Obesity management as a primary treatment goal for type 2 diabetes: time to reframe the conversation.

Obesity is now recognised as a disease that is associated with serious morbidity and increased mortality. One of its main metabolic complications is type 2 diabetes, as the two conditions share key pathophysiological mechanisms. Weight loss is known to reverse the underlying metabolic abnormalities of type 2 diabetes and, as such, improve glucose control; loss of 15% or more of bodyweight can have a disease-modifying effect in people with type 2 diabetes, an outcome that is not attainable by any other glucose-lowering intervention. Furthermore, weight loss in this population exerts benefits that extend beyond glycaemic control to improve risk factors for cardiometabolic disease and quality of life. We review the evidence supporting the role of weight loss in the management of type 2 diabetes and propose that many patients with type 2 diabetes would benefit from having a primary weight-centric approach to diabetes treatment. We discuss the logistical challenges to implementing a new weight-centric primary treatment goal in people with type 2 diabetes.

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Declaration of interests IL received research grants (paid to the institution) from Novo Nordisk, Sanofi, Boehringer Ingelheim, Merck, Pfizer, Mylan, and the National Institutes of Health; participated in scientific advisory roles or engaged in consulting for Novo Nordisk, Eli Lilly, Sanofi, AstraZeneca, Boehringer Ingelheim, Janssen, Intercept, Intarcia, TARGETPharma, Mannkind, Valeritas, Merck, Bayer, and Zealand Pharma; received non-financial support from Novo Nordisk, Eli Lilly, Sanofi, AstraZeneca, Boehringer Ingelheim, Janssen, TARGETPharma, Merck, and Pfizer. PS received a research grant (paid to the institution) from the National Health and Medical Research Council; received honoraria for lectures; and participated in scientific advisory boards for Novo Nordisk and is an Australian and New Zealand Obesity Society council member (unpaid role). RVC received research grants from Johnson & Johnson Medical Devices Brazil; received honoraria for lectures from Johnson & Johnson Brazil, Medtronic, Janssen Pharmaceutical; and participated in scientific advisory boards for Johnson & Johnson Brazil, Medtronic, GI Dynamics, Novo Nordisk, Abbott, Baritek, and Keyron. CWlR reports grants from the Irish Research Council, Science Foundation Ireland, Anabio, and the Health Research Board. He serves on advisory boards of Novo Nordisk, Herbalife, GI Dynamics, Eli Lilly, Johnson & Johnson, Sanofi Aventis, AstraZeneca, Janssen, Bristol-Myers Squibb, Glia, and Boehringer Ingelheim. CWlR is a member of the Irish Society for Nutrition and Metabolism outside the area of work commented on here. He is the chief medical officer and director of the Medical Device Division of Keyron since January, 2011. Both of these are unremunerated positions. CWlR was a previous investor in Keyron, which develops endoscopically implantable medical devices intended to mimic the surgical procedures of sleeve gastrectomy and gastric bypass. The product has only been tested in rodents and none of Keyron's products are currently licensed. They do not have any contracts with other companies to put their products into clinical practice. No patients have been included in any of Keyron's studies and they are not listed on the stock market. CWlR was gifted stock holdings in September, 2021 and divested all stock holdings in Keyron in September, 2021. He continues to provide scientific advice to Keyron for no remuneration.