Leveraging Weight Loss Type 2 Diabetes 2012 Part 1 of 4

7/30/2019 Leveraging Weight Loss Type 2 Diabetes 2012 Part 1 of 4

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Leveraging Weight Loss in the

Treatment of Type 2 Diabetes

Part 1 of 4


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Overview

Overweight/obesity health risks associated with type 2

diabetes American Diabetes Association (ADA) guidelines for

medical nutrition therapy (MNT) and lifestyle changes

Glycemic benefits and additional advantages of weight lossin type 2 diabetes

Application to clinical practice


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BodyWeight(lb)

200

220

240

260

280

300

320

Adapted from Kendall DM, et al. 2004 International Diabetes Center, Minneapolis, MN. All rights reserved.

Years

DiabetesDiagnosis

Onset

Prediabetes (IFG, IGT)

Metabolic Syndrome

Fasting Glucose

Postmeal Glucose

Glucose(m

g/dL)

50

100

150

200250

300

350

Obesity, Inactivity,

Genetics

RelativeFunction

-10 -5 0 5 10 15 20 25 30

Insulin Resistance

Insulin Response

0

50

100

150

200

250

-15

Progressive -Cell Defect (glucose specific)

Amylin Response

Oral Agents/Incretin Enhancers

Basal Insulin

Basal/Bolus Insulin

Amylin Replacement

Natural History of Type 2 Diabetes and Obesity


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Prevalence of Overweight and Obesity

Among Adults Diagnosed With Diabetes

BMI = body mass index.

Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2004;53:1066-1068.www.cdc.gov/mmwr/preview/mmwrhtml/mm5345a2.htm. Accessed April 9,2008.

20-64 650

20

40

60

80

100

Age (years)

%

Obese (BMI 30)

Overweight or Obese (BMI 25)


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Health Risks of Obesity

Increased morbidity

Hypertension Dyslipidemia

Coronary heart disease

Type 2 diabetes

Stroke Cancer (endometrial, breast, colon)

Impairments in health-related quality of life andpsychosocial well-being

Sleep apnea Osteoarthritis

Increased mortality

NIH-NHLBI. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. 1998.


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Excess Weight in Individuals With Type 2Diabetes Increases Mortality Risk

Comorbidities of Obesity

TC = total cholesterol; Ref category = normal weight without the risk factor.

Wei M, et al. JAMA. 1999;282:1547-1553.

Relative Risk of All-Cause Death by BMI Categories for Selected Mortality Predictors

Ref Category Normal Overweight Obese

RelativeRisk

Adjusted

forAgeandE

xamYear

0

0.5

1

1.5

2

2.5

3

3.5

TC >239 Diabetes Hypertension Smoker


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Additional Problems Associated With

Obesity in Individuals With Type 2 Diabetes

Exacerbation of metabolic risk factors

Hyperglycemia

Dyslipidemia

Increased thrombogenic risk (eg, increased PAI-1) Increased insulin resistance and glucose intolerance

Increased risk of hypertension and cardiovascular disease

Increased mortality

Mortality ratio for individuals with diabetes whose body

weights are 20% to 30% above ideal is 2.5 to 3.3 times

higher than those of normal body weight

PAI-1 = Plasminogen activator inhibitor-1.

Maggio CA, et al. Diabetes Care. 1997;20:1744-1766.


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Additional Problems Associated With

Obesity in Individuals With Type 2 Diabetes

Exacerbation of metabolic risk factors

Hyperglycemia

Dyslipidemia

Increased thrombogenic risk (eg, increased PAI-1) Increased insulin resistance and glucose intolerance

Increased risk of hypertension and cardiovascular disease

Increased mortality

Mortality ratio for individuals with diabetes whose body

weights are 20% to 30% above ideal is 2.5 to 3.3 times

higher than those of normal body weight

PAI-1 = Plasminogen activator inhibitor-1.

Maggio CA, et al. Diabetes Care. 1997;20:1744-1766.


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Standards of Medical Care in Type 2

Diabetes: 2008 ADA Glycemic Goals

A1C


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Standards of Medical Care in Type 2 Diabetes:

2008 ADA Weight Recommendations

Weight loss is an important therapeutic objective1

85% of individuals with type 2 diabetes are obese/overweight2

Physical activity and behavior modification are important1

Moderate weight loss (5% in short-term studies)1 Decreased insulin resistance

Improved measures of glycemia and lipemia

Reduced blood pressure

The importance of controlling body weight in reducing risks

related to diabetes is of great importance but sustaining

weight loss is difficult1

1. American Diabetes Association. Diabetes Care. 2008;31(suppl 1):S12-S78.2. www.cdc.gov/mmwr/preview/mmwrhtml/mm5345a2.htm. Accessed April 9,2008.


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Modest Weight Loss Can Drastically

Reduce Abdominal Visceral Fat

Before Weight Loss

(95 kg, BMI 32)

After 10% Weight Loss

(85 kg, BMI 29)

Desprs J-P. Baillires Clin Endocrinol Metab. 1994;8:629-660.


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Weight Loss in Type 2 Diabetes:

Study Objective and Design

Objective: Determine if modest weight loss would provide

a long-term benefitWeight Control Program

Group treatment

Individualized treatment goals to produce

a 1-kg/wk weight loss

Calorie/food restriction with focus on reduced

fat intake

Gradual increase of exercise goals with finalgoal of 3.2 km/d, 5 days per week

Behavior-modification strategies

1-Year Follow-up Physical

Wing RR, et al. Arch Intern Med. 1987;147:1749-1753.

N=114Type 2 diabetes

treated with insulin,

orals, diet only, or

insulin plus oral

medications


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Weight Loss in T2DM Dramatically Improves

Glycemia and Metabolic Risk Factors

Body Weight (%)

A1C

Body Weight (kg)

0

-0.4

0.4

0.8

-0.8

-1.2

-1.6

-20

-40

0

Triglycerides (mg/dL)

-60

-80

-100

HDL-C (mg/dL)

8

6

10

12

4

2

0

Body Weight (kg)

Wing RR, et al. Arch Intern Med. 1987;147:1749-1753.


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Hamdy O, et al. Diabetes Care. 2003;26:2119-2125.Monzillo LU. Obes Res. 2003;11:1048-1054.

Chan

geFrom

Baselin

e(%) IL-6 TNF- hCRP PAI-1 Leptin

P

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