Managment of Obesity in Diabetes mellitus

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Management of Obesity in DM Dealing with a Bad
Companion

• By
• Tarek Al Areeny , MD
• tarekareny69_at_yahoo.com
• www.elarenycenter.com
• 01092933193

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Presentation Outlines

• Obesity definition stages
• Diabetes Prediabetes diagnostic criteria
• Diabetes obesity Comorbidity, and why they
  are considered Bad Companion?
• Multidisciplinary approach to managing coexistent
  type 2 diabetes and obesity
• lifestyle Modifications
• Medications
• Bariatric surgery its impact on type
  II DM
• Take Home Messages

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Obesity definition stages

• Overweight and Obesity are defined as degrees of
  excess weight that are associated with increases
  in morbidity and mortality.
• But weight alone is not an adequate measure of
  adiposity so the calculation of the body mass
  index (BMI), which is weight (kg) divided by the
  height (meters) squared, gives a reasonable
  approximation of adiposity and this is widely
  used in both clinical practice and research.

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Diabetes mellitus diagnostic criteria
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Criteria for testing for DM in asymptomatic
adults
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Categories of increased risk for diabetes
(prediabetes)
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Diabetes Obesity Co-morbidity

• In Nurses Health Study , it was Found that the
  most important risk factor for developing type 2
  diabetes was BMI
• The relative risk of diabetes was 38.8 in women
  with BMI of 35 kg/m2 or higher , and 20.1 for
  women with BMI between 30-34.9 kg/m2 when
  compared to women with BMI less than 23 kg/m2
• In fact , the relative risk was not only
  increased in the obese but in the overweight
  groups as well

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Diabetes Obesity Co-morbidity

• Similar results were found in the third National
  Health and Nutrition Examination survey (
  NHANES), denoting that the prevalence of DM was
  dramatically increased with an increase in BMI.
• The prevalence of DM was 2.5 times higher in
  overweight men and 3 times in overweight women
  when compared to normal weight group.

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Diabetes Obesity Co-morbidity

• This prevalence continued to increase and was 6
  times higher in men and 5.5 times higher in women
  with BMI between 35 and 39.9 km/m2
• Unfortunately, not only obesity increase the
  prevalence of diabetes,
• it also makes it more difficult to treat !
• why?

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Why obesity hinders diabetes control and increase
mortality ?

• Increase insulin resistance glucose intolerance
  
• Exacerbating other metabolic complications such
  as hypertension and dyslipidemia
• Regarding mortality, compared with normal weight
  individuals with diabetes, the mortality rate is
  2.5-3.3 times higher in diabetics with body
  weights that are 20-30 above their ideal weight
  and 5.2-7.9 times higher in those with body
  weights 40 above ideal weight

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Why obesity hinders diabetes control and increase
mortality ?

• The proposed mechanism of this increased
  mortality in obese diabetics may be due to
  excess body fat, particularly abdominal fat,
  along with the presence of insulin resistance
  leads to a Pro-Atherogenic lipid profile with
  high triglyceride and apolipoprotein B
  concentrations, an increased proportion of small
  dense LDL particles, and a reduced concentration
  of HDL cholesterol.

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Why obesity hinders diabetes control and increase
mortality ?

• This Pro-Atherogeinc factor, along with a
  pro-thrombotic and a pro-inflammatory profile
  significantly worsens an individuals risk of
  cardiovascular disease and overall mortality.
  

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American Association of Clinical Endocrinologists
andAmerican College of Endocrinology Clinical
Practice Guidelines for Developing a Diabetes
Mellitus Comprehensive Care Plan
Writing Committee Cochairpersons Yehuda
Handelsman MD, FACP, FACE, FNLA Zachary T.
Bloomgarden, MD, MACE George Grunberger, MD,
FACP, FACE Guillermo Umpierrez, MD, FACP,
FACE Robert S. Zimmerman, MD, FACE
ENDOCRINE PRACTICE Vol 21 No. 4 April 2015
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Diagnosis of Obesity and Staging of for Management
Q13. How is obesity managed in patients with
diabetes?

• Diagnose obesity according to body mass index
  (BMI)
• Overweight BMI 25-29.9 kg/m2
• Obese BMI 30 kg/m2
• Consider waist circumference measurement for
  patients with BMI between 25 and 35 kg/m2
• Larger waist circumference higher risk for
  metabolic disease
• Men gt102 cm (40 in)
• Women gt88 cm (35 in)
• Evaluate patients for obesity-related
  complications to determine disease severity and
  appropriate management

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BMI 23-24.9 may be considered obese in certain
ethnicities perform waist circumference and use
ethnicity-specific criteria in risk analysis.
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Medical Complications of Obesity
Q13. How is obesity managed in patients with
diabetes?
Obesity
Cardiometabolic
Biomechanical
Other
Dismotility/disability GERD Lung
functiondefects Osteoarthritis Sleep
apnea Urinaryincontinence
Hypertension
Dyslipidemia
Androgen deficiency Cancer Gallbladder
disease Psychologicaldisorders
Prediabetic states
PCOS
NAFLD
Diabetes
Cardiovascular Disease
GERD, gastroesophageal reflux disease NAFLD,
nonalcoholic fatty liver disease PCOS,
polycystic ovary syndrome. Pi-Sunyer X. Postgrad
Med. 200912121-33.
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Multidisciplinary approach to managing
coexistent type 2 diabetes and obesity (Diabesity)

• Weight management is critical for limiting the
  development of glucose intolerance and
  progression from a state of impaired glucose
  tolerance to diabetes, as well as for optimal
  management in those who go on to develop T2D.
• However, a number of current diabetes therapies
  promote weight gain in an already overweight
  population

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Multidisciplinary approach to managing
coexistent type 2 diabetes and obesity (Diabesity)

• This complexity means that an integrated and
  coordinated approach, using a dedicated
  multidisciplinary team focusing on managing both
  T2D and obesity in unified manner, is required.
• The aim of the service is to manage the complex
  healthcare needs of people with diabesity and to
  address both conditions in a unified way,
  simultaneously optimizing glycemic control and
  weight management.

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Value of this Multidisciplinary approach in
managing Diabesity

• Most clinicians will agree that a
  multidisciplinary one-stop clinic approach
  improves patient adherence, thereby
  simultaneously optimizing glycaemic control and
  weight management. This leads to cost savings in
  terms of pharmacotherapy usage and healthcare
  professionals time.

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Members of the multidisciplinary team (MDT) in
managing diabesity

• A consultant , diabesity specialist nurse,
  clinical psychologist, specialist dietitian,
  physiotherapist, occupational therapist, moving
  and handling specialist, and a coordinator.
• 8 members
• With this combined expertise, the service is able
  to address all aspects of T2D and obesity in a
  way that optimizes the management of both
  conditions.

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Referral to the service procedure

• people are accepted into the diabesity service if
  they have T2D with an HbA1c level (gt8) and a BMI
  gt27.5 kg/m2.
• Following referral, individuals undergo initial
  assessment by the consultant. These measure a
  range of biometric and psychological parameters,
  aimed at evaluating the individuals status with
  regard to their diabetes and obesity.

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Initial investigations

• A number of initial investigations are required
  to give a detailed understanding of the
  physiological health status of individuals
  referred to the service. Initial investigations
  requested include baseline kidney and liver
  function tests, full blood count and HbA1c level.
• Endocrine abnormality is an established cause of
  weight gain in around 10 of people attending the
  diabesity clinic, and is assessed by using blood
  tests looking for thyroid dysfunction.

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Initial investigations

• If indicated, tests for hypogonadism and
  hypercortisolism are organized.
• Sleep patterns and daytime sleepiness are also
  assessed using the Epworth Sleepiness Scale if
  the score is 10, patients are referred for sleep
  study to rule out obstructive sleep apnoea.
• Patients are also asked to complete food, blood
  glucose and hunger pattern diaries and to bring
  them to each appointment.

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Weight management at Diabesity Clinic

• Weight loss is a 1st priority in a patient with
  newly diagnosed type 2 DM
• Calorie restriction and Weight loss have a
  positive effect on almost every risk factor
  associated with diabetes and obesity

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Weight management at Diabesity Clinic

• Regarding Weight loss, There is a significant
  decrease in fasting glucose levels in those
  patients who experienced weight loss in the first
  3 months .
• This was also accompanied by a decrease in
  fasting insulin levels, increase in insulin
  sensitivity and improvement of beta-cell function

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Weight management at Diabesity Clinic

• Similar improvements are also noted in coexisting
  conditions such as hypertension and dyslipidemia
• In 1990 Mike Lean demonstrated that for people
  with type 2 DM, at 12 months from diagnosis, each
  1 kg of weight loss was associated with 3-4
  months increased survival.

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Weight management at Diabesity Clinic

• A 10 reduction in weight can result in a
• 30-40 reduction in diabetes-related deaths
• 15 reduction in HbA1c
• 30-50 reduction in fasting glucose
• 10 reduction in total cholesterol.
• without doubt weight loss should be a goal
  standard outcome in type 2 diabetes

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Artificial weight loss

• Weight loss can be a sign of poorly controlled
  diabetes. Glycosuria can cause artificial
  weight loss if blood glucose levels are
  persistently above the renal threshold, ( usually
  180 mg/dl)
• All medical therapies that correct hyperglycemia
  will cause indirect weight gain through reduced
  glycosuria and associated calorie loss.
• This means that as medical therapies are
  commenced, small deficits in calorie intake
  should be negotiated to limit weight gain. For
  some individuals, weight maintenance might be a
  more realistic option

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Prescribing a diet for diabesity patients

• An overweight patient ( BMI 25-30 kg/m2) should
  be started on a reducing diet of approximately
  1000-1500 kcal daily.
• Opinions vary as to whether obese individuals,
  BMI ?30 kg/m2, should be advised on even greater
  caloric restriction a target of 800-1000 kcal
  daily is ideal, although many patients will have
  difficulty complying with this.
• While there are usually advantages to a slow and
  steady approach to weight loss, others advocate
  using a newly diagnosed patients high motivation
  to aim for more rapid loss.

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Prescribing a diet for diabesity patients

• For most people changing the dietary habits of a
  lifetime is challenging, so one needs to take a
  sympathetic approach.
• A diet history should be taken, and review of a
  complete 3-day diet diary, including all snacks,
  can lead many patients to recognize previously
  unappreciated sources of excess calories ( i.e.
  soft drinks and fruit juices)
• Foods that are labeled diabetic are not
  recommended, as they usually contain nonglucose
  refined sugars such as sucrose or fructose.

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Prescribing a diet for diabesity patients

• Artificial sweeteners are useful and could be
  used as an alternative to sugars concerns that
  they may cause cancer have not been confirmed.
• Patients on insulin or on oral agents should be
  advised to eat the same amount at the same time
  each day
• Tailor the diet of the patent according to the
  previous rules with carbohydrates constitutes
  about 55,meanwhile, fats and proteins,
  constitute 15 and 30 respectively

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Exercise

• Encourage small changes on overall lifestyle
  changes, for example
• using stairs instead of elevators
• Parking at the point furthest from ones
  place of destination
• Getting off the bus a stop early
• walking faster walking a dog
• Regular scheduled exercise, even if only
  walking, should be encouraged, perhaps even
  prescribed, the aim being at least a half-hour
  each day on average

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Pharmacologic obesity therapy

• Pharmacologic obesity therapy is indicated with
  BMI 27 with comorbidity ( hypertension
  dyslipidemia - obstructive sleep apnea) or BMI ?
  30
• If an individual has a history of unsuccessfully
  losing and maintain weight with lifestyle
  interventions, he/she is a candidate for obesity
  pharmacotherapy
• Combined lifestyle changes weight loss
  medications can produce greater weight loss and
  cardiometabolic improvements compared with
  lifestyle alone

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Weight loss medications available in USA

• Phentermine
• Phentermine/topiramte
• Diethylepropion
• Lorcaserine
• Orlistat
• Naltrexone/bupropion
• Liraglutide

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Matching weight loss medications to patient
profiles

• Phentermine Diethylepropion are associated with
  blood pressure elevations , so both are not
  recommended for patients with uncontrolled
  hypertension, a history of cardiovascular disease
  or arrhythmias, or seizures
• Lorcaserine is not recommended in patients with
  depression and treated with SSRI Or SNRI , for
  fear of development of serotonin syndrome
• Orlistat, a lipase inhibitor, is likely safe for
  all individuals

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Anti hyperglycemic medications choice in type 2
DM

• Anti hyperglycemic medications that promote
  weight loss or weight neutrality are recommended
  
• GLP-1 receptor agonists namely liraglutide
  which is the only one approved by FDA for weight
  loss
• SGLT2 inhibitors , Metformin, DPP-4
  inhibitors pramlintide ( all are not FDA
  approved for weight loss )

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Individuals with type 2 DM who require insulin

• Add metformin, pramlintide, or a GLP-1 receptor
  agonist to mitigate insulin associated weight
  gain
• First-line insulin basal is preferable (
  consider prior to premixed or combination insulin
  therapy)

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Role of bariatric surgery

• bariatric surgery should be considered as the
  final step in weight management strategy, also in
  combination with appropriate lifestyle
  modifications
• Recent guidelines recognize the benefits of
  bariatric procedures in carefully selected type 2
  diabetic patients with BMI 35 kg/m2
• Furthermore, surgical weight loss interventions
  can be considered as an alternative treatment for
  poorly controlled type 2 diabetes patients with
  mild to moderate obesity (BMI 30-35 kg/m2)

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Main types of bariatric surgeries
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Main types of bariatric surgeries
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Gastric Banding
http//www.healthierweight.co.uk/obesity-surgery/g
astric-band/what-is-a-gastric-band/how-does-the-ba
nd-work/
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http//www.webmd.com/diet/video/bariatric-surgery
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Take home messages

• Diabesity is a growing worldwide epidemic that
  must be taken seriously
• Presence of obesity in a diabetic patient could
  hinder both diabetes control obesity management
  
• Multidisciplinary approach is considered nowadays
  the most successful way of management of both
  conditions

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Take home messages

• weight reduction through dietary interventions,
  exercise pharcotherapy must be a 1st and long
  lasting step in management of diabesity cases
• Lastly, bariatric surgeries may be indicated in
  some categories of patients according to their
  special situations

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