Written by Dr Harriet Treacy1 and Professor Carel Le Roux1,2 1Beyond BMI, Dublin, Ireland 2Diabetes Complications Research Centre, University College Dublin, Ireland
Introduction
We have seen a significant evolution in the primary treatment goal for type two diabetes (T2D) over the last two decades. The first big shift came when a primary glucocentric approach, aimed at lowering glucose and HbA1c, evolved to incorporate a complications-centric approach, focused on reducing the downstream macro and microvascular complications such as cardiovascular disease, chronic kidney disease, and retinopathy. Arguably, the most significant shift, one which takes a more upstream, “root-cause” approach to managing T2D is currently underway. This shift to a “weightcentric” approach acknowledges the underlying pathophysiology of T2D as a disease that is both caused by, and complicated by, dysfunctional and excess fat accumulation, as such, making it an complication of the disease of obesity. For too long, obesity and T2D, have been treated as disparate disease states. Here, we will explore the critical intersection between these two disease states, with a specific focus on men, because men represent half of the population with the disease of obesity, but only 20% of people currently receiving treatment for the disease of obesity. Our aim is to help pharmacists recognize and understand the importance of treating obesity, both as a disease in its own right and as an upstream treatment for T2D, thus empowering pharmacists to play a pivotal role in supporting men living with obesity and T2D.
The pathophysiology causing T2D
Obesity causes T2D through recognised pathophysiology, including insulin resistance, chronic inflammation, adipokine dysregulation, ectopic fat deposition, beta-cell dysfunction, hormonal imbalances, and gut microbiota alterations. Obesity is characterised by chronic low-grade inflammation of adipocytes (fat cells). Dysfunctional adipocytes secrete proinflammatory cytokines, such as TNF-alpha and interleukin-6 (IL-6), contributing to insulin resistance and directly impairing the function of pancreatic beta cells responsible for producing insulin. Adipocytes, being a metabolically active endocrine organ, also secrete hormones such as leptin (a regulator of adipocyte mass). Despite this, people living with obesity and T2D have pathognomonic symptoms of increased hunger and a lack of satiety.
An Upstream Approach to T2D
Taking a weight-centric approach to T2D treatment has a significant impact on disease progression. Weight loss of at least 15%, has disease modifying effects and often results in remission of T2D which reduces the risk of macro and microvascular complications. Thus, by treating the disease of obesity, we can not only prevent T2D, but often cause T2D to go into remission.
The Weight Maintenance Challenge
One of the pressing challenges in adopting a weight-centric approach is the difficulty of sustaining weight loss. While diet and exercise play crucial roles in health gain, it’s important to acknowledge the complex interplay of genetic, biological and environmental factors that influence an individual’s ability to lose weight, and more importantly, maintain that weight loss. Lifestyle treatments are successful in treating the disease of obesity in approximately 20% of patients, but it appears that the motivation of the patient is not a predictor of success but rather success is determined by the biology of the disease of obesity and how the lifestyle treatment alters this pathophysiology. Pharmacological therapies, like GLP-1 or GLP-1/GIP agonists, are becoming a mainstay in the treatment of obesity as they target the subcortical areas of the brain where our appetite is regulated thus targeting the underlying biological drivers of obesity. Overcoming this elusive weight maintenance challenge, requires an evolution in how we approach obesity as a disease. As healthcare professionals, we need to move away from the outdated thinking that obesity is simply a “lifestyle choice” to treating it as a chronic disease best managed under a chronic disease management framework.
A Shared Internalised Stigma
People living with type 2 diabetes and obesity often hold the belief that the disease they live with is their fault. It’s not hard to see how this internalised stigma came about given the outdated thinking around obesity as a lifestyle choice. Moreover treatment for the disease was linked in the past with overpromising cosmetic benefits. Therefore, men might be reluctant to ask health-care professionals for help due to misconceptions that the responsibility for weight loss is entirely their own, that they will be blamed for the disease, and that the benefits are only cosmetic. There are a number of ways pharmacists can support
men living with obesity to combat this stigma and promote effective chronic disease management.
Top Tips for Pharmacists to Support Men living with obesity:
1. Educate on Obesity as a Disease: Begin by counselling patients on the fact that obesity is not a simple lifestyle choice. Help them understand that it involves complex physiological factors beyond their control, reducing any potential feelings of self-blame or guilt.
2. Educate About the ObesityT2D Connection: Take the time to explain the causative relationship between obesity and T2D. Use evidence-based information to emphasise that addressing obesity is a crucial aspect of managing their diabetes effectively and visa versa. Move the focus of obesity treatment away from “weight loss” to “health gain”.
3. Multidisciplinary Collaboration: Encourage them to take a holistic approach to the complex disease of obesity. Collaborate with other healthcare professionals, including dietitians, exercise specialists, and psychologists, to provide comprehensive care. A multidisciplinary approach can be highly effective in addressing the complex factors contributing to obesity and T2D.
4. Focus on Technical Management: Emphasize the technical aspects of managing obesity and related conditions. This includes practical guidance on how to use medications effectively, such as insulin pens or anti-obesity medications. Ensure patients are comfortable with the tools and techniques needed to manage their disease.
5. Promote Independence and Autonomy: Encourage men to take an active role in managing the disease of obesity. Provide opportunities for them to exert independence, autonomy, and ownership over decision-making to improve their engagement and compliance with treatment. References available on request
