Obesity, Lifestyle and Your Patients With Diabetes

A recently-released Medscape Diabetes & Endocrinology Clinical Management Module entitled "Lifestyle and Behavior Modification in the Management of Obesity," by Pamela M. Peeke, MD, MPH and Leslie G. Womble, PhD, has important implications for the treatment of patients with diabetes. New information supports the significant benefits of incorporating physical activity, behavior and use of medication into the treatment of obesity.

For years, the conventional treatment for obesity consisted primarily of a hypocaloric diet. But now the tide has shifted away from dietary intake and weight management as the treatment for most patients. According to Peeke and Womble, "The emphasis of obesity treatment has dramatically shifted from weight management alone, to a comprehensive program of lifestyle modification, for the purposes of decreasing disease risk and enhancing quality of life." Thus, physicians and patients need tools and models to manage weight as part of a constellation of treatment.

In her section on "The Role of Diet and Exercise in Weight Management," Pamela Peeke uses data about the positive correlation of weight-to-hip ratio (a specific type of body fat distribution) with obesity-related medical conditions to highlight the shortcomings of using only weight and body mass index (BMI) as barometers of health for all patients.

Additionally, analysis of the National Weight Control Registry's study of more than 3,000 patients who have successfully lost weight found that their long-term success was due to a combination of a healthy, low-fat diet and regular, moderate exercise. Other studies have also demonstrated the powerful risk-reducing effect that moderate exercise can have on heart disease, diabetes, hypertension and stroke. These conditions are all tied to the metabolic syndrome (or "Syndrome X")-which is associated with increased abdominal obesity-and are of increased concern in the treatment of patients with diabetes.

Regular physical activity can also be of significant benefit to people with type 2 diabetes because of the important role skeletal muscle plays in insulin sensitivity and the maintenance of a normal blood lipid profile. Physical activity changes muscle fiber content and the vascular supply to the muscle, allowing increased control of lipid levels and boosting insulin sensitivity. People with diabetes who exercised regularly for three months have also shown a significant increase in their levels of high-density lipoprotein cholesterol (HDL-C). This suggests a reduced risk for cardiovascular problems. Your patients with diabetes should know that "diet and exercise" are essential and inseparable parts of their disease management.

In a section entitled "Practical Aspects in the Treatment of Obesity," Leslie Womble recollects that two decades ago, patients and practitioners typically aimed for attainment of the ideal body weight (as measured by height-weight charts).

She concludes that:

Today, the most effective behavioral and pharmacological interventions provide an average 7% to 10% reduction in initial body weight. Although modest, these weight losses have been associated with positive health outcomes, including improved blood pressure and lipid levels, increased energy and decreased joint pain. . . . One of the greatest challenges in treating overweight and obese patients is helping patients adopt and embrace these more realistic weight loss goals.

Because patients often want to lose much more than 10% of their weight, there is a large gap between patients' desired and actual weight losses. Womble emphasizes the need for practitioners to help patients focus on nonweight outcomes, such as improved lab results, blood pressure and self-esteem. Patients with diabetes should know that such non-weight outcomes could be significantly more important to their disease management than the reading on their scale.

Womble gives many suggestions to help practitioners promote adherence to a weight management plan:

• Have your patient set specific, realistic and flexible goals.

• Help your patient identify a specific behavior to be changed (e.g., increase his or her activity level).

• Discuss with your patient why it is important to adopt this particular behavior (emphasize the correlation between exercise and maintenance of weight loss).

• Encourage your patient to keep a record of his or her behavior change.

• Record your patient's goal in your notes.

• When the patient returns to the office, be sure to ask whether she or he met the goal that was set during the last visit (to emphasize the importance of this change).

• Give positive feedback.

• Assume that nonadherence is due to a lack of skills rather than to a lack of motivation. Develop a specific plan for the future.

• Let your patient know you will continue to provide support.

Since patients often struggle with such a comprehensive lifestyle modification, refer them to additional sources for support. Advise them to build a good healthcare team and to consult with diabetes educators, registered dieticians and exercise physiologists. Ask your local library about their materials for health and exercise. Encourage patients to read authoritative online articles, use online tracking forms and other tools and visit interactive online discussion groups. A recent study demonstrated the efficacy of Web-based educational and emotional resources for people with diabetes and their families. The combination of online resources and the participation of a healthcare professional greatly enhanced the experience of people with diabetes.

Rick Mendosa