As blogged previously, elevated weight and type 2 diabetes are closely interconnected for the vast majority of people with type 2 diabetes.  Knowing this, then, exactly HOW do we treat type 2 diabetes and help manage elevated weight at the same time?


From a nutrition perspective, the Obesity Canada guidelines chapter  notes that nutrition recommendations for adults of all body sizes should be personalized to meet individual values, preferences and treatment goals to support a dietary approach that is safe, effective, nutritionally adequate, culturally acceptable and affordable for long-term adherence.


As far as which dietary approaches to consider, there are several that have evidence for improving sugar control, including Mediterranean, vegetarian, low glycemic index, and DASH approach.  Note that the dietary approaches in the Obesity Canada guidelines all have some type of health benefit, though not all have been shown to reduce weight.  The nutrition approaches that do reduce weight have only a small weight benefit for most people.


The keto diet is often asked about. As there is no evidence of any macronutrient distribution (protein vs fat vs carbs) being effective for weight management, the keto diet is not listed as a recommended option in the Obesity Canada guidelines.  As the keto diet (<50g carbs per day) falls outside of the nutrient distribution recommended by the Diabetes Canada guidelines, it is not a recommended option by Diabetes Canada either.  Further, due to higher risk of diabetic ketoacidosis, the ketogenic diet should not be followed in people with type 1 diabetes, people on SGLT2 inhibitors, nor people with low endogenous (from their own body) insulin production (eg on multiple doses of insulin daily).   More on this here and here.


Intermittent Fasting (IF) is also another popular approach for weight management.  A randomized controlled trial found no difference in A1C reduction nor weight at one year compared to restricting calories daily.   From a safety perspective, if a person with type 2 diabetes is about to embark on an IF diet, insulin and sulfonylureas should be proactively adjusted BEFORE starting the IF approach, to avoid low blood sugars.  There are several types of IF, and it’s important to evaluate meds in the context of exactly what the IF plan is going to be.   SGLT2i users must be sure to keep good hydration, and avoid full days without calories (due to risk of diabetic ketoacidosis).


From a diabetes medication perspective, we have the good fortune of two classes of medications which can facilitate weight loss: the GLP1 receptor agonists, and the SGLT2 inhibitors.  These two classes also provide important heart and kidney protection, lower blood sugars, improve blood pressure, and don’t cause low blood sugars.  Thus, these are now recommended by Diabetes Canada as priority treatments for most people with type 2 diabetes.


Weight management medications should also be considered in people with type 2 diabetes.  Liraglutide and semaglutide, which are both diabetes medications, are also approved at higher doses for weight management, in people with or without type 2 diabetes.  Naltrexone/bupropion and orlistat are also approved obesity treatments that can be used in people with type 2 diabetes.


Bariatric surgery is an important treatment option to manage weight and type 2 diabetes.  The Obesity Canada guidelines recommend that bariatric surgery can be considered for people with BMI  ≥35 to induce control and remission of type 2 diabetes, and should be considered in people with BMI ≥30 with poorly controlled type 2 diabetes despite optimal medical management.  The challenge here is access to surgery, with demand eclipsing the current supply/availability of bariatric surgery in Canada.


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