My patients are asking about new diabetes and weight loss medications. What can I tell them based on the latest evidence?-RK, KA
Martha M. Funnell, MS, RN, CDCES, FAAN, responds: Each year, the American Diabetes Association reviews and updates its Standards of Medical Care.1,2 The 2023 Standards have a stronger focus on the prevention of cardiovascular and renal complications, treatment for obesity, and self-management education and psychosocial care.1 In addition, new insulin pumps and better coverage for continuous glucose meters for people with type 2 diabetes increase access to these important technologies.
Cardiorenal care
One striking change in 2023 is the new definition of hypertension.1 The diagnostic criterion of 130/80 mm Hg or greater is now recommended, rather than the previous level of 140/90 mm Hg or greater. Medications and lifestyle changes should be considered to reach and sustain the new diagnostic criteria once a diagnosis is confirmed (two measures on different days).1
The 2023 Standards also recommend that high-intensity statin therapy be initiated in people with diabetes ages 40 to 75 who have established cardiovascular disease to achieve at least a 50% reduction in cholesterol from baseline and a low-density lipoprotein cholesterol level of less than 55 mg/dL.1 Those over 75 years old should continue statin treatment or consider the benefits and risks of beginning moderate-intensity statin therapy. The expanded use of sodium-glucose cotransporter-2 (SGLT2) inhibitors to reduce the development and progression of heart failure in those with type 2 diabetes was also incorporated.1,3
SGLT-2 inhibitors are more effective than other medications in reducing end-stage kidney disease.3 The threshold for initiation of an SGLT-2 inhibitor medication is now recommended at an estimated glomerular filtration rate (eGFR) of 20 mL/min per 1.73 m2 or greater and urinary albumin of 200 mg/g creatinine or more.1 A referral to nephrology is also recommended with increasing albumin or decreasing eGFR levels or a measured eGFR of 30 mL/min per 1.73 m2.1
Weight management
There is no standard "diabetic diet", and the choice of weight-loss method can differ by goals and food choices, as long the plan results in a 500-750 kcal/day deficit.1,4 Effective strategies are based on personal preferences; health status; and emotional, cultural, financial, and other lifestyle circumstances and priorities.4,5 The effect on weight should be considered when choosing glucose-lowering and other medications.1,3 In addition, referral to a registered dietitian nutritionist for Medical Nutrition Therapy should be made at diagnosis and annually.1,4,5
Although weight management has always been part of diabetes care, the 2023 Standards support higher levels of weight loss of up to 10% to 15% of body weight to improve glucose outcomes and decrease risks for heart disease.1 This change is related to both the growing recognition of obesity as a chronic illness and the efficacy of the incretin hormones and newer dual incretin medications that can potentially reduce both blood glucose and weight.1,3,6
Incretin hormones are secreted by the gut in response to food intake. The two incretin hormones that have the largest effect on postprandial glucose levels are glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic peptide (GIP).7 These stimulate the pancreas to release insulin and limit the release of glucagon from the liver after meals. Incretin hormones support earlier satiety by slowing down digestion and suppressing the release of glucagon to prevent hunger. The normal effect of these hormones is diminished in people with type 2 diabetes.7
Two classes of medications are used to manage type 2 diabetes based on these hormones: dipeptidyl peptidase-4 (DPP-4) inhibitors and GLP-1 agonists. DPP-4 inhibitors, such as sitagliptin, decrease glucagon, enhance the activity of the incretin hormones, and increase insulin levels. These oral medications are weight-neutral.1,3 GLP-1 agonist medications, such as dulaglutide, bind with GLP-1 receptors and have the same effect as the natural hormones.7 The GLP-1 medications used to treat type 2 diabetes are primarily available as injections taken weekly or daily, although an oral form is also available. Because the action of both DPP-4 and GLP-1 medications are glucose-dependent, the risk of hypoglycemia when taking these medications is low.3,6-8 Adverse reactions include unintentional weight loss and gastrointestinal problems, such as nausea, gastric pain, and flulike symptoms. Dual incretin medications, such as tirzepatide, are newer and include both GIP and GLP-1 agonists. These are currently approved for only treating type 2 diabetes but have been highly efficacious for reducing body weight.3,8
Although the weight-loss properties of GLP-1 medications have been known since they were first approved for diabetes treatment in 2005, the first (liraglutide) was not approved for weight loss until 2014, and the second (semaglutide) in 2021.6,8 The formulation is the same for both the diabetes treatment and weight-loss forms, but the dosing and indications are different. It is common to lose 5%-20% of body weight during the first year of use.3,6,8
Because weight loss is a newer indication for GLP-1 agonists, the long-term impact of these medications on the care and lives of people with diabetes and obesity is not known. Furthermore, the medications are expensive and standardized indications have not been developed or clearly communicated by payors; the most effective, evidence-based strategies that involve all healthcare team members have not been defined; and the required length of use of these medications to sustain weight goals is unknown at the time of this writing.
Self-management education and support
It is recommended that all people with diabetes receive diabetes self-management education and support (DSMES) and should be assessed for their educational needs in these four instances: at diagnosis; annually or when not meeting treatment or other goals; when medical, physical, or psychosocial complicating factors develop; or during transitions in care or life.1,2,8,9 Effective DSMES focuses on empowering persons with diabetes with the knowledge, coping skills, and behavioral strategies to make informed and wise self-management decisions.1,2 Nurses have important roles in implementing DSMES programs and providing ongoing education during routine care using practical strategies (for example, see 5 M's Framework for diabetes self-management and decision-making2).
Effective telecare, digital coaching, or other digital solutions and the involvement of community health workers are recommended to improve access to this critical service.1 Along with the emphasis on person-centered approaches and shared decision-making, the 2023 Standards recommend screening for food insecurity and sleep health and using social determinants of health to guide the design and implementation of DSMES sessions and programs.1,10 DSMES interventions should include specific emphasis on strategies for diabetes distress, anxiety, stigma related to diabetes, and other common issues. Also, conversational, person-first language, such as "person with diabetes/obesity" instead of "diabetic" or "obese person," should be used.11
Implementing the Standards of Care and using these new medications offer hope and help for people with diabetes and those with obesity.
5 M's Framework for diabetes self-management and decision-making2
* Medications: Type and dose
* Mood: Emotions, diabetes distress, stress, and physical stress
* Meals: Foods, portions, snacks, and beverages
* Movement: Physical activity and exercise
* Minutes: Timing of medications, meals, and movement
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