ada T2DM. They stress the value of even moderate


ADA 2018 guidelines (American Diabetes Association, 2018) provide comprehensive evidence
based recommendations on obesity management for T2DM. They stress the value of
even moderate sustained weight loss of 5-10% in those who are overweight or
obese in achieving reductions in Hba1c, TGs and BGL.  Further weight loss can even reduce the need
for medication. They stress that HCP should assess the patient’s readiness to
lose weight and jointly with the patient determine goals and an intervention
strategy for weight loss made up from:

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physical activity

behavioral therapy


metabolic surgery

However, they modify this patient centered approach to management
by adding that weight loss medications should only be used in patients who have
been selected carefully and only them in conjunction with the top 3


In the use of pharmacotherapy are 3 recommendations by ADA:

Choose diabetes medications which are either
weight neutral or that are associated with weight loss

Avoid or minimize the use of other medications for
comorbid conditions which are known to cause weight gain.

When considering weight loss medications do a
risk/benefit analysis Cease if weight loss<5% after 3 months or if there are issues with safety or side effects and consider changing to another medication or another approach such as surgery. The guidelines conclude by saying the effectiveness of drug treatment for obesity has been limited by ·        Low adherence ·        Modest efficacy ·        Adverse side effects ·        Weight regain after ceasing the drug However, in my view some of these issues are not such a concern if the medication being used for weight is also a diabetic medication and is prescribed for a long-term medication with less side effects and better adherence.  Also, the guidelines point out that a met analysis looking at 227 RCT found that the efficacy of diabetic medication on Hba1c was not dependent on baseline BMI. This suggest that obese and overweight patients almost benefit from antihyperglycemic treatment.(Cai et al., 2016) Word count 321 Surgery Has been shown to be able to achieve significant weight loss and improvements in glycemic control comparable to that achieve by VLCDs even to the stage of remission but with the advantage of weight loss being more sustained. Improvements in CVD and microvascular complications  and reductions in mortality although seen or suggested in observational or cohort have not been proven by RCTs(American Diabetes Association, 2018) . However it  is expense and not without risk or side effect, There a several techniques available. ADA 2018 guidelines recommend metabolic surgery as an option where: ·        BMI >=
40 (37.5 Asian) regardless of glycemic control or diabetic medication regime.

35-39.9 (32.5-37.4 Asian) where diabetes poorly controlled on optimal therapy.

Consider metabolic
surgery as an option Where control poor control on optimal therapy:

30-34.9 (27.5-32.4 Asian)

Some international diabetes organizations have recommended extending
indication further to BMI as low as 30 (27.5  for Asian) where control is inadequate due to
the growing evidence in support of metabolic surgery.(Rubino et al.,

They also recommend
that surgery only be performed in specialized centres with experienced multidisciplinary
teams. Also, these patients need to be provided with of long-term lifestyle support
and routine nutritional monitoring. Full mental health assessment should be done
as part of presurvey assessment to screen for alcohol or drug abuse, depression
other mental health issues which hinder their adjustment.

A 30-63% continued remission
rate has been seen post-surgery over 1-5 years period. Of those who achieve
remission 35-50% relapse back to diabetes eventually. Of those patients who
achieved remission following Roux-en-Y gastric bypass the median remission period
was 8.3 years.