Diabetes Care Volume 47, Supplement 1, January 2024 S145

8. Obesity and Weight Management American Diabetes Association

Professional Practice Committee*
for the Prevention and Treatment
of Type 2 Diabetes: Standards of
Care in Diabetes–2024

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Diabetes Care 2024;47(Suppl. 1):S145–S157 | https://doi.org/10.2337/dc24-S008

8. OBESITY AND WEIGHT MANAGEMENT

The American Diabetes Association (ADA) “Standards of Care in Diabetes”
includes the ADA’s current clinical practice recommendations and is intended to
provide the components of diabetes care, general treatment goals and guide-
lines, and tools to evaluate quality of care. Members of the ADA Professional
Practice Committee, an interprofessional expert committee, are responsible for
updating the Standards of Care annually, or more frequently as warranted. For a
detailed description of ADA standards, statements, and reports, as well as the
evidence-grading system for ADA’s clinical practice recommendations and a full
list of Professional Practice Committee members, please refer to Introduction
and Methodology. Readers who wish to comment on the Standards of Care are
invited to do so at professional.diabetes.org/SOC.

Obesity is a chronic, often relapsing disease with numerous metabolic, physical, and
psychosocial complications, including a substantially increased risk for type 2 diabetes
(1). There is strong and consistent evidence that obesity management can delay the
progression from prediabetes to type 2 diabetes (2–6) and is highly beneficial in treat-
ing type 2 diabetes (7–17). In people with type 2 diabetes and overweight or obesity,
modest weight loss improves glycemia and reduces the need for glucose-lowering
medications (7–9), and larger weight loss substantially reduces A1C and fasting glu-
cose and may promote sustained diabetes remission (11,18–22). Metabolic surgery,
which induces on average >20% of body weight loss, strongly improves glycemia and
often leads to remission of diabetes, improved quality of life, improved cardiovascular
outcomes, and reduced mortality (23,24). Several modalities, including intensive be- *A complete list of members of the American
havioral and lifestyle counseling, obesity pharmacotherapy, and metabolic surgery, Diabetes Association Professional Practice Committee
may aid in achieving and maintaining meaningful weight loss and reducing obesity- can be found at https://doi.org/10.2337/dc24-SINT.
associated health risks. This section aims to provide evidence-based recommendations Duality of interest information for each author is
for obesity management, including behavioral, pharmacologic, and surgical interven- available at https://doi.org/10.2337/dc24-SDIS.
tions, in people with, or at high risk of, type 2 diabetes. Additional considerations re- This section has received endorsement from The
garding weight management in older individuals and children can be found in Section Obesity Society.
13, “Older Adults,” and Section 14, “Children and Adolescents,” respectively. Suggested citation: American Diabetes Association
Professional Practice Committee. 8. Obesity and
weight management for the prevention and
ASSESSMENT AND MONITORING OF THE INDIVIDUAL WITH treatment of type 2 diabetes: Standards of Care
OVERWEIGHT AND OBESITY in Diabetes—2024. Diabetes Care 2024;47
(Suppl. 1):S145–S157
Recommendations
8.1 Use person-centered, nonjudgmental language that fosters collaboration be- © 2023 by the American Diabetes Association.
Readers may use this article as long as the
tween individuals and health care professionals, including person-first language work is properly cited, the use is educational
(e.g., “person with obesity” rather than “obese person” and “person with diabetes” and not for profit, and the work is not altered.
rather than “diabetic person”). E More information is available at https://www
.diabetesjournals.org/journals/pages/license.
S146 Obesity and Weight Management for Type 2 Diabetes Diabetes Care Volume 47, Supplement 1, January 2024

8.2a To support the diagnosis of consequences (26,27). BMI is especially during weighing and other anthropometric
obesity, measure height and weight prone to misclassification in individuals measurements, particularly for those indi-
to calculate BMI and perform addi- who are very muscular or frail, as well as viduals who report or exhibit a high level
tional measurements of body fat distri- in populations with different body com- of disease-related distress or dissatisfaction.
bution, like waist circumference, waist- position and cardiometabolic risk (28). A Anthropometric measurements should be
diagnosis of obesity should be made performed and reported nonjudgmentally;
to-hip ratio, and/or waist-to-height
based on an overall assessment of the in- such information should be regarded as
ratio. E
dividual’s adipose tissue mass (BMI can sensitive health information.
8.2b Monitor obesity-related anthropo-
be used as a general guidance), distribution Health care professionals should advise
metric measurements at least annually
(using other anthropometric measurements individuals with overweight or obesity and
to inform treatment considerations. E
like waist circumference, waist-to-hip cir- those with increasing weight trajectories
8.3 Accommodations should be made
cumference ratio, or waist-to-height that, in general, greater fat accumulation
to provide privacy during anthropo-

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ratio), or function and, importantly, the increases the risk of diabetes, cardiovascu-
metric measurements. E
presence of associated health or well-be- lar disease, and all-cause mortality and has
8.4 In people with type 2 diabetes and
ing consequences: metabolic, physical, or multiple adverse health and quality of life
overweight or obesity, weight manage-
psychological/well-being (29). consequences. Health care professionals
ment should represent a primary goal Obesity is a key pathophysiologic driver should assess readiness to engage in be-
of treatment along with glycemic man- of diabetes, other cardiovascular risk fac- havioral changes for weight loss and jointly
agement. A tors (e.g., hypertension, hyperlipidemia, determine behavioral and weight loss
8.5 People with diabetes and over- nonalcoholic fatty liver disease, and in- goals and individualized intervention
weight or obesity may benefit from flammatory state), and ultimately cardio- strategies using shared decision-making
any magnitude of weight loss. Weight vascular and kidney disease (30). Diabetes (38). Strategies may include nutrition and
loss of 3–7% of baseline weight im- can further exacerbate obesity, setting up dietary changes, physical activity and ex-
proves glycemia and other intermediate a vicious cycle that contributes to disease ercise, behavioral counseling, pharmaco-
cardiovascular risk factors. A Sustained progression and occurrence of microvascu- therapy, medical devices, and metabolic
loss of >10% of body weight usually lar and macrovascular complications. As surgery. The initial and subsequent thera-
confers greater benefits, including dis- such, treatment goals for both glycemia peutic choice should be individualized
ease-modifying effects and possible re- and weight are recommended in people based on the person’s medical history, life
mission of type 2 diabetes, and may with diabetes to address both hyperglyce- circumstances, preferences, and motiva-
improve long-term cardiovascular out- mia and its underlying pathophysiologic tion (39). Combination treatment ap-
comes and mortality. B driver (obesity) and therefore benefit the proaches may be appropriate in higher-
8.6 Individualize initial treatment person holistically. risk individuals.
approaches for obesity (i.e., lifestyle A person-centered communication style Among people with type 2 diabetes
and nutritional therapy, pharmaco- that uses inclusive and nonjudgmental lan- and overweight or obesity who have in-
logic agents, or metabolic surgery) A guage and active listening to elicit individ- adequate glycemic, blood pressure, and
based on the person’s medical his- ual preferences and beliefs and assesses lipid management and/or other obesity-
tory, life circumstances, preferences, potential barriers to care should be used related metabolic complications, modest
and motivation. C Consider combin- to optimize health outcomes and health- and sustained weight loss (3–7% of body
ing treatment approaches if appropri- related quality of life. Use person-first lan- weight) improves glycemia, blood pres-
ate. E guage (e.g., “person with obesity” rather sure, and lipids and may reduce the need
than “obese person”) to avoid defining for disease-specific medications (7–9,40). In
people by their condition (26,31,32). people at risk, 3–7% weight loss reduces
Obesity is defined by the World Health Measurement of weight and height (to progression to diabetes (2,7,8,41,42).
Organization as an abnormal or excessive calculate BMI) and other anthropometric Greater weight loss may produce addi-
fat accumulation that presents a risk to measurements should be performed at tional benefits (20,21). Mounting data
health (25). BMI (calculated as weight least annually to aid the diagnosis of obesity have shown that >10% body weight loss
in kilograms divided by the square of and to monitor its progression and re- usually confers greater benefits on glyce-
height in meters [kg/m2]) has been used sponse to treatment (33). Clinical consider- mia and possibly diabetes remission and
widely to diagnose and stage obesity ations, such as the presence of comorbid improves other metabolic comorbidities,
(overweight: BMI 25–29.9 kg/m2; obesity heart failure or unexplained weight change, including cardiovascular outcomes, nonal-
class I: BMI 30–34.9 kg/m2; obesity class may warrant more frequent evaluation coholic steatohepatitis, nonalcoholic fatty
II: BMI 35–39.9 kg/m2; obesity class III: (34,35). If such measurements are ques- liver disease, adipose tissue inflamma-
BMI $40 kg/m2); however, BMI should tioned or declined by the individual, the tion, and sleep apnea, as well as physical
not be relied on as a sole diagnostic and practitioner should be mindful of possible comorbidities and quality of life (6,20,
staging tool (19). Despite its ease of mea- prior stigmatizing experiences and query 21,30,41,43–52).
surement, BMI is at most an imperfect for concerns, and the value of monitoring With the increasing availability of more
measure of adipose tissue mass and does should be explained as a part of the medi- effective treatments, individuals with dia-
not measure adipose tissue distribution cal evaluation process that helps to inform betes and overweight or obesity should
or function, nor does it factor in the pres- treatment decisions (36,37). Accommoda- be informed of the potential benefits of
ence of weight-related health or well-being tions should be made to ensure privacy both modest and more substantial weight
diabetesjournals.org/care Obesity and Weight Management for Type 2 Diabetes S147

loss and guided in the range of available 8.12 When short-term nutrition inter- 500–750 kcal/day energy deficit, which
treatment options, as discussed in the vention using structured, very-low- in most cases is approximately 1,200–
sections below. Shared decision-making calorie meals (800–1,000 kcal/day) is 1,500 kcal/day for women and 1,500–
should be used when counseling on 1,800 kcal/day for men, adjusted for the
considered, it should be prescribed to
behavioral changes, intervention choices, individual’s baseline body weight. Clinical
carefully selected individuals by trained
and weight management goals. benefits typically begin upon achieving 5%
practitioners in medical settings with
weight loss (19,54), and the benefits of
close monitoring. Long-term, compre-
weight loss are progressive; more inten-
NUTRITION, PHYSICAL ACTIVITY, hensive weight maintenance strategies
sive weight loss goals (>7%, >10%,
AND BEHAVIORAL THERAPY and counseling should be integrated >15%, etc.) may be pursued to achieve
to maintain weight loss. B further health improvements if the indi-
Recommendations
8.13 Nutritional supplements have not vidual is motivated and more intensive
8.7 Nutrition, physical activity, and
been shown to be effective for weight

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behavioral therapy to achieve and goals can be feasibly and safely attained.
loss and are not recommended. A
maintain $5% weight loss are rec- Nutrition interventions may differ by
ommended for people with type 2 macronutrient goals and food choices as
diabetes and overweight or obesity. B For a more detailed discussion of life- long as they create the necessary energy
8.8a Interventions including high fre- style management approaches and rec- deficit to promote weight loss (19,55–57).
quency of counseling ($16 sessions ommendations, see Section 5, “Facilitating Using meal replacement plans prescribed
in 6 months) with focus on nutrition Positive Health Behaviors and Well-being by trained practitioners, with close moni-
changes, physical activity, and be- to Improve Health Outcomes.” For a de- toring, can be beneficial. Within the inten-
havioral strategies to achieve a sive lifestyle intervention group of the
tailed discussion of nutrition interventions,
Look AHEAD trial, for example, the use of
500–750 kcal/day energy deficit have please also refer to “Nutrition Therapy for
been shown to be beneficial for weight a partial meal replacement plan was asso-
Adults With Diabetes or Pre-diabetes: A
loss and should be considered when ciated with improvements in nutrition
Consensus Report” (53).
available. A quality and weight loss (54), and improve-
8.8b Consider structured programs de- ment in cardiovascular risk factors (41). In
Look AHEAD Trial
livering behavioral counseling (face-to- a systematic review and meta-analysis, ef-
Although the Action for Health in Diabetes
face or remote) to address barriers to ficacy and safety of meal replacements
(Look AHEAD) trial did not show that the
access. E (partial or total meal replacement) as com-
intensive lifestyle intervention reduced
8.9 Nutrition recommendations should pared with conventional diets showed im-
cardiovascular events in adults with type 2
be individualized to the person’s pref- provements in A1C, FBG, body weight,
diabetes and overweight or obesity (41), it
erences and nutritional needs. Use nu- and BMI (58). The nutrition choice should
did confirm the feasibility of achieving and
tritional plans that create an energy be based on the individual’s health status
maintaining long-term weight loss in peo- and preferences, including a determina-
deficit, regardless of macronutrient ple with type 2 diabetes. In the intensive
composition, to achieve weight loss. A tion of food availability and other cultural
lifestyle intervention group, mean weight circumstances that could affect nutrition
8.10 When developing a plan of care, loss was 4.7% at 8 years (42). Approxi-
consider systemic, structural, and so- patterns (59).
mately 50% of intensive lifestyle interven- Proven intensive behavioral interventions
cioeconomic factors that may impact tion participants lost and maintained $5%
nutrition patterns and food choices, included $16 sessions during an initial
of their initial body weight, and 27% lost 6 months and focus on nutritional changes,
such as food insecurity and hunger, and maintained $10% of their initial body
access to healthful food options, cul- physical activity, and behavioral strategies
weight at 8 years (42). Participants as- to achieve an
500–750 kcal/day energy
tural circumstances, and other social signed to the intensive lifestyle group re-
determinants of health. C deficit. Such interventions should be pro-
quired fewer glucose-, blood pressure-, vided by trained individuals and can be
8.11a For those who achieve weight
and lipid-lowering medications than those conducted in either individual or group
loss goals, long-term ($1 year) weight
randomly assigned to standard care. Sec- sessions (54). Assessing a person’s moti-
maintenance programs are recom-
ondary analyses of the Look AHEAD trial vation level, life circumstances, and will-
mended, when available. Effective pro-
and other large cardiovascular outcome ingness to implement behavioral changes
grams provide monthly contact and
studies document additional weight loss to achieve weight loss should be consid-
support, recommend ongoing monitor-
benefits in people with type 2 diabetes, in- ered along with medical status when
ing of body weight (weekly or more
cluding improved mobility, physical and such interventions are recommended
frequently) and other self-monitoring
sexual function, and health-related quality and initiated (38,60). If such intensive be-
strategies, and encourage regular phys-
of life (34). Moreover, several subgroups havioral interventions are not available or
ical activity (200–300 min/week). A
had improved cardiovascular outcomes, accessible, structured programs deliver-
8.11b For those who achieve weight
including those who achieved >10% ing behavioral counseling (face-to-face or
loss goals, continue to monitor prog-
weight loss (43). remote) can be considered; however,
ress periodically, provide ongoing sup-
port, and recommend continuing their effectiveness varies (61,62).
Behavioral Interventions People with type 2 diabetes and over-
adopted interventions to maintain
Significant weight loss can be attained weight or obesity who have lost weight
goals long term. E
with lifestyle programs that achieve a should be offered long-term ($1 year)
S148 Obesity and Weight Management for Type 2 Diabetes Diabetes Care Volume 47, Supplement 1, January 2024

comprehensive weight loss maintenance may be indicated in cases of documented surgery, additional pharmacologic
programs that provide at least monthly deficiency (76), and protein supplements agents, and structured lifestyle man-
contact with trained individuals and focus may be indicated as adjuncts to medically agement programs). A
on ongoing monitoring of body weight supervised weight loss therapies (77,78).
(weekly or more frequently) and/or other Health disparities adversely affect peo-
self-monitoring strategies such as tracking ple who have systematically experienced Glucose-Lowering Therapy
intake, steps, etc.; continued focus on nu- greater obstacles to health based on their Numerous effective glucose-lowering medi-
trition and behavioral changes; and par- race or ethnicity, socioeconomic status, cations are currently available. However, to
ticipation in high levels of physical activity gender, disability, or other factors. Over- achieve both glycemic and weight manage-
(200–300 min/week) (63,64). Some com- whelming research shows that these dis- ment goals for diabetes treatment, health
mercial and proprietary weight loss pro- parities may significantly affect health care professionals should prioritize the use
grams have shown promising weight loss outcomes, including increasing the risk of glucose-lowering medications with a ben-

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results; however, results vary across these for obesity, diabetes, and diabetes-related eficial effect on weight. Agents associated
programs, most lack evidence of effec- complications. Health care professionals with clinically meaningful weight loss in-
tiveness, many do not satisfy guideline should evaluate systemic, structural, and clude glucagon-like peptide 1 (GLP-1) re-
recommendations, and some promote socioeconomic factors that may impact ceptor agonists, dual glucose-dependent
unscientific and possibly dangerous prac- food choices, access to healthful foods, insulinotropic polypeptide (GIP) and GLP-1
tices (65,66). and nutrition patterns; behavioral pat- receptor agonist (tirzepatide), sodium–
Structured, very-low-calorie meals, typ- terns, such as neighborhood safety and
glucose cotransporter 2 inhibitors, metfor-
ically 800–1,000 kcal/day, utilizing high- availability of safe outdoor spaces for
min, and amylin mimetics. Dipeptidyl pepti-
protein foods and meal replacement physical activity; environmental exposures;
dase 4 inhibitors, centrally acting dopamine
products, may increase the pace and/or access to health care; social contexts; and,
agonist (bromocriptine), a-glucosidase in-
magnitude of initial weight loss and glyce- ultimately, diabetes risk and outcomes.
hibitors, and bile acid sequestrants (colese-
mic improvements compared with stan- For a detailed discussion of social determi-
velam) are considered weight neutral. In
dard behavioral interventions (20,21). nants of health, refer to “Social Determi-
contrast, insulin secretagogues (sulfonylur-
However, such an intensive nutritional in- nants of Health: A Scientific Review” (79).
eas and meglitinides), thiazolidinediones,
tervention should be provided only by
and insulin are often associated with weight
trained practitioners in medical settings
PHARMACOTHERAPY gain (see Section 9, “Pharmacologic
with close ongoing monitoring and in-
Approaches to Glycemic Treatment”).
tegration with behavioral support and Recommendations
counseling, and only for short term (gen- 8.14 Whenever possible, minimize
Concomitant Medications
erally up to 3 months). Furthermore, due medications for comorbid conditions
to the high risk of complications (electro- Health care professionals should carefully
that are associated with weight gain. E
lyte abnormalities, severe fatigue, cardiac review the individual’s concomitant medi-
8.15 When choosing glucose-lowering
arrhythmias, etc.), such intensive inter- cations and, whenever possible, minimize
medications for people with type 2
vention should be prescribed only to or provide alternatives for medications
diabetes and overweight or obesity,
carefully selected individuals, such as that promote weight gain. Examples of
prioritize medications with beneficial
those requiring weight loss and/or gly- medications associated with weight gain
effect on weight. B
cemic management before a needed include antipsychotics (e.g., clozapine,
8.16 Obesity pharmacotherapy should
surgery, if the benefits exceed the po- olanzapine, risperidone), some antide-
be considered for people with diabetes
tential risks (67–69). As weight recur- pressants (e.g., tricyclic antidepressants,
and overweight or obesity along with
rence is common, such interventions some selective serotonin reuptake inhibi-
lifestyle changes. Potential benefits and
should include long-term, comprehen- tors, and monoamine oxidase inhibitors),
risks must be considered. A
sive weight maintenance strategies and glucocorticoids, injectable progestins, some
8.17 In people with diabetes and over-
counseling to maintain weight loss and be- anticonvulsants (e.g., gabapentin and pre-
weight or obesity, the preferred phar-
havioral changes (70,71). gabalin), b-blockers, and possibly sedating
macotherapy should be a glucagon-like
Despite widespread marketing and ex- antihistamines and anticholinergics (80).
peptide 1 receptor agonist or dual glucose-
orbitant claims, there is no clear evidence dependent insulinotropic polypeptide
that nutrition supplements (such as herbs Approved Obesity Pharmacotherapy
and glucagon-like peptide 1 receptor
and botanicals, high-dose vitamins and The U.S. Food and Drug Administration
agonist with greater weight loss effi-
minerals, amino acids, enzymes, antioxi- (FDA) has approved several medications for
cacy (i.e., semaglutide or tirzepatide),
dants, etc.) are effective for obesity man- weight management as adjuncts to reduced
especially considering their added
agement or weight loss (72–75). Several calorie diet and increased physical activity
weight-independent benefits (e.g.,
large systematic reviews show that most in individuals with a BMI $30 kg/m2 or
glycemic and cardiometabolic). A
trials evaluating nutrition supplements 8.18 To prevent therapeutic inertia, $27 kg/m2 with one or more obesity-
for weight loss are of low quality and at for those not reaching goals, reevalu- associated comorbid conditions (e.g., type 2
high risk for bias. High-quality published ate weight management therapies diabetes, hypertension, and/or dyslipide-
studies show little or no weight loss bene- and intensify treatment with addi- mia). Nearly all FDA-approved obesity
fits. In contrast, vitamin/mineral (e.g., iron, tional approaches (e.g., metabolic medications have been shown to improve
vitamin B12, vitamin D) supplementation glycemia in people with type 2 diabetes
diabetesjournals.org/care Obesity and Weight Management for Type 2 Diabetes S149

and delay progression to type 2 diabetes for use in individuals who are nursing. Indi- these devices in the treatment of individu-
in at-risk individuals (22), and some of viduals of childbearing potential should als with diabetes has created uncertainty
these agents (e.g., liraglutide and sema- receive counseling regarding the use of for their current use (87).
glutide) have an indication for glucose reliable methods of contraception. Of An oral hydrogel (cellulose and citric
lowering as well as weight management. note, while weight loss medications are acid) has been approved for long-term
Phentermine and other older adrenergic often used in people with type 1 diabe- use in those with BMI >25 kg/m2 to
agents are approved for short-term treat- tes, clinical trial data in this population simulate the space-occupying effect of
ment (#12 weeks) (81), while all others are limited. implantable gastric balloons. Taken with
are approved for long-term treatment water 30 min before meals, the hydrogel
(>12 weeks) (22) (Table 8.1). (Refer to Assessing Efficacy and Safety of expands to fill a portion of the stomach
Section 14, “Children and Adolescents,” Obesity Pharmacotherapy volume to help decrease food intake dur-
for medications approved for adolescents Upon initiating medications for obesity, ing meals. The average weight loss was

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with obesity.) In addition, setmelanotide, assess their efficacy and safety at least relatively small (2.1% greater than pla-
a melanocortin 4 receptor agonist, is ap- monthly for the first 3 months and at cebo), and very few participants had dia-
proved for use in cases of rare genetic least quarterly thereafter. Modeling from betes at baseline (
10%) (88).
mutations resulting in severe hyperphagia published clinical trials consistently shows
and extreme obesity, such as leptin recep- that early responders have improved
METABOLIC SURGERY
tor deficiency and proopiomelanocortin long-term outcomes (84,85); however, it
deficiency. is notable that the response rate with the Recommendations
In people with type 2 diabetes and latest generation of obesity pharmaco- 8.19 Consider metabolic surgery as a
overweight or obesity, agents with both therapies is much higher (48,83). Unless weight and glycemic management ap-
glucose-lowering and weight loss ef- clinical circumstances (such as poor toler- proach in people with diabetes with
fects are preferred (refer to Section 9, ability) or other considerations (such as fi- BMI $30.0 kg/m2 (or $27.5 kg/m2 in
“Pharmacologic Approaches to Diabetes nancial expense or individual preference) Asian American individuals) who are
Treatment”), which include agents from suggest otherwise, those who achieve otherwise good surgical candidates. A
the GLP-1 receptor agonist class and the sufficient early weight loss upon starting 8.20 Metabolic surgery should be
dual GIP and GLP-1 receptor agonist a chronic obesity medication (typically de- performed in high-volume centers
class. Should use of these medications fined as >5% weight loss after 3 months with interprofessional teams knowl-
not result in achievement of weight of use) should continue the medication edgeable about and experienced
management goals, or if they are not tol- long term. When early weight loss results in managing obesity, diabetes, and
erated or contraindicated, other obesity are modest (typically <5% weight loss af- gastrointestinal surgery (www.facs
treatment approaches should be consid- ter 3 months of use), the benefits of on- .org/quality-programs/accreditation-
ered. Two phase 3 trials have demon- going treatment need to be balanced in and-verification/metabolic-and-bariatric-
strated the potential for use of the dual the context of the glycemic response, the surgery-accreditation-and-quality-
GIP and GLP-1 receptor agonist (tirzepa- improvement-program/). E
availability of other potential treatment
tide) for obesity (SURMOUNT-1, individuals 8.21 People being considered for met-
options, treatment tolerance, and overall
with obesity, and SURMOUNT-2, individuals abolic surgery should be evaluated for
treatment burden.
with obesity and type 2 diabetes) (82,83). comorbid psychological conditions and
Ongoing monitoring of the achievement
In the SURMOUNT-2 trial, tirzepatide re- social and situational circumstances
and maintenance of weight management
sulted in body weight loss of 9.6% and that have the potential to interfere
goals is recommended. For those not reach-
11.6% more than placebo and A1C lower- with surgery outcomes. B
ing or maintaining weight-related treatment
ing of 1.55% and 1.57% more than placebo 8.22 People who undergo metabolic
goals, reevaluate weight management ther-
after 72 weeks of treatment with the 10 surgery should receive long-term med-
apies and intensify treatment with addi-
mg and 15 mg doses, respectively, with ical and behavioral support and rou-
tional approaches (e.g., metabolic surgery,
adverse effects similar to those seen with tine micronutrient, nutritional, and
additional pharmacologic agents, and struc-
the GLP-1 receptor agonist class (83). metabolic status monitoring. B
tured lifestyle management programs).
Health care professionals should be 8.23 If post–metabolic surgery hypogly-
knowledgeable about the benefits, dosing, cemia is suspected, clinical evaluation
and risks for each treatment option to bal- MEDICAL DEVICES FOR WEIGHT
LOSS should exclude other potential disor-
ance the potential benefits of successful ders contributing to hypoglycemia, and
weight loss against the potential risks for While gastric banding devices have fallen
management should include education,
each individual. The high risk and preva- out of favor due to their limited long-
medical nutrition therapy with a regis-
lence of cardiovascular disease in people term efficacy and high rate of complica-
tered dietitian/nutritionist experienced in
with diabetes has to be balanced against tions, several minimally invasive medical
post–metabolic surgery hypoglycemia,
the lack of long-term cardiovascular out- devices have been approved by the FDA
and medication treatment, as needed.
comes trial data for agents like naltrexone- for short-term weight loss, including im-
A Continuous glucose monitoring
bupropion and phentermine-topiramate. planted gastric balloons, a vagus nerve
should be considered as an important
All these medications are contraindicated stimulator, and gastric aspiration therapy
adjunct to improve safety by alerting
in individuals who are pregnant or actively (86). High cost, limited insurance coverage,
individuals to hypoglycemia, especially
trying to conceive and are not recommended and limited data supporting the efficacy of
 S150

Table 8.1—Obesity pharmacotherapy

Medication name and Average wholesale price National Average Drug Weight loss
typical adult maintenance (median and range for Acquisition Cost (% loss from Common side effects Possible safety concerns and
dose 30-day supply) (142) (30-day supply) (143) Treatment arms baseline) (144–149) considerations (144–149)
Short-term treatment (12 weeks)
Sympathomimetic amine anorectic
Phentermine (150)
8–37.5 mg q.d.* $43 ($5–$90), $2 15 mg q.d. 5.0 Dry mouth, insomnia,  Contraindicated for use in
37.5 mg/day (37.5 mg dose) 7.5 mg q.d. 4.9 dizziness, irritability, combination with monoamine
Placebo 1.9 increased blood pressure, oxidase inhibitors
elevated heart rate
Long-term treatment (52 or 56 weeks)
Lipase inhibitor
Orlistat (4)
60 mg t.i.d. (OTC) $52 ($41–$82) NA 120 mg t.i.d.† 9.6 Abdominal pain, flatulence,  Potential malabsorption of fat-
Obesity and Weight Management for Type 2 Diabetes

120 mg t.i.d. (Rx) $843 ($781–$904) $722 Placebo 5.6 fecal urgency soluble vitamins (A, D, E, K) and of
certain medications (e.g.,
cyclosporine, thyroid hormone,
anticonvulsants)
 Rare cases of severe liver injury
reported
 Cholelithiasis
 Nephrolithiasis
Sympathomimetic amine anorectic/antiepileptic combination
Phentermine/topiramate ER (47)
7.5 mg/46 mg q.d.‡ $223 $179 15 mg/92 mg q.d.§ 9.8 Constipation, paresthesia,  Contraindicated for use in
(7.5 mg/46 mg dose) (7.5 mg/46 mg 7.5 mg/46 mg q.d.§ 7.8 insomnia, nasopharyngitis, combination with monoamine
dose) Placebo 1.2 xerostomia, increased oxidase inhibitors
blood pressure  Birth defects
 Cognitive impairment
 Acute angle-closure glaucoma
Opioid antagonist/antidepressant combination
Naltrexone/bupropion ER (15)
16 mg/180 mg b.i.d. $750 $599 16 mg/180 mg b.i.d. 5.0 Constipation, nausea,  Contraindicated in people with
Placebo 1.8 headache, xerostomia, unmanaged hypertension and/or
insomnia, elevated heart seizure disorders
rate and blood pressure  Contraindicated for use with
chronic opioid therapy
 Acute angle-closure glaucoma
Black box warning:
 Risk of suicidal behavior/ideation in
people younger than 24 years old
who have depression
Continued on p. S151
Diabetes Care Volume 47, Supplement 1, January 2024

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Table 8.1—Continued
Medication name and Average wholesale price National Average Drug Weight loss
typical adult maintenance (median and range for Acquisition Cost (% loss from Common side effects Possible safety concerns and
dose 30-day supply) (142) (30-day supply) (143) Treatment arms baseline) (144–149) considerations (144–149)
Glucagon-like peptide 1 receptor agonist
Liraglutide (16,49)jj
3 mg q.d. $1,619 $1,294 3.0 mg q.d. 6.0 Gastrointestinal side effects
diabetesjournals.org/care

 Pancreatitis has been reported in

1.8 mg q.d. 4.7 (nausea, vomiting, clinical trials, but causality has not
Placebo 2.0 diarrhea, esophageal been established. Discontinue if
reflux), injection site pancreatitis is suspected.
reactions, elevated heart  Use caution in people with kidney
rate, hypoglycemia disease when initiating or increasing
dose due to potential risk of acute
kidney injury.
 May cause cholelithiasis and gallstone-
related complications.
 Gastrointestinal disorders (severe
constipation and small bowel
obstruction/ileus progression)
 Monitor for potential consequences of
delayed absorption of oral medications.
Black box warning:
 Risk of thyroid C-cell tumors in
rodents; human relevance not
determined
Semaglutide (48,151)jj
2.4 mg once weekly $1,619 $1,295 2.4 mg weekly 9.6 Gastrointestinal side effects  Pancreatitis has been reported in
1.0 mg weekly 7.0 (nausea, vomiting, clinical trials, but causality has not
Placebo 3.4 diarrhea, esophageal been established. Discontinue if
reflux), injection site pancreatitis is suspected.
reactions, elevated heart  Use caution in people with kidney
rate, hypoglycemia disease when initiating or increasing
dose due to potential risk of acute
kidney injury.
 May cause cholelithiasis and gallstone-
related complications.
 Gastrointestinal disorders (severe
constipation and small bowel
obstruction/ileus progression)
 Monitor for potential consequences of
delayed absorption of oral medications.
Black box warning:
 Risk of thyroid C-cell tumors in
rodents; human relevance not
determined
Obesity and Weight Management for Type 2 Diabetes

Continued on p. S152
S151

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 S152

Table 8.1—Continued
Medication name and Average wholesale price National Average Drug Weight loss
typical adult maintenance (median and range for Acquisition Cost (% loss from Common side effects Possible safety concerns and
dose 30-day supply) (142) (30-day supply) (143) Treatment arms baseline) (144–149) considerations (144–149)
Dual glucose-dependent insulinotropic polypeptide and glucagon-like peptide 1 receptor agonist
Tirzepatide (83)
5 mg, 10 mg, or NA NA 10 mg weekly 12.8 Gastrointestinal side effects  Pancreatitis has been reported in
15 mg once weekly 15 mg weekly 14.7 (nausea, vomiting, clinical trials, but causality has not
Placebo 3.2 diarrhea, esophageal been established. Discontinue if
reflux), injection site pancreatitis is suspected.
reactions, elevated heart  Use caution in people with kidney
rate, hypoglycemia disease when initiating or increasing
dose due to potential risk of acute
Obesity and Weight Management for Type 2 Diabetes

kidney injury.
 May cause cholelithiasis and
gallstone-related complications.
 Gastrointestinal disorders (severe
constipation and small bowel
obstruction/ileus progression)
 Monitor effects of oral medications
with narrow therapeutic index
(warfarin) or whose efficacy is
dependent on threshold
concentration.
 Advise those using oral hormonal
contraception to use or add a non-
oral contraception method for
4 weeks after initiation and dose
escalations.
Black box warning:
 Risk of thyroid C-cell tumors in
rodents; human relevance not
determined.
Select safety and side effect information is provided; for a comprehensive discussion of safety considerations, please refer to the prescribing information for each agent. b.i.d., twice daily; ER, extended release;
OTC, over the counter; NA, data not available; Rx, prescription; t.i.d., three times daily, p.o., by mouth; SC, subcutaneous injection; AWP, average wholesale price; NADAC, National Average Drug Acquisition
Cost. *Use lowest effective dose; maximum appropriate dose is 37.5 mg. Weight loss data were extracted from the 12-week time point, as phentermine is approved for use for up to 12 weeks. †Enrolled partic-
ipants had normal (79%) or impaired (21%) glucose tolerance. ‡Maximum dose, depending on response, is 15 mg/92 mg q.d. §Approximately 68% of enrolled participants had type 2 diabetes or impaired glu-
cose tolerance. jjAgent has indication for reduction of cardiovascular events (49,151). AWP and NADAC prices for 30-day supply of maximum or maintenance dose as of 6 September 2023.
Diabetes Care Volume 47, Supplement 1, January 2024

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diabetesjournals.org/care Obesity and Weight Management for Type 2 Diabetes S153

for those with severe hypoglycemia removed, leaving behind a long, thin cost-effective or even cost-saving for indi-
or hypoglycemia unawareness. E sleeve-shaped pouch. RYGB creates a viduals with type 2 diabetes. However,
8.24 In people who undergo metabolic much smaller stomach pouch (roughly these results largely depend on assump-
surgery, routinely screen for psychoso- the size of a walnut), which is then tions about the long-term effectiveness
cial and behavioral health changes and attached to the distal small intestine, and safety of the procedures (117,118).
thereby bypassing the duodenum and The safety of metabolic surgery has im-
refer to a qualified behavioral health
jejunum. proved significantly with continued refine-
professional as needed. C
Metabolic surgery has been demon- ment of minimally invasive (laparoscopic)
8.25 Monitor individuals who have
strated to have beneficial effects on type 2 approaches, enhanced training and
undergone metabolic surgery for in-
diabetes irrespective of the presurgical credentialing, and involvement of inter-
sufficient weight loss or weight recur-
BMI (107). The American Society for Met- professional teams. Perioperative mortal-
rence at least every 6–12 months. E
abolic and Bariatric Surgery is now recom- ity rates are typically 0.1–0.5%, similar to
In those who have insufficient weight

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mending metabolic surgery for people those of common abdominal procedures
loss or experience weight recurrence, with type 2 diabetes and a BMI $30 kg/m2 such as cholecystectomy or hysterectomy
assess for potential predisposing fac- (or $27.5 kg/m2 for Asian American indi- (119–123). Major complications occur in
tors and, if appropriate, consider addi- viduals) in surgically eligible individuals. 2–6% of those undergoing metabolic sur-
tional weight loss interventions (e.g., Studies have documented diabetes remis- gery, which compares favorably with the
obesity pharmacotherapy). C sion after 1–5 years in 30–63% of individ- rates for other commonly performed elec-
uals with RYGB (17,108). tive operations (123). Postsurgical recovery
Surgical procedures for obesity treat- Most notably, the Surgical Treatment times and morbidity have also dramatically
ment—often referred to interchangeably and Medications Potentially Eradicate Di- declined. Minor complications and need
abetes Efficiently (STAMPEDE) trial, which for operative reintervention occur in up
as bariatric surgery, weight loss surgery,
randomized 150 participants with poorly to 15% (119–128). Empirical data suggest
metabolic surgery, or metabolic/bariatric
managed diabetes to receive either meta- that the proficiency of the operating sur-
surgery—can promote significant and du-
bolic surgery or medical treatment, found geon and surgical team is an important fac-
rable weight loss and improve type 2 dia-
that 29% of those treated with RYGB and tor in determining mortality, complications,
betes. Given the magnitude and rapidity
23% treated with VSG achieved A1C of reoperations, and readmissions (129). Ac-
of improvement of hyperglycemia and
6.0% or lower after 5 years (45). Available cordingly, metabolic surgery should be
glucose homeostasis, these procedures
data suggest an erosion of diabetes re- performed in high-volume centers with
have been suggested as treatments for
mission over time (46); at least 35–50% interprofessional teams experienced in
type 2 diabetes even in the absence of
of individuals who initially achieve remis- managing diabetes, obesity, and gastroin-
severe obesity, hence the current pre-
sion of diabetes eventually experience re- testinal surgery. Refer to the American
ferred terminology of “metabolic sur- currence. Still, the median disease-free College of Surgeons website for informa-
gery” (89). period among such individuals following tion on accreditation and to locate an ac-
A substantial body of evidence, includ- RYGB is 8.3 years (109,110), and the major- credited program (https://www.facs.org/
ing data from numerous large cohort ity of those who undergo surgery maintain quality-programs/accreditation-and-
studies and randomized controlled (non- substantial improvement of glycemia verification/metabolic-and-bariatric-surgery-
blinded) clinical trials, demonstrates that from baseline for at least 5–15 years accreditation-and-quality-improvement-
metabolic surgery achieves superior gly- (45,91,94,95,110–113). program/).
cemic management and reduction of car- Exceedingly few presurgical predictors Beyond the perioperative period, longer-
diovascular risk in people with type 2 of success have been identified, but youn- term risks include vitamin and mineral defi-
diabetes and obesity compared with non- ger age, shorter duration of diabetes (e.g., ciencies, anemia, osteoporosis, dumping
surgical intervention (45). In addition to <8 years) (84), and lesser severity of dia- syndrome, and severe hypoglycemia (130).
improving glycemia, metabolic surgery re- betes (better glycemic control, not using Nutritional and micronutrient deficiencies
duces the incidence of microvascular dis- insulin) are associated with higher rates and related complications occur with a vari-
ease (90), improves quality of life (45,91,92), of diabetes remission (45,94,112,114). able frequency depending on the type of
decreases cancer risk, and improves car- Greater baseline visceral fat area may procedure and require routine monitoring
diovascular disease risk factors and long- also predict improved postoperative out- of micronutrient and nutritional status and
term cardiovascular events (93–104). comes, especially among Asian American lifelong vitamin/nutritional supplementa-
Cohort studies that match surgical and people with type 2 diabetes (115). tion (130). Dumping syndrome usually oc-
nonsurgical subjects strongly suggest that Although surgery has been shown to curs shortly (10–30 min) after a meal and
metabolic surgery reduces all-cause mor- improve the metabolic profiles and car- may present with diarrhea, nausea, vom-
tality (105,106). diovascular risk of people with type 1 dia- iting, palpitations, and fatigue; hypoglyce-
The overwhelming majority of proce- betes, larger and longer-term studies are mia is usually not present at the time of
dures in the U.S. are vertical sleeve gastrec- needed to determine the role of meta- symptoms but, in some cases, may de-
tomy (VSG) and Roux-en-Y gastric bypass bolic surgery in such individuals (116). velop several hours later. Post–metabolic
(RYGB). Both procedures result in an ana- Whereas metabolic surgery has greater surgery hypoglycemia can occur with
tomically smaller stomach pouch and often initial costs than nonsurgical obesity treat- RYGB, VSG, and other gastrointestinal
robust changes in enteroendocrine hor- ments, retrospective analyses and model- procedures and may severely impact
mones. In VSG,
80% of the stomach is ing studies suggest that surgery may be quality of life (131–133). Post–metabolic
S154 Obesity and Weight Management for Type 2 Diabetes Diabetes Care Volume 47, Supplement 1, January 2024

surgery hypoglycemia is driven in part by surgery to optimize behavioral health and parameters in overweight and obese patients with
altered gastric emptying of ingested postsurgical outcomes. type 2 diabetes. Diabetes Care 2013;36:4022–
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