought to be substantially due to adipocyte and adipose tissue immunopathies and endocrinopathies. When encountering patients with obesity and metabolic diseases such as type 2 diabetes mellitus, the OMA CPS states: “Treatment of obesity is the priority for most patients without acute illness, especially if the therapies chosen for treatment of the obesity are also expected to improve the complications of obesity.”

Healio: Why is this such an important priority for the OMA?

Bays: A prior 2022 OMA CPS, entitled “Thirty Obesity Myths, Misunderstandings, and/or Oversimplifications,” identified how obesity meets all checklist criteria to be characterized as a “disease.” The OMA CPS regarding obesity and diabetes mellitus furthers the “obesity is a disease” medical reality by providing clinicians the answer to the fundamental question: “How does obesity cause diabetes mellitus?”

The 2023 OMA CPS on obesity and diabetes mellitus identifies how fat cell hypertrophy, adipose tissue accumulation and their adiposopathic consequences lead to intraorganellar stress and dysfunction, generation of reactive oxygen species, impaired insulin receptor function, increased inflammation, and release of pathogenic hormones, free fatty acids and bioactive exosomes — with some of the sentinel consequences being among most common metabolic abnormalities encountered in clinical practice.

Healio: What are the biggest takeaways of the clinical practice statement for primary care physicians?

Bays: One of the biggest takeaway messages of the 2023 OMA CPS is that body fat is not an inert organ. To the contrary, adipocytes and adipose tissue are active from both an immune and hormone standpoint — each having clinical relevance. Increased body fat can lead to immunopathies and endocrinopathies resulting in “sick fat,” which depending on interactions with other body tissues, often contribute to the most common metabolic abnormalities encountered in clinical practice (eg, diabetes mellitus, hypertension and dyslipidemia). Thus, if the clinician determines that the adiposopathic consequences of obesity represent the primary contributors to metabolic disease, then many clinicians find it only logical to treat obesity first.

Healio: What are some common misconceptions about obesity care among PCPs?

Bays: In some instances, the causes of diabetes mellitus, hypertension and dyslipidemia can be independent of an increase in body fat. Even when obesity substantially contributes to metabolic disease, this most often involves the “disharmonious” interactions with multiple body organs (eg, liver, muscle, pancreas, brain, etc.). That said, clinicians should not be misled into thinking adipose tissue is clinically irrelevant with respect to well-described obesity complications such as diabetes mellitus, hypertension, dyslipidemia, cardiovascular disease and cancer.

According to the OMA CPS on obesity and diabetes mellitus: “Utilizing the principles of Ockham’s razor (ie, parsimony, economy or succinctness in problem-solving) with the patient-centered provision that reversibility is preferred over irreversibility when assigning causation, then a logical conclusion might be, ‘When multiple abnormalities promote an adverse health outcome, it is the defect most directly, simply, and reversibly associated with promoting a disease, and the defect most beneficial when corrected, which is best labeled the primary cause.’ The adipocentric paradigm and philosophical perspective regarding causality of common cardiometabolic diseases and cancer helps explain why body fat gain is often accompanied by onset of cardiometabolic disease (ie, development of adiposopathic “sick fat”). The adipocentric paradigm helps explain why healthful nutrition, routine physical activity, behavior modification, anti-obesity medication and bariatric procedures may not only reduce body weight, may not only improve metabolic diseases and cardiometabolic risk factors, but also improve cardiometabolic disease and in some cases improve cancer outcome.”

Healio: Is there anything else you would like to add?

Bays: A common clinical example is a patient with that fat weight gain who develops type 2 diabetes mellitus. If obesity is determined to be a substantial and treatable cause of the elevated blood sugar, then unless the patient has acute, profound elevations in blood sugar, the priority should be to initially focus on the underlying primary cause of the diabetes mellitus. This approach supports the “treat obesity first” paradigm. This concept and approach is further supported by the 2013 OMA CPS, which provides the evidence supporting that: (1) The main dietary factor leading to type 2 diabetes mellitus remission is the degree the nutritional intervention promotes weight reduction, regarding of diet type; (2) the main contributor to sustained type 2 diabetes mellitus remission in a weight management program is sustained weight reduction; and (3) type 2 diabetes mellitus remission after bariatric surgery is more likely to occur with extensive weight reduction. Thus, whether it be the evidence of the potential pathogenic effects of adipose tissue, or whether it be the clear benefits of treatment of excess body fat, the “treat obesity first” paradigm is often the most effective approach when encountering patients whose increase in body fat has contributed to their metabolic disease.

References:

• Apovian CM, et al. J Clin Endocrinol Metab. 2015;doi:10.1210/jc.2015-1782.
• Bays HE, et al. Obesity Pillars. 2023;doi:10.1016/j.obpill.2023.100056.
• Bays HE, et al. Obesity Pillars. 2022;doi:10.1016/j.obpill.2022.100034.