LANCET publishes: "Treat sugar first, treat fat", a new management strategy for type 2 diabetes, which is more suitable for Asians

Edited and written by Yimaitong, please do not reprint without authorization
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Introduction: A few days ago, Yimaitong shared with the teachers the new concept of diabetes management, which is currently being heatedly discussed in the world of "treating sugar before obesity".
Double-digit weight loss (preferably ≥15%) "As the initial treatment target for a considerable part of type 2 diabetes, this view has been actively expressed by many experts from professional organizations such as ADA and EASD)
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This concept coincides with the core content of the "China Expert Consensus on Type 2 Diabetes Mitigation", which was just released at the end of September, led by Professor Zou Dajin, Professor Zhang Zheng, and Professor Ji Linong
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It can be seen that with the improvement of evidence-based medicine, "weight management plays an increasingly important role in the treatment of type 2 diabetes" has been unanimously recognized by experts at home and abroad
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In addition to the above viewpoints, the article puts forward the "primary and secondary treatment goals for type 2 diabetes" under the new framework, and believes that this management concept is particularly suitable for Asian populations.
More details will now be shared
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Focus on upstream-"Weight loss as the main treatment goal of type 2 diabetes" can achieve broader benefits.
The article points out that in the past ten years, the management of type 2 diabetes has undergone several major conceptual changes, except for the long-term In addition to the "hyperglycemic as the center" that has been insisted since, with the announcement of multiple milestone CVOT research results, the focus of diabetes management has gradually shifted to the reduction of cardiovascular complications.
(In CVOT research, new hypoglycemic drugs can further reduce myocardial The risk of infarction, stroke, and cardiovascular death is largely independent of the effects of blood sugar)
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But even so, the current treatment framework for type 2 diabetes is mainly focused on preventing or treating the downstream adverse metabolic consequences, and these adverse consequences often occur in the late stages of the disease course
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And adopting a weight-centered management approach, focusing on the upstream of diabetes will bring broader benefits (Figure 1)
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Figure 1 The upstream weight-centered management strategy can bring broader benefits.
1.
Weight loss can help achieve diabetes remission.
Four experts wrote a joint claim that for most patients with type 2 diabetes, it is recommended that weight loss be ≥15 % (Maintenance) is positioned as the initial main treatment goal
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Although different degrees of weight loss will bring different degrees of clinical benefits, a weight loss of ≥15% is more likely to achieve remission of type 2 diabetes than a small weight loss
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The benefits of weight loss improve the risk factors for cardiometabolic diseases and the quality of life, beyond the control of blood sugar
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2.
In different stages of disease development, weight loss can bring benefits.
Intervention in the pre-diabetes stage can reduce weight or bring relief or prevent further deterioration; intervention after the diagnosis of the disease may bring relief of diabetes or improvement of blood sugar management
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In short, weight loss in the entire development stage of type 2 diabetes can bring different degrees of benefits, and the benefits are not only blood sugar, but also improvement of metabolic comorbidities (Figure 2), prevention or even reversal of diabetes-related microvascular complications Symptoms (such as chronic kidney disease)
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Figure 2 The benefits of weight loss interventions cover the entire stage of type 2 diabetes (picture source: Metabolic Network) The new strategy of "treatment of sugar and obesity first" is especially suitable for Asian people.
Type 2 diabetes is mainly caused by "insulin resistance" or "β function" Obesity is driven by two major factors.
Insulin resistance and obesity share many common pathophysiological pathways.
These patients will benefit the most from weight loss; while the latter-type 2 diabetes patients driven mainly by β-cell dysfunction It is unlikely to be alleviated
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But despite this, weight loss will also reduce the body's demand for insulin, reduce β-cell lipotoxicity and glucose toxicity, thereby improving metabolism and blood sugar control
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In short, regardless of the main driver of type 2 diabetes, weight loss is beneficial
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And considering that the former proportion is higher in the Asian patient population, this strategy is particularly suitable for use in the Asian population
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However, weight loss methods need to be monitored to ensure that the benefits outweigh the risks (Table 1)
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Table 1 Common side effects of different weight loss strategies New goals under the new framework-primary and secondary treatment goals for type 2 diabetes Treatment goals"
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Table 2 Primary and secondary treatment goals of type 2 diabetes 1.
Patients with "β-cell dysfunction as the main driving factor" For patients with type 2 diabetes who are mainly driven by β-cell dysfunction, the initial treatment should focus on the reduction of blood glucose levels
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2.
Patients with "Combined Cardiovascular Disease" For type 2 diabetes patients with atherosclerotic cardiovascular disease, the main management goal is to reduce the risk of major adverse cardiovascular events.
This recommendation is related to the diagnosis and treatment guidelines of ADA and EASD.
Unanimous
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For this reason, priority should be given to the use of SGLT2i or GLP1RA with proven cardiovascular benefits; for patients with heart failure or chronic kidney disease with reduced ejection fraction, similar management methods should be adopted, and priority should be given to those with proven benefits SGLT2i
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3.
Patients with "insulin resistance as the main driving factor" Obesity-related type 2 diabetes patients have one or more characteristics of insulin resistance, and weight-centered treatment may bring more benefits
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Notable features are: central obesity, increased waist circumference, acanthosis nigricans, multiple skin diseases, hypertension, hypertriglyceridemia, non-alcoholic fatty liver, or laboratory evidence of hyperinsulinemia
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For this population, the proposed treatment goal is to reduce the overall weight by ≥15%.
The main purpose is to destroy the core pathophysiological mechanism that leads to the occurrence and development of type 2 diabetes, and strive to change the course of the disease to prevent related complications, not just to improve blood sugar
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Therefore, in this population, priority should be given to interventions that are most likely to promote sustained weight loss, followed by medications that can reduce/prevent the risk of cardiovascular complications (including other medications that promote blood sugar control)
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Among them, if additional drugs are needed to achieve blood glucose goals, priority should be given to drugs that have weight loss effects or have little effect on body weight
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Young people or newly diagnosed patients with type 2 diabetes are more likely to fall into this category.
The benefits of this weight-centered approach do not depend on the course of diabetes, so even patients with long courses can be considered
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It must be emphasized that the new "weight-centered strategy" is a supplement to the current strategy and does not conflict or replace other management strategies
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However, this approach/concept is very important to address the key driving factors in the pathogenesis of type 2 diabetes
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Although in most cases, double-digit weight loss can improve blood sugar, if the blood sugar goal is still not achieved, further blood sugar lowering strategies should be added to minimize the risk of microvascular, and proceed in sequence.
If it is accompanied by clinical urgency, Should be done at the same time
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This article summarizes in recent decades, 2 new diabetes management concepts have experienced "emphasis on disease control-the importance of strengthening hypoglycemic", "patient-centered individualized treatment", "comprehensive management of multiple risk factors", "emphasis In different stages, such as “cardiovascular outcome”, on the whole, it has developed from “simple blood sugar control” to “outcome-oriented” treatment strategies
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It is worth looking forward to whether the strategy of “focusing on weight loss and focusing on the upstream of diseases” will become a new concept of disease management
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