1. Canadian Diabetes Association Clinical Practice Guidelines Weight Management in Diabetes Chapter 17 Sean Wharton, Arya M. Sharma, David C.W. Lau

2. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Key Points 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 anti- hyperglycemic medications 5.Bariatric surgery is appropriate in select refractory cases 2013

3. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association The Growing Epidemic 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! Overweight or Obese * 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.

4. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Height, weight, BMI, waist circumference Hypertension, dyslipidemia and CVD Waist Circumference and Risk of Health Problems: Thresholds MenCaucasian, African≥94 cm Asian, South or Central American ≥90 cm All Women≥80 cm Assessing the Problem

5. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Canadian Guidelines for Body Weight Classification in Adults ClassificationBMI (kg/m 2 )Risk of Health Problems Underweight<18.5Increased Normal weight18.5-24.9Least Overweight25.0-29.9Increased Obese≥30.0 Class I30.0-34.9High Class II35.0-39.9Very High Class III≥40.0Extremely High Health Canada. Canadian Guidelines for Body Weight Classification in Adults. 204 Ottawa, ON: Health Canada; 2003. Publication H49-179/2003E.

6. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 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

7. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Treatment Strategies Health behaviour interventions – Lifestyle Pharmacotherapy Bariatric surgery

8. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 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

9. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 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

10. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Weight GainWeight 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 WeightWeight 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 4. Consider Weight Effects When Selecting Antihyperglycemic Medications Hollander, P. Diabetes Spectrum 2007; 20(3): 159-165

11. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 5. Bariatric Surgery is Appropriate in Select Refractory Cases Class III (BMI ≥ 40 kg/m 2 ), or class II (BMI 35.0-39.9 kg/m 2 ) 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 2013

12. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 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] Recommendation 1

13. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 2 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] 2013

14. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 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]

15. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association CDA Clinical Practice Guidelines http://guidelines.diabetes.cahttp://guidelines.diabetes.ca – for professionals 1-800-BANTING (226-8464) http://diabetes.ca http://diabetes.ca – for patients