Understanding DIABESITY by Dr. Fahim.pptx

Understanding DIABESITY by Dr. Fahim

1. Understanding DIABESITY Dr. Md. Seum Siddiki Fahim

2. Introduction “Diabesity” describe the very strong pathophysiological link between diabetes and excess body weight in 1970s. ‘Diabesity’, the term coined to show the strong interlink between obesity and diabetes, is the direct consequence of the obesity pandemic, and poses significant challenges in the management of the disease. Without addressing the clinical and mechanistic complications of obesity such as metabolic-associated fatty liver disease and obstructive sleep apnoea , a rational management algorithm for diabesity cannot be developed. Management of diabesity: Current concepts: World J Diabetes. 2023 Apr 15; 14(4): 396–411.

3. Epidemiology 800 million people around the world at present live with obesity, with an estimated health expenditure of one trillion United States dollars budgeted for managing obesity-related conditions in the year 2025 Rates of overweight and obesity continue to grow in adults and children. From 1975 to 2016, the prevalence of overweight or obese children and adolescents aged 5–19 years increased more than four-fold from 4% to 18% globally. There is also an expected increase in childhood obesity to 250 million by the year 2030 Management of diabesity: Current concepts:World J Diabetes 2023 April 15; 14(4): 396-411 who/health-topics/obesity

4. Obesity Overweight and obesity are defined as abnormal or excessive fat accumulation that presents a risk to health. A body mass index (BMI) over 25 is considered overweight, and over 30 is obese. who/health-topics/obesity

5. Causes Consequences Prevention

6. Causes Consequences Prevention

7. Causes Consequences Prevention

8. Causes Consequences Prevention

9. BMI Chart https://www.nutritionmasterclass.com.ph/bmi-calculator

10. How does weight relate to Diabetes? honorhealth /medical-services/bariatric-weight-loss-surgery/patient-education-and-support/comorbidities-type-2-diabetes When an individual predisposed to diabetes has excess weight, the cells in the body become less sensitive to the insulin. Fat cells are more resistant to insulin than muscle cells. E xcess circulating lipid substrates, such as fatty acids, due to excessive consumption through a high fat diet, which also results in chronic inflammation and oxidative stress. A long-term high fat diet may result in lipid deposition in tissues that would not normally be targeted by insulin.. Obesity and morbid obesity greatly increase your risk of having heart disease, type 2 diabetes, certain types of cancer, sleep apnea, osteoarthritis and much more.

11. Pathophysiology of Diabesity Management of diabesity: Current concepts-World J Diabetes 2023 April 15; 14(4): 396-411

12. MAJOR COMORBIDITIES TO BE ADDRESSED IN MANAGING DIABESITY Management of diabesity: Current concepts-World J Diabetes 2023 April 15; 14(4): 396-411 Metabolic Associated Fatty Liver Disease (MAFLD) has the significant link between fatty liver disease & insulin resistance. Hepatic cellular damage, oxidative stress, and insulin resistance develop in such cases. A study investigating the presence of fatty liver disease vs simple hepatic steatosis in patients with T2DM or metabolic syndrome, revealed that almost all diabetic patients showed evidence of steatohepatitis on liver biopsy, without necessarily showing derangement in their liver function. This suggests that MAFLD may be one of the early end-organ complications of T2DM and metabolic syndrome, with early occult onset and progression without any clinical signs MAFLD OSA involves partial or complete obstruction of the airway during sleep, which results in transient hypoxaemia , sleep restriction and reduction in intrathoracic pressures. OSA and hypoxia have also been linked to alterations in adipokine levels as well as oxidative stress. All, in turn, lead to the accumulation of excess adipose tissue and the development insulin resistance. OSA could be aggravated by T2DM and obesity OSA and sleep disturbances Diabesity significantly contributes to endothelial damage and heart failure, which are both exacerbated by dyslipidaemia . Inefficient energy production and expenditure, causing cardiac stress. Diabetes exhibit cardiac oxidative stress and poor utilisation of energy substrates, in turn causing dysfunction in cardiac muscle contraction. Increased consumption of fats may also contribute to cardiac steatosis which will also impair cardiac function. Dyslipidemia and cardiovascular risk Obese individuals without metabolic complications had a significantly higher coronary calcium score when compared to non-obese patients (17% increase in risk of higher coronary artery calcium scores). Obesity alone, even without the presence of diabetes, would result in increased coronary artery disease risk. Recent advances in cardiac imaging modalities, including cardiac MR and computed tomography coronary angiography, may allow for early identification and management of coronary artery disease in diabesity patients Hypertension and coronary artery disease Development of diabesity-related kidney disease may be mediated through insulin resistance. Insulin is essential for normal glomerular function and podocyte biology, and dysfunctional insulin signaling has been shown to dysregulate vascular endothelial growth factor A signaling pathway and affects glucose transport. Excessive amounts of glucose, fatty acids, and amino acids present in the proximal tubule due to obesity or diabetes, will cause dysregulation in the relevant pathways normally protecting kidney, and consequently result in tubular injury, fibrosis, and inflammation. Therefore, medications such as SGLT-2 inhibitors may help to prevent the presence of excessive nutrients in proximal tubule cells, due to induction of glycosuria, and therefore help to minimize tubular damage through this mechanism. Diabetes-related chronic kidney disease

13. MAJOR COMORBIDITIES TO BE ADDRESSED IN MANAGING DIABESITY Management of diabesity: Current concepts-World J Diabetes 2023 April 15; 14(4): 396-411 Metabolic Associated Fatty Liver Disease (MAFLD) has the significant link between fatty liver disease & insulin resistance. Hepatic cellular damage, oxidative stress, and insulin resistance develop in such cases. A study investigating the presence of fatty liver disease vs simple hepatic steatosis in patients with T2DM or metabolic syndrome, revealed that almost all diabetic patients showed evidence of steatohepatitis on liver biopsy, without necessarily showing derangement in their liver function. This suggests that MAFLD may be one of the early end-organ complications of T2DM and metabolic syndrome, with early occult onset and progression without any clinical signs MAFLD OSA involves partial or complete obstruction of the airway during sleep, which results in transient hypoxaemia , sleep restriction and reduction in intrathoracic pressures. OSA and hypoxia have also been linked to alterations in adipokine levels as well as oxidative stress. All, in turn, lead to the accumulation of excess adipose tissue and the development insulin resistance. OSA could be aggravated by T2DM and obesity OSA and sleep disturbances Diabesity significantly contributes to endothelial damage and heart failure, which are both exacerbated by dyslipidaemia . Inefficient energy production and expenditure, causing cardiac stress. Diabetes exhibit cardiac oxidative stress and poor utilisation of energy substrates, in turn causing dysfunction in cardiac muscle contraction. Increased consumption of fats may also contribute to cardiac steatosis which will also impair cardiac function. Dyslipidemia and cardiovascular risk Obese individuals without metabolic complications had a significantly higher coronary calcium score when compared to non-obese patients (17% increase in risk of higher coronary artery calcium scores). Obesity alone, even without the presence of diabetes, would result in increased coronary artery disease risk. Recent advances in cardiac imaging modalities, including cardiac MR and computed tomography coronary angiography, may allow for early identification and management of coronary artery disease in diabesity patients Hypertension and coronary artery disease Development of diabesity-related kidney disease may be mediated through insulin resistance. Insulin is essential for normal glomerular function and podocyte biology, and dysfunctional insulin signaling has been shown to dysregulate vascular endothelial growth factor A signaling pathway and affects glucose transport. Excessive amounts of glucose, fatty acids, and amino acids present in the proximal tubule due to obesity or diabetes, will cause dysregulation in the relevant pathways normally protecting kidney, and consequently result in tubular injury, fibrosis, and inflammation. Therefore, medications such as SGLT-2 inhibitors may help to prevent the presence of excessive nutrients in proximal tubule cells, due to induction of glycosuria, and therefore help to minimize tubular damage through this mechanism. Diabetes-related chronic kidney disease

14. MAJOR COMORBIDITIES TO BE ADDRESSED IN MANAGING DIABESITY Management of diabesity: Current concepts-World J Diabetes 2023 April 15; 14(4): 396-411 Metabolic Associated Fatty Liver Disease (MAFLD) has the significant link between fatty liver disease & insulin resistance. Hepatic cellular damage, oxidative stress, and insulin resistance develop in such cases. A study investigating the presence of fatty liver disease vs simple hepatic steatosis in patients with T2DM or metabolic syndrome, revealed that almost all diabetic patients showed evidence of steatohepatitis on liver biopsy, without necessarily showing derangement in their liver function. This suggests that MAFLD may be one of the early end-organ complications of T2DM and metabolic syndrome, with early occult onset and progression without any clinical signs MAFLD OSA involves partial or complete obstruction of the airway during sleep, which results in transient hypoxaemia , sleep restriction and reduction in intrathoracic pressures. OSA and hypoxia have also been linked to alterations in adipokine levels as well as oxidative stress. All, in turn, lead to the accumulation of excess adipose tissue and the development insulin resistance. OSA could be aggravated by T2DM and obesity OSA and sleep disturbances Diabesity significantly contributes to endothelial damage and heart failure, which are both exacerbated by dyslipidaemia . Inefficient energy production and expenditure, causing cardiac stress. Diabetes exhibit cardiac oxidative stress and poor utilisation of energy substrates, in turn causing dysfunction in cardiac muscle contraction. Increased consumption of fats may also contribute to cardiac steatosis which will also impair cardiac function. Dyslipidemia and cardiovascular risk Obese individuals without metabolic complications had a significantly higher coronary calcium score when compared to non-obese patients (17% increase in risk of higher coronary artery calcium scores). Obesity alone, even without the presence of diabetes, would result in increased coronary artery disease risk. Recent advances in cardiac imaging modalities, including cardiac MR and computed tomography coronary angiography, may allow for early identification and management of coronary artery disease in diabesity patients Hypertension and coronary artery disease Development of diabesity-related kidney disease may be mediated through insulin resistance. Insulin is essential for normal glomerular function and podocyte biology, and dysfunctional insulin signaling has been shown to dysregulate vascular endothelial growth factor A signaling pathway and affects glucose transport. Excessive amounts of glucose, fatty acids, and amino acids present in the proximal tubule due to obesity or diabetes, will cause dysregulation in the relevant pathways normally protecting kidney, and consequently result in tubular injury, fibrosis, and inflammation. Therefore, medications such as SGLT-2 inhibitors may help to prevent the presence of excessive nutrients in proximal tubule cells, due to induction of glycosuria, and therefore help to minimize tubular damage through this mechanism. Diabetes-related chronic kidney disease

15. Metabolic Associated Fatty Liver Disease (MAFLD) has the significant link between fatty liver disease & insulin resistance. Hepatic cellular damage, oxidative stress, and insulin resistance develop in such cases. A study investigating the presence of fatty liver disease vs simple hepatic steatosis in patients with T2DM or metabolic syndrome, revealed that almost all diabetic patients showed evidence of steatohepatitis on liver biopsy, without necessarily showing derangement in their liver function. This suggests that MAFLD may be one of the early end-organ complications of T2DM and metabolic syndrome, with early occult onset and progression without any clinical signs MAFLD MAJOR COMORBIDITIES TO BE ADDRESSED IN MANAGING DIABESITY Management of diabesity: Current concepts-World J Diabetes 2023 April 15; 14(4): 396-411 OSA involves partial or complete obstruction of the airway during sleep, which results in transient hypoxaemia , sleep restriction and reduction in intrathoracic pressures. OSA and hypoxia have also been linked to alterations in adipokine levels as well as oxidative stress. All, in turn, lead to the accumulation of excess adipose tissue and the development insulin resistance. OSA could be aggravated by T2DM and obesity OSA and sleep disturbances Diabesity significantly contributes to endothelial damage and heart failure, which are both exacerbated by dyslipidaemia . Inefficient energy production and expenditure, causing cardiac stress. Diabetes exhibit cardiac oxidative stress and poor utilisation of energy substrates, in turn causing dysfunction in cardiac muscle contraction. Increased consumption of fats may also contribute to cardiac steatosis which will also impair cardiac function. Dyslipidemia and cardiovascular risk Obese individuals without metabolic complications had a significantly higher coronary calcium score when compared to non-obese patients (17% increase in risk of higher coronary artery calcium scores). Obesity alone, even without the presence of diabetes, would result in increased coronary artery disease risk. Recent advances in cardiac imaging modalities, including cardiac MR and computed tomography coronary angiography, may allow for early identification and management of coronary artery disease in diabesity patients Hypertension and coronary artery disease Development of diabesity-related kidney disease may be mediated through insulin resistance. Insulin is essential for normal glomerular function and podocyte biology, and dysfunctional insulin signaling has been shown to dysregulate vascular endothelial growth factor A signaling pathway and affects glucose transport. Excessive amounts of glucose, fatty acids, and amino acids present in the proximal tubule due to obesity or diabetes, will cause dysregulation in the relevant pathways normally protecting kidney, and consequently result in tubular injury, fibrosis, and inflammation. Therefore, medications such as SGLT-2 inhibitors may help to prevent the presence of excessive nutrients in proximal tubule cells, due to induction of glycosuria, and therefore help to minimize tubular damage through this mechanism. Diabetes-related chronic kidney disease

16. OSA involves partial or complete obstruction of the airway during sleep, which results in transient hypoxaemia , sleep restriction and reduction in intrathoracic pressures. OSA and hypoxia have also been linked to alterations in adipokine levels as well as oxidative stress. All, in turn, lead to the accumulation of excess adipose tissue and the development insulin resistance. OSA could be aggravated by T2DM and obesity OSA and sleep disturbances Metabolic Associated Fatty Liver Disease (MAFLD) has the significant link between fatty liver disease & insulin resistance. Hepatic cellular damage, oxidative stress, and insulin resistance develop in such cases. A study investigating the presence of fatty liver disease vs simple hepatic steatosis in patients with T2DM or metabolic syndrome, revealed that almost all diabetic patients showed evidence of steatohepatitis on liver biopsy, without necessarily showing derangement in their liver function. This suggests that MAFLD may be one of the early end-organ complications of T2DM and metabolic syndrome, with early occult onset and progression without any clinical signs MAFLD MAJOR COMORBIDITIES TO BE ADDRESSED IN MANAGING DIABESITY Management of diabesity: Current concepts-World J Diabetes 2023 April 15; 14(4): 396-411 Diabesity significantly contributes to endothelial damage and heart failure, which are both exacerbated by dyslipidaemia . Inefficient energy production and expenditure, causing cardiac stress. Diabetes exhibit cardiac oxidative stress and poor utilisation of energy substrates, in turn causing dysfunction in cardiac muscle contraction. Increased consumption of fats may also contribute to cardiac steatosis which will also impair cardiac function. Dyslipidemia and cardiovascular risk Obese individuals without metabolic complications had a significantly higher coronary calcium score when compared to non-obese patients (17% increase in risk of higher coronary artery calcium scores). Obesity alone, even without the presence of diabetes, would result in increased coronary artery disease risk. Recent advances in cardiac imaging modalities, including cardiac MR and computed tomography coronary angiography, may allow for early identification and management of coronary artery disease in diabesity patients Hypertension and coronary artery disease Development of diabesity-related kidney disease may be mediated through insulin resistance. Insulin is essential for normal glomerular function and podocyte biology, and dysfunctional insulin signaling has been shown to dysregulate vascular endothelial growth factor A signaling pathway and affects glucose transport. Excessive amounts of glucose, fatty acids, and amino acids present in the proximal tubule due to obesity or diabetes, will cause dysregulation in the relevant pathways normally protecting kidney, and consequently result in tubular injury, fibrosis, and inflammation. Therefore, medications such as SGLT-2 inhibitors may help to prevent the presence of excessive nutrients in proximal tubule cells, due to induction of glycosuria, and therefore help to minimize tubular damage through this mechanism. Diabetes-related chronic kidney disease

17. OSA involves partial or complete obstruction of the airway during sleep, which results in transient hypoxaemia , sleep restriction and reduction in intrathoracic pressures. OSA and hypoxia have also been linked to alterations in adipokine levels as well as oxidative stress. All, in turn, lead to the accumulation of excess adipose tissue and the development insulin resistance. OSA could be aggravated by T2DM and obesity OSA and sleep disturbances Metabolic Associated Fatty Liver Disease (MAFLD) has the significant link between fatty liver disease & insulin resistance. Hepatic cellular damage, oxidative stress, and insulin resistance develop in such cases. A study investigating the presence of fatty liver disease vs simple hepatic steatosis in patients with T2DM or metabolic syndrome, revealed that almost all diabetic patients showed evidence of steatohepatitis on liver biopsy, without necessarily showing derangement in their liver function. This suggests that MAFLD may be one of the early end-organ complications of T2DM and metabolic syndrome, with early occult onset and progression without any clinical signs MAFLD MAJOR COMORBIDITIES TO BE ADDRESSED IN MANAGING DIABESITY Management of diabesity: Current concepts-World J Diabetes 2023 April 15; 14(4): 396-411 Diabesity significantly contributes to endothelial damage and heart failure, which are both exacerbated by dyslipidaemia . Inefficient energy production and expenditure, causing cardiac stress. Diabetes exhibit cardiac oxidative stress and poor utilisation of energy substrates, in turn causing dysfunction in cardiac muscle contraction. Increased consumption of fats may also contribute to cardiac steatosis which will also impair cardiac function. Dyslipidemia and cardiovascular risk Obese individuals without metabolic complications had a significantly higher coronary calcium score when compared to non-obese patients (17% increase in risk of higher coronary artery calcium scores). Obesity alone, even without the presence of diabetes, would result in increased coronary artery disease risk. Recent advances in cardiac imaging modalities, including cardiac MR and computed tomography coronary angiography, may allow for early identification and management of coronary artery disease in diabesity patients Hypertension and coronary artery disease Development of diabesity-related kidney disease may be mediated through insulin resistance. Insulin is essential for normal glomerular function and podocyte biology, and dysfunctional insulin signaling has been shown to dysregulate vascular endothelial growth factor A signaling pathway and affects glucose transport. Excessive amounts of glucose, fatty acids, and amino acids present in the proximal tubule due to obesity or diabetes, will cause dysregulation in the relevant pathways normally protecting kidney, and consequently result in tubular injury, fibrosis, and inflammation. Therefore, medications such as SGLT-2 inhibitors may help to prevent the presence of excessive nutrients in proximal tubule cells, due to induction of glycosuria, and therefore help to minimize tubular damage through this mechanism. Diabetes-related chronic kidney disease

18. Management Of Diabesity Management of diabesity: Current concepts-World J Diabetes 2023 April 15; 14(4): 396-411 The first step in the management of diabesity, prior to medical intervention would be to attempt weight loss via lifestyle modifications such as changes in diet and exercise. Smaller degrees of weight loss such as 5 kg have been shown to decrease fasting blood glucose and improve the insulin sensing ability of adipose, skeletal muscle and liver tissues. Stepwise incremental weight loss has been shown to result in a gradual improvement in HbA1c. Dietary modifications

19. Management Of Diabesity Management of diabesity: Current concepts-World J Diabetes 2023 April 15; 14(4): 396-411 Regular physical activity, regardless of the associated weight loss, has been shown to improve HbA1c and insulin sensitivity. Exercise comes with a variety of benefits including reduction in visceral adipose tissue, improvement in lipids and blood pressure and hence a reduction in the cardiometabolic risk. A combined diet and exercise program is recommended in order to achieve the best possible outcome. Results from the Malmö study further support this, where patients on a combined diet and exercise modification program demonstrated long-term sustainable benefits, with half the T2DM patients in remission at 5 years. Physical activity

20. Management Of Diabesity Management of diabesity: Current concepts-World J Diabetes 2023 April 15; 14(4): 396-411 First-line medications for the management of T2DM. Metformin works by inhibiting hepatic gluconeogenesis, improving insulin sensitivity in skeletal muscle and reduction of appetite. It may also positively affect the composition of the gut microbiome and may potentially lead to improved glucose metabolism in the gut, resulting in weight loss. Metformin demonstrated significant benefits in a variety of health issues including chronic kidney disease, cardiovascular disease and several cancers by preventing growth and metastasis of tumor cells and the effect on the gut microbiome Drug Therapy (Metformin)

21. Management Of Diabesity Management of diabesity: Current concepts-World J Diabetes 2023 April 15; 14(4): 396-411 Insulin therapy is recommended in patients with significantly elevated HbA1c, where the aim is rapid and effective optimization of glycemic control. Insulin therapy has been associated with significant weight gain, especially when compared to other hypoglycemic agents. Weight gain ranging between 1.56-5.75 kg has been reported with insulin use, which may make clinicians reluctant to prescribe it in overweight/obese diabetic patients. Basal insulin has been shown to have a lesser effect on weight than pre-mixed insulin. Careful consideration, with joint decision making between patients and specialists, is recommended when prescribing insulin in patients with diabesity, to minimize the risk of weight gain while achieving the benefits of rapid optimization of glycemic control Drug Therapy (Insulin)

22. Management Of Diabesity Management of diabesity: Current concepts-World J Diabetes 2023 April 15; 14(4): 396-411 Sulfonylureas are generally not recommended in patients with obesity, due to significant risk of hypoglycemia, weight gain, reduced efficacy, and the need for careful dose titration in patients with renal disease. Hypoglycemia risk has been reported to vary between sulfonylurea agents, with Gliclazide having the lowest reported incidence among this class of medications Drug Therapy (Sulfonylureas)

23. Management Of Diabesity Management of diabesity: Current concepts-World J Diabetes 2023 April 15; 14(4): 396-411 Thiazolidinediones are the only oral antihyperglycemic agents that specifically target and improve the phenomenon of insulin resistance. Through the activation of the peroxisome proliferator-activated receptor gamma system, they increase glucose utilization, decrease hepatic steatosis, and decrease circulating free fatty acids. These oral agents, despite having a low risk of hypoglycemia, and relatively favorable efficacy in HbA1c reduction, have been also associated with significant weight gain between 2.3-4.25 kg. Drug Therapy (Thiazolidinediones)

24. Management Of Diabesity Management of diabesity: Current concepts-World J Diabetes 2023 April 15; 14(4): 396-411 Dipeptidyl peptidase-4 (DPP-4) agents are considered as “weight neutral” agents, with minimal effect on overall body weight. They work by inhibiting the breakdown of GLP-1 and glucose dependent insulinotropic peptide (GIP) in the gut, maximizing the duration of action of these incretin hormones. This class of medications is not generally used as monotherapy, rather than in combination with other oral antihyperglycemic agents. The addition of DPP-4 inhibitors to metformin therapy, showed favorable weight outcomes when compared to the addition of sulfonylureas or thiazolidinedione in recent trials. DPP-4 inhibitors has been shown to increase the incidence of hospitalization from heart failure. Drug Therapy (Dipeptidyl peptidase-4 inhibitors)

25. Management Of Diabesity Management of diabesity: Current concepts-World J Diabetes 2023 April 15; 14(4): 396-411 GLP-1 receptor agonists work by the stimulation of insulin secretion and suppression of glucagon production. It reduces appetite & improves feeling of satiety, hence contributing to weight loss (1.14-6.9 kg) & an improvement in HbA1c between 1%-2%. Liraglutide & Semaglutide has shown to be beneficial in the management obese nondiabetic patients. Additionally, GLP-1 agonists have been shown to have significant systemic benefits, including reduction in cardiovascular risk in high-risk patients and reduction in urinary albumin excretion. Drug Therapy (GLP-1 receptor agonists)

26. Management Of Diabesity Management of diabesity: Current concepts-World J Diabetes 2023 April 15; 14(4): 396-411 Drug Therapy (GLP-1 receptor agonists) The mechanisms of actions of GLP-1 agonists in improving diabesity

27. Management Of Diabesity Management of diabesity: Current concepts-World J Diabetes 2023 April 15; 14(4): 396-411 SGLT-2 inhibitors reduce the glucose reabsorption in the renal tubules, resulting in increased glucose excretion in the urine. They have been associated with a reduction in HbA1c of about 0.69% and a weight loss between 0.9-2.5 kg. Studies have shown improvement in waist circumference, central obesity, and visceral adiposity, all of which are features of diabesity as well as metabolic syndrome. The EMPEROR-R trial further demonstrated that empagliflozin improved renal outcomes in patients with reduced ejection fraction or other types of heart failure. The main risks associated with the use of SGLT-2 inhibitors include increased incidence of UTI and genital thrush, due to glycosuria, as well as euglycemic ketoacidosis. Drug Therapy (SGLT-2 inhibitors)

28. Management Of Diabesity Management of diabesity: Current concepts-World J Diabetes 2023 April 15; 14(4): 396-411 Drug Therapy (SGLT-2 inhibitors) Mechanisms of actions of sodium glucose cotransporter-2 inhibitors in improving diabesity and their potential effects on organ protection such as kidney and heart.

29. Management Of Diabesity Management of diabesity: Current concepts-World J Diabetes 2023 April 15; 14(4): 396-411 Amylin is a pancreatic hormone secreted in response to the presence of nutrients in the gut. It modulates calcitonin and amylin receptors, and thereby regulates energy utilization as well as body weight. This is achieved through the enhancement of satiety and delay in gastric emptying. Pramlintide, a type of amylin analogue has been associated with a reduction in HbA1c and also a weight loss of 1.5-2.5 kg Drug Therapy (Amylin Analogues)

30. Management Of Diabesity Management of diabesity: Current concepts-World J Diabetes 2023 April 15; 14(4): 396-411 Endoscopic methods target the stomach, and through a variety of techniques aim to restrict gastric capacity, emptying or food absorption. Intragastric balloon (IGB) is generally recommended for patients with a body mass index (BMI) between 35-40 kg/m², or as an interim measure, with an aim for more definitive bariatric surgery, in patients with BMI > 40 kg/m ². In this procedure, studies showed a 18% total body weight loss at 24 month, with relatively low adverse effect profile. Bariatric Procedures (Bariatric Endoscopy)

31. Management Of Diabesity Management of diabesity: Current concepts-World J Diabetes 2023 April 15; 14(4): 396-411 Bariatric surgery continues to be the most effective mode of definitive treatment for marked weight loss and diabesity. Duodenal switch was associated with the most weight loss, of 70%-80% at 2 years, and resolution of obesity and diabetes related comorbidities. In terms of cardiovascular disease, metabolic surgery was shown to improve 5-year survival from coronary artery disease, in diabetic patients who are insulin treated. Bariatric Procedures (Metabolic Surgery)

32. An evidence-based management algorithm for the management of diabesity Management of diabesity: Current concepts-World J Diabetes 2023 April 15; 14(4): 396-411

33. Conclusion Diabesity is a growing worldwide epidemic that must be taken seriously. Presence of obesity in a diabetic patient could hinder both diabetes control & obesity management. Multidisciplinary approach is considered now a days the most successful way of management of both conditions. Weight reduction through dietary interventions & exercise must be 1 st and long-lasting step-in management of diabesity. Lastly, bariatric surgeries may be indicated.