Delivered for the 25th Annual Convention of the Philippine Association for the Study of Overweight and Obese (PASOO) at the EDSA Shangri-la Hotel in Manila.

1. How to control sugar and
weight of the fat diabetic
patient
Jeremy F. Robles, MD, FPCP, FPSEDM
25th Annual Convention of the
Philippine Association for the Study of Overweight and Obesity
(PASOO) September 5, 2019 “Fat TALKS: Trends, Advances, Latest
Knowledge and Science”

2. Objectives
• Explain the relationship of obesity with diabetes
• Discuss the effects of obesity in people with diabetes
• Review the Non pharmacologic & Pharmacologic
treatments for hyperglycemia and obesity
• Synthesize the available data on Diabesity in 30 mins.

3. Overweight & Obese in the ASEAN Region
Tackling obesity in ASEAN Prevalence, impact, and guidance on interventions 2017
An Economist Intelligence Unit report commissioned by the Asia Roundtable on Food Innovation for Improved Nutrition

4. Overweight & Obese in the ASEAN Region
Tackling obesity in ASEAN Prevalence, impact, and guidance on interventions 2017
An Economist Intelligence Unit report commissioned by the Asia Roundtable on Food Innovation for Improved Nutrition

5. Overweight & Obese in the ASEAN Region
Tackling obesity in ASEAN Prevalence, impact, and guidance on interventions 2017
An Economist Intelligence Unit report commissioned by the Asia Roundtable on Food Innovation for Improved Nutrition

6. Overweight & Obese in the Philippines
DOST - FNRI EXPANDED NATIONAL NUTRITIONAL SURVEY 2018

7. Overweight & Obese in the Philippines
DOST - FNRI EXPANDED NATIONAL NUTRITIONAL SURVEY 2018

8. Diabetes & Pre-diabetes in the Philippines
DOST - FNRI EXPANDED NATIONAL NUTRITIONAL SURVEY 2018

9. Congestive Heart Failure/ Stroke/
Chronic Kidney Disease
Adiposity to Major Risk Factors
and Common Chronic Disease
NEJM 376:3 January 19, 2017
Diabesity

10. INTERPLAY OF HORMONES
Am J Physiol Heart Circ Physiol 288: H2031–H2041, 2005
INSULIN RESISTANCE ENDOTHELIAL DYSFUNCTION

11. INTERPLAY OF HORMONES
Am J Physiol Heart Circ Physiol 288: H2031–H2041, 2005
It’s a bit more
complicated.

12. Better to have love and lost
than never to have loved at all.
lost weight and gained
lost weight at all.
- Look AHEAD Trial -

13. The Look AHEAD (Action for Health in Diabetes) Trial
• A multi-center, RCT to examine the long-term effects of a lifestyle intervention
designed to achieve and maintain weight loss.
• Investigate the effects of the intervention on heart attacks, stroke &
cardiovascular-related death in individuals with type 2 diabetes who are also
overweight or obese.
• 5,145 adults with type 2 diabetes who had a body mass index (BMI) > 25,
followed for 11 years.
Intensive Lifestyle
Intervention (ILI) Group
• Individual sessions with a nutritionist
and/or a trainer
• Group sessions
• Refresher courses
• Given all the tools they needed to
really work on and succeed at their
lifestyle intervention
Diabetes Support and
Education Group (DSE)
• Control group
• Education and meetings twice a year
• not given the intervention that we
provided to the lifestyle group

14. WEIGHT
A1C

15. The Look AHEAD (Action for Health in Diabetes) Trial
• Showed that we could produce modest weight loss and improve
physical activity over time in these individuals with type 2 diabetes.
• Improvements noted on lipids, blood pressure, sleep apnea,
renal disease, fitness, depression
• Did not show was a reduction in cardiovascular events and
death. (PRIMARY OUTCOME)
• Even with the relative maintenance of weight losses in the study,
A1C levels worsened through the follow-up period.

16. ADA Recommendations for Obesity & Diabetes
DIABETES DIABETES + OBESITY
WEIGHT
LOSS
At least 5% for beneficial
outcomes in glycemic control,
lipids, and blood pressure
> 5% weight loss for patients with type
2 diabetes who are overweight or
obese & ready to achieve weight loss.
EXERCISE
Aerobic activity at least 10 min,
with the goal of 30 min/day or
more, most days of the week for
adults with type 2 diabetes. Not >
2 days to elapse between sessions
High levels of physical activity
(200– 300 min/week).
(Supervised closely)
DIET
Provide 1200-1500 kcal for women and 1500-1800 kcal for men adjusted
for individual’s baseline BW
Target 500-750 kcal/day deficit
Diabetes Care 2019;42(Suppl. 1):S46–S60
Diabetes Care 2019;42(Suppl. 1):S81–S89

17. Future Pathways
Tackling obesity in ASEAN Prevalence, impact, and guidance on interventions 2017
An Economist Intelligence Unit report commissioned by the Asia Roundtable on Food Innovation for Improved Nutrition
N Engl J Med 2017;376:254-66.
Non Pharmaceutical Management of Obesity
A variety of dietary approaches that differ widely in macronutrient composition, can lead to weight loss provided
they induce an adequate energy deficit. The guidelines recommended potential contribution to the
management of obesity-related coexisting disorders (e.g., type 2 diabetes and hypertension).

18. Future Pathways
Tackling obesity in ASEAN Prevalence, impact, and guidance on interventions 2017
An Economist Intelligence Unit report commissioned by the Asia Roundtable on Food Innovation for Improved Nutrition
N Engl J Med 2017;376:254-66.
Medical Management of Obesity
Medications Approved by the Food and Drug Administration for Long-Term Weight Management.

19. Future Pathways
Tackling obesity in ASEAN Prevalence, impact, and guidance on interventions 2017
An Economist Intelligence Unit report commissioned by the Asia Roundtable on Food Innovation for Improved Nutrition
N Engl J Med 2017;376:254-66.
Medical Management of Obesity
The median percentages of participants who had a weight loss of at least 5% or 10% with each of five medications
approved for long-term weight management are from a meta-analysis by Khera et al. Data on the percentage of
participants with weight loss at 1 year of at least 15% of their initial weight were available for the Look AHEAD study
(16%), the DPP trial (11%), liraglutide (14%), phentermine–topiramate (32%), and naltrexone–bupropion (14%).

22. Future Pathways
Tackling obesity in ASEAN Prevalence, impact, and guidance on interventions 2017
An Economist Intelligence Unit report commissioned by the Asia Roundtable on Food Innovation for Improved Nutrition
Peptides 100 (2018) 61–67
Medical Management of Obesity (GLP-1)
GLP-1 and Cardiovascular Trials
GLP-1 Clinical and Structural Characteristics

23. Future Pathways
Tackling obesity in ASEAN Prevalence, impact, and guidance on interventions 2017
An Economist Intelligence Unit report commissioned by the Asia Roundtable on Food Innovation for Improved Nutrition
Peptides 100 (2018) 61–67
Medical Management of Obesity (SGLT-2 inhibitors)
Sglt-2 inhibitors Clinical Characteristics
Dose Weight Loss

24. Future Pathways
Tackling obesity in ASEAN Prevalence, impact, and guidance on interventions 2017
An Economist Intelligence Unit report commissioned by the Asia Roundtable on Food Innovation for Improved Nutrition
Medical Management of Obesity (SGLT-2 inhibitors)

25. Future Pathways
Tackling obesity in ASEAN Prevalence, impact, and guidance on interventions 2017
An Economist Intelligence Unit report commissioned by the Asia Roundtable on Food Innovation for Improved Nutrition
N Engl J Med 2017;376:254-66.
Medical vs Surgical Management of Obesity
Weight Loss at 1 Year with Bariatric Surgery and Lifestyle Interventions as Compared with
Lifestyle Interventions Alone.

26. ADA Recommendations for Obesity & Diabetes
Diabetes Care 2019;42(Suppl. 1):S46–S60
Diabetes Care 2019;42(Suppl. 1):S81–S89
• Diet - food restriction effective if leads to energy deficit ; consider meal replacements
• Intensive behavioral lifestyle - >/= 16 sessions on diet/first 6 mos, activities, strategies
• Pharmacotherapy - consider DM meds with weight loss effect as adjunct
• Metabolic Surgery - surgical candidates with BMI >/= 40 kg/m2 (BMI >/= 37.5 kg/m2 in
Asian Americans) and in adults with BMI 35.0–39.9 kg/m2 (32.5–37.4 kg/m2 in Asian
Americans) ; done in high volume centers, multidisciplinary team with long term support.

27. General Interventions
Tackling obesity in ASEAN Prevalence, impact, and guidance on interventions 2017
An Economist Intelligence Unit report commissioned by the Asia Roundtable on Food Innovation for Improved Nutrition

28. Summary
• Fat cells play a central role in the pathophysiology of
diabetes and obesity. Key mechanisms include insulin
resistance and endothelial dysfunction.
• Diet and exercise still play an important role in the
management. Weight loss can be sustained but
diabetes progression continues.
• Behavioral lifestyle intervention is a powerful tool to
initiate weight loss and maintenance. ( Individual and
peer intervention)
• Dietary goal of 500 - 750 kcal/day energy deficit with
caloric limits adjusted to baseline BMI.

29. Summary
• Philippines have limited options for pharmacologic
management of obesity with or wither diabetes.
• International Diabetes guideline now target obesity
management. 2 key drugs used are GLP-1 agonists
and SGLT-2 inhibitors.
• Surgical management of obesity may be effective
and curative for some diabetic patients. Limited
centers and prohibitive costs in the Philippines.
• Combination of non-pharmacologic, pharmacologic
and surgical procedures may be warranted in severe
cases.

30. How to control sugar and
weight of the fat diabetic
patient
Jeremy F. Robles, MD, FPCP, FPSEDM
25th Annual Convention of the
Philippine Association for the Study of Overweight and Obesity
(PASOO) September 5, 2019 “Fat TALKS: Trends, Advances, Latest
Knowledge and Science”