Lifestyle changes that help patients with newly-diagnosed type 2 diabetes to improve glycaemic control and other risk factors for cardiovascular disease by losing weight are the starting point for diabetes therapy.2,3,4
Consequences of additional weight gain in overweight patients
Excess weight is an independent risk factor for cardiovascular disease, even in individuals without diabetes.5 Based on a comprehensive review of the literature, researchers have estimated that every kilogram of weight gained in adulthood increases the projected risk for coronary heart disease by 3-6% among the general population.6 For every unit of BMI gained, the risk increases by 9-16%.7
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Projected coronary heart disease (CHD) risk increase associated with weight gain7
CHD= Coronary Heart Disease
Figures are based on the general population and are not specific to
individuals with type 2 diabetes
Adapted from Anderson J et al., 2001.7
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Weight gain may undermine the benefits of improved glycaemic control8 and its psychological effect may reduce the patient's willingness to adhere to the treatment regimen, further risking hyperglycaemia and complications associated with it.
By contrast, even modest weight loss can improve insulin resistance, glycaemic control and cardiovascular risk profile.9,10 This shows how support promoting weight loss behaviour is crucial. In the Look AHEAD study, patients with type 2 diabetes who received intensive lifestyle intervention lost 12-times as much of their initial weight as patients who received diabetes support and education. A greater proportion of these patients saw improvements in diabetes, hypertension and dyslipidaemia.11
Why do people on insulin gain weight?
There are several factors thought to influence weight gain with insulin:
- Defensive eating to prevent or avert hypoglycaemia12
- Reduced calorie 'wastage' (glycosuria)13
- Anabolic effects14
- Insulin may be acting on the central nervous system to influence food intake15
The need for further intensification can therefore raise dilemmas for physicians as they seek to balance the need for improved glycaemic control with concern about side effects such as weight gain and hypoglycaemia, and this may make them reluctant to proceed. In patients strive to control their weight, the prospect of weight gain associated with therapy is demotivating and may compromise efforts to protect against cardiovascular disease.5
This can be ameliorated by keeping up with lifestyle interventions, by adding pharmacological therapy for weight gain and by choice of insulin.2,3
References
1American Diabetes Association. Standards of medical care in diabetes - 2010. Diabetes Care 2010; 33(Suppl 1): S11-S61.
2International Diabetes Federation guidelines: Global guidelines for type 2 diabetes 2005. Available at: http://www.idf.org. Accessed 21 January 2010.
3Nathan DM, Buse JB, Davidson MB et al., Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy. A consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2009; 32: 193-203.
4Hughes TA, Gwynne JT, Switzer BR, Herbst C, White G. Effects of caloric restriction and weight loss on glycemic control, insulin release and resistance, and atherosclerotic risk in obese patients with type II diabetes mellitus. Am J Med 1984; 77: 7-17.
5Hubert HB, Feinleib M, McNamara PM et al., Obesity as an independent risk factor for cardiovascular disease: a 26-year follow-up of participants in the Framingham Heart Study. Circulation. 1983; 67(5): 968-977.
6Nauck M, Frid A, Hermansen K, et al., For the LEAD-2 Study Group. Efficacy and safety comparison of liraglutide, glimepiride, and placebo, all in combination with metformin, in type 2 diabetes: the LEAD (liraglutide effect and action in diabetes)-2 study. Diabetes Care. 2009; 32(1): 84-90.
7Anderson J et al., Obesity and disease management: effects of weight loss on comorbid conditions. Obesity Research 2001; 9 (Suppl 4): 326S-334S.
8Hermansen K, Mortensen LS. Bodyweight changes associated with antihyperglycaemic agents in type 2 diabetes mellitus. Drug Safety. 2007; 30(12): 1127-1142.
9Wing RR, Koeske R, Epstein LH, et al., Long-term effects of modest weight loss in type II diabetic patients. Arch Intern Med 1987; 147: 1749-1753.
10Williamson DF, Thompson TJ, Thun M. Intentional weight loss and mortality among overweight individuals with diabetes. Diabetes Care 2000; 23: 1499-1504.
11Wadden TA, West DS, Neiberg R et al., One-year weight losses in the Look AHEAD study: factors associated with success. Obesity 2009; 17(4): 713-722.
12Carver C. Insulin treatment and the problem of weight gain in type 2 diabetes. Diabetes Educ 2006; 32(6): 910-917.
13Russell-Jones D, Khan R. Insulin-associated weight gain in diabetes - causes, effects and coping strategies. Diabetes, Obesity and Metabolism 2007; 9: 799-812.
14Heller S. Weight gain during insulin therapy in patients with type 2 diabetes mellitus. Diabetes Res Clin Pract 2004; 65: S23-S27.
15Kaiyala KJ, Prigeon RL, Kahn SE et al., Obesity induced by a high-fat diet is associated with reduced brain insulin transport in dogs. Diabetes 2000; 49(9): 1525-1533.