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Standards of Care

8. Obesity Management for the Treatment of Type 2 Diabetes: Standards of Medical Care in Diabetes—2021

  1. American Diabetes Association
Diabetes Care 2021 Jan; 44(Supplement 1): S100-S110. https://doi.org/10.2337/dc21-S008
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Abstract

The American Diabetes Association (ADA) “Standards of Medical 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 guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), 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, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Introduction

There is strong and consistent evidence that obesity management can delay the progression from prediabetes to type 2 diabetes (1–5) and is highly beneficial in the treatment of type 2 diabetes (6–17). In patients with type 2 diabetes who also have overweight or obesity, modest and sustained weight loss has been shown to improve glycemic control and reduce the need for glucose-lowering medications (6–8). Several studies have demonstrated that in patients with type 2 diabetes and obesity, more intensive dietary energy restriction with very-low-calorie diets can substantially reduce A1C and fasting glucose and promote sustained diabetes remission through at least 2 years (10,18–21). The goal of this section is to provide evidence-based recommendations for obesity management, including dietary, behavioral, pharmacologic, and surgical interventions, in patients with type 2 diabetes. This section focuses on obesity management in adults. Further discussion on obesity in older individuals and children can be found in Section 12 “Older Adults” (https://doi.org/10.2337/dc21-S012) and Section 13 “Children and Adolescents” (https://doi.org/10.2337/dc21-S013), respectively.

Assessment

Recommendations

  • 8.1 Use patient-centered, nonjudgmental language that fosters collaboration between patients and providers, including people-first language (e.g., “person with obesity” rather than “obese person”). E

  • 8.2 Measure height and weight and calculate BMI at annual visits or more frequently. Assess weight trajectory to inform treatment considerations. E

  • 8.3 Based on clinical considerations, such as the presence of comorbid heart failure or significant unexplained weight gain or loss, weight may need to be monitored and evaluated more frequently. B If deterioration of medical status is associated with significant weight gain or loss, inpatient evaluation should be considered, especially focused on associations between medication use, food intake, and glycemic status. E

  • 8.4 Accommodations should be made to provide privacy during weighing. E

A patient-centered communication style that uses inclusive and nonjudgmental language and active listening, elicits patient preferences and beliefs, and assesses potential barriers to care should be used to optimize patient health outcomes and health-related quality of life. Use people-first language (e.g., “person with obesity” rather than “obese person”) to avoid defining patients by their condition (22,23,23a).

Height and weight should be measured and used to calculate BMI at annual visits or more frequently when appropriate (19). BMI, calculated as weight in kilograms divided by the square of height in meters (kg/m2), will be calculated automatically by most electronic medical records. Use BMI to document weight status (overweight: BMI 25–29.9 kg/m2; obesity class I: BMI 30–34.9 kg/m2; obesity class II: BMI 35–39.9 kg/m2; obesity class III: BMI ≥40 kg/m2). Note that misclassification can occur, particularly in very muscular or frail individuals. In some populations, notably Asian and Asian American populations, the BMI cut points to define overweight and obesity are lower than in other populations due to differences in body composition and cardiometabolic risk (Table 8.1) (24,25). Clinical considerations, such as the presence of comorbid heart failure or unexplained weight change, may warrant more frequent weight measurement and evaluation (26,27). If weighing is questioned or refused, the practitioner should be mindful of possible prior stigmatizing experiences and query for concerns, and the value of weight monitoring should be explained as a part of the medical evaluation process that helps to inform treatment decisions (28,29). Accommodations should be made to ensure privacy during weighing, particularly for those patients who report or exhibit a high level of weight-related distress or dissatisfaction. Scales should be situated in a private area or room. Weight should be measured and reported nonjudgmentally. Care should be taken to regard a patient’s weight (and weight changes) and BMI as sensitive health information. Additionally, assessing weight gain pattern and trajectory can further inform risk stratification and treatment options (30). Providers should advise patients with overweight or obesity and those with increasing weight trajectories that, in general, higher BMIs increase the risk of diabetes, cardiovascular disease, and all-cause mortality, as well as other adverse health and quality of life outcomes. Providers should assess readiness to engage in behavioral changes for weight loss and jointly determine behavioral and weight-loss goals and patient-appropriate intervention strategies (31). Strategies may include dietary changes, physical activity, behavioral therapy, pharmacologic therapy, medical devices, and metabolic surgery (Table 8.1). The latter three strategies may be prescribed for carefully selected patients as adjuncts to dietary changes, physical activity, and behavioral counseling.

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Table 8.1

Treatment options for overweight and obesity in type 2 diabetes

Diet, Physical Activity, and Behavioral Therapy

Recommendations

  • 8.5 Diet, physical activity, and behavioral therapy designed to achieve and maintain ≥5% weight loss is recommended for most patients with type 2 diabetes who have overweight or obesity and are ready to achieve weight loss. Greater benefits in control of diabetes and cardiovascular risk may be gained from even greater weight loss. B

  • 8.6 Such interventions should include a high frequency of counseling (≥16 sessions in 6 months) and focus on dietary changes, physical activity, and behavioral strategies to achieve a 500–750 kcal/day energy deficit. A

  • 8.7 An individual's preferences, motivation, and life circumstances should be considered, along with medical status, when weight loss interventions are recommended. C

  • 8.8 Behavioral changes that create an energy deficit, regardless of macronutrient composition, will result in weight loss. Dietary recommendations should be individualized to the patient's preferences and nutritional needs. A

  • 8.9 Evaluate systemic, structural, and socioeconomic factors that may impact dietary patterns and food choices, such as food insecurity and hunger, access to healthful food options, cultural circumstances, and social determinants of health. C

  • 8.10 For patients who achieve short-term weight-loss goals, long-term (≥1 year) weight-maintenance programs are recommended when available. Such programs should, at minimum, provide monthly contact and support, recommend ongoing monitoring of body weight (weekly or more frequently) and other self-monitoring strategies, and encourage high levels of physical activity (200–300 min/week). A

  • 8.11 Short-term dietary intervention using structured, very-low-calorie diets (800–1,000 kcal/day) may be prescribed for carefully selected patients by trained practitioners in medical settings with close monitoring. Long-term, comprehensive weight-maintenance strategies and counseling should be integrated to maintain weight loss. B

Among patients with both type 2 diabetes and overweight or obesity who have inadequate glycemic, blood pressure, and lipid control and/or other obesity-related medical conditions, modest and sustained weight loss improves glycemic control, blood pressure, and lipids and may reduce the need for medications to control these risk factors (6–8,32). Greater weight loss may produce even greater benefits (20,21). For a more detailed discussion of lifestyle management approaches and recommendations see Section 5 “Facilitating Behavior Change and Well-being to Improve Health Outcomes” (https://doi.org/10.2337/dc21-S005). For a detailed discussion of nutrition interventions, please also refer to “Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report” (33).

Look AHEAD Trial

Although the Action for Health in Diabetes (Look AHEAD) trial did not show that the intensive lifestyle intervention reduced cardiovascular events in adults with type 2 diabetes and overweight or obesity (34), it did confirm the feasibility of achieving and maintaining long-term weight loss in patients with type 2 diabetes. In the intensive lifestyle intervention group, mean weight loss was 4.7% at 8 years (35). Approximately 50% of intensive lifestyle intervention participants lost and maintained ≥5% of their initial body weight, and 27% lost and maintained ≥10% of their initial body weight at 8 years (35). Participants assigned to the intensive lifestyle group required fewer glucose-, blood pressure–, and lipid-lowering medications than those randomly assigned to standard care. Secondary analyses of the Look AHEAD trial and other large cardiovascular outcome studies document additional benefits of weight loss in patients with type 2 diabetes, including improvements in mobility, physical and sexual function, and health-related quality of life (26). Moreover, several subgroups had improved cardiovascular outcomes, including those who achieved >10% weight loss (36) and those with moderately or poorly controlled diabetes (A1C >6.8%) at baseline (37).

Lifestyle Interventions

Significant weight loss can be attained with lifestyle programs that achieve a 500–750 kcal/day energy deficit, which in most cases is approximately 1,200–1,500 kcal/day for women and 1,500–1,800 kcal/day for men, adjusted for the individual's baseline body weight. Clinical benefits typically begin upon achieving 3–5% weight loss (19,38), and the benefits of weight loss are progressive; more intensive weight-loss goals (>5%, >7%, >15%, etc.) may be pursued if needed to achieve further health improvements and/or if the patient is more motivated and more intensive goals can be feasibly and safely attained.

Dietary interventions may differ by macronutrient goals and food choices as long as they create the necessary energy deficit to promote weight loss (19,39–41). Use of meal replacement plans prescribed by trained practitioners, with close patient monitoring, can be beneficial. Within the intensive lifestyle intervention group of the Look AHEAD trial, for example, use of a partial meal replacement plan was associated with improvements in diet quality and weight loss (38). The diet choice should be based on the patient's health status and preferences, including a determination of food availability and other cultural circumstances that could affect dietary patterns (42).

Intensive behavioral lifestyle interventions should include ≥16 sessions in 6 months and focus on dietary changes, physical activity, and behavioral strategies to achieve an ∼500–750 kcal/day energy deficit. Interventions should be provided by trained interventionists in either individual or group sessions (38). Assessing an individual's motivation level, life circumstances, and willingness to implement lifestyle changes to achieve weight loss should be considered along with medical status when weight-loss interventions are recommended and initiated (31,43).

Patients with type 2 diabetes and overweight or obesity who have lost weight should be offered long-term (≥1 year) comprehensive weight-loss maintenance programs that provide at least monthly contact with trained interventionists and focus on ongoing monitoring of body weight (weekly or more frequently) and/or other self-monitoring strategies such as tracking intake, steps, etc.; continued focus on dietary and behavioral changes; and participation in high levels of physical activity (200–300 min/week) (44). Some commercial and proprietary weight-loss programs have shown promising weight-loss results, though most lack evidence of effectiveness, many do not satisfy guideline recommendations, and some promote unscientific and possibly dangerous practices (45,46).

When provided by trained practitioners in medical settings with ongoing monitoring, short-term (generally up to 3 months) intensive dietary intervention may be prescribed for carefully selected patients, such as those requiring weight loss prior to surgery and persons needing greater weight loss and glycemic improvements. When integrated with behavioral support and counseling, structured very-low-calorie diets, typically 800–1,000 kcal/day utilizing high-protein foods and meal replacement products, may increase the pace and/or magnitude of initial weight loss and glycemic improvements compared with standard behavioral interventions (20,21). As weight regain is common, such interventions should include long-term, comprehensive weight-maintenance strategies and counseling to maintain weight loss and behavioral changes (47,48).

Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their race or ethnicity, socioeconomic status, gender, disability, or other factors. Overwhelming research shows that these disparities may significantly affect health outcomes, including increasing the risk for diabetes and diabetes-related complications. Health care providers should evaluate systemic, structural, and socioeconomic factors that may impact food choices, access to healthful foods, and dietary patterns; other behavioral patterns, such as neighborhood safety and availability of safe outdoor spaces for physical activity; environmental exposures; access to health care; social contexts; and, ultimately, diabetes risk and outcomes. For a detailed discussion of social determinants of health, please refer to “Social Determinants of Health: A Scientific Review” (49).

Pharmacotherapy

Recommendations

  • 8.12 When choosing glucose-lowering medications for patients with type 2 diabetes and overweight or obesity, consider the medication's effect on weight. B

  • 8.13 Whenever possible, minimize medications for comorbid conditions that are associated with weight gain. E

  • 8.14 Weight-loss medications are effective as adjuncts to diet, physical activity, and behavioral counseling for selected patients with type 2 diabetes and BMI ≥27 kg/m2. Potential benefits and risks must be considered. A

  • 8.15 If a patient’s response to weight-loss medication is effective (typically defined as >5% weight loss after 3 months’ use), further weight loss is likely with continued use. When early response is insufficient (typically <5% weight loss after 3 months’ use), or if there are significant safety or tolerability issues, consider discontinuation of the medication and evaluate alternative medications or treatment approaches. A

Glucose-Lowering Therapy

A meta-analysis of 227 randomized controlled trials of glucose-lowering treatments in type 2 diabetes found that A1C changes were not associated with baseline BMI, indicating that patients with obesity can benefit from the same types of treatments for diabetes as normal-weight patients (50). As numerous effective medications are available, when considering medication regimens health care providers should consider each medication’s effect on weight. Agents associated with varying degrees of weight loss include metformin, α-glucosidase inhibitors, sodium–glucose cotransporter 2 inhibitors, glucagon-like peptide 1 receptor agonists, and amylin mimetics. Dipeptidyl peptidase 4 inhibitors are weight neutral. In contrast, insulin secretagogues, thiazolidinediones, and insulin are often associated with weight gain (see Section 9 “Pharmacologic Approaches to Glycemic Treatment,” https://doi.org/10.2337/dc21-s009).

Concomitant Medications

Providers should carefully review the patient's concomitant medications and, whenever possible, minimize or provide alternatives for medications that promote weight gain. Examples of medications associated with weight gain include antipsychotics (e.g., clozapine, olanzapine, risperidone, etc.), some antidepressants (e.g., tricyclic antidepressants, some selective serotonin reuptake inhibitors, and monoamine oxidase inhibitors), glucocorticoids, injectable progestins, some anticonvulsants (e.g., gabapentin, pregabalin), and possibly sedating antihistamines and anticholinergics (51).

Approved Weight-Loss Medications

The U.S. Food and Drug Administration (FDA) has approved medications for both short-term and long-term weight management as adjuncts to diet, exercise, and behavioral therapy. Nearly all FDA-approved medications for weight loss have been shown to improve glycemic control in patients with type 2 diabetes and delay progression to type 2 diabetes in patients at risk (52). Phentermine and other older adrenergic agents are indicated for short-term (≤12 weeks) treatment (53). Four weight-loss medications are FDA approved for long-term use (>12 weeks) in patients with BMI ≥27 kg/m2 with one or more obesity-associated comorbid condition (e.g., type 2 diabetes, hypertension, and/or dyslipidemia) who are motivated to lose weight (52). Medications approved by the FDA for the treatment of obesity are summarized in Table 8.2. The rationale for weight-loss medication use is to help patients adhere to dietary recommendations, in most cases by modulating appetite or satiety. Providers should be knowledgeable about the product label and should balance the potential benefits of successful weight loss against the potential risks of the medication for each patient. These medications are contraindicated in women who are pregnant or actively trying to conceive and not recommended for use in women who are nursing. Women of reproductive potential should receive counseling regarding the use of reliable methods of contraception.

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Table 8.2

Medications approved by the FDA for the treatment of obesity

Assessing Efficacy and Safety

Upon initiating weight-loss medication, assess efficacy and safety at least monthly for the first 3 months and at least quarterly thereafter. Modeling from published clinical trials consistently shows that early responders have improved long-term outcomes (54–56). Unless clinical circumstances (such as poor tolerability) or other considerations (such as financial expense or patient preference) suggest otherwise, those who achieve sufficient early weight loss upon starting a chronic weight-loss medication (typically defined as >5% weight loss after 3 months’ use) should continue the medication. When early use appears ineffective (typically <5% weight loss after 3 months’ use), it is unlikely that continued use will improve weight outcomes; as such, it should be recommended to discontinue the medication and consider other treatment options.

Medical Devices for Weight Loss

Several minimally invasive medical devices have been approved by the FDA for short-term weight loss (57,58). It remains to be seen how these are used for obesity treatment. Given the high cost, limited insurance coverage, and paucity of data in people with diabetes at this time, medical devices for weight loss are currently not considered to be the standard of care for obesity management in people with type 2 diabetes.

Metabolic Surgery

Recommendations

  • 8.16 Metabolic surgery should be a recommended option to treat type 2 diabetes in screened surgical candidates with BMI ≥40 kg/m2 (BMI ≥37.5 kg/m2 in Asian Americans) and in adults with BMI 35.0–39.9 kg/m2 (32.5–37.4 kg/m2 in Asian Americans) who do not achieve durable weight loss and improvement in comorbidities (including hyperglycemia) with nonsurgical methods. A

  • 8.17 Metabolic surgery may be considered as an option to treat type 2 diabetes in adults with BMI 30.0–34.9 kg/m2 (27.5–32.4 kg/m2 in Asian Americans) who do not achieve durable weight loss and improvement in comorbidities (including hyperglycemia) with nonsurgical methods. A

  • 8.18 Metabolic surgery should be performed in high-volume centers with multidisciplinary teams knowledgeable about and experienced in the management of diabetes and gastrointestinal surgery. E

  • 8.19 Long-term lifestyle support and routine monitoring of micronutrient and nutritional status must be provided to patients after surgery, according to guidelines for postoperative management of metabolic surgery by national and international professional societies. C

  • 8.20 People being considered for metabolic surgery should be evaluated for comorbid psychological conditions and social and situational circumstances that have the potential to interfere with surgery outcomes. B

  • 8.21 People who undergo metabolic surgery should routinely be evaluated to assess the need for ongoing mental health services to help with the adjustment to medical and psychosocial changes after surgery. C

Several gastrointestinal (GI) operations, including partial gastrectomies and bariatric procedures (44), promote dramatic and durable weight loss and improvement of type 2 diabetes in many patients. Given the magnitude and rapidity of the effect of GI surgery on hyperglycemia and experimental evidence that rearrangements of GI anatomy similar to those in some metabolic procedures directly affect glucose homeostasis (45), GI interventions have been suggested as treatments for type 2 diabetes, and in that context they are termed “metabolic surgery.”

A substantial body of evidence has now been accumulated, including data from numerous randomized controlled (nonblinded) clinical trials, demonstrating that metabolic surgery achieves superior glycemic control and reduction of cardiovascular risk factors in patients with type 2 diabetes and obesity compared with various lifestyle/medical interventions (17). Improvements in microvascular complications of diabetes, cardiovascular disease, and cancer have been observed only in nonrandomized observational studies (59–70). Cohort studies attempting to match surgical and nonsurgical subjects suggest that the procedure may reduce longer-term mortality (60,71).

While several surgical options are available, the overwhelming majority of procedures in the U.S. are vertical sleeve gastrectomy and Roux-en-Y gastric bypass (RYGB). Both procedures result in an anatomically smaller stomach pouch and often robust changes in enteroendocrine hormones. On the basis of this mounting evidence, several organizations and government agencies have recommended expanding the indications for metabolic surgery to include patients with type 2 diabetes who do not achieve durable weight loss and improvement in comorbidities (including hyperglycemia) with reasonable nonsurgical methods at BMIs as low as 30 kg/m2 (27.5 kg/m2 for Asian Americans) (72–79). Randomized controlled trials have documented diabetes remission during postoperative follow-up ranging from 1 to 5 years in 30–63% of patients with RYGB, which generally leads to greater degrees and lengths of remission compared with other bariatric surgeries (17,80). Available data suggest an erosion of diabetes remission over time (81): 35–50% or more of patients who initially achieve remission of diabetes eventually experience recurrence. However, the median disease-free period among such individuals following RYGB is 8.3 years (82,83). With or without diabetes relapse, the majority of patients who undergo surgery maintain substantial improvement of glycemic control from baseline for at least 5 years (84,85) to 15 years (60,61,83,86–88).

Exceedingly few presurgical predictors of success have been identified, but younger age, shorter duration of diabetes (e.g., <8 years) (89), nonuse of insulin, maintenance of weight loss, and better glycemic control are consistently associated with higher rates of diabetes remission and/or lower risk of weight regain (60,87,89,90). Greater baseline visceral fat area may also help to predict better postoperative outcomes, especially among Asian American patients with type 2 diabetes, who typically have more visceral fat compared with Caucasians with diabetes of the same BMI (91). Beyond improving glycemia, metabolic surgery has been shown to confer additional health benefits in randomized controlled trials, including substantial reductions in cardiovascular disease risk factors (17), reductions in incidence of microvascular disease (92), and enhancements in quality of life (84,89,93).

Although metabolic surgery has been shown to improve the metabolic profiles of patients with type 1 diabetes and morbid obesity, establishing the role of metabolic surgery in such patients will require larger and longer studies (94).

Metabolic surgery is more expensive than nonsurgical management strategies, but retrospective analyses and modeling studies suggest that metabolic surgery may be cost-effective or even cost-saving for patients with type 2 diabetes. However, results are largely dependent on assumptions about the long-term effectiveness and safety of the procedures (95,96).

Adverse Effects

The safety of metabolic surgery has improved significantly over the past several decades, with continued refinement of minimally invasive approaches (laparoscopic surgery), enhanced training and credentialing, and involvement of multidisciplinary teams. Mortality rates with metabolic operations are typically 0.1–0.5%, similar to cholecystectomy or hysterectomy (97–101). Morbidity has also dramatically declined with laparoscopic approaches. Major complications and need for operative reintervention occur in 2–6% of those undergoing bariatric surgery, with other minor complications in up to 15% (97–106). These rates compare favorably with those for other commonly performed elective operations (101). Empirical data suggest that proficiency of the operating surgeon is an important factor for determining mortality, complications, reoperations, and readmissions (107). Accordingly, metabolic surgery should be performed in high-volume centers with multidisciplinary teams knowledgeable about and experienced in the management of diabetes and GI surgery.

Longer-term concerns include dumping syndrome (nausea, colic, and diarrhea), vitamin and mineral deficiencies, anemia, osteoporosis, and severe hypoglycemia (108). Long-term nutritional and micronutrient deficiencies and related complications occur with variable frequency depending on the type of procedure and require lifelong vitamin/nutritional supplementation; thus, long-term lifestyle support and routine monitoring of micronutrient and nutritional status should be provided to patients after surgery (109,110). Postprandial hypoglycemia is most likely to occur with RYGB (110,111). The exact prevalence of symptomatic hypoglycemia is unknown. In one study, it affected 11% of 450 patients who had undergone RYGB or vertical sleeve gastrectomy (108). Patients who undergo metabolic surgery may be at increased risk for substance use, including drug and alcohol use and cigarette smoking. Additional potential risks of metabolic surgery that have been described include worsening or new-onset depression and/or anxiety, need for additional GI surgery, and suicidal ideation (112–115).

People with diabetes presenting for metabolic surgery also have increased rates of depression and other major psychiatric disorders (116). Candidates for metabolic surgery with histories of alcohol, tobacco, or substance abuse or significant depression, suicidal ideation, or other mental health conditions should therefore first be assessed by a mental health professional with expertise in obesity management prior to consideration for surgery (117). Surgery should be postponed in patients with alcohol or substance abuse disorders, significant depression, suicidal ideation, or other mental health conditions until these conditions have been fully addressed. Individuals with preoperative psychopathology should be assessed regularly following metabolic surgery to optimize mental health management and to ensure that psychiatric symptoms do not interfere with weight loss and lifestyle changes.

Footnotes

  • Suggested citation: American Diabetes Association. 8. Obesity management for the treatment of type 2 diabetes: Standards of Medical Care in Diabetes—2021. Diabetes Care 2021;44(Suppl. 1):S100–S110

  • © 2020 by the American Diabetes Association
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Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More information is available at https://www.diabetesjournals.org/content/license.

References

  1. 1.↵
    1. Knowler WC,
    2. Barrett-Connor E,
    3. Fowler SE, et al.; Diabetes Prevention Program Research Group
    . Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393–403
    OpenUrlCrossRefPubMedWeb of Science
  2. 2.
    1. Garvey WT,
    2. Ryan DH,
    3. Henry R, et al
    . Prevention of type 2 diabetes in subjects with prediabetes and metabolic syndrome treated with phentermine and topiramate extended release. Diabetes Care 2014;37:912–921
    OpenUrlAbstract/FREE Full Text
  3. 3.
    1. Torgerson JS,
    2. Hauptman J,
    3. Boldrin MN,
    4. Sjöström L
    . XENical in the prevention of Diabetes in Obese Subjects (XENDOS) study: a randomized study of orlistat as an adjunct to lifestyle changes for the prevention of type 2 diabetes in obese patients. Diabetes Care 2004;27:155–161
    OpenUrlAbstract/FREE Full Text
  4. 4.
    1. le Roux CW,
    2. Astrup A,
    3. Fujioka K, et al.; SCALE Obesity Prediabetes NN8022-1839 Study Group
    . 3 years of liraglutide versus placebo for type 2 diabetes risk reduction and weight management in individuals with prediabetes: a randomised, double-blind trial. Lancet 2017;389:1399–1409
    OpenUrlCrossRefPubMed
  5. 5.↵
    1. Booth H,
    2. Khan O,
    3. Prevost T, et al
    . Incidence of type 2 diabetes after bariatric surgery: population-based matched cohort study. Lancet Diabetes Endocrinol 2014;2:963–968
    OpenUrlPubMed
  6. 6.↵
    1. UKPDS Group
    . UK Prospective Diabetes Study 7: response of fasting plasma glucose to diet therapy in newly presenting type II diabetic patients. Metabolism 1990;39:905–912
    OpenUrlCrossRefPubMedWeb of Science
  7. 7.
    1. Goldstein DJ
    . Beneficial health effects of modest weight loss. Int J Obes Relat Metab Disord 1992;16:397–415
    OpenUrlPubMedWeb of Science
  8. 8.↵
    1. Pastors JG,
    2. Warshaw H,
    3. Daly A,
    4. Franz M,
    5. Kulkarni K
    . The evidence for the effectiveness of medical nutrition therapy in diabetes management. Diabetes Care 2002;25:608–613
    OpenUrlFREE Full Text
  9. 9.
    1. Lim EL,
    2. Hollingsworth KG,
    3. Aribisala BS,
    4. Chen MJ,
    5. Mathers JC,
    6. Taylor R
    . Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol. Diabetologia 2011;54:2506–2514
    OpenUrlCrossRefPubMedWeb of Science
  10. 10.↵
    1. Jackness C,
    2. Karmally W,
    3. Febres G, et al
    . Very low-calorie diet mimics the early beneficial effect of Roux-en-Y gastric bypass on insulin sensitivity and β-cell function in type 2 diabetic patients. Diabetes 2013;62:3027–3032
    OpenUrlAbstract/FREE Full Text
  11. 11.
    1. Rothberg AE,
    2. McEwen LN,
    3. Kraftson AT,
    4. Fowler CE,
    5. Herman WH
    . Very-low-energy diet for type 2 diabetes: an underutilized therapy? J Diabetes Complications 2014;28:506–510
    OpenUrlCrossRefPubMed
  12. 12.
    1. Hollander PA,
    2. Elbein SC,
    3. Hirsch IB, et al
    . Role of orlistat in the treatment of obese patients with type 2 diabetes. A 1-year randomized double-blind study. Diabetes Care 1998;21:1288–1294
    OpenUrlAbstract/FREE Full Text
  13. 13.
    1. Garvey WT,
    2. Ryan DH,
    3. Bohannon NJV, et al
    . Weight-loss therapy in type 2 diabetes: effects of phentermine and topiramate extended release. Diabetes Care 2014;37:3309–3316
    OpenUrlAbstract/FREE Full Text
  14. 14.
    1. O’Neil PM,
    2. Smith SR,
    3. Weissman NJ, et al
    . Randomized placebo-controlled clinical trial of lorcaserin for weight loss in type 2 diabetes mellitus: the BLOOM-DM study. Obesity (Silver Spring) 2012;20:1426–1436
    OpenUrlCrossRefPubMed
  15. 15.
    1. Hollander P,
    2. Gupta AK,
    3. Plodkowski R, et al.; COR-Diabetes Study Group
    . Effects of naltrexone sustained-release/bupropion sustained-release combination therapy on body weight and glycemic parameters in overweight and obese patients with type 2 diabetes. Diabetes Care 2013;36:4022–4029
    OpenUrlAbstract/FREE Full Text
  16. 16.
    1. Davies MJ,
    2. Bergenstal R,
    3. Bode B, et al.; NN8022-1922 Study Group
    . Efficacy of liraglutide for weight loss among patients with type 2 diabetes: the SCALE diabetes randomized clinical trial. JAMA 2015;314:687–699
    OpenUrlCrossRefPubMed
  17. 17.↵
    1. Rubino F,
    2. Nathan DM,
    3. Eckel RH, et al.; Delegates of the 2nd Diabetes Surgery Summit
    . Metabolic surgery in the treatment algorithm for type 2 diabetes: a joint statement by international diabetes organizations. Diabetes Care 2016;39:861–877
    OpenUrlAbstract/FREE Full Text
  18. 18.↵
    1. Steven S,
    2. Hollingsworth KG,
    3. Al-Mrabeh A, et al
    . Very low-calorie diet and 6 months of weight stability in type 2 diabetes: pathophysiological changes in responders and nonresponders. Diabetes Care 2016;39:808–815
    OpenUrlAbstract/FREE Full Text
  19. 19.↵
    1. Jensen MD,
    2. Ryan DH,
    3. Apovian CM, et al.; American College of Cardiology/American Heart Association Task Force on Practice Guidelines; Obesity Society
    . 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. J Am Coll Cardiol 2014;63(25 Pt B):2985–3023
    OpenUrlFREE Full Text
  20. 20.↵
    1. Lean ME,
    2. Leslie WS,
    3. Barnes AC, et al
    . Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet 2018;391:541–551
    OpenUrlCrossRefPubMed
  21. 21.↵
    1. Lean MEJ,
    2. Leslie WS,
    3. Barnes AC, et al
    . Durability of a primary care-led weight-management intervention for remission of type 2 diabetes: 2-year results of the DiRECT open-label, cluster-randomised trial. Lancet Diabetes Endocrinol 2019;7:344–355
    OpenUrlPubMed
  22. 22.↵
    1. AMA Manual of Style Committee
    . AMA Manual of Style: A Guide for Authors and Editors. 11th ed. New York, Oxford University Press, 2020
  23. 23.↵
    1. American Medical Association
    . Person-First Language for Obesity H-440.821. Accessed16 September 2020. Available from https://policysearch.ama-assn.org/policyfinder/detail/obesity?uri=%2FAMADoc%2FHOD.xml-H-440.821.xml
  24. 23a.↵
    1. Rubino F,
    2. Puhl RM,
    3. Cummings DE, et al
    . Joint international consensus statement for ending stigma of obesity. Nat Med 2020;26:485–497
    OpenUrl
  25. 24.↵
    1. WHO Expert Consultation
    . Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 2004;363:157–163
    OpenUrlCrossRefPubMedWeb of Science
  26. 25.↵
    1. Araneta MRG,
    2. Kanaya A,
    3. Hsu WC, et al
    . Optimum BMI cut points to screen Asian Americans for type 2 diabetes. Diabetes Care 2015;38:814–820
    OpenUrlAbstract/FREE Full Text
  27. 26.↵
    1. Yancy CW,
    2. Jessup M,
    3. Bozkurt B, et al.; American College of Cardiology Foundation; American Heart Association Task Force on Practice Guidelines
    . 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;62:e147–e239
    OpenUrlFREE Full Text
  28. 27.↵
    1. Bosch X,
    2. Monclús E,
    3. Escoda O, et al
    . Unintentional weight loss: clinical characteristics and outcomes in a prospective cohort of 2677 patients. PLoS One. 2017;12:e0175125
    OpenUrl
  29. 28.↵
    1. Wilding JPH
    . The importance of weight management in type 2 diabetes mellitus. Int J Clin Pract 2014;68:682–691
    OpenUrlCrossRefPubMed
  30. 29.↵
    1. Van Gaal L,
    2. Scheen A
    . Weight management in type 2 diabetes: current and emerging approaches to treatment. Diabetes Care 2015;38:1161–1172
    OpenUrlAbstract/FREE Full Text
  31. 30.↵
    1. Kushner RF,
    2. Batsis JA,
    3. Butsch WS, et al
    . Weight history in clinical practice: the state of the science and future directions. Obesity (Silver Spring) 2020;28:9–17
    OpenUrl
  32. 31.↵
    1. Warren J,
    2. Smalley B,
    3. Barefoot N
    . Higher motivation for weight loss in African American than Caucasian rural patients with hypertension and/or diabetes. Ethn Dis 2016;26:77–84
    OpenUrl
  33. 32.↵
    1. Rothberg AE,
    2. McEwen LN,
    3. Kraftson AT, et al
    . Impact of weight loss on waist circumference and the components of the metabolic syndrome. BMJ Open Diabetes Res Care 2017;5:e000341
    OpenUrlAbstract/FREE Full Text
  34. 33.↵
    1. Evert AB,
    2. Dennison M,
    3. Gardner CD, et al
    . Nutrition therapy for adults with diabetes or prediabetes: a consensus report. Diabetes Care 2019;42:731–754
    OpenUrlFREE Full Text
  35. 34.↵
    1. Look AHEAD Research Group;
    2. Wing RR,
    3. Bolin P,
    4. Brancati FL, et al
    . Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med 2013;369:145–154
    OpenUrlCrossRefPubMedWeb of Science
  36. 35.↵
    1. Look AHEAD Research Group
    . Eight-year weight losses with an intensive lifestyle intervention: the Look AHEAD study. Obesity (Silver Spring) 2014;22:5–13
    OpenUrlCrossRefPubMed
  37. 36.↵
    1. Gregg EW,
    2. Jakicic JM,
    3. Blackburn G, et al.; Look AHEAD Research Group
    . Association of the magnitude of weight loss and changes in physical fitness with long-term cardiovascular disease outcomes in overweight or obese people with type 2 diabetes: a post-hoc analysis of the Look AHEAD randomised clinical trial. Lancet Diabetes Endocrinol 2016;4:913–921
    OpenUrlPubMed
  38. 37.↵
    1. Baum A,
    2. Scarpa J,
    3. Bruzelius E,
    4. Tamler R,
    5. Basu S,
    6. Faghmous J
    . Targeting weight loss interventions to reduce cardiovascular complications of type 2 diabetes: a machine learning-based post-hoc analysis of heterogeneous treatment effects in the Look AHEAD trial. Lancet Diabetes Endocrinol 2017;5:808–815
    OpenUrl
  39. 38.↵
    1. Franz MJ,
    2. Boucher JL,
    3. Rutten-Ramos S,
    4. VanWormer JJ
    . Lifestyle weight-loss intervention outcomes in overweight and obese adults with type 2 diabetes: a systematic review and meta-analysis of randomized clinical trials. J Acad Nutr Diet 2015;115:1447–1463
    OpenUrlCrossRefPubMed
  40. 39.↵
    1. Sacks FM,
    2. Bray GA,
    3. Carey VJ, et al
    . Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. N Engl J Med 2009;360:859–873
    OpenUrlCrossRefPubMedWeb of Science
  41. 40.
    1. de Souza RJ,
    2. Bray GA,
    3. Carey VJ, et al
    . Effects of 4 weight-loss diets differing in fat, protein, and carbohydrate on fat mass, lean mass, visceral adipose tissue, and hepatic fat: results from the POUNDS LOST trial. Am J Clin Nutr 2012;95:614–625
    OpenUrlAbstract/FREE Full Text
  42. 41.↵
    1. Johnston BC,
    2. Kanters S,
    3. Bandayrel K, et al
    . Comparison of weight loss among named diet programs in overweight and obese adults: a meta-analysis. JAMA 2014;312:923–933
    OpenUrlCrossRefPubMedWeb of Science
  43. 42.↵
    1. Leung CW,
    2. Epel ES,
    3. Ritchie LD,
    4. Crawford PB,
    5. Laraia BA
    . Food insecurity is inversely associated with diet quality of lower-income adults. J Acad Nutr Diet 2014;114:1943–53.e2
    OpenUrl
  44. 43.↵
    1. Kahan S,
    2. Manson JE
    . Obesity treatment, beyond the guidelines: practical suggestions for clinical practice. JAMA 2019;321:1349–1350
    OpenUrl
  45. 44.↵
    1. Donnelly JE,
    2. Blair SN,
    3. Jakicic JM,
    4. Manore MM,
    5. Rankin JW,
    6. Smith BK; American College of Sports Medicine
    . American College of Sports Medicine Position Stand. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Med Sci Sports Exerc 2009;41:459–471
    OpenUrlCrossRefPubMedWeb of Science
  46. 45.↵
    1. Gudzune KA,
    2. Doshi RS,
    3. Mehta AK, et al
    . Efficacy of commercial weight-loss programs: an updated systematic review. Ann Intern Med 2015;162:501–512
    OpenUrlCrossRefPubMed
  47. 46.↵
    1. Bloom B,
    2. Mehta AK,
    3. Clark JM,
    4. Gudzune KA
    . Guideline-concordant weight-loss programs in an urban area are uncommon and difficult to identify through the internet. Obesity (Silver Spring) 2016;24:583–588
    OpenUrl
  48. 47.↵
    1. Tsai AG,
    2. Wadden TA
    . The evolution of very-low-calorie diets: an update and meta-analysis. Obesity (Silver Spring) 2006;14:1283–1293
    OpenUrlCrossRefPubMed
  49. 48.↵
    1. Johansson K,
    2. Neovius M,
    3. Hemmingsson E
    . Effects of anti-obesity drugs, diet, and exercise on weight-loss maintenance after a very-low-calorie diet or low-calorie diet: a systematic review and meta-analysis of randomized controlled trials. Am J Clin Nutr 2014;99:14–23
    OpenUrlAbstract/FREE Full Text
  50. 49.↵
    1. Hill-Briggs F,
    2. Adler NE,
    3. Berkowitz SA, et al
    . Social determinants of health and diabetes: a scientific review. Diabetes Care. 2 November 2020 [Epub ahead of print]. DOI: 10.2337/dci20-0053
  51. 50.↵
    1. Cai X,
    2. Yang W,
    3. Gao X,
    4. Zhou L,
    5. Han X,
    6. Ji L
    . Baseline body mass index and the efficacy of hypoglycemic treatment in type 2 diabetes: a meta-analysis. PLoS One 2016;11:e0166625
    OpenUrl
  52. 51.↵
    1. Domecq JP,
    2. Prutsky G,
    3. Leppin A, et al
    . Clinical review: drugs commonly associated with weight change: a systematic review and meta-analysis. J Clin Endocrinol Metab 2015;100:363–370
    OpenUrlCrossRefPubMed
  53. 52.↵
    1. Kahan S,
    2. Fujioka K
    . Obesity pharmacotherapy in patients with type 2 diabetes. Diabetes Spectr 2017;30:250–257
    OpenUrlAbstract/FREE Full Text
  54. 53.↵
    1. Drugs.com
    . Phentermine [FDA prescribing information]. Accessed 29 October 2020. Available from https://www.drugs.com/pro/phentermine.html
  55. 54.↵
    1. Apovian CM,
    2. Aronne LJ,
    3. Bessesen DH, et al.; Endocrine Society
    . Pharmacological management of obesity: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2015;100:342–362
    OpenUrlCrossRefPubMed
  56. 55.
    1. Fujioka K,
    2. O’Neil PM,
    3. Davies M, et al
    . Early weight loss with liraglutide 3.0 mg predicts 1-year weight loss and is associated with improvements in clinical markers. Obesity (Silver Spring) 2016;24:2278–2288
    OpenUrl
  57. 56.↵
    1. Fujioka K,
    2. Plodkowski R,
    3. O’Neil PM,
    4. Gilder K,
    5. Walsh B,
    6. Greenway FL
    . The relationship between early weight loss and weight loss at 1 year with naltrexone ER/bupropion ER combination therapy. Int J Obes 2016;40:1369–1375
    OpenUrl
  58. 57.↵
    1. Sullivan S
    . Endoscopic medical devices for primary obesity treatment in patients with diabetes. Diabetes Spectr 2017;30:258–264
    OpenUrlAbstract/FREE Full Text
  59. 58.↵
    1. Greenway FL,
    2. Aronne LJ,
    3. Raben A, et al
    . A randomized, double-blind, placebo-controlled study of Gelesis100: a novel nonsystemic oral hydrogel for weight loss. Obesity (Silver Spring) 2019;27:205–216
    OpenUrl
  60. 59.↵
    1. Sjöström L,
    2. Lindroos A-K,
    3. Peltonen M, et al.; Swedish Obese Subjects Study Scientific Group
    . Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004;351:2683–2693
    OpenUrlCrossRefPubMedWeb of Science
  61. 60.↵
    1. Sjöström L,
    2. Peltonen M,
    3. Jacobson P, et al
    . Association of bariatric surgery with long-term remission of type 2 diabetes and with microvascular and macrovascular complications. JAMA 2014;311:2297–2304
    OpenUrlCrossRefPubMedWeb of Science
  62. 61.↵
    1. Adams TD,
    2. Davidson LE,
    3. Litwin SE, et al
    . Health benefits of gastric bypass surgery after 6 years. JAMA 2012;308:1122–1131
    OpenUrlCrossRefPubMedWeb of Science
  63. 62.
    1. Sjöström L,
    2. Narbro K,
    3. Sjöström CD, et al.; Swedish Obese Subjects Study
    . Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007;357:741–752
    OpenUrlCrossRefPubMedWeb of Science
  64. 63.
    1. Sjöström L,
    2. Gummesson A,
    3. Sjöström CD, et al.; Swedish Obese Subjects Study
    . Effects of bariatric surgery on cancer incidence in obese patients in Sweden (Swedish Obese Subjects Study): a prospective, controlled intervention trial. Lancet Oncol 2009;10:653–662
    OpenUrlCrossRefPubMedWeb of Science
  65. 64.
    1. Sjöström L,
    2. Peltonen M,
    3. Jacobson P, et al
    . Bariatric surgery and long-term cardiovascular events. JAMA 2012;307:56–65
    OpenUrlCrossRefPubMedWeb of Science
  66. 65.
    1. Adams TD,
    2. Gress RE,
    3. Smith SC, et al
    . Long-term mortality after gastric bypass surgery. N Engl J Med 2007;357:753–761
    OpenUrlCrossRefPubMedWeb of Science
  67. 66.
    1. Arterburn DE,
    2. Olsen MK,
    3. Smith VA, et al
    . Association between bariatric surgery and long-term survival. JAMA 2015;313:62–70
    OpenUrlCrossRefPubMed
  68. 67.
    1. Adams TD,
    2. Arterburn DE,
    3. Nathan DM,
    4. Eckel RH
    . Clinical outcomes of metabolic surgery: microvascular and macrovascular complications. Diabetes Care 2016;39:912–923
    OpenUrlAbstract/FREE Full Text
  69. 68.
    1. Sheng B,
    2. Truong K,
    3. Spitler H,
    4. Zhang L,
    5. Tong X,
    6. Chen L
    . The long-term effects of bariatric surgery on type 2 diabetes remission, microvascular and macrovascular complications, and mortality: a systematic review and meta-analysis. Obes Surg 2017;27:2724–2732
    OpenUrlPubMed
  70. 69.
    1. Fisher DP,
    2. Johnson E,
    3. Haneuse S, et al
    . Association between bariatric surgery and macrovascular disease outcomes in patients with type 2 diabetes and severe obesity. JAMA 2018;320:1570–1582
    OpenUrlPubMed
  71. 70.↵
    1. Billeter AT,
    2. Scheurlen KM,
    3. Probst P, et al
    . Meta-analysis of metabolic surgery versus medical treatment for microvascular complications in patients with type 2 diabetes mellitus. Br J Surg 2018;105:168–181
    OpenUrlPubMed
  72. 71.↵
    1. Aminian A,
    2. Zajichek A,
    3. Arterburn DE, et al
    . Association of metabolic surgery with major adverse cardiovascular outcomes in patients with type 2 diabetes and obesity. JAMA 2019;322:1271–1282
    OpenUrl
  73. 72.↵
    1. Rubino F,
    2. Kaplan LM,
    3. Schauer PR,
    4. Cummings DE; Diabetes Surgery Summit Delegates
    . The Diabetes Surgery Summit consensus conference: recommendations for the evaluation and use of gastrointestinal surgery to treat type 2 diabetes mellitus. Ann Surg 2010;251:399–405
    OpenUrlCrossRefPubMedWeb of Science
  74. 73.
    1. Cummings DE,
    2. Cohen RV
    . Beyond BMI: the need for new guidelines governing the use of bariatric and metabolic surgery. Lancet Diabetes Endocrinol 2014;2:175–181
    OpenUrl
  75. 74.
    1. Zimmet P,
    2. Alberti KGMM,
    3. Rubino F,
    4. Dixon JB
    . IDF’s view of bariatric surgery in type 2 diabetes. Lancet 2011;378:108–110
    OpenUrlCrossRefPubMedWeb of Science
  76. 75.
    1. Kasama K,
    2. Mui W,
    3. Lee WJ, et al
    . IFSO-APC consensus statements 2011. Obes Surg 2012;22:677–684
    OpenUrlCrossRefPubMed
  77. 76.
    1. Wentworth JM,
    2. Burton P,
    3. Laurie C,
    4. Brown WA,
    5. O’Brien PE
    . Five-year outcomes of a randomized trial of gastric band surgery in overweight but not obese people with type 2 diabetes. Diabetes Care 2017;40:e44–e45
    OpenUrlFREE Full Text
  78. 77.
    1. Cummings DE,
    2. Arterburn DE,
    3. Westbrook EO, et al
    . Gastric bypass surgery vs intensive lifestyle and medical intervention for type 2 diabetes: the CROSSROADS randomised controlled trial. Diabetologia 2016;59:945–953
    OpenUrlCrossRefPubMed
  79. 78.
    1. Liang Z,
    2. Wu Q,
    3. Chen B,
    4. Yu P,
    5. Zhao H,
    6. Ouyang X
    . Effect of laparoscopic Roux-en-Y gastric bypass surgery on type 2 diabetes mellitus with hypertension: a randomized controlled trial. Diabetes Res Clin Pract 2013;101:50–56
    OpenUrlCrossRefPubMed
  80. 79.↵
    1. Aminian A,
    2. Chang J,
    3. Brethauer SA,
    4. Kim JJ; American Society for Metabolic and Bariatric Surgery Clinical Issues Committee
    . ASMBS updated position statement on bariatric surgery in class I obesity (BMI 30–35 kg/m2). Surg Obes Relat Dis 2018;14:1071–1087
    OpenUrl
  81. 80.↵
    1. Isaman DJM,
    2. Rothberg AE,
    3. Herman WH
    . Reconciliation of type 2 diabetes remission rates in studies of Roux-en-Y gastric bypass. Diabetes Care 2016;39:2247–2253
    OpenUrlAbstract/FREE Full Text
  82. 81.↵
    1. Ikramuddin S,
    2. Korner J,
    3. Lee W-J, et al
    . Durability of addition of Roux-en-Y gastric bypass to lifestyle intervention and medical management in achieving primary treatment goals for uncontrolled type 2 diabetes in mild to moderate obesity: a randomized control trial. Diabetes Care 2016;39:1510–1518
    OpenUrlAbstract/FREE Full Text
  83. 82.↵
    1. Sjöholm K,
    2. Pajunen P,
    3. Jacobson P, et al
    . Incidence and remission of type 2 diabetes in relation to degree of obesity at baseline and 2 year weight change: the Swedish Obese Subjects (SOS) study. Diabetologia 2015;58:1448–1453
    OpenUrlCrossRefPubMed
  84. 83.↵
    1. Arterburn DE,
    2. Bogart A,
    3. Sherwood NE, et al
    . A multisite study of long-term remission and relapse of type 2 diabetes mellitus following gastric bypass. Obes Surg 2013;23:93–102
    OpenUrlCrossRefPubMed
  85. 84.↵
    1. Mingrone G,
    2. Panunzi S,
    3. De Gaetano A, et al
    . Bariatric-metabolic surgery versus conventional medical treatment in obese patients with type 2 diabetes: 5 year follow-up of an open-label, single-centre, randomised controlled trial. Lancet 2015;386:964–973
    OpenUrlCrossRefPubMed
  86. 85.↵
    1. Schauer PR,
    2. Bhatt DL,
    3. Kirwan JP, et al.; STAMPEDE Investigators
    . Bariatric surgery versus intensive medical therapy for diabetes—5-year outcomes. N Engl J Med 2017;376:641–651
    OpenUrlCrossRefPubMed
  87. 86.↵
    1. Cohen RV,
    2. Pinheiro JC,
    3. Schiavon CA,
    4. Salles JE,
    5. Wajchenberg BL,
    6. Cummings DE
    . Effects of gastric bypass surgery in patients with type 2 diabetes and only mild obesity. Diabetes Care 2012;35:1420–1428
    OpenUrlAbstract/FREE Full Text
  88. 87.↵
    1. Brethauer SA,
    2. Aminian A,
    3. Romero-Talamás H, et al
    . Can diabetes be surgically cured? Long-term metabolic effects of bariatric surgery in obese patients with type 2 diabetes mellitus. Ann Surg 2013;258:628–636; discussion 636–637
    OpenUrlCrossRefPubMed
  89. 88.↵
    1. Hsu C-C,
    2. Almulaifi A,
    3. Chen J-C, et al
    . Effect of bariatric surgery vs medical treatment on type 2 diabetes in patients with body mass index lower than 35: five-year outcomes. JAMA Surg 2015;150:1117–1124
    OpenUrl
  90. 89.↵
    1. Schauer PR,
    2. Bhatt DL,
    3. Kirwan JP, et al.; STAMPEDE Investigators
    . Bariatric surgery versus intensive medical therapy for diabetes—3-year outcomes. N Engl J Med 2014;370:2002–2013
    OpenUrlCrossRefPubMedWeb of Science
  91. 90.↵
    1. Hariri K,
    2. Guevara D,
    3. Jayaram A,
    4. Kini SU,
    5. Herron DM,
    6. Fernandez-Ranvier G
    . Preoperative insulin therapy as a marker for type 2 diabetes remission in obese patients after bariatric surgery. Surg Obes Relat Dis 2018;14:332–337
    OpenUrl
  92. 91.↵
    1. Yu H,
    2. Di J,
    3. Bao Y, et al
    . Visceral fat area as a new predictor of short-term diabetes remission after Roux-en-Y gastric bypass surgery in Chinese patients with a body mass index less than 35 kg/m2. Surg Obes Relat Dis 2015;11:6–11
    OpenUrlCrossRefPubMed
  93. 92.↵
    1. O’Brien R,
    2. Johnson E,
    3. Haneuse S, et al
    . Microvascular outcomes in patients with diabetes after bariatric surgery versus usual care: a matched cohort study. Ann Intern Med 2018;169:300–310
    OpenUrlPubMed
  94. 93.↵
    1. Halperin F,
    2. Ding S-A,
    3. Simonson DC, et al
    . Roux-en-Y gastric bypass surgery or lifestyle with intensive medical management in patients with type 2 diabetes: feasibility and 1-year results of a randomized clinical trial. JAMA Surg 2014;149:716–726
    OpenUrl
  95. 94.↵
    1. Kirwan JP,
    2. Aminian A,
    3. Kashyap SR,
    4. Burguera B,
    5. Brethauer SA,
    6. Schauer PR
    . Bariatric surgery in obese patients with type 1 diabetes. Diabetes Care 2016;39:941–948
    OpenUrlAbstract/FREE Full Text
  96. 95.↵
    1. Rubin JK,
    2. Hinrichs-Krapels S,
    3. Hesketh R,
    4. Martin A,
    5. Herman WH,
    6. Rubino F
    . Identifying barriers to appropriate use of metabolic/bariatric surgery for type 2 diabetes treatment: Policy Lab results. Diabetes Care 2016;39:954–963
    OpenUrlAbstract/FREE Full Text
  97. 96.↵
    1. Fouse T,
    2. Schauer P
    . The socioeconomic impact of morbid obesity and factors affecting access to obesity surgery. Surg Clin North Am 2016;96:669–679
    OpenUrl
  98. 97.↵
    1. Longitudinal Assessment of Bariatric Surgery (LABS) Consortium;
    2. Flum DR,
    3. Belle SH,
    4. King WC, et al
    .. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med 2009;361:445–454
    OpenUrlCrossRefPubMedWeb of Science
  99. 98.
    1. Courcoulas AP,
    2. Christian NJ,
    3. Belle SH, et al.; Longitudinal Assessment of Bariatric Surgery (LABS) Consortium
    . Weight change and health outcomes at 3 years after bariatric surgery among individuals with severe obesity. JAMA 2013;310:2416–2425
    OpenUrlPubMedWeb of Science
  100. 99.
    1. Arterburn DE,
    2. Courcoulas AP
    . Bariatric surgery for obesity and metabolic conditions in adults. BMJ 2014;349:g3961
    OpenUrlAbstract/FREE Full Text
  101. 100.
    1. Young MT,
    2. Gebhart A,
    3. Phelan MJ,
    4. Nguyen NT
    . Use and outcomes of laparoscopic sleeve gastrectomy vs laparoscopic gastric bypass: analysis of the American College of Surgeons NSQIP. J Am Coll Surg 2015;220:880–885
    OpenUrlCrossRefPubMed
  102. 101.↵
    1. Aminian A,
    2. Brethauer SA,
    3. Kirwan JP,
    4. Kashyap SR,
    5. Burguera B,
    6. Schauer PR
    . How safe is metabolic/diabetes surgery? Diabetes Obes Metab 2015;17:198–201
    OpenUrlCrossRefPubMed
  103. 102.
    1. Birkmeyer NJO,
    2. Dimick JB,
    3. Share D, et al.; Michigan Bariatric Surgery Collaborative
    . Hospital complication rates with bariatric surgery in Michigan. JAMA 2010;304:435–442
    OpenUrlCrossRefPubMedWeb of Science
  104. 103.
    1. Altieri MS,
    2. Yang J,
    3. Telem DA, et al
    . Lap band outcomes from 19,221 patients across centers and over a decade within the state of New York. Surg Endosc 2016;30:1725–1732
    OpenUrl
  105. 104.
    1. Hutter MM,
    2. Schirmer BD,
    3. Jones DB, et al
    . First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg 2011;254:410–420; discussion 420–422
    OpenUrlCrossRefPubMed
  106. 105.
    1. Nguyen NT,
    2. Slone JA,
    3. Nguyen X-MT,
    4. Hartman JS,
    5. Hoyt DB
    . A prospective randomized trial of laparoscopic gastric bypass versus laparoscopic adjustable gastric banding for the treatment of morbid obesity: outcomes, quality of life, and costs. Ann Surg 2009;250:631–641
    OpenUrlPubMedWeb of Science
  107. 106.↵
    1. Courcoulas AP,
    2. King WC,
    3. Belle SH, et al
    . Seven-year weight trajectories and health outcomes in the Longitudinal Assessment of Bariatric Surgery (LABS) study. JAMA Surg 2018;153:427–434
    OpenUrl
  108. 107.↵
    1. Birkmeyer JD,
    2. Finks JF,
    3. O’Reilly A, et al.; Michigan Bariatric Surgery Collaborative
    . Surgical skill and complication rates after bariatric surgery. N Engl J Med 2013;369:1434–1442
    OpenUrlCrossRefPubMedWeb of Science
  109. 108.↵
    1. Service GJ,
    2. Thompson GB,
    3. Service FJ,
    4. Andrews JC,
    5. Collazo-Clavell ML,
    6. Lloyd RV
    . Hyperinsulinemic hypoglycemia with nesidioblastosis after gastric-bypass surgery. N Engl J Med 2005;353:249–254
    OpenUrlCrossRefPubMedWeb of Science
  110. 109.↵
    1. Mechanick JI,
    2. Kushner RF,
    3. Sugerman HJ, et al.; American Association of Clinical Endocrinologists; Obesity Society; American Society for Metabolic & Bariatric Surgery
    . American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Obesity (Silver Spring) 2009;17(Suppl. 1):S1–S70
    OpenUrlPubMed
  111. 110.↵
    1. Mechanick JI,
    2. Youdim A,
    3. Jones DB, et al.; American Association of Clinical Endocrinologists; Obesity Society; American Society for Metabolic & Bariatric Surgery
    . Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity (Silver Spring) 2013;21(Suppl. 1):S1–S27
    OpenUrlCrossRefPubMed
  112. 111.↵
    1. Lee CJ,
    2. Clark JM,
    3. Schweitzer M, et al
    . Prevalence of and risk factors for hypoglycemic symptoms after gastric bypass and sleeve gastrectomy. Obesity (Silver Spring) 2015;23:1079–1084
    OpenUrlCrossRefPubMed
  113. 112.↵
    1. Conason A,
    2. Teixeira J,
    3. Hsu C-H,
    4. Puma L,
    5. Knafo D,
    6. Geliebter A
    . Substance use following bariatric weight loss surgery. JAMA Surg 2013;148:145–150
    OpenUrl
  114. 113.
    1. Bhatti JA,
    2. Nathens AB,
    3. Thiruchelvam D,
    4. Grantcharov T,
    5. Goldstein BI,
    6. Redelmeier DA
    . Self-harm emergencies after bariatric surgery: a population-based cohort study. JAMA Surg 2016;151:226–232
    OpenUrl
  115. 114.
    1. Peterhänsel C,
    2. Petroff D,
    3. Klinitzke G,
    4. Kersting A,
    5. Wagner B
    . Risk of completed suicide after bariatric surgery: a systematic review. Obes Rev 2013;14:369–382
    OpenUrlCrossRefPubMed
  116. 115.↵
    1. Jakobsen GS,
    2. Småstuen MC,
    3. Sandbu R, et al
    . Association of bariatric surgery vs medical obesity treatment with long-term medical complications and obesity-related comorbidities. JAMA 2018;319:291–301
  117. 116.↵
    1. Young-Hyman D,
    2. Peyrot M
    . Psychosocial Care for People with Diabetes. 1st ed. Alexandria, VA, American Diabetes Association, 2012
  118. 117.↵
    1. Greenberg I,
    2. Sogg S,
    3. M Perna F
    . Behavioral and psychological care in weight loss surgery: best practice update. Obesity (Silver Spring) 2009;17:880–884
    OpenUrlCrossRefPubMed
  119. 118.
    Truven Health Analytics. Introduction to RED BOOK Online. Accessed 13 October 2020. Available from https://www.micromedexsolutions.com/micromedex2/4.34.0/WebHelp/RED_BOOK/Introduction_to_REDB_BOOK_Online.htm
  120. 119.
    Data.Medicaid.gov. NADAC (National Average Drug Acquisition Cost), 2019. Accessed 13 October 2020. Available from https://data.medicaid.gov/Drug-Pricing-and-Payment/NADAC-National-Average-Drug-Acquisition-Cost-/a4y5-998d
  121. 120.
    U.S. National Library of Medicine. Phentermine – phentermine hydrochloride capsule. Accessed 13 October 2020. Available from https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=737eef3b-9a6b-4ab3-a25c-49d84d2a0197
  122. 121.
    Nalpropion Pharmaceuticals. Contrave (naltrexone HCl/bupropion HCl) Extended-Release Tablets. Accessed 13 October 2020. Available from https://contrave.com
  123. 122.
    CHEPLAPHARM and H2-Pharma. Xenical (orlistat). Accessed 13 October 2020. Available from https://xenical.com
  124. 123.
    VIVUS, Inc. Qsymia (phentermine and topiramate extended-release) capsules. Accessed 13 October 2020. Available from https://qsymia.com
  125. 124.
    Novo Nordisk. Saxenda (liraglutide injection 3 mg). Accessed 13 October 2020. Available from https://www.saxenda.com
  126. 125.
    Aronne LJ, Wadden TA, Peterson C, Winslow D, Odeh S, Gadde KM. Evaluation of phentermine and topiramate versus phentermine/topiramate extended-release in obese adults. Obesity (Silver Spring) 2013;21:2163–2171PubMed
  127. 126.
    Gadde KM, Allison DB, Ryan DH, et al. Effects of low-dose, controlled-release, phentermine plus topiramate combination on weight and associated comorbidities in overweight and obese adults (CONQUER): a randomised, placebo-controlled, phase 3 trial. Lancet 2011;377:1341–1352PubMed
  128. 127.
    1. Marso SP,
    2. Daniels GH,
    3. Brown-Frandsen K, et al.; LEADER Steering Committee; LEADER Trial Investigators
    . Liraglutide and cardiovascular outcomes in type 2 diabetes. N Engl J Med 2016;375:311–322
    OpenUrlCrossRefPubMed
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Diabetes Care: 44 (Supplement 1)

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January 2021, 44(Supplement 1)
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8. Obesity Management for the Treatment of Type 2 Diabetes: Standards of Medical Care in Diabetes—2021
American Diabetes Association
Diabetes Care Jan 2021, 44 (Supplement 1) S100-S110; DOI: 10.2337/dc21-S008

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8. Obesity Management for the Treatment of Type 2 Diabetes: Standards of Medical Care in Diabetes—2021
American Diabetes Association
Diabetes Care Jan 2021, 44 (Supplement 1) S100-S110; DOI: 10.2337/dc21-S008
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  • 13. Children and Adolescents: Standards of Medical Care in Diabetes—2021
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