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

Lingvay, I., Sumithran, P., Cohen, R. V., & le Roux, C. W. | 2021 | Obesity management as a primary treatment goal for type 2 diabetes: time to reframe the conversation| The Lancet | https://doi.org/10.1016/S0140-6736(21)01919-X

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 per cent 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.

Interested in the full article? Rotherham NHS staff can request this article from their Library & Knowledge Service  

CCD Rounds: Sharing knowledge and scaling up action to bend the curve on diabetes- latest one 18 June

Cities Changing Diabetes | June 2021 | Sharing knowledge and scaling up action to bend the curve on diabetes

Cities Changing Diabetes is a partnership created to address the social and cultural factors that increase type 2 diabetes vulnerability in urban environments. The partnership is pleased to bring CCD Rounds: a new webinar series for global sharing of best practice and hands-on insight to bend the curve on diabetes. CCD Rounds webinars are an opportunity to learn about diabetes and obesity prevention through real-world examples of health promotion, activities around childhood obesity and best practice policy initiatives.

Tackling the causes of type 2 diabetes & overcoming health inequities with Healthy Goals

Tune in tomorrow (Friday 18 June) from 15:00 –16:00 pm and discover how a sport-and-lifestyle education programme sparked a healthy living movement in a vulnerable community in Leicester, UK. Leicester is home to one of the largest populations of people with diabetes in the country, with around 9 per cent of residents diagnosed with the condition – well above the national average.

Join us to engage with Dr Sophie O’Connell, from the Centre for BME Health, together with Alisson Tripney, from Leicester City in the Community, and learn how Healthy Goals is helping people sustainably improve their wellbeing. The programme has built enthusiastic support among the city’s South Asian society and has leveraged the city’s pride in its home football team to reach an underserved group with practical, fun and educational sessions over a twelve-week programme (Source: Cities Changing Diabetes)

You can read more about the case from Cities Changing Diabetes

Associations between body-mass index and COVID-19 severity in 6·9 million people in England: a prospective, community-based, cohort study

Gao, M. et al | 2021| Associations between body-mass index and COVID-19 severity in 6·9 million people in England: a prospective, community-based, cohort study | The Lancet Diabetes & Endocrinology | DOI: https://doi.org/10.1016/S2213-8587(21)00089-9

The authors of this paper, report the results of a large, representative community-based cohort study of 6·9 million people in England, UK, to thoroughly characterise the association between BMI and severe COVID-19 outcomes and to explore interactions with demographic characteristics and other known risk factors.

Their findings suggest that the hazard ratio of severe outcomes from COVID-19 (i.e. admission to hospital, admission to ICU, or death) increase progressively above a BMI of 23 kg/m2, which is not attributable to excess risks of related diseases such as type 2 diabetes. We found that BMI is a greater risk factor for younger people (aged 20 to 39 years) than for older people (more than or equal to 80 years), and for Black people than for White people.

Summary

Background

Obesity is a major risk factor for adverse outcomes after infection with SARS-CoV-2. We aimed to examine this association, including interactions with demographic and behavioural characteristics, type 2 diabetes, and other health conditions.

Methods

In this prospective, community-based, cohort study, we used de-identified patient-level data from the QResearch database of general practices in England, UK. We extracted data for patients aged 20 years and older who were registered at a practice eligible for inclusion in the QResearch database between Jan 24, 2020 (date of the first recorded infection in the UK) and April 30, 2020, and with available data on BMI. Data extracted included demographic, clinical, clinical values linked with Public Health England’s database of positive SARS-CoV-2 test results, and death certificates from the Office of National Statistics. Outcomes, as a proxy measure of severe COVID-19, were admission to hospital, admission to an intensive care unit (ICU), and death due to COVID-19. We used Cox proportional hazard models to estimate the risk of severe COVID-19, sequentially adjusting for demographic characteristics, behavioural factors, and comorbidities.

Findings

Among 6 910 695 eligible individuals (mean BMI 26·78 kg/m2 [SD 5·59]), 13 503 (0·20%) were admitted to hospital, 1601 (0·02 per cent ) to an ICU, and 5479 (0·08 per cent) died after a positive test for SARS-CoV-2. We found J-shaped associations between BMI and admission to hospital due to COVID-19 (adjusted hazard ratio [HR] per kg/m2 from the nadir at BMI of 23 kg/m2 of 1·05 [95 per cent CI 1·05–1·05]) and death (1·04 [1·04–1·05]), and a linear association across the whole BMI range with ICU admission (1·10 [1·09–1·10]). We found a significant interaction between BMI and age and ethnicity, with higher HR per kg/m2 above BMI 23 kg/m2 for younger people (adjusted HR per kg/m2 above BMI 23 kg/m2 for hospital admission 1·09 [95% CI 1·08–1·10] in 20–39 years age group vs 80–100 years group 1·01 [1·00–1·02]) and Black people than White people (1·07 [1·06–1·08] vs 1·04 [1·04–1·05]). The risk of admission to hospital and ICU due to COVID-19 associated with unit increase in BMI was slightly lower in people with type 2 diabetes, hypertension, and cardiovascular disease than in those without these morbidities.

Interpretation

At a BMI of more than 23 kg/m2, we found a linear increase in risk of severe COVID-19 leading to admission to hospital and death, and a linear increase in admission to an ICU across the whole BMI range, which is not attributable to excess risks of related diseases. The relative risk due to increasing BMI is particularly notable people younger than 40 years and of Black ethnicity.

Paper available from The Lancet Diabetes & Endocrinology

The Lancet: Obesity and COVID-19: a call for action from people living with obesity #covid19rftlks

Caussy, C., et al. (2020). Prevalence of obesity among adult inpatients with COVID-19 in France|The Lancet Diabetes & Endocrinology8| 7|P. 562-564.

Most people who develop COVID-19 after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection present with paucisymptomatic and non-severe disease.1 However, approximately 20% of patients develop severe COVID-19 requiring hospitalisation, including 5% who are admitted to the intensive care unit (ICU).2 The ongoing COVID-19 outbreak has led to an unprecedented health crisis. Hence, it is crucial to identify individuals who are susceptible to developing severe COVID-19 and could require hospitalisation, especially in the ICU.Evidence is emerging that obesity-related conditions seem to worsen the effect of the virus. Studies from Chinese cohorts of patients with COVID-19 have identified several risk factors of severe COVID-19 including age, cardiomyopathy, and obesity-related complications such as type 2 diabetes and hypertension.3

Most people who develop COVID-19 after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection present with paucisymptomatic and non-severe disease.1 However, approximately 20% of patients develop severe COVID-19 requiring hospitalisation, including 5% who are admitted to the intensive care unit (ICU).2 The ongoing COVID-19 outbreak has led to an unprecedented health crisis. Hence, it is crucial to identify individuals who are susceptible to developing severe COVID-19 and could require hospitalisation, especially in the ICU.Evidence is emerging that obesity-related conditions seem to worsen the effect of the virus. Studies from Chinese cohorts of patients with COVID-19 have identified several risk factors of severe COVID-19 including age, cardiomyopathy, and obesity-related complications such as type 2 diabetes and hypertension.

Prevalence of obesity among adult inpatients with COVID-19 in France







Prevalence of obesity among adult inpatients with COVID-19 in France

Obesity, unfavourable lifestyle and genetic risk of type 2 diabetes: a case-cohort study

Schnurr, T.M.. et al. (2020). Obesity, unfavourable lifestyle and genetic risk of type 2 diabetes: a case-cohort study. Diabetologia. https://doi.org/10.1007/s00125-020-05140-5

A study reports that obesity is the greatest risk factor for developing type 2 diabetes. The case-cohort studied over 400 Danes who developed type 2 during follow up as part of a different study, their data was compared to a sample of more than 5000 individuals, who were randomly selected. The findings,published in Diabetologica, show a risk factor eight times greater for those with obesity

Abstract

Aims/hypothesis

We aimed to investigate whether the impact of obesity and unfavourable lifestyle on type 2 diabetes risk is accentuated by genetic predisposition.

Methods

We examined the joint association of genetic predisposition, obesity and unfavourable lifestyle with incident type 2 diabetes using a case-cohort study nested within the Diet, Cancer and Health cohort in Denmark. The study sample included 4729 individuals who developed type 2 diabetes during a median 14.7 years of follow-up, and a randomly selected cohort sample of 5402 individuals. Genetic predisposition was quantified using a genetic risk score (GRS) comprising 193 known type 2 diabetes-associated loci (excluding known BMI loci) and stratified into low (quintile 1), intermediate and high (quintile 5) genetic risk groups. Lifestyle was assessed by a lifestyle score composed of smoking, alcohol consumption, physical activity and diet. We used Prentice-weighted Cox proportional-hazards models to test the associations of the GRS, obesity and lifestyle score with incident type 2 diabetes, as well as the interactions of the GRS with obesity and unfavourable lifestyle in relation to incident type 2 diabetes.

Results

Obesity (BMI more than or equal to 30 kg/m2) and unfavourable lifestyle were associated with higher risk for incident type 2 diabetes regardless of genetic predisposition. The effect of obesity on type 2 diabetes risk was high, whereas the effects of high genetic risk and unfavourable lifestyle were relatively modest. Even among individuals with low GRS and favourable lifestyle, obesity was associated with a more than 8-fold risk of type 2 diabetes compared with normal-weight individuals in the same GRS and lifestyle stratum.

Conclusions/interpretation

Having normal body weight is crucial in the prevention of type 2 diabetes, regardless of genetic predisposition.

Abstract from Diabetologica

Related:

Diabetes UK Obesity is greatest risk factor for type 2 diabetes irrespective of genetics

 

Early puberty and risk for type 2 diabetes in men

Ohlsson, C., Bygdell, M., Nethander, M. et al. 2020. Early puberty and risk for type 2 diabetes in men. Diabetologia.  https://doi.org/10.1007/s00125-020-05121-8

Data from more than 30000 Swedish males such as their BMI was used to evaluate the association between pubertal timing and risk of adult type 2 diabetes. 

Abstract

Aims/hypothesis

The association between pubertal timing and type 2 diabetes, independent of prepubertal BMI, is not fully understood. The aim of the present study was to evaluate the association between pubertal timing and risk of adult type 2 diabetes, independent of prepubertal BMI, in Swedish men.

Methods

We included 30,697 men who had data for BMI at age 8 and 20 years and age at Peak Height Velocity (PHV), an objective assessment of pubertal timing, available from the BMI Epidemiology Study Gothenburg (BEST Gothenburg), Sweden. Information on type 2 diabetes (n = 1851) was retrieved from the Swedish National Patient Register. HRs and 95% CIs were estimated by Cox regression analysis. We observed violations of the assumption of proportional hazards for the association between age at PHV and the risk of type 2 diabetes and therefore split the follow-up period at the median age of type 2 diabetes diagnosis (57.2 years of age) to define early (≤57.2 years) and late (>57.2 years) type 2 diabetes diagnosis.

Results

Age at PHV was inversely associated with both early (HR 1.28 per year decrease in age at PHV, 95% CI 1.21, 1.36) and late (HR 1.13, 95% CI 1.06, 1.19) type 2 diabetes. After adjustment for childhood BMI, the associations between age at PHV and both early (HR 1.24, 95% CI 1.17, 1.31) and late (HR 1.11, 95% CI 1.05, 1.17) type 2 diabetes were similar. Moreover, early age at PHV predicted insulin treatment of type 2 diabetes (OR 1.25 per year decrease in age at PHV, 95% CI 1.17, 1.33). Assuming a higher risk among those with an age at PHV below the median, the population attributable factor indicates that 15% fewer of the diagnosed individuals would have developed type 2 diabetes had they not reached puberty early.

Conclusions/interpretation

These findings indicate that early puberty may be a novel independent risk factor for type 2 diabetes.

Impact of obesity on the increasing incidence of type 1 diabetes

Buzzetti, R. Zampetti, S., & Pozzilli, P. 2020 Impact of obesity on the increasing incidence of type 1 diabetes. Diabetes, obesity and metabolism.  https://doi.org/10.1111/dom.14022

Abstract

Published estimates of the incidence of type 1 diabetes (T1D) in children in the last decade varies between 2% and 4% per annum. If this trend continued, the disease incidence would double in the next 20 years. The risk of developing T1D is determined by a complex interaction between multiple genes (mainly human leukocyte antigens) and environmental factors. Notwithstanding that genetic susceptibility represents a relevant element in T1D risk, genetics alone cannot explain the increase in incidence. Various environmental factors have been suggested as potential triggers for T1D, including several viruses and the hygiene hypothesis; however, none of these seems to explain the large increase in T1D incidence observed over the last decades. Several studies have demonstrated that the prevalence of childhood/adolescence overweight and obesity has risen during the past 30 years in T1D. Currently, at diagnosis, the majority of patients with T1D have normal or elevated body weight and ~50% of patients with longstanding T1D are either overweight or obese. The growing prevalence of obesity in childhood and adolescence offers a plausible explanation for the increase in T1D incidence observed in recent decades. Possible mechanisms of the enhancement of β‐cell autoimmunity by obesity include: a) insulin resistance‐induced β‐cell secretory demand triggering autoimmunity through cytokine release, neo‐epitope antigen formation and increase in β‐cell apoptosis, and b) obesity‐induced low‐grade inflammation with pro‐inflammatory cytokines secreted by locally infiltrating macrophages, which contribute to the presentation by islet cells of autoantigens generally not accessible to T cells. Further studies are needed to clarify whether the control of body weight can prevent or delay the current and continuing rise in T1D incidence.

 

The full article is available from Diabetes, obesity and metabolism 

Diabetes UK strategy 2020-2025

Diabetes UK has launched a new strategy called ‘A generation to end the harm: Diabetes UK Strategy 2020-2025’ coinciding with World Diabetes Day 2019 

diabstrat
Image source: https://www.diabetes.org.uk/

There are an estimated 2.85 million people diagnosed with type 2 diabetes in England, and more than 850,000 living with the condition who do not know they have it because they have not yet been diagnosed − bringing the total up to 3.7 million.

The new strategy from Diabetes UK focuses on achieving five key outcomes by 2025:

  • more people with type 1, type 2 and all other forms of diabetes will benefit from new treatments that cure or prevent the condition
  • more people will be in remission from type 2 diabetes
  • more people will get the quality of care they need to manage their diabetes well
  • fewer people will get type 2 and gestational diabetes
  • more people will live better and more confident lives with diabetes, free from discrimination.

The charity said that more than half of all cases of type 2 diabetes could be prevented or delayed, and in turn, the risk of developing the related complications, by tackling overweight and obesity.

Full document: A generation to end the harm: Diabetes UK Strategy 2020-2025

See also: Obesity rate doubles over past 20 years | OnMedica

Obesity and poor lifestyle increase type 2 diabetes-risk independent of genetic predisposition

Jakupovic, H. et al | 2019| Obesity and unfavourable lifestyle increase type 2 diabetes-risk independent of genetic predisposition

Research that will be presented at this week’s Annual Meeting of the European Association for the Study of Diabetes (EASD), suggests that people with poor lifestyle and obesity are at greater risk of developing type 2 diabetes (via OnMedica). 

Favourable lifestyle was defined as having at least three of the following healthy lifestyle factors: no current smoking, moderate alcohol consumption, regular physical activity, and a healthy diet; whereas an unfavourable lifestyle as no or only one healthy lifestyle factor; and the remaining participants were defined as having an intermediate lifestyle. They also assessed genetic risk score (GRS) according to 213 genetic loci robustly associated with T2D, and stratified people’s GRS as low (lowest 25%), intermediate (middle 50%), and high-risk (top 25%) groups.

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The abstract for the research is available from the European Association for the Study of Diabetes 

Research retrieved from: https://www.easd.org/virtualmeeting/home.html#!resources/obesity-and-unfavourable-lifestyle-increase-type-2-diabetes-risk-independent-of-genetic-predisposition-128e36e7-81ac-4126-960a-823559bb5c14

See also: OnMedica Obesity linked to nearly six-fold risk of developing type 2 diabetes

 

Children of obese mums at higher diabetes risk

University of Edinburgh | June 2019 |Children of obese mums at higher diabetes risk

New research indicates that babies who are born to mothers with obesity have a higher risk factor for developing type 2 diabetes in later life. The study also reports that being overweight in pregnancy also increases the child’s diabetes risk by a half. 

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The experts behind the research analysed data from the birth records of 100000 children born in Aberdeen during 1950 and 2011 and linked them with the national register for diagnosed diabetes in Scotland. Figures revealed around one quarter of women were overweight during pregnancy over the 60-year period. One in ten were obese, with a body mass index (BMI) greater than 40.

Offspring whom mums were overweight or obese during pregnancy had an associated risk factor of between 1.4 and 3.5-fold increased incidence.

The study indicates that the proportion of obese mothers increased five-fold from around one in 30 during the 1950s to almost one in six between 2000 and 201 (Source: University of Edinburgh)

Read press release in full from University of Edinburgh

Journal article Consequences of being overweight or obese during pregnancy on diabetes in the offspring: a record linkage study in Aberdeen, Scotland

Full reference: Lahti-Pulkkinen, et al. | 2019| Consequences of being overweight or obese during pregnancy on diabetes in the offspring: a record linkage study in Aberdeen, Scotland| Diabetologia| 1-8.

Abstract

Aims/hypothesis

Maternal obesity in pregnancy is associated with cardiovascular disease and mortality rate in the offspring. We aimed to determine whether maternal obesity is also associated with increased incidence of type 2 and type 1 diabetes in the offspring, independently of maternal diabetes as a candidate mechanistic pathway.

 

Methods

Birth records of 118,201 children from 1950 to 2011 in the Aberdeen Maternity and Neonatal Databank were linked to Scottish Care Information–Diabetes, the national register for diagnosed diabetes in Scotland, to identify incident and prevalent type 1 and type 2 diabetes up to 1 January 2012. Maternal BMI was calculated from height and weight measured at the first antenatal visit. The effect of maternal obesity on offspring outcomes was tested using time-to-event analysis with Cox proportional hazards regression to compare outcomes in offspring of mothers in underweight, overweight or obese categories of BMI, compared with offspring of women with normal BMI.

 

Results

Offspring of obese (BMI more than or equal to 30 kg/m2) and overweight (BMI 25–29.9 kg/m2) mothers had an increased hazard of type 2 diabetes compared with mothers with normal BMI, after adjustment for gestation when weight was measured, maternal history of diabetes before pregnancy, maternal history of hypertension, age at delivery, parity, socioeconomic status, and sex of the offspring: HR 3.48 (95% CI 2.33, 5.06) and HR 1.39 (1.06, 1.83), respectively.

 

Conclusions/interpretation

Maternal obesity is associated with increased incidence of type 2 diabetes in the offspring. Evidence-based strategies that reduce obesity among women of reproductive age and that might reduce the incidence of diabetes in their offspring are urgently required.