Weight Management Using a Meal Replacement Strategy in Type 2 Diabetes

The growing prevalence of diabetes parallels the increased prevalence of obesity. Overweight and obese individuals with diabetes who attempt weight reduction face considerable challenges. However, several recent studies showed that weight reduction in patients with diabetes is feasible using a multidisciplinary approach that incorporates structured dietary intervention and meal replacements (MRs). Nutritionally complete MRs are shown to be useful at the start of weight reduction programs and for weight maintenance because of their nutrition adequacy. However, patients using this approach need to monitor their blood glucose levels closely and may need to adjust their diabetes medications. Most commercial MRs are currently fortified with vitamins and minerals to prevent long-term deficiency in essential micronutrients that are commonly seen in low-calorie diet plans. They also come in different flavors and formats that improve their general acceptability. To successfully initiate weight loss, MRs are generally used as absolute replacement of an agreed upon number of meals/snacks. This article covers the use of MRs for patients with diabetes for short-term and long-term weight reduction in clinical trials and real-world clinical practice.     

A Patient-centered Approach to Managing Patients with Type 2 Diabetes

Despite the availability of a number of therapeutic options, management of type 2 diabetes (T2DM) and hyperglycemia remains suboptimal. Evidence shows that physicians are not adequately individualizing incretin-based therapies as there is lack of clear understanding of the similarities and differences between various incretin-based therapies. Additionally, sodium-dependent glucose co-transporter 2 (SGLT2) inhibitors, a very recent addition to the therapeutic armamentarium, are not adequately utilized in managing patients with T2DM due to a lack of awareness or an increased concern regarding their safety, efficacy, and the mechanism of action. Insulin therapy is also not initiated or intensified appropriately due to a lack of clear understanding on when to add and how to intensify them and, more importantly, due to fear of increasing the risk of hypoglycemia in patients. To address these gaps, in the first section of this educational activity, the expert faculty will review the current understanding of the risks associated with hypoglycemia—one of the main factors that limit the successful use of insulin therapy—and when to initiate insulin therapy, as well as the available data on the risk of hypoglycemia with emerging agents. The expert faculty will also provide practical strategies on how to minimize the risk of hypoglycemia in patients. In the second section, the expert faculty will highlight the differences between the various incretin-based therapies in addition to providing strategies for physicians to individualize their choice of incretin-based therapy. The expert faculty will also review the mechanism of action, safety, efficacy, and the appropriate place for this class of therapies in the treatment continuum. In the third section, the expert faculty will discuss the mechanism of action, safety, and efficacy of the currently available SGLT2 inhibitors as well as the appropriate use of these newer agents in T2DM management.This CME Multimedia Activity is also available through the Website of The American Journal of Medicine (www.amjmed.com). Click on the CME Multimedia Activity button in the navigation bar for full access. Or access: www.elseviercme.com/537.     

Insulin Therapy and Type 2 Diabetes: Management of Weight Gain

The potential for insulin-related weight gain in patients with type 2 diabetes presents a therapeutic dilemma and frequently leads to delays in the initiation of insulin therapy. It also poses considerable challenges when treatment is intensified. Addressing insulin-related weight gain is highly relevant to the prevention of metabolic and cardiovascular consequences in this high-risk population with type 2 diabetes. In addition to lifestyle changes (eg, diet and exercise) and available medical interventions to minimize the risk of weight gain with insulin treatment, familiarity with the weight gain patterns of different insulins may help deal with this problem. The use of basal insulin analogs may offer advantages over conventional human insulin preparations in terms of more physiologic time-action profiles, reduced risk of hypoglycemia, and reduced weight gain.     

Dysphagic Patients with Tracheotomies: A Multidisciplinary Approach to Treatment and Decannulation Management

In 2000 a multidisciplinary protocol for weaning dysphagic patients from the tracheotomy tube and a decannulation decision chart created according to principles of the F.O.T.T.((R)) Concept (Face and Oral Tract Therapy) were introduced in the Swiss Neurological Rehabilitation Centre REHAB in Basel. In the present study we introduce these guidelines and present an evaluation of the treatment and decannulation procedure. We retrospectively compared data from patients before and after introduction of the multidisciplinary procedure with regard to mean cannulation times and success of decannulation. Furthermore, we analyzed the rehabilitation progress of the group who underwent multidisciplinary treatment as well as the participation of the speech language therapist. The results show that the treatment introduced to improve swallowing functions and wean patients from the tracheotomy tube led to a fast and safe decannulation of our patients. The mean length of cannulation time was reduced significantly. After decannulation the patients showed clear functional improvements. Interdisciplinary treatment using the approach discussed in this study can be considered efficient and an important basis for further functional progress in the rehabilitation process.     

A Comprehensive Cardiovascular-Renal-Metabolic Risk Reduction Approach to Patients with Type 2 Diabetes Mellitus

Despite decades of research into risk-reduction strategies, cardiovascular disease and renal disease remain leading causes of morbidity and mortality among patients with type 2 diabetes mellitus. Given the tight clustering of cardiovascular and renal disease with the metabolic abnormalities of type 2 diabetes mellitus, we can think of these conditions together as cardiovascular-renal-metabolic disease states. A holistic view of cardiovascular-renal-metabolic disease states is critical to provide integrated patient-centered care to individuals with these disease states. Here, we explore the cardiovascular and renal risks associated with type 2 diabetes mellitus and highlight the importance of reducing cardiovascular-renal-metabolic disease risk in a comprehensive manner. We advocate a cross-disciplinary, team-based model to manage cardiovascular-renal-metabolic disease risk among patients with type 2 diabetes mellitus.     

Fat Versus Carbohydrate-Based Energy-Restricted Diets for Weight Loss in Patients With Type 2 Diabetes

Purpose of Review

The prevalence of combined obesity and diabetes has increased dramatically in the last few decades. Although medical and surgical weight management are variably effective in addressing this epidemic, it is essential to parallel these strategies with a hypocaloric diet comprising the appropriate macronutrient composition to induce weight loss, enhance glycemic control, and improve cardiovascular risk factors. This review reports the current evidence of the role of carbohydrates and fat-based diets for weight management in patients with combined type 2 diabetes (T2D) and obesity.

Recent Findings

Low-carbohydrate diets were shown to decrease postprandial glucose levels whereas high-carbohydrate, low-fat diets are considered cardio-protective.

Summary

A diet with an optimal macronutrient composition remains uncertain for patients with combined T2D and obesity. Further research is still needed to define the best dietary composition that achieves the maximum benefits on weight management, glycemic control, and cardiovascular risk factors.

     

Biopsychosocial Aspects of Weight Management in Type 1 Diabetes: a Review and Next Steps

Purpose of Review

This review aims to summarize the type 1 diabetes (T1D) and weight literature with an emphasis on barriers associated with weight management, the unique T1D-specific factors that impact weight loss success, maladaptive and adaptive strategies for weight loss, and interventions to promote weight loss.

Recent Findings

Weight gain is associated with intensive insulin therapy. Overweight and obese weight status in individuals with T1D is higher than the general population and prevalence is rising. A variety of demographic (e.g., female sex), clinical (e.g., greater insulin needs), environmental (e.g., skipping meals), and psychosocial (e.g., depression, stress) factors are associated with overweight/obese weight status in T1D. Fear of hypoglycemia is a significant barrier to engagement in physical activity. Studies evaluating adaptive weight loss strategies in people with T1D are limited.

Summary

There is a growing literature highlighting the prevalence and seriousness of overweight and obesity among both youth and adults with T1D. There is an urgent need to develop evidence-based weight management guidelines and interventions that address the unique concerns of individuals with T1D and that concurrently address glycemic control.

     

Cost Effectiveness Analysis of a Hypertension Management Program in Patients With Type 2 Diabetes

Hypertension is a costly disease; however, the investment needed for a cost-neutral hypertension management program (HMP) is unknown. A Markov decision analytic model simulated the outcomes of a hypothetical HMP. Patients were between the ages of 25 and 65 years, had existing hypertension, and were newly diagnosed with diabetes. The control group received standard care. The HMP group received standard care and were enrolled in an HMP. Data regarding rates of disease states and costs were gathered from the literature. A third-party payer can invest as much as $159, $109, and $41 per person per month in an HMP for a neutral return on investment in the 5-year, 3-year, and 1-year time horizon, respectively. The HMP group achieved greater gains in quality-adjusted life-years and lower total health-related costs. As the time horizon increases, more money can be invested. HMPs can be a cost-effective and cost-neutral proposition.     

健康干预对社区2型糖尿病患者生活质量的影响

目的探讨健康干预对社区2型糖尿病患者生活质量的影响。方法采用调查问卷方式对社区健康服务中心182例糖尿病患者糖尿病知识、自我护理能力、糖尿病代谢各种自控指标、生活满意度进行健康管理前后的评估,同时根据评估情况进行个性化健康管理。结果健康干预前后患者的自我护理能力,糖尿病知识知晓率及总评分,糖尿病代谢自控指标、生活满意度均有明显提高(P0.01)。结论健康干预的实施能有效改善被管理人员的整体健康状况和生活质量。     

健康管理干预对社区2型糖尿病患者生活质量的效果评价

目的探讨健康管理干预对社区2型糖尿病患者生活质量的影响。方法采用调查问卷方式对21家社区健康服务中心182例糖尿病患者的糖尿病知识、自我护理能力、糖尿病代谢各种自控指标、生活满意度进行健康管理前后的评估,同时根据评估情况进行个性化健康管理。结果干预前后182例糖尿病患者糖尿病基本知识、并发症预防知识及检查治疗知识、空腹血糖、餐后2h血糖、末梢血血糖间差异均有统计学意义（P〈0．01）。干预前、后患者定期监测血糖、足部自我检查率间差异均有统计学意义（P〈0．01）。干预前后患者体力健康、精神健康、总体功能及总分、生活满意度差异均有统计学意义（P〈0．01）。结论健康管理的实施能有效改善2型糖尿病患者的整体健康状况和生活质量。     

Managing Type 2 Diabetes Mellitus in Patients with Obesity

Obesity is the most important modifiable risk factor for type 2 diabetes mellitus and most patients with diabetes are overweight or obese. It is well known that excess bodyweight induces or aggravates insulin resistance, which is a characteristic feature of type 2 diabetes. Thus, bodyweight plays a central role in the prevention and treatment of diabetes. Recent data suggest that lifestyle intervention in patients with impaired glucose tolerance results in an impressive reduction in the conversion to overt diabetes, which is greater than the effect of early intervention with drugs such as metformin or acarbose. The prevention of diabetes has been shown to be associated with the extent of weight loss. In patients with type 2 diabetes, weight loss by any means is followed by an improvement of metabolic control and associated risk factors. The most appropriate recommendation for obese patients with type 2 diabetes is a nutritionally balanced, moderately hypocaloric diet with a reduced intake of saturated fat and an increase in physical activity. If this standard approach is only partly successful or not at all, additional strategies such as weight-lowering drugs, very low-calorie diets for limited periods of up to 12 weeks, and, for severely obese patients, bariatric surgery should be carefully considered. A large body of data suggests that such measures can be very effective in this patient group by improving metabolic disturbances and blood pressure. However, it is extremely important for the long-term outcome that the treatment is tailored to the needs and wishes of the individual patient. There is growing agreement that due to the low success rate of conventional therapies and the overwhelming benefit from weight loss, more determined and aggressive strategies may be appropriate to achieve the central goal of weight reduction in obese patients with type 2 diabetes.     

Postprandial Hyperglycemia in Patients with Type 2 Diabetes Mellitus

The role of postprandial hyperglycemia (PPHG) in diabetes mellitus is being increasingly recognized. It is known that PPHG contributes to the increased risk of both micro- and macrovascular complications in patients with diabetes mellitus. This review looks at the clinical significance of PPHG and the currently available therapeutic modalities. The causes of PPHG are influenced by many factors which include a rapid flux of glucose from the gut, impaired insulin release, endogenous glucose production by the liver and peripheral insulin resistance. Knowledge of the pathophysiology of PPHG is essential when adopting treatment options to tackle the problem. Although most oral antihyperglycemic agents and insulins lower both fasting and postprandial blood glucose levels, drugs are now available which specifically act to control PPHG. These drugs may be classified based on the site of their action. alpha-Glucosidase inhibitors like acarbose and miglitol attenuate the rate of absorption of sucrose by acting on the luminal enzymes. Adverse effects of these agents are predominantly gastrointestinal. Newer insulin secretagogues have been developed which attempt to mimic the physiological release of insulin and thus ameliorate PPHG. These include third generation sulfonylureas like glimepiride and nonsulfonylurea secretagogues like repaglinide and nateglinide. Rapid-acting insulin analogs, the amino acid sequences of which have been altered such that they have a faster onset of action, help to specifically target PPHG. Pre-mixed formulations of the analogs have also been developed. Finally, drugs under development which hold promise in the management of patients with PPHG include pramlintide, an amylin analog, and glucagon-like peptide-1 and its analogs.     

Risk vs Benefit in Diabetes Pharmacotherapy: a Rational Approach to Choosing Pharmacotherapy in Type 2 Diabetes

Type 2 diabetes now affects more than 1 in 10 US adults and is a leading cause of morbidity, mortality, and healthcare expense. There are increasing numbers of available pharmacotherapies, with established agents as well as newer drugs developed from hormones in the incretin pathway, among others. New data are accumulating continuously with respect to potential benefits of both long-standing and new agents, as well as risks identified through post-marketing surveillance. Here we review the commonly prescribed pharmacotherapy options with attention to recently published information and provide a rational approach to choice of therapy.     

体质量变化对老年2型糖尿病患者代谢的影响

目的观察住院老年2型糖尿病超重患者体质量变化对营养代谢的影响。方法收集本院2004年—2005年进入营养治疗的体质指数≥24kg/m2的老年2型糖尿病86例,根据营养治疗结束时体质量变化分为A组(体质量下降)、B组(体质量无变化)、C组(体质量上升)。对比3组患者体质量、体质指数与空腹血糖(FPG)、餐后2h血糖(2hPPG)、三酰甘油(TG)、总胆固醇(CH)、总蛋白、白蛋白代谢关联性。结果组内比较:A组FPG、2hPPG、TG、CH和B组FPG、2hPPG下降差异有统计学意义(P0.05)。组间比较:治疗后A组2hPPG、TG、CH低于B组,差异有统计学意义(P0.05);A、B组CH低于C组,差异有统计学意义(P0.05)。结论体质量超标的老年糖尿病患者血糖、血脂的变化与体质量变化相一致,体质量降低,血糖、血脂恢复理想。     

Diabetes Care in South Asian and White European Patients with Type 2 Diabetes

Aspects of diabetes care in South Asian and white European patients with Type 2 diabetes attending a hospital review clinic were explored. Among the clinic population of 1710 patients, 25B (15%) were of South Asian origin. A significantly greater proportion (95% CI for difference in proportions 8–22%) of these patients was treated with oral hypoglycaemic drugs than in white Europeans, in whom there was a correspondingly greater proportion receiving insulin treatment. In a case-control study, where 154 patients in each racial group were stratified according to treatment regimen, significantly more South Asian patients (13/30 vs 6/30, p < 0.05) on insulin were treated with a once-daily regimen. Despite these observed differences in treatment of diabetes, glycaemic control was no worse in South Asian patients when compared to their white European counterparts. South Asian diabetic patients attending hospital diabetes clinics in the UK can experience similar levels of glycaemic control to white Europeans.     

氯沙坦对Ⅱ型糖尿病肾病患者的肾脏和心血管疾病的影响

背景　糖尿病肾病可导致终末期肾病 ,阻断肾素 -血管紧张素系统可以减慢Ⅰ型糖尿病肾病患者病情的恶化 ,但尚未在Ⅱ型糖尿病病人中得到同样的结果。本文作者评价ＡｎｇⅡ受体拮抗剂对Ⅱ型糖尿病肾病的作用 ,还将评价氯沙坦对心血管疾病、尿蛋白和肾病恶化发病率和死亡率的影响。方法　一项多国、双盲、随机、安慰剂对照研究中 ,评价ＡｎｇⅡ受体拮抗剂氯沙坦对Ⅱ型糖尿病肾病患者的肾保护作用。在 2 8个国家 2 5 0个研究中心 ,共有 15 13例Ⅱ型糖尿病肾病患者参与此项研究。在为期 6周的筛选期间 ,病人仍接受常规的抗高血压治疗 ,并根据尿蛋…     

Diabetic Renal Disease in Patients with Type 2 Diabetes Mellitus

Over the last 35 years an increasing number of patients with type 2 diabetes mellitus have developed advanced renal disease and the need for dialysis. At present in the US, about 50% of the patients in dialysis units have type 2 diabetes mellitus. The explanation for the increase in the number of patients with type 2 diabetes mellitus in end-stage renal disease programs is not completely clear, but the overall number of patients with this type of diabetes is rapidly increasing - and is expected to continue to increase over the next years. The diagnosis of renal disease in type 2 diabetes mellitus is usually straightforward, and is mainly dependent upon measurements of urinary albumin or urinary protein excretion as well as serum creatinine measurements. Renal biopsies or exact glomerular filtration rate measurements are rarely necessary. Microalbuminuria is the first sign of renal disease in diabetes mellitus. It predicts overt nephropathy and cardiovascular disease. Several studies document that albuminuria and microalbuminuria can be reduced by treatment with antihypertensives, especially agents that block the renin angiotensin system. New studies show that end-stage renal disease can be postponed by the use of angiotensin II receptor antagonists. ACE inhibitors are also useful, and dual blockade of the renin angiotensin system has been utilized as well. However, generally speaking, patients with proteinuria have a poor prognosis. Screening for microalbuminuria is therefore proposed, and glycemic control and blood pressure should be optimized.