14
VOLUME 10 NUMBER 1 • MARCH 2013
REVIEW
SA JOURNAL OF DIABETES & VASCULAR DISEASE
intensive glucose control in cardiovascular mortality is controversial.
Higher body mass index (BMI) in type 2 diabetes has not been
consistently associated with a higher risk for cardiovascular events.
On the contrary, several studies have demonstrated a lower risk
for cardiovascular mortality in overweight compared to leaner
diabetics, even in patients at very high cardiovascular risk.
22,23
In the UKPDS, despite a significant increase in weight compared to
conventional therapy, intensive glucose control with insulin was asso-
ciated with fewer microvascular complications without an increase
in cardiovascular mortality.
15
One observation that might explain
this paradox is that weight accumulation related to intensive glu-
cose control is not limited to the abdomen, but rather is generalised,
being distributed between fat mass and lean mass. Furthermore, the
increase in fat mass is predominantly peripheral rather than central,
so it may not result in an overall increase in cardiovascular risk.
21,24
Nevertheless, there is direct evidence that intentional weight
loss among overweight patients with type 2 diabetes is associated
with an improvement in glycaemia, blood pressure, triglycerides,
high-density lipoprotein cholesterol (HDL-C) and other markers of
cardiovascular risk, such as C-reactive protein (CRP), and with a
reduction in cardiovascular mortality.
25-27
In a 12-year, prospective
observational study including 4 970 overweight individuals with
type 2 diabetes aged 40 to 64 years of age, intentional weight
loss was associated with a 25% reduction in total mortality and a
28% reduction in cardiovascular and diabetes-related mortality.
27
Compared to patients who did not try to lose weight, the intention
to lose weight was associated with reductions in mortality regardless
of whether weight loss actually occurred.
In another prospective, observational study including 1 401 type 2
diabetes subjects over the age of 35 years, individuals who reported
trying to lose weight had a 23% lower mortality rate than those
who did not and this was the same regardless of whether attempts
at weight loss were successful.
28
These results suggest that lifestyle
changes and behaviours associated with weight loss attempts
improve longevity irrespective of the degree of weight loss, or they
may reflect that achieved weight loss is difficult to maintain, but
nevertheless may be associated with improved long-term health.
Excess adiposity and weight gain in type 2 diabetes are associated
with a number of physical and psychological consequences that
affect adherence and response to therapy, and long-term glucose
control. Increased fat mass is associated with insulin resistance,
which exacerbates beta-cell dysfunction and increases requirement
for insulin and further weight gain.
20
Higher BMI at initiation of
treatment predicts a poorer response to insulin therapy.
29,30
Weight gain may compound feelings of depression and anxiety,
which are already common in patients with diabetes and which
are associated with poor adherence and self-care.
5
In the Diabetes
Attitudes Wishes and Needs (DAWN) study, which surveyed the
perceptions surrounding diabetes care and self management among
more than 5 000 type 2 diabetes subjects, 50%of patients expressed
anxiety about their body weight, which contributed to a common
poor sense of wellbeing.
11
The fear of weight gain discourages both
initiation of and adherence to insulin therapy. Patients concerned
about weight gain are more likely to omit insulin doses or adjust
their insulin dose in order to aim for higher blood glucose targets
and to avoid normoglycaemia in an attempt to manage their body
weight. This behaviour is associated with a significant increase in
risk of diabetes-related emergency room visits and hospitalisations,
and higher rates of retinopathy and neuropathy.
31
So, while concerns about weight gain should not discourage
insulin use in patients who require more intensive glucose control,
it would make sense to seek out strategies to limit the impact of
treatment on body weight.
Limiting treatment-related weight gain
Lifestyle modification
Because insulin-related weight gain is dose dependent, one broad
strategy to limit weight gain is to use less insulin. Diet and exercise
form the cornerstone of management for type 2 diabetes, improving
cardiovascular health, helping to control weight and glycaemia and
improving insulin sensitivity. Because adiposity is inversely associated
with insulin sensitivity, diet and exercise can help to break the cycle
of higher insulin use and increasing weight.
20
A healthy diet comprises reduced calorie intake and consumption
of less saturated fats, trans fats, cholesterol and sodium.
4
However,
because dietary lifestyle change is one that needs to be continued
for life, it is very important that the diet be tailored to individual
patients according to their personal and cultural preferences in order
to achieve long-term success. Regular follow up and counselling is
also beneficial to help maintain compliance.
32
Table 1.
Lifestyle advice to help achieve and maintain weight loss
4,34-36
Avoid soft drinks and other sweet beverages.
•
Avoid fast food.
•
Do not skip breakfast.
•
Eat regular, evenly distributed meals throughout the day.
•
Keep a record of your weight, what you eat and what you do for physical activity.
•
Eat family meals at the table and not in front of the television.
•
Cut down on the amount of time you spend watching television.
•
Do not use food as a way to reward yourself.
•
Find fun and easy activities that require minimal preparation; e.g. walking outside, running on a treadmill or riding a stationary bicycle in front of the television
•
or while listening to music.
If time is a barrier, two or three short exercise sessions still have benefit. Activity may be accumulated throughout the day with a minimum of 10 minutes or
•
more for each exercise session.
Exercise when your energy levels are at their highest.
•
Join a health club and seek professional advice from a personal fitness trainer or join an exercise class.
•
If you prefer to train at home, make use of fitness DVDs and home exercise equipment.
•
Set realistic time-related goals.
•
Exercising with friends or family is more fun and will help to keep you motivated.
•
The internet is a useful source of information, including menu planning, recipes, healthy eating guides, shopping tips, record keeping (food intake, physical
•
activity, carbohydrate and/or caloric balance, blood glucose monitoring, body weight and body mass index) and physical activity programmes.
