S128 Diabetes Care Volume 46, Supplement 1, January 2023

8. Obesity and Weight Nuha A. ElSayed, Grazia Aleppo,

Vanita R. Aroda, Raveendhara R. Bannuru,
Management for the Prevention Florence M. Brown, Dennis Bruemmer,
Billy S. Collins, Marisa E. Hilliard,
and Treatment of Type 2 Diana Isaacs, Eric L. Johnson, Scott Kahan,
Kamlesh Khunti, Jose Leon, Sarah K. Lyons,
Diabetes: Standards of Care in

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Mary Lou Perry, Priya Prahalad,
Richard E. Pratley, Jane Jeffrie Seley,
Diabetes—2023 Robert C. Stanton, and Robert A. Gabbay,
on behalf of the American Diabetes
Diabetes Care 2023;46(Suppl. 1):S128–S139 | https://doi.org/10.2337/dc23-S008 Association
8. OBESITY AND WEIGHT MANAGEMENT

The American Diabetes Association (ADA) “Standards of Care in Diabetes” in-

cludes the ADA’s current clinical practice recommendations and is intended to
provide the components of diabetes care, general treatment goals and guide-
lines, and tools to evaluate quality of care. Members of the ADA Professional
Practice Committee, a multidisciplinary expert committee, are responsible for up-
dating the Standards of Care annually, or more frequently as warranted. For a de-
tailed description of ADA standards, statements, and reports, as well as the
evidence-grading system for ADA’s clinical practice recommendations and a full
list of Professional Practice Committee members, please refer to Introduction
and Methodology. Readers who wish to comment on the Standards of Care are
invited to do so at professional.diabetes.org/SOC.

Obesity is a chronic and often progressive disease with numerous medical, physical,
and psychosocial complications, including a substantially increased risk for type 2
diabetes (1). There is strong and consistent evidence that obesity management can
delay the progression from prediabetes to type 2 diabetes (2–6) and is highly bene-
ficial in treating type 2 diabetes (7–18). In people with type 2 diabetes and over-
weight or obesity, modest weight loss improves glycemia and reduces the need for
glucose-lowering medications (7–9), and larger weight loss substantially reduces A1C
and fasting glucose and has been shown to promote sustained diabetes remission
through at least 2 years (11,19–23). Several modalities, including intensive behavioral
counseling, obesity pharmacotherapy, and bariatric surgery, may aid in achieving and Disclosure information for each author is
maintaining meaningful weight loss and reducing obesity-associated health risks. available at https://doi.org/10.2337/dc23-SDIS.
Metabolic surgery strongly improves glycemia and often leads to remission of diabe- Suggested citation: ElSayed NA, Aleppo G, Aroda
VR, et al., American Diabetes Association. 8.
tes, improved quality of life, improved cardiovascular outcomes, and reduced mortal- Obesity and weight management for the pre-
ity. The importance of addressing obesity is further heightened by numerous studies vention and treatment of type 2 diabetes:
showing that both obesity and diabetes increase the risk for more severe coronavirus Standards of Care in Diabetes—2023. Diabetes
disease 2019 (COVID-19) infections (24–27). This section aims to provide evidence- Care 2023;46(Suppl. 1):S128–S139
based recommendations for obesity management, including behavioral, pharmaco- © 2022 by the American Diabetes Association.
logic, and surgical interventions, in people with type 2 diabetes and in those at risk. Readers may use this article as long as the
work is properly cited, the use is educational
This section focuses on obesity management in adults; further discussion on obesity
and not for profit, and the work is not altered.
in older individuals and children can be found in Section 13, “Older Adults,” and Sec- More information is available at https://www.
tion 14, “Children and Adolescents,” respectively. diabetesjournals.org/journals/pages/license.
diabetesjournals.org/care Obesity and Weight Management for Type 2 Diabetes S129

ASSESSMENT Height and weight should be measured counseling, pharmacologic therapy, medical
to calculate BMI annually or more fre- devices, and metabolic surgery (Table 8.1).
Recommendations
quently when appropriate (20). BMI, calcu- The latter three strategies may be consid-
8.1 Use person-centered, nonjudg- ered for carefully selected individuals as
lated as weight in kilograms divided by the
mental language that fosters
square of height in meters (kg/m2), is calcu- adjuncts to nutrition changes, physical ac-
collaboration between individ- lated automatically by most electronic med- tivity, and behavioral counseling.
uals and health care professio- ical records. Use BMI to document weight Among people with type 2 diabetes
nals, including person-first lan- status (overweight: BMI 25–29.9 kg/m2; and overweight or obesity who have in-
guage (e.g., “person with obesity” obesity class I: BMI 30–34.9 kg/m2; obesity adequate glycemic, blood pressure, and
rather than “obese person”). E class II: BMI 35–39.9 kg/m2; obesity class lipid control and/or other obesity-related
8.2 Measure height and weight III: BMI $40 kg/m2) but note that misclassi- medical conditions, modest and sustained

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and calculate BMI at annual fication can occur, particularly in very mus- weight loss improves glycemia, blood
visits or more frequently. As- cular or frail individuals. In some groups, pressure, and lipids and may reduce the
sess weight trajectory to inform notably Asian and Asian American popu- need for medications (7–9,38). Greater
treatment considerations. E lations, the BMI cut points to define over- weight loss may produce even greater
8.3 Based on clinical considera- weight and obesity are lower than those benefits (21,22).
tions, such as the presence of in other populations due to differences in As little as 3–7% weight loss reduces
comorbid heart failure or signif- body composition and cardiometabolic the risk for diabetes in people at risk and
icant unexplained weight gain risk (Table 8.1) (30,31). Clinical considera- improves glycemia in those with diabetes
or loss, weight may need to be tions, such as the presence of comorbid (2,7,8,39,40). Given the challenge of losing
monitored and evaluated more heart failure or unexplained weight change, weight and maintaining weight loss, aim-
frequently. B If deterioration of may warrant more frequent weight mea- ing for relatively small and attainable
medical status is associated with surement and evaluation (32,33). If weigh- weight loss is often an effective clinical
significant weight gain or loss, ing is questioned or refused, the practitioner strategy, particularly for individuals who
inpatient evaluation should be should be mindful of possible prior stigma- feel overwhelmed by larger weight loss
considered, especially focused tizing experiences and query for concerns, targets. Nevertheless, mounting data from
on associations between medi- and the value of weight monitoring should intensive nutrition and behavioral change
cation use, food intake, and gly- be explained as a part of the medical eval- interventions, pharmacotherapy, and bar-
cemic status. E uation process that helps to inform treat- iatric surgery have shown that more sub-
8.4 Accommodations should be stantial weight loss usually confers still
ment decisions (34,35). Accommodations
greater benefits on glycemia and possi-
made to provide privacy dur- should be made to ensure privacy during
bly disease remission as well as other
ing weighing. E weighing, particularly for those individuals
cardiometabolic and quality-of-life out-
8.5 Individuals with diabetes and who report or exhibit a high level of
comes (6,21–23,41–50).
overweight or obesity may weight-related distress or dissatisfaction.
With the increasing availability of more
benefit from modest or larger Scales should be situated in a private area
effective obesity treatments, individuals
magnitudes of weight loss. or room. Weight should be measured and
with diabetes and overweight or obesity
Relatively small weight loss reported nonjudgmentally. Care should be
should be informed of the potential bene-
(approximately 3–7% of base- taken to regard a person’s weight (and
fits of both modest and more substantial
line weight) improves glycemia weight changes) and BMI as sensitive
weight loss and guided in the range of
and other intermediate cardio- health information. In addition to weight
available treatment options, as discussed
vascular risk factors. A Larger, and BMI, assessment of weight distribu- in the sections below. Shared decision-
sustained weight losses (>10%) tion (including propensity for central/ making should be used when counseling
usually confer greater benefits, visceral adipose deposition) and weight on behavioral changes, intervention choices,
including disease-modifying ef- gain pattern and trajectory can further and weight management goals.
fects and possible remission of inform risk stratification and treatment
type 2 diabetes, and may im- options (36).
NUTRITION, PHYSICAL ACTIVITY,
prove long-term cardiovascular Health care professionals should ad- AND BEHAVIORAL THERAPY
outcomes and mortality. B vise individuals with overweight or obe-
sity and those with increasing weight Recommendations
trajectories that, in general, higher BMIs 8.6 Nutrition, physical activity, and
A person-centered communication style increase the risk of diabetes, cardiovas- behavioral therapy to achieve
that uses inclusive and nonjudgmental lan- cular disease, and all-cause mortality, as and maintain $5% weight loss
guage and active listening to elicit individ- well as other adverse health and quality are recommended for most
ual preferences and beliefs and assesses of life outcomes. Health care professio-
people with type 2 diabetes
potential barriers to care should be used nals should assess readiness to engage
and overweight or obesity.
to optimize health outcomes and health- in behavioral changes for weight loss and
Additional weight loss usually
related quality of life. Use person-first lan- jointly determine behavioral and weight
results in further improve-
guage (e.g., “person with obesity” rather loss goals and individualized intervention
ments in the management of di-
than “obese person”) to avoid defining strategies (37). Strategies may include nutri-
abetes and cardiovascular risk. B
people by their condition (28–30). tion changes, physical activity, behavioral
S130 Obesity and Weight Management for Type 2 Diabetes Diabetes Care Volume 46, Supplement 1, January 2023

Table 8.1—Treatment options for overweight and obesity in type 2 diabetes

BMI category (kg/m2)
Treatment 25.0–26.9 (or 23.0–24.9*) 27.0–29.9 (or 25.0–27.4*) $30.0 (or $27.5*)
Nutrition, physical activity, and behavioral counseling † † †
Pharmacotherapy † †
Metabolic surgery †

*Recommended cut points for Asian American individuals (expert opinion). †Treatment may be indicated for select motivated individuals.

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8.7 Such interventions should in- practitioners in medical set- sexual function, and health-related quality
clude a high frequency of tings with close monitoring. of life (32). Moreover, several subgroups
counseling ($16 sessions in Long-term, comprehensive had improved cardiovascular outcomes,
6 months) and focus on nutri- weight maintenance strate- including those who achieved >10%
tion changes, physical activity, gies and counseling should weight loss (41) and those with moder-
and behavioral strategies to be integrated to maintain ately or poorly managed diabetes (A1C
achieve a 500–750 kcal/day weight loss. B >6.8%) at baseline (42).
energy deficit. A 8.13 There is no clear evidence that
8.8 An individual’s preferences, mo- nutrition supplements are ef- Behavioral Interventions
tivation, and life circumstances fective for weight loss. A Significant weight loss can be attained
should be considered, along with lifestyle programs that achieve
with medical status, when a 500–750 kcal/day energy deficit,
weight loss interventions are For a more detailed discussion of lifestyle which in most cases is approximately
recommended. C management approaches and recom- 1,200–1,500 kcal/day for women and
8.9 Behavioral changes that create mendations, see Section 5, “Facilitating 1,500–1,800 kcal/day for men, ad-
an energy deficit, regardless of Positive Health Behaviors and Well-being justed for the individual’s baseline
macronutrient composition, will to Improve Health Outcomes.” For a de- body weight. Clinical benefits typically be-
result in weight loss. Nutrition tailed discussion of nutrition interven- gin upon achieving 3–5% weight loss
(20,51), and the benefits of weight loss
recommendations should be tions, please also refer to “Nutrition
individualized to the person’s are progressive; more intensive weight
Therapy for Adults With Diabetes or Pre-
preferences and nutritional loss goals (>5%, >7%, >15%, etc.) may
diabetes: A Consensus Report” (127).
needs. A be pursued if needed to achieve further
8.10 Evaluate systemic, structural, health improvements and/or if the individ-
Look AHEAD Trial
and socioeconomic factors that ual is more motivated and more intensive
Although the Action for Health in Diabe-
may impact nutrition patterns goals can be feasibly and safely attained.
tes (Look AHEAD) trial did not show
and food choices, such as food Nutrition interventions may differ
that the intensive lifestyle intervention
insecurity and hunger, access by macronutrient goals and food choices
reduced cardiovascular events in adults
to healthful food options, cul- as long as they create the necessary en-
with type 2 diabetes and overweight or
tural circumstances, and social ergy deficit to promote weight loss
obesity (39), it did confirm the feasibil- (20,52–54). Using meal replacement plans
determinants of health. C ity of achieving and maintaining long-
8.11 For those who achieve weight prescribed by trained practitioners, with
term weight loss in people with type 2 close monitoring, can be beneficial.
loss goals, long-term ($1 year) diabetes. In the intensive lifestyle inter-
weight maintenance programs Within the intensive lifestyle interven-
vention group, mean weight loss was tion group of the Look AHEAD trial, for
are recommended when avail- 4.7% at 8 years (40). Approximately 50%
able. Such programs should, at example, the use of a partial meal re-
of intensive lifestyle intervention partici- placement plan was associated with
minimum, provide monthly pants lost and maintained $5% of their
contact and support, recom- improvements in nutrition quality and
initial body weight, and 27% lost and weight loss (51). The nutrition choice
mend ongoing monitoring of
maintained $10% of their initial body should be based on the individual’s
body weight (weekly or more
weight at 8 years (40). Participants as- health status and preferences, including
frequently) and other self-
signed to the intensive lifestyle group a determination of food availability and
monitoring strategies, and en-
required fewer glucose-, blood pressure–, other cultural circumstances that could
courage regular physical activity
and lipid-lowering medications than those affect nutrition patterns (55).
(200–300 min/week). A
randomly assigned to standard care. Sec- Intensive behavioral interventions should
8.12 Short-term nutrition intervention
using structured, very-low-calorie
ondary analyses of the Look AHEAD trial include $16 sessions during the initial
and other large cardiovascular outcome 6 months and focus on nutrition changes,
meals (800–1,000 kcal/day) may
studies document additional weight loss physical activity, and behavioral strategies
be prescribed for carefully se-
lected individuals by trained benefits in people with type 2 diabetes, to achieve an
500–750 kcal/day energy
including improved mobility, physical and deficit. Interventions should be provided
diabetesjournals.org/care Obesity and Weight Management for Type 2 Diabetes S131

by trained interventionists in either indi- little or no weight loss benefits. In contrast, discontinuation of the medi-
vidual or group sessions (51). Assessing vitamin/mineral (e.g., iron, vitamin B12, vi- cation and evaluate alterna-
an individual’s motivation level, life cir- tamin D) supplementation may be indicated tive medications or treatment
cumstances, and willingness to implement in cases of documented deficiency, and pro- approaches. A
behavioral changes to achieve weight loss tein supplements may be indicated as ad-
should be considered along with medical juncts to medically supervised weight loss
status when weight loss interventions are therapies. Glucose-Lowering Therapy
recommended and initiated (37,56). Health disparities adversely affect peo- A meta-analysis of 227 randomized con-
People with type 2 diabetes and over- ple who have systematically experienced trolled trials of glucose-lowering treat-
weight or obesity who have lost weight greater obstacles to health based on their ments in type 2 diabetes found that A1C
should be offered long-term ($1 year) race or ethnicity, socioeconomic status,

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changes were not associated with base-
comprehensive weight loss maintenance gender, disability, or other factors. Over- line BMI, indicating that people with obe-
programs that provide at least monthly whelming research shows that these dis-
sity can benefit from the same types of
contact with trained interventionists and parities may significantly affect health
treatments for diabetes as normal-weight
focus on ongoing monitoring of body outcomes, including increasing the risk for
individuals (66). As numerous effective
weight (weekly or more frequently) and/ obesity, diabetes, and diabetes-related
medications are available when consider-
or other self-monitoring strategies such complications. Health care professionals
ing medication plans, health care profes-
as tracking intake, steps, etc.; continued should evaluate systemic, structural, and
sionals should consider each medication’s
focus on nutrition and behavioral changes; socioeconomic factors that may impact
effect on weight. Agents associated
and participation in high levels of physical food choices, access to healthful foods,
with varying degrees of weight loss in-
activity (200–300 min/week) (57). Some and nutrition patterns; behavioral pat-
terns, such as neighborhood safety and clude metformin, a-glucosidase inhibi-
commercial and proprietary weight loss tors, sodium–glucose cotransporter 2
programs have shown promising weight availability of safe outdoor spaces for phys-
ical activity; environmental exposures; ac- inhibitors, glucagon-like peptide 1 re-
loss results. However, most lack evi-
cess to health care; social contexts; and, ceptor agonists, dual glucagon-like pep-
dence of effectiveness, many do not
ultimately, diabetes risk and outcomes. For tide 1/glucose–dependent insulinotropic
satisfy guideline recommendations, and
a detailed discussion of social determi- polypeptide receptor agonist (tirzepa-
some promote unscientific and possibly
nants of health, refer to “Social Determi- tide), and amylin mimetics. Dipeptidyl
dangerous practices (58,59).
nants of Health: A Scientific Review” (65). peptidase 4 inhibitors are weight neu-
When provided by trained practitioners
tral. In contrast, insulin secretagogues,
in medical settings with ongoing monitor-
PHARMACOTHERAPY thiazolidinediones, and insulin are often as-
ing, short-term (generally up to 3 months)
sociated with weight gain (see Section 9,
intensive nutrition intervention may be
Recommendations “Pharmacologic Approaches to Glycemic
prescribed for carefully selected individu-
8.14 When choosing glucose-lowering Treatment”).
als, such as those requiring weight loss be-
medications for people with
fore surgery and those needing greater
type 2 diabetes and overweight Concomitant Medications
weight loss and glycemic improvements.
or obesity, consider the medica- Health care professionals should carefully
When integrated with behavioral support
tion’s effect on weight. B review the patient’s concomitant medica-
and counseling, structured very-low-calo-
8.15 Whenever possible, minimize tions and, whenever possible, minimize or
rie meals, typically 800–1,000 kcal/day,
medications for comorbid con-
utilizing high-protein foods and meal re- provide alternatives for medications that
ditions that are associated with
placement products, may increase the promote weight gain. Examples of medica-
weight gain. E
pace and/or magnitude of initial weight tions associated with weight gain include
8.16 Obesity pharmacotherapy is
loss and glycemic improvements compared antipsychotics (e.g., clozapine, olanzapine,
effective as an adjunct to nu-
with standard behavioral interventions risperidone), some antidepressants (e.g.,
trition, physical activity, and be-
(21,22). As weight regain is common, such tricyclic antidepressants, some selective
havioral counseling for selected
interventions should include long-term,
people with type 2 diabetes serotonin reuptake inhibitors, and mono-
comprehensive weight maintenance strate-
and BMI $27 kg/m2. Potential amine oxidase inhibitors), glucocorticoids,
gies and counseling to maintain weight loss
benefits and risks must be con- injectable progestins, some anticonvul-
and behavioral changes (60,61).
sidered. A sants (e.g., gabapentin, pregabalin), and
Despite widespread marketing and ex-
8.17 If obesity pharmacotherapy possibly sedating antihistamines and anti-
orbitant claims, there is no clear evidence
is effective (typically defined
that nutrition supplements (such as herbs cholinergics (67).
as $5% weight loss after
and botanicals, high-dose vitamins and
3 months’ use), further weight
minerals, amino acids, enzymes, antioxidants, Approved Obesity Pharmacotherapy
loss is likely with continued
etc.) are effective for obesity manage- Options
use. When early response is in-
ment or weight loss (62–64). Several large The U.S. Food and Drug Administration
sufficient (typically <5% weight
systematic reviews show that most trials (FDA) has approved medications for both
loss after 3 months’ use) or
evaluating nutrition supplements for weight short-term and long-term weight manage-
if there are significant safety
loss are of low quality and at high risk for ment as adjuncts to nutrition, physical ac-
or tolerability issues, consider
bias. High-quality published studies show tivity and behavioral therapy. Nearly all
S132 Obesity and Weight Management for Type 2 Diabetes Diabetes Care Volume 46, Supplement 1, January 2023

FDA-approved obesity medications have continue the medication. When early use with BMI 30.0–34.9 kg/m2
been shown to improve glycemia in peo- appears ineffective (typically <5% weight (27.5–32.4 kg/m 2 in Asian
ple with type 2 diabetes and delay pro- loss after 3 months’ use), it is unlikely that American individuals) who do
gression to type 2 diabetes in at-risk continued use will improve weight out- not achieve durable weight loss
individuals (23). Phentermine and other comes; as such, it should be recom-
and improvement in comorbid-
older adrenergic agents are indicated for mended to discontinue the medication
ities (including hyperglycemia)
short-term (#12 weeks) treatment (68). and consider other treatment options.
with nonsurgical methods. A
Five medications are FDA approved for
8.20 Metabolic surgery should
long-term use (>12 weeks) in adults with MEDICAL DEVICES FOR WEIGHT LOSS
BMI $27 kg/m2 with one or more obe- be performed in high-volume
While gastric banding devices have fallen centers with multidisciplinary
sity-associated comorbid conditions (e.g.,

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out of favor in recent years, since 2015, teams knowledgeable about
type 2 diabetes, hypertension, and/or
several minimally invasive medical devices and experienced in managing
dyslipidemia) who are motivated to lose
have been approved by the FDA for short-
weight (23). (Refer to Section 14, “Children obesity, diabetes, and gastro-
term weight loss, including implanted gas- intestinal surgery. E
and Adolescents,” for medications ap-
tric balloons, a vagus nerve stimulator, and 8.21 People being considered for
proved for adolescents with obesity.) Med-
gastric aspiration therapy (72). Given the metabolic surgery should be
ications approved by the FDA for the
treatment of obesity, summarized in Table current high cost, limited insurance cover- evaluated for comorbid psycho-
8.2, include orlistat, phentermine/topira- age, and paucity of data in people with
logical conditions and social
mate ER, naltrexone/bupropion ER, liraglu- diabetes, medical devices for weight loss
and situational circumstances
tide 3 mg, and semaglutide 2.4 mg. (In are rarely utilized at this time, and it re-
that have the potential to inter-
addition, setmelanotide, a melanocortin 4 mains to be seen how they may be used
fere with surgery outcomes. B
receptor agonist, is approved for use in in the future (73).
8.22 People who undergo meta-
cases of rare genetic mutations resulting in An oral hydrogel (Plenity) has re-
bolic surgery should receive
severe hyperphagia and extreme obesity, cently been approved for long-term use
long-term medical and behav-
such as leptin receptor deficiency and in those with BMI >25 kg/m2 to simu-
late the space-occupying effect of im- ioral support and routine mi-
proopiomelanocortin deficiency.) In princi-
plantable gastric balloons. Taken with cronutrient, nutritional, and
ple, medications help improve adherence
water 30 min before meals, the hydro- metabolic status monitoring. B
to nutrition recommendations, in most
gel expands to fill a portion of the stom- 8.23 If postbariatric hypoglycemia is
cases by modulating appetite or satiety.
Health care professionals should be knowl- ach volume to help decrease food intake suspected, clinical evaluation
edgeable about the product label and bal- during meals. Though average weight loss should exclude other potential
ance the potential benefits of successful is relatively small (2–3% greater than pla- disorders contributing to hypo-
weight loss against the potential risks of cebo), the subgroup of participants with glycemia, and management
the medication for each individual. These prediabetes or diabetes at baseline had includes education, medical
medications are contraindicated in individ- improved weight loss outcomes (8.1% nutrition therapy with a dieti-
uals who are pregnant or actively trying to weight loss) compared with the overall tian experienced in postbariatric
conceive and not recommended for use treatment (6.4% weight loss) and placebo hypoglycemia, and medication
in women who are nursing. Individuals of (4.4% weight loss) groups (74). treatment, as needed. A Contin-
reproductive potential should receive uous glucose monitoring should
counseling regarding the use of reliable METABOLIC SURGERY be considered as an important
methods of contraception. Of note, while adjunct to improve safety by
weight loss medications are often used in Recommendations alerting individuals to hypoglyce-
people with type 1 diabetes, clinical trial 8.18 Metabolic surgery should be a mia, especially for those with
data in this population are limited. recommended option to treat severe hypoglycemia or hypo-
type 2 diabetes in screened glycemia unawareness. E
Assessing Efficacy and Safety surgical candidates with BMI 8.24 People who undergo meta-
Upon initiating weight loss medication, as- $40 kg/m2 (BMI $37.5 kg/m2 bolic surgery should routinely
sess efficacy and safety at least monthly in Asian American individuals) be evaluated to assess the
for the first 3 months and at least quar- and in adults with BMI 35.0– need for ongoing mental health
terly thereafter. Modeling from published 39.9 kg/m2 (32.5–37.4 kg/m2 in services to help with the adjust-
clinical trials consistently shows that early Asian American individuals) who ment to medical and psychoso-
responders have improved long-term out- do not achieve durable weight cial changes after surgery. C
comes (69–71). Unless clinical circumstan- loss and improvement in co-
ces (such as poor tolerability) or other
morbidities (including hyper-
considerations (such as financial expense Surgical procedures for obesity treat-
glycemia) with nonsurgical
or individual preference) suggest other- ment—often referred to interchangeably
methods. A
wise, those who achieve sufficient early as bariatric surgery, weight loss surgery,
8.19 Metabolic surgery may be
weight loss upon starting a chronic weight metabolic surgery, or metabolic/bariatric
considered as an option to
loss medication (typically defined as >5% surgery—can promote significant and du-
treat type 2 diabetes in adults
weight loss after 3 months’ use) should rable weight loss and improve type 2
Table 8.2—Medications approved by the FDA for the treatment of overweight or obesity in adults
1-Year (52- or 56-week)
mean weight loss (% loss from baseline)
National Average
Typical adult Average wholesale Drug Acquisition Weight loss
maintenance price (30-day Cost (30-day (% loss from Common side effects Possible safety concerns/
Medication name dose supply) (128) supply) (129) Treatment arms baseline) (130–134) considerations (130–134)
diabetesjournals.org/care

Short-term treatment (£12 weeks)

Sympathomimetic amine anorectic
Phentermine (135) 8–37.5 mg q.d.* $5–$56 (37.5 mg $2–$3 (37.5 mg 15 mg q.d.† 6.1 Dry mouth, insomnia,  Contraindicated for use in
dose) dose) 7.5 mg q.d.† 5.5 dizziness, irritability, combination with monoamine
PBO 1.2 increased blood pressure, oxidase inhibitors
elevated heart rate
Long-term treatment (>12 weeks)
Lipase inhibitor
Orlistat (4) 60 mg t.i.d. (OTC) $41$82 NA 120 mg t.i.d.‡ 9.6 Abdominal pain, flatulence,  Potential malabsorption of fat-
120 mg t.i.d. (Rx) $781$904 $722 PBO 5.6 fecal urgency soluble vitamins (A, D, E, K) and
of certain medications (e.g.,
cyclosporine, thyroid hormone,
anticonvulsants, etc.)
 Rare cases of severe liver injury
reported
 Cholelithiasis
 Nephrolithiasis
Sympathomimetic amine anorectic/antiepileptic combination
Phentermine/ 7.5 mg/46 mg q.d.§ $223 (7.5 mg/46 mg $179 (7.5 mg/46 mg 15 mg/92 mg q.d.k 9.8 Constipation, paresthesia,  Contraindicated for use in
topiramate ER (45) dose) dose) 7.5 mg/46 mg q.d.k 7.8 insomnia, nasopharyngitis, combination with monoamine
PBO 1.2 xerostomia, increased oxidase inhibitors
blood pressure  Birth defects
 Cognitive impairment
Opioid antagonist/antidepressant combination  Acute angle-closure glaucoma
Naltrexone/ 16 mg/180 mg b.i.d. $750 $599 16 mg/180 mg b.i.d. 5.0 Constipation, nausea,  Contraindicated in people with
bupropion ER (16) PBO 1.8 headache, xerostomia, unmanaged hypertension and/or
insomnia, elevated heart seizure disorders
rate and blood pressure  Contraindicated for use with
chronic opioid therapy
 Acute angle-closure glaucoma
Black box warning:
 Risk of suicidal behavior/ideation
in people younger than 24 years
old who have depression
Continued on p. S134
Obesity and Weight Management for Type 2 Diabetes
S133

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 S134

Table 8.2—Continued
1-Year (52- or 56-week)
mean weight loss (% loss from baseline)
National Average
Typical adult Average wholesale Drug Acquisition Weight loss
maintenance price (30-day Cost (30-day (% loss from Common side effects Possible safety concerns/
Medication name dose supply) (128) supply) (129) Treatment arms baseline) (130–134) considerations (130–134)
Glucagon-like peptide 1 receptor agonist
Liraglutide (17)** 3 mg q.d. $1,619 $1,295 3.0 mg q.d. 6.0 Gastrointestinal side effects  Pancreatitis has been reported in
1.8 mg q.d. 4.7 (nausea, vomiting, diarrhea, clinical trials, but causality has not
PBO 2.0 esophageal reflux), injection been established. Discontinue if
site reactions, elevated heart pancreatitis is suspected.
rate, hypoglycemia  Use caution in people with kidney
Obesity and Weight Management for Type 2 Diabetes

disease when initiating or increasing

dose due to potential risk of acute
kidney injury.
 May cause cholelithiasis and gallstone-
related complications.
Black box warning:
 Risk of thyroid C-cell tumors in
rodents; human relevance not
determined
Semaglutide (46,47) 2.4 mg once weekly $1,619 $1,295 2.4 mg weekly 9.6 Gastrointestinal side effects  Pancreatitis has been reported in
PBO 3.4 (nausea, vomiting, diarrhea, clinical trials, but causality has
esophageal reflux), injection not been established. Discontinue
site reactions, elevated heart if pancreatitis is suspected.
rate, hypoglycemia  May cause cholelithiasis and gallstone-
related complications.
Black box warning:
 Risk of thyroid C-cell tumors in
rodents; human relevance not
determined
All medications are contraindicated in individuals who are or may become pregnant. Individuals of reproductive potential must be counseled regarding the use of reliable methods of contraception. Se-
lect safety and side effect information is provided; for a comprehensive discussion of safety considerations, please refer to the prescribing information for each agent. b.i.d., twice daily; ER, extended
release; OTC, over the counter; NA, data not available; PBO, placebo; q.d., daily; Rx, prescription; t.i.d., three times daily. *Use lowest effective dose; maximum appropriate dose is 37.5 mg. †Duration
of treatment was 28 weeks in a general adult population with obesity. ‡Enrolled participants had normal (79%) or impaired (21%) glucose tolerance. §Maximum dose, depending on response, is 15
mg/92 mg q.d. jjApproximately 68% of enrolled participants had type 2 diabetes or impaired glucose tolerance. **Agent has demonstrated cardiovascular safety in a dedicated cardiovascular outcome
trial (47).
Diabetes Care Volume 46, Supplement 1, January 2023

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diabetesjournals.org/care Obesity and Weight Management for Type 2 Diabetes S135

diabetes. Given the magnitude and rapid-

ity of improvement of hyperglycemia and
glucose homeostasis, these procedures
have been suggested as treatments for
type 2 diabetes even in the absence of
severe obesity and will be referred to
here as “metabolic surgery.”
A substantial body of evidence, includ-
ing data from numerous large cohort
studies and randomized controlled (non-
blinded) clinical trials, demonstrates that

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metabolic surgery achieves superior gly-
cemic control and reduction of cardio-
vascular risk in people with type 2
diabetes and obesity compared with Figure 8.1—A: Vertical sleeve gastrectomy. B: Roux-en-Y gastric bypass surgery. Images
nonsurgical intervention (18). In addition reprinted from National Institute of Diabetes and Digestive and Kidney Diseases (92).
to improving glycemia, metabolic surgery
reduces the incidence of microvascular diabetes remission over time (44); at approaches, enhanced training and
disease (75), improves quality of life least 35–50% of patients who initially credentialing, and involvement of multi-
(43,76,77), decreases cancer risk, and achieve remission of diabetes eventually disciplinary teams. Perioperative mortal-
improves cardiovascular disease risk fac- experience recurrence. Still, the median ity rates are typically 0.1–0.5%, similar to
tors and long-term cardiovascular events disease-free period among such individ- those of common abdominal procedures
(78–89). Cohort studies that match surgi- uals following RYGB is 8.3 years (94,95), such as cholecystectomy or hysterec-
cal and nonsurgical subjects strongly sug- and the majority of those who undergo tomy (104–108). Major complications
gest that metabolic surgery reduces surgery maintain substantial improve- occur in 2–6% of those undergoing met-
all-cause mortality (90,91). ment of glycemia from baseline for at abolic surgery, which compares favor-
The overwhelming majority of proce-
least 5–15 years (43,76,79,80,95–98). ably with the rates for other commonly
dures in the U.S. are vertical sleeve gas-
Exceedingly few presurgical predictors performed elective operations (108).
trectomy (VSG) and Roux-en-Y gastric
of success have been identified, but Postsurgical recovery times and morbid-
bypass (RYGB). Both procedures result in
younger age, shorter duration of diabetes ity have also dramatically declined. Minor
an anatomically smaller stomach pouch
(e.g., <8 years) (70), and lesser severity complications and need for operative rein-
and often robust changes in enteroendo-
of diabetes (better glycemic control, non- tervention occur in up to 15% (104–113).
crine hormones. In VSG,
80% of the
use of insulin) are associated with higher Empirical data suggest that the proficiency
stomach is removed, leaving behind a
rates of diabetes remission (43,79,97,99). of the operating surgeon and surgical
long, thin sleeve-shaped pouch. RYGB
Greater baseline visceral fat area may team is an important factor in determin-
creates a much smaller stomach pouch
also predict improved postoperative out- ing mortality, complications, reoperations,
(roughly the size of a walnut), which is
then attached to the distal small intes- comes, especially among Asian American and readmissions (114). Accordingly, met-
tine, thereby bypassing the duodenum people with type 2 diabetes (100). abolic surgery should be performed in
and jejunum (Fig. 8.1). Although surgery has been shown to high-volume centers with multidisciplinary
Several organizations recommend low- improve the metabolic profiles of people teams experienced in managing diabetes,
ering the BMI criteria for metabolic surgery with type 1 diabetes, larger and longer- obesity, and gastrointestinal surgery.
to 30 kg/m2 (27.5 kg/m2 for Asian Ameri- term studies are needed to determine Beyond the perioperative period,
can individuals) for people with type 2 dia- the role of metabolic surgery in such in- longer-term risks include vitamin and
betes who have not achieved sufficient dividuals (101). mineral deficiencies, anemia, osteopo-
weight loss and improved comorbidities Whereas metabolic surgery has greater rosis, dumping syndrome, and severe
(including hyperglycemia) with reasonable initial costs than nonsurgical obesity hypoglycemia (115). Nutritional and
nonsurgical treatments. Studies have docu- treatments, retrospective analyses and micronutrient deficiencies and related
mented diabetes remission after 1–5 years modeling studies suggest that surgery complications occur with a variable fre-
in 30–63% of patients with RYGB (18,93). may be cost-effective or even cost- quency depending on the type of proce-
Most notably, the Surgical Treatment saving for individuals with type 2 diabe- dure and require routine monitoring of
and Medications Potentially Eradicate tes. However, these results largely depend micronutrient and nutritional status and
Diabetes Efficiently (STAMPEDE) trial, on assumptions about the long-term ef- lifelong vitamin/nutritional supplemen-
which randomized 150 participants with fectiveness and safety of the procedures tation (115). Dumping syndrome usually
unmanaged diabetes to receive either (102,103). occurs shortly (10–30 min) after a meal
metabolic surgery or medical treatment, and may present with diarrhea, nausea,
found that 29% of those treated with Potential Risks and Complications vomiting, palpitations, and fatigue; hy-
RYGB and 23% treated with VSG achieved The safety of metabolic surgery has im- poglycemia is usually not present at the
A1C of 6.0% or lower after 5 years (43). proved significantly with continued refine- time of symptoms but, in some cases,
Available data suggest an erosion of ment of minimally invasive (laparoscopic) may develop several hours later.
S136 Obesity and Weight Management for Type 2 Diabetes Diabetes Care Volume 46, Supplement 1, January 2023

Postbariatric hypoglycemia (PBH) can mental health conditions until these condi- phentermine and topiramate extended release.
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