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VOLUME 17 NUMBER 2 • NOVEMBER 2020
Report
SA JOURNAL OF DIABETES & VASCULAR DISEASE
Clinical focus with Dr Lombard
Top tips for motivating patients to adopt a better lifestyle
Dr Lombard points out that from his clinical experience, the
following strategies or interventions work best:
• Motivating patients to lose weight, especially poorly controlled
overweight diabetics, is more achievable when they understand
the serious implications of their condition. If diagnosed with
T2DM at 50 years of age, lifespan is likely to be reduced by 10
years; if diagnosed before the age of 40 years, the individual is
unlikely to reach retirement age
• A weight loss of at least 10 kg or 10% of body weight is not
easy to achieve and sustain; the addition of anti-obesity drugs
is useful, although they are not reimbursed by South African
medical aids. Options include orlistat, topiramate, liraglutide
and phentermine. Phentermine can only be used short term
as it has significant risks; the prescriber should be aware of its
indications and contraindications
• Consultation with a motivated and dedicated dietitian can be
of great help; a team effort and regular follow up are necessary
• Ensure that other medications are not contributing to weight
gain
• Choose diabetic medications that contribute to weight loss.
Pharmacotherapy in diabetes: what are the options
for combined obesity and diabetes treatment?
Effective treatment of obesity should simultaneously improve
body weight, body composition and glycaemic control. Although
metabolic surgery is the best treatment option for patients with
diabesity, most patients can only be managed with antidiabetic
medications because metabolic surgery is invasive, unacceptable to
many patients and expensive, currently around R180 000.
Antidiabetic agents may affect diabesity outcomes because
of their effects on body weight and other metabolic parameters.
Consequently, rational use of antidiabetic medications is imperative
to optimise long-term management of diabesity. The focus of a
suitable antidiabetic treatment for obese/overweight patients
should at the very least be the prevention of additional weight gain.
Glucose-lowering agents that support weight reduction or are
weight neutral should be the first choice after the obligatory
metformin therapy.
1,15
Metformin
Although metformin is generally considered weight-neutral,
weight loss ranging from 0.6 to 2.9 kg has been shown in multiple
studies with HbA
1c
reduction of ≥ 1%, especially when coupled
with lifestyle interventions. Antidiabesity effects arise from
inhibition of hepatic gluconeogenesis, improvement of muscle
insulin sensitivity and the agent’s appetite-suppressing effect.
Metformin treatment in combination with lifestyle modifications
has shown improvements in polycystic ovary syndrome (PCOS),
gestational diabetes mellitus, non-alcoholic fatty liver disease
(NAFLD) and cancer, all of which are health problems directly or
indirectly linked to diabesity.
5,15
GLP-1 RAs
The glucagon-like peptide-1 receptor agonists (GLP-1 RAs) can lead
to weight loss by decreasing appetite, delaying gastric emptying and
enhancing satiety. Collectively, these effects result in a significant
improvement in diabesity, with protective effects on the heart,
In many ways the treatments for diabetes are similar to
those for addressing obesity. The treatment of obesity always
entails reduction of body weight through lifestyle interventions,
pharmaceutical interventions or metabolic surgery. Canada is the
only country to publish clinical guidelines for the management of
obesity as a chronic disease.
The available treatments for diabetes are variable and based on
the type of diabetes with which an individual has been diagnosed.
Important factors that need to be considered include a person’s
lifestyle habits, diet and their medicine choices.
1,13,14
What is the role of lifestyle in management of weight
and diabetes?
Patients’ understanding of the role of diet and exercise in preventing
and managing diabetes is critical to long-term health status change.
Any recommended lifestyle changes should be specific to the
patient; patients that participate in lifestyle reconciliation decision-
making have a much greater ability to lose weight. However, the
reality is that intensive lifestyle interventions are difficult to achieve
and maintain over a long period of time.
1,13
Exercise
The effects of physical activity in improving a patient’s metabolic
profile are unequivocal. Studies have consistently shown improved
glycaemic control, lipid profile, cardiovascular fitness and antioxidant
status, along with reduced inflammatory markers, adiposity and
atherogenic progression, thereby confirming that physical activity
is an evidence-based treatment modality to combat diabesity.
6
Exercising more than three times per week, averaging 150 minutes
of physical activity every week, should entail a combination of
aerobic exercise with twice-weekly strength training. Aside from
obviously strengthening muscle and bone and improving lean mass,
strength training also improves insulin sensitivity and can lower
blood glucose. There is an additive effect on weight loss when
exercise is combined with an energy-restricted diet.
1,13
Diet and nutrition
Nutritional therapy is practical and useful for improving glycaemic
control and metabolism. An energy-restricted diet can be achieved
either by a low-fat, low-carbohydrate diet, or the Mediterranean-
style diet, which is characterised by beneficial metabolic effects.
However, it is not the diet type that determines the success of
weight loss, but rather sustained adherence to the diet of choice.
Ideally, a broad spectrum of different diet options should be
available to best match the patient’s individual food preferences,
lifestyle and medical conditions.
Table 1.
Benefits of weight loss in diabetes patients
• Improves overall fitness
• Reduces HbA
1c
levels
• Improves cardiovascular disease risk factors
• Decreases the use of antihyperglycaemic, antihypertensive and lipid-
lowering agents
• Reduces symptoms of depression
• Reduces severity of, or promotes remission of, symptoms of obstructive
sleep apnoea.