DIET, PHYSICAL ACTIVITY, AND BEHAVIORAL THERAPY

• Diet, physical activity, and behavioral therapy designed to achieve and maintain >5% weight loss should be prescribed for patients with type 2 diabetes who are overweight or obese and ready to achieve weight loss. 
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• Such interventions should be high intensity (≥16 sessions in 6 months) and focus on diet, physical activity, and behavioral strategies to achieve a 500–750 kcal/day energy deficit. 
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• Diets should be individualized, as those that provide the same caloric restriction but differ in protein, carbohydrate, and fat content are equally effective in achieving weight loss. 
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• For patients who achieve short-term weight-loss goals, long-term (≥1 year) comprehensive weight-maintenance programs should be prescribed. Such programs should provide at least monthly contact and encourage ongoing monitoring of body weight (weekly or more frequently) and/or other self-monitoring strategies, such as tracking intake, steps, etc.; continued consumption of a reduced-calorie diet; and participation in high levels of physical activity (200–300 min/week). 
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• To achieve weight loss of >5%, short-term (3-month) interventions that use very low-calorie diets (≤800 kcal/day) and total meal replacements may be prescribed for carefully selected patients by trained practitioners in medical care settings with close medical monitoring. To maintain weight loss, such programs must incorporate long-term comprehensive weight-maintenance counseling. 
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Among patients with type 2 diabetes who are overweight or obese and have inadequate glycemic, blood pressure, and lipid control and/or other obesity-related medical conditions, lifestyle changes that result in modest and sustained weight loss produce clinically meaningful reductions in blood glucose, A1C, and triglycerides.

Greater weight loss produces even greater benefits, including reductions in blood pressure, improvements in LDL and HDL cholesterol, and reductions in the need for medications to control blood glucose, blood pressure, and lipids, and may result in achievement of glycemic goals in the absence of antihyperglycemia agent use in some patients.

PHARMACOTHERAPY

• When choosing glucose-lowering medications for overweight or obese patients with type 2 diabetes, consider their effect on weight.
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• Whenever possible, minimize medications for comorbid conditions that are associated with weight gain.
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• Weight-loss medications are effective as adjuncts to diet, physical activity, and behavioral counseling for selected patients with type 2 diabetes and BMI ≥27 kg/m². Potential benefits must be weighed against the potential risks of the medications.
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• If a patient's response to weight-loss medications is <5% weight loss after 3 months or if there are significant safety or tolerability issues at any time, the medication should be discontinued and alternative medications or treatment approaches should be considered. 

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