Obesity in Patients with Type 1 Diabetes: Causes and Consequences

Obesity in patients with type 1 diabetes (T1D) is an increasingly important problem in diabetology. According to recent studies, the prevalence of overweight and obesity among patients with T1D varies from 15 to 50%. About a quarter of patients with T1D have metabolic syndrome. On the one hand, weight gain in patients with T1D reflects a general population trend. On the other hand, diabetes-related factors such as basal-bolus insulin therapy, chronic insulin overdose, hypoglycemia, and psychological problems associated with the disease can be promoters of weight gain. The relationship between T1D and obesity can be bidirectional. It has been established that overweight and obesity increase the risk of T1D, probably contributing to the autoimmune destruction of beta cells. Individuals with overweight and obesity, compared with patients with normal body weight, more often have insulin resistance, dyslipidemia and require higher doses of insulin to achieve targets of glycemic control. Obesity in individuals with T1D a risk factor for diabetic microvascular complications, arterial hypertension, chronic kidney disease, chronic heart failure, cardiovascular events, non-alcoholic fatty liver disease, and is associated with increased mortality. Therefore, maintaining normal body weight should be considered as an important option in the management of T1D. Education, moderate calorie restriction diet, and physical activity are the basis of the strategy for the prevention and treatment of obesity in individuals with T1D. Glucagon-like peptide-1 agonists, dual agonists of glucagon-like peptide-1 and glucose-dependent insulinotropic polypeptide, sodium-glucose cotransporter 2 inhibitors, and metformin are considered promising therapeutic options; however, data on the efficacy and safety of these drugs in patients with T1D are still limited. Experience in performing bariatric interventions in individuals with T1D and morbid obesity is accumulating. Further research is needed to create programs for the prevention and treatment of obesity in patients with T1D.

1. Ogle GD, Wang F, Gregory GA, Maniam J; T1D Index consortium. Type 1 diabetes estimates in children and adults - 2022 [cited 2024 Sep 17]. Available online: https://diabetesatlas.org/atlas/t1d-index-2022/

2. Dedov II, Shestakova MV, Vikulova OK, et al. Diabetes mellitus in the Russian Federation: dynamics of epidemiological indicators according to the Federal Register of Diabetes Mellitus for the period 2010–2022. Diabetes mellitus. 2023;26(2):104-123. (In Russ.). doi: https://doi.org/10.14341/DM13035

3. Redondo MJ, Morgan NG. Heterogeneity and endotypes in type 1 diabetes mellitus. Nat Rev Endocrinol. 2023;19(9):542-554. doi: https://doi.org/10.1038/s41574-023-00853-0

4. GBD 2015 Obesity Collaborators; Afshin A, Forouzanfar MH, Reitsma MB, et al. Health Effects of Overweight and Obesity in 195 Countries over 25 Years. N Engl J Med. 2017;377(1):13-27. doi: https://doi.org/10.1056/NEJMoa1614362

5. Lavens A, Nobels F, De Block C, et al. Effect of an Integrated, Multidisciplinary Nationwide Approach to Type 1 Diabetes Care on Metabolic Outcomes: An Observational Real-World Study. Diabetes Technol Ther. 2021;23(8):565-576. doi: https://doi.org/10.1089/dia.2021.0003

6. Edqvist J, Rawshani A, Adiels M, et al. BMI, Mortality, and Cardiovascular Outcomes in Type 1 Diabetes: Findings Against an Obesity Paradox. Diabetes Care. 2019;42(7):1297-1304. doi: https://doi.org/10.2337/dc18-1446

7. Wallace AS, Chang AR, Shin JI, et al. Obesity and Chronic Kidney Disease in US Adults With Type 1 and Type 2 Diabetes Mellitus. J Clin Endocrinol Metab. 2022;107(5):1247-1256. doi: https://doi.org/10.1210/clinem/dgab927

8. Foster NC, Beck RW, Miller KM, et al. State of Type 1 Diabetes Management and Outcomes from the T1D Exchange in 2016-2018. Diabetes Technol Ther. 2019;21(2):66-72. doi: https://doi.org/10.1089/dia.2018.0384

9. Fellinger P, Fuchs D, Wolf P, et al. Overweight and obesity in type 1 diabetes equal those of the general population. Wien Klin Wochenschr. 2019;131(3-4):55-60. doi: https://doi.org/10.1007/s00508-018-1434-9

10. Lavens A, De Block C, Oriot P, et al. Metabolic health in people living with type 1 diabetes in Belgium: a repeated cross-sectional study. Diabetologia. 2024; in press. doi: https://doi.org/10.1007/s00125-024-06273-7

11. Minges KE, Whittemore R, Weinzimer SA, et al. Correlates of overweight and obesity in 5529 adolescents with type 1 diabetes: The T1D Exchange Clinic Registry. Diabetes Res Clin Pract. 2017;126:68-78. doi: https://doi.org/10.1016/j.diabres.2017.01.012

12. Fröhlich-Reiterer EE, Rosenbauer J, Bechtold-Dalla Pozza S, et al. Predictors of increasing BMI during the course of diabetes in children and adolescents with type 1 diabetes: data from the German/Austrian DPV multicentre survey. Arch Dis Child. 2014;99(8):738-743. doi: https://doi.org/10.1136/archdischild-2013-304237

13. Maffeis C, Birkebaek NH, Konstantinova M, et al. Prevalence of underweight, overweight, and obesity in children and adolescents with type 1 diabetes: Data from the international SWEET registry. Pediatr Diabetes. 2018;19(7):1211-1220. doi: https://doi.org/10.1111/pedi.12730

14. Belete R, Ataro Z, Abdu A, Sheleme M. Global prevalence of metabolic syndrome among patients with type I diabetes mellitus: a systematic review and meta-analysis. Diabetol Metab Syndr. 2021;13(1):25. doi: https://doi.org/10.1186/s13098-021-00641-8

15. Kogan-Yasnyj VM. Terapevticheskoe znachenie insulina. Programmnyj doklad na IX s»ezde terapevtov. L.: Prakticheskaya medicina, 1926 (In Russ.)

16. Purnell JQ, Braffett BH, Zinman B, et al. Impact of Excessive Weight Gain on Cardiovascular Outcomes in Type 1 Diabetes: Results From the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Study. Diabetes Care. 2017;40(12):1756-1762. doi: https://doi.org/10.2337/dc16-2523

17. Edgerton DS, Lautz M, Scott M, et al. Insulin’s direct effects on the liver dominate the control of hepatic glucose production. J Clin Invest. 2006;116(2):521-7. doi: https://doi.org/10.1172/JCI27073

18. Zaharieva DP, Addala A, Simmons KM, Maahs DM. Weight Management in Youth with Type 1 Diabetes and Obesity: Challenges and Possible Solutions. Curr Obes Rep. 2020;9(4):412-423. doi: https://doi.org/10.1007/s13679-020-00411-z

19. Van der Schueren B, Ellis D, Faradji RN, et al. Obesity in people living with type 1 diabetes. Lancet Diabetes Endocrinol. 2021;9(11):776-785. doi: https://doi.org/10.1016/S2213-8587(21)00246-1

20. Merger SR, Kerner W, Stadler M, et al. Prevalence and comorbidities of double diabetes. Diabetes Res Clin Pract. 2016;119:48-56. doi: https://doi.org/10.1016/j.diabres.2016.06.003

21. Apperley LJ, Ng SM. Increased insulin requirement may contribute to risk of obesity in children and young people with Type 1 Diabetes Mellitus. Diabetes Metab Syndr. 2019;13(1):492-495. doi: https://doi.org/10.1016/j.dsx.2018.11.005

22. Klimontov VV, Yushin AY, Semenova YF, et al. Overweight and obesity in patients with type 1 diabetes: associations with vascular complications and biomarkers of vascular remodeling. Diabetes mellitus. 2024;27(6):528-535. (In Russ.) doi: https://doi.org/10.14341/DM13209

23. Birkebaek NH, Kahlert J, Bjarnason R, et al. Body mass index standard deviation score and obesity in children with type 1 diabetes in the Nordic countries. HbA1c and other predictors of increasing BMISDS. Pediatr Diabetes. 2018;19(7):1198-1205. doi: https://doi.org/10.1111/pedi.12693

24. Fureman AL, Lilja M, Lind T, et al. Comparing continuous subcutaneous insulin infusion and multiple daily injections in children with Type 1 diabetes in Sweden from 2011 to 2016-A longitudinal study from the Swedish National Quality Register (SWEDIABKIDS). Pediatr Diabetes. 2021;22(5):766-775. doi: https://doi.org/10.1111/pedi.13217

25. Tauschmann M, Schwandt A, Prinz N, et al. Three-variate trajectories of metabolic control, body mass index, and insulin dose: Heterogeneous response to initiation of pump therapy in youth with type 1 diabetes. Pediatr Diabetes. 2022;23(3):330-340. doi: https://doi.org/10.1111/pedi.13320

26. El-Jamal S, Elfane H, Chamlal H, et al. Assessment of nutritional status, dietary intake and adherence to dietary recommendations in type 1 diabetic children and adolescents. Rocz Panstw Zakl Hig. 2022;73(3):303-313. doi: https://doi.org/10.32394/rpzh.2022.0222

27. Galli-Tsinopoulou A, Grammatikopoulou MG, Stylianou C, et al. A preliminary case-control study on nutritional status, body composition, and glycemic control of Greek children and adolescents with type 1 diabetes. J Diabetes. 2009;1(1):36-42. doi: https://doi.org/10.1111/j.1753-0407.2008.00002.x

28. Wagner G, Karwautz A. Eating disorders in adolescents with type 1 diabetes mellitus. Curr Opin Psychiatry. 2020;33(6):602-610. doi: https://doi.org/10.1097/YCO.0000000000000650

29. AlOzairi A, Irshad M, AlKandari J, et al. Prevalence and predictors of diabetes distress and depression in people with type 1 diabetes. Front Psychiatry. 2024;15:1367876. doi: https://doi.org/10.3389/fpsyt.2024.1367876

30. Kaminsky LA, Dewey D. The association between body mass index and physical activity, and body image, self esteem and social support in adolescents with type 1 diabetes. Can J Diabetes. 2014;38(4):244-9. doi: https://doi.org/10.1016/j.jcjd.2014.04.005

31. Tran T, Igudesman D, Burger K, et al. Eating behaviors and estimated body fat percentage among adolescents with type 1 diabetes. Diabetes Res Clin Pract. 2024;207:111070. doi: https://doi.org/10.1016/j.diabres.2023.111070

32. Nip ASY, Reboussin BA, Dabelea D, et al. Disordered Eating Behaviors in Youth and Young Adults With Type 1 or Type 2 Diabetes Receiving Insulin Therapy: The SEARCH for Diabetes in Youth Study. Diabetes Care. 2019;42(5):859-866. doi: https://doi.org/10.2337/dc18-2420

33. Elrokhsi SH, Bluez GP, Chin CN, et al. Differences in sleep architecture according to body mass index in children with type 1 diabetes. Pediatr Diabetes. 2020;21(1):98-105. doi: https://doi.org/10.1111/pedi.12918

34. Wilkin TJ. The accelerator hypothesis: weight gain as the missing link between Type I and Type II diabetes. Diabetologia. 2001;44(7):914-22. doi: https://doi.org/10.1007/s001250100548

35. Nitecki M, Gerstein HC, Balmakov Y, et al. High BMI and the risk for incident type 1 Diabetes Mellitus: a systematic review and meta-analysis of aggregated cohort studies. Cardiovasc Diabetol. 2023;22(1):300. doi: https://doi.org/10.1186/s12933-023-02007-y

36. Li X, Zhu J, Zhao W, et al. The Causal Effect of Obesity on the Risk of 15 Autoimmune Diseases: A Mendelian Randomization Study. Obes Facts. 2023;16(6):598-605. doi: https://doi.org/10.1159/000534468

37. Ciężki S, Kurpiewska E, Bossowski A, Głowińska-Olszewska B. Multi-Faceted Influence of Obesity on Type 1 Diabetes in Children - From Disease Pathogenesis to Complications. Front Endocrinol (Lausanne). 2022;13:890833. doi: https://doi.org/10.3389/fendo.2022.890833

38. Oboza P, Ogarek N, Olszanecka-Glinianowicz M, Kocelak P. Can type 1 diabetes be an unexpected complication of obesity? Front Endocrinol (Lausanne). 2023;14:1121303. doi: https://doi.org/10.3389/fendo.2023.1121303

39. Ferrara-Cook C, Geyer SM, Evans-Molina C, et al. Excess BMI Accelerates Islet Autoimmunity in Older Children and Adolescents. Diabetes Care. 2020;43(3):580-587. doi: https://doi.org/10.2337/dc19-1167

40. Emet DC, Karavar HN, Gozmen O, et al. Early weight gain after diagnosis may have an impact on remission status in children with new-onset type 1 diabetes mellitus. J Diabetes. 2023;15(12):1011-1019. doi: https://doi.org/10.1111/1753-0407.13455

41. Kurpiewska E, Ciężki S, Jamiołkowska-Sztabkowska M, et al. Excessive BMI is associated with higher C-peptide level at recognition but also with its greater loss in two years clinical observation in children with new onset type 1 diabetes. Front Immunol. 2023;14:1176403. doi: https://doi.org/10.3389/fimmu.2023.1176403

42. Szadkowska A, Pietrzak I, Mianowska B, et al. Insulin sensitivity in Type 1 diabetic children and adolescents. Diabet Med. 2008;25(3):282-8. doi: https://doi.org/10.1111/j.1464-5491.2007.02357.x

43. Cree-Green M, Stuppy JJ, Thurston J, et al. Youth With Type 1 Diabetes Have Adipose, Hepatic, and Peripheral Insulin Resistance. J Clin Endocrinol Metab. 2018;103(10):3647-3657. doi: https://doi.org/10.1210/jc.2018-00433

44. Lu Z, Xiong Y, Feng X, et al. Insulin resistance estimated by estimated glucose disposal rate predicts outcomes in acute ischemic stroke patients. Cardiovasc Diabetol. 2023;22(1):225. doi: https://doi.org/10.1186/s12933-023-01925-1

45. Semenova JF, Yushin AY, Korbut AI, Klimontov VV. Glucose Variability in People with Type 1 Diabetes: Associations with Body Weight, Body Composition, and Insulin Sensitivity. Biomedicines. 2024;12(9):2006. doi: https://doi.org/10.3390/biomedicines12092006

46. Zeng Q, Chen XJ, He YT, et al. Body composition and metabolic syndrome in patients with type 1 diabetes. World J Diabetes. 2024;15(1):81-91. doi: https://doi.org/10.4239/wjd.v15.i1.81

47. Marques CL, Beretta MV, Prates RE, et al. Body adiposity markers and insulin resistance in patients with type 1 diabetes. Arch Endocrinol Metab. 2023;67(3):401-407. doi: https://doi.org/10.20945/2359-3997000000599

48. DuBose SN, Hermann JM, Tamborlane WV, et al. Obesity in Youth with Type 1 Diabetes in Germany, Austria, and the United States. J Pediatr. 2015;167(3):627-32.e1-4. doi: https://doi.org/10.1016/j.jpeds.2015.05.046

49. Giandalia A, Russo GT, Ruggeri P, et al. The Burden of Obesity in Type 1 Diabetic Subjects: A Sex-specific Analysis From the AMD Annals Initiative. J Clin Endocrinol Metab. 2023;108(11):e1224-e1235. doi: https://doi.org/10.1210/clinem/dgad302

50. Özkaya V, Özkaya ŞÖ, Adal SE. Relationship between visceral adiposity index and glycemic and metabolic control in children and adolescents with type 1 diabetes mellitus. Ir J Med Sci. 2024;193(1):181-189. doi: https://doi.org/10.1007/s11845-023-03375-w

51. Genua I, Franch-Nadal J, Navas E, et al. Obesity and related comorbidities in a large population-based cohort of subjects with type 1 diabetes in Catalonia. Front Endocrinol (Lausanne). 2022;13:1015614. doi: https://doi.org/10.3389/fendo.2022.1015614

52. Clinck I, Mertens J, Wouters K, et al. Insulin resistance and CGM-derived parameters in people with type 1 diabetes: are they associated? J Clin Endocrinol Metab. 2024; in press. dgae015. doi: https://doi.org/10.1210/clinem/dgae015

53. Lalanne-Mistrih ML, Bonhoure A, Messier V, et al. Overweight and Obesity in People Living With Type 1 Diabetes: A Cross-Sectional Analysis of the BETTER Registry. Diabetes Metab Res Rev. 2024;40(6):e3837. doi: https://doi.org/10.1002/dmrr.3837

54. Petty LD, Soto-Pedre E, McCrimmon RJ, Pearson ER. Body Mass Index’s influence on arterial hypertension in Type 1 diabetes - A brief report from IMI-SOPHIA study. J Diabetes Complications. 2024;38(6):108747. doi: https://doi.org/10.1016/j.jdiacomp.2024.108747

55. Moosaie F, Ghaemi F, Mechanick JI, et al. Obesity and Diabetic Complications: A Study from the Nationwide Diabetes Report of the National Program for Prevention and Control of Diabetes (NPPCD-2021) Implications for Action on Multiple Scales. Prim Care Diabetes. 2022;16(3):422-429. doi: https://doi.org/10.1016/j.pcd.2022.03.009

56. Parente EB, Harjutsalo V, Forsblom C, Groop PH; FinnDiane Study Group. The impact of central obesity on the risk of hospitalization or death due to heart failure in type 1 diabetes: a 16-year cohort study. Cardiovasc Diabetol. 2021;20(1):153. doi: https://doi.org/10.1186/s12933-021-01340-4

57. Chillarón JJ, Goday A, Flores-Le-Roux JA, et al. Estimated glucose disposal rate in assessment of the metabolic syndrome and microvascular complications in patients with type 1 diabetes. J Clin Endocrinol Metab. 2009;94(9):3530-4. doi: https://doi.org/10.1210/jc.2009-0960

58. Garofolo M, Gualdani E, Scarale MG, et al. Insulin Resistance and Risk of Major Vascular Events and All-Cause Mortality in Type 1 Diabetes: A 10-Year Follow-up Study. Diabetes Care. 2020;43(10):e139-e141. doi: https://doi.org/10.2337/dc20-0433

59. Sun R, Wang J, Li M, et al. Association of Insulin Resistance With Cardiovascular Disease and All-Cause Mortality in Type 1 Diabetes: Systematic Review and Meta-analysis. Diabetes Care 2024:dc240475. doi: https://doi.org/10.2337/dc24-0475

60. Grzelka-Woźniak A, Uruska A, Szymańska-Garbacz E, et al. Indirect insulin resistance markers are associated with nonalcoholic fatty liver disease in type 1 diabetes. Pol Arch Intern Med. 2023;133(5):16404. doi: https://doi.org/10.20452/pamw.16404

61. Mantovani A, Morieri ML, Aldigeri R, et al. MASLD, hepatic steatosis and fibrosis are associated with the prevalence of chronic kidney disease and retinopathy in adults with type 1 diabetes mellitus. Diabetes Metab. 2024;50(1):101497. doi: https://doi.org/10.1016/j.diabet.2023.101497

62. Lee AS, Twigg SM, Flack JR. Metabolic syndrome in type 1 diabetes and its association with diabetes complications. Diabet Med. 2021;38(2):e14376. doi: https://doi.org/10.1111/dme.14376

63. Igudesman D, Crandell J, Corbin KD, et al. Weight management in young adults with type 1 diabetes: The advancing care for type 1 diabetes and obesity network sequential multiple assignment randomized trial pilot results. Diabetes Obes Metab. 2023;25(3):688-699. doi: https://doi.org/10.1111/dom.14911

64. Güneş Kaya D, Arslan N, Ayyıldız F, et al. The potential of the Mediterranean diet to improve metabolic control and body composition in youths with Type 1 Diabetes Mellitus. BMC Endocr Disord. 2024;24(1):63. doi: https://doi.org/10.1186/s12902-024-01593-6

65. Huerta-Uribe N, Hormazábal-Aguayo IA, Izquierdo M, García-Hermoso A. Youth with type 1 diabetes mellitus are more inactive and sedentary than apparently healthy peers: A systematic review and meta-analysis. Diabetes Res Clin Pract. 2023;200:110697. doi: https://doi.org/10.1016/j.diabres.2023.110697

66. Muntis FR, Igudesman D, Sarteau AC, et al. Relationship Between Moderate-to-Vigorous Physical Activity and Glycemia Among Young Adults with Type 1 Diabetes and Overweight or Obesity: Results from the Advancing Care for Type 1 Diabetes and Obesity Network (ACT1ON) Study. Diabetes Technol Ther. 2022;24(12):881-891. doi: https://doi.org/10.1089/dia.2022.0253

67. Freeby M, Lane K. Treating obesity in type 1 diabetes mellitus - review of efficacy and safety. Curr Opin Endocrinol Diabetes Obes. 2024;31(1):1-7. doi: https://doi.org/10.1097/MED.0000000000000841

68. Liu YS, Chen CN, Chen ZG, et al. Vascular and metabolic effects of metformin added to insulin therapy in patients with type 1 diabetes: A systematic review and meta-analysis. Diabetes Metab Res Rev. 2020;36(6):e3334. doi: https://doi.org/10.1002/dmrr.3334

69. Tandon S, Ayis S, Hopkins D, et al. The impact of pharmacological and lifestyle interventions on body weight in people with type 1 diabetes: A systematic review and meta-analysis. Diabetes Obes Metab. 2021;23(2):350-362. doi: https://doi.org/10.1111/dom.14221

70. Danne T, Garg S, Peters AL, et al. International Consensus on Risk Management of Diabetic Ketoacidosis in Patients With Type 1 Diabetes Treated With Sodium-Glucose Cotransporter (SGLT) Inhibitors. Diabetes Care. 2019;42(6):1147-1154. doi: https://doi.org/10.2337/dc18-2316

71. Dejgaard TF, Schmidt S, Frandsen CS, et al. Liraglutide reduces hyperglycaemia and body weight in overweight, dysregulated insulin-pump-treated patients with type 1 diabetes: The Lira Pump trial-a randomized, double-blinded, placebo-controlled trial. Diabetes Obes Metab. 2020;22(4):492-500. doi: https://doi.org/10.1111/dom.13911

72. Garg SK, Akturk HK, Kaur G, et al. Efficacy and Safety of Tirzepatide in Overweight and Obese Adult Patients with Type 1 Diabetes. Diabetes Technol Ther. 2024;26(6):367-374. doi: https://doi.org/10.1089/dia.2024.0050

73. Edwards K, Li X, Lingvay I. Clinical and Safety Outcomes With GLP-1 Receptor Agonists and SGLT2 Inhibitors in Type 1 Diabetes: A Real-World Study. J Clin Endocrinol Metab. 2023;108(4):920-930. doi: https://doi.org/10.1210/clinem/dgac618

74. Kermansaravi M, Valizadeh R, Jazi AD, et al. Current Status of Metabolic/Bariatric Surgery in Type 1 Diabetes Mellitus: an Updated Systematic Review and Meta-analysis. Obes Surg. 2022;32(5):1726-1733. doi: https://doi.org/10.1007/s11695-022-05980-7

75. Abi Mosleh K, Salameh Y, Ghusn W, et al. Impact of metabolic and bariatric surgery on weight loss and insulin requirements in type 1 and insulin-treated type 2 diabetes. Clin Obes. 2024:e12689; in press. doi: https://doi.org/10.1111/cob.1268

76. Korakas E, Kountouri A, Raptis A, et al. Bariatric Surgery and Type 1 Diabetes: Unanswered Questions. Front Endocrinol (Lausanne). 2020;11:525909. doi: https://doi.org/10.3389/fendo.2020.525909