Obesity and Type 2 Diabetes

BMI remains a practical screening metric: U.S. obesity is conventionally BMI at least 30 kg/m², with class 1, 2, and 3 thresholds of 30 to less than 35, 35 to less than 40, and at least 40 kg/m², respectively. BMI is limited because it cannot distinguish fat from lean mass or fluid retention, and it does not characterize central adiposity. jaccjacc2025 Concise Clinical Guidance: An ACC Expert Consensus Statement on Medical Weight Management for Optimization of Cardiovascular Health: A Report of the American College of Cardiology Solution Set Oversight Committee

Measure waist circumference in addition to BMI when central adiposity or cardiometabolic risk classification is clinically uncertain. Thresholds cited by ACC are at least 35 inches in women and at least 40 inches in men; waist-to-height ratio of at least 0.50 is also abnormal. For many Asian populations, lower BMI and waist thresholds apply. jaccjacc2025 Concise Clinical Guidance: An ACC Expert Consensus Statement on Medical Weight Management for Optimization of Cardiovascular Health: A Report of the American College of Cardiology Solution Set Oversight Committee

The initial obesity-focused diabetes evaluation should identify treatment-relevant complications and contributors: ASCVD, HF phenotype, CKD and albuminuria, hypertension, dyslipidemia, sleep-disordered breathing, atrial fibrillation, MASLD, osteoarthritis, medication-associated weight gain, depression or eating disorder, food insecurity, and affordability barriers. Obesity and diabetes management should not be separated from prevention and treatment of these complications. BMJ+2BMJAdvances in the management of type 2 diabetes in adultsjacc2025 ACC Scientific Statement on the Management of ...jacc2025 Concise Clinical Guidance: An ACC Expert Consensus Statement on Medical Weight Management for Optimization of Cardiovascular Health: A Report of the American College of Cardiology Solution Set Oversight Committee

Excess and dysfunctional adipose tissue promotes insulin resistance through ectopic lipid accumulation, altered adipokine signaling, inflammation, and impaired insulin action in liver and skeletal muscle; the practical consequence is progressive hyperglycemia and greater cardiometabolic risk. PubMedPubMedThe Role of Obesity in Type 2 Diabetes Mellitus—An Overview

Weight loss as small as 5% is associated with improvement in blood pressure, triglycerides, fasting glucose, and incident diabetes risk; for people seeking improvement in weight-related comorbidities, ACC guidance identifies a practical target of at least 10% weight loss. jaccjacc2025 Concise Clinical Guidance: An ACC Expert Consensus Statement on Medical Weight Management for Optimization of Cardiovascular Health: A Report of the American College of Cardiology Solution Set Oversight Committee

In adults with type 2 diabetes, lifestyle intervention is foundational but should not be expected to replace evidence-based pharmacotherapy when cardiorenal risk, significant obesity, or treatment failure is present. In Look AHEAD, intensive lifestyle treatment did not reduce the primary cardiovascular composite outcome versus usual care, although participants achieving at least 10% loss in year 1 had lower cardiovascular event risk in post hoc analysis. BMJBMJAdvances in the management of type 2 diabetes in adults

For adults with type 2 diabetes and established ASCVD or indicators of high ASCVD risk, initiate a GLP-1 receptor agonist or SGLT2 inhibitor with demonstrated cardiovascular benefit regardless of HbA1c or background therapy. In cardiovascular outcomes trials, dulaglutide, liraglutide, subcutaneous semaglutide, canagliflozin, and empagliflozin reduced major adverse cardiovascular events versus placebo. BMJBMJAdvances in the management of type 2 diabetes in adults

For HF, SGLT2 inhibitors have consistent outcome benefit and should be prioritized. For CKD with eGFR below 60 mL/min/1.73 m² or albuminuria, SGLT2 inhibitors are preferred to slow CKD progression; current prescribing information described in the evidence allows initiation for kidney benefit at eGFR at least 20 mL/min/1.73 m², although glucose-lowering efficacy is substantially reduced below eGFR 45 mL/min/1.73 m². BMJBMJAdvances in the management of type 2 diabetes in adults

When obesity or weight-related complications are a major treatment target, tirzepatide and subcutaneous semaglutide have the highest weight-loss efficacy among the glucose-lowering options summarized in the supplied evidence. Metformin and DPP-4 inhibitors are generally weight neutral; SGLT2 inhibitors produce more modest weight loss. BMJBMJAdvances in the management of type 2 diabetes in adults

When initiating incretin-based weight therapy in diabetes, reassess insulin and insulin secretagogues to prevent hypoglycemia. In patients with HF or hypertension, reassess diuretics and antihypertensives during dose escalation and clinically meaningful weight loss to avoid intravascular depletion or hypotension. jacc+1jacc2025 ACC Scientific Statement on the Management of ...jacc2025 Concise Clinical Guidance: An ACC Expert Consensus Statement on Medical Weight Management for Optimization of Cardiovascular Health: A Report of the American College of Cardiology Solution Set Oversight Committee

SGLT2 inhibitors are associated with diabetic ketoacidosis, including euglycemic presentations. In type 2 diabetes, discontinue the SGLT2 inhibitor when ketoacidosis is suspected and hold it 3 to 4 days before scheduled surgery, during prolonged fasting or very low carbohydrate intake, and during critical illness. BMJBMJAdvances in the management of type 2 diabetes in adults

Monitor symptoms rather than serial lipase concentrations for pancreatitis. If pancreatitis develops while receiving a GLP-1 receptor agonist, DPP-4 inhibitor, or tirzepatide, discontinue therapy and do not restart it. BMJBMJAdvances in the management of type 2 diabetes in adults

In obesity-related HFpEF, semaglutide and tirzepatide have randomized evidence for improved symptoms and functional capacity. In STEP-HFpEF, semaglutide improved Kansas City Cardiomyopathy Questionnaire clinical summary score and 6-minute walk distance; in SUMMIT, tirzepatide reduced the composite of cardiovascular death or worsening HF. jacc+1jacc2025 ACC Scientific Statement on the Management of ...jacc2025 Concise Clinical Guidance: An ACC Expert Consensus Statement on Medical Weight Management for Optimization of Cardiovascular Health: A Report of the American College of Cardiology Solution Set Oversight Committee

Do not extrapolate HFpEF incretin evidence to HFrEF. Earlier liraglutide trials in advanced HFrEF raised concern for HF hospitalization and arrhythmias, while larger cardiovascular outcomes studies have not demonstrated clear harm; safety and efficacy of modern anti-obesity incretin therapy in HFrEF remain uncertain. jaccjacc2025 ACC Scientific Statement on the Management of ...

Metabolic and bariatric surgery produces larger and more durable weight loss than lifestyle therapy or pharmacotherapy, but established HF increases perioperative risk. Observational data suggest fewer HF events after surgery, yet randomized outcomes trials in established HF are lacking; optimize HF therapy and refer to experienced multidisciplinary centers. jaccjacc2025 ACC Scientific Statement on the Management of ...