Weight Management as Treatment for Diabetes

Transcription

1 Weight Management as Treatment for Diabetes

2 Age-Adjusted Relative Risk Relationship Between Increasing BMI and Risk of Type 2 Diabetes 100 Men Women <22 < Chan J et al. Diabetes Care 1994;17:961. Colditz G et al. Ann Intern Med 1995;122:481. Body Mass index (kg/m 2 )

3 Do You Know Your Own BMI? Weight (lbs) Height

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6 Typical Treatment of Overweight Patient with Diabetes Diabetes Metformin other medications High Blood pressure 2 3 medications High cholesterol 1 medication Reflux 1 medication Sleep apnea CPAP

7 Treat Weight First - Then Comorbidities Monito r Diet Meds Monitor Diet Exercise Meds Old Treatment Paradigm Treat Weight LAST Dyslipidemia Dyslipidemia Lipid panels Lipoproteins subsets Total fat Chol. Fiber Statins Fibrates Resins Niacin Weight and BMI HTN Blood Pressure Ambulatory Blood Pressure Sodium K ++ Central acting Renal effective Peripherally acting diuretics Thiazide diuretics Overweight/Obesity Any diet patient will adhere to IGT Blood sugar Glycosylated hemoglobin distribution Sugar Distribute CHO, PRO, Fat Insulin Sulfonylureas Glidizones Absorption agents 150 minutes of moderate-intensity aerobic activity/wk and muscle-strengthening activities on > 2 days/wk Orlistat, phentermine, phentermine/topiramate, lorcaserin New Treatment Paradigm Monitor Diet Exercise Meds Monitor Diet Meds Weight and BMI Lipid panels Lipoproteins subsets Sat + trans fat Omega-3s MUFA Simple CHOs ETOH Statins Fibrates Weight FIRST Overweight/Obesity Any diet patient will adhere to HTN Blood Pressure Ambulatory Blood Pressure DASH Diet Sodium ETOH ACE Inhibitors ARBs Thiazide diuretics IGT Treat 150 minutes of moderate-intensity aerobic activity/wk and muscle-strengthening activities on > 2 days/wk Orlistat, phentermine, phen/top, lorcaserin, naltr/bupr Blood sugar Glycosylated hemoglobin distribution Glycemic index diet Fiber Diabetic diet Metformin Exenatide Liraglutide

8 Currently Available Options Accept weight where it is Diet/Exercise: 3-10% weight loss Drugs: 5-12% weight loss Medically Supervised/Combination of Diet + Drug: 10-15% weight loss Surgery: 15-30% weight loss Effectiveness Low High

9 Medications That May Affect Weight Consider management of medications for chronic disease which might lead to weight gain Medications With Weight Effects Disease Weight Gain Weight Neutral Weight Loss Diabetes Insulin Metformin GLP-1 analogs Sulfonylureas pioglitazone DPP4s SGLT-2 inhibitors Depression Most SSRIs Desvenlafaxine Bupropion Many others Venlafaxine Hypertension Beta-blockers most Antipsychotics Progesterone All? Depo-provera

10 Weight effects of Diabetes Medications Weight gain Sulfonylureas (glipizide, glimepiride, glyburide) Pioglitazone Insulin Weight loss GLP-1 RA (Victoza, Bydureon, Trulicity, Tanzeum) SGLT-2 I (Invokana, Farxiga, Jardiance) Weight neutral DPP-4 I (Januvia, Onglyza, Tradjenta) Metformin Acarbose

11 Treatment of Obesity Behavioral change therapy Food intake (amount and type) Activity level Anti-obesity Medications Surgery LAP-BAND Gastric sleeve Gastric Bypass

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15 Initial Steps in Counselling about Weight Loss Discuss treatment options Understand realistic weight loss Success is not measured only by the scale Achievement of health goals Improvement in related conditions Daily function Quality of Life

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24 What is the best diet? The one you will stick to over the long-term Think of it as a life-long change in your relationship with food.

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27 Office Based Treatment Obesity Society Guidelines Recommend: Energy intake < Energy balance Men: kcal per day Women kcal per day Energy deficit of 500 kcal/day If not counting calories, use a restrictive diet Like low carb diet Meal replacement.

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38 Sitting Disease? Please Stand

39 Increased standing time improved survival rate Katzmarzyk, MSSE, 46:5, (2014)

40 What happens while you sit Electrical activity in your muscles drop Calorie burning rate immediately plunges to about 1 kilocal/minute Insulin effectiveness drops Enzymes responsible for breaking down lipids and triglycerides plunge HDL (good cholesterol) falls Source: Hamilton, M. et al. (2008). Too Little Exercise and Too Much Sitting: Inactivity Physiology and the Need for New Recommendations on Sedentary Behavior. Current Cardiovascular Risk Reports, 2,

41 We are hard-wired not to starve!!!

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43 The Brain Plays a Key Role in Balancing Energy Intake and Expenditure.

44 The Diet Strategy Failure Rate of Diet Alone 90-98% New Set Point Baseline Weight 5-10% Counter-Regulation

45 Weight Loss Drugs Approved by FDA Generic Name Naletrexone+Bupropion Phentermine+Topiramate Lorcaserin Orlistat Liraglutide Phentermine Diethylpropion Phendimetrazine Methamphetamine Benzphetamine Trade Name Contrave Qsymia Belviq Xenical, Alli Saxenda Adipex, Fastin, Ionamin Tenuate, Tenuate, Dospan Bontril Desoxyn Didrex, Regimex

46 Weight Loss with Lorcaserin 2.16 ± 0.14% 5.81 ± 0.16% Smith, et al. N Engl J Med 2010;363:

47 Weight Loss with Lorcaserin 47.5% 20.3% 22.6% 7.7% Smith, et al. N Engl J Med 2010;363:

48 Lorcasarin: BLOOM Diabetes Study Obesity (2012) 20,

49 Lap Band Sleeve Gastrectomy Gastric Bypass Low Effectiveness Risk High

50 Bariatric Surgery Reduces Mortality in Swedish Obese Subjects 30% Reduction in All Cause Mortality Sjostrom L et al. NEJM 2007;357:741-52

51 Summary Management of weight should be first line treatment in patients with diabetes Lifestyle is foundation of treatment Consider other medications that might be causing weight gain Try to avoid diabetes medications that cause weight gain Medications that treat obesity lower glucose levels

52 Weight Loss Meds: Final Thoughts Supported by a wide range of societies and guidelines Current medications result in modest but clinically meaningful weight loss Should be used as an adjunct to lifestyle modification Should optimally be used long-term What about intermittent therapy? Typically not covered by insurers, so cost is a barrier Goal is to have a conversation with patients that is helpful to them

53 Obesity, Lifestyle and Diabetes How Should Diabetes Therapy Change? When more food than is proper has been taken, it occasions disease. If we could give every individual the right amount of nourishment, we would have the safest way to health. Hippocrates

54 The greatest weakness lies in giving up. The most certain way to succeed is always to try just one more time Thomas A. Edison