“Treating the Obese Diabetic” was a 2012
article published in Expert Reviews in
Clinical Pharmacology. It is a thorough, comprehensive and balanced review
of anti-diabetic pharmacological agents for the treatment of the obese Type 2
diabetic. It also, as so many articles in the mainstream medical literature do
these days, seems to me to make a big push to boost the business of the
bariatric surgery industry. They’ve got boat payments to make.
I can
spare you having to read the whole paper. The abstract is brief and to the
point. Here it is in its entirety:
“Type 2 diabetes and obesity are intimately
linked; reduction of bodyweight improves glycemic control, mortality and
morbidity. Treating obesity in the diabetic is hampered as some diabetic
treatments lead to weight gain. Bariatric surgery is currently the most
effective antiobesity treatment and causes long-term remission of diabetes in
many patients. However, surgery has a high cost and is associated with a
significant risk of complications, and in practical terms only limited numbers
can undergo this therapy. The choice of pharmacological agents suitable for
treatment of diabetes and obesity is currently limited. The glucagon-like
peptide-1 receptor agonists improve glycemia and induce a modest weight loss,
but there are doubts over their long-term safety. New drugs such as lorcaserin
and phentermine/topiramate are being approved for obesity and have modest,
salutary effects on glycemia, but again long-term safety is unclear. This
article will also examine some future avenues for development, including gut
hormone analogues that promise to combine powerful weight reduction with
beneficial effects on glucose metabolism.”
The only pharmacological agent that
gets a clean bill of health in this comprehensive review is Metformin. All the others come with
qualifiers like weight gain and doubts over their long-term safety.
“Metformin,
as per current American Diabetes Association (ADA) and European Association for
the Study of Diabetes recommendations, is the first-line medication used for
those with Type 2 diabetes and has an established safety record. It inhibits
hepatic gluconeogenesis, and to a lesser extent glycogenolysis, but also
increases insulin sensitivity. The UKPDS 34 study suggested improved
cardiovascular (CV) outcomes in those taking metformin, although recent
meta-analyses have failed to confirm this. Metformin not only offers useful
glycemic control but has also been shown in some trials to induce weight loss,
although two meta-analyses comparing metformin to placebo have shown its
overall long-term effect appears to be weight neutral. Metformin has been in
use clinically since the 1950s (in the USA since 1995), so it has a
well-understood long-term safety profile with the most common side effects
being transient gastrointestinal symptoms. Lactic acidosis is a rare side effect
but cases have been reported in the literature.”
The
Expert Commentary is succinct and pithy. The first paragraph tells the story.
The emphasis is mine.
“Faced with a newly diagnosed obese diabetic
patient in a real-world setting, it is important to ensure that the medications
prescribed are effective and safe, without inducing weight gain. Ideally, our
therapeutic strategy would utilize treatments with a long-term safety record
that can induce weight loss and have been shown to improve CV outcomes. The
only treatments that offer this level of evidence at present are bariatric
surgery and metformin.”
The
paper includes 204 references and has a very interesting forward-looking
“Five-year View” section near the end which is worth a look for the healthcare
professionals among my readers.
Sadly,
this article treats only what the medical professional can do to “treat the
obese diabetic:” write multiple scripts or, in eligible cases, recommend
surgery. It does not address counseling the patient to change their diet to
reduce the one thing that causes elevated glucose in the disregulated
metabolism: dietary carbohydrates.
If you
are a regular reader here, you know why persons with insulin resistance become
obese. You also know that excess carbohydrates in insulin resistant people cause elevated blood glucose. There
is no “fix” for this condition once you have developed it except to eat many
fewer carbs (and moderate amounts of protein). If you continue to eat a “balanced
diet,” even with progressively more anti-diabetic medications, you will lose
the battle. Your pancreas eventually will be unable to produce the
extra insulin to take blood glucose to your cells (that won’t take them up), and
you will eventually become an insulin-dependent Type 2 and develop the
“inevitable complications.”
So, you
can let your doctor “treat the obese diabetic” in the way described in this
“expert review”, with the risks they frankly explain (and the outcomes I have suggested),
or
you can change your diet and “treat” yourself. It’s up to you.
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