Beyond Dropping a Few Pounds: What matters more in cardiovascular health
18 Apr 2023
byJoanne G. Blanco, MD
Diabetes is a concerning public health issue that affects millions of people worldwide. The
current prevalence rates for type 2 diabetes are still rising1 and is compounded by an increase in
obesity as well.2
Obesity contributes directly to diabetes and leads to the development of cardiovascular disease and mortality regardless of risk factors. Recently, there has been a highlight on abdominal obesity, measured by waist circumference, as a cardiovascular disease risk marker independent of body mass index. Studies that quantify fat depots also support excess visceral adiposity as an independent indicator of poor cardiovascular outcomes.2
In response, the ADA/EASC 2022 Consensus Report for the management of diabetes put greater emphasis on weight management as a targeted therapy, together with medications for glycemic control, cardiorenal protection, and cardiovascular risk factor management in the holistic person-centered approach to type 2 diabetes management.3
Management of type 2 diabetes is a multi-faceted process, relying on four pillars to achieve the best outcome: medications, risk factor management, organ protection, and weight management. It is imperative to note that risk-factor management is integral to the holistic approach to diabetes care. Risk factors that can be modified in patients with type 2 diabetes are blood pressure, lipid management, smoking cessation, poor diet, obesity/overweight, and physical inactivity.3
The recent recognition of obesity as an equally important therapeutic target has ushered in the rise of pharmacologic agents that provide glycemic control while also promoting weight loss. Among such agents are the relatively new glucagon-like peptide receptor agonists (GLP1-RAs) which have been demonstrated to possess very high potential for weight loss.3 Other medications for glycemic management that also afford weight loss include metformin with potential for modest loss and SGLT2-inhibitors that is associated with intermediate weight loss.
Glucagon-like-peptide-1 (GLP-1) is a gut hormone that contributes to glucose homeostasis and promotes satiety.4 GLP-1 receptor agonism with GLP-1 RA and emerging combined anti-obesity medications provide a benchmark for future pharmacological anti-obesity treatments.
However, the potential for marked weight loss associated with GLP-1 RAs have raised concern over its off-label prescription in non-diabetic patients solely for the purpose of weight loss. This scenario is particularly concerning as it could hinder access to medications by diverting the supply of medications away from patients with diabetes, thus possibly blunting its impact in revolutionizing the landscape of diabetes management and cardiovascular outcomes.
Furthermore, although obesity and overweight has been recognized as a therapeutic target in diabetes management, it should be noted that weight loss in itself is more of a parameter rather than an end-goal. In fact, a recent scientific statement from the American Heart Association (AHA) discussed how short-term weight loss may not be sufficient to fully overcome the deleterious effects of long-term obesity on the vasculature.6 Rather, it is physical activity, particularly aerobic exercise, that is associated with improved insulin sensitivity, endothelial function, and reduction in pro-inflammatory markers, and that these benefits have been observed to be independent of weight loss.7
Therefore, it imperative to note that while there may be initial visible benefits from losing pounds due to these drugs, physicians on the forefront of diabetes management should remain mindful about prioritizing their long-term objective: providing holistic quality care when treating individuals with diabetes. Clinicians should also keep in mind their role in stewarding better patient access thru responsible prescriptions to ensure that these medications reach patients who will truly benefit from them.
While it is true that losing some excess pounds helps managing type 2 diabetes better – clinicians should always consider what matters more: beyond just dropping a few pounds; creating an environment centered on physical activity can reap much higher long term for patients with diabetes.
Obesity contributes directly to diabetes and leads to the development of cardiovascular disease and mortality regardless of risk factors. Recently, there has been a highlight on abdominal obesity, measured by waist circumference, as a cardiovascular disease risk marker independent of body mass index. Studies that quantify fat depots also support excess visceral adiposity as an independent indicator of poor cardiovascular outcomes.2
In response, the ADA/EASC 2022 Consensus Report for the management of diabetes put greater emphasis on weight management as a targeted therapy, together with medications for glycemic control, cardiorenal protection, and cardiovascular risk factor management in the holistic person-centered approach to type 2 diabetes management.3
Management of type 2 diabetes is a multi-faceted process, relying on four pillars to achieve the best outcome: medications, risk factor management, organ protection, and weight management. It is imperative to note that risk-factor management is integral to the holistic approach to diabetes care. Risk factors that can be modified in patients with type 2 diabetes are blood pressure, lipid management, smoking cessation, poor diet, obesity/overweight, and physical inactivity.3
The recent recognition of obesity as an equally important therapeutic target has ushered in the rise of pharmacologic agents that provide glycemic control while also promoting weight loss. Among such agents are the relatively new glucagon-like peptide receptor agonists (GLP1-RAs) which have been demonstrated to possess very high potential for weight loss.3 Other medications for glycemic management that also afford weight loss include metformin with potential for modest loss and SGLT2-inhibitors that is associated with intermediate weight loss.
Glucagon-like-peptide-1 (GLP-1) is a gut hormone that contributes to glucose homeostasis and promotes satiety.4 GLP-1 receptor agonism with GLP-1 RA and emerging combined anti-obesity medications provide a benchmark for future pharmacological anti-obesity treatments.
However, the potential for marked weight loss associated with GLP-1 RAs have raised concern over its off-label prescription in non-diabetic patients solely for the purpose of weight loss. This scenario is particularly concerning as it could hinder access to medications by diverting the supply of medications away from patients with diabetes, thus possibly blunting its impact in revolutionizing the landscape of diabetes management and cardiovascular outcomes.
Furthermore, although obesity and overweight has been recognized as a therapeutic target in diabetes management, it should be noted that weight loss in itself is more of a parameter rather than an end-goal. In fact, a recent scientific statement from the American Heart Association (AHA) discussed how short-term weight loss may not be sufficient to fully overcome the deleterious effects of long-term obesity on the vasculature.6 Rather, it is physical activity, particularly aerobic exercise, that is associated with improved insulin sensitivity, endothelial function, and reduction in pro-inflammatory markers, and that these benefits have been observed to be independent of weight loss.7
Therefore, it imperative to note that while there may be initial visible benefits from losing pounds due to these drugs, physicians on the forefront of diabetes management should remain mindful about prioritizing their long-term objective: providing holistic quality care when treating individuals with diabetes. Clinicians should also keep in mind their role in stewarding better patient access thru responsible prescriptions to ensure that these medications reach patients who will truly benefit from them.
While it is true that losing some excess pounds helps managing type 2 diabetes better – clinicians should always consider what matters more: beyond just dropping a few pounds; creating an environment centered on physical activity can reap much higher long term for patients with diabetes.