Diabetes 3 of 4

Prioritizing Obesity and Type 2 Diabetes Care

As the epidemic of type 2 diabetes has grown in parallel with unprecedented rates of obesity, physicians have long prioritized controlling blood glucose over helping a patient manage his weight. Type 2 diabetes care typically takes priority over obesity care in a primary care setting.

In some ways, this has been a perfectly rational choice for primary care providers. But a new study published in Diabetes Care suggests that the results of this tradeoff are costly. Gregory Nichols and colleagues examined medical records of 8,154 patients with type 2 diabetes. They looked at medical costs as a function of two variables: glycemic (blood sugar) control and weight gain.

The lowest costs were associated with patients who kept their weight relatively stable over the three years of the study – regardless of their glycemic control. Patients with both weight gain (>5%) and poor glycemic control (A1C>7%) had the highest costs. Nichols explained:

Simply put, weight gain is expensive. Even if you struggle with keeping your blood sugar under control, preventing weight gain is really important.

It’s not that blood sugar control isn’t important – it definitely is – but if your blood sugar is not terribly out of control, preventing weight gain may be a more important goal.

Because some drugs (like insulin) used to control blood sugar can cause weight gain, diabetologists sometimes seem conflicted about which goal should be primary: weight control or glycemic control. In type 1 diabetes, tight glycemic control clearly leads to better outcomes. The same cannot be said for type 2 diabetes, which is often a consequence of uncontrolled obesity.

But the medical options for controlling blood sugar are abundant. By comparison, weight management is more challenging for many doctors. They often simply instruct the patient to lose weight through diet and exercise.

In a New York Times op-ed this weekend, Sarah Hallberg and Osama Hamdy presented a narrow focus on dietary interventions. They argued for utilizing low carbohydrate diets more aggressively to manage type 2 diabetes. Unfortunately, they made their case by presenting those diets as an alternative to bariatric surgery. They characterized recommendations for surgery as “nonsensical” because low carbohydrate diets are underutilized.

It’s an apples-and-oranges argument.

They are likely correct about low carbohydrate diets having untapped potential in type 2 diabetes. However, controversy persists about the need for more robust evidence to support stronger dietary guidance. That controversy frustrates advocates like Hallberg and Hamdy. Regardless of their frustration, pitting two underused therapies against each other makes no sense whatsoever. What does make sense is to rely on the considerable evidence that favors better utilization of both of these therapies.

We need to use all the tools we have to bring obesity and type 2 diabetes under control.

Click here for the study by Nichols et al and here for the op-ed by Hallberg and Hamdy. Click here and here for more about low-carb diets in type 2 diabetes care.

Diabetes 3 of 4, photograph © Dennis Skley / flickr

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September 12, 2016

2 Responses to “Prioritizing Obesity and Type 2 Diabetes Care”

  1. September 12, 2016 at 2:08 pm, Allen Browne said:

    We need to use all the tools and find which one (or ones) works (or work) best for whom. It’s the patient that is important – not the tool.

    • September 12, 2016 at 3:03 pm, Ted said: