Many adults with diabetes also have overweight or obesity. Although the mechanisms underlying the connection between diabetes and adiposity are not fully understood, experts point to insulin resistance induced by excess weight as the cause of elevated blood glucose levels. Moreover, type 2 diabetes and overweight and obesity share common etiologies, including environment, genetics, and physiological and social factors.
Patricia G. Davidson
“Possibly, the real question is, ‘Which comes first: obesity or diabetes?’” Patricia G. Davidson, DCN, RDN, CDE, FAND, associate professor of nutrition in the College of Health Science at West Chester University in Pennsylvania, told Endocrine Today. “Obesity is a major contributor to the type 2 diabetes epidemic. Overweight and obesity are global epidemics and are associated with type 2 diabetes mellitus, which itself increases the risk for weight gain.”
Katherine S. O’Neal
When addressing better living with diabetes, the topic of weight reduction should be broached early and with compassion, according to Katherine S. O’Neal, PharmD, MBA, CDE, associate professor in the college of pharmacy at the University of Oklahoma Health Sciences Center in Oklahoma City.
“Providers should be honest and straightforward with patients when discussing all risks and potential complications of diabetes,” O’Neal told Endocrine Today. “Weight-loss and weight-management efforts should be a standard part of the lifestyle measures that all patients with diabetes incorporate.”
An individualized approach
When formulating a weight-loss plan for an individual with diabetes, there are options ranging from diet and exercise to bariatric surgery. According to Davidson, the proper intervention should be tailored to the needs and habits of the individual patient, but lifestyle changes should be the basis of all weight-loss plans. Providing guidance and support for lifestyle modifications is part of the diabetes educator’s job, she said.
“Comprehensive lifestyle modification should be the foundation and adjunctive to all treatment strategies, including pharmacotherapy and metabolic surgery,” Davidson said. “Research has underscored the importance of ongoing support as well as the role of the diabetes educator in providing weight-loss strategies and developing coping strategies with weight loss and maintenance. Every person with diabetes is unique in how they respond to weight-loss strategies, and therefore these strategies need to be individualized, ongoing and include their input.”
Developing a lifestyle plan
Clinical recommendations suggest a goal of 5% to 10% total body weight loss from baseline within 6 months is reasonable. In many cases, diet and exercise are sufficient to reach the goal weight, Davidson said, but the success of lifestyle interventions depends on motivation.
“We need to close the gap between the patient’s recommendations for weight loss and the clinical recommendations,” Davidson said. “Patients expect to achieve a weight loss of 24% to 38% of their initial weight, as compared to the clinical recommendations of 5% to 7%. Jointly determined weight-loss goals and intervention strategies, such as diet and exercise, are important.”
For people with or at risk for type 2 diabetes, developing a diet and exercise plan is an essential step in achieving and maintaining a healthy weight. High-fiber foods may lower blood glucose levels while also helping with weight loss. In a recent practice paper from the American Association of Diabetes Educators, Davidson and O’Neal advise adults on a weight-loss plan to read labels and aim for 25 g to 30 g of fiber daily. A minimum of 10 g of this fiber intake should be in the form of fruits and vegetables. Five servings of fruits and vegetables are ideal for weight loss and maintenance, they wrote. Consumption of whole grains when eating carbohydrates also provides fiber and promotes weight loss.
The help of a diabetes educator is useful in planning and sticking to a diet. Additionally, the use of mobile apps provides the benefit of food and/or activity tracking. This emphasizes motivation and accountability, according to O’Neal.
“There are many apps and smartwatches or fitness watches available that can help individuals track lifestyle parameters such as diet and physical activity,” she said. “The technology is even to the point where individuals can ‘compete’ with each other on progress toward goals. I find this helps keep individuals accountable. Additionally, some smartwatches have the capability to modify goals and to continue to push the individual harder.”
In some cases, medications can make weight loss difficult. Besides addressing glycemic control, diabetes educators should also consider the effect of various diabetes medications on body weight, Davidson and O’Neal wrote.
Glucocorticoids are generally linked to weight gain, as are some diabetes medications, such as sulfonylureas, insulin and thiazolidinediones. Weight gain is also associated with antidepressants such as amitriptyline, imipramine, nortriptyline and selective serotonin reuptake inhibitors (SSRIs). Additionally, certain antipsychotic and antiepileptic drugs may result in weight gain. The weight gain may manifest in a slowed metabolism, appetite increase, fluid retention, hypoglycemia or reduction in glycosuria. According to Davidson and O’Neal, intensive glycemic control with sulfonylureas, TZDs and insulin has been correlated with weight gain in both type 1 and type 2 diabetes. In turn, this weight gain can result in insulin resistance and hyperglycemia, hypertension, high cholesterol and other cardiovascular risk factors. For this reason, choosing the right diabetes medication and monitoring its effects in the individual patient is crucial, according to Davidson.
“As part of any weight-loss program, a comprehensive evaluation of a person’s medication regimen should be completed to determine the potential for medications to contribute to weight gain or inhibit weight loss,” she said. “Switching medications can improve weight loss as well as improve adherence with recommended dietary changes.”
When managing diabetes medications in individuals with overweight or obesity, it is important to balance the possible consequences of switching against the weight-loss benefits, O’Neal said. “Oftentimes, medications that induce weight gain will have alternative medication classes that can provide similar benefits while minimizing the risk of weight gain.”
In some cases, surgery may be the right choice to achieve the desired weight loss and may also yield significant health improvements.
“The evidence for choosing this option when an individual’s BMI is less than 35 kg/m2 is limited,” O’Neal said. “If an individual chooses to have weight-loss surgery, it is crucial to remember that lifestyle changes must still accompany the individual after the procedure.”
Moreover, patients who undergo bariatric surgery should take part in postoperative education to address their unique nutritional needs and possible medication changes.
“In general, reduced-calorie diets alone and as adjunct to other interventions can lead to clinically meaningful weight loss and improvement in metabolic parameters,” Davidson said. “However, metabolic surgery along with ongoing follow-up and comprehensive lifestyle change is an option to consider jointly.” – by Jennifer Byrne
American Association of Diabetes Educators. Addressing obesity in diabetes. August 2018. Available at: www.diabeteseducator.org/docs/default-source/practice/practice-documents/practice-papers/addressing-obesity-in-diabetes.pdf?sfvrsn=0. Accessed Dec. 4, 2018.
For more information:
Patricia G. Davidson, DCN, RDN, CDE, can be reached at Sturzebecker Health Science Center, Room 307, West Chester University, 855 S. New St., West Chester, PA 19383; email: email@example.com.
Katherine S. O’Neal, PharmD, MDA, CDE, can be reached at the University of Oklahoma College of Pharmacy, P.O. Box 26901, Oklahoma City, OK 73126.
Disclosures: Davidson and O’Neal report no relevant financial disclosures.