2008 Clinical Practice Guidelines - Canadian Diabetes Association

2008 CLINICAL PRACTICE GUIDELINES
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Table 2.WC and risk of developing
health problems (6)
WC cutoff points *† Risk of developing
health problems
Men ≥102 cm (40 inches) Increased
Women ≥88 cm (35 inches) Increased
*WC cutoffs may be lower in some populations (e.g. older
individuals, Asian population [See Table 3]), especially in the presence
of the metabolic syndrome (such as hypertriglyceridemia)
† Increased WC can also be a marker for increased risk, even in
persons with normal weight
WC = waist circumference
TREATMENT OF OBESITY
The goals of therapy for overweight and obese people with
diabetes are to reduce body fat, attain and maintain a
healthy or lower body weight for the long term, and prevent
weight regain. In general, obese people with diabetes
have greater difficulty with weight loss compared to similarly
obese people without diabetes (14). A modest weight
loss of 5 to 10% of initial body weight can substantially
improve insulin sensitivity, glycemic control, high blood
pressure (BP) and dyslipidemia (15-19).The optimal rate of
weight loss is 1 to 2 kg/month. A negative energy balance
of 500 kcal/day is typically required to achieve a weight
loss of 0.45 kg/week (20).
Lifestyle interventions
Lifestyle intervention is recommended for weight loss in
order to improve health status and quality of life (20,21). In
people with diabetes who are overweight or obese, achieving
a healthy weight through an active lifestyle promotes a general
sense of well-being and cardiovascular (CV) fitness,
along with other benefits, such as reducing CVD, morbidity,
Table 3. Ethnic-specific values for WC (13)
mortality and other complications attributable to obesity
(22). Lifestyle interventions that combine dietary modification,
increased and regular physical activity and behaviour
therapy are the most effective (23-25). Structured interdisciplinary
programs have demonstrated the best short- and
long-term results (24). Ongoing follow-up with the healthcare
team is important to plan individualized dietary and
activity changes to facilitate weight loss.Adjustments to antihyperglycemic
agents may be required as the individual with
diabetes loses weight (26).
All weight-loss diets must be well balanced and nutritionally
adequate to ensure optimal health. In general, a carbohydrate
intake of at least 100 g/day is required to spare protein
breakdown and muscle wasting, and to avoid large shifts in
fluid balance and ketosis. High-fibre foods that take longer to
eat and digest are associated with greater satiety. Adequate
protein intake is required to maintain lean body mass and
other essential physiological processes. Reduced intake of saturated
fat and energy-dense foods should be emphasized to
achieve the required daily energy deficit to promote weight
loss. Very low-calorie diets with 100 individual studies evaluating
behaviour modification techniques support their effectiveness
in promoting weight loss as adjuncts to lifestyle
intervention (29,30).
Members of the healthcare team should consider using a
structured approach to providing advice and feedback on
physical activity, healthy eating habits and weight loss (31-34).
Country or ethnic group Central obesity as defined by WC
*NCEP-ATP III guidelines (11,12) and Health Canada (6) define central obesity as WC values ≥102 cm (40 inches) in men and
≥88 cm (35 inches)
WC = waist circumference
Men Women
Europid* ≥94 cm ≥80 cm
South Asian, Chinese, Japanese ≥90 cm ≥80 cm
South and Central American Use South Asian cutoff points until more specific data are available
Sub-Saharan African Use Europid cutoff points until more specific data are available
Eastern Mediterranean and Middle East (Arab) Use Europid cutoff points until more specific data are available