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Diabetes and Obesity

Diabetes - Obesity and Metabolic Syndrome

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Introduction

Obesity is more strongly related to the onset of type 2 diabetes than hypercholesterolemia to coronary artery disease or smoking to bronchial carcinoma.

The presentation of obesity with metabolic syndrome increases the risk of cardiovascular disease & its complications four fold.

Obesity also increases the risk of various common cancers in humans by 1.5 to 2 fold. Obesity also predisposes to the following conditions.

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Osteoarthritis

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Cholelithiasis

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Infertility due to its association with Polycystic Ovarian Syndrome

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Sleep Apnoea

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Depression

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Poor quality of life & premature mortality

Obesity also has serious economic costs. Treatment may seem expensive but is cost effective. NICE has issued guidance on the management of obesity.

 

Prevalence

Prevalence of adult obesity has trebled in England over the last 20 years

 MenWomen
19808%6%
200223%22%

Obesity is seen with increasing age, more in lower socio-economic and lower income groups, and more so in particular ethnic groups like Asian women and African-Caribbeans.

 Definition of Obesity
 WHO defines Obesity as:
Overweight: BMI over 25kg/m2
Obesity: BMI of over 30kg/m2.
Morbid Obesity:BMI over 40kg/m2.  
 WHO also recommends a limit for waist circumference of
  • 102cms for men
  • 88cms for women.
 

However the International Diabetes Federation has proposed the following waist circumference thresholds:

Europids:
Men 94 cm (37 in)
Women80 cm (31.5 in)
South Asians or Chinese:
Men90 cm (35.4 in)
Women80 cm (31.5 in)
 Definition of Metabolic Syndrome
 

The International Diabetes Federation defines Metabolic Syndrome as

High waist circumference

plus any two of following conditions

Hypertension

(>130/>85mmHg)

Low HDL

Men < 1.0 mmol/L

 

Women <1.3 mmol/L

High Triglycerides

>1.7 mmol/L

Impaired glucose tolerance or diabetes

Fasting blood sugar >5.6 mmol/L or type 2 diabetes

 

However, health risks of increased body fat rise progressively above BMI levels of 20-22kg/m2 in all populations.

 Relationship between Obesity and Diabetes

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Increased risk of diabetes

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Weight gain leads to development of insulin resistance

Impact on diabetes control 5-10 % weight loss will achieve significant improvement in overall diabetes control and other cardiovascular risk factors. Even modest weight reduction can markedly reduce the risk of development of diabetes in susceptible individuals.

Deterioration of glycaemic control is generally associated with unintentional weight loss in diabetes.

Improvement of glycaemic control generally results in weight gain unless preceded by appropriate education & empowerment of patients.

Exercise, dietary calorie & carbohydrate restriction and a correct understanding of action of diabetes medication can reduce the amount of weight gained with hypoglycaemic therapies

Use of newer hypoglycaemic agents such as GLP1 agonists is the only treatment for type 2 diabetes that often causes significant weight loss

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Factors that influence Outcome of Obesity Interventions

Outcome of any obesity intervention depends on following key factors

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Patients motivation/expectation

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Diet

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Exercise (See - Exercise & Physical Activity)

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Co-morbidities

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Other lifestyle issues, occupation, smoking, alcohol

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Psychological barriers

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Past history of obesity interventions and outcomes

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Incorrect health beliefs

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Timely & appropriate therapeutic interventions

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Principles of Management of Obesity

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Goal Setting

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Adjustment of Hypoglycaemic medication – acute reduction in calorie intake can lead to dramatic improvement of glycaemic control requiring concomitant reduction of hypoglycaemic medication (eg Insulin or SU) to avoid weight gain triggered by hypoglycaemia.

Non-pharmacological

Dietary interventions  such as Counterweight and Shape Up

Exercise increases calorie expenditure and insulin sensitivity

Commercial programmes (eg, Weight Watchers, Rosemary Conley  etc)

Psychological assessment & support

 

Patients in Beds & Luton can access Slimming World and Weight Watchers programmes without charge for 10- 12 weeks via specific referral forms

ESTA (North Beds Only)

ESTA stands for Eat Smart Think Active. It is a weight management programme designed for people with type 2 diabetes. ESTA helps participants to manage their weight while keeping control of their diabetes through fun and interactive activities.

PDF File Eat Smart Think Active (ESTA) information leaflet
PDF File Eat Smart Think Active (ESTA) referral form
   
Lifestyle Hub for North and Central Beds
The Lifestyle Hub offers several referral programmes. Train staff assess patients and signpost them to the most appropriate and suitable programme. They also front line advice on healthy eating and practical ways to get physically active.

PDF File Lifestyle Hub Referral Form
The programmes that the lifestyle hub refered to include, but are not limited to:
   
  Weight Watchers
  Slimming World
  Exercise on Referral
  Imperative Health Online
  Let’s Get Moving
  Opportunistic signposting for
  Stop Smoking
  Carers in Bedfordshire
  Drugs & Alcohol Liaison Group
  
  Luton PCT Obesity Strategy
 Principles of Steady Weight Loss

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A steady weight loss is better than a ‘crash diet’

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Aim for ½ kg weight loss a week

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Reducing food intake by mere 500 kcal/day can cause a steady ½ kg weight loss/week

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500 kcal roughly is:

2 pints of beer, or

1 packet of crisp + 5 digestives, or

8oz steak

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Exercise or increased physical activity alone seldom achieves sufficient weight loss unless combined with reduced calorie intake.

 

General Guide to Weight Loss

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Eat regular meals

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At least 5 portions of fruit and vegetable a day

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Mainstay of meals should be carbohydrates from high fibre food (wholemeal products)

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Aim for steady weight loss – ½ to 1 kg a week

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Have realistic targets 5–10% of starting weight rather than ‘normal’ weight

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Look out for ‘visible fat’ in food

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Follow general health measures

Stop smoking

Take regular exercise

Increase activity – stairs, not lifts; carry basket, not trolleys; farthest parking space, not the nearest one.

Reduce salt intake

Reduce alcohol intake

 Pharmacological Interventions in Obesity

If a patient loses significant amounts of weight through any means their diabetes medication will need to be reviewed and may need to be reduced.

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Orlistat

Orlistat prevents the absorption of fat molecules in the intestinal tract.  If excess fat is consumed the fat that would have otherwise been absorbed passes through the gut leading to ‘fatty stool’.

Side effects:

Rarely it can reduce absorption of fat soluble vitamins (A, D, E, K) needing supplementation.

Contraindication:

Chronic malabsorption, cholestasis, pregnancy and breast-feeding.

Patient selection:

Diabetics with BMI over 28kg/m2.

Patients should have simultaneous dietary and lifestyle advice.

Recommended age 18-75yrs.

Weight loss criteria have been removed

Dosage:

120 mg three times a day before, during or within an hour of a main meal (maximum 360mg / day). Omit if a meal is omitted.

Monitoring

Ongoing weight loss needs to be documented. Reachable targets are 5% loss in 3 months and 10% in 6 months. Orlistat is not licensed for use beyond 2 years. On stopping Orlistat, there may be a gradual weight gain. 

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Bariatric Surgery

The Morbid obesity surgery service is centrally managed by the East of England Specialised Commissioning team.

Criteria for Referral:

Patients should have undergone all appropriate primary care interventions as per PCT obesity management care pathway before referral.

Patients with a BMI >40 with Type 2 diabetes and / or severe sleep apnoea, aged 18-60 years can be referred for surgery.

Patients who do not meet EoESCG criteria can be referred to Exception Treatment Panel for grant of permission / funding for bariatric surgery on exceptional grounds.

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Referral for Specialist Obesity Services

The Luton and Dunstable Hospital Obesity Service is the local provider for this service.

Management of Obesity is now divided into 4 levels

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Level 1 & Level 2 care needs to take place in the community: care pathway awaiting finalisation.

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Level 3 care require assessment & management by a specialist team (secondary care)

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Level 4 care is provided by centres which can deliver bariatric intervention for patients who have failed to achieve desired weight loss despite level 3 care and meet EoESCG criteria

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EoESCG criteria for bariatric intervention is reserved for those individuals who despite full compliance to Level 1-3 care still have

BMI > 40   plus a

Co-morbidity either diabetes or severe sleep apnoea.

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Useful External Resources / Links

PDF FileLuton PCT Obesity Strategy - 2009 to 2014
PDF File Slimming World Referral Form 2013
PDF File Weight Watchers Referral Form 2013
PDF File Lifestyle Hub Referral Form
PDF File Eat Smart Think Active (ESTA) information leaflet
 

PDF File

Eat Smart Think Active (ESTA) referral form

View

NICE Guidance on the Management of Obesity - CG43 2006

The NICE clinical guideline on the prevention, identification, assessment and management of overweight and obesity in adults and children.

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