2008 Clinical Practice Guidelines - Canadian Diabetes Association

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<strong>2008</strong> CLINICAL PRACTICE GUIDELINES S78 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
Pharmacotherapy Pharmacotherapy for overweight people with diabetes not only improves glycemic control, but also results in a significant reduction in the doses of antihyperglycemic agents (26). Pharmacotherapy is an acceptable adjunct in the short- and long-term management of obesity when lifestyle measures fail to achieve the desired weight loss after an adequate trial of 3 to 6 months (20,35). Pharmacotherapy can be considered for people with BMI ≥30.0 kg/m 2 with no obesityrelated comorbidities or risk factors, or BMI ≥27.0 kg/m 2 with obesity-related comorbidities or risk factors (20). Antiobesity drug therapy may be considered as an adjunct to nutrition therapy, physical activity and behaviour modification to achieve a target weight loss of 5 to 10% of initial body weight and for weight maintenance (20,35). Two medications, orlistat and sibutramine, have been approved in Canada for long-term management of obesity (Table 4). Drug therapy leads to even greater weight loss when coupled with lifestyle intervention and behaviour modification therapy. Both drugs have been shown to be effective in obese people with type 2 diabetes, improving glycemic and metabolic control, and resulting in favourable changes in lipid levels, BP profile and fat distribution (26,36,37). In obese people with impaired glucose tolerance (IGT), orlistat also improves glucose tolerance and reduces the progression to type 2 diabetes (38). <strong>Clinical</strong> trials with antiobesity agents have confirmed a smaller degree of weight loss in people with diabetes compared with obese people who do not have diabetes (14,26). When pharmacotherapy is being considered in the treatment of the obese or overweight person with type 2 diabetes, the choice of drug should be based on the individual’s CV risk profile, dietary habits and concomitant disease(s). People with irregular eating habits, such as those who “snack” frequently, may be better suited to sibutramine therapy because of its long-acting satiety-enhancing properties. Combining orlistat and sibutramine therapy is not advocated for clinical use. Sibutramine should be avoided in patients with ischemic heart disease, congestive heart failure or other major cardiac disease. Orlistat should be avoided in patients with inflammatory or other chronic bowel disease. Other available antiobesity drugs, such as diethylpropion and phentermine, are sympathomimetic noradrenergic appetite suppressants that are approved only for short-term use of a few weeks. They are not recommended because of modest efficacy and frequent adverse side effects. Currently, a number of new molecular entities that target receptors and metabolic processes relevant to energy metabolism are being developed for the treatment of obesity. Among these emerging strategies, cannabinoid type 1 receptor antagonists currently appear to be the most promising (39). Surgery Individuals who are candidates for surgical procedures should be carefully selected after evaluation by an interdisciplinary team with medical, surgical, psychiatric and nutritional expertise. Surgery is usually reserved for people with class III obesity (BMI ≥40.0 kg/m 2 ), or class II obesity (BMI=35.0–39.9 kg/m 2 ) in the presence of comorbidities (40) and the inability to achieve weight-loss goals following an adequate trial of lifestyle intervention. Long-term, if not lifelong, medical surveillance after surgical therapy is necessary for most people. Preferred surgical options for weight loss include laparoscopic vertical banded gastroplasty and laparoscopic Roux-en-Y gastric bypass (41-43). Table 4. Medications approved for the treatment of obesity in type 2 diabetes Class Generic (trade) name Gastrointestinal lipase inhibitor Norepinephrine and serotonin reuptake inhibitor Recommended regimen orlistat (Xenical) 120 mg TID (during or up to 1 hour after each meal) sibutramine (Meridia) 10–15 mg OD (in the morning) Action Adverse effects • Nonsystemic pancreatic lipase inhibitor that exerts its therapeutic activity in the stomach and gastrointestinal tract by reducing dietary fat digestion and absorption by about 30% • Reduces food intake by enhancing satiety • May increase thermogenesis • May prevent decline in energy expenditure with weight loss • Abdominal bloating, pain and cramping • Steatorrhea • Fecal incontinence • Xerostomia • Increase heart rate and blood pressure • Constipation • Dizziness S79 MANAGEMENT
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2008 Clinical Practice Guidelines - Canadian Diabetes Association

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