Post on 04-Apr-2018
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