Comorbid Obesity and Diabetes
June 2013
Volume 4, Issue 4

Introduction

Recent Research Sheds Light on Potential Causes of These Overlapping Problems As Well As Effective Management Strategies for Both

Welcome from Louis Kuritzky, MD

No clinician today, regardless of specialty, remains untouched by the consequences of obesity, diabetes, or both, on their patients. Most of the explanation for the current burgeoning of obesity and diabetes—which typically track hand in hand—suggests the simple conspiracy of excessive calories coupled with insufficient exercise as the culprits. I wish it were that simple.

Clinical trials suggest that strict adherence to lifestyle changes (diet AND exercise) produces prompt weight loss for up to 6 months, but then weight loss stops.1 I wonder if we are missing something critical about weight maintenance mechanisms? In the Diabetes Prevention Program randomized clinical trial, half of study subjects randomized to 150 minutes of exercise weekly and a goal weight reduction of 7% had achieved that goal (at the mean baseline weight of 94 kg, that would be approximately 14.5 pounds) by 6 months, but after that point, no further weight reduction occurred; indeed, over the ensuing 3.5 years of follow-up there was progressive, albeit modest, weight gain despite adherence to exercise and diet regimens.2

Simplistic explanations for the failure to achieve further weight reduction include increased muscle mass, metabolic changes associated with decreased fat mass, and increased appetite associated with increased physical activity and increased muscle mass. Whether or not these hypotheses are correct, the fundamental crux of the problem remains that even with intensive support for diet and exercise, highly motivated individuals can rarely achieve ideal body weight despite their best efforts and intentions. What may be even more discouraging is that sustained adherence to healthful lifestyle changes, after an initial period of success, is not likely to continue to produce meaningful weight reduction in the majority of individuals. Certainly maintaining the component of weight that has been lost is metabolically beneficial, but may not provide the positive reinforcement that patients need to continue fighting the battle against being overweight.

This is not to suggest that because of such limitations clinicians should simply throw up their hands in resignation; rather, we must continue to be vigilant for one or more of the following opportunities:

  1. Even though weight loss will plateau in 6 months’ time with lifestyle management for most individuals, some individuals will continue to experience progressive weight loss. We don’t know who these “sustained responders” are, but it’s worth promoting the opportunity to any patients willing to participate.
  2. Regardless of weight change, engaging in regular physical activity is associated with numerous physiological and psychological benefits. Rare is the patient who does not report quality-of-life improvements from a sustained exercise program.
  3. Diet and exercise are associated with favorable metabolic changes, including lipid levels, blood pressure, and glucose metabolism.
  4. Awareness of the benefits of healthful lifestyle may propagate through the patient to other members of the family.
  5. Ignoring weight and exercise issues may give the impression to the patient that these items are not important, and we must avoid this possibility.
  6. Patients feel blamed for being overweight.

We have the opportunity to acknowledge to our patients that science has not yet developed the insight to understand ways of optimizing progressive weight loss other than through surgery. By approaching weight management patients with an attitude of validation and acceptance, we can show respect for the difficult battle they face.

To help health care providers better partner with their patients in this uphill battle, we scanned the literature on diabetes and obesity to find recent studies that provide insight into the potential causes of these overlapping problems as well as effective management strategies for both. The studies range from scientific research suggesting a viral link to weight gain and glycemic alterations, to surgery, medications, and financial-based programs for weight loss. Together the studies provide a broad spectrum of the current approach to preventing and treating comorbid diabetes and obesity.

References

  1. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403.
  2. Diabetes Prevention Program Research Group, Knowler WC, Fowler SE, et al. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet. 2009;374(9702):1677-1686.
First Article:
Can Diabetes Be Cured by Surgery?
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