Weight Management in Patients With Type 2 Diabetes JOAN TEMMERMAN, MD, MS, FAAFP, CNS American Association of Diabetic Educators Annual Meeting, Indianapolis,

Weight Management in Patients With Type 2 Diabetes

JOAN TEMMERMAN, MD, MS, FAAFP, CNS

American Association of Diabetic Educators Annual Meeting, Indianapolis, IN August 3,

2012

Objectives

• Describe the obesity epidemic and its impact on diabetes

• Review various options for weight loss and expected results

• Review diabetes weight management studies: Look AHEAD & Why WAIT

• Distinguish among different bariatric surgical procedures

• Summarize the IDF position statement on bariatric surgery in the treatment of obese patients with T2DM

• Examine recommendations for pre-operative and post-operative diabetic care

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The age of obesity: Inactive lifestyle, poor nutrition, calorie

imbalance

Threatens steady gains in longevity

2000

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 2000, 2010

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

2010

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: Behavioral Risk Factor Surveillance System, CDC

Obesity associated with increased

mortality

• 2-3-fold increased risk of death

• Serious health effects: obesity major risk for DM, CVD, HTN,stroke, and some cancers

James WPT, J Intern Med 2008:336-352

Diabesity: obesity strongly related to the epidemic of type 2 diabetes (T2DM)

Nguyen & El-Serag, Gastroenterol Clin North Am. 2010

Strong link between obesity and T2DM

Marrero DG. J Diabetes Sci Technol 2009;3(4):757-760.

42-foldincreased risk

93-fold increased risk

Obesity linked to T2DM

• Diabetes primarily caused by obesity: 90% of type 2 diabetes due to excess body weight and lifestyle

• Rapid increases in T2DM parallel rise of obesity• 26 million Americans have Type 2 diabetes• 27% are unaware (7 million people)!• T2DM: 1 in 4 ages ≥ 60 years (27%)• Also occurring at younger ages

CDC 2011 National Diabetes Fact Sheet

Increased Risk for Diabetes (pre-diabetes)

• 79 million people in the US with pre-diabetes in 2010 (35% of adults)

• Up from 57 million 2008

• High risk for developing diabetes

• Prevention urgent

CDC 2011 National Diabetes Fact Sheet

Global projections for the diabetes epidemic: 2010–2030

Chen, L. et al.The worldwide epidemiology of type 2 diabetes mellitus—present and future perspectives. Nat. Rev. Endocrinol. 2012;( 8):228-236

Obesity promotes diabetes; weight loss counteracts it

Weight loss from diet or metabolic surgery correlates with increased insulin sensitivity

Ferrannini E , Mingrone G Dia Care 2009;32:514-520

2011 American Diabetes Association, Inc.

Diabetic patients may have more difficulty losing weight

– Genetic differences– Metabolic factors inflammation, insulin resistance,

adipokines

– Medications: insulin, TZDs, sulfonylureas – Increased food to avoid hypoglycemia– Limited physical activity– Diet fatigue (carbohydrate restriction)

Anderson JW, Kendall CWC, et al. J Am Coll Nutr. 2003;22(5):331-339.

T2DM and Lifestyle interventionLook AHEAD Study (Action for Health in Diabetes) • Multicenter randomized 10 year clinical trial examining lifestyle intervention

• One of largest diabetes weight management studies using meal replacement (MR) strategy for weight reduction

• Weight loss at 1 year directly related to # of MR; addition of MR to lifestyle group increased weight loss to 8.6% (0.7% in usual care/control)

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Wadden, West, et al. Obesity 2009;17(4):713-722

T2DM and Lifestyle intervention: Why WAIT

• Short-term intensive weight loss program effective for 4 yrs

• 120 patients, weekly group visits for 12 weeks

• Lifestyle intervention: 2 MR, 2 snacks, healthy dinner

• ~50% maintained 10% wt loss (24 #) at 4 years; total group maintained 6.3% at 4 years

• Significant metabolic improvements; 50% reduction in diabetic meds & 27% decrease overall health costs

13

Hamdy O. Diabetes Weight Management in Clinical Practice: Why WAIT Program

Why WAIT Program

• Results more robust than Look AHEAD 4 year results

• Intensive lifestyle modification very valid option to bariatric surgery

• At least as effective as common bariatric surgery (gastric banding), much less costly & fewer side effects

• Comprehensive lifestyle intervention can produce sustainable clinically significant weight loss

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Hamdy O. Diabetes Weight Management in Clinical Practice: Why WAIT Program

Meal Replacements (MRs) highly effective in T2DM

• MR diet: significantly greater weight loss & less regain after 1 year of maintenance than standard, self-selected, food-based diet

• Statistically significant improvements in: weight loss, BMI, waist/hip measurements, fasting glucose, insulin and HbA1c level, lipids, & BP

• Achieved significantly lower levels of insulin and HbA1c than standard diet group

• 25% reduced diabetic medications

126 overwt/obese adults, T2DM, isocaloric MR vs ADA diet

Cheskin et al; Diabetes Educ 2008;34:118-127

Diabetes and MRs

• MR are viable and cost-effective for weight loss and maintenance in T2DM

• MR diet more effective in reducing metabolic risk factors, insulin & leptin than fat-restricted low-calorie diet

• Superior glycemic control with high-protein VLCD compared to traditional low-fat diet

Hamdy O, Zwiefelhofer D. Curr Diab Rep. 2010;10:159-164

Konig D, et al. Ann Nutr Metab 2008;52:74-78

Wing, Marcus et al; Arch Intern Med 1991;151:1334-40

17Effects of weight loss with VLEDs on fasting plasma glucose values for obese persons with type 2 diabetes

Anderson JW, Kendall CWC, et al. J Am Coll Nutr. 2003;22(5):331-339

Joslin New Nutrition Guidelines

• Reduce Daily Caloric Intake by 250-500 calories

• ~40% Carbohydrates, LGI, High Fiber

• 20-30% Protein

• 30% Fat (no TF, 7-10% SF, 20% Mono & Poly UF)

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www.joslin.org

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Bariatric Surgery

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Bariatric surgery

•Most effective treatment for sustained weight loss

•Most patients have complete resolution of T2DM, HTN, OSA, dyslipidemia

•Criteria to qualify:• Ages 16* – 65• BMI ≥ 40• BMI ≥ 35 with serious comorbidities (T2DM, OSA, HTN, cardiovascular disease)

Surgical Procedures

Roux-en-Y gastric bypass (RYGB)

• Gold Standard

• Laparoscopic

• Both restrictive and malabsorptive

• Metabolic effect

• Most common bariatric surgery in US

Roux-en-Y gastric bypass

Stomach before bariatric surgery. (B) Stomach after Roux-en-Y gastric bypass procedure; food is redirected to the middle portion of the small intestine, limiting absorption of calories.

American Family Physician - April 15, 2006

Adjustable gastric banding (AGB)

• Laparoscopic

• Primarily restrictive

• Potentially reversible

• Most common bariatric surgery in Australia and Europe

Adjustable Gastric Banding

Inflatable ring inserted laparoscopically; adjusted via subcutaneous access

port American Family Physician – April 15, 2006

AGB: poor long-term outcomes

• 151 consecutive patients 1994-1997; 82 followed:

• Reoperation rate 60%

• 1/3 experienced band erosions

• ~50% require band removal

Himpens, Cadiere et al. Arch Surg. March 22, 2011

RYGB has better risk-benefit profile than LB

• RYGB greater weight loss, increased resolution of diabetes, improved QOL

• Low complication rate similar to LB

• Lower rate late complications (reoperations)

Campos, Rabl et al. Arch Surg. 2011;146(2):149-155.

Vertical Sleeve Gastrectomy (VSG) (Sleeve Gastrectomy; Vertical Gastrectomy)

• 2/3 of stomach removed; remaining stomach 3-4 oz (~ 100 cc)

• Ghrelin not produced (loss of appetite)

• Irreversible

• Purely restrictive although has metabolic effect

• Easy to modify; sometimes done as staged procedure

• Weight loss superior to Band

Vertical Sleeve Gastrectomy

Resolution of T2 diabetes

% EBWL % DM resolved

Band 46.256.7

Gastroplasty (VSG) 55.5 79.7 Gastric Bypass 59.780.3

BPD/DS 63.695.1Buchwald, Estok et al. Am J Med 2009;122(3):248-256

RYGB, VSG, BPD/DS associated with rapid metabolic

improvements

Metabolic improvements

•Metabolic surgery (RYGB, VSG, BPD/DS) state of negative energy balance and rapid weight loss:

– decreased appetite & early satiety, not hunger– Suggests resetting of weight set point to a lower

level

•After metabolic surgery,– rapid improvement in glycemic control in T2DM

patients – diabetes remission occurs almost immediately

before significant weight loss has occurred

– alterations in gut hormones seem to underlie glucose homeostasis

Energy homeostasis & weight regulation highly complex

Stanley, Physiol. Review 85:1131, 2005

Key hormones in energy homeostasis• Hormone expression altered by metabolic surgery:

– Ghrelin– GLP-1– PYY1–36– GIP– Insulin– Leptin– Adiponectin

Metabolic adaptations after RYGB, VSG & BPD/DS

– Ghrelin (appetite stimulating & prodiabetic hormone produced by stomach and duodenum) may decrease *

– Incretin hormones increased (enhance insulin secretion, decrease glucagon secretion, inhibit gastric emptying; exert trophic effects on beta cells in response to meals), CNS effect to reduce food intake

• Glucagon-like peptide-1 (GLP-1)• Gastric inhibitory peptide (GIP)• Peptide YY (PYY)

*early decrease; inconsistent long-term; variable methods used in studies (Harvey et al, 2010)

gut hormones mediate glucose metabolism after bariatric surgery; reduce food intake

.

KASHYAP S R et al. Cleveland Clinic Journal of Medicine 2010;77:468-476

©2010 by Cleveland Clinic

Summary of IDF Position Statement for T2DM • Obesity and diabetes epidemics are serious chronic diseases

& major global public health issues

• Prejudices about severe obesity, which also exist within the health care system, should not be a barrier to effective treatment options

• Bariatric surgery can significantly improve T2DM

• Effective, safe, cost-effective therapy

• Bariatric surgery is an appropriate treatment for people with T2DM and obesity not achieving recommended treatment targets with medical therapies especially when there are other major co-morbidities

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IDF Position Statement for T2DM

• Surgery accepted option in people with T2DM & BMI ≥ 35

• Surgery should be considered as treatment option in persons with BMI 30-35 when diabetes not adequately controlled by optimal medical regimen especially in the presence of other major cardiovascular diseases risk factors

• Procedures must be performed within accepted guidelines

• Requires comprehensive approach and ongoing multidisciplinary care, patient education and follow up

• Surgery should be considered complementary to medical therapies

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Post-op requirements (Bariatric program requirements vary)

• Maintain good nutrition• 60-80 g protein daily• B12 supplementation:

– 500 mcg SL/d; – 500-1000 mcg oral/d; – 500 mcg/wk nasal; – 1000 mcg/month IM

OR B complex

• Calcium citrate 1200-1800 mg/d (divided doses; separate from iron)

Post-op requirements

• Complete multivitamin (with iron): 1-2/d*

• Menstruating women may need additional iron: 120-200 mg elemental Fe daily divided

– May develop anemia refractory to oral Fe and require parenteral Fe infusions

• Vitamin D if deficient

•Do not recommend prenatal vitamins

• If become pregnant, one complete MV + one PNV daily

•NO GTT!!!

*Ca and Fe need to be separated

Post-op lab parameters

• CBC with differential• CMP• B12• B1 (thiamine)• 25(OH) D• Ferritin• Serum iron• RBC folate (most reliable indicator of folate tissue stores;

steadier value)• Pre albumin (most sensitive laboratory indicator of protein

status) • Lipid profile• PTH intact• *Hgb A1c, TSH (If h/o DM or hypothyroid)

Every 6 months for 1st yr; then yearly

Recommendations for pre- and post-operative diabetic care

• Optimize glycemic control peri-operatively & closely monitor after surgery

• Tips from IU Health Bariatric Center Diabetic Educator Angela Marsden, RD, MS, CHES, CD, CDE:

• Check A1c and lipids pre-op; A1c should be < 8% for surgery

• If A1c > 7.5%, patient contacted and asked what they are doing for BS control

• If A1c ≥ 8%, PCP notified to assist in achieving good control pre-op

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Pre- and post-operative diabetic careTips from IU Health Bariatric Center Diabetic Educator Angela Marsden, RD, MS, CHES, CD, CDE:

• Patients educated during pre-op class:– Managing glucose during clear liquid diet– Maintaining diabetes self-care behaviors after surgery– How to treat low blood sugar after surgery– Potential causes of hypoglycemia (too many carbs;

poorly timed meals)

• Ongoing support and monitoring

• Data collection following post-op progress: BMI, BP, LDL, A1c

• Address post-op individual concerns: hypoglycemia, dumping syndrome

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Is there a difference between surgical and medical weight loss?

Weight loss: surgical vs medical

•Surgery is the most effective treatment for sustained weight loss RYBG, VSG metabolic effect

•Surgery is the most effective treatment for diabetes

• Difficult to lose >100# without surgery

• Nonsurgical typical maximum weight loss 1/3:– If 300 #; getting to 200 # good result– if 400 #; 270# best result

Surgical vs. medical weight loss

• Observational study comparing people who lost large amounts of weight through surgery vs non-surgical means (NWCR data)

• Possible to have massive weight loss through intensive lifestyle/behavioral efforts sometimes comparable to surgery

• Marked behavioral differences: non-surgical worked much harder in terms of diet and exercise

Bond DS et al. Int J Obes 2009;33:173-80

What happens after medical weight loss?

•Unfavorable metabolic adaptations occur

• Neuroendocrine changes convey “energy deficit signal”

– Decreased leptin, PYY, cholecystokinin, insulin, amylin (anorexigenic hormones satiety)

– Increased ghrelin, pancreatic peptide (oxeigenic hormones increase appetite

MacLean et al; Am J Physiol Regulatory Integrative Comp Physiol 2009;297

Sumithran et al; NEJM 2011;365;Oct 27, 2011

What happens after medical weight loss?• Increased drive to eat

• Decreased energy expenditure/REE

large energy gap between appetite and expenditure

•~8 kcal/# lost/day less energy

MacLean et al; 2009Sumithran et al; NEJM 2011;365; Oct 27, 2011

ADA position: weight management; J Am Diet Assoc. 2009

Summary

• Weight management is most important therapy for patients with T2DM obesity promotes diabetes; weight loss counteracts it

• Comprehensive lifestyle intervention can produce sustainable clinically significant weight loss

• Metabolic surgery most effective intervention

• Therapeutic lifestyle changes cornerstone of therapy for all approaches

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49

Marrero DG. J Diabetes Sci Technol 2009;3(4):757-760.

James WPT, J Intern Med 2008:336-352

Nguyen & El-Serag, Gastroenterol Clin North Am. 2010.

Chen, L. et al. The worldwide epidemiology of type 2 diabetes mellitus—present and future perspectives. Nat. Rev. Endocrinol. 2012;( 8):228-236

Wadden TA, West DS, et al. One-year weight losses in the Look AHEAD Study: Factors associated with success. Obesity 2009;17(4):713-72

Joslin Study Shows Short-Term Intensive Weight Loss Program Works For Four Years. Accessed June 14, 2012 at http://www.joslin.org/news/short-term-intensive-weight-loss-program-works-for-four-years.html andhttp://www.joslin.org/care/why_wait.html (description of program)

Diabetes Weight Management in Clinical Practice: Why WAIT Program. Hamdy O. Accessed June 14, 2012 at http://www.joslin.org/docs/WHY_WAIT_2007.pdf

References

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Wadden TA, Neiberg RH, et al, Four-year weight losses in the Look AHEAD Study: Factors associated with long-term success. Obesity (Silver Spring) 2011;19(10):1987-1998.

Cheskin LJ, Mitchell AM, Jhaveri AD, Mitola AH, Davis LM, Lewis RA, Yep MA, Lycan TW. Efficacy of meal replacements versus a standard food-based diet for weight loss in type 2 diabetes: a controlled clinical trial. Diabetes Educ. 2008 Jan-Feb;34(1):118-27.

Anderson JW, Kendall CWC, et al. Importance of weight management in type 2 diabetes: Review with Meta-analysis of clinical studies. J Am Coll Nutr. 2003;22(5):331-339.

Wing RR, Marcus MD, Salata R, Epstein LH, Miaskiewicz s, Blair EH. Effects of a very-low-calorie diet on long-term glywemic control in obese type-2 diabetic subjects. Arch Intern Med. 1991;151:1334-40.

Hamdy O, Zwiefelhofer D. Weight management using a meal replacement strategy in type 2 diabetes. Curr Diab Rep. 2010;10:159-164.

51

Konig D, et al. Ann Nutr Metab 2008;52:74-78

Himpens, Cadiere et al. Arch Surg. March 22, 2011

Buchwald H, Estok R, Fahrbach K, et al. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med . 2009 Mar;122(3):248-256.

Kashyap SR et al. Bariatric surgery for type 2 diabetes: Weighing the impact for obese patients. Clev Clin J Med. 2010;77(7):468-476.

Bariatric Surgical and Procedural. Interventions in the Treatment of Obese Patients with Type 2 Diabetes. A position statement from the. International Diabetes Federation Taskforce on Epidemiology and Prevention. Accessed July 17, 2012 at http://www.diabetes.org.br/anexo/idf-position-statement-bariatric-surgery.pdf

Harvey et al; Mount Sinai J of Medicine 2010; 77:446-465).

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Kohli R, Stefater MA, Inge TH. Rev Endocr Metab Disord 2011.

Bond DS et al. Int J Obes 2009;33:173-80

MacLean PS, Higgins JA, et al. Regular exercise attenuates the metabolic drive to regain weight after long-term weight Loss. Am J Physiol Regulatory Integrative Comp Physiol 2009;297:R793-R802.

Sumithran et al; NEJM 2011;365; Oct 27, 2011

Position of the American Dietetic Association: Weight Management. J Am Diet Assoc. 2009;109(2):330-346. Ferrannini E, Mingrone G. Impact of Different Bariatric Surgical Procedures on Insulin Action and β-Cell Function in Type 2 Diabetes. Diabetes Care March 2009 vol. 32 no. 3 514-520