Weight Management in Diabetes

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee

Sean Wharton MD, FRCPC, PharmD Arya M. Sharma MD, PhD, FRCPC David C.W. Lau MD, PhD, FRCPC

  • Key Messages
  • Recommendations
  • Figures
  • Full Text
  • References

Key Messages

  • An estimated 80% to 90% of persons with type 2 diabetes are overweight or obese. Higher body mass index in people with diabetes is associated with increased overall mortality.
  • A modest weight loss of 5% to 10% of initial body weight can substantially improve glycemic control and cardiovascular disease risk factors.
  • Comprehensive health behaviour intervention should be implemented in overweight and obese people with diabetes or those at risk for diabetes to prevent weight gain and to achieve and maintain a reduced body weight. Many classes of antihyperglycemic medications are associated with weight gain, while some are weight neutral or associated with weight loss. The drug effects on body weight should be considered in glycemic management.
  • Bariatric surgery may be considered for appropriate patients when other interventions fail to achieve and maintain a healthy body weight.


Obesity is widely considered a chronic health problem that is often progressive and difficult to treat. An estimated 80% to 90% of persons with type 2 diabetes are also overweight or obese (1). Obesity is also becoming more prevalent in people with type 1 diabetes; a study has indicated a 7-fold increase in obesity in 20 years (2). Furthermore, intensive insulin therapy and some glucose-lowering medications are associated with weight gain (3,4). Weight loss has been shown to improve glycemic control by increasing insulin sensitivity and glucose uptake and diminishing hepatic glucose output (5). The risk of death from all causes, cardiovascular disease (CVD) and some forms of cancer increases with excessive body fat (6). This relationship between increasing body fat accumulation and adverse health outcomes exists throughout the range of overweight and obese men and women in all age groups, including those ≥75 years of age (7). Analysis of 57 prospective studies in ∼900,000 adults by the Prospective Studies Collaboration indicated that each 5 kg/m2 higher body mass index (BMI) above 25 kg/m2 was associated with about 30% higher overall mortality (8).

Assessment of Overweight and Obesity

The initial assessment of people with diabetes should include the following measurements: height, weight, calculation of BMI (kg/m2) (Table 1) (9) and waist circumference (WC) to assess the degree of abdominal obesity (Table 2) (9). Metabolic comorbidities, such as hypertension, dyslipidemia and CVD risk factors, should also be assessed since they are highly correlated with increasing BMI (10,11). Excessive abdominal adiposity is a strong independent predictor of metabolic comorbidities (12,13). Cutoff values for WC vary among expert guidelines. Table 2 (14,15) lists National Cholesterol and Education Program Adult Treatment Panel III (NCEP-ATP III) WC values. The International Diabetes Federation has proposed population specific WC cutoff values (Table 3) (16). These guidelines have not been fully validated against the development of clinical events, and considerable population-based research is needed in this area.

Table 1
Canadian guidelines for body weight classification in adults using BMI (8)
 Body mass index (BMI) values are age and gender independent and may not be correct for all ethnic populations.
Classification BMI category (kg/m2) Risk of developing health problems
Underweight <18.5 Increased
Normal weight 18.5–24.9 Least
Overweight 25.0–29.9 Increased
Obese ≥30.0  
    Class I 30.0–34.9 High
    Class II 35.0–39.9 Very High
    Class III ≥40.0 Extremely High

Assessment of overweight and obese patients should include determining reasons for the previous or current positive energy balance that led them to become overweight or obese, or to continually gain weight. An etiological approach assessing causes of lower metabolic rates, such as medications and hormonal imbalances, should be considered (17). People with diabetes often take medications that are associated with weight gain; these include antihyperglycemic, antihypertensive, pain relief and antidepressant agents (18). Psychological aspects of eating behaviours, such as emotional eating, binge eating and depression, also should be assessed (19). Physical parameters that impede activity, such as osteoarthritis or dyspnea, should be assessed (20). Comorbid conditions, such as osteoarthritis and obstructive sleep apnea, can also impact the ability to lose weight (21). These conditions should be assessed and treated.

Table 2
NCEP-ATP III WC and risk of developing health problems (8)
 Waist circumference (WC) cutoffs may be lower in some populations (e.g. older individuals, Asian population [See Table 3]), especially in the presence of the metabolic syndrome (e.g. hypertriglyceridemia).
WC cutoff points∗,† Risk of developing health problems
Men ≥102 cm (40 inches) Increased
Women ≥88 cm (35 inches) Increased
Table 3
Ethnic-specific values for WC from International Diabetes Federation(13)
National Cholesterol and Education Program Adult Treatment Panel III (NCEP-ATP III) guidelines (11,12) and Health Canada (6) define central obesity as waist circumference (WC) values ≥102 cm (40 inches) in men and ≥88 cm (35 inches).
Country or ethnic group Central obesity as defined by WC
  Men Women
Europid ≥94 cm ≥80 cm
South Asian, Chinese, Japanese ≥90 cm ≥80 cm
South and Central American Use South Asian cutoff points until more specific data are available.
Sub-Saharan African Use Europid cutoff points until more specific data are available.
Eastern Mediterranean and Middle Eastern (Arab) Use Europid cutoff points until more specific data are available.
Table 4
Checklist for weight management programs (46)
  1. The program assesses and treats comorbid conditions.
  2. The program provides individualized nutritional, exercise and behavioral programs and counselling.
  3. Nutritional advice is provided by qualified experts (e.g. registered dietitians) and diets are not less than 900 kcal/day.
  4. Exercise is encouraged but physical activity is promoted at a gradual pace.
  5. >Reasonable weight loss goals are set at 1 to 2 lb/week.
  6. Cost is not prohibitive, and there are no financial contracts.
  7. There is no requirement to buy products, supplements, vitamins or injections.
  8. The program does not make unsubstantiated claims.
  9. The program has an established maintenance program.

Treatment of Overweight and Obesity

The goals of therapy for overweight and obese people with diabetes are to achieve optimal glycemic and metabolic control initially through health behaviour intervention. Attaining and maintaining a healthy body weight and preventing weight regain are the short- and long-term goals. In general, obese people with diabetes have greater difficulty with weight loss compared to similarly obese people without diabetes (22). Many antihyperglycemic medications are associated with weight gain, and attempts should be made to minimize these medications without compromising glycemic control or to switch to alternative agents not associated with weight gain (18). For many patients, prevention of weight gain can be considered a realistic and sustainable outcome. A modest weight loss of 5% to 10% of initial body weight can substantially improve insulin sensitivity, glycemic control, high blood pressure (BP) and dyslipidemia (23–27). The optimal rate of weight loss is 1 to 2 kg/month but is generally self-limiting due to physiological counterregulation (17,28). A negative energy balance of 500 kcal/day is typically required to achieve a weight loss of 0.45 kg/week (29). As individuals lose weight, adjustment in antihyperglycemic medications may be required to avoid hypoglycemia.

Table 5
Medication approved for the treatment of obesity in type 2 diabetes (36)
Class Generic (trade) name Recommended regimen Action Adverse effects
Gastrointestinal lipase inhibitor Orlistat (Xenical) 120 mg tid (during or up to 1 hour after each meal)
  • Nonsystemic pancreatic lipase inhibitor reduces dietary fat digestion and absorption by about 30%
  • Abdominal bloating, pain and cramping
  • Steatorrhea
  • Fecal incontinence

The National Institutes of Health (NIH)-sponsored multicenter Look AHEAD (Action for Health in Diabetes) trial, whose design is based largely on the United States (US) Diabetes Prevention Program, investigated the effects of lifestyle intervention on changes in weight, fitness, and CVD risk factors and events in people with type 2 diabetes (30). The 1- and 4-year interim data reported beneficial effects of modest weight loss of 5% to 10% in improving glycemic control, lowering of CV risk markers, BP and lipid levels (30,31). Greater improvement in risk factors occurred with greater weight losses. There was some expected weight regain at 4 years, yet there continued to be beneficial metabolic effects.

Table 6
Glucose-lowering medications and their effects on weight (17)
Weight gain Weight effect (lb)
Insulin (fast acting, NPH) (2) +8.8 – +11.0
Thiazolidinediones (TZDs) (57) +5.2 – +10.6
Sulphonylureas (2,57) +3.5 – +5.7
Meglitinides (58) +1.54 – +3.97
Weight neutral or decrease weight Weight effect
Insulin (basal analogues, detemir, glargine) (59,60) −0.22 – +0.88
Metformin (61) −8.4 – +0.88
Alpha-glucosidase inhibitors (62,63) +0.0 – +0.44
Dipeptidyl peptidase-4 (DPP-4) inhibitors (64,65) +0.0 – +0.46
Glucagon-like peptide-1 (GLP-1) receptor agonists (66,67)     −6.6 – −3.5

Healthy Behaviour Interventions

The overall goal of health behaviour intervention in people with diabetes who are overweight or obese is to improve health status and quality of life (32,33).

Health behaviour interventions that combine dietary modification, increased and regular physical activity and behaviour therapy are the most effective (34–37). Structured interdisciplinary programs have demonstrated better short- and long-term results (36).

All weight-loss diets must be well balanced and nutritionally adequate to ensure optimal health. In general, a carbohydrate intake of at least 100 g/day is required to spare protein breakdown and muscle wasting and to avoid large shifts in fluid balance and ketosis. High-fibre foods are associated with greater satiety. Adequate protein intake is required to maintain lean body mass and other essential physiological processes. Reduced intake of saturated fat and energy-dense foods should be emphasized. Very-low-calorie diets with <900 kcal/day are not recommended, except under medical supervision.

As understanding and adhering to healthy and nutritionally balanced meal plans can be challenging, people with diabetes should be counselled by qualified professionals on appropriate serving sizes, caloric and carbohydrate intake and how to select nutrient-rich meals (38,39).

Two large-scale reviews of >100 individual studies evaluating behaviour modification techniques support their effectiveness in promoting weight loss (40,41).

Members of the healthcare team should consider using a structured approach to providing advice and feedback on physical activity, healthy eating habits and weight loss (42–45). Programs and clinics dedicated to weight management may be beneficial, particularly those that adhere to the checklist in Table 4 (46).

Figure 1
Biliopancreatic Diversion with Duodenal Switch.

The stomach and small intestine are surgically reduced so that nutrients are absorbed only in a 50-cm “common limb.” (From Shukla A, Rubino F. Secretion and function of gastrointestinal hormones after bariatric surgery: their role in type 2 diabetes. Can J Diabetes 2011;35:115-122.)

Figure 2
Roux-en-Y Gastric Bypass.

A surgical stapler is used to create a small gastric pouch. Ingested food bypasses ∼95% of the stomach, the entire duodenum and a portion of the jejunum. (From Shukla A, Rubino F. Secretion and function of gastrointestinal hormones after bariatric surgery: their role in type 2 diabetes. Can J Diabetes 2011;35:115-122.)

Figure 3
Gastric Sleeve.

A longitudinal (sleeve) resection of the stomach reduces the functional capacity of the stomac and eliminates the ghrelin-rich gastric fundus. (From Shukla A, Rubino F. Secretion and function of gastrointestinal hormones after bariatric surgery: their role in type 2 diabetes. Can J Diabetes 2011;35:115-122.)

Figure 4
Adjustable Gastric Band.

The upper part of the stomach is encircled with a constrictive saline-filled tube. The amount of restriction can be adjusted by injecting or withdrawing saline solution. (From Shukla A, Rubino F. Secretion and function of gastrointestinal hormones after bariatric surgery: their role in type 2 diabetes. Can J Diabetes 2011;35:115-122.)


Orlistat is currently the only approved medication in Canada for long-term management of obesity (Table 5) (47). When used to treat overweight and obese people with diabetes, orlistat has been demonstrated to improve glycemic control and to reduce the doses of antihyperglycemic agents that can promote weight gain (47).

However, pharmacotherapy options are limited in weight management, and many approved agents have been discontinued by the developers or rejected by government drug approval boards due to unacceptable side effects (18). Pharmacotherapy can be considered for people with BMI ≥30.0 kg/m2 with no obesity-related comorbidities or risk factors, or for those with BMI ≥27.0 kg/m2 with obesity-related comorbidities or risk factors (29). Antiobesity drug therapy may be considered as an adjunct to nutrition therapy, physical activity and behaviour modification to achieve a target weight loss of 5% to 10% of initial body weight and for weight maintenance (32,48). There are several new antiobesity agents that may be available within the near future and that may have a beneficial impact on diabetes management.

Orlistat leads to greater weight loss when coupled with healthy behaviour interventions (47). Orlistat has been shown to be effective at improving glycemic and metabolic control in obese people with type 2 diabetes (47,49,50). In obese people with impaired glucose tolerance, orlistat also improves glucose tolerance and reduces the progression to type 2 diabetes (51). Clinical trials with antiobesity agents have confirmed a smaller degree of weight loss in people with diabetes compared with obese people who do not have diabetes (22,38). Orlistat should be avoided in patients with inflammatory or other chronic bowel disease.

Some antihyperglycemic medications are associated with weight gain (insulin, insulin secretagogues, thiazolidinediones), and the magnitude of weight gain can vary from 4 to 9 kg or more, depending on the choice of drugs (Table 6 ) (18). Insulin is associated with the most weight gain, whereas metformin, glucosidase inhibitors and the incretin class of antihyperglycemic agents typically are weight neutral or associated with a weight loss of about 3 kg (18).

Other available anti-obesity drugs, such as diethylpropion and phentermine, are sympathomimetic noradrenergic appetite suppressants that are approved only for short-term use of a few weeks. They are not recommended because of modest efficacy and frequent adverse side effects.

Bariatric Surgery

Bariatric surgery has emerged as an innovative alternative option in the management of type 2 diabetes. These procedures can result in sustained body weight loss and significant improvement in obesity-related comorbidities (52). Surgery is usually reserved for people with class III obesity (BMI ≥40.0 kg/m2) or class II obesity (BMI = 35.0 to 39.9 kg/m2) in the presence of comorbidities (52) and the inability to achieve weight loss maintenance following an adequate trial of health behaviour intervention. Individuals who are candidates for surgical procedures should be selected after evaluation by an interdisciplinary team with medical, surgical, psychiatric and nutritional expertise. Long-term, if not lifelong, medical surveillance after surgical therapy is necessary for most people. Bariatric surgery procedures can be classified as restrictive, malabsorptive or combined restrictive and malabsorptive. Biliopancreatic diversion with duodenal switch procedure (Figure 1), roux-en-Y gastric bypass (Figure 2), gastric sleeve (Figure 3) and laparoscopic adjustable gastric banding (Figure 4 ) have all demonstrated significant improvements and even remission in type 2 diabetes (53–55).


  1. An interdisciplinary weight management program (including a nutritionally balanced, calorie-restricted diet; regular physical activity; education; and counselling) for overweight and obese people with, or at risk for, diabetes should be implemented to prevent weight gain and to achieve and maintain a lower, healthy body weight [Grade A, Level 1A (30,56) ].
  2. In overweight or obese adults with type 2 diabetes, the effect of antihyperglycemic agents on body weight should be taken into account [Grade D, Consensus].
  3. Adults with type 2 diabetes and class II or III obesity (BMI ≥35.0 kg/m2) may be considered for bariatric surgery when lifestyle interventions are inadequate in achieving healthy weight goals [Grade B, Level 2 (53–55) ].

Other Relevant Guidelines

Physical Activity and Diabetes, p. S40

Nutrition Therapy, p. S45


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