The importance of weight loss in diabetes Print E-mail
Written by Stephen Kreitzman PhD RNut (UK registered nutritionist) and Valerie Beeson, Howard Foundation Resear   
Weight loss has been advocated as an adjunct to treatment for patients with conditions such as diabetes type 2, hypertension, osteo-arthritis and a catalogue of other disabilities.

Generally, little attention is paid to this option because of the difficulty patients have in losing adequate amounts of weight and keeping it off. The widespread availability of effective weight loss programmes in UK and Irish pharmacies, however, makes a strong case for offering overweight patients, especially those with type 2 diabetes, an opportunity to try a course that leads to less dependence on drugs and frequently leads to long-term remission of disease.

For diabetes, there are two basic facts to consider. The first is that type 2 diabetes is a disease with a primary aetiology close to 100 per cent reversibly related to excess body weight. The second fact is that diabetic patients can lose enough weight in a few days to bring their blood sugars under control and with further weight loss within weeks they can crucially reduce their cardiovascular risk factors and apparently keep the disease in remission, even with some weight regain.

Weight spiral


Standard treatment for type 2 diabetes, with its emphasis on using drugs to lower the blood sugar, often results in a relentless vicious circle. High blood sugar leads to drug intervention, which results in increased body weight, which in turn elevates the blood sugar, which increases the requirement for more potent drugs, which spirals to obesity and possible insulin dependency. Patients get fatter as a result of treatment and this necessitates more aggressive drug usage. With significant weight loss, drug usage can be reduced and in many cases stopped permanently.

The practice time and resources involved in assisting overweight and obese patients to lose weight can be justified. The link to type 2 diabetes alone is sufficient as, with rapid weight loss, normalisation of blood sugar levels is achieved in days and, with further weight loss, the disease can be held in remission. Better long-term glycaemic control is achieved with rapid weight loss, even after some weight regain, than is achieved with the same weight lost more slowly. About 50 per cent of hypertensive patients can reduce drug treatments with weight loss. Surgical interventions can be scheduled when substantial weight is lost. Fewer antidepressants are required and the overall frequency of GP visits is significantly lower for leaner patients.

There is no shortage of choice to meet the weight loss needs of individual patients. Drugs, dietetic referral, exercise on prescription and pharmacy-based treatment programmes are all needed to deal with the massive problem of obesity. Each has a place depending on the patient’s specific clinical needs. An exercise prescription may not be the best choice for a 40st patient who may struggle simply to walk.

Long-term weight managment


While willpower can often help people lose weight over a short defined period, control for the months, years or even decades required for stability is a different story. Loss of weight by any means confers absolutely no lasting legacy for weight maintenance. Weight loss, however achieved, is only the beginning of the treatment, not the end point. When the drug therapy is discontinued, when the counsellor moves on, when the patient is ‘cured’ of excess weight – this is the point at which a dieter requires the maximum attention and assistance. Weight management requires control of eating behaviour over a sustained period of time and the implementation of lifestyle changes.

Pharmacists are best placed to offer this in the community. Justifying GP time and resources for a patient who has achieved weight loss and is now both healthier and at a normal weight is difficult. The expectation that this patient will sustain the weight loss without considerable help, however, is naïve. Pharmacy-based programmes are ideal for the varying long-term weight management needs of patients.

Obesity prevention can also be part of the pharmacy complement of health promotion services, dealing with excess weight before it reaches obese levels and exacerbates co-morbidities. The care of patients during weight loss is advantageous when monitored by the pharmacist, who understands the implications of other drug treatments that may interact with the weight loss programme. But it is at the post-diet stage that the pharmacist is best equipped to provide essential long-term guidance, support and education that will increase the length of time that the weight loss is maintained.

Both the new GP and pharmacy contracts strongly encourage interactive efforts to deal with a range of health problems, most of which have weight-related implications. Weight loss is vital for management of cholesterol, blood lipids, diabetes, hypertension or asthma. It even impacts on programmes for smoking cessation.

Maximum safe rate of loss


Modest reductions in calories can theoretically result in weight loss but the reduction has to be from the equilibrium level, not from current intake. If a person is overeating by 2,000 calories a day (common in the obese), a modest reduction in intake will not cause weight loss.

There is a maximum rate of weight loss for any individual. A total fast provides zero calories and therefore requires that all the calories necessary for life come from the body fuel reserves. A total fast, however, provides no nutrients and as an obese patient has a far greater reserve of calories than stores of other essential nutrients, a total fast is out of the question. To be healthy, a diet has to supply adequate essential amino acids, essential fatty acids, vitamins, minerals and trace elements. A total fast cannot be a valid treatment for obesity. The simple idea of reducing fat levels in an enteral formula solves both the calorie and the nutrient problem, achieving the absolute minimum of calories consistent with a healthy diet.

Benefits of weight loss


There is extensive literature on the beneficial effects of weight loss on cardiovascular risk factors, blood lipid profiles and blood pressure. Managing weight in general practice is time-consuming. The benefits from reliable weight loss on the glycaemic control and the cardiovascular risk factors more than justifies pharmacy involvement; it benefits patients and makes good use of pharmacists’ training and facilities.

Weight has a critical influence on the clinical course of many medical conditions. Uniquely, however, with type 2 diabetes it is essential that hypoglycaemic medications are stopped prior to dieting because the blood sugar can normalise so quickly when weight is lost rapidly. This requires an understanding on the GP’s part. The authors have an ongoing series of editorials and sponsored features in publications targeted at GPs and nurses, which encourage GPs to co-operate with pharmacists for overweight patients, especially when weight loss has medical implications.

The importance of pharmacy


The need to deal with excess weight is no longer simply a cosmetic issue. Obesity has become pandemic. The serious consequences of excess weight are being acknowledged as type 2 diabetes rates soar in children as well as adults. There is probably no other service that a pharmacist can provide that will prove to be as valuable as weight management. When effective self-funding programmes are available that do not require allocation of scarce resources from primary care trusts, it is hard to imagine any pharmacy failing to offer weight management.

The problem has become so pervasive that it will take a wide variety of treatments, drugs and public education to have any impact. Hospital programmes for weight management are overwhelmed. Pharmacy is the best community resource and pharmacists’ training ideal for providing professional assistance in dealing with the major health issue of the decade.

Further reading
1. Shaper AG, Wannamethee SG, Walker M. Body weight: implications for the prevention of coronary heart disease, stroke and diabetes mellitus in a cohort study of middle aged men. Brit Med J 1997; 314: 1311–1317.
2. Uusitupa M, Alaakso M et al. Effects of a VLCD on metabolic control and cardiovascular risk factors in the treatment of obese non-insulin-dependent diabetes. Amer J Clin Nutr 1990; 51: 768–773.
3. Weck M, Hanefeld M, Schollberg K. Effects of VLCD in obese NIDDM (non-insulin-dependent diabetes) on glucose, insulin and C peptide dynamics. Internat J Obes 1989; 13 (Suppl 2): 159–160.
4. Wing RR, Blair E et al. Calorie restriction per se is a significant factor in improvement in glycemic control and insulin sensitivity during weight loss in obese NIDDM patients. Diabetes Care 1994; 17: 30–36.
5. Wing RR, Marcus MD, Bononi P. Glycemic control after weight loss is affected by how weight loss is achieved. Diabetes 1990; 39 (Suppl 1): 50A.
6. Wing RR, Marcus MD, Salata R, Epstein LH, Miaskiewicz S, Blair EH. Effects of a very low calorie diet on long-term glycemic control in obese type II diabetic subjects. Arch Int Med 1991; 151: 1334–1340.
 
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