Diabetes Standards of Care and Resources for Clinicians and Educators
Adult Weight Management
Weight loss and body fat reduction in people who are overweight or obese offer many health benefits and can improve health-related quality of life. It is an evidence-based strategy for diabetes prevention and management. People with type 2 diabetes will generally experience improvement in blood sugar control, reduced need for diabetes medications, and improved ability to engage in physical activities as they lose weight. Individuals who have significant weight loss may even experience diabetes remission.
Weight loss is also an effective treatment for metabolic dysfunction-associated steatotic liver disease (MASLD) and obstructive sleep apnea. Furthermore, it reduces the risk of other diabetes-associated complications such as atherosclerotic cardiovascular disease (ASCVD) and diabetic kidney disease.
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Treatment for overweight and obesity should be individualized based on medical conditions, social circumstances, and a person’s preferences. It is important to assess an individual’s readiness to address weight loss and to seek their permission to discuss treatment strategies. Therapeutic lifestyle interventions designed to help individuals lose weight remain the cornerstone of weight management. Medications and surgery can be valuable treatment methods for some individuals, but are most effective when paired with lifestyle interventions.
Food and nutrition insecurity increases the risk of obesity, is more common in people with diabetes,1 and is prevalent in many American Indian and Alaska Native (AI/AN) communities. It can predispose people to overeating, skipping meals, and choosing less nutritious, less expensive foods that contribute to weight gain and hyperglycemia, if they have diabetes. It represents a significant challenge to people attempting to achieve and maintain a healthy weight and should be routinely assessed and addressed.
Obesity is a chronic, relapsing disease which can have a significant impact on diabetes management. Ongoing care and frequent support from the health care team is essential to help individuals achieve and maintain healthy weight and blood sugar control. It is important to re-evaluate the effectiveness of obesity care interventions on a regular basis.
Clinical Practice Recommendations
Recommendations for Weight Management
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The BMI, a ratio of weight to height, is used as a screening tool for adiposity and obesity. Other measures used for evaluating adiposity include waist circumference, waist-to-hip ratio, or other body composition analytic methods (i.e. DEXA, bioelectrical impedance analysis, etc.). See Gold Standard for Determining Body Fat Exit Disclaimer: You Are Leaving www.ihs.gov and Utility of Body Composition Assessment Exit Disclaimer: You Are Leaving www.ihs.gov for additional information.
- Assess weight at every diabetes visit. Height should be assessed at least once a year.
- Evaluate BMI at every visit. See Adult BMI Calculator Exit Disclaimer: You Are Leaving www.ihs.gov from the Centers for Disease Control and Prevention (CDC).
Classification BMI (Adults) Underweight ≤18.4 kg/m2 Normal weight 18.5 kg/m2 to 24.9 kg/m2 Overweight 25 kg/m2 to 29.9 kg/m2 Obesity (Class 1) 30 kg/m2 to 34.9 kg/m2 Obesity (Class 2) 35 kg/m2to 39.9 kg/m2 Obesity (Class 3) ≥40 kg/m2 -
- Provide nutrition assessment, education, and personalized goal setting at the initial visit and as needed for ongoing weight management and diabetes care.
- Refer people to a Registered Dietitian (RD) for nutrition assessments and medical nutrition therapy (MNT). Healthcare team members should offer basic nutrition assessment and education if an RD is unavailable. The Conversation Starter for Food and Nutrition [PDF – 1.5 MB] provides tips to help clinicians and educators talk with people about food, nutrition, and eating behaviors.
- Take into account health status, clinical considerations, cultural preferences, social drivers of health, and other circumstances that affect eating and activity patterns.
- Consider willingness and ability to make behavioral changes.
- Use the IHS Food Insecurity Assessment Tool and Resource List [PDF – 534 KB] to screen for and address food and nutrition insecurity, as a part of an ongoing strategy to help people achieve a healthier weight.
- Collaborate to develop and refine a plan for reducing caloric intake and optimizing nutrition.
- Use a food diary/dietary recall and blood glucose readings as a basis for working together to develop and refine plans.
- Address disordered eating patterns or triggers for overeating if present.
- Provide general guidance regarding the following:
- Energy Balance - generally speaking, women should aim for about 1200-1500 kcals per day. Men should aim for about 1500-1800 kcals per day.2
- Healthy eating patterns with limited carbohydrates (carbs) – focus on healthy carbs in appropriate amounts throughout the day. Encourage limiting carb intake to 2-4 carb servings at each meal for improved glucose management. High fiber carbs should be emphasized (to promote satiety and gut health).
- Adequate protein – weight reduction can adversely impact muscle and bone mass. Protein intake goals should be sufficient to help preserve muscle mass.
- General adult population - recommended daily allowance is 0.8 g/kg/d.
- Individuals using glucagon-like peptide-1 (GLP-1) receptor agonists - consider higher protein targets.3
- People with chronic kidney disease stages 3-5 – referral to RD and a lower target of 0.6-0.8 g/kg/d is recommended.
- Limit ultra-processed foods (UPFs) and high fat foods – UPFs and fats should be limited as they are a dense source of calories, unhealthy fats, sugars, and sodium.
- Hydration – ensure adequate hydration with non-caloric beverages.
References
- American Diabetes Association. 8. Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes: Standards of Care in Diabetes–2025. Exit Disclaimer: You Are Leaving www.ihs.gov Diabetes Care 2025, Vol.48, S167-S180. doi: 10.2337/dc25-S008
- Mozaffarian, D., Agarwal, M., Aggarwal, M., Alexander, L., et al, Nutritional priorities to support GLP-1 therapy for obesity: a joint Advisory from the American College of Lifestyle Medicine, the American Society for Nutrition, the Obesity Medicine Association, and The Obesity Society. Exit Disclaimer: You Are Leaving www.ihs.gov The American Journal of Clinical Nutrition. 122 (2025) 344-367. doi: 10.1016/j.ajcnut.2025.04.023
- Provide nutrition assessment, education, and personalized goal setting at the initial visit and as needed for ongoing weight management and diabetes care.
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- Assess current level of physical activity (PA) at each visit.
- Advise people to get at least 150 minutes/week of moderate-to-vigorous PA and, optimally, work up to 250 or more minutes/week.
- Recommend the addition of resistance exercise two to three days a week to help increase and maintain muscle mass and prevent sarcopenia.
- Advise breaking up sedentary time with light-intensity PA. See Move More Sit Less [PDF – 920 KB] Tip Sheet for additional guidance.
Note: Specific recommendations for increasing PA will vary by type of diabetes, age, activity, and presence of diabetes-related complications. See the IHS Standards of Care for Physical Activity for detailed guidance.
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- Screen for anxiety, depression, eating disorders, and substance use, and refer for behavioral health services as needed. See the Screening Tools Resource List for links to screening tools.
- Assess and address sleep management
- Screen for sleep problems, quantity, quality, as well as sleep disorders such as obstructive sleep apnea, chronic insomnia, and daytime sleepiness. See the Screening Tools Resource List for links to screening tools.
- Refer as indicated for further evaluation and treatment.
Screening Tools Resource List
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- Refer people to a structured lifestyle intervention program and health coaching (if available) to help them lose at least 5% of their weight and maintain this weight loss. Structured lifestyle intervention programs such as those described in the Look AHEAD4 study can facilitate long-term weight loss in people with diabetes.
- Encourage utilization of other resources to increase engagement and support weight loss efforts including:
- locally available resources such as weight management programs, support groups, fitness specialists, behavioral specialists, diabetes educators, and health coaches;
- online resources including individual or group education and support sessions with counselors, and internet-based support programs; and
- digital health technologies including mobile apps and wearable devices such as smart watches.
References
- Look AHEAD Research Group. Eight-year weight losses with an intensive lifestyle intervention: The Look AHEAD study. Exit Disclaimer: You Are Leaving www.ihs.gov Obesity 2014;22(1):5-13. doi: 10.1002/oby.20662.
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Medications for people with type 2 diabetes or comorbid conditions should be optimized to promote weight loss and minimize weight gain.
- Prescribe antidiabetic medication(s) from any of the following classes that promote weight loss. See IHS DDTP Algorithm, Glucose Management in Type 2 Diabetes. [PDF – 203 KB]
- Incretin mimetics, such as dulaglutide, liraglutide, semaglutide, and tirzepatide may decrease appetite and promote weight loss. Counsel people about maintaining muscle mass as well as managing common GI side effects including nausea, vomiting, diarrhea, constipation, and early satiety.
- Sodium-glucose cotransporter-2 inhibitors can cause glycosuria and weight loss.
Note: a subset of people may not experience significant weight loss with these medications, but they are effective antidiabetic medications with cardiac, renal, and/or hepatic benefits.
- Consider weight neutral antidiabetic medications if a person cannot tolerate medications above. See IHS DDTP Algorithm, Glucose Management in Type 2 Diabetes. [PDF – 203 KB]
- Metformin is the initial treatment of choice for people with no other co-morbidities who require medication to manage diabetes.
- Dipeptidyl peptidase-4 inhibitors and alpha-glucosidase inhibitors have little effect on weight.
- Advise people that weight gain is an expected side effect when prescribing insulin or oral agents, such as thiazolidinediones, sulfonylureas, or meglitinides. Monitor blood glucose levels. Consider titrating off these medications.
- Review the medication list for other drugs that promote weight gain, including psychiatric, cardiac, pulmonary, anticonvulsant, and progestin medications. Recommend modifications if appropriate.
- Consider any weight-loss medication with U.S. Food and Drug Administration (FDA) approval for people with a BMI of at least 27 kg/m2 who have not had an adequate response to a lifestyle intervention.
- Different formulations of incretin mimetics are available as weight loss medications. When prescribing these medications, counsel people about maintaining muscle mass as well as managing common GI side effects – including nausea, vomiting, diarrhea, constipation, and early satiety.
- Evaluate if the individual is a candidate for other weight loss medications including orlistat, phentermine, phentermine/topiramate, and naltrexone/bupropion.
- Discontinue the weight loss medication if the individual does not lose more than 5% of their baseline weight within 3 months.
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Bariatric (or metabolic) surgery results in significant weight loss for people with diabetes and obesity, and it can even lead to diabetes remission.5 People with diabetes and a BMI of at least 30 kg/m2 who have not had long-lasting weight loss and reduction in diabetes complications with lifestyle interventions, pharmacologic interventions, or both might consider bariatric surgery.
- Discuss various types of bariatric surgeries with people (e.g., Roux-en-Y gastric bypass or vertical-sleeve gastrectomy) along with each procedure’s risks, side effects, and potential for weight regain. For details on each type of surgery, see Types of Weight-Loss Surgery Exit Disclaimer: You Are Leaving www.ihs.gov from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).
- Refer people to a behavioral health assessment before surgery and address cultural, traditional, and social practices related to food that may arise after surgery.
- Refer people who might be candidates for metabolic surgery to a multidisciplinary weight management team at a facility that conducts many of these procedures each year.
- Manage the person’s medical and nutritional needs and provide behavioral and social support services after the surgery.
References
- Purnell JQ, Dewey EN, Laferrere B, Selzer F, Flum DR, Mitchel JE, et al. Diabetes remission status during seven-year follow-up of the Longitudinal Assessment of Bariatric Surgery Study. Exit Disclaimer: You Are Leaving www.ihs.gov J Clin Endocrinol Metab. 2021;106(3):774-788. doi: 10.1210/clinem/dgaa849.
Clinician and Educator Resources
Featured Weight Management, Overweight, and Obesity Resources
Patient Education Resources
Weight Management, Overweight, and Obesity Patient Education Resources
CME Training
| Session Title | Session Material | CME/CE Information |
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Ai-Ling Lin DO FACP
Clinical Consultant, Division of Diabetes Treatment and Prevention Indian Health Service Department of Health and Human Services (Originally presented on 05/29/2025) |
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New Helping Children with Obesity: Context, Understanding, and Tools Exit Disclaimer: You Are Leaving www.ihs.gov
Thomas Faber MD
Albuquerque Area Indian Health Service (Originally presented on 01/15/2025) |
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New Evaluation and Management of Pediatric Obesity: An Overview of the AAP Clinical Practice Guideline Exit Disclaimer: You Are Leaving www.ihs.gov
Ashley Weedn MD, MPH, FAAP
University of Oklahoma Health Sciences Center Medical Director, Healthy Futures Clinic, OU Health (Originally presented on 03/27/2024) |
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References
- Levi, R., Bleich, S., Seligman, H., Food Insecurity and Diabetes: Overview of Intersections and Potential Dual Solutions. Exit Disclaimer: You Are Leaving www.ihs.gov Diabetes Care 2023 June 24; 46(9): 1599-1608. doi: 10.2337/dci23-0002
