Canadian Diabetes Association Clinical Practice Guidelines Weight Management in Diabetes

1. Canadian Diabetes Association Clinical Practice GuidelinesWeight Management in Diabetes Chapter 17 Sean Wharton, AryaM. Sharma, David C.W. Lau

2. Key Points 2013 • Modest weight loss CAN make a difference • Combined diet, physical activity and behavioural therapy are most effective • Weight loss drugs are of limited benefit • Consider weight effects when selecting anti-hyperglycemic medications • Bariatric surgery is appropriate in select refractory cases

3. The Growing Epidemic • 80-90% of patients with T2DM overweight or obese* • Some antihyperglycemic therapies contribute to weight gain • Higher BMI increases mortality Overweight or Obese • BUT, weight loss of only 5-10% can improve metabolic parameters! *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.

4. Assessing the Problem • Height, weight, BMI, waist circumference • Hypertension, dyslipidemia and CVD

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

6. 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

7. Treatment Strategies • Health behaviour interventions • Lifestyle • Pharmacotherapy • Bariatric surgery

8. 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

9. 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

10. 4. Consider Weight Effects When Selecting AntihyperglycemicMedications Hollander, P. Diabetes Spectrum 2007; 20(3): 159-165

11. 5. Bariatric Surgery is Appropriate in Select Refractory Cases 2013 • 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

12. Recommendation 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]

13. Recommendation 2 2013 • 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]

14. Recommendation 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]

15. CDA Clinical Practice Guidelines http://guidelines.diabetes.ca – for professionals 1-800-BANTING (226-8464) http://diabetes.ca – for patients