---

Obesity Treatment: The Key to Managing the Type 2 Diabetes Time bomb?

Obesity Treatment: The Key to Managing the Type 2 Diabetes Time bomb? -- Posted by Gumbo on 10-29-04 05:07

Obesity Treatment: The Key to Managing the Type 2 Diabetes Time bomb?
Posted 10/11/2004

John Wilding, Guest Editor

Introduction
The readership of this journal will be well aware that the epidemic of
type 2 diabetes and associated vascular disease threatens to overwhelm
health services worldwide over the next two decades. This is particularly
the case in some countries in the developing world, but even in the USA, the
rising costs of treating diabetes and vascular disease are likely to
contribute to the projected bankruptcy of the Medicare budget by the year
2019,[1] and in the UK the costs of treating diabetes and its complications
are already at least 9% of the total health costs of running the NHS,[2] and
set to rise further if nothing is done.

The Role of Obesity, Lifestyle and Genetics
There is now ample epidemiological evidence that the majority of cases
of type 2 diabetes are related to obesity, physical inactivity and other
lifestyle factors such as smoking.[3,4] Type 2 diabetes is characterized by
insulin resistance and progressive beta-cell failure, and is associated with
a host of other abnormalities that comprise the metabolic syndrome, as
reviewed by Jayapaul and Walker in this issue of the journal.[5] Whilst the
importance of genetic background should not be underestimated, and may be
particularly important in determining appropriate treatment for some
individuals,[6] lifestyle factors are clearly the major modifiable risk
factors for the development of glucose intolerance and associated vascular
disease in the population.

Delay and Prevention of Type 2 Diabetes
There is now clear and overwhelming evidence that type 2 diabetes can
be delayed or prevented in subjects with impaired glucose tolerance by
lifestyle changes accompanied by weight loss of just 4-5% of body
weight.[7,8] There is also evidence for efficacy of specific oral
hypoglycaemic drugs including acarbose, metformin and thiazolidinediones,
but in general the effects of these agents have been less in the clinical
trials than was seen with lifestyle intervention.[8-10] The addition of
drugs to help with weight loss, specifically orlistat, was demonstrated in
the recently published Xendos trial, which showed an additional reduction in
the risk of developing diabetes of 45% over and above that achieved by
lifestyle intervention in those patients with impaired glucose
tolerance.[11] Finally, there is also evidence from surgical studies of
weight loss that type 2 diabetes can be prevented in morbidly obese patients
treated with a variety of surgical procedures.[12,13]

The NSF for Diabetes has as its first standard that "The NHS will
develop, implement and monitor strategies to reduce the risk of developing
type 2 diabetes in the population as a whole, and reduce the inequalities
and the risk of developing type 2 diabetes." Given the evidence that
targeted intervention in high-risk groups is effective at delaying or
preventing diabetes, I will next consider the barriers that are currently
preventing implementation of standard 1 of the NSF for diabetes.

Identifying Those at Greatest Risk
Tringham and Davies discuss the issue of screening for IGT and
diabetes in some detail; they focus on the issue of screening for impaired
glucose tolerance, highlight the impracticalities of carrying out widespread
glucose tolerance testing and propose the use of various screening
assessment tools that have been developed to identify patients with diabetes
and other degrees of glucose intolerance.[14] The problem with the majority
of these tools is that they have only been validated from single
populations, mostly in the context of screening for diabetes, and require
validation in other settings before their use can be generally applied.
Nevertheless, this approach does seem an attractive way of enriching the
population of individuals who are likely to benefit from screening, although
there will inevitably be some false negative and false positive results.

Deciding the Best Strategy to Prevent Diabetes
Assuming an effective screening strategy can be implemented, it is
important to consider which of the many proven interventions would be most
appropriate. In a review in this edition of the journal, Banerjee and
Cruickshank discuss the concept of 'pre-diabetes' and highlight the fact
that early stages of diabetes including impaired fasting glucose and
impaired glucose tolerance are not only markers of the prediabetic state,
but are also associated with increased vascular risk in their own right.[15]
It remains unclear whether the interventions that have been shown to prevent
diabetes in these pre-diabetic states are also effective in dealing with the
associated vascular disease, although most of the published studies do show
expected improvements in risk factors. The choice of approach may also
involve a consideration of effects on other risk factors, as well as
progression to diabetes.

The least contentious interventions are those which that encourage
lifestyle change and weight management; these would require considerable
resources to implement, although they are likely to be cost-effective.[16]
The use of meal replacements in those who do not respond, and the addition
of drugs such as orlistat have also been proven efficacious.[7,8,11] The use
of specific anti-hyperglycemic pharmacological intervention should not be
dismissed however, as there is preliminary evidence that agents such as
thiazolidinediones may have effects that alter the natural history of the
disease, and also influence other risk factors, although weight gain can be
a problem with this class of drugs.[9,17,18] In the most severely obese
patients with morbid obesity, other co-morbidities are frequently present,
thus strengthening the case for considering surgical intervention in these
patients.[19]

Treating Obesity in Existing Diabetes
Evidence from clinical studies of dietary, pharmacological (using
sibutramine or orlistat) and surgical intervention in patients with diabetes
all support the concept that weight loss can be a useful adjunctive
treatment for type 2 diabetes, but it is recognized that this is difficult
to achieve in the majority of patients.[13,20-23] As a result, structured
weight management programmes are rarely a part of routine diabetes care. It
is clear that further evidence is needed in this area, and the ongoing Look
AHEAD (Action for Health in Diabetes) study in the USA may provide some
answers to this question.[24] The case for surgical treatment in severely
obese patients with type 2 diabetes is not yet proven, but as discussed by
Kerrigan and Pinkney there is mounting evidence that surgical management in
patients with a body mass index over 35 can frequently result in
normalization of glucose tolerance in many patients with type 2 diabetes,
particularly if intervention is carried out early in the course of the
disease before beta-cell failure is fully established.[25] Surgical
treatment also tends to improve other risk factors, so the benefits may be
greater than simply resolution of hyperglycaemia. Whether this is a more
effective approach than current therapeutic treatment for type 2 diabetes
with diet, oral hypoglycaemic agents and insulin, plus multi factorial
intervention for other risk factors has not yet been tested in a clinical
trial, but if this was the case, the management of severely obese patients
with type 2 diabetes would be transformed.

In summary, obesity, the development of type 2 diabetes and vascular
risk are inextricably linked. There is increasing evidence that weight loss
can be beneficial in both the prevention and treatment of type 2 diabetes,
with modest degrees of weight loss being most effective early in the course
of the disease, but more dramatic weight loss is needed to produce remission
once the disease has become established (table 1). To tackle this epidemic
requires intervention at all levels, with public health measures to avoid
weight gain and encourage appropriate modest weight loss in low risk groups;
targeted screening followed by intervention should be considered for
pre-diabetes; structured weight management with or without drug therapy more
widely adopted in established diabetes and surgical approaches considered
for the most severely obese patients.

Reprint Address

Correspondence to: Dr John Wilding, Department of Medicine, Clinical
Sciences Centre, University Hospital Aintree, Longmoor Lane, Liverpool, L9
7AL, UK. Tel: +44 (0)151 529 5885. Fax: +44 (0)151 529 5888. E-mail:
j.p.h.wilding@liv.ac.uk

References
1.. Medicare payment advisory commission. Healthcare Spending and
the medicare program. 2004.
2.. Currie CJ, Kraus D, Morgan CL, Gill L, Stott NCH, Peters JR. NHS
acute sector expenditure for diabetes: the present, future, and excess
inpatient cost of care. Diabet Med 1997;14:686-92.
3.. Chan JM, Stampfer MJ, Ribb EB, Willett WC, Colditz GA. Obesity,
fat distribution and weight gain as risk factors for clinical diabetes in
man. Diabetes Care 1994;17:961-9.
4.. Hu FB, Manson JE, Stampfer MJ et al. Diet, lifestyle, and the
risk of type 2 diabetes mellitus in women. N Engl J Med 2001;345:790-7.
5.. Jayapaul MK, Walker M. Mechanisms contributing to the
development of type 2 diabetes. Br J Diabetes Vasc Dis 2004;4:227-31.
6.. Pearson ER, Starkey BJ, Powell RJ, Gribble FM, Clark PM,
Hattersley AT. Genetic cause of hyperglycaemia and response to treatment in
diabetes. Lancet 2003;362:1275-81.
7.. Tuomilheto J, Lindstrom J, Erickson JG et al. Prevention of type
2 diabetes mellitus by changes in lifestyle anongst subjects with impaired
glucose tolerance. N Engl J Med 2001;344:1343-50.
8.. Diabetes Prevention Program Research Group Reduction in the
incidence of type 2 diabetes with lifestyle intervention or metformin. N
Engl J Med 2002;346:393-403.
9.. Buchanan TA, Xiang AH, Peters RK et al. Protection from type 2
diabetes persists in the TRIPOD cohort eight months after stopping
troglitazone. Diabetes 2001;50:A81.
10.. Chiasson JL, Josse RG, Gomis R, Hanefeld M, Karasik A, Laakso
M. Acarbose for prevention of type 2 diabetes mellitus: the STOPNIDDM
randomised trial. Lancet 2002;359:2072-7.
11.. Torgerson JS, Hauptman J, Boldrin MN, Sjostrom L. XENical in
the prevention of diabetes in obese subjects (XENDOS) study. Diabetes Care
2004;27:155-61.
12.. Sjostrom CD, Lissner L, Wedel H, Sjostrom L. Reduction in
incidence of diabetes, hypertension and lipid disturbances after intentional
weight loss induced by bariatric surgery: The SOS Intervention Study. Obes
Res 1999;7:477-84.
13.. Pories WJ, Swanson MS, MacDonald KG et al. Who would have
thought it - an operation proves to be the most effective therapy for
adult-onset diabetes-mellitus. Ann Surg 1995;222:339-52.
14.. Tringham JR, Davies MJ. Screening for IGT and diabetes. Br J
Diabetes Vasc Dis 2004;4:254-8.
15.. Banerjee M, Cruickshank JK. 'Prediabetes': is the term useful?
Br J Diabetes Vasc Dis 2004;4:221-5.
16.. Palmer AJ, Roze S, Valentine WJ, Spinas GA, Shaw JE, Zimmet PZ.
Intensive lifestyle changes or metformin in patients with impaired glucose
tolerance: Modeling the long-term health economic implications of the
Diabetes Prevention Program in Australia, France, Germany, Switzerland, and
the United Kingdom. Clin Ther 2004;26:304-21.
17.. Mohanty P, Aljada A, Ghanim H et al. Evidence for a potent
antiinflammatory effect of rosiglitazone. J Clin Endocrinol Metab
2004;89:2728-35.
18.. Bennett SMA, Agrawal A, Elashat H et al. Rosiglitazone improves
insulin sensitivity, glucose tolerance and ambulatory blood pressure in
subjects with impaired glucose tolerance. Diabet Med 2004;21:415-22.
19.. Sjostrom L, Larsson B, Backman L, Bengtsson C, Bouchard C,
Dahlgren S.e.a. Swedish obese subjects (SOS). Recruitment for an
interventionstudy and a selected description of the obese state. Int J Obes
Relat Metab Disord 1992;16:465-79.
20.. Wing RR, Koeske R, Epstein LH, Nowalk MP, Gooding W, Becker D.
Long-term effects of modest weight-loss in type-ii diabetic-patients. Arch
Intern Med 1987;147:1749-53.
21.. McNulty SJ, Ur E, Williams G. A randomized trial of sibutramine
in the management of obese type 2 diabetic patients treated with metformin.
Diabetes Care 2003;26:125-31.
22.. Hollander PA, Elbein SC, Hirsch IB et al. Role of orlistat in
the treatment of obese patients with type 2 diabetes - A 1-year randomized
double-blind study. Diabetes Care 1998;21:1288-94.
23.. Manley SE, Stratton IM, Cull CA et al. Effects of three months'
diet after diagnosis of Type 2 diabetes on plasma lipids and lipoproteins
(UKPDS 45). UK Prospective Diabetes Study Group. Diabet Med 2000;17:518-23.
24.. Action for Health in Diabetes.
http://www.nih.gov/news/pr/jun2001/niddk-25.htm
25.. Pinkney J, Kerrigan D. When should bariatric surgery be used in
the treatment of type 2 diabetes? Br J Diabetes Vasc Dis 2004;4:232-7.
26.. Sjostrom L, Rissanen A, Andersen T et al. Randomised
placebo-controlled trial of orlistat for weight loss and prevention of
weight regain in obese patients. Lancet 1998;352:167-72.
27.. James WPT, Astrup A, Finer N et al. Effect of sibutramine on
weight maintenance after weight loss: a randomised trial. Lancet 2000;356:
2119-25.
28.. UK Prospective Diabetes Study 7: response of fasting plasma
glucose to diet therapy in newly presenting type II diabetic patients, UKPDS
Group. Metabolism 1990;39:905-12.
29.. Dixon JB, O'Brien PE. Health outcomes of severely obese type 2
diabetic subjects 1 year after laparoscopic adjustable gastric banding.
Diabetes Care 2002;25:358-63.

begin 666 spacer.gif
K1TE&.#EA`0`!`( ``````````"'Y! $`````+ `````!``$```("1 $`.P``
`
end

Re: Obesity Treatment: The Key to Managing the Type 2 Diabetes Time bomb? -- Posted by Harvey R. Stone on 10-29-04 10:34

I just wanted to thank you for all of your informative posts. It takes a
dedicated person to do what it takes to keep people informed on the latest
information. Gumbo is OKkkk in my book,,,, better then OK.

Harv
"Gumbo" wrote in message
news:cltbqn$hbl$0@pita.alt.net...
> Obesity Treatment: The Key to Managing the Type 2 Diabetes Time bomb?
> Posted 10/11/2004
>
> John Wilding, Guest Editor
>
> Introduction
> The readership of this journal will be well aware that the epidemic
> of
> type 2 diabetes and associated vascular disease threatens to overwhelm
> health services worldwide over the next two decades. This is particularly
> the case in some countries in the developing world, but even in the USA,
> the
> rising costs of treating diabetes and vascular disease are likely to
> contribute to the projected bankruptcy of the Medicare budget by the year
> 2019,[1] and in the UK the costs of treating diabetes and its
> complications
> are already at least 9% of the total health costs of running the NHS,[2]
> and
> set to rise further if nothing is done.
>
> The Role of Obesity, Lifestyle and Genetics
> There is now ample epidemiological evidence that the majority of
> cases
> of type 2 diabetes are related to obesity, physical inactivity and other
> lifestyle factors such as smoking.[3,4] Type 2 diabetes is characterized
> by
> insulin resistance and progressive beta-cell failure, and is associated
> with
> a host of other abnormalities that comprise the metabolic syndrome, as
> reviewed by Jayapaul and Walker in this issue of the journal.[5] Whilst
> the
> importance of genetic background should not be underestimated, and may be
> particularly important in determining appropriate treatment for some
> individuals,[6] lifestyle factors are clearly the major modifiable risk
> factors for the development of glucose intolerance and associated vascular
> disease in the population.
>
> Delay and Prevention of Type 2 Diabetes
> There is now clear and overwhelming evidence that type 2 diabetes can
> be delayed or prevented in subjects with impaired glucose tolerance by
> lifestyle changes accompanied by weight loss of just 4-5% of body
> weight.[7,8] There is also evidence for efficacy of specific oral
> hypoglycaemic drugs including acarbose, metformin and thiazolidinediones,
> but in general the effects of these agents have been less in the clinical
> trials than was seen with lifestyle intervention.[8-10] The addition of
> drugs to help with weight loss, specifically orlistat, was demonstrated in
> the recently published Xendos trial, which showed an additional reduction
> in
> the risk of developing diabetes of 45% over and above that achieved by
> lifestyle intervention in those patients with impaired glucose
> tolerance.[11] Finally, there is also evidence from surgical studies of
> weight loss that type 2 diabetes can be prevented in morbidly obese
> patients
> treated with a variety of surgical procedures.[12,13]
>
> The NSF for Diabetes has as its first standard that "The NHS will
> develop, implement and monitor strategies to reduce the risk of developing
> type 2 diabetes in the population as a whole, and reduce the inequalities
> and the risk of developing type 2 diabetes." Given the evidence that
> targeted intervention in high-risk groups is effective at delaying or
> preventing diabetes, I will next consider the barriers that are currently
> preventing implementation of standard 1 of the NSF for diabetes.
>
> Identifying Those at Greatest Risk
> Tringham and Davies discuss the issue of screening for IGT and
> diabetes in some detail; they focus on the issue of screening for impaired
> glucose tolerance, highlight the impracticalities of carrying out
> widespread
> glucose tolerance testing and propose the use of various screening
> assessment tools that have been developed to identify patients with
> diabetes
> and other degrees of glucose intolerance.[14] The problem with the
> majority
> of these tools is that they have only been validated from single
> populations, mostly in the context of screening for diabetes, and require
> validation in other settings before their use can be generally applied.
> Nevertheless, this approach does seem an attractive way of enriching the
> population of individuals who are likely to benefit from screening,
> although
> there will inevitably be some false negative and false positive results.
>
> Deciding the Best Strategy to Prevent Diabetes
> Assuming an effective screening strategy can be implemented, it is
> important to consider which of the many proven interventions would be most
> appropriate. In a review in this edition of the journal, Banerjee and
> Cruickshank discuss the concept of 'pre-diabetes' and highlight the fact
> that early stages of diabetes including impaired fasting glucose and
> impaired glucose tolerance are not only markers of the prediabetic state,
> but are also associated with increased vascular risk in their own
> right.[15]
> It remains unclear whether the interventions that have been shown to
> prevent
> diabetes in these pre-diabetic states are also effective in dealing with
> the
> associated vascular disease, although most of the published studies do
> show
> expected improvements in risk factors. The choice of approach may also
> involve a consideration of effects on other risk factors, as well as
> progression to diabetes.
>
> The least contentious interventions are those which that encourage
> lifestyle change and weight management; these would require considerable
> resources to implement, although they are likely to be cost-effective.[16]
> The use of meal replacements in those who do not respond, and the addition
> of drugs such as orlistat have also been proven efficacious.[7,8,11] The
> use
> of specific anti-hyperglycemic pharmacological intervention should not be
> dismissed however, as there is preliminary evidence that agents such as
> thiazolidinediones may have effects that alter the natural history of the
> disease, and also influence other risk factors, although weight gain can
> be
> a problem with this class of drugs.[9,17,18] In the most severely obese
> patients with morbid obesity, other co-morbidities are frequently present,
> thus strengthening the case for considering surgical intervention in these
> patients.[19]
>
> Treating Obesity in Existing Diabetes
> Evidence from clinical studies of dietary, pharmacological (using
> sibutramine or orlistat) and surgical intervention in patients with
> diabetes
> all support the concept that weight loss can be a useful adjunctive
> treatment for type 2 diabetes, but it is recognized that this is difficult
> to achieve in the majority of patients.[13,20-23] As a result, structured
> weight management programmes are rarely a part of routine diabetes care.
> It
> is clear that further evidence is needed in this area, and the ongoing
> Look
> AHEAD (Action for Health in Diabetes) study in the USA may provide some
> answers to this question.[24] The case for surgical treatment in severely
> obese patients with type 2 diabetes is not yet proven, but as discussed by
> Kerrigan and Pinkney there is mounting evidence that surgical management
> in
> patients with a body mass index over 35 can frequently result in
> normalization of glucose tolerance in many patients with type 2 diabetes,
> particularly if intervention is carried out early in the course of the
> disease before beta-cell failure is fully established.[25] Surgical
> treatment also tends to improve other risk factors, so the benefits may be
> greater than simply resolution of hyperglycaemia. Whether this is a more
> effective approach than current therapeutic treatment for type 2 diabetes
> with diet, oral hypoglycaemic agents and insulin, plus multi factorial
> intervention for other risk factors has not yet been tested in a clinical
> trial, but if this was the case, the management of severely obese patients
> with type 2 diabetes would be transformed.
>
> In summary, obesity, the development of type 2 diabetes and vascular
> risk are inextricably linked. There is increasing evidence that weight
> loss
> can be beneficial in both the prevention and treatment of type 2 diabetes,
> with modest degrees of weight loss being most effective early in the
> course
> of the disease, but more dramatic weight loss is needed to produce
> remission
> once the disease has become established (table 1). To tackle this epidemic
> requires intervention at all levels, with public health measures to avoid
> weight gain and encourage appropriate modest weight loss in low risk
> groups;
> targeted screening followed by intervention should be considered for
> pre-diabetes; structured weight management with or without drug therapy
> more
> widely adopted in established diabetes and surgical approaches considered
> for the most severely obese patients.
>
>
> Reprint Address
>
> Correspondence to: Dr John Wilding, Department of Medicine, Clinical
> Sciences Centre, University Hospital Aintree, Longmoor Lane, Liverpool, L9
> 7AL, UK. Tel: +44 (0)151 529 5885. Fax: +44 (0)151 529 5888. E-mail:
> j.p.h.wilding@liv.ac.uk
>
> References
> 1.. Medicare payment advisory commission. Healthcare Spending and
> the medicare program. 2004.
> 2.. Currie CJ, Kraus D, Morgan CL, Gill L, Stott NCH, Peters JR.
> NHS
> acute sector expenditure for diabetes: the present, future, and excess
> inpatient cost of care. Diabet Med 1997;14:686-92.
> 3.. Chan JM, Stampfer MJ, Ribb EB, Willett WC, Colditz GA. Obesity,
> fat distribution and weight gain as risk factors for clinical diabetes in
> man. Diabetes Care 1994;17:961-9.
> 4.. Hu FB, Manson JE, Stampfer MJ et al. Diet, lifestyle, and the
> risk of type 2 diabetes mellitus in women. N Engl J Med 2001;345:790-7.
> 5.. Jayapaul MK, Walker M. Mechanisms contributing to the
> development of type 2 diabetes. Br J Diabetes Vasc Dis 2004;4:227-31.
> 6.. Pearson ER, Starkey BJ, Powell RJ, Gribble FM, Clark PM,
> Hattersley AT. Genetic cause of hyperglycaemia and response to treatment
> in
> diabetes. Lancet 2003;362:1275-81.
> 7.. Tuomilheto J, Lindstrom J, Erickson JG et al. Prevention of
> type
> 2 diabetes mellitus by changes in lifestyle anongst subjects with impaired
> glucose tolerance. N Engl J Med 2001;344:1343-50.
> 8.. Diabetes Prevention Program Research Group Reduction in the
> incidence of type 2 diabetes with lifestyle intervention or metformin. N
> Engl J Med 2002;346:393-403.
> 9.. Buchanan TA, Xiang AH, Peters RK et al. Protection from type 2
> diabetes persists in the TRIPOD cohort eight months after stopping
> troglitazone. Diabetes 2001;50:A81.
> 10.. Chiasson JL, Josse RG, Gomis R, Hanefeld M, Karasik A, Laakso
> M. Acarbose for prevention of type 2 diabetes mellitus: the STOPNIDDM
> randomised trial. Lancet 2002;359:2072-7.
> 11.. Torgerson JS, Hauptman J, Boldrin MN, Sjostrom L. XENical in
> the prevention of diabetes in obese subjects (XENDOS) study. Diabetes Care
> 2004;27:155-61.
> 12.. Sjostrom CD, Lissner L, Wedel H, Sjostrom L. Reduction in
> incidence of diabetes, hypertension and lipid disturbances after
> intentional
> weight loss induced by bariatric surgery: The SOS Intervention Study. Obes
> Res 1999;7:477-84.
> 13.. Pories WJ, Swanson MS, MacDonald KG et al. Who would have
> thought it - an operation proves to be the most effective therapy for
> adult-onset diabetes-mellitus. Ann Surg 1995;222:339-52.
> 14.. Tringham JR, Davies MJ. Screening for IGT and diabetes. Br J
> Diabetes Vasc Dis 2004;4:254-8.
> 15.. Banerjee M, Cruickshank JK. 'Prediabetes': is the term useful?
> Br J Diabetes Vasc Dis 2004;4:221-5.
> 16.. Palmer AJ, Roze S, Valentine WJ, Spinas GA, Shaw JE, Zimmet
> PZ.
> Intensive lifestyle changes or metformin in patients with impaired glucose
> tolerance: Modeling the long-term health economic implications of the
> Diabetes Prevention Program in Australia, France, Germany, Switzerland,
> and
> the United Kingdom. Clin Ther 2004;26:304-21.
> 17.. Mohanty P, Aljada A, Ghanim H et al. Evidence for a potent
> antiinflammatory effect of rosiglitazone. J Clin Endocrinol Metab
> 2004;89:2728-35.
> 18.. Bennett SMA, Agrawal A, Elashat H et al. Rosiglitazone
> improves
> insulin sensitivity, glucose tolerance and ambulatory blood pressure in
> subjects with impaired glucose tolerance. Diabet Med 2004;21:415-22.
> 19.. Sjostrom L, Larsson B, Backman L, Bengtsson C, Bouchard C,
> Dahlgren S.e.a. Swedish obese subjects (SOS). Recruitment for an
> interventionstudy and a selected description of the obese state. Int J
> Obes
> Relat Metab Disord 1992;16:465-79.
> 20.. Wing RR, Koeske R, Epstein LH, Nowalk MP, Gooding W, Becker D.
> Long-term effects of modest weight-loss in type-ii diabetic-patients. Arch
> Intern Med 1987;147:1749-53.
> 21.. McNulty SJ, Ur E, Williams G. A randomized trial of
> sibutramine
> in the management of obese type 2 diabetic patients treated with
> metformin.
> Diabetes Care 2003;26:125-31.
> 22.. Hollander PA, Elbein SC, Hirsch IB et al. Role of orlistat in
> the treatment of obese patients with type 2 diabetes - A 1-year randomized
> double-blind study. Diabetes Care 1998;21:1288-94.
> 23.. Manley SE, Stratton IM, Cull CA et al. Effects of three
> months'
> diet after diagnosis of Type 2 diabetes on plasma lipids and lipoproteins
> (UKPDS 45). UK Prospective Diabetes Study Group. Diabet Med
> 2000;17:518-23.
> 24.. Action for Health in Diabetes.
> http://www.nih.gov/news/pr/jun2001/niddk-25.htm
> 25.. Pinkney J, Kerrigan D. When should bariatric surgery be used
> in
> the treatment of type 2 diabetes? Br J Diabetes Vasc Dis 2004;4:232-7.
> 26.. Sjostrom L, Rissanen A, Andersen T et al. Randomised
> placebo-controlled trial of orlistat for weight loss and prevention of
> weight regain in obese patients. Lancet 1998;352:167-72.
> 27.. James WPT, Astrup A, Finer N et al. Effect of sibutramine on
> weight maintenance after weight loss: a randomised trial. Lancet 2000;356:
> 2119-25.
> 28.. UK Prospective Diabetes Study 7: response of fasting plasma
> glucose to diet therapy in newly presenting type II diabetic patients,
> UKPDS
> Group. Metabolism 1990;39:905-12.
> 29.. Dixon JB, O'Brien PE. Health outcomes of severely obese type 2
> diabetic subjects 1 year after laparoscopic adjustable gastric banding.
> Diabetes Care 2002;25:358-63.
>
>
>
>

Re: Obesity Treatment: The Key to Managing the Type 2 Diabetes Time bomb? -- Posted by Gumbo on 10-30-04 06:37

thanks.. just started to get involved in this group..

"Harvey R. Stone" wrote in message
news:gavgd.5921$bP2.3085@newssvr12.news.prodigy.com...
> I just wanted to thank you for all of your informative posts. It takes a
> dedicated person to do what it takes to keep people informed on the latest
> information. Gumbo is OKkkk in my book,,,, better then OK.
>
> Harv
> "Gumbo" wrote in message
> news:cltbqn$hbl$0@pita.alt.net...
> > Obesity Treatment: The Key to Managing the Type 2 Diabetes Time bomb?
> > Posted 10/11/2004
> >
> > John Wilding, Guest Editor
> >
> > Introduction
> > The readership of this journal will be well aware that the epidemic
> > of
> > type 2 diabetes and associated vascular disease threatens to overwhelm
> > health services worldwide over the next two decades. This is
particularly
> > the case in some countries in the developing world, but even in the USA,
> > the
> > rising costs of treating diabetes and vascular disease are likely to
> > contribute to the projected bankruptcy of the Medicare budget by the
year
> > 2019,[1] and in the UK the costs of treating diabetes and its
> > complications
> > are already at least 9% of the total health costs of running the NHS,[2]
> > and
> > set to rise further if nothing is done.
> >
> > The Role of Obesity, Lifestyle and Genetics
> > There is now ample epidemiological evidence that the majority of
> > cases
> > of type 2 diabetes are related to obesity, physical inactivity and other
> > lifestyle factors such as smoking.[3,4] Type 2 diabetes is characterized
> > by
> > insulin resistance and progressive beta-cell failure, and is associated
> > with
> > a host of other abnormalities that comprise the metabolic syndrome, as
> > reviewed by Jayapaul and Walker in this issue of the journal.[5] Whilst
> > the
> > importance of genetic background should not be underestimated, and may
be
> > particularly important in determining appropriate treatment for some
> > individuals,[6] lifestyle factors are clearly the major modifiable risk
> > factors for the development of glucose intolerance and associated
vascular
> > disease in the population.
> >
> > Delay and Prevention of Type 2 Diabetes
> > There is now clear and overwhelming evidence that type 2 diabetes
can
> > be delayed or prevented in subjects with impaired glucose tolerance by
> > lifestyle changes accompanied by weight loss of just 4-5% of body
> > weight.[7,8] There is also evidence for efficacy of specific oral
> > hypoglycaemic drugs including acarbose, metformin and
thiazolidinediones,
> > but in general the effects of these agents have been less in the
clinical
> > trials than was seen with lifestyle intervention.[8-10] The addition of
> > drugs to help with weight loss, specifically orlistat, was demonstrated
in
> > the recently published Xendos trial, which showed an additional
reduction
> > in
> > the risk of developing diabetes of 45% over and above that achieved by
> > lifestyle intervention in those patients with impaired glucose
> > tolerance.[11] Finally, there is also evidence from surgical studies of
> > weight loss that type 2 diabetes can be prevented in morbidly obese
> > patients
> > treated with a variety of surgical procedures.[12,13]
> >
> > The NSF for Diabetes has as its first standard that "The NHS will
> > develop, implement and monitor strategies to reduce the risk of
developing
> > type 2 diabetes in the population as a whole, and reduce the
inequalities
> > and the risk of developing type 2 diabetes." Given the evidence that
> > targeted intervention in high-risk groups is effective at delaying or
> > preventing diabetes, I will next consider the barriers that are
currently
> > preventing implementation of standard 1 of the NSF for diabetes.
> >
> > Identifying Those at Greatest Risk
> > Tringham and Davies discuss the issue of screening for IGT and
> > diabetes in some detail; they focus on the issue of screening for
impaired
> > glucose tolerance, highlight the impracticalities of carrying out
> > widespread
> > glucose tolerance testing and propose the use of various screening
> > assessment tools that have been developed to identify patients with
> > diabetes
> > and other degrees of glucose intolerance.[14] The problem with the
> > majority
> > of these tools is that they have only been validated from single
> > populations, mostly in the context of screening for diabetes, and
require
> > validation in other settings before their use can be generally applied.
> > Nevertheless, this approach does seem an attractive way of enriching the
> > population of individuals who are likely to benefit from screening,
> > although
> > there will inevitably be some false negative and false positive results.
> >
> > Deciding the Best Strategy to Prevent Diabetes
> > Assuming an effective screening strategy can be implemented, it is
> > important to consider which of the many proven interventions would be
most
> > appropriate. In a review in this edition of the journal, Banerjee and
> > Cruickshank discuss the concept of 'pre-diabetes' and highlight the fact
> > that early stages of diabetes including impaired fasting glucose and
> > impaired glucose tolerance are not only markers of the prediabetic
state,
> > but are also associated with increased vascular risk in their own
> > right.[15]
> > It remains unclear whether the interventions that have been shown to
> > prevent
> > diabetes in these pre-diabetic states are also effective in dealing with
> > the
> > associated vascular disease, although most of the published studies do
> > show
> > expected improvements in risk factors. The choice of approach may also
> > involve a consideration of effects on other risk factors, as well as
> > progression to diabetes.
> >
> > The least contentious interventions are those which that encourage
> > lifestyle change and weight management; these would require considerable
> > resources to implement, although they are likely to be
cost-effective.[16]
> > The use of meal replacements in those who do not respond, and the
addition
> > of drugs such as orlistat have also been proven efficacious.[7,8,11] The
> > use
> > of specific anti-hyperglycemic pharmacological intervention should not
be
> > dismissed however, as there is preliminary evidence that agents such as
> > thiazolidinediones may have effects that alter the natural history of
the
> > disease, and also influence other risk factors, although weight gain can
> > be
> > a problem with this class of drugs.[9,17,18] In the most severely obese
> > patients with morbid obesity, other co-morbidities are frequently
present,
> > thus strengthening the case for considering surgical intervention in
these
> > patients.[19]
> >
> > Treating Obesity in Existing Diabetes
> > Evidence from clinical studies of dietary, pharmacological (using
> > sibutramine or orlistat) and surgical intervention in patients with
> > diabetes
> > all support the concept that weight loss can be a useful adjunctive
> > treatment for type 2 diabetes, but it is recognized that this is
difficult
> > to achieve in the majority of patients.[13,20-23] As a result,
structured
> > weight management programmes are rarely a part of routine diabetes care.
> > It
> > is clear that further evidence is needed in this area, and the ongoing
> > Look
> > AHEAD (Action for Health in Diabetes) study in the USA may provide some
> > answers to this question.[24] The case for surgical treatment in
severely
> > obese patients with type 2 diabetes is not yet proven, but as discussed
by
> > Kerrigan and Pinkney there is mounting evidence that surgical management
> > in
> > patients with a body mass index over 35 can frequently result in
> > normalization of glucose tolerance in many patients with type 2
diabetes,
> > particularly if intervention is carried out early in the course of the
> > disease before beta-cell failure is fully established.[25] Surgical
> > treatment also tends to improve other risk factors, so the benefits may
be
> > greater than simply resolution of hyperglycaemia. Whether this is a more
> > effective approach than current therapeutic treatment for type 2
diabetes
> > with diet, oral hypoglycaemic agents and insulin, plus multi factorial
> > intervention for other risk factors has not yet been tested in a
clinical
> > trial, but if this was the case, the management of severely obese
patients
> > with type 2 diabetes would be transformed.
> >
> > In summary, obesity, the development of type 2 diabetes and
vascular
> > risk are inextricably linked. There is increasing evidence that weight
> > loss
> > can be beneficial in both the prevention and treatment of type 2
diabetes,
> > with modest degrees of weight loss being most effective early in the
> > course
> > of the disease, but more dramatic weight loss is needed to produce
> > remission
> > once the disease has become established (table 1). To tackle this
epidemic
> > requires intervention at all levels, with public health measures to
avoid
> > weight gain and encourage appropriate modest weight loss in low risk
> > groups;
> > targeted screening followed by intervention should be considered for
> > pre-diabetes; structured weight management with or without drug therapy
> > more
> > widely adopted in established diabetes and surgical approaches
considered
> > for the most severely obese patients.
> >
> >
> > Reprint Address
> >
> > Correspondence to: Dr John Wilding, Department of Medicine,
Clinical
> > Sciences Centre, University Hospital Aintree, Longmoor Lane, Liverpool,
L9
> > 7AL, UK. Tel: +44 (0)151 529 5885. Fax: +44 (0)151 529 5888. E-mail:
> > j.p.h.wilding@liv.ac.uk
> >
> > References
> > 1.. Medicare payment advisory commission. Healthcare Spending and
> > the medicare program. 2004.
> > 2.. Currie CJ, Kraus D, Morgan CL, Gill L, Stott NCH, Peters JR.
> > NHS
> > acute sector expenditure for diabetes: the present, future, and excess
> > inpatient cost of care. Diabet Med 1997;14:686-92.
> > 3.. Chan JM, Stampfer MJ, Ribb EB, Willett WC, Colditz GA.
Obesity,
> > fat distribution and weight gain as risk factors for clinical diabetes
in
> > man. Diabetes Care 1994;17:961-9.
> > 4.. Hu FB, Manson JE, Stampfer MJ et al. Diet, lifestyle, and the
> > risk of type 2 diabetes mellitus in women. N Engl J Med 2001;345:790-7.
> > 5.. Jayapaul MK, Walker M. Mechanisms contributing to the
> > development of type 2 diabetes. Br J Diabetes Vasc Dis 2004;4:227-31.
> > 6.. Pearson ER, Starkey BJ, Powell RJ, Gribble FM, Clark PM,
> > Hattersley AT. Genetic cause of hyperglycaemia and response to treatment
> > in
> > diabetes. Lancet 2003;362:1275-81.
> > 7.. Tuomilheto J, Lindstrom J, Erickson JG et al. Prevention of
> > type
> > 2 diabetes mellitus by changes in lifestyle anongst subjects with
impaired
> > glucose tolerance. N Engl J Med 2001;344:1343-50.
> > 8.. Diabetes Prevention Program Research Group Reduction in the
> > incidence of type 2 diabetes with lifestyle intervention or metformin. N
> > Engl J Med 2002;346:393-403.
> > 9.. Buchanan TA, Xiang AH, Peters RK et al. Protection from type
2
> > diabetes persists in the TRIPOD cohort eight months after stopping
> > troglitazone. Diabetes 2001;50:A81.
> > 10.. Chiasson JL, Josse RG, Gomis R, Hanefeld M, Karasik A,
Laakso
> > M. Acarbose for prevention of type 2 diabetes mellitus: the STOPNIDDM
> > randomised trial. Lancet 2002;359:2072-7.
> > 11.. Torgerson JS, Hauptman J, Boldrin MN, Sjostrom L. XENical in
> > the prevention of diabetes in obese subjects (XENDOS) study. Diabetes
Care
> > 2004;27:155-61.
> > 12.. Sjostrom CD, Lissner L, Wedel H, Sjostrom L. Reduction in
> > incidence of diabetes, hypertension and lipid disturbances after
> > intentional
> > weight loss induced by bariatric surgery: The SOS Intervention Study.
Obes
> > Res 1999;7:477-84.
> > 13.. Pories WJ, Swanson MS, MacDonald KG et al. Who would have
> > thought it - an operation proves to be the most effective therapy for
> > adult-onset diabetes-mellitus. Ann Surg 1995;222:339-52.
> > 14.. Tringham JR, Davies MJ. Screening for IGT and diabetes. Br J
> > Diabetes Vasc Dis 2004;4:254-8.
> > 15.. Banerjee M, Cruickshank JK. 'Prediabetes': is the term
useful?
> > Br J Diabetes Vasc Dis 2004;4:221-5.
> > 16.. Palmer AJ, Roze S, Valentine WJ, Spinas GA, Shaw JE, Zimmet
> > PZ.
> > Intensive lifestyle changes or metformin in patients with impaired
glucose
> > tolerance: Modeling the long-term health economic implications of the
> > Diabetes Prevention Program in Australia, France, Germany, Switzerland,
> > and
> > the United Kingdom. Clin Ther 2004;26:304-21.
> > 17.. Mohanty P, Aljada A, Ghanim H et al. Evidence for a potent
> > antiinflammatory effect of rosiglitazone. J Clin Endocrinol Metab
> > 2004;89:2728-35.
> > 18.. Bennett SMA, Agrawal A, Elashat H et al. Rosiglitazone
> > improves
> > insulin sensitivity, glucose tolerance and ambulatory blood pressure in
> > subjects with impaired glucose tolerance. Diabet Med 2004;21:415-22.
> > 19.. Sjostrom L, Larsson B, Backman L, Bengtsson C, Bouchard C,
> > Dahlgren S.e.a. Swedish obese subjects (SOS). Recruitment for an
> > interventionstudy and a selected description of the obese state. Int J
> > Obes
> > Relat Metab Disord 1992;16:465-79.
> > 20.. Wing RR, Koeske R, Epstein LH, Nowalk MP, Gooding W, Becker
D.
> > Long-term effects of modest weight-loss in type-ii diabetic-patients.
Arch
> > Intern Med 1987;147:1749-53.
> > 21.. McNulty SJ, Ur E, Williams G. A randomized trial of
> > sibutramine
> > in the management of obese type 2 diabetic patients treated with
> > metformin.
> > Diabetes Care 2003;26:125-31.
> > 22.. Hollander PA, Elbein SC, Hirsch IB et al. Role of orlistat
in
> > the treatment of obese patients with type 2 diabetes - A 1-year
randomized
> > double-blind study. Diabetes Care 1998;21:1288-94.
> > 23.. Manley SE, Stratton IM, Cull CA et al. Effects of three
> > months'
> > diet after diagnosis of Type 2 diabetes on plasma lipids and
lipoproteins
> > (UKPDS 45). UK Prospective Diabetes Study Group. Diabet Med
> > 2000;17:518-23.
> > 24.. Action for Health in Diabetes.
> > http://www.nih.gov/news/pr/jun2001/niddk-25.htm
> > 25.. Pinkney J, Kerrigan D. When should bariatric surgery be used
> > in
> > the treatment of type 2 diabetes? Br J Diabetes Vasc Dis 2004;4:232-7.
> > 26.. Sjostrom L, Rissanen A, Andersen T et al. Randomised
> > placebo-controlled trial of orlistat for weight loss and prevention of
> > weight regain in obese patients. Lancet 1998;352:167-72.
> > 27.. James WPT, Astrup A, Finer N et al. Effect of sibutramine on
> > weight maintenance after weight loss: a randomised trial. Lancet
2000;356:
> > 2119-25.
> > 28.. UK Prospective Diabetes Study 7: response of fasting plasma
> > glucose to diet therapy in newly presenting type II diabetic patients,
> > UKPDS
> > Group. Metabolism 1990;39:905-12.
> > 29.. Dixon JB, O'Brien PE. Health outcomes of severely obese type
2
> > diabetic subjects 1 year after laparoscopic adjustable gastric banding.
> > Diabetes Care 2002;25:358-63.
> >
> >
> >
> >
>
>

Related Discussion:

How to Read Food Labels (1 posts)
by Gumbo - Last post on: 11-10-04 19:13
This is a multi-part message in MIME format. ------=_NextPart_000_001B_01C4C772.92029B20 Content-Type: multipart/alternative; boundary="----=_NextPart_001_001C_01C4C772.92029B20" ------=_NextPart_001_001C_01C4C772.92029B20 Content-Type: text/plain; charset="iso-8859-1" Content-Transfe... (Read More)

Gastric bypass urged for very obese diabetics (1 posts)
by Gumbo - Last post on: 11-09-04 17:55
Gastric bypass urged for very obese diabetics Oct 23 (Reuters Health) - Stomach bypass surgery should become 'standard treatment' for morbidly obese patients with type 2 diabetes, researchers recommend, because the majority achieve excellent glucose control following the procedure. In the A... (Read More)

Diabetes Increases Risk of Blood Poisoning (1 posts)
by Gumbo - Last post on: 02-16-05 05:27
Diabetes Increases Risk of Blood Poisoning A new study adds potentially fatal blood infections to the list of health risks from diabetes, a condition that is on the rise in the United States as obesity rates climb, according to a new study. Researchers have known for years that obesity... (Read More)

Aspirin Risks In Healthy Individuals (29 posts)
by Roman Bystrianyk - Last post on: 01-18-05 03:50
http://www.healthsentinel.com/org_news.php?event=org_news_print_list_item&id=16 Roman Bystrianyk, "Aspirin Risks In Healthy Individuals", Health Sentinel, January 16, 2005, Felix Hoffman at Bayer Industries synthesized aspirin over 100 years ago. Today there have been many ads promoting aspi... (Read More)

Top Discussions From Our Archives

Health Benefits

Your greater health

A New Set of Knees Comes at a Price: A Whole Lot of Pain

Diabetes Patients: See why it's called "The Greatest Vitamin in the World"

johnson & johnson "rotating platform" knee replacement

Re: Your personal team of doctors is here.

Other Discussion Categories

Diabetes Symptoms
Health Care Policy
Health Care Providers HMO
Arthritis Symptoms

Home | Discussion Archives |