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Weight Loss in Diabetes: A Lost Cause?

Mike Huckabee was a 135-kg man when he was elected governor of Arkansas in 1998. His weight was too much that the steps of the Arkansas capitol were so long and steep that he would be out of breath and exhausted by the time he reached the top of the stairs. In his book Quit Digging Your Grave with a Knife and Fork, he recounts how he secretly feared that he would be interviewed by media at the top of the steps—and that he would be too out of breath to respond.

In 2003, Huckabee was diagnosed with type 2 diabetes, which, suffice to say, was partly due to his obesity. He even shared that his physicians informed him he would not live more than 10 years if he did not lose weight. Type 2 diabetes made quite an impact on Huckabee’s life in such a way that that he seriously considered losing weight to rid himself of the disease.

The subsequent death of former governor Frank D. White, whose obesity contributed to a fatal heart attack, made Huckabee consider eating a healthier diet and exercising. His efforts to lose over 110 pounds (50 kg), were so impressive that the New York Times described the rapid weight loss “…as if he simply unzipped a fat suit and stepped out.”

Huckabee’s story lends hope to many obese diabetic patients, but an important question must be addressed: is this something that everyone can do? Although it is common knowledge that obesity significantly contributes to the development of type 2 diabetes, not all obese people develop this condition. In fact, the American Diabetes Association reported that 50 percent of men and 70 percent of women are obese at the onset of diabetes; diabetes is diagnosed in nonobese individuals, and a number of obese people never develop type 2 diabetes.

The problem of obesity
Obesity is a serious worldwide problem. In their study published in 2004 in the New England Journal of Medicine, Parvez Hossain and colleagues noted that there were 1.1 billion overweight adults worldwide, 312 million of which were considered obese. This same study also noted that in the past 20 years, the rates of obesity have tripled in the Middle East, the Pacific Islands, Southeast Asia, India, and China—developing countries that adopted Western lifestyle.

As a consequence, the number of people with diabetes in these countries is also expected to increase, from 84 million in 2000 to 380 million by 2025 if nothing is done about it. Dr. Rosa Allyn Sy of the Cardinal Santos Medical Center, in her lecture during the 3rd PSEM Congress on Prediabetes and the Metabolic Syndrome, explained that obesity is a well-established risk factor for the development of insulin resistance, a condition that is believed to be the origin of type 2 diabetes.

Marion J. Franz stressed that preventing obesity is of high priority for the prevention of diabetes and other chronic diseases. “According to some obesity researchers, it may not be possible to decrease the current numbers of overweight and obese people in the United States, but we need to try to slow or prevent the increase that has been occurring at an alarming rate,” she writes.

The problem with weight loss Anybody who’s tried shedding pounds will attest (vehemently, I should add) how difficult it is to lose weight. To make matters worse, it is doubly difficult to maintain weight loss.

Dr. John P. Bantle of the University of Minnesota writes that energy intake, energy expenditure, and body weight are all centrally regulated by the hypothalamus—a small portion of the brain whose function is to link the nervous system to the endocrine system. “When we ask patients to restrict energy intake and increase energy expenditure through exercise to lose weight, we are asking them to override a powerful biological control system. This is something most people simply cannot do.”

In addition, Franz said that people with diabetes receive mixed messages about weight loss from magazines, newspapers, friends, family, and, yes, even health professionals. She explains that a prevailing mindset among patients is that losing weight is just a matter of willpower, and if they have been losing weight and reach a plateau, it’s because they’ve lost their willpower and are no longer following their prescribed diet. This couldn’t be farther from the truth.

Realistic goals
Achieving an ideal body mass index (BMI) is targeted by people with diabetes. But is this something that many patients can do? Are doctors failing to realize that ideal may not be achievable? In their meta-analysis of 80 studies, Franz et al. found that after 6 months of losing weight (mean loss of 5-8.5 kg) involving reduced-energy diets and/or weight-loss medications, weight loss reaches a plateau resulting in the dieters becoming discouraged and frustrated.

Does weight loss equate to improved glucose control?
“Should weight loss or improved blood glucose control be the focus of nutrition therapy for type 2 diabetes?” Franz asks. Her study found that achievable weight loss has only a modest effect on HbA1c levels. However, Dr. Bantle explained that modest decrement is better than no change at all. “If a type 2 diabetic patient loses 5 kg in 1 year, he or she can expect a decrement in HbA1c of 0.4%. This probably underestimates the effect of weight loss because, without intervention, one would expect a type 2 diabetes patient to demonstrate a modest increment in HbA1c in 1 year.”

But Franz explained that other nutritional interventions that tend to focus more on metabolic control and less on weight loss have been shown to improve HbA1c levels by 1-2 percent. She furthers that in the early course of diabetes (when insulin resistance is still prominent), calorie restriction or weight loss will improve blood glucose levels. “But as the disease progresses and insulin deficiency becomes more prominent, it may be too late for weight loss to be helpful.”

One cannot deny, though, the potential benefit of weight loss to managing diabetes, as epitomized by Mike Huckabee’s case. According Dr. Bantle, weight loss is an important therapeutic goal for type 2 diabetic patients. He said that if an overweight type 2 diabetic patient is able to lose weight, he or she can expect substantial health benefits, not only on glycemia, but also on cholesterol levels and blood pressure, conditions known to cluster (and worsen) type 2 diabetes. But the best dietary weight loss strategy has not yet been defined, said Dr. Bantle. “And all such strategies are compromised by the body’s potent methods of maintaining energy homeostasis and defeating weight loss.”

However, those who aim to lose weight and set themselves free of diabetes shouldn’t lose heart. In fact, setting realistic weight goals and aiming for moderation are generally the best approaches, according to Franz. “Eating fewer calories and getting regular physical activity improves blood glucose control independent of body weight and weight loss.”

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