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56
VOLUME 17 NUMBER 2 • NOVEMBER 2020
Report
SA JOURNAL OF DIABETES & VASCULAR DISEASE
‘Diabesity’: interlinking treatments to improve outcomes
in diabetes and obesity
Correspondence to: deNovo Medica
70 Arlington Street, Everglen, Cape Town, 7550
e-mail:
info@denovomedica.comLandi Lombard
Endocrinologist, Cape Town
Previously published by deNovo Medica, May 2020
S Afr J Diabetes Vasc Dis
2020;
17
: 56–62
Introduction
Over recent decades obesity has emerged as the largest chronic
health concern globally, with major driving factors being the
consumption of high-calorie, high-carbohydrate and high-fat foods
and a shift towards a sedentary lifestyle. Moreover, the incidence of
severe obesity [i.e. a body mass index (BMI) > 40 kg/m
2
] is increasing
rapidly and carries an especially elevated mortality risk. Obesity is
associated with more than 45 co-morbidities and is known to be
the primary risk factor for cardiovascular disease, type 2 diabetes
mellitus (T2DM), hypertension, coronary heart disease and certain
types of cancer. Obesity is also a cause of diverse psychological
problems and various physical disabilities, including a significantly
increased risk of developing an arthritic condition. In the context
of the COVID-19 pandemic, obesity and diabetes are associated
with more severe outcomes of the disease and markedly increased
mortality. The infection itself may precipitate acute metabolic
complications through direct negative effects on pancreatic
β
-cell
function.
1-4
It is important for the clinician to recognise the cycle of insulin
resistance and obesity, whereby each gives rise to the other and
can result in more severe obesity and T2DM. The term ‘diabesity’
describes the pathophysiological interlink between obesity and
diabetes, as both metabolic disorders are characterised by insulin
resistance and insulin deficiency. There is a tendency towards
decreased treatment success in diabetes whenever weight gain
is observed, and weight reduction is considered a key therapeutic
goal in the treatment of T2DM. This raises the question of whether
Learning objectives
You will learn:
• ‘Diabesity’ is a term used to describe the pathophysiological interlink
between obesity and type 2 diabetes mellitus, both of which are
characterised by insulin resistance and insulin deficiency.
• Significant benefits of weight loss have been observed in type 2 diabetes
mellitus prevention and treatment.
• Rational use of antidiabetic medications is imperative to optimise long-
term management of diabesity, balancing optimal glycaemic control with
the most appropriate diabesity management regimen.
weight management and diabetes should be targeted with
combined treatment strategies.
1,5,6
Diabesity is the pandemic that will stay with us long after
COVID-19 has passed. Of the South African adult population, 20%
are diabetic or pre-diabetic, and half of these remain undiagnosed.
This will place an enormous burden on our health system in the
coming decade. To improve long-term metabolic control, Dr
Lombard confidently favours diabetic treatments that contribute to
weight loss or that are at least weight neutral.
From obesity to diabetes
Obesity causes sustained elevation of free fatty acid plasma
levels, both in the basal state and following glucose load; this is
a major contributing factor to insulin resistance and ultimately
the development of diabetes (Fig. 1). Hyperglycaemia and
compensatory hyperinsulinaemia associated with insulin resistance
and glucose intolerance lead to pathological glycation of circulating
proteins and the formation of advanced glycation end-products.
This progression ultimately leads to pancreatic
β
-cell secretory
failure and apoptosis.
6
See page 61 for further information on
these inflammatory pathways.
What is the importance of body fat distribution?
A high proportion of body fat is regularly seen in people with a
BMI > 30 kg/m
2
, but this is also observed in one-third of people
with normal weight and can usually be identified using waist
circumference measurements (women > 80 cm, men > 94 cm).