Canadian Diabetes Association Clinical Practice Guidelines

Weight Management in DiabetesChapter 17(Updated July 2015)

Sean Wharton, Arya M. Sharma, David C.W. Lau

2015

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Key Points

1. Modest weight loss CAN make a difference

2. Combined diet, physical activity and behavioural therapy are most effective

3. Weight loss drugs are of limited benefit4. Consider weight effects when selecting anti-

hyperglycemic medications

5. Bariatric surgery is appropriate in select refractory cases

2013

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The Growing Epidemic

• 80-90% of patients with T2DM overweight or obese*

• Some antihyperglycemic therapies contribute to weight gain

• Higher BMI increases mortality

BUT, weight loss of only 5-10% can improve metabolic parameters!

Overweight or Obese

*Wing RR. Weight loss in the management of type 2 diabetes. In: Gerstein HC, Haynes B editor(s). Evidence-Based Diabetes Care. Ontario, Canada: B.C. Decker, Inc, 2000:252–76.

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• Height, weight, BMI, waist circumference• Hypertension, dyslipidemia and CVD

Waist Circumference and Risk of Health Problems: Thresholds

Men Caucasian, African ≥94 cmAsian, South or Central American

≥90 cm

All Women ≥80 cm

Assessing the Problem

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Canadian Guidelines for Body Weight Classification in Adults

Classification BMI (kg/m2) Risk of Health Problems

Underweight <18.5 IncreasedNormal weight 18.5-24.9 LeastOverweight 25.0-29.9 IncreasedObese ≥30.0

Class I 30.0-34.9 HighClass II 35.0-39.9 Very HighClass III ≥40.0 Extremely High

Health Canada. Canadian Guidelines for Body Weight Classification in Adults. 204 Ottawa, ON: Health Canada; 2003. Publication H49-179/2003E.

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1. Modest Weight Loss CAN Make a Difference

• Goal is to prevent weight gain, promote weight loss and prevent weight re-gain

• Weight loss of only 5-10% improves:– Insulin sensitivity – Glycemic control – Blood pressure– Lipid levels

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Treatment Strategies

• Health behaviour interventions– Lifestyle

• Pharmacotherapy

• Bariatric surgery

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2. Combined Diet, Physical Activity, and Behavioural Therapy are Most Effective

• Structured interdisciplinary programs work best

• Very low calorie diet (<900kCal/d) discouraged– Adequate carbohydrate (>100g/d), adequate protein, high

fibre, low fat are preferred

• Increased, regular, appropriate exercise

• Reasonable weight loss goals of 1-2 lbs/week

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3. Weight Loss Drugs are of Limited Benefit

• Pharmacotherapeutic options limited

• Intestinal fat absorption inhibition (orlistat) currently the only accepted option

• Consider effects of antihyperglycemic therapies on weight 2013

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Weight Gain Weight Effect (kg)Insulin +4.5 to 5.0Thiazolidenediones (TZDs) +4.2 to 4.8Sulfonylureas +1.6 to 2.6Meglitinides + 0.7 to 1.8Weight Neutral or Decrease Weight Weight Effect (kg)Metformin -4.6 to 0.4α-Glucosidase inhibitors +0.0 to 0.2Dipeptidyl peptidase-4 (DPP-4) inhibitors +0.0 to 0.4Glucagon-like peptide-1 (GLP-1) receptor agonists

-1.3 to 3.0

4. Consider Weight Effects When Selecting Antihyperglycemic Medications

Hollander, P. Diabetes Spectrum 2007; 20(3): 159-165

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5. Bariatric Surgery is Appropriate in Select Refractory Cases

• Class III (BMI ≥ 40 kg/m2), or class II (BMI 35.0-39.9 kg/m2)

obesity with comorbidities• Assessment by interdisciplinary team

– Medical, surgical, psychiatric, and nutritional

• Laparoscopic Roux-en-Y gastric bypass or biliopancreatic diversion with duodenal switch

• Long-term medical follow up• Be aware of any provincial regulations with respect

to bariatric surgery

2013

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1. An interdisciplinary weight management program (including a nutritionally balanced, calorie-restricted diet, regular physical activity, education and counselling) for overweight and obese people with, or at risk for, diabetes should be implemented to prevent weight gain and to achieve, and maintain a lower, healthy body weight [Grade A, Level 1A]

Recommendation 1

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Recommendation 2

2. In overweight or obese adults with type 2 diabetes, the effect of antihyperglycemic agents on body weight should be taken into account [Grade D, Consensus]

2013

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Recommendation 3

3. Adults with type 2 diabetes and class II or III obesity (BMI ≥35.0 kg/m2) may be considered for bariatric surgery when other lifestyle interventions are inadequate in achieving healthy weight goals [Grade B, Level 2]

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CDA Clinical Practice Guidelines

http://guidelines.diabetes.ca – for professionals

1-800-BANTING (226-8464)

http://diabetes.ca – for patients