Weight Management in Diabetes

Diabetes Canada Clinical Practice Guidelines Expert Committee

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

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

Key Messages

  • Sustained weight loss of ≥5% of initial body weight can improve glycemic control and cardiovascular risk factors.
  • In people with diabetes and obesity, weight loss and A1C lowering can be achieved with healthy behaviour interventions as the cornerstone of treatment. Weight management medications can improve glycemic and metabolic control in people with diabetes and obesity.
  • Bariatric surgery may be considered appropriate for people with diabetes and obesity.
  • When selecting the most appropriate antihyperglycemic agent(s) for a person with diabetes, the effect on body weight should be considered.

Key Messages for People with Diabetes

  • When you have diabetes, having overweight or obesity increases your risk for complications.
  • Healthy behaviour modifications, including regular physical activity and eating well can help with your blood glucose control and reduce your risk for other health problems associated with diabetes.
  • Your diabetes health-care team can help you with weight management. For some people with diabetes, weight management medications and bariatric surgery may be helpful.

Introduction

Obesity is a chronic health problem that is often progressive and difficult to treat. An estimated 80% to 90% of people with type 2 diabetes have overweight or obesity (1). Obesity is also becoming more prevalent in people with type 1 diabetes; one study reported a sevenfold increase in the last 20 years (2). In addition, intensive insulin therapy and some antihyperglycemic medications are associated with weight gain which, in turn, leads to obesity-related comorbid conditions (3,4). The relationship between increasing body fat accumulation and adverse health outcomes exists throughout the range of overweight and obesity in men and women of all age groups (5). Weight loss has been shown to improve glycemic control by increasing insulin sensitivity and glucose uptake and diminishing hepatic glucose output (6).

Assessment of Overweight and Obesity

Health Canada guidelines recommend that the initial assessment of people with diabetes should include the following measurements: height, weight, calculation of body mass index (BMI) (kg/m2) and waist circumference (WC) (7) (Table 1). Metabolic comorbidities are highly correlated with increasing BMI and WC (8,9). Excessive abdominal adiposity is a strong independent predictor of metabolic comorbidities (10,11). Cut-off values for healthy WC vary among expert guidelines (12,13). Table 2 lists National Cholesterol and Education Program Adult Treatment Panel III (NCEP-ATP III) WC values. The International Diabetes Federation (IDF) has proposed population specific WC cut-off values; however, these guidelines have not been fully validated against the development of clinical events (14) (Table 3).

In people with diabetes and overweight or obesity, the reasons for the previous or current positive energy balance can often be identified. People with diabetes often take medications that are associated with weight gain; these include antihyperglycemic, antihypertensive, pain relief and antidepressant agents (15). Assessing psychological aspects of eating behaviours, such as emotional eating, binge eating, attention deficit and hyperactivity disorder (ADHD), and depression, is also relevant in determining reasons for weight gain (16). Physical parameters that impede activity, such as osteoarthritis or dyspnea, can contribute to obesity (17). Comorbid conditions, such as osteoarthritis and obstructive sleep apnea (OSA), can also impact the ability to lose weight (18).

Table 1
Canadian guidelines for body weight classification in adults using BMI
BMI, body mass index.
Adapted from reference 74
 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
Healthy weight 18.5–24.9 Least
Overweight 25.0–29.9 Increased
Obesity ≥30.0  
    Class I 30.0–34.9 High
    Class II 35.0–39.9 Very High
    Class III ≥40.0 Extremely High

Treatment of Overweight and Obesity

The goals of therapy for people with diabetes and overweight or obesity are to achieve optimal glycemic and metabolic control and, ultimately, improve quality of life, morbidity and mortality. Attaining and maintaining a healthy body weight, and preventing weight regain, are key components of optimizing glycemic control in people with diabetes. Often people with obesity and diabetes have greater difficulty with achieving weight loss compared to people with obesity but without diabetes (19). Health-care providers should attempt to minimize use of weight-inducing agents without compromising glycemic control, or switch the person with diabetes to agents not associated with weight gain (15).

For many people with diabetes, prevention of further weight gain is a realistic and sustainable target. A modest weight loss of 5% to 10% of initial body weight can improve insulin sensitivity, glycemic control and blood pressure. Greater amounts of weight loss may be needed to improve OSA and dyslipidemia (20–24). The 2006 Canadian Obesity Guidelines have suggested a weight loss of 2 to 4 kg/month (25). A negative energy balance of approximately 500 kcal/day is needed to achieve this weight loss. Metabolic and physiologic adaptations following weight loss can promote weight regain and make sustained weight loss challenging (26). Adjustment of the caloric deficit may be required as weight loss progresses. In addition, as individuals lose weight, adjustment in antihyperglycemic medications may be required to avoid hypoglycemia (27).

The National Institutes of Health (NIH)-sponsored multicentre Look AHEAD (Action for Health in Diabetes) trial, investigated the effects of lifestyle intervention on changes in weight, fitness and cardiovascular (CV) risk factors and events in people with type 2 diabetes (28). The 8-year data revealed a 4.7% decrease in weight in the intensive lifestyle arm (29). This provided evidence that lifestyle changes can have a positive impact on weight change, fitness level and a decrease in medications, along with a small decrease in glycated hemoglobin (A1C) and other health benefits (29).

Table 2
Waist circumference (WC) and risk of developing health problems
WC, waist circumference.
Adapted from reference 74.
WC cut-offs may be lower in some populations (e.g. older individuals, Asian population [see Table 3]), especially in the presence of the metabolic syndrome (such as hypertriglyceridemia).
Increased WC can also be a marker for increased risk, even in persons with healthy weight.
WC cut-off points*† Risk of developing health problems
Men ≥102 cm Increased
Women ≥88 cm Increased
Table 3
Ethnic-specific values for waist circumference (WC)
Adapted from reference 11
NCEP-ATP III guidelines (9,78) and Health Canada (79) define central obesity as WC values ≥102 cm in men and ≥88 cm in women.
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
Adapted from reference 38
  1. The program assesses and treats comorbid conditions.
  2. The program recommends healthy behaviour modifications, and pharmacotherapy or surgery for those who qualify.
  3. The program provides individualized nutritional, physical activity and behavioural programs and counselling.
  4. Reasonable weight loss goals are set at 1–2 kg/month.
  5. Cost is not prohibitive.
  6. There is no requirement to buy products, supplements, vitamins or injections.
  7. The program does not make unsubstantiated claims.
  8. The program provides access to a weight maintenance program.

Healthy Behaviour Interventions

Healthy behaviour interventions are essential components of successful weight management. (30,31). Interventions that combine dietary modification, increased and regular physical activity and behaviour therapy are the most effective at improving health outcomes (32–35). Structured interprofessional programs and group programs have demonstrated better results (34) compared to solo health-care professional-based interventions (36).

Dietary plans for people with diabetes should be evidence based and nutritionally adequate to ensure optimal health. Specific dietary recommendations for weight loss can be found in the Nutrition Therapy chapter, p. S64. Moderate carbohydrate reduction has been beneficial in people with diabetes, demonstrating improvements in high density lipoprotein (HDL) and triglycerides, blood glucose stability, and reductions in diabetes medication requirements (37).

People with obesity and diabetes benefit from advice by qualified professionals on appropriate serving sizes, caloric and carbohydrate intake and how to select nutrient-rich meals, as demonstrated by the Look AHEAD Study (28). Programs and clinics dedicated to weight management may be beneficial, particularly those that adhere to the checklist in Table 4 (38).

Table 5
Medications approved for the treatment of obesity in type 2 diabetes
GLP-1, Glucagon-like peptide-1.
Class Realtive weight loss Side effects Therapeutic considerations Cost
Gastrointestinal lipase inhibitor (orlistat) (45) Loose stools, GI upset, rare liver failure Oral medication, decreases fat absorption, may require vitamin supplementation $$$
GLP-1 receptor agonist (liraglutide 3.0 mg) (42) ↓↓ Nausea, GI upset, rare gallstones and pancreatitis Subcutaneous injectable, increases satiety $$$$

Pharmacotherapy

The effect of antihyperglycemic medication on body weight varies by class of medication. 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 (15,39,40) (see Pharmacologic Glycemic Management of Type 2 Diabetes in Adults chapter, p. S88). Insulin is associated with the most weight gain (41). Metformin, acarbose and DPP-4 inhibitors are typically weight neutral (15). Glucagon-like peptide-1 (GLP-1) receptor agonists are associated with a weight loss of about 3 kg in people with diabetes (42). Sodium-glucose co-transporter 2 (SGLT2) inhibitors are associated with a typical weight loss of 2 to 3 kg (43). People with type 1 diabetes may have a tendency toward slightly higher body weight with use of neutral protamine Hagedorn (NPH) insulin compared to long-acting basal insulin analogues (44).

Orlistat and liraglutide are the only approved medications for chronic weight management in Canada (42,45) (Table 5). When used to treat people with overweight or obesity and type 2 diabetes, both have been demonstrated to improve glycemic control and to reduce the doses of antihyperglycemic agents that promote weight gain (45). For people with type 2 diabetes or prediabetes, pharmacotherapy is indicated for chronic weight management with a BMI ≥27.0 kg/m2, in whom healthy behaviour interventions have been unsuccessful or insufficient for improvement in health. Clinical trials with weight loss agents have confirmed a smaller degree of weight loss in people with diabetes compared to people with obesity without diabetes (42,46,47).

Orlistat leads to greater weight loss when coupled with healthy behaviour interventions (45). It has been shown to be effective at improving glycemic and metabolic control in people with obesity and type 2 diabetes (45,48–50). In people with obesity and IGT, orlistat also improves glucose tolerance and reduces the progression to type 2 diabetes (19,51,52). Potential adverse effects include loose stools and other gastrointestinal side effects that may affect long-term compliance (53). Rare cases of fulminant liver failure have also been reported (54).

Liraglutide is a GLP-1 receptor agonist, which acts to increase satiety and decrease hunger in the brain. While most of the blood glucose lowering benefits of liraglutide are seen at 1.8 mg per day, there is an additional dose dependent weight loss effect up to 3.0 mg per day (42). Liraglutide is indicated at 1.2 or 1.8 mg per day for the treatment of type 2 diabetes, and at 3.0 mg per day for weight management in people with (42) or without type 2 diabetes (46). In people with type 2 diabetes, liraglutide 3.0 mg is effective to facilitate weight loss in addition to improving glycemic control and metabolic parameters, in combination with a lifestyle modification program (42,55,56). In people with prediabetes, liraglutide 3.0 mg is effective to delay progression to type 2 diabetes (46) (see Reducing the Risk of Developing Diabetes chapter, p. S20). Gastrointestinal side effects, including nausea, are generally transient in nature. Gallbladder disease and acute pancreatitis are rare potential complications of treatment (46).

Pharmacotherapy directed at weight management has not been adequately studied in people with type 1 diabetes.

Figure 1
Gastric sleeve.

Gastric sleeve. A longitudinal (sleeve) resection of the stomach reduces the functional capacity of the stomach and eliminates the ghrelin-rich gastric fundus (80).

Figure 2
Roux-en-Y gastric bypass.

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 (80).

Figure 3
Biliopancreatic diversion with duodenal switch.

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” (80).

Bariatric Surgery

Bariatric surgery is a therapeutic option in the management of people with type 2 diabetes and obesity. “Bariatric surgery” is the preferred term over “metabolic surgery”, as the benefits encompass metabolic, mechanical and psychological improvements. These procedures can result in sustained weight loss and significant improvements in obesity-related comorbidities, including control or remission of type 2 diabetes. Surgery is a treatment option for people with BMI ≥40.0 kg/m2 or with BMI 35.0 to 39.9 kg/m2 in the presence of comorbidities, such as type 2 diabetes, who have demonstrated an inability to achieve weight loss maintenance following an adequate trial of healthy behaviour interventions and/or pharmacotherapy. Evaluation for candidacy and appropriateness for surgical procedures includes assessment by an interdisciplinary team with medical, surgical, psychiatric and nutritional expertise (57). The benefits and risks of bariatric surgery must be carefully considered for each individual, and candidates must be prepared to comply with lifelong medical surveillance.

Commonly performed bariatric surgeries include Roux-en-Y gastric bypass (RYGB) (Figure 2), sleeve gastrectomy (Figure 1), and biliopancreatic diversion with or without duodenal switch (BPD/BPD-DS) (Figure 3). These procedures lead to sustained weight loss and improvements in or remission of type 2 diabetes (58–61). The likelihood of improvement in control or remission of type 2 diabetes is higher with Roux-en-Y gastric bypass surgery, sleeve gastrectomy or BPD compared to gastric banding (62–65). The gastric band has largely been abandoned in North America due to less sustained weight loss and metabolic benefits, and high surgical complication rates necessitating band removal (66).

Predictors of likelihood of remission of type 2 diabetes after bariatric surgery include higher preoperative serum C-peptide, younger age, shorter duration of diabetes and lack of need for insulin therapy preoperatively (67,68). People who experience remission of type 2 diabetes with bariatric surgery may experience recurrence of diabetes years later; thus, life-long monitoring and screening for recurrence is important (69). Evidence of the risks and outcomes of bariatric metabolic surgery in people with type 2 diabetes and BMI between 30 to 35 kg/m2 is very limited and cannot be recommended at this time.

Bariatric surgery can prevent the development and progression of albuminuria (70). Studies have shown variable effects of bariatric surgery on diabetic retinopathy (71). One study has shown that bariatric surgery may reduce the risk of myocardial infarction in people with type 2 diabetes (72). Bariatric surgery has not been adequately studied in people with type 1 diabetes (73–76).

Recommendations

  1. For people with overweight or obesity who have or are at risk for diabetes, an interprofessional weight management program is recommended to prevent weight gain and improve CV risk factors [Grade A, Level 1A (24,28)].

  2. Weight management medication may be considered in people with diabetes and overweight or obesity to promote weight loss and improved glycemic control [Grade A, Level 1A (42) for liraglutide; Grade A, Level 1A (45) for orlistat].

  3. In adults with type 2 diabetes and overweight or obesity, the effect of antihyperglycemic agents on body weight should be considered when selecting pharmacotherapy [Grade D, Consensus].

  4. Bariatric surgery may be considered for selected adults with type 2 diabetes and obesity with BMI ≥35.0 when healthy behaviour interventions with or without weight management medication(s) are inadequate in achieving target glycemic control or healthy weight goals [Grade A, Level 1A (58,59,61)].

Abbreviations:

A1C, glycated hemoglobin; BPD/BPD-DS, biliopancreatic diversion with or without duodenal switch; BMI, body mass index; CV, cardiovascular; CVD, cardiovascular disease; IGT, impaired glucose tolerance; LAGB; laparoscopic adjustable gastric banding; MI, myocardial infarction; RYGB, Roux-en-Y gastric bypass; WC, waist circumference.

Literature Review Flow Diagram for Chapter 17: Weight Management in Diabetes

*Excluded based on: population, intervention/exposure, comparator/control or study design.

From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(6): e1000097. doi:10.1371/journal.pmed1000097 (81).

For more information, visit www.prisma-statement.org.

Author Disclosures

Dr. Wharton reports personal fees from Novo Nordisk, Janssen, Lilly, Merck, and Valeant, outside the submitted work. Dr. Lau reports grants and personal fees from AstraZeneca, Boehringer Ingelheim, and Novo Nordisk; and personal fees from Valeant, Amgen, Merck, Janssen, Eli Lilly, Sanofi, and SHIRE, outside the submitted work. Dr. Pedersen reports personal fees and non-financial support from Novo Nordisk, personal fees and non-financial support from Janssen, grants, personal fees and non-financial support from Eli Lilly, personal fees from Merck, personal fees and non-financial support from Valeant, grants, personal fees and non-financial support from Astra Zeneca, grants and personal fees from Abbott, grants and personal fees from Boehringer Ingelheim, grants and personal fees from Sanofi, personal fees from Prometic, and personal fees from Pfizer, outside the submitted work. Dr. Sharma reports personal fees from Novo Nordisk, Valeant, Merck, and Berlin Chemie, outside the submitted work.

References

  1. 1R.R.WingWeight loss in the management of type 2 diabetesH.C.GersteinB.HyanesEvidence-based diabetes care2000B.C. Decker Inc.Hamilton252276
  2. 2B.ConwayR.G.MillerT.CostacouTemporal patterns in overweight and obesity in type 1 diabetesDiabet Med272010398404
  3. 3UK Prospective Diabetes Study (UKPDS) GroupIntensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33)Lancet3521998837853
  4. 4N.RudermanD.ChisholmX.Pi-SunyerThe metabolically obese, normal-weight individual revisitedDiabetes471998699713
  5. 5J.StevensCaiJ.E.R.PamukThe effect of age on the association between body-mass index and mortalityN Engl J Med338199817
  6. 6T.P.MarkovicA.B.JenkinsL.V.CampbellThe determinants of glycemic responses to diet restriction and weight loss in obesity and NIDDMDiabetes Care211998687694
  7. 7Health CanadaCanadian guidelines for body weight classification in adultsOttawa2003Report No.: H49-179/2003Ehttps://preventdisease.com/pdf/weight_book-livres_des_poids_e.pdf
  8. 8S.W.RabkinChenY.L.LeiterRisk factor correlates of body mass index. Canadian Heart Health Surveys Research GroupCMAJ157Suppl. 11997S26S31
  9. 9World Health OrganizationObesity: Preventing and managing the global epidemic. Report of a WHO consultationWorld Health Organ Tech Rep Ser8942000ixii1-253
  10. 10B.A.ReederA.SenthilselvanJ.P.DespresThe association of cardiovascular disease risk factors with abdominal obesity in Canada. Canadian Heart Health Surveys Research GroupCMAJ1571997S39S45
  11. 11J.P.DespresI.LemieuxD.Prud'hommeTreatment of obesity: Need to focus on high risk abdominally obese patientsBMJ3222001716720
  12. 12Expert Panel on Detection Evaluation, Treatment of High Blood Cholesterol in AdultsExecutive summary of the third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel III)JAMA285200124862497
  13. 13S.M.GrundyJ.I.CleemanS.R.DanielsDiagnosis and management of the metabolic syndrome: An American Heart Association/National Heart, Lung, and Blood Institute scientific statementCirculation112200527352752
  14. 14International Diabetes FederationThe IDF consensus worldwide definition of the metabolic syndrome2006IDF CommunicationsBrusselshttps://www.idf.org/webdata/docs/MetS_def_update2006.pdf
  15. 15P.HollanderAnti-diabetes and anti-obesity medications: Effects on weight in people with diabetesDiabetes Spectr202007159165
  16. 16A.A.GorinH.M.NiemeierP.HoganBinge eating and weight loss outcomes in overweight and obese individuals with type 2 diabetes: Results from the Look AHEAD trialArch Gen Psychiatry65200814471455
  17. 17P.M.RibislLangW.S.A.JaramilloExercise capacity and cardiovascular/metabolic characteristics of overweight and obese individuals with type 2 diabetes: The Look AHEAD clinical trialDiabetes Care30200726792684
  18. 18R.R.GrunsteinK.StenlofJ.A.HednerTwo year reduction in sleep apnea symptoms and associated diabetes incidence after weight loss in severe obesitySleep302007703710
  19. 19R.R.WingM.D.MarcusL.H.EpsteinType II diabetic subjects lose less weight than their overweight nondiabetic spousesDiabetes Care101987563566
  20. 20A.M.DattiloP.M.Kris-EthertonEffects of weight reduction on blood lipids and lipoproteins: A meta-analysisAm J Clin Nutr561992320328
  21. 21D.J.GoldsteinBeneficial health effects of modest weight lossInt J Obes Relat Metab Disord161992397415
  22. 22P.J.ElmerR.GrimmJrB.LaingLifestyle intervention: Results of the Treatment of Mild Hypertension Study (TOMHS)Prev Med241995378388
  23. 23J.TuomilehtoJ.LindstromJ.G.ErikssonPrevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose toleranceN Engl J Med344200113431350
  24. 24W.C.KnowlerE.Barrett-ConnorS.E.FowlerReduction in the incidence of type 2 diabetes with lifestyle intervention or metforminN Engl J Med3462002393403
  25. 25D.C.W.LauJ.D.DouketisK.M.Morrison2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and childrenCMAJ17620075759
  26. 26P.SumithranL.A.PrendergastE.DelbridgeLong-term persistence of hormonal adaptations to weight lossN Engl J Med365201115971604
  27. 27A.AhnisA.FiguraT.HofmannSurgically and conservatively treated obese patients differ in psychological factors, regardless of body mass index or obesity-related co-morbidities: A comparison between groups and an analysis of predictorsPLoS ONE102015e0117460
  28. 28Look AHEAD Research GroupR.R.WingLong-term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus: Four-year results of the Look AHEAD trialArch Intern Med170201015661575
  29. 29Look Ahead Research GroupEight-year weight losses with an intensive lifestyle intervention: The look AHEAD studyObesity (Silver Spring)222014513
  30. 30American Diabetes Association's (ADA)The American Diabetes Association (ADA) has been actively involved in the development and dissemination of diabetes care standards, guidelines, and related documents for many yearsDiabetes Care35 Suppl 12012S1S2
  31. 31W.C.WillettW.H.DietzG.A.ColditzGuidelines for healthy weightN Engl J Med3411999427434
  32. 32D.F.WilliamsonT.J.ThompsonM.ThunIntentional weight loss and mortality among overweight individuals with diabetesDiabetes Care23200014991504
  33. 33K.N.PavlouS.KreyW.P.SteffeeExercise as an adjunct to weight loss and maintenance in moderately obese subjectsAm J Clin Nutr49198911151123
  34. 34R.R.WingJ.O.HillSuccessful weight loss maintenanceAnnu Rev Nutr212001323341
  35. 35R.R.WingM.G.GoldsteinK.J.ActonBehavioral science research in diabetes: Lifestyle changes related to obesity, eating behavior, and physical activityDiabetes Care242001117123
  36. 36L.M.DelahantyK.M.DaltonB.PornealaImproving diabetes outcomes through lifestyle change–a randomized controlled trialObesity (Silver Spring)23201517921799
  37. 37R.D.FeinmanW.K.PogozelskiA.AstrupDietary carbohydrate restriction as the first approach in diabetes management: Critical review and evidence baseNutrition312015113
  38. 38Y.FreedhoffA.M.SharmaBest weight: A practical guide to office-based obesity management2010Canadian Obesity NetworkEdmontonhttp://www.obesitynetwork.ca/best-weight
  39. 39P.D.HomeR.M.BergenstalG.B.BolliNew insulin glargine 300 units/mL versus glargine 100 units/mL in people with type 1 diabetes: A randomized, phase 3a, open-label clinical trial (EDITION 4)Diabetes Care38201522172225
  40. 40R.RitzelR.RousselG.B.BolliPatient-level meta-analysis of the EDITION 1, 2 and 3 studies: Glycaemic control and hypoglycaemia with new insulin glargine 300 U/ml versus glargine 100 U/ml in people with type 2 diabetesDiabetes Obes Metab172015859867
  41. 41D.C.W.LauH.TeohImpact of current and emerging glucose-lowering drugs on body weight in type 2 diabetesCan J Diabetes392015S148S154
  42. 42M.J.DaviesR.BergenstalB.BodeEfficacy of liraglutide for weight loss among patients with type 2 diabetes: The SCALE diabetes randomized clinical trialJAMA3142015687699
  43. 43M.A.NauckUpdate on developments with SGLT2 inhibitors in the management of type 2 diabetesDrug Des Devel Ther8201413351351
  44. 44I.De LeeuwP.VagueJ.L.SelamInsulin detemir used in basal-bolus therapy in people with type 1 diabetes is associated with a lower risk of nocturnal hypoglycaemia and less weight gain over 12 months in comparison to NPH insulinDiabetes Obes Metab720057382
  45. 45P.A.HollanderS.C.ElbeinI.B.HirschRole of orlistat in the treatment of obese patients with type 2 diabetes. A 1-year randomized double-blind studyDiabetes Care21199812881294
  46. 46X.Pi-SunyerA.AstrupK.FujiokaA randomized, controlled trial of 3.0 mg of liraglutide in weight managementN Engl J Med37320151122
  47. 47D.C.LauH.TeohCurrent and emerging pharmacotherapies for weight management in prediabetes and diabetesCan J Diabetes39Suppl. 52015S134S141
  48. 48A.J.ScheenP.J.LefebvreAntiobesity pharmacotherapy in the management of type 2 diabetesDiabetes Metab Res Rev162000114124
  49. 49N.FinerS.R.BloomG.S.FrostSibutramine is effective for weight loss and diabetic control in obesity with type 2 diabetes: A randomised, double-blind, placebo-controlled studyDiabetes Obes Metab22000105112
  50. 50N.M.AldekhailJ.LogueP.McLooneEffect of orlistat on glycaemic control in overweight and obese patients with type 2 diabetes mellitus: A systematic review and meta-analysis of randomized controlled trialsObes Rev16201510711080
  51. 51S.B.HeymsfieldK.R.SegalJ.HauptmanEffects of weight loss with orlistat on glucose tolerance and progression to type 2 diabetes in obese adultsArch Intern Med160200013211326
  52. 52B.J.RollsE.L.MorrisL.S.RoePortion size of food affects energy intake in normal-weight and overweight men and womenAm J Clin Nutr76200212071213
  53. 53K.JohanssonK.NeoviusS.M.DeSantisDiscontinuation due to adverse events in randomized trials of orlistat, sibutramine and rimonabant: A meta-analysisObes Rev102009564575
  54. 54I.J.DouglasJ.LanghamK.BhaskaranOrlistat and the risk of acute liver injury: Self controlled case series study in UK Clinical Practice Research DatalinkBMJ3462013f1936
  55. 55J.RosenstockH.W.RodbardS.C.BainOne-year sustained glycemic control and weight reduction in type 2 diabetes after addition of liraglutide to metformin followed by insulin detemir according to HbA1c targetJ Diabetes Complications272013492500
  56. 56K.NiswenderX.Pi-SunyerJ.BuseWeight change with liraglutide and comparator therapies: An analysis of seven phase 3 trials from the liraglutide diabetes development programmeDiabetes Obes Metab1520134254
  57. 57J.I.MechanickA.YoudimD.B.JonesClinical 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 SurgeryEndocr Pract192013337372
  58. 58F.AbbatiniM.RizzelloG.CasellaLong-term effects of laparoscopic sleeve gastrectomy, gastric bypass, and adjustable gastric banding on type 2 diabetesSurg Endosc24201010051010
  59. 59G.MingroneS.PanunziA.De GaetanoBariatric surgery versus conventional medical therapy for type 2 diabetesN Engl J Med366201215771585
  60. 60S.IkramuddinC.J.BillingtonW.J.LeeRoux-en-Y gastric bypass for diabetes (the Diabetes Surgery Study): 2-year outcomes of a 5-year, randomised, controlled trialLancet Diabetes Endocrinol32015413422
  61. 61P.R.SchauerD.L.BhattJ.P.KirwanBariatric surgery versus intensive medical therapy for diabetes - 5-year outcomesN Engl J Med3762017641651
  62. 62WangS.LiP.SunX.F.Comparison between laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding for morbid obesity: A meta-analysisObes Surg232013980986
  63. 63A.P.CourcoulasB.H.GoodpasterJ.K.EagletonSurgical vs medical treatments for type 2 diabetes mellitus: A randomized clinical trialJAMA Surg1492014707715
  64. 64N.PuzziferriT.B.Roshek3rdH.G.MayoLong-term follow-up after bariatric surgery: A systematic reviewJAMA3122014934942
  65. 65G.MingroneS.PanunziA.De GaetanoBariatric-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 trialLancet3862015964973
  66. 66Z.KhorgamiS.ShoarA.AndalibTrends in utilization of bariatric surgery, 2010–2014: Sleeve gastrectomy dominatesSurg Obes Relat Dis132017774778
  67. 67WangG.F.YanY.X.XuN.Predictive factors of type 2 diabetes mellitus remission following bariatric surgery: A meta-analysisObes Surg252015199208
  68. 68ChenY.ZengG.TanJ.Impact of roux-en Y gastric bypass surgery on prognostic factors of type 2 diabetes mellitus: Meta-analysis and systematic reviewDiabetes Metab Res Rev312015653662
  69. 69L.SjöströmM.PeltonenP.JacobsonAssociation of bariatric surgery with long-term remission of type 2 diabetes and with microvascular and macrovascular complicationsJAMA311201422972304
  70. 70S.JacksonC.W.le RouxN.G.DochertyBariatric surgery and microvascular complications of type 2 diabetes mellitusCurr Atheroscler Rep162014453
  71. 71D.CheungN.J.SwitzerD.EhmannThe impact of bariatric surgery on diabetic retinopathy: a systematic review and meta-analysisObes Surg25201516041609
  72. 72S.RomeoC.MaglioM.A.BurzaCardiovascular events after bariatric surgery in obese subjects with type 2 diabetesDiabetes Care35201226132617
  73. 73K.K.MahawarN.De AlwisW.R.CarrBariatric surgery in type 1 diabetes mellitus: A systematic reviewObes Surg262016196204
  74. 74J.P.KirwanA.AminianS.R.KashyapBariatric surgery in obese patients with type 1 diabetesDiabetes Care392016941948
  75. 75A.ChowN.J.SwitzerDangJ.A systematic review and meta-analysis of outcomes for type 1 diabetes after bariatric surgeryJ Obes201620166170719
  76. 76H.AshrafianL.HarlingT.TomaType 1 diabetes mellitus and bariatric surgery: A systematic review and meta-analysisObes Surg26201616971704
  77. 77Prospective Studies CollaborationG.WhitlockS.LewingtonBody-mass index and cause-specific mortality in 900 000 adults: Collaborative analyses of 57 prospective studiesLancet373200910831096
  78. 78S.B.ReederEmerging quantitative magnetic resonance imaging biomarkers of hepatic steatosisHepatology58201318771880
  79. 79Health CanadaCanadian guidelines for body weight classification in adultsOttawa2015https://www.canada.ca/en/health-canada/services/food-nutrition/healthy-eating/healthy-weights/canadian-guidelines-body-weight-classification-adults.htmlAccessed November 8, 2017
  80. 80A.ShuklaF.RubinoSecretion and function of gastrointestinal hormones after bariatric surgery: Their role in type 2 diabetesCan J Diabetes352011115122
  81. 81D.MoherA.LiberatiJ.TetzlaffPreferred reporting items for systematic reviews and meta-analyses: The PRISMA statementPLoS Med62009e1000097
 
Reproduced with permission from Canadian Journal of Diabetes © 2018 Canadian Diabetes Association. To cite this article, please refer to For citation.
 

*The Canadian Diabetes Association is the registered owner of the name Diabetes Canada. All content on guidelines.diabetes.ca, CPG Apps and in our online store remains exactly the same. For questions, contact communication@diabetes.ca.