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The Obesity Medicine Association's (CPS) on obesity, type 2 diabetes mellitus (T2DM), and cardiometabolic risks says that treatment should first prioritize the patient's obesity.

The comprehensive educational overview by Harold E. Bays, MD, of Louisville Metabolic and Atherosclerosis Research Center at the University of Louisville School of Medicine in Kentucky, and colleagues touches on many clinical, therapeutic, and physiological topics – the latter including T2DM and obesity as cardiometabolic risk factors, mechanisms of obesity-related insulin resistance, and beta-cell dysfunction. The statement explains how adipose tissue acts as an active immune and endocrine organ, whose dysfunction contributes to metabolic abnormalities often encountered in clinical practice, including hyperglycemia.

The authors also clarify the way in which adiposopathy leads to clinical metabolic disease through crosstalk interactions and biometabolic responses in non-adipose tissue organs such as the liver, muscle, pancreas, kidney, and brain.

In the following interview, Bays, who is also editor-in-chief of Obesity Pillars, starts off by discussing the background for creating the CPS.

What was the impetus for issuing this Clinical Practice Statement?

Bays: T2DM is among the most common complications of obesity. This practice review was intended to assist clinicians in the care of patients with the disease of obesity and T2DM.

Did the COVID-19 pandemic play any role in the release of the CPS?

Bays: While it was not a major reason for the publication, it is true that the COVID-19 pandemic increased the risks associated with obesity, including a higher risk of T2DM among patients with COVID-19 infection.

Is this CPS an evolution from previous OMA annual algorithms?

Bays: It was a natural addition to multiple OMA statements regarding other major cardiometabolic risk factors, such as and

Perhaps one of the most significant novel concepts in the recommendation is to "treat obesity first" for patients having mild to moderate metabolic abnormalities that are reasonably thought to be due to obesity. This is especially so when the recommended treatment includes evidence-based nutritional intervention, physical activity, behavior modification, anti-obesity medications, and possibly bariatric surgeries known to reduce high blood glucose, high blood pressure, and high blood triglycerides.

What are a few of the main new concepts/recommendations that doctors need to familiarize themselves with, and have any changed since the CPS's publication?

Bays: The information has not significantly changed since publication. The following are the key points:

• T2DM is a common complication of obesity. It is a major risk factor for cardiovascular disease (CVD) and also . These are the two most common causes of morbidity and mortality among patients with obesity and T2DM.

• Patients with obesity and T2DM should optimally undergo global risk reduction for CVD through healthful nutrition and physical activity, weight reduction, smoking cessation, as well as optimal control of blood glucose, blood pressure, and blood lipids.

• Among patients with T2DM, administration of glucagon-like peptide-1 receptor agonists may reduce body weight, reduce cardiometabolic risk factors, and reduce the risk for CVD events.

• Administration of sulfonylureas and many insulins may increase body weight and may increase the risk for CVD events.

Have any recommendations been controversial or triggered negative feedback?

Bays: No controversies. No negative feedback.

Will better understanding of the genetic, metabolic, and psychological mechanisms at work in obesity help both primary care physicians and patients approach obesity differently?

Bays: It's important that clinicians understand the complexity of obesity and how obesity promotes major cardiometabolic risk factors such as high blood pressure, high blood lipids, and increased risk of thrombosis.

Additionally, the current CPS on T2DM provides detailed, clinically relevant mechanistic explanations as to how and why obesity may lead to T2DM.

Will better understanding expose myths about obesity and lessen the associated stigma in the public sphere and perhaps even in the medical community that still plagues this condition?

Bays: Having a better understanding of how obesity causes T2DM allows for a more informed ability to explain how and why obesity is a disease.

What is the main takeaway message of the statement for physicians treating patients with obesity?

Bays: The review is intended to assist clinicians in the care of patients with the disease of obesity and T2DM. It also provides a simplified overview of how obesity may cause insulin resistance, pre-diabetes, and T2DM. In addition, it provides an algorithmic approach toward treatment of a patient with obesity and T2DM, with "treat obesity first" as a priority.

Finally, it explains that the treatment of obesity and T2DM might best focus on therapies that not only improve the weight of patients but also improve the health outcomes of patients -- for example, by reducing the risk of CVD and cancer.

Read the study here and expert commentary about it here.

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