This presentation summaries state of the art management of obesity in diabetes mellitus (diabesity) including definition and classifications of both obesity and diabetes. Multidisciplinary approach , pharmacotherapy & bariatric surgery

1. Management of Obesity in DM
“ Dealing with a Bad Companion”
By
Tarek Al Areeny , MD
tarekareny69@yahoo.com
www.elarenycenter.com
01092933193
‫مايو‬ ‫للصيادلة‬ ‫األول‬ ‫المنيا‬ ‫مؤتمر‬2015

2. Presentation Outlines:
 Obesity “definition & stages”
 Diabetes & Prediabetes “ diagnostic criteria”
 Diabetes & obesity Comorbidity, and why they
are considered “Bad Companion”?
 Multidisciplinary approach to managing
coexistent type 2 diabetes and obesity
* lifestyle Modifications
* Medications
* Bariatric surgery & its impact on type II DM
 Take Home Messages

4. Obesity “definition & stages”
 Overweight and Obesity are defined as degrees
of excess weight that are associated with
increases in morbidity and mortality.
 But weight alone is not an adequate measure of
adiposity so the calculation of the body mass index
(BMI), which is weight (kg) divided by the height
(meters) squared, gives a reasonable approximation of
adiposity and this is widely used in both clinical
practice and research.

7. Diabetes mellitus “ diagnostic criteria”
ADA 2015

8. Criteria for testing for DM in asymptomatic adults:
ADA 2015

9. Categories of increased risk for
diabetes (prediabetes):

12. Diabetes & Obesity Co-morbidity:
 In Nurse‟s Health Study* , it was Found that the most
important risk factor for developing type 2 diabetes was
BMI
 The relative risk of diabetes was 38.8% in women with
BMI of 35 kg/m
2
or higher , and 20.1% for women with
BMI between 30-34.9 kg/m
2
when compared to
women with BMI less than 23 kg/m
2
 In fact , the relative risk was not only increased in the
obese but in the overweight groups as well
* Hu FB et al. Diet and lifestyle, and the risk of type 2 diabetes mellitus in women . N England J
Med.2001;345:790-7.

13. Diabetes & Obesity Co-morbidity:
 Similar results were found in the third National
Health and Nutrition Examination survey (
NHANES), denoting that the prevalence of DM
was dramatically increased with an increase in
BMI.
 The prevalence of DM was 2.5 times higher in
overweight men and 3 times in overweight
women when compared to normal weight
group.

14. Diabetes & Obesity Co-morbidity:
 This prevalence continued to increase and was
6 times higher in men and 5.5 times higher in
women with BMI between 35 and 39.9 km/m
2
 Unfortunately, not only obesity increase the
prevalence of diabetes,
 it also makes it more difficult to treat !
why?

15. Why obesity hinders diabetes control
and increase mortality ?
 Increase insulin resistance & glucose
intolerance
 Exacerbating other metabolic complications
such as hypertension and dyslipidemia
 Regarding mortality, compared with normal
weight individuals with diabetes, the mortality
rate is 2.5-3.3 times higher in diabetics with
body weights that are 20-30% above their ideal
weight and 5.2-7.9 times higher in those with
body weights 40% above ideal weight

16. Why obesity hinders diabetes control
and increase mortality ?
 The proposed mechanism of this increased
mortality in obese diabetics may be due to
excess body fat, particularly abdominal fat,
along with the presence of insulin resistance
leads to a Pro-Atherogenic lipid profile with
high triglyceride and apolipoprotein B
concentrations, an increased proportion of
small dense LDL particles, and a reduced
concentration of HDL cholesterol.

17. Why obesity hinders diabetes
control and increase mortality ?
 This Pro-Atherogeinc factor, along
with a pro-thrombotic and a pro-
inflammatory profile significantly
worsens an individual‟s risk of
cardiovascular disease and overall
mortality.

18. Copyright © 2015 AACE.
May not be reprinted in any form without express written permission from AACE.
ENDOCRINE PRACTICE Vol 21 No. 4 April 2015
American Association of Clinical
Endocrinologists and
American College of Endocrinology
Clinical Practice Guidelines for
Developing a Diabetes Mellitus
Comprehensive Care Plan
Writing Committee Cochairpersons
Yehuda Handelsman MD, FACP, FACE, FNLA
Zachary T. Bloomgarden, MD, MACE
George Grunberger, MD, FACP, FACE
Guillermo Umpierrez, MD, FACP, FACE
Robert S. Zimmerman, MD, FACE
18

19. Copyright © 2015 AACE.
May not be reprinted in any form without express written permission from AACE.
Diagnosis of Obesity and Staging of for
Management
 Diagnose obesity according to body mass index (BMI)
 Overweight: BMI 25-29.9 kg/m2
 Obese*: BMI ≥30 kg/m2
 Consider waist circumference measurement for patients
with BMI between 25 and 35 kg/m2
 Larger waist circumference = higher risk for metabolic disease
 Men: >102 cm (40 in)
 Women: >88 cm (35 in)
 Evaluate patients for obesity-related complications to
determine disease severity and appropriate management
19
Q13. How is obesity managed in patients with diabetes?
19
*BMI 23-24.9 may be considered obese in certain ethnicities; perform waist circumference and use ethnicity-specific criteria in risk
analysis.

20. Copyright © 2015 AACE.
May not be reprinted in any form without express written permission from AACE.
Medical Complications of Obesity
20
NAFLD
Cardiovascular Disease
Dismotility/disability
GERD
Lung function
defects
Osteoarthritis
Sleep apnea
Urinary
incontinence
Prediabetic states
HypertensionDyslipidemia
PCOS
Diabetes
CardiometabolicBiomechanical Other
GERD, gastroesophageal reflux disease; NAFLD, nonalcoholic fatty liver disease; PCOS, polycystic ovary syndrome.
Pi-Sunyer X. Postgrad Med. 2009;121:21-33.
Androgen
deficiency
Cancer
Gallbladder
disease
Psychological
disorders
Obesity
Q13. How is obesity managed in patients with diabetes?

21. Copyright © 2015 AACE.
May not be reprinted in any form without express written permission from AACE.

22.  Multidisciplinary approach to managing
coexistent type 2 diabetes and obesity (Diabesity)
*Weight management is critical for limiting the
development of glucose intolerance and
progression from a state of impaired glucose
tolerance to diabetes, as well as for optimal
management in those who go on to develop T2D.
* However, a number of current diabetes
therapies promote weight gain in an already
overweight population

23.  Multidisciplinary approach to managing
coexistent type 2 diabetes and obesity (Diabesity)
• This complexity means that an integrated and
coordinated approach, using a dedicated
multidisciplinary team focusing on managing both
T2D and obesity in unified manner, is required.
• The aim of the service is to manage the complex
healthcare needs of people with diabesity and to
address both conditions in a unified way,
simultaneously optimizing glycemic control and
weight management.

24.  Value of this Multidisciplinary approach in
managing Diabesity
Most clinicians will agree that a
multidisciplinary one-stop clinic approach
improves patient adherence, thereby
simultaneously optimizing glycaemic control
and weight management. This leads to cost
savings in terms of pharmacotherapy usage and
healthcare professionals’ time.

25. Members of the multidisciplinary team (MDT)
in managing diabesity:
 A consultant , diabesity specialist nurse, clinical
psychologist, specialist dietitian, physiotherapist,
occupational therapist, moving and handling
specialist, and a coordinator.
8 members
 With this combined expertise, the service is able
to address all aspects of T2D and obesity in a
way that optimizes the management of both
conditions.

26. Referral to the service & procedure:
 people are accepted into the diabesity service if
they have T2D with an HbA1c level (>8%) and a
BMI >27.5 kg/m2.
 Following referral, individuals undergo initial
assessment by the consultant. These measure a
range of biometric and psychological parameters,
aimed at evaluating the individual’s status with
regard to their diabetes and obesity.

27. Initial investigations:
 A number of initial investigations are required to give
a detailed understanding of the physiological health
status of individuals referred to the service. Initial
investigations requested include baseline kidney and
liver function tests, full blood count and HbA1c level.
 Endocrine abnormality is an established cause of
weight gain in around 10% of people attending the
diabesity clinic, and is assessed by using blood tests
looking for thyroid dysfunction.

28. Initial investigations:
 If indicated, tests for hypogonadism and
hypercortisolism are organized.
 Sleep patterns and daytime sleepiness are also assessed
using the Epworth Sleepiness Scale if the score is ≥10,
patients are referred for sleep study to rule out
obstructive sleep apnoea.
 Patients are also asked to complete food, blood glucose
and hunger pattern diaries and to bring them to each
appointment.

29. Weight management at “Diabesity Clinic”
 Weight loss is a 1st priority in a patient with
newly diagnosed type 2 DM
 Calorie restriction and Weight loss have a
positive effect on almost every risk factor
associated with diabetes and obesity

30. Weight management at “Diabesity Clinic”
 Regarding Weight loss, There is a significant
decrease in fasting glucose levels in those patients
who experienced weight loss in the first 3 months .
 This was also accompanied by a decrease in
fasting insulin levels, increase in insulin sensitivity
and improvement of beta-cell function

31. Weight management at “Diabesity Clinic”
 Similar improvements are also noted in coexisting
conditions such as hypertension and dyslipidemia
 In 1990 Mike Lean demonstrated that for people with
type 2 DM, at 12 months from diagnosis, each 1 kg of
weight loss was associated with 3-4 months increased
survival.

32. Weight management at “Diabesity Clinic”
A 10% reduction in weight can result in a :
 30-40% reduction in diabetes-related deaths;
 15% reduction in HbA1c;
 30-50% reduction in fasting glucose;
 10% reduction in total cholesterol.
without doubt weight loss should be a „goal standard‟
outcome in type 2 diabetes

33. Artificial weight loss:
• Weight loss can be a sign of poorly controlled diabetes.
Glycosuria can cause „artificial‟ weight loss if blood glucose
levels are persistently above the renal threshold, ( usually 180
mg/dl)
• All medical therapies that correct hyperglycemia will cause
indirect weight gain through reduced glycosuria and
associated calorie loss.
• This means that as medical therapies are commenced, small
deficits in calorie intake should be negotiated to limit weight
gain. For some individuals, weight maintenance might be a
more realistic option

34. Prescribing a diet for diabesity patients:
 An overweight patient ( BMI 25-30 kg/m
2
) should be
started on a reducing diet of approximately 1000-1500
kcal daily.
 Opinions vary as to whether obese individuals, BMI ˃30
kg/m
2
, should be advised on even greater caloric
restriction; a target of 800-1000 kcal daily is ideal,
although many patients will have difficulty complying with
this.
 While there are usually advantages to a „slow and steady‟
approach to weight loss, others advocate using a newly
diagnosed patient‟s high motivation to aim for more rapid
loss.

35. Prescribing a diet for diabesity patients:
 For most people changing the dietary habits of a lifetime
is challenging, so one needs to take a sympathetic
approach.
 A diet history should be taken, and review of a complete
3-day diet diary, including all snacks, can lead many
patients to recognize previously unappreciated sources of
excess calories ( i.e. soft drinks and fruit juices)
 Foods that are labeled „diabetic‟ are not recommended,
as they usually contain nonglucose refined sugars such
as sucrose or fructose.

36. Prescribing a diet for diabesity patients:
 Artificial sweeteners are useful and could be used as an
alternative to sugars; concerns that they may cause
cancer have not been confirmed.
 Patients on insulin or on oral agents should be advised to
eat the same amount at the same time each day
 Tailor the diet of the patent according to the previous
rules with carbohydrates constitutes about
55%,meanwhile, fats and proteins, constitute 15% and
30% respectively

37. Exercise :
# Encourage small changes on overall lifestyle changes,
for example:
* using stairs instead of elevators
* Parking at the point furthest from one‟s place of
destination
* Getting off the bus a stop early
* walking faster; walking a dog
# Regular scheduled exercise, even if only walking,
should be encouraged, perhaps even prescribed, the aim
being at least a half-hour each day on average

38. Pharmacologic obesity therapy:
 Pharmacologic obesity therapy is indicated with BMI ≥
27 with comorbidity ( hypertension – dyslipidemia -
obstructive sleep apnea) or BMI ˃ 30
 If an individual has a history of unsuccessfully losing
and maintain weight with lifestyle interventions, he/she
is a candidate for obesity pharmacotherapy
 Combined lifestyle changes & weight loss medications
can produce greater weight loss and cardiometabolic
improvements compared with lifestyle alone

39. Weight loss medications
available in USA :
 Phentermine
 Phentermine/topiramte
 Diethylepropion
 Lorcaserine
 Orlistat
 Naltrexone/bupropion
 Liraglutide

40. Matching weight loss medications to
patient profiles
 Phentermine & Diethylepropion are associated
with blood pressure elevations , so both are not
recommended for patients with uncontrolled
hypertension, a history of cardiovascular disease
or arrhythmias, or seizures
 Lorcaserine is not recommended in patients with
depression and treated with SSRI Or SNRI , for
fear of development of serotonin syndrome
 Orlistat, a lipase inhibitor, is likely safe for all
individuals

41. Anti hyperglycemic medications
choice in type 2 DM
 Anti hyperglycemic medications that promote
weight loss or weight neutrality are
recommended :
* GLP-1 receptor agonists namely liraglutide
which is the only one approved by FDA for
weight loss
* SGLT2 inhibitors , Metformin, DPP-4
inhibitors & pramlintide ( all are not FDA
approved for weight loss )

42. Individuals with type 2 DM who
require insulin :
 Add metformin, pramlintide, or a GLP-1
receptor agonist to mitigate insulin
associated weight gain
 First-line insulin : basal is preferable (
consider prior to premixed or combination
insulin therapy)

43. Role of bariatric surgery :
 bariatric surgery should be considered as the final
step in weight management strategy, also in
combination with appropriate lifestyle modifications
 Recent guidelines recognize the benefits of bariatric
procedures in carefully selected type 2 diabetic
patients with BMI ≥ 35 kg/m
2
 Furthermore, surgical weight loss interventions can be
considered as an alternative treatment for poorly
controlled type 2 diabetes patients with mild to
moderate obesity (BMI 30-35 kg/m2
)

44. Main types of bariatric surgeries:
• Laparoscopic adjustable
gastric banding (LAGB)
• Gastric sleeve ( sleeve
gastrectomy)
Restrictive
• Jujenoileal bypass
• Biliopancreatic
diversion
Malabsorptive

45. Main types of bariatric surgeries:
• Reduce the stomach size
• Enhance early satiety
• Reduce food intake
Restrictive
• Shortens the length of the small
intestine
• Limiting the time for digestion and
absorption of nutrients
Malabsorptive

46. http://www.healthierweight.co.uk/obesity-surgery/gastric-band/what-is-a-gastric-band/how-does-the-band-work/
Gastric Banding

49. http://www.webmd.com/diet/video/bariatric-surgery

50. Take home messages
 Diabesity is a growing worldwide epidemic that
must be taken seriously
 Presence of obesity in a diabetic patient could
hinder both diabetes control & obesity
management
 Multidisciplinary approach is considered
nowadays the most successful way of
management of both conditions

51. Take home messages
 weight reduction through dietary interventions,
exercise & pharcotherapy must be a 1st and
long lasting step in management of diabesity
cases
 Lastly, bariatric surgeries may be indicated in
some categories of patients according to their
special situations