Diabetes Weight Management in Clinical Practice—The Why WAIT Model

Diabetes Weight Management in Clinical Practice—The Why WAIT Model

Hamdy Osama
US Endocrinology - Volume 4 - Issue II
Published: April 2009
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Over the past 20 years, the prevalence of type 2 diabetes has increased dramatically from 30 million cases worldwide in 1988 to 239 million cases at present. The World Health Organization (WHO) declared diabetes to be “the health hazard of the 21st century.”1 A historically unique combination of two phenomena—rapid aging of the population and the dramatic increase in obesity2—is the major cause of this growing epidemic of diabetes in the US. Currently, most patients with type 2 diabetes are overweight, obese, or severely obese. Data from the 1999–2002 National Health and Nutrition Examination Survey (NHANES)3 indicate that the prevalence of overweight and obesity among US adults with diabetes now exceeds 80%. Several barriers specific to the combination of diabetes and obesity make weight management for patients with diabetes even more difficult. These barriers include the weight-promoting effect of many of the currently available diabetes medications including insulin, sulfonylurea, glinides, and thiozolidenidiones. Although it has not been systematically studied, many clinicians have raised the concern that weight gain associated with diabetes medications may wipe out the metabolic benefits of these medications over time. Over a 10-year treatment period, participants in the UK Prospective Diabetes Study (UKPDS) gained a significant amount of weight, particularly those treated with insulin.4 Similarly, patients with type 2 diabetes treated with intensive insulin therapy gained on average 8.7kg over a six-month period.5 Patients frequently find it confusing when their treating physicians are advising them to lose weight while prescribing them medications that promote weight gain.

Furthermore, as most medical insurance companies do not typically cover obesity medications or weight-management programs, physicians often perceive weight management as an impractical and costly approach. Adding to these paradoxes, ingesting a higher percentage of calories from carbohydrates (currently 50–55% of total caloric intake) in a disease that is still defined as a carbohydrate intolerance problem is the traditional recommendation. Taken together, these factors may contribute to the inertia and skepticism of providers about the long-term maintenance of any achievable weight loss in patients with diabetes.

We previously demonstrated that modest weight reduction of approximately 7% over a six-month period through caloric reduction and increased physical activity improved insulin sensitivity, endothelial function, and several markers of inflammation and coagulation in obese patients with and without diabetes.6,7 The ongoing Look AHEAD (Action for Health in Diabetes) study is also exploring the health outcomes associated with modest weight loss maintained over 10 years following an intensive lifestyle intervention (ILI) that combines decreased caloric intake, increased physical activity, and behavioral support versus the standard diabetes support and education (DSE) in patients with type 2 diabetes. The Look AHEAD study group recently published their first-year results, which are encouraging.8 The study found that participants randomized to ILI lost an average of 8.6% of their initial bodyweight compared with 0.7% in the DSE group. Although both groups experienced blood glucose reductions compared with baseline, HbA1c improvement in the ILI group was significantly greater than that observed in the DSE group (absolute HbA1c reduction: -0.64% [ILI] versus -0.14% [DSE]; p<0.001; baseline HbA1c for both groups: ~7.3%). Notably, glycated hemoglobin (HbA1c) lowering was observed in the context of decreased glucose-lowering medication use in the ILI group and increased medication use in the DSE group. Therefore, the available data indicate that short-term weight loss of 7–10% in patients with diabetes is metabolically beneficial. More substantial weight loss (23.4% at two years and 16.1% at 10 years) has recently been reported post-operatively in severely obese patients treated with bariatric surgery; this was associated with diabetes remission in 72% of patients at two years and 36% at 10 years. Despite these impressive results in clinical trials, physicians remain skeptical about the feasibility of applying similar intervention protocols in routine clinical practice. Surveys indicate that onethird to half of physicians do not recommend weight management to their overweight and obese patients, with some research indicating that physicians may not believe their patients are adequately motivated to achieve weight loss.9,10

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