407
Management of Obesity in Diabetes Mellitus CARLENE C. HAMILTON, RD; PATTI B. GEIL, MS, RD, CDE; JAMES W ANDERSON, MD
University of Kentucky College of Medicine Lexington, Kentucky
A primary goal of treatment in obese individuals with NIDDM is weight loss and maintenance.
Obesity is a precipitating factor for the development of NIDDM in individuals who
are
genetically at risk. A variety of weight-loss regimens are available to match the specific needs and lifestyles of individuals. Hypocaloric high-fiber diets have been found to be effective in achieving weight loss, as well as aiding in glycemic and lipid control. very low calorie diets, administered under medical supervision, are useful for obese NIDDM patients with 18-55 kilograms of weight to lose. Lifestyle education appears to be an important element of any successful weight loss program.
The combination of obesity and diabetes mellitus clearly produces adverse effects on health and longevity. Diabetes mellitus is a leading cause of morbidity and mortality in the United States,’ and obesity has earned the distinction of being considered a separate disease entity in this century. Although obesity has been associated with other forms of diabetes, it is primarily associated with non-insulin-dependent diabetes mellitus (NIDDM). Obesity is a precipitating factor for the development of NIDDM in genetically predisposed individuals .2 In addition, obesity contributes to excess mortality in NIDDM by increasing insulin resistance, making pharmacologic treatment more difficult, as well as increasing the risk for developing coronary heart disease (CHD) .3 &dquo;Diabesity&dquo; has been used to describe the combination of diabetes and obesity in an affected individual .4 Weight loss and maintenance should be a goal of treatment in diabetes mellitus, particularly in the obese patient with NIDDM. Attaining an &dquo;ideal&dquo; body weight is not necessarily the primary goal; even the loss of modest amounts of weight produces health benefits.5 Diet therapy is well-tolerated, cost-effective, and safe, but is often neglected because of the time, education, and behavioral modification required. Several options for the treatment of diabesity are available; tailoring the treatment provides the individual with NIDDM the best chance for success.
Tailoring the Treatment treatment approaches for obesity in NIDDM are outlined in Table 1. Hypocaloric high-fiber diets are the treatment of choice for individuals with 9-18 kilograms to lose. These diets can produce gradual weight losses of up to one kilogram per week. Numerous research studies document the benefits of fiber consumption in the management of both diabetes mellitus and obesity.119 Dietary fiber is the portion of the plant cell not digested in the human small intestine. Different types of fiber are distinguished by their physiologic properties and systemic effects. Water insoluble fiber, found primarily in wheat, vegetables, and most grain products, alters gastrointestinal function by decreasing intestinal transit time and increasing fecal bulk. Insoluble fiber generally does not lower blood glucose or cholesterol. Soluble fiber becomes viscous or gummy when mixed with water, increasing intestinal transit time, delaying gastric emptying, and slowing glucose absorption. Food sources of soluble fiber include oats, legumes, barley, and fruits.
Suggested
Reprint request to James W. Anderson, MD. VA Medical Center, Cooper Drive Division (1 11-C), Lexington, KY 40511. Downloaded from tde.sagepub.com at FUDAN UNIV LIB on May 11, 2015
408
In the treatment of diabetes, dietary fiber improves glycemic control by decreasing insulin secretion and increasing insulin sensitivity, allowing for reduced dosages of hypoglycemic medications.6.9 In addition, high-fiber diets lower the risk for CHD in persons with diabetes by reducing lipid levels.10 Dietary fiber aids in the management of obesity through physiologic and hormonal effects, as well as by promoting changes in behavior. 11.12 High-fiber foods often contain fewer calories per ounce and take longer to eat than lowfiber foods. High-fiber foods are also more filling. Through a variety of mechanisms, they increase satiety and decrease between-meal hunger. Foods rich in soluble fiber delay gastric emptying and decrease serum levels of insulin, which is an appetite stimulant. Foods rich in dietary fiber may modify certain eating behaviors. Because they require more chewing and take longer to eat, high-fiber foods may decrease the total amount of food consumed or may displace the intake of other nutrients, such as fat.
Meal Planning With
Table 1. Mellitus
Tailoring the Treatment for Obesity in Diabetes
Table 2.
Sample High-fiber Nutrition Plan
(1200 Calories, 30 Grams Total Fiber, 10 Grams Soluble Fiber)
Hypocaloric High-fiber Diets
guidelines for a hypocaloric high-fiber diet include: 800-1500 kcal/day 12-16% protein (0.8 g/kg body weight) 55-60% carbohydrate (60-70% complex, 30-40% simple)
General o 0 o
15-25 % fat 25-50 g fiber (30-35 g/1000 kcal) Caloric needs can be estimated by allowing 22-26 calories per kilogram (current weight) for sedentary adults, 28-33 calories per kilogram for moderately active adults, and 3544 calories per kilogram for very active adults. To promote a weight loss of roughly one-half kilogram per week, approximately 500 calories daily should be subtracted from this estimate.’ These guidelines are easily converted into a meal plan (Table 2) that can be individualized to accommodate the diabetes treatment regimen, as well as food preferences and other factors. Because a high-fiber diet lowers insulin requirements, the insulin dose should be decreased about 10%, and the dose of any oral agent should be decreased by onethird to one-half when the diet is begun.’33 Most persons with diabetes can boost the fiber in their meal plan to the recommended level if they do so gradually. Generous fluid intake helps the body adjust to increased gas production, a common side effect of added fiber. Increased fiber consumption is unlikely to cause nutrient deficiencies, but a multivitamin and mineral supplement is suggested as a precautionary measure.’4 As with any meal plan, effective nutrition education and counseling are central to success. Educational materials have been developed to support high-fiber nutrition counseling.15.17 When the entire health care team is enthusiastic and supportive of a high-fiber nutrition plan, individuals with diabesity can change their eating patterns and closely adhere to a prescribed plan. Approximately 70% of patients instructed on a high-fiber diet report good or excellent adherence after two years; only 5% demonstrate poor adherence. 11 .
a
Use of Very-low-calorie Diet Programs
Very-low-calorie diet (VLCD) programs provide 400-800 day. Comprehensive programs combine the use
calories per
of
a
VLCD with medical
monitoring
and
patient weight-
management education.’9 The standard program sequence includes: initial orientation to identify appropriate patients for treatment, weight loss phase using VLCD regimen, refeeding phase in which foods are gradually reintroduced, and the weight maintenance phase .20 Patients accepted into VLCD programs should exceed desirable body weights by 30% or have a body mass index
Downloaded from tde.sagepub.com at FUDAN UNIV LIB on May 11, 2015
409
Table 3.
Responses of Persons with NIDDM to
12-week Treatment with 800 kcal Diet
(BMI) of > 30 kg/m~. They also should meet inclusion criteria based upon initial medical, electrocardiogram (ECG), and laboratory screenings. Approximately 10% of patients accepted into the VLCD program at the University of Kentucky have NIDDM.20-21 The most frequently used VLCD in a medically supervised program is a powdered product providing 45-100 grams per day of egg or milk-based protein. The powder is typically mixed with water or another noncaloric liquid and consumed three or more times daily. Carbohydrate content of VLCDs ranges from 30-80 grams per day. Fat content is variable. Vitamin and mineral supplements are used with VLCDs to meet recommended dietary allowances. Patients are advised to drink a minimum of two liters per day of noncaloric fluids. Patients are encouraged to continue the VLCD regimen until desired weight loss is achieved. 19.20.22 After the VLCD phase, foods are gradually reintroduced over a three- to five-week period to achieve calorie intake for weight maintenance. VLCD supplement use is gradually decreased as foods are added to the diet. High carbohydrate, low fat foods, such as fruits, vegetables, and grains are introduced first, followed by lean protein foods and moderate amounts of fat.’-’ During the weight loss and refeeding phase of a comprehensive VLCD program, patients are seen weekly by program nurses who obtain weight, measure blood pressure, and record interval medical history. Patients are also seen by a physician who reviews the interval history and performs a limited physical exam as indicated. Multiphasic chemistry profiles are obtained every other week to assess changes, especially in liver function, electrolytes, minerals, and blood urea nitrogen. Complete blood counts are usually performed every four weeks. ECGs are obtained and evaluated at approximately 12 kilogram weight-loss intervals.23 Permanent lifestyle changes are essential for weight loss maintenance. Patients benefit from attending weekly education sessions during VLCD and post-VLCD treatment. Lifestyle education, including physical activity, nutrition knowledge, behavioral modification, and self-management of weight should be taught to patients by qualified, trained staff. The behavioral educators should encourage patients to achieve levels of physical activity averaging over 2000 calories/week during the VLCD and maintenance program?4
Regimens
education classes ideally should continue for at least 18 months after weight loss is completed.20 Typically, patients can expect to lose about one to three kilograms per week with VLCD treatment.’-5 Serum cholesterol and glucose values usually decrease by 5-15%. Systolic blood pressure usually decreases 8-12% and diastolic blood pressure decreases an average of 9-13%.20 Patients with NIDDM have typical serum glucose decreases of 3244%.~u.2I.~5 Common side effects of medically supervised VLCD therapy include fatigue, dizziness, constipation, diarrhea, nausea, headache, and cold intolerance. Most of these side effects subside upon adjustment to the VLCD .211 Surgical management of severe obesity (Table 1 ) is recommended only after repeated failure of supervised, nonsurgical methods. The invasive nature of surgical treatment increases the incidence of side effects, complications, morbidity, and mortality, compared with noninvasive treatments. The long-term efficacy of surgical intervention depends upon the inclusion of comprehensive behavioral-lifestyle education, which remains an infrequent component of many
Lifestyle
surgical therapies. ~1J.~ó How Do Persons with Diabetes Respond To Very-low-calorie Diet Program?
a
is one of the biggest challenges for persons with NIDDM. Many studies have reported safe and rapid weight loss using medically-monitored VLCD regimens for obese NIDDM patients.21 We recently completed a research study designed to test the effectiveness of two different weight loss plans on glycemic control and weight loss for persons with NIDDM .21 For this 12-week study, the 40 participants were assigned to either an 800 calorie per day diet of five nutritionally complete liquid supplements or two liquid supplements per day plus a recommended evening meal of 500 calories. Subjects were allocated to treatment groups using a stratified, randomization procedure based on gender, BMI, and insulin use. Increased physical activity was emphasized and both groups attended weekly lifestyle education classes. Thirty-nine subjects completed the research study. The results of this study are summarized in Table 3. For participants using insulin, doses were usually decreased by 50% after initiating the 800 calorie diet and then
Losing weight
Downloaded from tde.sagepub.com at FUDAN UNIV LIB on May 11, 2015
410
an additional 10% after one week. Six of the eight participants using insulin initially were able to discontinue it by Week 4 of the study, while 22 of 24 participants were taken off oral agents by Week 6. All of the remaining persons
decreased
diabetes medications decreased their doses. One year after completing the program, the 39 subjects were maintaining an average weight loss of 8.6 kilograms, approximately 55% of their original weight loss. Supplement-only and supplement-plus-food regimens were similarly effective in promoting weight loss and improvements in metabolic parameters. Because both groups received intensive education and emphasis on physical activity in this research study, the differences in the two diet groups may have been minimized. on
Summary and maintenance is a primary goal of treatment in obese individuals with NIDDM. Many weight loss treatment options are available, each offering distinct advantages for selected individuals. Hypocaloric high-fiber diets promote gradual weight loss of up to one kilogram per week and are especially suitable for persons with 9-18 kilograms of weight to lose. In addition, dietary fiber uniquely aids in glycemic and lipid control. For obese NIDDM patients with 18-55 kilograms to lose, comprehensive VLCD therapy produces rapid weight loss of one to three kilograms per week and swift reductions in glycemic, lipid, and blood pressure parameters. Lifestyle education used in conjunction with VLCD and post-VLCD treatment fosters weight maintenance. Surgical management of obesity is an option for persons with more than 36 kilograms to lose, but is recommended only after repeated failure of supervised, nonsurgical methods.
Weight loss
7. Anderson JW, Gustafson NJ, Bryant CA, et al. Dietary fiber and diabecomprehensive review and practical application. J Am Diet Assoc
tes : a
1987;87:1189-97. 8. Anderson JW, Smith BM, Geil PB.
graduate Med 1990;88:157-68. 9. Smith U. Dietary fibre, 1987;11(suppl 1):27-31.
diabetes and
obesity,
Int J
Obesity
10. Anderson JW, Deakins DA, Floore TL, et al. Dietary fiber and nary heart disease. Crit Rev Food Sci Nutr 1990;29:95-147. 11. Leeds AR.
Dietary
Post-
coro-
fibre: mechanisms of action. Int J Obes 1987;11
(suppl 1):3-7. 12. Blundell JE, Burley VJ. Satiation, satiety and the action of fibre food intake. Int J Obes 1987;11(suppl 1 ):9-25.
on
13. Anderson JW. Nutrition management of metabolic conditions. Lex-
ington, Ky: HCF Diabetes Foundation, Inc., 1986;19-81. 14. Anderson JW, Ferguson SK, Karounos D, et al. Mineral and vitamin status on high-fiber diets: long-term studies of diabetic patients. Diabetes Care 1980;3:74-76. 15. Anderson JW. The HCF
guide
book.
Lexington, Ky:
HCF Diabetes
Foundation, Inc., 1987. 16. Anderson JW. The high carbohydrate, high fiber (HCF) nutrition HCF Diabetes Foundation, Inc., 1987.
plan.
Lexington, Ky:
17. Anderson JW. Dr. Anderson’s
life-saving diet.
Los
Angeles: The Body
Press, 1986. 18. Anderson JW, Gustafson NJ. Adherence to fiber diets. Diabetes Educ 1989; 15:429-34.
high-carbohydrate, high-
19. Wadden TA, Van Itallie TB, Blackburn GL. Responsible and irresponsible use of very-low-calorie diets in the treatment of obesity. JAMA
1990;263:83-85. 20. Anderson JW, Hamilton CC, Brinkman-Kaplan V. Benefits and risks of an intensive very-low-calorie diet program for severe obesity. Am J
Gastroenterology1992;87:6-15. 21. Anderson JW, Hamilton CC, Crown-Weber E, et al. Safety and effectiveness of a multidisciplinary very-low-calorie diet program for selected obese individuals. J Am Diet Assoc 1991;91:1582-84.
References 1. American Diabetes Association. The direct and indirect cost of diabein the United States in 1987. Alexandria, Va: American Diabetes Association, 1988. tes
2. National Institutes of Health Consensus Development Conference Statement. Health implications of obesity. Ann Intern Med 1985;103: 1073-77.
22. Health Management Resources medical prospectus. Boston: Health Management Resources, Inc, 1986. 23. American Dietetic Association. Position of American Dietetic Association : very-low-calorie weight loss diets. J Am Diet Assoc 1990;90: 722-26. 24. Health
3. Reaven GM.
Non-insulin-dependent diabetes mellitus, abnormal lipoprotein metabolism, and atherosclerosis. Metabolism 1987;36(suppl I): 1-8. 4. National Institutes of Health. Successful diet and exercise conducted in Vermont for "diabesity." JAMA 1980;243:519-20.
therapy is
Bryant CA. Dietary fiber:
Gastroenterology 1986;81:898-906.
diabetes and
obesity.
Management Resources Management Resources, Inc, 1989. 25. diet
behavioral reference. Boston: Health
Henry RR, Gumbiner B. Benefits and limitations of very-low-calorie therapy in obese NIDDM. Diabetes Care1991;14:802-23.
26. National Institutes of Health. Gastrointestinal surgery for severe obeConsensus statement. Bethesda, Md: NIH Consensus Development
sity.
5. Blackburn GL, Kanders BS. Medical evaluation and treatment of the obese patient with cardiovascular disease. Am J Cardiol 1987;60: 55G-58G.
6. Anderson JW,
High-fiber diet for diabetes.
Am J
Conference, 1991;9:1-20. 27. Anderson JW, Brinkman-Kaplan V, Hamilton CC, et al. Comparison of 800-kcal weight loss programs for obese individuals with NIDDM: supplement only versus supplement plus food. Submitted to Diabetes Care, 1992.
Downloaded from tde.sagepub.com at FUDAN UNIV LIB on May 11, 2015
Management of Obesity in Diabetes Mellitus CARLENE C. HAMILTON, RD; PATTI B. GEIL, MS, RD, CDE; JAMES W ANDERSON, MD
University of Kentucky College of Medicine Lexington, Kentucky
A primary goal of treatment in obese individuals with NIDDM is weight loss and maintenance.
Obesity is a precipitating factor for the development of NIDDM in individuals who
are
genetically at risk. A variety of weight-loss regimens are available to match the specific needs and lifestyles of individuals. Hypocaloric high-fiber diets have been found to be effective in achieving weight loss, as well as aiding in glycemic and lipid control. very low calorie diets, administered under medical supervision, are useful for obese NIDDM patients with 18-55 kilograms of weight to lose. Lifestyle education appears to be an important element of any successful weight loss program.
The combination of obesity and diabetes mellitus clearly produces adverse effects on health and longevity. Diabetes mellitus is a leading cause of morbidity and mortality in the United States,’ and obesity has earned the distinction of being considered a separate disease entity in this century. Although obesity has been associated with other forms of diabetes, it is primarily associated with non-insulin-dependent diabetes mellitus (NIDDM). Obesity is a precipitating factor for the development of NIDDM in genetically predisposed individuals .2 In addition, obesity contributes to excess mortality in NIDDM by increasing insulin resistance, making pharmacologic treatment more difficult, as well as increasing the risk for developing coronary heart disease (CHD) .3 &dquo;Diabesity&dquo; has been used to describe the combination of diabetes and obesity in an affected individual .4 Weight loss and maintenance should be a goal of treatment in diabetes mellitus, particularly in the obese patient with NIDDM. Attaining an &dquo;ideal&dquo; body weight is not necessarily the primary goal; even the loss of modest amounts of weight produces health benefits.5 Diet therapy is well-tolerated, cost-effective, and safe, but is often neglected because of the time, education, and behavioral modification required. Several options for the treatment of diabesity are available; tailoring the treatment provides the individual with NIDDM the best chance for success.
Tailoring the Treatment treatment approaches for obesity in NIDDM are outlined in Table 1. Hypocaloric high-fiber diets are the treatment of choice for individuals with 9-18 kilograms to lose. These diets can produce gradual weight losses of up to one kilogram per week. Numerous research studies document the benefits of fiber consumption in the management of both diabetes mellitus and obesity.119 Dietary fiber is the portion of the plant cell not digested in the human small intestine. Different types of fiber are distinguished by their physiologic properties and systemic effects. Water insoluble fiber, found primarily in wheat, vegetables, and most grain products, alters gastrointestinal function by decreasing intestinal transit time and increasing fecal bulk. Insoluble fiber generally does not lower blood glucose or cholesterol. Soluble fiber becomes viscous or gummy when mixed with water, increasing intestinal transit time, delaying gastric emptying, and slowing glucose absorption. Food sources of soluble fiber include oats, legumes, barley, and fruits.
Suggested
Reprint request to James W. Anderson, MD. VA Medical Center, Cooper Drive Division (1 11-C), Lexington, KY 40511. Downloaded from tde.sagepub.com at FUDAN UNIV LIB on May 11, 2015
408
In the treatment of diabetes, dietary fiber improves glycemic control by decreasing insulin secretion and increasing insulin sensitivity, allowing for reduced dosages of hypoglycemic medications.6.9 In addition, high-fiber diets lower the risk for CHD in persons with diabetes by reducing lipid levels.10 Dietary fiber aids in the management of obesity through physiologic and hormonal effects, as well as by promoting changes in behavior. 11.12 High-fiber foods often contain fewer calories per ounce and take longer to eat than lowfiber foods. High-fiber foods are also more filling. Through a variety of mechanisms, they increase satiety and decrease between-meal hunger. Foods rich in soluble fiber delay gastric emptying and decrease serum levels of insulin, which is an appetite stimulant. Foods rich in dietary fiber may modify certain eating behaviors. Because they require more chewing and take longer to eat, high-fiber foods may decrease the total amount of food consumed or may displace the intake of other nutrients, such as fat.
Meal Planning With
Table 1. Mellitus
Tailoring the Treatment for Obesity in Diabetes
Table 2.
Sample High-fiber Nutrition Plan
(1200 Calories, 30 Grams Total Fiber, 10 Grams Soluble Fiber)
Hypocaloric High-fiber Diets
guidelines for a hypocaloric high-fiber diet include: 800-1500 kcal/day 12-16% protein (0.8 g/kg body weight) 55-60% carbohydrate (60-70% complex, 30-40% simple)
General o 0 o
15-25 % fat 25-50 g fiber (30-35 g/1000 kcal) Caloric needs can be estimated by allowing 22-26 calories per kilogram (current weight) for sedentary adults, 28-33 calories per kilogram for moderately active adults, and 3544 calories per kilogram for very active adults. To promote a weight loss of roughly one-half kilogram per week, approximately 500 calories daily should be subtracted from this estimate.’ These guidelines are easily converted into a meal plan (Table 2) that can be individualized to accommodate the diabetes treatment regimen, as well as food preferences and other factors. Because a high-fiber diet lowers insulin requirements, the insulin dose should be decreased about 10%, and the dose of any oral agent should be decreased by onethird to one-half when the diet is begun.’33 Most persons with diabetes can boost the fiber in their meal plan to the recommended level if they do so gradually. Generous fluid intake helps the body adjust to increased gas production, a common side effect of added fiber. Increased fiber consumption is unlikely to cause nutrient deficiencies, but a multivitamin and mineral supplement is suggested as a precautionary measure.’4 As with any meal plan, effective nutrition education and counseling are central to success. Educational materials have been developed to support high-fiber nutrition counseling.15.17 When the entire health care team is enthusiastic and supportive of a high-fiber nutrition plan, individuals with diabesity can change their eating patterns and closely adhere to a prescribed plan. Approximately 70% of patients instructed on a high-fiber diet report good or excellent adherence after two years; only 5% demonstrate poor adherence. 11 .
a
Use of Very-low-calorie Diet Programs
Very-low-calorie diet (VLCD) programs provide 400-800 day. Comprehensive programs combine the use
calories per
of
a
VLCD with medical
monitoring
and
patient weight-
management education.’9 The standard program sequence includes: initial orientation to identify appropriate patients for treatment, weight loss phase using VLCD regimen, refeeding phase in which foods are gradually reintroduced, and the weight maintenance phase .20 Patients accepted into VLCD programs should exceed desirable body weights by 30% or have a body mass index
Downloaded from tde.sagepub.com at FUDAN UNIV LIB on May 11, 2015
409
Table 3.
Responses of Persons with NIDDM to
12-week Treatment with 800 kcal Diet
(BMI) of > 30 kg/m~. They also should meet inclusion criteria based upon initial medical, electrocardiogram (ECG), and laboratory screenings. Approximately 10% of patients accepted into the VLCD program at the University of Kentucky have NIDDM.20-21 The most frequently used VLCD in a medically supervised program is a powdered product providing 45-100 grams per day of egg or milk-based protein. The powder is typically mixed with water or another noncaloric liquid and consumed three or more times daily. Carbohydrate content of VLCDs ranges from 30-80 grams per day. Fat content is variable. Vitamin and mineral supplements are used with VLCDs to meet recommended dietary allowances. Patients are advised to drink a minimum of two liters per day of noncaloric fluids. Patients are encouraged to continue the VLCD regimen until desired weight loss is achieved. 19.20.22 After the VLCD phase, foods are gradually reintroduced over a three- to five-week period to achieve calorie intake for weight maintenance. VLCD supplement use is gradually decreased as foods are added to the diet. High carbohydrate, low fat foods, such as fruits, vegetables, and grains are introduced first, followed by lean protein foods and moderate amounts of fat.’-’ During the weight loss and refeeding phase of a comprehensive VLCD program, patients are seen weekly by program nurses who obtain weight, measure blood pressure, and record interval medical history. Patients are also seen by a physician who reviews the interval history and performs a limited physical exam as indicated. Multiphasic chemistry profiles are obtained every other week to assess changes, especially in liver function, electrolytes, minerals, and blood urea nitrogen. Complete blood counts are usually performed every four weeks. ECGs are obtained and evaluated at approximately 12 kilogram weight-loss intervals.23 Permanent lifestyle changes are essential for weight loss maintenance. Patients benefit from attending weekly education sessions during VLCD and post-VLCD treatment. Lifestyle education, including physical activity, nutrition knowledge, behavioral modification, and self-management of weight should be taught to patients by qualified, trained staff. The behavioral educators should encourage patients to achieve levels of physical activity averaging over 2000 calories/week during the VLCD and maintenance program?4
Regimens
education classes ideally should continue for at least 18 months after weight loss is completed.20 Typically, patients can expect to lose about one to three kilograms per week with VLCD treatment.’-5 Serum cholesterol and glucose values usually decrease by 5-15%. Systolic blood pressure usually decreases 8-12% and diastolic blood pressure decreases an average of 9-13%.20 Patients with NIDDM have typical serum glucose decreases of 3244%.~u.2I.~5 Common side effects of medically supervised VLCD therapy include fatigue, dizziness, constipation, diarrhea, nausea, headache, and cold intolerance. Most of these side effects subside upon adjustment to the VLCD .211 Surgical management of severe obesity (Table 1 ) is recommended only after repeated failure of supervised, nonsurgical methods. The invasive nature of surgical treatment increases the incidence of side effects, complications, morbidity, and mortality, compared with noninvasive treatments. The long-term efficacy of surgical intervention depends upon the inclusion of comprehensive behavioral-lifestyle education, which remains an infrequent component of many
Lifestyle
surgical therapies. ~1J.~ó How Do Persons with Diabetes Respond To Very-low-calorie Diet Program?
a
is one of the biggest challenges for persons with NIDDM. Many studies have reported safe and rapid weight loss using medically-monitored VLCD regimens for obese NIDDM patients.21 We recently completed a research study designed to test the effectiveness of two different weight loss plans on glycemic control and weight loss for persons with NIDDM .21 For this 12-week study, the 40 participants were assigned to either an 800 calorie per day diet of five nutritionally complete liquid supplements or two liquid supplements per day plus a recommended evening meal of 500 calories. Subjects were allocated to treatment groups using a stratified, randomization procedure based on gender, BMI, and insulin use. Increased physical activity was emphasized and both groups attended weekly lifestyle education classes. Thirty-nine subjects completed the research study. The results of this study are summarized in Table 3. For participants using insulin, doses were usually decreased by 50% after initiating the 800 calorie diet and then
Losing weight
Downloaded from tde.sagepub.com at FUDAN UNIV LIB on May 11, 2015
410
an additional 10% after one week. Six of the eight participants using insulin initially were able to discontinue it by Week 4 of the study, while 22 of 24 participants were taken off oral agents by Week 6. All of the remaining persons
decreased
diabetes medications decreased their doses. One year after completing the program, the 39 subjects were maintaining an average weight loss of 8.6 kilograms, approximately 55% of their original weight loss. Supplement-only and supplement-plus-food regimens were similarly effective in promoting weight loss and improvements in metabolic parameters. Because both groups received intensive education and emphasis on physical activity in this research study, the differences in the two diet groups may have been minimized. on
Summary and maintenance is a primary goal of treatment in obese individuals with NIDDM. Many weight loss treatment options are available, each offering distinct advantages for selected individuals. Hypocaloric high-fiber diets promote gradual weight loss of up to one kilogram per week and are especially suitable for persons with 9-18 kilograms of weight to lose. In addition, dietary fiber uniquely aids in glycemic and lipid control. For obese NIDDM patients with 18-55 kilograms to lose, comprehensive VLCD therapy produces rapid weight loss of one to three kilograms per week and swift reductions in glycemic, lipid, and blood pressure parameters. Lifestyle education used in conjunction with VLCD and post-VLCD treatment fosters weight maintenance. Surgical management of obesity is an option for persons with more than 36 kilograms to lose, but is recommended only after repeated failure of supervised, nonsurgical methods.
Weight loss
7. Anderson JW, Gustafson NJ, Bryant CA, et al. Dietary fiber and diabecomprehensive review and practical application. J Am Diet Assoc
tes : a
1987;87:1189-97. 8. Anderson JW, Smith BM, Geil PB.
graduate Med 1990;88:157-68. 9. Smith U. Dietary fibre, 1987;11(suppl 1):27-31.
diabetes and
obesity,
Int J
Obesity
10. Anderson JW, Deakins DA, Floore TL, et al. Dietary fiber and nary heart disease. Crit Rev Food Sci Nutr 1990;29:95-147. 11. Leeds AR.
Dietary
Post-
coro-
fibre: mechanisms of action. Int J Obes 1987;11
(suppl 1):3-7. 12. Blundell JE, Burley VJ. Satiation, satiety and the action of fibre food intake. Int J Obes 1987;11(suppl 1 ):9-25.
on
13. Anderson JW. Nutrition management of metabolic conditions. Lex-
ington, Ky: HCF Diabetes Foundation, Inc., 1986;19-81. 14. Anderson JW, Ferguson SK, Karounos D, et al. Mineral and vitamin status on high-fiber diets: long-term studies of diabetic patients. Diabetes Care 1980;3:74-76. 15. Anderson JW. The HCF
guide
book.
Lexington, Ky:
HCF Diabetes
Foundation, Inc., 1987. 16. Anderson JW. The high carbohydrate, high fiber (HCF) nutrition HCF Diabetes Foundation, Inc., 1987.
plan.
Lexington, Ky:
17. Anderson JW. Dr. Anderson’s
life-saving diet.
Los
Angeles: The Body
Press, 1986. 18. Anderson JW, Gustafson NJ. Adherence to fiber diets. Diabetes Educ 1989; 15:429-34.
high-carbohydrate, high-
19. Wadden TA, Van Itallie TB, Blackburn GL. Responsible and irresponsible use of very-low-calorie diets in the treatment of obesity. JAMA
1990;263:83-85. 20. Anderson JW, Hamilton CC, Brinkman-Kaplan V. Benefits and risks of an intensive very-low-calorie diet program for severe obesity. Am J
Gastroenterology1992;87:6-15. 21. Anderson JW, Hamilton CC, Crown-Weber E, et al. Safety and effectiveness of a multidisciplinary very-low-calorie diet program for selected obese individuals. J Am Diet Assoc 1991;91:1582-84.
References 1. American Diabetes Association. The direct and indirect cost of diabein the United States in 1987. Alexandria, Va: American Diabetes Association, 1988. tes
2. National Institutes of Health Consensus Development Conference Statement. Health implications of obesity. Ann Intern Med 1985;103: 1073-77.
22. Health Management Resources medical prospectus. Boston: Health Management Resources, Inc, 1986. 23. American Dietetic Association. Position of American Dietetic Association : very-low-calorie weight loss diets. J Am Diet Assoc 1990;90: 722-26. 24. Health
3. Reaven GM.
Non-insulin-dependent diabetes mellitus, abnormal lipoprotein metabolism, and atherosclerosis. Metabolism 1987;36(suppl I): 1-8. 4. National Institutes of Health. Successful diet and exercise conducted in Vermont for "diabesity." JAMA 1980;243:519-20.
therapy is
Bryant CA. Dietary fiber:
Gastroenterology 1986;81:898-906.
diabetes and
obesity.
Management Resources Management Resources, Inc, 1989. 25. diet
behavioral reference. Boston: Health
Henry RR, Gumbiner B. Benefits and limitations of very-low-calorie therapy in obese NIDDM. Diabetes Care1991;14:802-23.
26. National Institutes of Health. Gastrointestinal surgery for severe obeConsensus statement. Bethesda, Md: NIH Consensus Development
sity.
5. Blackburn GL, Kanders BS. Medical evaluation and treatment of the obese patient with cardiovascular disease. Am J Cardiol 1987;60: 55G-58G.
6. Anderson JW,
High-fiber diet for diabetes.
Am J
Conference, 1991;9:1-20. 27. Anderson JW, Brinkman-Kaplan V, Hamilton CC, et al. Comparison of 800-kcal weight loss programs for obese individuals with NIDDM: supplement only versus supplement plus food. Submitted to Diabetes Care, 1992.
Downloaded from tde.sagepub.com at FUDAN UNIV LIB on May 11, 2015
