Diabesity:

The goal of achieving optimum glycemic control through the use of

stages of change (SOC), motivational interviewing (MI), and relapse

Prevention (RP).

Raymond Zakhari, NPMetro Medical Direct

Obesity Diabetes Connection

• Type 2 Diabeteso Insulin resistanceo Relative beta-cell failureo Central adiposityo Elevated Triglycerides

**Reduction of central adiposity (Weight Loss) is better than medications in controlling T2DM

Significance

1) Heart Disease: 696,9473) Stroke: 162,6726) Diabetes: 73,249

CDC: 2002 http://www.cdc.gov/nchs/fastats/lcod.htm

The only people who truly welcome change are wet

babies!!

If you want to understand something, try to change it!

(Kurt Lewin 1951)

Persuasion Exercise

• 53 yo. M. venture capitalist, starting your own firm. T2DM, HTN, Obesity, (Metabolic Syndrome). You don’t ever exercise because you think it’s too much for your heart to take. You want to be made just to feel better.

Persuasion Exercise

• You’re a New PCP, who just started in a new group practice, you want to help ALL your patients improve.

The patient has been passed around from provider to provider with no improvement and if he doesn’t loose weight and exercise he may have some serious complications.

Your Mission

• Get the patient to do something about his weight and inactivity and his disease management. This is a serious problem.

• You have 5 minutes!!. . . . On your mark!! Get set!!!!GO!!!!!

Type 2 Diabetes ? ?

What comes to mind?

Behaviors

• Pre- Diagnosiso InactivityoPoor Eating Habits

• Post-Diagnosiso Inactivityo Poor Eating Habitso Medication Managemento SMBG (self-monitoring

blood glucose)o Health appointments

You Want Me to . . .

• Stop eating my favorite foods

• Start exercising everyday

• Stick my finger at least 3 times per day

• See my PCP, Eye Doctor, Dentist, Podiatrist, Nutritionist, Diabetic Educator

• Take the following Medications Every Day:o 1) ASAo 2) ARB / ACE-Io 3) TZD / Biguanadineo 4) Statin

• Blood work every 3 months at least

Adherence Complications

• ACE-I : irritating cough• TZD: legs may swell, fluid in lungs—SOB• Biguanadine- diarrhea and stomach cramps• ASA- nausea• Statin- generalized muscle aches and pains• ARB- dizziness

Non-adherence Complications

• Renal Failure• Cardiovascular disease• Stroke• Amputation of limbs• Sexual dysfunction• Peripheral Neuropathy• Gastroparesis

Stages Of ChangePrecontemplator

“I feel fine. Your test must be wrong.”“Your not even a doctor”“Those medicines all have side effects worse than this disease that you claim I have”“There is no way I can make all those changes”“What difference does it make? We all have to go sometime, and if I go, I want to go happy.”“I’ve tried before and I can’t do it.”

Contemplators

• “Uncontrolled diabetes is bad”• “My relative had this and they lost their . . .”• “How many times do I really have to check

my sugar?”• “Do I really have to give up all my favorite

foods?”• “I know I need to loose weight”• “I don’t want to become a burden to . . .”

Preparatory Stage

• “I’m going to join a gym closer to my house this time”

• “I’m going to pack my lunch and an afternoon snack so I don’t raid the vending machine”

• “I’m going to get a daily pill box and put it next to my tooth brush”

• “I can put my glucometer on my night stand”• “I can schedule something fun to do after my

appointments”

Action

• “I booked or have gone to my appointments”• “I got the prescription filled”• “I calibrated my glucometer”• “I pre-poured my med’s for the week”• “I’m walking 20 minutes every day”• “I look at my feet every night”• “I didn’t super-size my fast-food lunch”

Maintenance

• “I feel so much better and I never want to go back to the way I used to be”

• “Did you know that they serve grilled chicken at fast-food places and I can get mustard instead of mayo?”

• “If I don’t eat everything on my plate at dinner I can have lunch the next day.”

• “I can now fit into my old clothes”

Lapse/ Relapse

• “I had a pasta dinner, wine and the whole Tiramisu”Two Pathways

“Next time I could eat half the pasta, and share the Tiramisu with everyone, or save it for tomorrow”

“I loved not feeling restricted in what I eat, if I want pasta, wine and dessert I’ll do it. This diabetes thing really isn’t that bad.”

High Risk Eating

• Situational DeterminantsDarpkin et al. (1995):1) Family celebration w/ favorite foods.2) Argument ends with escape to kitchen full of favorite foods.3) Visit the kitchen during a TV commercial.4) Work break from pressure situation snacks by coworker.What would you do to Avoid over eating?

• Rate your temptation:

• Rate your self efficacy regarding not overeating

• Those that came up with coping strategies had lasting effects of long-term weight loss (>6 months).

Providing Alternatives for Maladaptive Eating

• How to counter High Risk Situations Boredom/ lack of activities Emotionally charged situations

• Development of healthy addictions: Exercise, Meditation

RP

• Build Self Efficacy• How should one interpret lapse and relapse?• Abstinence Violation Effect (AVE)

o Cognitive attribution for the lapseo Affective reaction to the attribution

o The higher the AVE the more maladaptive eating ensues as a means of restoring feelings of well- being

The individual’s state of health and well-being are multivariable in nature– While anyone can write the right prescription to fix the numbers, the prudent clinician must not focus merely on what those numbers represent, but who those numbers represent.

Case Study

• 52 yo. W M. Opera Composer & pianist, single

Risk Factors:• Family History• Central adiposity• Hypertriglycericdemia• Sedentary

Case study continued

• SHx:o Many social engagementso Much alone timeo Difficulty getting commissiono NO SMBG

• Labs:o A1C- 10, Creat. 1.2, Random Urine Micro Albumin

100, AST—15, ALT--20

Case Study Continued

• Meds./ Treatmento glipizide 10mg, BIDo Exercise, watch carbs., try too loose weight.o Plan to start Insulin

Perceived Resistance/ Non-compliant

Major Concerns Loss of sensitivity to fingers related to finger sticks What to eat at parties Occasional hypoglycemic events Needle phobia

Assessment and Plan

• Type 2 Diabetes, Uncontrolledo 1) Weekly visits X 4 o 2) Stop glipizide, start metformin 500 b.i.d.

Warn of GI adverse effectso 3) Instruct in SMBGo 4) Refer to internet sites for Diabetic dieto 5) Review foot examso 6) Journal concernso 7) Repeat Random Chemistry in week 4

A/P continued

• Increase metformen to 1500 mgs. q.h.s.• Add rosiglitazone 4mgs q hs, add Asprin.• Creative solution to finger-sticks• RV in 4 weeks with journal of ideas for

desired outcomes and check LFTs, phone f/u PRN.

• AII-RB started• Referral to RD

9 Month Follow-up Visit

• A1C- 6.8, microalbumin—30mg/dl.• SMBG done 3 times per week with food

journaling• Exercising 4 times per week X 45 minutes

(home aerobic machine)• Reported Weight Loss of 6 inches (48 to 42)• Meds adjusted to 1 combination pill of

rosiglitazone/ metformin 4/2000 daily.

References

Collins, R.L. (2005) Relapse Prevention for Eating Disorders and Obesity. In Marlatt, G.A. & Donovan, D.M., Relapse Prevention: Maintenance strategies in the Treatment of Addictive Beahviors (248- 269). New York: The Guilford Press.