Obesity management is one of the biggest challenges facing primary care. It requires considerable time within a busy practice setting, demanding skills that the clinician may not have specialist training in, combined with a feeling that success may often be unlikely. If committed, it is unusual that the individual cannot lose weight and reap the associated health benefits, but maintenance of the weight lost is an issue and leaves many healthcare professionals feeling that this is a task with no solution.
A realistic approach to obesity management
Obesity therapy should be based on a comprehensive clinical assessment and review of both metabolic cardiovascular (CV) and locomotor risks. For some obese individuals, recognition, brief intervention and simple lifestyle advice may be all that is needed. For many, however, a more intensive programme is required, along with adequate long-term follow-up, to ensure that weight maintenance is sustained (Björvell and Rössner, 1992).
Both clinicians and obese individuals can have unrealistic expectations of weight reduction. When setting goals, it may not be necessary to aim for “ideal” weight but rather a goal of 5–10% weight reduction. A modest target may not only be attainable but will also yield a significant reduction in the risk of developing type 2 diabetes and CV problems (National Heart, Lung, and Blood Institute, 1998).
Complexities of coexistent obesity and type 2 diabetes
Obesity is strongly associated with type 2 diabetes and lipid disorders, which are both significant CV risk factors with other associated comorbidities.
The term “diabesity” reflects this close association between obesity and type 2 diabetes, and in a practical sense highlights the need for a unified approach to these two conditions. However, while obesity is estimated to account for 80% of the overall risk of developing type 2 diabetes (Wolf and Colditz, 1998), the condition is multifactorial in origin, and obesity is not the sole determinant. Indeed, 20–50% of those who are morbidly obese do not develop type 2 diabetes, while 20% people with type 2 diabetes do not fulfil the conventional criteria to be called obese (Chan et al, 1994). Box 1 highlights common risk factors for type 2 diabetes.
The link between weight gain and type 2 diabetes, however, remains strong. It has been demonstrated that weight gain in adult life is significantly linked with high risk of type 2 diabetes and that weight loss of >5 kg can reduce the risk of type 2 diabetes by 50% (Colditz et al, 1995). The length of time that an individual is overweight has also been shown to be a significant influence, with the British Regional Heart Study showing that the longer a person is overweight, the higher their risk of developing type 2 diabetes (Wannamethee and Shaper, 1999). Furthermore, it has been found that central obesity is a powerful predictor of type 2 diabetes in both sexes. Although BMI is the dominant risk factor for type 2 diabetes, the condition is strongly correlated with waist circumference (Chan et al, 1994).
In both the US and Finnish Diabetes Prevention Programmes, weight loss was the most important determinant for reducing the risk of impaired glucose tolerance going on to develop diabetes (Kubaszek et al, 2003; Hamman et al, 2006).
The challenge in primary care
The importance of managing diabesity in a way that addresses both obesity and type 2 diabetes in unison is key. In primary care, this is highlighted through the common clinical characteristics of diabesity and the metabolic syndrome, such pro-coagulant and pro-inflammatory changes in the blood (Van Gaal et al, 2006), endothelial dysfunction (Jiang et al, 1999), renal disease (Sarnak et al, 2003), fatty liver disease, polycystic ovarian syndrome (Dunaif, 1997) and sleep apnoea (Vgontzas et al, 2000), thereby highlighting the linkage between body weight, type 2 diabetes, CV disease (CVD) and renal impairment. (CVD remains the main cause of death among Caucasian people with type 2 diabetes, where as non-caucasians are more likely to die from stroke or renal disease [Morrish et al, 2001].)
To successfully manage diabesity in primary care, we need to equip ourselves with essential tools, including:
- Staff, trained in obesity and diabetes care, involved with the running of the clinic. The training must include expertise in assessment, management and skills at dealing with the psychological issues.
- A recognised weight-management programme that deals with lifestyle and diet.
- Suitable equipment that is capable of accurate assessment.
- A clearly defined follow-up procedure.
New therapies for managing diabesity are in development, and bariatric surgery has proven successful when individuals are properly selected. However, pharmacotherapy is not a solution to all, and bariatric surgery is rationed due to locality and cost issues.
Conclusion
With diabesity affecting ever younger ages, the concern of an epidemic in cardiac, vascular and renal disease is very real, and will only increase the demands to be placed on the already limited NHS resources, particularly those within primary care. The emphasis now must be on addressing both diabetes and obesity in a systematic and complementary way, and not as two conditions in isolation. From the primary care perspective, we must look to develop specialist diabesity clinics, fully equipped to manage this burgeoning problem, and to the future, by focusing our attention on reducing the development of ill health by dealing with the source of the problem: the obesogenic state.
Diabetes in
Practice
Issue:
Vol:01 | No:01
Diabesity: A pressing issue for primary care
Obesity management is one of the biggest challenges facing primary care. It requires considerable time within a busy practice setting, demanding skills that the clinician may not have specialist training in, combined with a feeling that success may often be unlikely. If committed, it is unusual that the individual cannot lose weight and reap the associated health benefits, but maintenance of the weight lost is an issue and leaves many healthcare professionals feeling that this is a task with no solution.
A realistic approach to obesity management
Obesity therapy should be based on a comprehensive clinical assessment and review of both metabolic cardiovascular (CV) and locomotor risks. For some obese individuals, recognition, brief intervention and simple lifestyle advice may be all that is needed. For many, however, a more intensive programme is required, along with adequate long-term follow-up, to ensure that weight maintenance is sustained (Björvell and Rössner, 1992).
Both clinicians and obese individuals can have unrealistic expectations of weight reduction. When setting goals, it may not be necessary to aim for “ideal” weight but rather a goal of 5–10% weight reduction. A modest target may not only be attainable but will also yield a significant reduction in the risk of developing type 2 diabetes and CV problems (National Heart, Lung, and Blood Institute, 1998).
Complexities of coexistent obesity and type 2 diabetes
Obesity is strongly associated with type 2 diabetes and lipid disorders, which are both significant CV risk factors with other associated comorbidities.
The term “diabesity” reflects this close association between obesity and type 2 diabetes, and in a practical sense highlights the need for a unified approach to these two conditions. However, while obesity is estimated to account for 80% of the overall risk of developing type 2 diabetes (Wolf and Colditz, 1998), the condition is multifactorial in origin, and obesity is not the sole determinant. Indeed, 20–50% of those who are morbidly obese do not develop type 2 diabetes, while 20% people with type 2 diabetes do not fulfil the conventional criteria to be called obese (Chan et al, 1994). Box 1 highlights common risk factors for type 2 diabetes.
The link between weight gain and type 2 diabetes, however, remains strong. It has been demonstrated that weight gain in adult life is significantly linked with high risk of type 2 diabetes and that weight loss of >5 kg can reduce the risk of type 2 diabetes by 50% (Colditz et al, 1995). The length of time that an individual is overweight has also been shown to be a significant influence, with the British Regional Heart Study showing that the longer a person is overweight, the higher their risk of developing type 2 diabetes (Wannamethee and Shaper, 1999). Furthermore, it has been found that central obesity is a powerful predictor of type 2 diabetes in both sexes. Although BMI is the dominant risk factor for type 2 diabetes, the condition is strongly correlated with waist circumference (Chan et al, 1994).
In both the US and Finnish Diabetes Prevention Programmes, weight loss was the most important determinant for reducing the risk of impaired glucose tolerance going on to develop diabetes (Kubaszek et al, 2003; Hamman et al, 2006).
The challenge in primary care
The importance of managing diabesity in a way that addresses both obesity and type 2 diabetes in unison is key. In primary care, this is highlighted through the common clinical characteristics of diabesity and the metabolic syndrome, such pro-coagulant and pro-inflammatory changes in the blood (Van Gaal et al, 2006), endothelial dysfunction (Jiang et al, 1999), renal disease (Sarnak et al, 2003), fatty liver disease, polycystic ovarian syndrome (Dunaif, 1997) and sleep apnoea (Vgontzas et al, 2000), thereby highlighting the linkage between body weight, type 2 diabetes, CV disease (CVD) and renal impairment. (CVD remains the main cause of death among Caucasian people with type 2 diabetes, where as non-caucasians are more likely to die from stroke or renal disease [Morrish et al, 2001].)
To successfully manage diabesity in primary care, we need to equip ourselves with essential tools, including:
New therapies for managing diabesity are in development, and bariatric surgery has proven successful when individuals are properly selected. However, pharmacotherapy is not a solution to all, and bariatric surgery is rationed due to locality and cost issues.
Conclusion
With diabesity affecting ever younger ages, the concern of an epidemic in cardiac, vascular and renal disease is very real, and will only increase the demands to be placed on the already limited NHS resources, particularly those within primary care. The emphasis now must be on addressing both diabetes and obesity in a systematic and complementary way, and not as two conditions in isolation. From the primary care perspective, we must look to develop specialist diabesity clinics, fully equipped to manage this burgeoning problem, and to the future, by focusing our attention on reducing the development of ill health by dealing with the source of the problem: the obesogenic state.
Obesity management is one of the biggest challenges facing primary care. It requires considerable time within a busy practice setting, demanding skills that the clinician may not have specialist training in, combined with a feeling that success may often be unlikely. If committed, it is unusual that the individual cannot lose weight and reap the associated health benefits, but maintenance of the weight lost is an issue and leaves many healthcare professionals feeling that this is a task with no solution.
A realistic approach to obesity management
Obesity therapy should be based on a comprehensive clinical assessment and review of both metabolic cardiovascular (CV) and locomotor risks. For some obese individuals, recognition, brief intervention and simple lifestyle advice may be all that is needed. For many, however, a more intensive programme is required, along with adequate long-term follow-up, to ensure that weight maintenance is sustained (Björvell and Rössner, 1992).
Both clinicians and obese individuals can have unrealistic expectations of weight reduction. When setting goals, it may not be necessary to aim for “ideal” weight but rather a goal of 5–10% weight reduction. A modest target may not only be attainable but will also yield a significant reduction in the risk of developing type 2 diabetes and CV problems (National Heart, Lung, and Blood Institute, 1998).
Complexities of coexistent obesity and type 2 diabetes
Obesity is strongly associated with type 2 diabetes and lipid disorders, which are both significant CV risk factors with other associated comorbidities.
The term “diabesity” reflects this close association between obesity and type 2 diabetes, and in a practical sense highlights the need for a unified approach to these two conditions. However, while obesity is estimated to account for 80% of the overall risk of developing type 2 diabetes (Wolf and Colditz, 1998), the condition is multifactorial in origin, and obesity is not the sole determinant. Indeed, 20–50% of those who are morbidly obese do not develop type 2 diabetes, while 20% people with type 2 diabetes do not fulfil the conventional criteria to be called obese (Chan et al, 1994). Box 1 highlights common risk factors for type 2 diabetes.
The link between weight gain and type 2 diabetes, however, remains strong. It has been demonstrated that weight gain in adult life is significantly linked with high risk of type 2 diabetes and that weight loss of >5 kg can reduce the risk of type 2 diabetes by 50% (Colditz et al, 1995). The length of time that an individual is overweight has also been shown to be a significant influence, with the British Regional Heart Study showing that the longer a person is overweight, the higher their risk of developing type 2 diabetes (Wannamethee and Shaper, 1999). Furthermore, it has been found that central obesity is a powerful predictor of type 2 diabetes in both sexes. Although BMI is the dominant risk factor for type 2 diabetes, the condition is strongly correlated with waist circumference (Chan et al, 1994).
In both the US and Finnish Diabetes Prevention Programmes, weight loss was the most important determinant for reducing the risk of impaired glucose tolerance going on to develop diabetes (Kubaszek et al, 2003; Hamman et al, 2006).
The challenge in primary care
The importance of managing diabesity in a way that addresses both obesity and type 2 diabetes in unison is key. In primary care, this is highlighted through the common clinical characteristics of diabesity and the metabolic syndrome, such pro-coagulant and pro-inflammatory changes in the blood (Van Gaal et al, 2006), endothelial dysfunction (Jiang et al, 1999), renal disease (Sarnak et al, 2003), fatty liver disease, polycystic ovarian syndrome (Dunaif, 1997) and sleep apnoea (Vgontzas et al, 2000), thereby highlighting the linkage between body weight, type 2 diabetes, CV disease (CVD) and renal impairment. (CVD remains the main cause of death among Caucasian people with type 2 diabetes, where as non-caucasians are more likely to die from stroke or renal disease [Morrish et al, 2001].)
To successfully manage diabesity in primary care, we need to equip ourselves with essential tools, including:
New therapies for managing diabesity are in development, and bariatric surgery has proven successful when individuals are properly selected. However, pharmacotherapy is not a solution to all, and bariatric surgery is rationed due to locality and cost issues.
Conclusion
With diabesity affecting ever younger ages, the concern of an epidemic in cardiac, vascular and renal disease is very real, and will only increase the demands to be placed on the already limited NHS resources, particularly those within primary care. The emphasis now must be on addressing both diabetes and obesity in a systematic and complementary way, and not as two conditions in isolation. From the primary care perspective, we must look to develop specialist diabesity clinics, fully equipped to manage this burgeoning problem, and to the future, by focusing our attention on reducing the development of ill health by dealing with the source of the problem: the obesogenic state.
Björvell H, Rössner S (1992) A ten-year follow-up of weight change in severely obese subjects treated in a combined behavioural modification programme. Int J Obes Relat Metab Disord 16: 623–5
Chan JM, Rimm EB, Colditz GA et al (1994) Obesity, fat distribution, and weight gain as risk factors for clinical diabetes in men. Diabetes Care 17: 961–9
Colditz GA, Willett WC, Rotnitzky A, Manson JE (1995) Weight gain as a risk factor for clinical diabetes mellitus in women. Ann Intern Med 122: 481–6
Dunaif A (1997) Insulin resistance and the polycystic ovary syndrome: mechanism and implications for pathogenesis. Endocr Rev 18: 774–800
Hamman RF, Wing RR, Edelstein SL et al (2006) Effect of weight loss with lifestyle intervention on risk of diabetes. Diabetes Care 29: 2102–7
Jiang ZY, Lin YW, Clemont A et al (1999) Characterization of selective resistance to insulin signaling in the vasculature of obese Zucker (fa/fa) rats. J Clin Invest 104: 447–57
Ko GT, Chan JC, Yeung VT et al (2001) A low socio-economic status is an additional risk factor for glucose intolerance in high risk Hong Kong Chinese. Eur J Epidemiol 17: 289–95
Kubaszek A, Pihlajamäki J, Komarovski V (2003) Promoter polymorphisms of the TNF-alpha (G-308A) and IL-6 (C-174G) genes predict the conversion from impaired glucose tolerance to type 2 diabetes: the Finnish Diabetes Prevention Study. Diabetes 52: 1872–6
Morrish NJ, Wang SL, Stevens LK et al (2001) Mortality and causes of death in the WHO Multinational Study of Vascular Disease in Diabetes. Diabetologia 44(Suppl 2): S14–21
National Heart, Lung, and Blood Institute (1998) Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NHLBI, Bethesda, MD, USA
Rana JS, Li TY, Manson JE, Hu FB (2007) Adiposity compared with physical inactivity and risk of type 2 diabetes in women. Diabetes Care 30: 53–8
Sarnak MJ, Levey AS, Schoolwerth AC et al (2003) Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention. Hypertension 42: 1050–65
Sawada SS, Lee IM, Muto T et al (2003) Cardiorespiratory fitness and the incidence of type 2 diabetes: prospective study of Japanese men. Diabetes Care 26: 2918–22
Shai I, Jiang R, Manson JE et al (2006) Ethnicity, obesity, and risk of type 2 diabetes in women: a 20-year follow-up study. Diabetes Care 29: 1585–90
Van Gaal LF, Mertens IL, De Block CE (2006) Mechanisms linking obesity with cardiovascular disease. Nature 444: 875–80
Vgontzas AN, Papanicolaou DA, Bixler EO et al (2000) Sleep apnea and daytime sleepiness and fatigue: relation to visceral obesity, insulin resistance, and hypercytokinemia. J Clin Endocrinol Metab 85: 1151–8
Wannamethee SG, Shaper AG (1999) Weight change and duration of overweight and obesity in the incidence of type 2 diabetes. Diabetes Care 22: 1266–72
Wolf AM, Colditz GA (1998) Current estimates of the economic cost of obesity in the United States. Obes Res 6: 97–106
Post-bariatric surgery care
Complications and considerations after bariatric surgery
Is a local tier 3 weight management service effective in supporting people with type 2 diabetes to lose weight?
Barriers facing people with obesity and type 2 diabetes in weight control: A systematic review
Cardiovascular outcome trials in type 2 diabetes – 2015
Freshman 15: Weight management at university
Should metformin be prescribed for pre-diabetes?
17 Dec 2015
16 Dec 2015
16 Dec 2015
16 Dec 2015