How to treat obesity-related diabetes? Scientific weight loss and medication selection are key.

Treatment of Obese Non-Insulin Dependent Diabetes Mellitus

Non-insulin dependent diabetes mellitus is classified into obese and non-obese types based on weight. Compared to non-obese diabetes mellitus, obese patients exhibit significant insulin resistance and hyperinsulinemia. Therefore, the following points should be considered in treatment:

1. Dietary therapy is particularly important for obese diabetes mellitus.
In addition to a low-fat, low-sugar, high-fiber diet, low-calorie diets (approximately 3762 J per day) and very low-calorie diets (approximately 2090 J per day) can be selected based on the degree of obesity and the patient's physical condition. Very low-calorie diets have been used to treat obesity for the past 20 years and have recently been increasingly used to treat obese type 2 diabetes patients. This diet results in particularly rapid weight loss and is especially effective in controlling blood sugar, blood pressure, and blood lipids. The typical course of treatment is 3 months, during which close medical monitoring is essential. After 3 months, the patient should switch to a low-calorie diet.

2. Drug Selection

① Because obese diabetes mellitus is characterized by significant insulin resistance and hyperinsulinemia, the first choice of medication should be drugs that increase insulin sensitivity. The use of sulfonylureas and insulin should be minimized, as these can lead to hyperinsulinemia, exacerbate insulin resistance, and create a vicious cycle.

② In addition, some weight-loss drugs can be added to treat obese diabetes mellitus. Currently, fenfluramine is widely used clinically; it is an appetite suppressant that not only reduces weight but also improves insulin sensitivity and glucose metabolism.

Hyperlipidemia includes high cholesterol, high blood sugar, and high triglycerides. Hyperlipidemia is a significant risk factor for coronary heart disease; therefore, proper prevention and treatment of hyperlipidemia are extremely important.

Obesity is one of the main factors affecting blood lipid levels. BMI is directly proportional to the degree of elevated blood lipids. The detection rate of hyperlipidemia in obese individuals is 23%–40%, far higher than in the general population. Randomized controlled studies have shown that weight loss can reduce plasma low-density lipoprotein and increase high-density lipoprotein, improving blood lipid composition and reducing the risk of cardiovascular disease.

Insulin resistance may be a key link between obesity and impaired glucose tolerance, hypertension, and dyslipidemia. Hypertrophic adipocytes have insensitive insulin receptors on their cell membranes, and the number of insulin receptors per unit area is reduced. Obesity reduces insulin sensitivity by 5 times compared to normal, while the number of receptors can decrease by 10 times. This leads to decreased lipoprotein lipase activity, impaired VLDL synthesis or clearance, decreased hepatic triglyceride activity, decreased LDL receptor activity, and reduced HDL. This is a major cause of lipid metabolism disorders in obese individuals. Reaven first proposed Syndrome X in 1988, characterized by: insulin resistance; decreased levels of high-density lipoprotein in the bloodstream; hypertriglyceridemia; and hypertension. Patients with Syndrome X have high mortality rates from cardiovascular disease and non-insulin-dependent diabetes mellitus.

When obesity is reduced, the cycle of insulin resistance and hyperinsulinemia is broken, and hypertriglyceridemia returns to normal. Because hypertensive patients with familial dyslipidemia often also have obesity, hyperinsulinemia, and hypertriglyceridemia, weight loss is particularly effective for these patients.