Treating "Diabesity": How to Help Your Diabetic Patients Lose Weight

From the American Diabetes AssociationLifestyle Changes as Effective as Drugs

NEW YORK CITY—At a recent American Diabetes Association meeting, presenters offered practical pointers for the management of obesity in patients with diabetes. “At my clinic, we treat diabesity,” said Robert T. Ferraro, MD, medical director of Southwest Endocrinology Associates in Albuquerque, NM, referring to the symbiotic pandemics of diabetes and obesity.

Although the 2 conditions present many challenges, physicians often regard obesity as the bigger, and often more frustrating, battle. By using a systematic approach to helping your patients lose weight, you can optimize your chances of success, Dr Ferraro advises.

The first step is to determine the patient’s body mass index (BMI), using the World Health Organization classification of overweight and obesity, which divides obesity into 3 classes based on BMI. “We do not use the term ‘morbid obesity’ in our clinic anymore,” Dr Ferraro emphasizes. “It’s very derogatory, and I would encourage all physicians remove it from their lexicon.”

Take a Focused History

Taking the weight-related history should be a major part of the assessment. Using the following questions can help you narrow down the problem and direct your intervention:

• When did the weight gain begin—middle school, adolescence, perimenopause?

• How did it begin—was it associated with an injury, illness, emotional stress?

• What is your previous experience with diets?

• Do you eat when you’re sad or angry?

• How many meals do you eat each day? If the answer is 2, ask which meal the patient skips; people who skip breakfast are 450% more likely to be obese

• How many times every week do you eat out in restaurants? If the answer is 4 to 7 times weekly, focus on this in your intervention.

Patients must be motivated to lose weight. Those who come to you requesting your assistance in losing weight are quite motivated. But for those who are not ready, “your job is to move them closer to that readiness,” Dr Ferraro says, and you must intervene to help them stop gaining weight. “No weight gain is a plus in a lot of patients.”

Potential Obstacles

Stress can thwart the chances of success. “It’s not a good idea to try to start losing weight if you’re in the middle of a divorce or job change,” Dr Ferraro says. In such patients, “It’s more important to attenuate weight gain during these stressful situations.”

Similarly, patients with severe psychiatric conditions, severe depression, or eating disorders need to have those conditions treated first, before they are going to be able to lose weight, although this could be a concurrent process.

Does the patient have the time it takes to lose weight? “If somebody doesn’t have a minimum of 15 to 30 minutes a day needed to keep a food diary over the next 26 weeks, it will be very difficult for them to adhere and get the best results,” he says.

Facilitate Lifestyle Changes

Diet, lifestyle changes, and behavior modifications are the cornerstone of weight-loss therapy. Dr Ferraro lists 5 steps you can take to facilitate change in your patients:

• Identify the behavior you want to change

• Review when, where, and how the behavior occurs

• Have the patient keep records of the behavior change

• Review the patient’s progress at the next visit

• Congratulate the patient on successes; don’t criticize the shortcomings.

Behavior modification also includes stimulus control. Identify triggers and then modify, manipulate, and attenuate them. Also develop strategies to deal with stress. Cognitive restructuring is a little more complicated, since it entails the development of more healthy thinking strategies, and it usually requires specialist referral.

Int J Behav Nutr Phys Act

Self-monitoring is the most important part of behavioral therapy. All patients should keep a food diary, noting what they eat and what is happening while they eat. Those who keep the best records tend to lose the most weight (. 2006; 3:17).

However, “You can’t just tell the patient to keep a diary. You must look at it,” Dr Ferraro says. This allows you to offer some constructive criticism, “but more important, to congratulate the patient on having done an important task, which is keeping those records.” The goal is to “empower the patients and have them feel good about themselves and their effort.”

Before deciding on the diet, you must first set a target. “A 10% weight reduction in 6 months is the mantra,” he says. And this is “safe and achievable in most circumstances.”

Be prepared that when you ask patients who weigh about 220 lb what their goal is, they’ll often respond that they would like to get down to about 140 lb. But “that’s not realistic, and I tell them that. They look at me like I’m an ogre. So I say, ‘Let’s set an initial goal and target of 10%, and if you achieve that, then we’ll negotiate additional weight loss beyond that.’”

Diet. Weight-loss diets are based on the following principle: the energy cost of 1 lb of weight loss is 3500 calories. The concept of energy balance—“energy in” equals “energy out”—is fundamental. The goal is to achieve a negative energy balance, in which there is more energy out than energy in.

The National Institutes of Health recommendations for the nutrient content of a weight-reducing diet are:

• ≥ 55% carbohydrate (carbs)

• 15% protein

• ≤ 30% fat.

The preponderance of evidence supports reducing the fat content of the diet to promote weight loss. However, Dr Ferraro believes that “it doesn’t really make any difference what the macronutrient composition of the diet is, whether it’s a preponderance of fat versus carbs. It’s negative energy deficit that causes weight loss.”

The fact is that “it’s very hard to lose 10% of your body weight.” But maintaining the weight loss is the true challenge. This is where exercise comes in.

Exercise. The importance of physical activity is not so much to facilitate weight loss, but rather to maintain the weight loss, which “is dependent on physical activity,” according to Dr Ferraro. To lose weight and maintain a certain weight, the optimum exercise regimen is >200 minutes weekly, or about 12,000 to 14,000 steps daily.

“How do you get our sluggish type of patients to do this?” Dr Ferraro asks. “You don’t set that as their goal.” Find out where they are at now, and increase the number of steps in small increments.

Ask the patient to use a step counter to measure how many steps they take each day. Then tell the patient to increase the amount of steps in small increments. Severely obese patients can increase the number of steps by 200 to 500 daily; aerobically fit persons by 1000 to 2000 steps daily.

Drug Therapy. Of the FDA-approved weight-loss drugs, phentermine HCl (Adipex-P, Ionamin, Pro-Fast) is most often prescribed.

Only 2 drugs have been approved for long-term use—orlistat (alli, Xenical) and sibutramine HCl (Meridia). The older drugs are only recommended for 3-month cycles.

Orlistat

blocks the digestion of fat and is a very safe drug. Its unique side effects means you should counsel your patients to limit their fat intake; about 20 g/meal is the limit when taking this drug. Orlistat is a very short-acting medication and only works for that specific meal. The side effect is not diarrhea, it’s an oil ooze. It is therefore a good indication for patients of how many grams of fat they are eating. It is a behavioral tool that focuses people on the fat content in their diet, and it malabsorbs 30% of the total fat in the meal.

The orlistat website offers 14-day meal planners that patients can download. “A lot of patients don’t get what 2000 calories means, but they’ll get it if they see meal plans,” says Dr Ferraro.

Sibutramine

blocks monoamine reuptake. In clinical trials, no differences were seen in the weight-loss effects in those who used it continuously or intermittently. It is an expensive medication, and most insurance companies do not pay for it. You can tell in the first month which patients will respond to this drug. Response is defined by a 4- to 5-lb weight loss or a loss of 2% of body weight.

Bariatric surgery. Obesity-related surgery is a drastic, life-altering, irreversible intervention. Most insurance plans, Medicare included, require a 6-month structured weight-loss intervention documented before authorization, by one group or physician, not by several groups or physicians. It is the most effective tool we currently have for weight loss and long-term weight maintenance.

Obesegenic Environment

“Obesity is a chronic and relapsing disease,” Dr Ferraro emphasizes. “We have an obesegenic environment, but we also have a preponderance of thrifty genes. That’s why we have a pandemic.”

Remember that even small changes in lifestyle can make a difference, and be sure to make your patient understand this fact. “A 5% to 10% reduction in body weight is an achievable goal for many of our patients and has a significant positive impact on health outcomes,” says Dr Ferraro.

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Additional Comments from Dr Ferraro

When assessing BMI value remember that women have a higher percentage of body fat than men, and older people have a higher percentage of body fat than younger people.

An important feature of a weight-reducing diet is low energy density. The density of food is directly related to the fat content and inversely related to the water content. There are fewer calories in lower-density foods, which is why you should encourage fruits and vegetables.

The weight-loss target depends on the patient’s initial body weight. To lose 1 pound a week, there must be a 500-calorie deficit per day.

Diabesity Case Study

A 35-year-old Hispanic man with type 2 diabetes and hypertension first consulted Dr Ferraro in November 2002, complaining of constant fatigue. In 1998, he was using methamphetamine regularly, and his weight was 200 pounds. At the time of this visit, he had not taken illicit drugs for 2 years, and his weight ballooned to 302 pounds.

He smoked irregularly and did not drink alcohol. He was taking pioglitazone HCl (Actos), atenolol (Tenormin), valsartan (Diovan), and sertraline HCl (Zoloft).

His BMI was 49 kg/m², but laboratory tests results were normal, with hemoglobin (Hb)A_1c of 6%.

A behavior assessment revealed a Beck Depression Inventory score of 8, indicative of mild dysthymia, but the patient scored high on “readiness to engage in a lifestyle behavioral program for weight control.” His “emotional eating score” was very high, and he admitted to binging at least once weekly and eating a lot of food.

Dr Ferraro’s first step was to switch him from sertraline to a more adrenergic-type antidepressant, and stop pioglitazone.

The patient agreed to start a comprehensive weight-control program. Psychotherapy was recommended, but he refused. “Needless to say, the eating disorder and depression were very difficult to control, and as a result his weight loss was slow due to poor compliance,” says Dr Ferraro.

In May 2003, the patient was diagnosed with severe obstructive sleep apnea and started continuous positive airway pressure treatment in June 2003. By August, he had lost 18 pounds.

He eventually agreed to begin psychotherapy, “but as in many of these types of patients, he was lost to follow-up in October of 2003,” said Dr Ferraro.

He did return 2 years later. His HbA_1c had increased to 7.5%. “We started to manipulate his medications. His weight went up. And then we started him on exenatide (Byetta), and he lost weight and his blood sugar control improved dramatically.”