Consider hypoglycemia risks when helping adults with diabetes lose weight
LAS VEGAS — When treating patients with type 2 diabetes who are attempting to lose weight, physicians must incorporate strategies that limit hypoglycemia risks, according to a speaker at ObesityWeek.
“It’s imperative to prevent hypoglycemic episodes, especially while losing weight,” Jeffrey Sicat, MD, FACE, FOMA, of Virginia Weight and Wellness in Glen Allen, Virginia, said during a presentation. “That is a prime time when people are going to have problems.”
Although reducing instances of hypoglycemia is a necessity, there is not one single way to accomplish this goal.
“We all have our different way of approaching diabetes,” Sicat said, while noting that guidelines from the American Association of Clinical Endocrinologists provide a more medication-focused approach. “If you look at the obesity medicine approach, we have different ways of approaching things.”
Depending on the patient, a change in dietary habits may be the most effective tool for managing diabetes and weight loss.
“Nutrition is the key,” Sicat said. “Any time I see a patient who has diabetes, I’m ... trying to figure out where are they in terms of their lifestyle.”
To determine whether a nutritional intervention is the right choice, Sicat said, physicians should assess the normal dietary habits of patients, particularly carbohydrate intake. Although nutritional interventions may be ineffective for those who are already consuming a small number of carbohydrates, if patients typically consumes a lot of carbohydrates, they may be able to lose weight and attain other benefits just from improving their diet.
“If someone at baseline has a pretty low carb intake, then that’s tough because we don’t have a whole lot of wiggle room to actually add lifestyle intervention,” Sicat said. “If someone has a baseline high-carb diet, where they’re eating carbs and sugars and sodas and all those different things, it turns out they have so much wiggle room in terms nutrition that actually they don’t need that much [diabetes] medication.”
Depending on the diet plan selected, there may be other benefits to be gained as well. Sicat noted that there may be a reduction in diabetes medication dosage with a ketogenic diet and that diabetes remission via meal replacement is possible.
“If we actually go by the guidelines and don’t take the dietary intervention history because that’s not part of these guidelines ... then sometimes we might be able to get ourselves in trouble if we’re adding too much medication,” Sicat said.
Diabetes medications still have their role to play. Avoiding those that may cause hypoglycemia is the next step in treatment after dietary intervention, Sicat said.
“So many times we talk about ‘do not be high’ and treat high blood sugars, but ... when you look at endocrinology, the No. 1 rule of diabetes is ‘do not be low’; prevent hypoglycemia and then treat the blood sugars from there,” Sicat said.
SGLT2 inhibitors, GLP-1 receptor agonists, metformin and DPP-IV inhibitors are associated with little hypoglycemia. Conversely, insulin, sulfonylureas and meglitinides may increase hypoglycemia risk.
Many patients will already be taking diabetes medications, including those that present hypoglycemia risk, before they attempt to lose weight. Depending on their dietary habits, there is opportunity to cut back on dosage and transition to other, less hypoglycemic medications, Sicat said.
“It’s one thing to add medications and try to figure out how much they need to add, but so many patients who you see are patients already on diabetes medications,” Sicat said. “I’m always trying to figure out how much can I reduce of a diabetes medicine.”
The assessment comes down to dietary considerations, Sicat said. Diabetes medications can be reduced the most for patients who consume more carbohydrates, whereas those who eat very few carbohydrates may not benefit as much if medication is decreased.
There is also a wide range of effects on weight across the spectrum of diabetes medications. According to Sicat, the same medications that are safe in terms of hypoglycemia also provide some weight-loss benefit (metformin, GLP-1 receptor agonists, SGLT2 inhibitors) or are weight neutral (DPP-IV inhibitors). Meanwhile, medications like insulin, sulfonylureas and meglitinides may be responsible for increases in weight.
“If we’re going to improve sugars, we might as well get some of the weight loss and other benefits in the process,” Sicat said.
Sicat recommended considering weight effects and hypoglycemia risk during the medication selection process.
“During active weight loss, aggressively titrate down or stop hypoglycemia-inducing medications,” Sicat said. “Consider choosing medications that are weight neutral or weight reducing, associated with fewer episodes of hypoglycemia and have cardiovascular and mortality benefits.” – by Phil Neuffer
Sicat J. Avoiding the crash and burn: Managing diabetes during weight loss. Presented at: ObesityWeek 2019; Nov. 3-7, 2019; Las Vegas.
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