November 2013 Issue

Battling the Twin Epidemics
By Constance Brown-Riggs, MSEd, RD, CDE, CDN
Today’s Dietitian
Vol. 15 No. 11 P. 28

The medical community is working hard to find solutions to the diabetes and obesity crises, and RDs have an important role.

It has been said that the 21st century is the unprecedented diabetogenic era in human history.1 The number of American adults diagnosed with type 2 diabetes continues to soar exponentially. Obesity, which is considered a major risk factor for type 2 diabetes, also is rising at an ever-increasing rate.

Because the prevalence of obesity and type 2 diabetes has been skyrocketing, the medical community refers to them as the twin epidemics and has coined the term “diabesity” to describe the occurrence of diabetes in the context of obesity. According to the annual report F as in Fat: How Obesity Threatens America’s Future 2012 from the Trust for America’s Health, diabesity is on course to increase dramatically in every state in the country over the next 20 years.

This grim statistic, among others, is what led the American Medical Association (AMA) to recognize obesity as a disease, which the medical community hopes will positively impact Americans’ health.2 Research supports that a modest weight loss of 5% to 10% of body weight can decrease the morbidity and mortality associated with obesity.3

Dietitians play a vital role in combating the twin epidemics, and therefore must be familiar with effective weight loss intervention strategies. To help, this article provides an overview of the diabesity epidemic; examines the potential impact of the AMA’s decision to classify obesity as a disease; discusses current research on lifestyle modification, very–low-calorie diets, bariatric surgery, and pharmacotherapy as treatment alternatives; and discusses the RD’s role in counseling patients who can benefit from weight loss.

Diabesity
Diabesity is not only considered a portmanteau of the twin epidemics, it’s also referred to as obesity-dependent diabetes1 and continues to increase with no decline in sight. If obesity rates stay on their current trajectories, 44% of the US population will be obese by 2030, and the number of new type 2 diabetes cases may increase 10 times between 2010 and 2020—and double again by 2030. It’s estimated that obesity could contribute to more than 6 million cases of type 2 diabetes in the next two decades.4

This is particularly problematic considering the health care costs of diabesity. Obesity and diabetes consume 5.7% and 14% of the US total health expenditure, respectively, representing the highest known expenditure on diabesity worldwide.1 Add the cost of being overweight to these figures and the upper limit of obesity expenditure rises to 9.1% of the US total health care expenditure. Moreover, diabesity is associated with the long-term complications of diabetes, such as myocardial infarction, cerebrovascular stroke, end-stage renal disease, a reduction in health-related functioning, decreased quality of life, and reduced overall life expectancy.1 Chronic stress, depression, and sleep disturbances also have been linked to diabesity.1

These staggering statistics speak to the urgent need to find solutions to this evolving problem.

Obesity Redefined
In June, the AMA issued a press release stating it has decided to recognize obesity as a disease, requiring a range of medical interventions to advance obesity treatment and prevention. The decision was made in hopes of improving clinical, public health, and payer strategies aimed at reducing the nation’s obesity rate.

In the release, AMA board member Patrice Harris, MD, said, “Recognizing obesity as a disease will help change the way the medical community tackles this complex issue that affects approximately one in three Americans.”

The new definition of obesity has direct implications for RDs. “Recognizing obesity as a disease creates a sense of urgency that should help ensure people with obesity have access to effective treatments and providers, including medical nutrition therapy and behavioral counseling by registered dietitian-nutritionists,” says Glenna McCollum, MPH, RDN, president of the Academy of Nutrition and Dietetics.

The timing of AMA’s decision couldn’t be better, according to those in the medical community, considering that Congress also introduced the Treat and Reduce Obesity Act of 2013 in June. The bill would allow RDs to independently provide and be reimbursed for intensive behavioral therapy for obesity.

Weight-Loss Intervention Strategies
Weight loss lowers the risk of diabetes and, in those who already have diabetes, weight loss can reduce blood glucose and hemoglobin A1c (HbA1c) levels.3 Besides improving blood glucose control, modest weight loss of 5% to 10% can decrease blood pressure and cholesterol and reduce the risk of other chronic diseases related to diabetes.5

Various treatment options for the management of diabesity are available, including lifestyle modifications, a very–low-calorie diet, bariatric surgery, and pharmacotherapy. Because there’s no single weight-loss approach that works for everyone, RDs will need to counsel clients and patients according to their individual lifestyles, food preferences, willingness to change, and preferred approach to weight loss.

Lifestyle Modification
Research supports the notion that the best outcomes are observed when weight-loss therapy is based on a comprehensive weight management program that includes diet, physical activity, and behavior therapy.6 This combination is most effective, particularly when a variety of behavior therapy strategies are used, such as self-monitoring, stress management, stimulus control, problem solving, contingency management, cognitive restructuring, and social support.6

Individuals participating in a structured, intensive lifestyle program involving patient education, individualized counseling, reduced calorie and fat intake (30% of total calories), regular physical activity, and frequent contact with a member of the treatment team can expect long-term weight loss of 5% to 7% of initial weight.7

The Weight Achievement and Intensive Treatment (Why WAIT) program at the Joslin Diabetes Center in Boston demonstrated that even greater long-term weight loss is possible. Why WAIT is a 12-week multidisciplinary program for weight control and intensive diabetes management. The program consists of intensive and interactive medication adjustments; structured modified dietary intervention; graded, balanced, and individualized exercise intervention; cognitive behavioral intervention; group education; and monthly support sessions aimed at long-term weight-loss maintenance.8

Forty-eight percent of Why WAIT participants maintained a 10% reduction of their initial weight for four years, according to Why WAIT dietitians Amanda Kirpitch, MA, RD, LDN, CDE, and Gillian Arathuzik, RD, LDN, CDE, who presented these results at the 2013 annual meeting of the American Association of Diabetes Educators.

The dietary intervention, as described by Kirpitch, was designed to provide a daily restriction of 1,000 kcal, with most women receiving 1,500 kcal/day and most men 1,800 kcal/day. The macronutrient composition was 40% carbohydrate, 30% protein, and 30% fat. Meal replacements, which are proven to be beneficial for individuals who have difficulty with self-selection and/or portion control, were permitted.9 Why WAIT participants used meal replacements containing no more than 250 kcal for one or two meals daily.

According to the National Heart, Lung, and Blood Institute obesity guidelines, weight loss produced by lifestyle modification lowers serum triglycerides and increases HDL cholesterol, and generally causes some reductions in serum total cholesterol and LDL cholesterol.3 In individuals with or without type 2 diabetes, weight loss through lifestyle modification results in decreased blood glucose levels and HbA1c.3

“There are multiple changes we see in patients who have undergone lifestyle intervention. We see improvements in insulin sensitivity and HbA1c,” Kirpitch said. “An additional benefit to lifestyle intervention is improved quality of life, helping them to stay engaged in healthier behaviors. Patients actually look and feel healthier.”

Very–Low-Calorie Diets
Placing diabesity patients on a very–low-calorie diet also is a successful treatment option. This type of diet usually is a liquid diet that provides 100% of the Daily Value of essential vitamins and minerals. They include commercial formulas such as liquid shakes, soups, or bars that provide up to 800 kcal/day.10 The goal is to promote large, rapid weight loss while providing adequate nutrition and preserving lean body mass as much as possible.9

These diets quickly can improve obesity-related medical conditions such as diabetes, high blood pressure, and high cholesterol.10 In fact, a study published in the June 2011 issue of Diabetologia showed that one week after participants started a very–low-calorie diet, fasting blood glucose and hepatic insulin sensitivity dropped to normal levels and intrahepatic lipid decreased by 30%. Over the eight weeks participants followed the diet, beta-cell function increased toward normal and pancreatic fat decreased.11

Researchers observed similar results in a small study of participants who received 500 kcal/day for 21 days.12 “We used 500 kcal per day given in three meals and three snacks—a challenge indeed,” says Wahida Karmally, RD, CDE, CLS, FNLA, director of nutrition at the Irving Institute for Clinical and Translational Research at Columbia University in New York City. At the end of the study, insulin secretion decreased from 13.8 to 6.8 mcIU/mL, and C-peptide, a measure of beta-cell function, dropped from 3.59 to 2.55 ng/mL.

As a result of these metabolic changes and a jump-start on weight loss, Karmally says, “Patients experience medication cutback or elimination, and it empowers the patient for self-management.”

Very–low-calorie diets shouldn’t be used routinely for weight-loss therapy because they require special monitoring and supplementation.13 “Very–low-calorie diets are appropriate for patients with high health risks: BMIs greater than 30 with no risk factors or BMIs greater than 27 with risk factors,” Karmally says, stressing that supplementation and careful medical supervision is required. Moreover, clinical trials show that low-calorie diets are as effective as very–low-calorie diets for producing weight loss after one year.13

Bariatric Surgery
Thanks to the effectiveness of very–low-calorie diets, clinicians increasingly are prescribing them before bariatric surgery to reduce overall surgical risks. Evidence suggests that following a very–low-calorie diet for at least two weeks reduces liver size and, when followed for up to six weeks, it decreases abdominal adiposity.9 However, further research is needed to evaluate the efficacy of this strategy.9

Weight-loss surgery is an option for weight reduction in patients with clinically severe obesity, classified as a BMI of 40 or greater or a BMI of 35 or greater with an obesity-related condition.13 Weight-loss surgery provides medically significant sustained weight loss for more than five years in most patients13 and can lessen the severity or resolve obesity-related disease and improve quality of life.9

“Metabolic changes evidenced after a bariatric surgery procedure include remission of diabetes, obstructive sleep apnea, hypertension, and hyperlipidemia,” says Margaret M. Furtado, MS, RD, LDN, a bariatric nutrition specialist at the University of Maryland Medical Center in Baltimore. “The research reveals that if someone with diabetes has bariatric surgery within five years of diagnosis, they have a very good chance [some studies cite 80% to 90%] of remission of diabetes.”

Two types of weight-loss surgeries have proven to be effective in this regard: those that restrict gastric capacity, such as adjustable gastric banding, and those that, in addition to limiting food intake, alter digestion, such as Roux-en-Y gastric bypass.13 New research shows that gastric bypass surgery results in diabetes remission,14 as evidenced in the STAMPEDE trial, a randomized five-year study comparing the efficacy of advanced medical therapy alone vs. bariatric surgery and therapy combined for the treatment of type 2 diabetes.15

Recently, the FDA approved the use of the adjustable gastric band for patients with a BMI greater than 30 who also have at least one condition associated with obesity, such as heart disease or diabetes.16 “Additionally, an ideal candidate has excellent support from family and friends, a stable home and work life, and is willing and able to make and maintain significant lifestyle changes,” Furtado says.

“Of course, a healthful diet, regular physical activity, adequate sleep, and a good stress management program are imperative to improving the chances of both remission of diabetes and maintenance of weight loss long-term,” she adds.

Pharmacotherapy
Pharmacotherapy is a treatment option that should be considered only if a patient has not lost 1 lb per week after six months of combined lifestyle therapy, which includes a low-calorie diet; increased physical activity; and behavior therapy.13

Research indicates that pharmacotherapy may be useful as an adjunct to diet and physical activity for patients with a BMI of 30 or greater without obesity-related risk factors or diseases. “[It] also may be useful for patients with a BMI of 27 or greater and who have obesity-related risk factors such as hypertension and hyperlipidemia,” says Eva M. Vivian, PharmD, MS, CDE, BC-ADM, FAADE, an associate professor at the University of Wisconsin-Madison School of Pharmacy.

Moreover, pharmacotherapy should be used only in the context of a treatment program that includes diet, physical activity, and behavior therapy.13 “Studies have shown that greater weight loss occurs if the medications are used in combination with lifestyle modification vs. drug therapy alone,” Vivian says.

Over the past year, the FDA has approved two novel weight-loss drugs for long-term use: lorcaserin (Belviq) and a combination drug called Qsymia (PHEN/TPM ER), comprised of phentermine and extended-release topiramate.

Lorcaserin, approved by the FDA in June 2012, works by activating a serotonin receptor in the brain that may help a person eat less and feel full after eating smaller amounts of food.17

Evidence suggests that lorcaserin can be beneficial as an adjunct to behavior modification for obese and overweight patients with type 2 diabetes. In the BLOOM-DM (Behavioral Modification and Lorcaserin for Obesity and Overweight Management in Diabetes Mellitus) study, obese and overweight patients with type 2 diabetes who used lorcaserin for up to one year lost an average of 5.5% of their starting weight. Additionally HbA1c, fasting blood glucose, and insulin resistance decreased significantly more in those treated with lorcaserin compared with placebo.18

 Phentermine, the most widely prescribed weight-loss drug in the United States,19 is indicated for short-term weight loss in overweight or obese adults who are exercising and eating a reduced-calorie diet. Topiramate primarily is indicated to treat certain types of seizures in people who have epilepsy and to prevent migraine headaches. When used in combination with phentermine, it helps promote long-term weight loss in overweight or obese adults who are exercising and eating a reduced-calorie diet. 

The efficacy of PHEN/TPM ER, when used in the primary care setting with lifestyle interventions, was demonstrated in the CONQUER trial, which compared two different doses of PHEN/TPM ER with placebo in the treatment of diabetes and obesity in adults with obesity-related comorbidities. Patients with type 2 diabetes had greater reductions in HbA1c (0.4%) than with placebo (0.1%) and, on average, experienced HbA1c levels below 6.5%. Patients with prediabetes had greater reductions in fasting blood glucose and insulin levels than those who received a placebo, and fewer patients with prediabetes progressed to type 2 diabetes. Moreover, those treated with PHEN/TPM ER were less likely to need a dosage increase in antidiabetes medications.19

However, not all patients respond to pharmacotherapy.13 Vivian suggests patients discontinue PHEN/TPM ER if they don’t achieve a 3% weight loss with the maximum dose within 12 weeks.

Where Dietitians Fit In
As mentioned, dietitians play an integral role in helping to treat the twin epidemics. To change the trajectory of obesity and diabetes, RDs must keep abreast of the latest research so they can help patients prevent weight gain, optimize individual weight-loss interventions, and achieve long-term weight loss.9

In addition to educating themselves, RDs will need to counsel clients and patients on how glycemic control is the primary focus of diabetes management, how to properly take diabetes medications to improve glycemic control, how medications increase or decrease weight, and how a small amount of weight loss can impact blood glucose control. Dietitians also must inform patients about the importance of energy restriction in lowering blood glucose levels and managing weight, how to prioritize weight-loss goals within the context of their medical treatment plan, how to make appropriate food choices, the benefits of exercise, and how to use data from blood glucose monitoring to evaluate the effectiveness of medication and weight-loss intervention.

It Will Take A Village
The evidence is strong that diabesity has become an epidemic creating a significant health and economic burden on the nation. As part of the strategy to find a solution to the diabesity crisis, the AMA redefined obesity, recognizing it as a disease. Research studies show that lifestyle modification, very–low-calorie diets, bariatric surgery, and pharmacotherapy, provided in the context of a comprehensive weight-loss program that includes RDs, are effective and essential in diabesity management. As the primary nutrition professional, dietitians must continue to work with the medical community to stem the tide of diabesity.

— Constance Brown-Riggs, MSEd, RD, CDE, CDN, is the national spokesperson for the Academy of Nutrition and Dietetics, specializing in African American nutrition; and author of the African American Guide to Living Well With Diabetes and Eating Soulfully and Healthfully With Diabetes.

 

References
1. Farag YM, Gaballa MR. Diabesity: an overview of a rising epidemic. Nephrol Dial Transplant. 2011;26(1):28-35.

2. AMA adopts new policies on second day of voting at annual meeting. American Medical Association website. http://www.ama-assn.org/ama/pub/news/news/2013/2013-06-18-new-ama-policies-annual-meeting.page. June 18, 2013. Accessed July 23, 2013.

3. National Heart, Lung, and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. Bethesda, MD: US Department of Health and Human Services; 1998.

4. Levi J, Segal LM, St Laurent R, Lang A, Rayburn J. F as in Fat: How Obesity Threatens America’s Future 2012. Trust for America’s Health website. http://healthyamericans.org/assets/files/TFAH2012FasInFatFnlRv.pdf. September 2012. Accessed July 23, 2013.

5. Losing weight: what is healthy weight loss? Centers for Disease Control and Prevention website. http://www.cdc.gov/healthyweight/losing_weight. Updated August 17, 2011. Accessed July 23, 2013.

6. Adult weight management evidence-based nutrition practice guidelines: executive summary of recommendations. Academy of Nutrition and Dietetics Evidence Analysis Library website. http://andevidencelibrary.com/topic.cfm?cat=3014. Accessed August 20, 2013.

7. American Diabetes Association, Bantle JP, Wylie-Rosett J, et al. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Diabetes Care. 2008;31 Suppl 1:S61-S78.

8. Hamdy O, Goebel-Fabbri A, Carver C, et al. Why WAIT program: a novel model for diabetes weight management in routine clinical practice. Obesity Management. 2008;4(4):176-183.

9. Seagle HM, Strain GW, Makris A, Reeves RS; American Dietetic Association. Position of the American Dietetic Association: weight management. J Am Diet Assoc. 2009;109(2):330-346.

10. Very low-calorie Diets. Weight Control Information Network website. http://win.niddk.nih.gov/publications/low_calorie.htm. Updated December 2012. Accessed July 24, 2013. NIH Publication No. 03-3894.

11. Lim EL, Hollingsworth KG, Aribisala BS, Chen MJ, Mathers JC, Taylor R.Reversal of type 2 diabetes: normalization of beta cell function in association with decreased pancreatic and liver triacylglycerol. Diabetologia. 2011;54(10):2506-2514.

12. Jackness C, Karmally W, Febres G, et al. Very low-calorie diet mimics the early beneficial effect of Roux-en-Y gastric bypass on insulin sensitivity and ß-cell function in type 2 diabetic patients. Diabetes. 2013;62(9):3027-3032.

13. National Heart, Lung, and Blood Institute Obesity Education Initiative. The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_b.pdf. October 2000. Accessed July 2012. NIH Publication No. 00-4084.

14. Vetter ML, Ritter S, Wadden TA, Sarwer DB. Comparison of bariatric surgical procedures for diabetes remission: efficacy and mechanisms. Diabetes Spectr. 2012;25(4):200-210.

15. Clinical trials: STAMPEDE trial. Cleveland Clinic website. http://my.clevelandclinic.org/research/clinical_trials/hic/stampede.aspx.

16. Bariatric surgery for severe obesity. Weight Control Information Network website. http://win.niddk.nih.gov/publications/gastric.htm. Updated June 2011. Accessed July 24, 2013. NIH Publication No. 08-4006.

17. Belviq. Arena Pharmaceuticals GmbH website. http://www.belviq.com. Accessed July 26, 2013.

18. O’Neil PM, Smith SR, Weissman NJ, et al. Randomized placebo-controlled clinical trial of lorcaserin for weight loss in type 2 diabetes mellitus: the BLOOM-DM study. Obesity (Silver Spring). 2012;20(7):1426-1436.

19. Gadde KM, Allison DB, Ryan DH, et al. Effects of low-dose, controlled-release, phentermine plus topiramate combination on weight and associated comorbidities in overweight and obese adults (CONQUER): a randomized, placebo-controlled, phase 3 trial. Lancet. 2011;377(9774):1341-1352.

 

Current Weight-Loss Drugs on the Market


Drug

FDA Approval

Mechanism of Action

Common Side Effects

Contraindications

Orlistat (Xenical, alli)

 

Approved in 1999 for long-term use in adults and children aged 12 and older

Inhibits gastric and pancreatic lipases, prevents triglyceride hydrolysis, which results in decreased absorption of dietary fats

Oily spotting, flatulence, fatty/oily stool, increased defecation, fecal incontinence, nausea, vomiting, reduced absorption of fat-soluble vitamins and beta-carotene, liver failure, and oxalate nephropathy

Pregnancy, chronic malabsorption syndrome, cholestasis, and hypersensitivity
Caution: If a meal is missed or contains no fat, dose should be omitted.
Daily fat intake (30% of calories), carbohydrate, and protein should be evenly distributed over three main meals.
Note: A multivitamin supplement (including vitamins A, D, E, and K) is recommended.

Lorcaserin (Belviq)

Approved in 2012 for long-term use in adults

Exact mechanism of action unknown; thought to decrease food consumption and promote satiety by selectively activating serotonin 5-HT2C receptors on anorexigenic pro-opiomelanocortin (a precursor protein) neurons located in the hypothalamus

Headache, upper respiratory tract infection, nasopharyngitis

Pregnancy

Caution: Should not be taken with selective serotonin reuptake inhibitors and monoamine oxidase inhibitors (MAOI).
May take with or without food. Discontinue if 5% weight loss is not achieved by week 12.

Phentermine and topiramate extended release  (Qsymia)

Approved in 2012 for long-term use in adults

Phentermine: Stimulates the central nervous system, inducing an anorectic effect via the release of norepinephrine in the hypothalamus, causing appetite suppression by increasing blood leptin concentration
Topiramate: Effect may be through appetite suppression and satiety enhancement that’s induced by a combination of pharmacologic effects, including augmenting neurotransmitter gamma-aminobutyrate activity, voltage-gated ion channels modulation, AMPA/kainite excitatory glutamate receptor inhibition, or carbonic anhydrase inhibition

Paresthesia, dry mouth, constipation, upper respiratory infection, metabolic acidosis, nasopharyngitis, headache

Hypersensitivity or idiosyncrasy to sympathomimetic amines, pregnancy, glaucoma, hyperthyroidism
Phentermine use is contraindicated during or within 14 days following intake of MAOIs because of the risk of a hypertensive crisis.
Caution: Take once daily in the morning with or without food.
Avoid dosing in the evening because of the possibility of insomnia.
Note: Sold only through certified pharmacies.

Phentermine
(Adipex P, Suprenza)

Approved in 1959 for short-term use in adults (up to 12 weeks)

Increases chemicals in the brain that affect appetite; makes person feel like he or she isn’t hungry or is full

Heart valve disorder, primary pulmonary hypertension, psychotic disorder
Bad taste in mouth, blurred vision, changes in libido, chills, constipation, diarrhea, drug-induced gastrointestinal disturbance, dry mouth, dysphoric mood, dysuria, excitement, hair loss, headache, hypertension, impotence, insomnia, myalgia, nausea, nervousness, palpitations, restlessness, tachycardia, tremor, urticaria, vomiting

Known hypersensitivity or idiosyncratic reaction to sympathomimetic amines; arteriosclerosis, cardiovascular disease, moderate-to-severe hypertension, glaucoma, agitation, history of drug abuse
MAOI use within preceding 14 days; concomitant administration of other central nervous system stimulants
Caution: Primary pulmonary hypertension and valvular disease have been reported with therapy.
Patients with diabetes mellitus should use caution with antidiabetic agents such as insulin or other hypoglycemic agents; dietary restrictions may lower requirements for antidiabetic therapy.
Discontinue if weight loss has not occurred within four weeks of therapy.

— Information compiled from Medscape.com

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