Canadian Diabetes Association
Clinical Practice Guidelines
Weight Management in Diabetes
Chapter 17
(Updated July 2015)
Sean Wharton, Arya M. Sharma,
David C.W. Lau
2015
Key Points
2013
1. Modest weight loss CAN make a difference
2. Combined diet, physical activity and behavioural
therapy are most effective
3. Weight loss drugs are of limited benefit
4. Consider weight effects when selecting antihyperglycemic medications
5. Bariatric surgery is appropriate in select refractory
cases
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The Growing Epidemic
•
•
Overweight or Obese
•
80-90% of patients with
T2DM overweight or obese*
Some antihyperglycemic
therapies contribute to
weight gain
Higher BMI increases
mortality
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.
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Assessing the Problem
•
•
Height, weight, BMI, waist circumference
Hypertension, dyslipidemia and CVD
Waist Circumference and Risk of Health
Problems: Thresholds
Men
Caucasian, African
Asian, South or
Central American
All Women
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≥94 cm
≥90 cm
≥80 cm
Canadian Guidelines for Body Weight Classification in
Adults
Classification
BMI (kg/m2) Risk of Health Problems
Underweight
Normal weight
Overweight
<18.5
18.5-24.9
25.0-29.9
Increased
Least
Increased
Obese
Class I
Class II
≥30.0
30.0-34.9
35.0-39.9
High
Very High
Class III
≥40.0
Extremely High
Health Canada. Canadian Guidelines for Body Weight Classification in Adults. 204
Ottawa, ON: Health Canada; 2003. Publication H49-179/2003E.
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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
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Treatment Strategies
•
Health behaviour interventions
–
Lifestyle
•
Pharmacotherapy
•
Bariatric surgery
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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
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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
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4. Consider Weight Effects When Selecting
Antihyperglycemic Medications
Weight Gain
Weight Effect (kg)
Insulin
+4.5 to 5.0
Thiazolidenediones (TZDs)
+4.2 to 4.8
Sulfonylureas
+1.6 to 2.6
Meglitinides
+ 0.7 to 1.8
Weight Neutral or Decrease Weight
Weight Effect (kg)
Metformin
-4.6 to 0.4
α-Glucosidase inhibitors
+0.0 to 0.2
Dipeptidyl peptidase-4 (DPP-4) inhibitors
+0.0 to 0.4
Glucagon-like peptide-1 (GLP-1) receptor
agonists
-1.3 to 3.0
Hollander, P. Diabetes Spectrum 2007; 20(3): 159-165
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2015
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
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Recommendation 1
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]
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Recommendation 2
2013
2. 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]
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Recommendation 3
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]
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CDA Clinical Practice Guidelines
http://guidelines.diabetes.ca – for professionals
1-800-BANTING (226-8464)
http://diabetes.ca – for patients
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