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Canadian Diabetes Association Clinical Practice Guidelines Weight Management in Diabetes. Chapter 17 Sean Wharton, Arya M. Sharma, David C.W. Lau. Key Points. 2013. Modest weight loss CAN make a difference Combined diet, physical activity and behavioural therapy are most effective - PowerPoint PPT Presentation
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Canadian Diabetes Association Clinical Practice Guidelines
Weight Management in DiabetesChapter 17(Updated July 2015)
Sean Wharton, Arya M. Sharma, David C.W. Lau
2015
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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.
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
• 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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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.
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Treatment Strategies
• Health behaviour interventions– Lifestyle
• Pharmacotherapy
• Bariatric surgery
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association 2015
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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]
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
CDA Clinical Practice Guidelines
http://guidelines.diabetes.ca – for professionals
1-800-BANTING (226-8464)
http://diabetes.ca – for patients