Weight Management in Diabetes Patients

Las Vegas—Weight management is crucial to successfully managing diabetes. Weight loss in patients with diabetes can promote healthy levels of glycated hemoglobin, blood pressure, high-density lipoprotein (HDL), plasma glucose, and triglycerides. To achieve weight loss, medication requirements should be reduced, and possibly eliminated, in patients with diabetes.

Donna H. Ryan, MD, FACP, FTOS, professor emeritus, Pennington Biomedical Research Center, addressed effective weight loss strategies for type 2 diabetes patients during a workshop at the CRS meeting.

There are many challenges to weight loss for diabetes patients. Some diabetes medications, including insulin, sulfonylureas, and thiazolidinediones, promote weight gain (Table). Other medications that are frequently prescribed, such as antidepressants and antipsychotics, promote weight gain as well.

Dr. Ryan offered some solutions to weight loss complications. Instead of adding food to a diet, defend against hypoglycemia by reducing diabetes medications, many of which are associated with hypoglycemic risk, including insulin, sulfonylureas, and meglitinides. She also mentioned that calorie restriction independent of weight loss improves glycemic control. Further weight loss improves glycemic control as well.

When adjusting diabetes medication during a period of weight loss, there are some considerations. The duration of the time the patient has had diabetes may affect the outcome. Initial glycemic control will affect the level of blood glucose change. Approximately 50% of alterations in the fasting blood glucose will happen within the first 10 days of calorie restriction.

Dr. Ryan listed 3 steps to overcome challenges of weight loss in type 2 diabetes patients. The first step is identifying high-risk patients by reviewing their medications. Patients prescribed insulin, sulfonylureas, repaglinide, or nateglinide are considered high risk. Preparing type 2 diabetes patients for weight loss includes monitoring glycated hemoglobin (HbA1c) levels twice daily for 1 week.

Clinicians should also focus on preventing hypoglycemia through medication regulation. Reduce antidiabetic medications at the start of the weight loss period based on pre-diet HbA1c levels. If the monitoring results show all with the exception of 2 HbA1c levels >100 mg/dL, reduce medication intake by 0% to 50%. If the results exhibit ≥3 HbA1c levels of 80 mg/dL to 100 mg/dL, decrease medication consumption by 25% to 75%. If the results show ≥3 HbA1c levels <80 mg/dL, a 50% to 100% reduction in medication intake is suggested.

If HbA1c monitoring results are unavailable, reduce diabetes medications once weight loss begins. Oral medications should be stopped, and patients should stop taking insulin if they reach <50 units of insulin per day. If patients are prescribed >50 units of insulin per day, decrease medications by 30% on day 1, 50% on day 2, and 75% on day 3. Patients may stop taking insulin on days 5 through 7.

The third step is to continually monitor HbA1c levels and episodes of hypoglycemia until the patient reaches stable condition. If 2 glucose values prior to a meal are >150 mg/dL each week, Dr. Ryan suggested titrating insulin or oral medications.

After weight loss has been achieved, maintain an HbA1c log twice daily for 2 weeks. If the log shows ≥2 blood glucose levels of >100 mg/dL, consider increasing medications.—Melissa D. Cooper