Diabesity

There is no question that we in the United States, as well as in the rest of the world, are facing a pandemic of overweight and obesity. Indeed, the global prevalence of obesity has tripled since 1975. This dramatic increase has been accompanied by a similarly dramatic increase in the prevalence of diabetes.

Strong, consistent evidence shows that managing obesity can delay progression of prediabetes to type 2 diabetes. Obesity management is also highly beneficial in treating type 2 diabetes, based on the degree of weight loss achieved. Losing excess weight improves glycemic control, reduces the need for glucose-lowering medications, can substantially reduce A1C, and can even promote sustained diabetes remission.

Many of us in primary care are frustrated by an inability to have a meaningful impact on this health challenge and watch somewhat helplessly as our patients struggle to lose weight, only to be sabotaged by their genetic predisposition and unforgiving and unfavorable physiology.

Despite overweight and obesity being common, they engender the additional challenge of prejudice from society in general and even from clinicians. Stereotypes that lead to stigma, prejudice, and discrimination may be both subtle and overt. Many clinicians may view patients with obesity as noncompliant, lazy, lacking in self-control, and annoying (1–3). As patients’ BMI increases, physicians report having less patience and less desire to help them; they also report considering patients with obesity to be a waste of time and having less respect for them (4).

Medical professionals do not necessarily espouse similar prejudices regarding patients with other diseases, and indeed they may not even recognize obesity as a disease. It was not until 2012 that the American Association of Clinical Endocrinologists acknowledged obesity as a disease (5), followed by the American Medical Association in 2013 (6).

Evidence supporting obesity as a chronic disease includes the presence of elevated BMI, existence of altered homeostatic mechanisms (7), and the fact that obesity also serves as an independent risk factor for many other diseases.

Primary care clinicians have a crucial role to play in the management of diabesity (i.e., obesity associated with diabetes). We can collaborate with our patients to develop and implement individualized treatment plans based on the Chronic Care Model of disease management (8), identify achievable short- and long-term goals, identify barriers to achieving goals, and implement strategies to overcome barriers. We can also endeavor to understand our patients’ values and beliefs and support them in achieving and maintaining their weight goals.

Chapter 8 of the American Diabetes Association’s Standards of Medical Care in Diabetes—2022 (9) addresses assessment and treatment recommendations for patients with obesity, summarizing the best available evidence to enable successful clinician-patient collaboration.

By addressing our own biases and offering hope to and partnering with our patients who struggle with this disease, we may be able to mitigate the insidious pandemic of diabesity.