An Australian endocrinologist has suggested healthcare professionals need to look upstream when treating diabetes with severe obesity.
Are you giving your patients with diabetes and severe obesity the most bang for their buck when it comes to controlling their metabolic issues?
During a session on the management of obesity with diabetes at the recent International Diabetes Federation Western Pacific Region Congress, Associate Professor Samantha Hocking, an endocrinologist from the Royal Prince Alfred Hospital in Sydney, posed the question of whether healthcare professionals are treating the wrong disease first in patients with both severe obesity and diabetes.
While there are many patients affected by both conditions, there isn’t really a unifying definition of severe obesity. Different organisations use different definitions depending on the context. For example, rather than defining obesity on the basis of BMI, the American Diabetes Association Professional Practice Committee for Obesity has recently recommended using the Edmonton Obesity Staging System to stage different levels of obesity.
“It’s actually a pretty simple system. It takes people with obesity from stage 0, where they have obesity but no physical signs of organ-related dysfunction or functional impairment, all the way through to stage 4… where you have severe disabling disease,” Professor Hocking said.
“At this point in time, it’s possibly too late to intervene in obesity, so we’re really defining obesity by stage 3 and stage 4. I think we’re really missing the opportunity to change people’s lives by treating their obesity.”
Staging obesity based on disease state – rather than classifying people into groups according to their BMI – is critical, according to a 2011 study that used data from the National Health and Human Nutrition Examination Surveys in the United States to explore the relationship between EOSS stage and mortality.
In this study, classing obesity based on BMI was not a very good predictor of survival. EOSS stage was a far stronger predictor, with individuals in stage 3 having the highest risk of death (participants in this study could not be assigned as stage 4 obesity due to missing data).
“It really tells us that obesity with complications is obesity that requires intervention,” said Professor Hocking.
“We really need to shift our thinking about adiposity-based chronic disease,” Professor Hocking continued, referring to a 2022 review from The Lancet that proposed focusing on obesity management as the primary treatment goal for type 2 diabetes.
“If we’re just focusing on lowering the glucose [levels], reducing microvascular complications, and reducing the macrovascular complications – which are obviously the largest cause of death for our patients with type 2 diabetes – are we missing the boat when we could be focusing upstream and treating the obesity, which for 53% of Australians is the driver of their type 2 diabetes, but it also drives these other adiposity-based chronic diseases?” Professor Hocking asked.
“When you treat obesity, you treat them all. You don’t selectively treat one over the other. The patient benefits across the many diseases that they hold.”
This, according to Professor Hocking, begs the question of whether we actually modify disease activity when patients lose weight.
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The endocrinologist, who is also a clinical academic at the University of Sydney, promptly answered her own question by pointing delegates towards a 2016 paper published in Cell Metabolism that explored the effects of moderate and subsequent progressive weight loss on metabolic function and adipose tissue biology in humans with obesity.
“It’s very old actually,” Professor Hocking said of the paper, “but I think it makes a really good point about the progressive benefits that people get with progressive weight loss.”
As part of the 2016 paper, which was a small, randomised trial, participants were assigned either to weight maintenance or diet-induced weight loss. Participants in the latter group initially aimed to lose 5% of their starting body weight. Individuals who successfully achieved this target then worked towards losing ~10% (in the first instance) and then ~15% of their starting weight.
“The first thing they found is when you lost body weight, you principally lose adipose tissue mass, and that’s obviously what we’re aiming for,” said Professor Hocking. “We’re aiming for reductions in obesity-related chronic disease, so we want people to lose fat.”
Participants who achieved the 5% weight loss goal saw small reductions in their total body adipose tissue mass, their intra-abdominal adipose tissue, and their intrahepatic triglyceride levels.
But participants who lost more weight saw disproportionally greater reductions in these outcomes. A 16% reduction in body weight was accompanied by a 27% reduction in total body fat, a 30% reduction in intra-abdominal fat, and a 65% reduction in intrahepatic triglycerides. Additional weight loss was also associated with improved β-cell function and insulin sensitivity in muscle.
“About 70% of people with type 2 diabetes have fatty liver, so we really should be aiming for these large degrees of weight loss in patients with type 2 diabetes,” Professor Hocking noted.
“I think this data has really shifted us away from that ‘one size fits all’ [idea of] 5% weight loss being the target. We now know that’s not true, and to modify certain diseases, you really need weight loss in excess of 10 to 15% body weight reduction.”
Additional data from the 2023 DiRECT-Aus study (led by Professor Hocking) suggested that losing an average of 8.1% of body weight over 12 months after using a low-energy total diet replacement saw 56% of obese individuals who had been recently diagnosed with type 2 diabetes achieve diabetes remission.
Further supporting the importance of obesity management in people with diabetes has been the inclusion of this concept in clinical guidelines, such as the American College of Endocrinologists pre-diabetes management algorithm and the American Diabetes Association diabetes management algorithm.
“In the pre-diabetes management algorithm, the comment is: if your patient has pre-diabetes and overweight or obesity, the weight loss target should be more than 7-10% body weight reduction, and if comorbidities are present, then it recommends specific therapies. Otherwise, it recommends treating patients with highly effective evidence-based obesity management medications and even considering bariatric surgery,” said Professor Hocking.
“Now, in this country, we don’t have great pathways for [the] care of pre-diabetes, and I’m not sure that this sort of advice would be being followed in our primary care settings.
“[Then] if we look at the ADA diabetes management algorithm… the first thing it says is to set individualised weight management goals, and then when choosing glucose-lowering therapy, consider a regimen with high to very high dual glucose and weight loss efficacy.”
Professor Hocking left delegates with a question for themselves.
“In your diabetes clinics, are you really, with every patient, setting an individualised weight management goal, and are you really choosing a therapy with very high efficacy for weight loss?”
The International Diabetes Federation Western Pacific Region Congress was held in Melbourne from 18 to 21 August 2026.
