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- J Obes Metab Syndr
- v.26(1); 2017 Mar
Two Cases of Successful Type 2 Diabetes Control with Lifestyle Modification in Children and Adolescents
Seon hwa lee.
1 Department of Pediatrics, Konkuk University Medical Center, Seoul, Korea
Myung Hyun Cho
Yong hyuk kim.
2 Department of Pediatrics, Wonju College of Medicine, Yonsei University, Wonju, Korea
Sochung Chung
Obesity and obesity-related disease are becoming serious global issues. The incidence of obesity and type 2 diabetes has increased in children and adolescents. Type 2 diabetes is a chronic disease that is difficult to treat, and the accurate assessment of obesity in type 2 diabetes is becoming increasingly important. Obesity is the excessive accumulation of fat that causes insulin resistance, and body composition analyses can help physicians evaluate fat levels. Although previous studies have shown the achievement of complete remission of type 2 diabetes after focused improvement in lifestyle habits, there are few cases of complete remission of type 2 diabetes. Here we report on obese patients with type 2 diabetes who were able to achieve considerable fat loss and partial or complete remission of diabetes through lifestyle changes. This case report emphasizes once again that focused lifestyle intervention effectively treats childhood diabetes.
INTRODUCTION
Obesity and obesity-related diseases are serious public health issues worldwide, and the increased incidence of type 2 diabetes in children and adolescents is associated with the increased incidence of obesity. 1 , 2 Excess weight gain is a risk factor for both type 2 diabetes and insulin resistance. Obesity refers to excessive fat accumulation and may affect the clinical course of diabetes in terms of insulin resistance. Therefore, the accurate assessment of obesity is important. 3 Body mass index (BMI) is used as an indicator to evaluate weight excess or obesity. 4 However, BMI is limited in that it is the sum of fat-free mass index (FFMI) and fat mass index (FMI) and does not only reflect excess fat. 5 , 6 Therefore, it may be helpful to use body composition analysis that measures fat mass (FM) without fat-free mass (FFM) as a tool to evaluate obesity. Although type 2 diabetes is considered a chronic disease that is difficult to completely cure 7 , 8 , studies have reported complete remission of type 2 diabetes in adults after intensive lifestyle modification. 9 Here we report two cases of type 2 diabetes with partial or complete response to lifestyle modification, particularly FM decrease. Our findings emphasize that lifestyle modifications including dietary treatment and exercise therapy comprise the first-line treatment in obese patients with type 2 diabetes. 10
CASE REPORT
Ms. L, 17 years and 5 months, female
Polydipsia, polyuria
Family history
Mother with hypertension, father with heart failure.
Past medical/social history
No significant history
History of present illness
This 17-year-old girl was diagnosed with diabetes at another hospital after a 1-month history of persistent polydipsia and polyuria. She presented to Konkuk University Medical Center for further diagnosis and treatment of her persistent symptoms.
Physical examination
On admission, her height was 173.1 cm (>97th percentile), weight was 107.2 kg (>97th percentile), and BMI was 35.8 kg/m 2 (>97th percentile) ( Table 1 ). She appeared obese but did not look ill and her mental status was intact. Her vital signs were normal except for a blood pressure of 137/81 mmHg (95–99th percentile). Her skin was warm and no dry mucous membranes were observed. A chest examination was unremarkable. No enlargement of the liver or spleen was appreciated on an abdominal examination. The rest of the physical exam was unremarkable.
Anthropometric data and patient body composition profiles of adolescent girls with type 2 diabetes who achieved remission after stopping medications
BMI, body mass index; FFM, fat free mass; FM, fat mass; FFMI, fat free mass index; FMI, fat mass index; FFMIZ, fat free mass index Z score; FMIZ, fat mass index Z score; PBF, percent body fat.
Lab findings
Labs on admission revealed a glycated hemoglobin (HbA1c) of 11.1%, fasting plasma glucose level of 102 mg/dL, insulin level of 23.12 μIU/mL, and C-peptide level of 4.13 ng/mL. Liver function tests revealed an elevated serum aspartate transaminase (AST) level of 115 IU/L and serum alanine transaminase (ALT) level of 141 IU/L. A lipid panel demonstrated a total cholesterol level of 133 mg/dL, triglycerides of 71 mg/dL, and high-density lipoprotein cholesterol (HDL-C) of 49 mg/dL ( Table 2 ). The total protein and albumin level was 7.0 g/dL and that of albumin was 4.5 g/dL. The free fatty acid level was elevated at 1214 μEq/L.
Biochemical profiles of adolescent girls with type 2 diabetes who achieved remission after stopping medications
HbA1c, glycated hemoglobin A1c; HDL, high lipoprotein; AST, aspartate transaminase; ALT, alanine transaminase.
Radiologic findings
There were no abnormal findings on a chest radiograph. An abdominal ultrasound showed severe fatty infiltration of the liver.
Treatment and progress
For glycemic control, the patient was started on oral medications (metformin 500 mg BID, glimepiride 1 mg QD) as well as a diet and exercise program as a lifestyle modification. Her dietary and nutritional knowledge were evaluated, and she was counseled to have regular meals with 70–75 g of proteins per day and maintain daily nutritional requirements of approximately 1,800 kcal. She was recommended to consume a low-carb, low-fat diet, limit high saturated fats, track her intake, and attend outpatient appointments every 1–2 months. She was instructed to perform aerobic and weight exercises that improve muscle strength for more than 1 hour at least 3 times per week. For 1 year, she did aerobic and anaerobic exercises for an hour or more per day. After 1 year, she incorporated a 7 km walk daily and Pilates more than 3 times per week to her exercise program. In the outpatient setting, we assessed her adherence to therapy at 1–2 month intervals, offered motivational support, and advised her to gradually increase her exercise duration rather than intensity. We measured her height and weight every year and used InBody720, a type of bioelectrical impedance analysis (BIA), to accurately evaluate her obesity. On diagnosis, the patient’s BMI was 35.8 kg/m 2 (FMI, 18.0 kg/m 2 ; FFMI, 17.8 kg/m 2 ), scoring >97th percentile, and percent body fat (PBF) was 50.4%. During the 2 years of outpatient monitoring, she had no difficulty controlling her blood sugar level using the combination of oral medication and lifestyle modification. However, the dose of metformin was increased to 1,000 mg BID due to difficulty maintaining her HbA1c <7.0% on the previous regimen; at that time, she was still considered obese with a BMI of 35.1 kg/m 2 (FMI, 17.2 kg/m 2 ; FFMI, 17.9 kg/m 2 ) and PBF of 48.9%. Her weight and body composition during treatment are shown in Fig. 1 .
Plot of changes in FFMI and FMI in two adolescent girls with T2DM who achieved remission. T2DM, type 2 diabetes; BMI, body mass index; PBF, percent body fat; FFMI, fat free mass index; FMI, fat mass index.
Three years later, the patient’s dietary therapy and exercise program resulted in an increased FFMI at 18.3 kg/m 2 and reduced FMI at 14.9 kg/m 2 , leading to discontinuation of the glimepiride and a reduction in the metformin dose to 500 mg BID.
Four years later, her HbA1c decreased to 5.4% and the metformin was discontinued due to her successful glycemic control. At that time, her fasting blood glucose level was 97 mg/dL, insulin level was 5.62 μIU/mL, and C-peptide level was 2.13 ng/mL. Her BMI was 27.1 kg/m 2 (FMI, 10.3 kg/m 2 ; FFMI, 16.8 kg/m 2 ) and PBF was 38.2%, which is still considered obese based on the World Health Organization diagnostic criteria for Asian adults; however, it was 8.7 kg/m 2 less than her BMI prior to treatment and her FMI had decreased by 7.7 kg/m 2 . Her FFMI was also reduced by 1.0 kg/m 2 , but still belonged to the 90–95th percentile; thus, her nutritional status was not a concern ( Table 1 ). Liver function tests and a lipid panel revealed AST 20 IU/L, ALT 12 IU/L, total cholesterol 114 mg/dL, triglycerides 59 mg/dL, and HDL-C 51 mg/dL ( Table 2 ). Her HbA1c has remained at <5.7% for more than a year without oral medications and will continue to be followed.
Ms. A, 12 years and 10 months, female
Hyperglycemia
Father with type 2 diabetes under treatment
12-year-old female who presented to Konkuk University Medical Center with post-prandial hyperglycemia of 330 mg/dL measured by her father one day prior to admission. Menarche occurred 1 year prior and her menstrual cycles were regular.
On admission, the patient’s height was 158.9 cm (25–50th percentile), weight was 75.5 kg (>97th percentile), and BMI was 29.9 kg/m 2 (>97th percentile) ( Table 1 ). Her vital signs were within the normal range with a blood pressure of 112/68 mmHg, pulse of 72 beats/min, respiratory rate of 20 breaths/min, and temperature of 36.6°C. She had a clear mental status, warm skin, and moist mucous membranes. A chest examination revealed no specific findings, while an abdominal examination revealed no hepatomegaly or splenomegaly. The rest of the physical examination was unremarkable.
Laboratory findings
Laboratory tests at the time of admission revealed an HbA1c level of 9.9%, fasting blood glucose level of 202 mg/dL, insulin level of 15.85 μIU/mL, and C-peptide level of 2.97 ng/mL. Liver function tests showed an elevated AST level at 47 IU/L and ALT level at 69 IU/L. A lipid panel and comprehensive metabolic panel showed a total cholesterol level of 165 mg/dL, triglyceride level of 104 mg/dL, HDL-C of 50 mg/dL, total protein of 7.6 g/dL, and albumin of 4.8 g/dL ( Table 2 ). The free fatty acid level was elevated at 671 μEq/L.
Radiologic finding
There were no significant findings on a chest radiograph. An abdominal ultrasound showed moderate fatty liver.
For glycemic control, combination therapy of oral medication (metformin 500 mg BID) and lifestyle modification through adjustments in dietary habits was prescribed. We evaluated her dietary and nutritional knowledge and then counseled her to consume regular meals with 70–90 g of protein per day, maintain daily nutritional requirements of approximately 1800 kcal, and eat a low-carb, low-fat diet. She was recommended to modify her habitual preference of salty and spicy foods, reduce her salt intake, track her meals, and attend outpatient monitoring appointments every 1–2 months.
For an exercise program, she was instructed to include aerobic and weight exercises that improve muscle strength. She was advised to walk >1 hour at least 5 days per week and visit a health training center for ≥1 hour of strength exercises at least 3 times per week. We measured her height and weight every 2 months, and used InBody720, a type of BIA for accurate assessment of obesity. On diagnosis, patient’s BMI was 29.9 kg/m 2 (FMI, 12.7 kg/m 2 ; FFMI, 17.2 kg/m 2 ) and PBF was 42.5%. Two years later after the diagnosis, an abdominal ultrasound showed improvements in her fatty liver and her HbA1c was successfully reduced to 6.0%. The oral medication was discontinued due to the successful glycemic control. At the time, her fasting blood sugar was 97 mg/dL, insulin level was 5.62 μIU/mL, and C-peptide level was 2.79 ng/mL. Her BMI (FMI+FFMI) was 23.2 kg/m 2 (7.0 kg/m 2 +16.2 kg/m 2 ), which was within the overweight range (85–90th percentile), and her PBF was 30.2%. Her BMI at that point was 6.7 kg/m 2 lower than that prior to therapy, with a 5.7 kg/m 2 reduction observed in her FMI ( Table 1 ). Liver function tests and a lipid panel revealed the following: AST, 20 IU/L; ALT, 34 IU/L; total cholesterol, 115 mg/dL; triglycerides, 70 mg/dL; and HDL-C, 30 mg/dL ( Table 2 ). The changes in the patient’s weight and body composition during treatment are shown in Fig. 1 . Since discontinuing the oral medication, the patient has maintained an HbA1c level <6.5%.
The prevalence of type 2 diabetes is increasing with changes in dietary habits and increases in the incidence of obesity among children and adolescents. Although it is already known that a reduced caloric intake and weight loss through lifestyle modifications can treat diabetes, few cases demonstrating such an effect have been reported to date. 9 As discussed previously in two cases, a notable reduction in FM resulted in an HbA1c level <6.5% and improved glycemic control as well as successful maintenance of HbA1c at goal level without medications. According to the 2009 consensus statement reported by the American Diabetes Association, a complete response is defined as blood sugar in the normal range for >1 year without any medications (fasting blood sugar <100 mg/dL, HbA1c <5.7%). Partial response is defined as a blood sugar level below the diabetes range for >1 year without any medications or medical procedures (HbA1C <6.5%; fasting blood sugar, 100–125 mg/dL). 11 In the two cases presented above, significant decreases in BMI and PBF were observed as well as subsequent improvements in HbA1c and fasting blood sugar level. In developing children, weight gain occurs with increasing age, and increases in BMI are common. However, such increases in BMI are due to increases in FFM, not FM. 6 Appropriate growth is one of the important objectives of pediatric diabetes management and treatment. Since proper nutrition and hormonal balance are essential for growth, it is more important to achieve a reduction in FM than a reduction in weight by having regular meals that are low in carbs and fat with a normal protein intake.
Weight loss through lifestyle modification generally affects FFM. In the cases discussed above, both patients had elevated FM and FFM on admission. By balancing appropriate dietary changes with aerobic and anaerobic exercises, the patient was able to maintain FFM and incur no significant effect on growth. In the present case, the patient was instructed to spend 1 hour exercising at least 3 times per week, assessed for compliance as an outpatient every 1–2 months, offered continuous motivational support, and told to gradually increase her exercise duration.
A recent study reported that oral medication was eventually needed to control hyperglycemia in patients with diabetes refractory to management with proper lifestyle modification. 12 However, lifestyle modification is important, and is a cornerstone in the treatment of diabetes, and it should be a mandatory treatment for type 2 diabetes. In females, it is common to see an increase in PBF with progression of puberty. 13 , 14 However, here we report cases of complete remission of diabetes in teenage girls with lifestyle modification and emphasize once again that intensive lifestyle improvement is an effective early treatment for diabetes. 15
Our results demonstrate that intensive lifestyle modification including regular exercise and dietary changes is very effective in the treatment of obese patients with type 2 diabetes.
CONFLICTS OF INTEREST
The authors declare that there are no conflicts of interest.
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Case Study: Diabetes and Obesity with Osteoarthrosis
This is an excerpt from acsm's exercise management for persons with chronic diseases and disabilities-4th by american college of sports medicine,geoffrey moore,j. larry durstine & patricia painter., type 2 diabetes and obesity with osteoarthrosis.
Presenter: Geoffrey E. Moore, MD, FACSM
"I intend to live into my 90s but I can't get there unless I'm dancing."
A 52-year-old woman with type 2 diabetes was referred for help on lifestyle. She had a family history of diabetes and tended toward a centripetal/abdominal fat distribution pattern associated with high CV risk. Her recent A1c values had been 6.5-6.6, and her a.m. fasting glucose was recently 102. She qualified as T2DM by A1c criteria but wasn't working on her diet or weight and had refused to start taking metformin, and her primary care physician was increasingly concerned.
She expressed a desire to be more active through dance, which she had loved since childhood and felt was a part of her culture (having immigrated to the United States as a child). She expressed little concern about her weight and was more worried that the pain in her L shoulder kept her from dancing. She had first experienced the shoulder problem 10 years earlier while swimming backstroke. She had been to physical therapy (PT) twice, which made it worse. She also had received subacromial cortisone injections, but the relief didn't last. Her shoulder is worse at night (rolls over on her left side); the pain was rated 8/10 and was daily and constant except for sharp pain that radiated to the side of the neck when she moved the shoulder too much. She tried not to take pain or anti-inflammatory medications because she said they "wreck her stomach." Acupuncture (cupping) helped.
She also noted a history of her L knee "giving out," causing falls, and of having 2 knee arthroscopic surgeries (4 and 10 years earlier). When she overdoes weight-bearing activity, her left knee swells "like a watermelon." She did PT after the surgeries and gets to her normal daily activities but can't dance.
- Height: 5 ft 4¾ in. (1.65 m)
- Weight: 234.4 lb (106.3 kg)
- BMI: 39 kg/m 2
- HR: 65 contractions/min
- BP: 188/98 mmHg
Pertinent Exam
- General: normal development, good nutrition, obese body habitus, no deformities
- CV: regular rhythm with normal S1 and S2, without rubs, gallops, or murmurs; distal pulses/circulation normal; no edema
- Normal gait and station, muscular build especially of lower extremities
- Valgus alignment of both knees, no tenderness but the L knee has a small effusion
- Normal ROM without pain, substantial crepitus in both knees
- + Painful arc
- + Glenohumeral laxity, with crepitus
- + Neer test, +/- Hawkins test, +/- Speed's test
- + Painful with resisted external rotation, - pain with resisted internal rotation
- + AC joint tenderness
- Osteoarthrosis in the acromioclavicular joint; severe osteoarthrosis in the glenohumeral joint with advanced sclerosis, subchondral cysts, and spurring; subluxed position of the humeral head at rest
Medications
- Coreg 10 mg once daily
- Diovan HCT 320/12.5 once daily
- Multivitamin once daily
- Increased CV risk: HTN, hyperlipidemia, diabetes by A1c criteria, sleep apnea, obesity
- Advanced glenohumeral osteoarthrosis and reduced function due to pain, status post - bilateral partial meniscectomies
Her shoulder markedly diminishes quality of life, impairing her ability to sleep and to recreate. Dance is her preferred form of physical activity, which she wants to do as her approach to improve the blood glucose and reduce her CV risk profile.
- L shoulder OA: refer to PT shoulder specialist
- It was explained that her shoulder would take a long time to get better, but she was likely to have some gains in reduced pain and better function after 3-6 months of PT
- Ibuprofen 500 mg every 8-12 hours and prior to bedtime as needed for pain
- Dance for exercise, but any dances that cause pain should be avoided
- Review on the difference between pain and discomfort
- High cardiovascular risk: She was not interested in addressing her cardiometabolic risk at the time of the first visit.
- Pain-free near-normal physical functioning of L shoulder
- Dance, including tango, for recreation and physical activity
- Physical therapy focused on rotator cuff and scapular stabilizer strengthening, postural control, manual therapy, and education on pain avoidance
- Gentle dancing that avoids painful arm movements started, daily for 30 min
- Dancing and daily activities to be increased as tolerated (i.e., shoulder discomfort)
Exercise Program
- Physical therapy twice weekly
- Home exercises daily, as advised by therapist
- Dancing that does not cause pain allowed as tolerated
- L shoulder OA
- Pain-avoidance techniques gave rapidly improved physical functioning of L upper extremity.
- Physical therapy made good progress over 3 months to near-normal physical functioning.
- Dance for aerobic exercise was very successful in getting her motivated.
- High cardiovascular risk
After 2 months of PT, she was motivated to work on weight management and diabetes prevention. She enrolled in a partial meal-replacement lifestyle intervention plan, lost 25 lb (11.3 kg) over the subsequent 3 months, and her fasting blood glucose/A1c returned to normal.
Senior Editor's Comment
This patient's story illustrates some of the art of exercise medicine, revealing the importance of working with patients to meet their emotional expectations and needs. Her primary care team was concerned about the diabetes and had been advising her about diet, weight loss, and taking metformin, but this was less important to the patient than the loss of her ability to dance. Dancing was the only type of physical exercise she enjoyed, so she needed to be able to dance as part of her pathway to improving insulin sensitivity. Close liaison with the physical therapist facilitated the process, because the therapist provided her with tips on how to avoid painful movements and begin to dance immediately. By accepting the need to dance as her top priority and then working to help overcome her barriers to dancing, the lifestyle intervention team gained her faith in them and she began to follow their advice on diet and weight. This approach seemed unusual to many who were involved in her care, as it appeared to put the diabetes problem on hold while focusing on a painful shoulder. But from another perspective, the painful shoulder was the most important problem to the patient and thus a significant barrier that needed to be overcome if exercise (in the form of dance) was to become her most important medicine.
Learn more about ACSM's Exercise Management for Persons With Chronic Diseases and Disabilities, Fourth Edition .
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A case study: obesity and the metabolic syndrome. a three-pronged program, targeting education, close follow-up and a dietary supplement, significantly decrease body weight and body fat, grethe s birketvedt.
Medical Center for Obesity and Research, Baerum, Oslo, Norway
E-mail : [email protected]
Carl Fredrik Schou
Teres Colosseum, Oslo, Norway
Erling Thom
ETC Research and Development, Oslo, Norway
DOI: 10.15761/IOD.1000143
A 38-year old woman with a body fat content of 52.2% and a BMI of 48.2 kg/m 2 was seeking medical treatment in an outpatient obesity clinic in Oslo, Norway. She suffered from a severe abdominal hernia and was not qualified for surgery of this condition until her BMI was under 30 kg/m 2 . Additionally, she was severely challenged in terms of mobility as she was born with cerebral palsy and required either a wheel chair or crutches to get around. Over the years she had sought several treatment options to control her obesity but with no success. She did not qualify for bariatric surgery and was severely depressed when she came to the clinic. After examination and diagnosis, the decision was made to begin a multi-pronged treatment using a natural dietary supplement, combined with the customized educational program called “The Body in the Brain”, and a close medical follow-up with regular appointments to the outpatient clinic. After twenty-three months of treatment, the woman had lost 38 kg of bodyweight and had normalized fat percentage for her age and gender. In conclusion, it is possible to successfully treat severe obesity and return a patient to a normal body fat percentage with the combination of a natural dietary supplement, a designed diet composition and a weight loss behavioral program.
obesity, weight loss, metabolic syndrome
Introduction
Obesity and the metabolic syndrome are linked together [1]. When an individual gets severely obese, insulin resistance, hypertension and increased abdominal circumference follow as a natural cause due to the excess fat in the body. Obesity and the metabolic syndrome has been extensively researched and today clinical evidence implicates intra-abdominal adiposity as a powerful driving force for elevated cardio metabolic risk [2]. This association appears to arise directly, via secretion of adipokines, and indirectly, through promotion of insulin resistance.
The most important therapeutic intervention effective in subjects with the metabolic syndrome should focus on weight reduction and regular daily physical activities. Health experts agree that making lifestyle changes, including following a healthy eating pattern, reducing caloric intake, and engaging in physical activity, are the basis for achieving long-term weight loss [3,4]. However, weight-loss and weight-management regimens have frequently been ineffective. Therefore, effective medical interventions to manage weight gain and slow or prevent progression to obesity are needed. Control of diet and exercise are cornerstones of the management of excess weight. A number of nutritional approaches and diets with different proportions of lipids, proteins and carbohydrates have been prescribed for weight loss. Initial guidance on weight loss was earlier years a restriction in saturated fats that unfortunately did not necessarily result in weight loss. Recently, a shift towards a reduction in refined carbohydrates has been a new approach to lose weight.
Several studies have indicated that fiber-rich foods and fiber supplements have moderate weight reducing effects, and may also improve the lipid profile in overweight and obese individuals [5,6]. There are hundreds of weight loss products sold over the counter today. Typically, these OTC supplements have not been clinically tested, can have significant unwanted side effects and not yield successful results in helping people to lose weight.
The natural product, used in this case study is supplement that consists of a unique combination of three natural ingredients: white kidney bean extract, locust bean gum extract and green tea extract that affect weight loss with little to no side effects. The white kidney bean extract is phaseolus vulgaris, a bean extract containing phaseolamin. Phaseolamin is a glycoprotein found mainly in white and red kidney beans and is an effective alfa-amylase inhibitor [7]. The extract of locust bean gum, is a seed-coat extract that decreases ghrelin [8], the hunger hormone and make you feel faster satiated and will postpone the hunger sensation after a meal. Locust bean gum has also shown lipid lowering effects in several studies [9]. The third ingredient is a green tea extract [10-12], Camellia sinensis with anti-inflammatory and antioxidant properties with a small increase in the energy expenditure.
Aim of study
The aim of this study was to investigate whether a dietary supplement with white kidney bean extract, locust bean gum extract and green tea extract in combination with a program with lifestyle changes would enhance weight loss and fat loss and improve the metabolic parameters in a severe obese patient with the metabolic syndrome.
A 38 year old woman with a history of obesity, diabetes type 2 and hypertension was seeking treatment in an out-patient clinic in Oslo, Norway for medical weight loss management. She was well aware of the link between obesity, diabetes and cardiovascular disease and felt this appointment she had asked for was her last chance in getting help with her health problems.
She had been normal weight as a child and adolescent, but do to a dependency of crutches and a wheelchair she had gradually put on weight in her twenties. She was married with two young children and she increased in weight after each child birth. She suffered a severe abdominal hernia that stressed her, but she had been refused surgery due to her heavy weight.
She had in her childhood and teens always been of normal weight, active and healthy in spite of her physical disabilities. When she got married, she gradually gained weight and the weight culminated after her second child was born. She had developed diabetes type 2 and hypertension after her children were born, and was medicated with antihypertensive and antidiabetics. Her primary care physician had not really been interested in her weight and had several times suggested higher doses of medications or insulin injections. The patient was not interested in insulin injections as she was afraid of gaining more weight.
Our patient had been sedentary the last 5 years due to the abdominal hernia. She had tried many weight loss efforts on her own, had started working with a personal trainer and had weekly sessions with a physical therapist. Her diet had been high in fat and calories although she was very well educated in nutritious food. However, she admitted to overeating, and periods of binging. She drunk about 2.5 liter of diet soda a day including diet juice. She was very conscious about eating habits when it came to her two kids, and they were both healthy and in normal weight. She had a university education and was well informed of her health situation. But she was under much stress in her daily life and struggled daily to get help from health authorities.
Her initial anthropometric measurements included a weight of 125kg with a height of 1.61m, a body mass index (BMI) of 48.2kg/m 2 which classified her as morbidly obese. Her fat % was 52.2% with 65 kg fat mass measured by bioelectrical impedance analysis (BIA)[13] (Tanita Body Composition Analyzer BC-418) for analyzing the composition of the body, such as weight, lean body mass (LBM), total body water(TBW), fat free mass (FFM) and basal metabolic rate (BMR). Her HbA1c had the last 2 months ranged from 11.7% till 8.8% and her hypertension was 160/95 mm Hg.
Informed consent
The patient has signed and approved the consent form.
On the first visit to our clinic, the patient was advised of which food items of simple carbohydrates she should try to avoid in her daily diet. She was given restrictions in caloric content and a diet plan, specifically designed for her health situation with emphasis on her hypertension and diabetes type 2. She was also advised to drink water with a slice of lime instead of diet sodas and diet juice. One of her main goals was to be able to not require medications for control of her hypertension that would then improve her diabetes type 2 and simultaneously decrease her weight. It was extremely important for the treating physician to give her food compositions that targeted the ability to relieve stress in the gut-brain axis.
Her resting metabolic rate (RMR) was measured to 1828 kcal and the physician designed a diet in the range of 1200kcal to 1600 kcal. In that way, she at least could have a deficit of about 400 kcal a day taking into account her limited physical activity level. In a two week period this regimen would theoretically allow her approximately a 0.5 kg loss in weight. Due to her decrease in simple carbohydrates she was advised to check her blood sugar 3 times per day and write the recordings down until next meeting. She was instructed on how to decrease her diabetes medication based on her blood sugar levels.
The weight management program at our clinic was continuing with bi-weekly visits by the patient for the next six weeks, and then monthly visits after that time. Furthermore, the patient was advised after six weeks to additionally take one capsule of the dietary supplement twenty minutes before each of the main meals, breakfast, lunch and dinner.
On a monthly basis, her weight and body fat percentage were recorded with BIA at the doctor visits. Moreover, she was given 1 hour consultation with behavioral modification with advise to lifestyle changes according to a program entitled the “Body in the Brain”, a recently published book in Norway, targeting education on how the brain and the body work together in hormonal harmony when the right diet is introduced for the right person. The patient was allowed to eat whatever she wanted in the diet plan restricted to 1200-1600 kcal, excluded from the carbohydrate list were white breads and pasta, cookies, cake, candy, sugar-sweetened sodas and drinks as well as diet sodas and diet juice. She followed the educational program related to the “Body in the Brain”[14] where she each month was given new insight into how the body and the brain worked together in a hormonally balanced way. She was also gradually introduced to healthier foods, e.g., food that was rich in tryptophan, an essential amino acid that target serotonin in the brain and indirectly impact insulin levels. In her diet plan was a list of tryptophan rich food such as e.g.salmon, chicken, cod, tuna, apricots, broccoli, sprouts, whole grain, skimmed milk and almonds, food that was known as comfort food or mood food. The list was extended each visit and the food the patient did not like was replaced with other food items.
In her first two weeks of treatment she lost only one pound, but she reported that her blood sugar had not spiked as much as prior times after she had tried to avoid sugar and other simple carbohydrates. She admitted it was difficult to avoid these foods as she always had had a sweet tooth. On her second visit she was educated in how the body relates to the brain in a hormonal way when certain food items are ingested. She was introduced to the amino acid tryptophan and how the tryptophan rich food would create more harmony in the gut-brain axis, increase serotonin levels and decrease cortisol and thereby improve insulin sensitivity. The education went on for 22 months and at each visit the biochemistry of food were addressed. How the food she ingested had an impact on her body and brain was a favorite topic of the visits to come.
Over the next four weeks she had lost only 1.2 kg. The visit two weeks later showed a decrease of an additional 0.7 kg, however the fat percentage in her body had not changed. Until this time, the fat lost was attributable to pure lean body mass. She was then introduced to the patented supplement consisting of Green tea extract, White kidney bean extract and Locust bean gum extract, a supplement that was sold over the counter in Norway, approved by the Norwegian Medicines Agency and also recently the ingredients were approved by the FDA in the US. She gradually lost weight each month with a simultaneous loss in fat percentage. 12 months later she had lost 21 kg of which 85% was loss in fat mass. She became less depressed, her energy level had improved, and she was still very motivated for further weight loss.
By the end of the 23 month treatment period she had lost 38 kg and the fat percentage in the body had decreased to 31.9% which was within normal limits for her age. Her blood sugar was under control. However, she was still on antidiabetics, however, her blood sugar and HbA1c was within normal limits and her hypertension was well regulated. Six months later, she was accepted for the surgery of her abdominal hernia as her fat mass was within normal range in spite of a BMI>30kg/m 2 .
The patented diet supplement with white kidney bean extract, locust bean gum and green tea extract in combination with an education program (The Body in The Brain) consisting of twenty-six outpatient clinic sessions, resulted in a very significant weight loss, improvement in fat percentage, hypertension and blood sugar levels in an obese woman following this program. In terms of the weight loss observed in this patient, fat was more than 75% of the total weight lost indicating a qualitative weight reduction where less than one quart of the weight lost was lean body mass[15]. The patient lost 25% more body fat of her weight lost than would predicted with lifestyle changes alone. The special designed diet program was modified accordingly in subsequent visits due to changes in the BMR. Her caloric intake was never changed to lesser than her BMR. The reason why her energy level increased and her mood improved, can very well be caused by the change in diet.,At each meal, she ate primarily foods rich in tryptophan combined with complex carbohydrates and thereby increased her serotonin levels. Several studies have shown that increased serotonin levels are related to mood elevations [16,17]. However, her improved mood and higher energy in this patient, may also be caused by the fat lost relieving the stress in the gut-brain axis.
The amount of fat mass lost of weight lost was far more than reported in earlier studies. This is in accordance with earlier unpublished pilot studies with the diet supplement used in this case report. We believe that adding this specific supplement to this combined treatment enhanced fat loss and thereby normalized parameters associated with the metabolic syndrome. Earlier studies have shown that in severe obese individuals it is almost impossible to reach normal fat mass with lifestyle changes and behavioral modification alone. We believe that our natural supplement had both carbohydrate and lipid lowering effects on fat metabolism and also increased the fat expenditure. Moreover, we believe that the education program, The Body in the Brain used in this three-pronged program, enhanced the weight loss. The patient understood the mechanisms in her body related to the food she ate, which increased her motivation for weight loss and prevented weight gain again as in earlier reports. Moreover, an encouraging physician at each visit may also be important for the patient to reach her goals. We cannot neglect the fact that obese patients are very sensitive to the knowledge of the physician and the way she is being encouraged on her road to weight loss.
A program like this can be a valuable method in the treatment of obesity in the future.
A three-pronged treatment paradigm that includes close physician follow-up, a well designed education program, and the addition of a dietary supplement consisting of an extract of white kidney bean, an extract of locust bean gum and an extract of green tea extract gave a substantial weight loss and a loss in fat mass towards a normal fat percentage in a severe obese person with the metabolic syndrome.
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- Birketvedt GS, Langbakk B, Florholmen J (2004)A Dietary Supplement with Bean Extract Decreases Body Weight, Body Fat, Waist Circumference and Blood Pressure in Overweight and Obese Subjects. Current Topics in Nutraceutical Research 3:137-142.
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- Zavoral JH, Hannan P, Fields DJ, Hanson MN, Frantz ID, et al. (1983) Thehypolipidemic effect of locust bean gum food products in familial hypercholesterolemic adults and children. Am J ClinNutr 38: 285-294. [ Crossref ]
- Toda (1989) Green tea extract has been shown to decrease weight in overweight subjects. Nippon SaikingakuZasshi 44: 669-672.
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Editorial Information
Editor-in-chief.
Sharma S Prabhakar Texas Tech University Health Sciences Center
Article Type
Publication history.
Received: January12, 2016 Accepted: February08, 2016 Published: February 11, 2016
©2016Birketvedt GS.This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Birketvedt GS, Schou CF, Thom E(2016) A case study: Obesity and the metabolic syndrome. A threepronged program, targeting education, close follow-up and a dietary supplement, significantly decrease body weight and body fat. Integr ObesityDiabetes. 2:doi: 10.15761/IOD.1000143
Corresponding author
Medical Center for Obesity and Research, Baerum, Oslo, Norway.
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Obesity Case 12
A 47-year-old woman with primary hypothyroidism and osteoarthritis of the right knee presented to the clinic for follow-up. She is trying to lose weight in preparation for right knee surgery. The weight loss has plateaued on a low-calorie meal plan. Her exercise is limited by chronic knee pain. She tracks her calories and daily steps. After the discussion about the risks and benefits of weight loss medications, she was started on phentermine/topiramate extended-release daily. She returns three months later and has lost 3% of her body weight since the last visit. On physical examination, her BMI is 34 kg/m². She has decreased range of motion of right knee. Otherwise, the physical examination is unremarkable.
Which of the following is true for cardiometabolic risk markers after weight loss?
The effect of phentermine/topiramate extended-release on cardiometabolic risk factors include lowering of hs-CRP and an increase in adiponectin. There is a reduction in systolic and diastolic blood pressure, reduction in triglycerides, total cholesterol and LDL cholesterol, and an increase in HDL cholesterol with weight loss.
Obesity Case 11
A 63-year-old African American male with a history of obesity, T2DM, CKD3b and recent NSTEMI was referred for cardiometabolic risk optimization.
Medications: atorvastatin 80mg, lisinopril 20mg, aspirin 162mg, metformin 1000mg bid, metoprolol 50mg daily, duloxetine 20mg daily
- Heavy in starchy and refined carbohydrates, “meat & potatoes,” and casseroles
- Doesn’t snack much and avoids sweets or baked goods during the day and evening but eats fruit for dessert
- No sugar-sweetened beverages and rare alcohol
Exercise: states he has always been physically active with his work but has been in cardiac rehab three times weekly for the past 6 weeks
Sleep: has OSA treated with cpap
Exam: BMI 37 and waist circumference 111cm; BP 140/90; pulse 66
Labs: HbA1c 7.6%, eGFR 44, total cholesterol 145, HDLc 45 mg/dL, trig 160 mg/dL, LDLc 68 mg/dL, albumin 4, ALT 35, platelets 300,000, urine albumin:creatinine 320
In addition to adding a SGLT2inh for cardiovascular and renal benefits, which medication approved for the chronic therapy of obesity would be preferred?
The GLP-1 analog, liraglutide, previously approved for the treatment of type 2 diabetes mellitus (T2DM), is also approved as a weight loss agent at a dose of 3 mg daily. In the SCALE diabetes trial, there was an average of about 4% placebo-subtracted weight loss and HbA1c reduction of 1% more than placebo and statistically better in both regards than the 1.8-mg dosing [1] . Liraglutide at all doses consistently improves cardiometabolic risk factors including lipids and blood pressure with slightly increased heart rate. A pooled post hoc analysis of the phase 3 trials involving liraglutide 3 mg suggested possible cardiovascular benefit but with small numbers of events and wide confidence intervals [2] . Further reassurance of cardiovascular safety, and perhaps benefit, could be drawn from the benefits shown in the LEADER trial of 1.8-mg liraglutide in patients with T2DM and high-risk (and high prevalence of established) CVD [3] .
The other medications are not preferred for reducing CV risk in this patient with established ascvd and CKD3b though could be considered [4] . Orlistat reduces cardiovascular risk factors and has no cardiovascular safety concerns but has not shown cardiovascular event reduction and is not as beneficial for this patients glycemic control and renal benefits. Sympathomimetics, like phentermine in the combination of phentermine/topiramate ER, are to be used in caution for patients at increased cardiovascular risk. While the cardiovascular safety of phentermine/topiramate ER is not established, data from the phase 3 trials are reassuring thus far [5] . Weight loss with naltrexone/bupropion ER is accompanied by improvements of several cardiometabolic parameters, though blood pressure generally remained higher than placebo in trials. A cardiovascular outcome trial was initiated for naltrexone/bupropion ER with reassuring early data, though with high discontinuation rate, but the trial had to be terminated due to public compromise of that data; thus, the cardiovascular safety has not been determined [6] .
[1] Davies MJ, et al. Efficacy of liraglutide for weight loss among patients with type 2
diabetes: the SCALE Diabetes Randomized Clinical Trial. JAMA 2015;314(7):687–699
[2] Davies MJ, et al. Liraglutide and cardiovascular outcomes in adults with overweight
or obesity: a post hoc analysis from SCALE randomized controlled trials. Diabetes Obes
Metab 2018;20:734–739
[3] Marso SP, et al. Liraglutide and cardiovascular outcomes in type 2 diabetes. N Engl J
Med 2016;375(4):311–322.
[4] Garvey WT, et al. American Association of Clinical Endocrinologists and American
College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care
of Patients with Obesity. Endocr Pract 2016;22(suppl 3):1–203
[5] Ritchey ME, et al. Cardiovascular safety during and after use of phentermine and
topiramate. J Clin Endocrinol Metab 2019;104(2):513–522. doi:10.1210/jc.2018-01010.
[6] Nissen SE, et al. Effect of naltrexone-bupropion on major adverse cardiovascular
events in overweight and obese patients with cardiovascular risk factors: a randomized
clinical trial. JAMA 2016;315(10):990–1004
Obesity Case 9
A 27 year-old woman with a history of obesity, polycystic ovary syndrome (PCOS) and primary hypothyroidism is referred to you for recent weight gain. She also has a history of recurrent kidney stones. Despite her best efforts to follow a meal plan as prescribed by a registered dietitian and increasing her physical activity by hiring a personal trainer, she has gained 20 pounds in the 6 months prior to her visit with you. She reports recent trouble with portion control. She generally eats three large meals per day and craves salty snacks like potato chips and tortilla chips in the evening while watching TV.
She was evaluated by another endocrinologist who documented a normal 11 pm salivary cortisol, fasting glucose, glycated hemoglobin A1c (HbA1c), and thyroid-stimulating hormone (TSH) level. Her past medical history is unremarkable. Her only medication is levothyroxine 100 mg daily. Her family history is notable for obesity and type 2 diabetes mellitus (T2DM) in her father. Her mother had medullary thyroid cancer but is currently free of disease. She is married, but does not desire to start a family yet, wishing to focus on her personal health first.
On review of systems, she has generalized anxiety and trouble sleeping. Menses are irregular. On physical examination, her heart rate is 88 beats/minute, and her blood pressure is 125/80 mm Hg. Her body mass index (BMI) is 36 kg/m2 (normal, 18.5 to 24.9 kg/m2), and her waist circumference is 96.5 cm. She has mild facial hirsutism on the chin and upper lip. The thyroid gland is minimally enlarged, but there are no palpable nodules. An ultrasound performed 6 months ago also did not show any nodules.
The most appropriate choice of pharmacotherapy for this patient is which of the following?
Increasing fat mass is always due to a positive energy balance. In addition to ongoing meal-planning and physical activity, pharmacotherapy plays a role in helping patients adhere to nutrition therapy. Scientifically, there is a growing armamentarium of medications for obesity.
Practically, as of 2017, obesity medications are not covered by the federal government or many third party payers. This results in patients having to incur the cost of medications out-of-pocket. This severely restricts patient access to needed care. Phentermine is an adrenergic agonist. It is approved for short-term use for the treatment of obesity (generally considered 3 months). Although it was originally labelled as having the potential for being habit-forming, tolerance-building, and addictive, we now know it is not. Phentermine is the most commonly used weight management medication because it is generic and cheap. It is safe and effective, but its side effect profile includes hyperadrenergic signs and symptoms. Phentermine use may cause an increase in the heart rate, jitteriness, shakiness, anxiety, palpitations, insomnia, dry mouth, constipation, and anxiety. Therefore, phentermine should be avoided in people who have underlying anxiety.
Phentermine in combination with topiramate is available as Qsymia® in the United States. This combination of medications allows for the phentermine dose to be lower. Although the phentermine dose is lower in Qsymia, its use would still be a concern in a patient with anxiety. Topiramate causes cleft-lip and cleft-palate malformations in women who take it during pregnancy. Topiramate is therefore absolutely contraindicated in women desiring pregnancy. There is also increased risk of nephrolithiasis with topiramate therapy thus not the preferred medication.
Orlistat is a pancreatic lipase inhibitor. For it to be effective, an orlistat capsule has to be taken with each meal containing fat. Orlistat acts entirely within the lumen of the gut. Lipase inhibition causes fat malabsorption. Fat malabsorption in turn may cause loose stools, oily stools, fecal incontinence, and anal leakage. Most of the symptoms of fat malabsorption go away with daily ingestion of soluble fiber (i.e., psyllium seeds), and the ingestion of 500 mg of calcium carbonate with each orlistat capsule. Calcium carbonate saponifies any oily residue and prevents its irritating effects. The combination of both psyllium and calcium carbonate makes most of the untoward symptoms of fat malabsorption due to orlistat go away, and patients may tolerate it. Over time, orlistat may lead to fat-soluble vitamin malabsorption, and it is recommended to prescribe a multivitamin to be taken apart from meals. Orlistat is probably not the best option due to her regular intake of high fat snacks as well as the increased risk of calcium oxalate stones. In addition, orlistat can block the absorption of levothyroxine, and its dosing would need to be separated from the thyroid medication making it a less optimal choice. Furthermore, orlistat is the only approved weight loss medication that does not work on appetite control which is her primary barrier to dietary adherence.
Liraglutide, 3 milligrams daily, is marketed as Saxenda® in the United States. Liraglutide is a glucagon-like peptide-1 (GLP-1) receptor agonist. It delays gastric emptying, improves insulin secretion in response to postprandial hyperglycemia in people with diabetes, suppresses glucagon release from the pancreas, and stimulates central receptors that promote early satiety. Liraglutide, being a polypeptide, must be injected subcutaneously. It is formulated as a daily injection and is the most costly of the weight-management medications available as of 2017. Liraglutide may cause nausea and other gastrointestinal symptoms. For patients with obesity and hyperglycemic derangements, it may be the preferred option. Due to carcinogenicity studies in rodents, liraglutide is contraindicated in patients with a personal or family history of medullary thyroid cancer or multiple endocrine neoplasia type 2 so this option is incorrect.
The best choice of agents for this patient is the combination of buproprion and naltrexone. Bupropion is a mood stabilizer that also decreases addictive and compulsive behavior. Naltrexone is an opioid receptor blocker and decreases the pleasure of meal intake. The combination of these medications helps to decrease food intake and reduce cravings. The naltrexone component predictably causes nausea, and therefore, the dose is gradually titrated from one tablet daily to two tablets twice daily over time. Most patients tolerate an increase of one tablet a day, once a week.
Obesity Case 8
A 58 year-old man is referred to see you for a fasting glucose of 108 mg/dL (normal, 70-100 mg/dL). He has a past medical history of hypertension treated with atenolol 25 mg daily and hypercholesterolemia treated with atorvastatin 20 mg daily. His only regular physical activity is walking four blocks to and from a diner each day at lunchtime. His father was a heavy smoker and had a myocardial infarction (MI) at age 43 years. On review of systems, he complains of fatigue, dyspnea on exertion, gastroesophageal reflux, lower extremity edema, snoring, sleep disturbance, loss of libido, erectile dysfunction, and a depressed mood without suicidal thoughts or ideation. On physical examination he has a body mass index (BMI) of 38 kg/m2 (normal, 18.5 to 34.9 kg/m2), blood pressure of 150/94 mm Hg, resting heart rate of 84 beats/minute, a neck circumference of 42 cm, a waist circumference of 109 cm, a crowded oropharynx, and 2+ pitting edema of the pretibial surfaces. Thyroid, lung, cardiac, abdominal, genital, and peripheral arterial exams are normal. Review of outside labs also includes a total cholesterol of 250 mg/dL (desirable, <200 mg/dL), triglycerides of 500 mg/dL (desirable, <150 mg/dL), and high density lipoprotein cholesterol (HDL-C) of 27 mg/dL (desirable, = 60 mg/dL). The patient's calculated LDL cholesterol (LDL-C) could not be determined due to the high triglycerides.
Which of the following is the most appropriate next step?
Overweight and obesity represent a continuum of a chronic disease that takes away from psychological, physical (adiposity), and metabolic (adiposopathy) health. The initial approach to a patient with overweight or obesity involves risk stratification. A thorough evaluation looking for causes or complications of the increased fat mass is the goal of the first patient encounter. Many of the complications of obesity generate vicious cycles that make ongoing accrual of fat mass likely and loss of fat mass difficult. These complications include insulin resistance, male hypogonadism, sleep apnea, depression, degenerative disc disease, and degenerative osteoarthritis.
Additionally, pharmacotherapy may cause the accumulation of fat mass or become an obstacle to weight loss. A careful review of medications is needed to remove the ones that may cause weight gain and introduce alternatives that may lead to weight loss. This patient is treated with a beta blocker. Beta blockers cause chronotropic insufficiency, depression, exacerbation of reactive airway disease, erectile dysfunction, and because of all of this, weight gain. Replacing the beta blocker with other antihypertensive medications is desirable in this patient, unless he already has coronary artery disease. This patient has dysmetabolic syndrome, with hyperglycemia, hypertension, high triglycerides, low HDL-C, and a high waist circumference, which places the patient at high risk of coronary artery disease. Therefore, an assessment of the patient's coronary artery reserve is the most important first step before making therapeutic decisions.Measuring the patient's total testosterone is appropriate since many of the patient's symptoms may be due to hypogonadism. These symptoms include fatigue, loss of libido, erectile dysfunction, and depression.
A low total testosterone needs further laboratory evaluation to determine whether the patient has primary hypogonadism or hypogonadotropic hypogonadism. A total testosterone of 200 ng/dL or less warrants treatment with testosterone replacement as a means to help the weight loss process.If the patient does not have established coronary artery disease, beta-blocker therapy may be discontinued. Treatment of the patient's hypertension is medically necessary. Angiotensin converting enzyme inhibitors or angiotensin receptor blockers are the preferred agents to treat hypertension in patients with obesity. Lisinopril should be added when atenolol is discontinued.The cornerstones of good health include meal planning, healthy eating, good nutrition, adequate daily physical activity, adequate sleep, and time for recreation. Referral to a dietician is always appropriate to help patients meet these goals.
Obesity Case 7
An older man with obesity and type 2 diabetes, without hypertension, comes for a second opinion about dietary management. His primary care physician recommends that he switch to a Mediterranean diet supplemented with mixed nuts, without worrying about energy restriction. The patient is concerned that such an approach will worsen his cardiovascular risk.
Which one of the following statements about the Mediterranean diet is correct?
The latest publication from the PREDIMED trial group reported a significant reduction in major cardiovascular events, but not overall mortality, after 5 years on a Mediterranean diet. Over 7000 persons at high cardiovascular risk were enrolled and assigned to either a low fat control group or a Mediterranean diet enriched in nuts or olive oil. Energy restriction was not specifically recommended. Both of these Mediterranean-based diets were successful, and the trial was halted just over one year early because of the significance of the results. The nut-supplemented group showed a shift in their lipid patterns to less atherogenic lipid profiles and reductions in small dense low density lipoprotein (LDL).
In a sub-study from PREDIMED reporting on patients with type 2 diabetes, Mediterranean diets supplemented with virgin olive oil or nuts reduced total body weight and improved glucose metabolism to the same extent as the usually recommended low-fat diet.The diet was effective in almost all subgroups within the trial, with the notable exception of patients with normal blood pressure. Patients with diabetes saw a benefit similar to the overall group. In contrast, lifestyle modification has been shown to prevent diabetes mellitus more consistently, but diet has been less consistent in preventing or reducing cardiovascular disease. The recent LOOK AHEAD study revealed no significant benefit of lifestyle modification on cardiovascular risk, although this paper studied only persons with pre-existing diabetes. Neither low carbohydrate diets nor addition of omega-3 fatty acids can prevent diabetes mellitus, and these diet modifications may even be associated with a higher risk of diabetes mellitus.
Obesity Case 6
A 55 year-old woman with a strong family history of both coronary artery disease and type 2 diabetes mellitus (T2DM) comes for evaluation. She has a 6-year history of hypertension, a long-standing problem with obesity, and pre-diabetes revealed by recent laboratory testing. She questions whether a low fat or low carbohydrate diet would be helpful in reducing her risk of coronary artery disease.
Which one of the following statements regarding the beneficial effect of diet in reducing cardiovascular risk and/or risk of diabetes mellitus is correct?
In the Women's Health Initiative Dietary Modification Trial, nearly 50,000 postmenopausal women were randomly assigned to a low-fat dietary pattern or to a usual diet comparison group. The 8.3-year intervention period ended in 2005, but all participants were followed for mortality through 2013. Incidence rates for cardiovascular disease (CVD) did not differ between the intervention and comparison groups.
Several studies have compared low carbohydrate and low fat diets in obesity. In one representative study, a one-year, multicenter, controlled trial randomized 63 men and women with obesity to either a low-carbohydrate diet or a low-calorie, high-carbohydrate, low-fat (conventional) diet. Subjects on the low carbohydrate diet lost more weight than subjects on the low fat diet at 3 and 6 months, but the difference at 12 months was not significant. No differences were found between the groups in total cholesterol or low density lipoprotein (LDL) cholesterol concentrations.
The increase in HDL cholesterol concentrations and the decrease in triglyceride concentrations were greater on the low carbohydrate diet compared to the conventional diet during most of the study. In a subsequent paper from the same researchers randomizing 307 persons for two years, weight loss was similar between diet strategies, but the major lipid difference at the two-year time point was lower triglycerides in the low carbohydrate group. These lipid changes have been consistent across many studies. In such research, adherence tends to be poor with high attrition, hence a paucity of long-term (i.e., 5-year) data.A meta-analysis of 23 trials from multiple countries containing more than 2500 randomized participants concluded that both low-carbohydrate and low-fat diets lowered weight and improved metabolic risk factors. Compared with subjects on low fat diets, persons on low carbohydrate diets had a slight benefit with regard to total cholesterol and LDL, but achieved a greater increase in HDL and a greater decrease in triglycerides. Reductions in body weight, waist circumference, and other metabolic risk factors were not different between the two diets.
Obesity Case 5
A 28 year-old woman seeks advice about prevention of gestational diabetes mellitus. Three of her sisters have had pregnancies complicated by gestational diabetes mellitus (GDM). Although good randomized trial data evaluating whether specific diets can prevent gestational diabetes are lacking, she was advised to lose weight. Eighteen months later, the patient has not succeeded in losing any weight, but has become pregnant. She continues to follow a typical Western diet with an abundance of processed food. She walks for 20 minutes five days per week. She comes to your office at 26 weeks of gestation because her glucose tolerance test showed gestational diabetes.
Which of the following statements reflect the best available evidence regarding which diet she should follow to control her blood sugars?
A low GI diet is typically advised as treatment for women with GDM. Although data from randomized control trials is limited, low GI diets have demonstrated benefits and no harm. In a meta-analysis, low GI diets demonstrated a lower risk of macrosomia and a lower risk of insulin usage. Additionally, low GI diets with increased dietary fiber have been shown to reduce the risk of macrosomia beyond that of a low glycemic index diet alone.
Most clinical practice guidelines recommend that women with gestational diabetes limit carbohydrate intake to 35% to 45% of total calories with a minimum of 175 g/day to avoid ketogenesis, distributed in three small- to moderate-sized meals and two to four snacks, including an evening snack. The carbohydrate choices should preferably be low glycemic index with increased dietary fiber.Energy restriction is recommended by the Endocrine Society with their guideline that women with obesity and overt or gestational diabetes reduce their calorie intake by approximately one-third (compared with their usual intake before pregnancy) while maintaining a minimum intake of 1600 to 1800 kcal/d.
For her next pregnancy, assuming that she is not diagnosed with diabetes at the conclusion of the current pregnancy, it is unclear which dietary recommendations should be given to prevent repeat gestational diabetes. Large population surveys have demonstrated that women eating the highest quantities of plant-based carbohydrate and protein and the lowest amount of saturated fat/red meat are least likely to be subsequently diagnosed with gestational diabetes mellitus (independent of body mass index). Low glycemic index and low carbohydrate diets have not been shown to be effective in preventing GDM in prospective randomized control trials. Low fat diets have been shown to reduce the risk of type 2 diabetes mellitus in persons with impaired glucose tolerance, but have not been studied in a population likely to develop GDM.
Obesity Case 4
A 54 year-old woman is scheduled for surgical neck exploration and laryngectomy for the recurrence of a laryngeal squamous cell carcinoma. She was initially treated with external beam radiation to the neck 3 years prior when she was first diagnosed. Over the past 6 months, she has lost 35 lbs, which was attributed to increased dysphagia and reduced appetite during this time. Despite strong support of family members and friends and a large supply of oral nutritional supplements at home, the patient is unable to meet her nutritional needs with oral intake. Her current weight is 93 lbs (42 kg), and her height is 65 inches (165 cm), giving her a body mass index (BMI) of 15 kg/m2 (normal, 18.5 to 24.9 kg/m2). Her other medical history includes hypothyroidism that developed 6 months after radiation therapy and hypertension. She previously smoked one pack of cigarettes daily for 25 years, but quit 10 years prior. She has mild emphysema and only rarely requires rescue inhalers for symptoms of wheezing. Her oral medications include levothyroxine, amlodipine, as well as opiate medications for pain. Two weeks prior to her scheduled surgery, the patient is admitted for nutritional optimization and a gastric feeding tube is placed.
Which tube feeding regimen should be administered to this patient?
The choice of tube feed formula can be daunting: a wide array of tube feed formulas are available for clinical use. In most cases, standard tube feeds are equally efficacious to specialty feed formulas, and standard feeds are the most cost effective. The use of specialized feeds is only clinically beneficial in a few specific instances. Some examples of these include the use of low carbohydrate feeds for patients with diabetes or the use of concentrated feeds with low potassium and low phosphorus for patients with renal insufficiency. Formulas with partially hydrolyzed proteins (semi-elemental) or formulas with amino acids and dipeptides as a protein source are more easily absorbed and can be used in patients with reduced intestinal absorptive area or intestinal ischemia and in pediatric populations.
For many other clinical scenarios, evidence for specialized tube feeds is lacking, or in some cases, no specific benefit has been demonstrated. For example, tube feed formulas directed for use in hepatic encephalopathy show no difference in mental status or cognition in clinical trials. In patients with pulmonary disease, use of a specialized pulmonary feeding formula that is fortified with lipids to alter the respiratory quotient (R) does not impact pulmonary function. While less CO2 is produced in the metabolism of formulas with a low R quotient, a higher amount of O2 is consumed. No differences in mortality, quality of life, or other clinically meaningful outcomes have been demonstrated with the use of specialized pulmonary formulas.Over the past few decades, dietary compounds that affect immune system function have been identified in animal studies and in human trials with purported health benefits. These include substances such as ?-3 fatty acids, glutamine, arginine, ribonucleic acids, and other antioxidant compounds.
For many clinical scenarios, however, the use of immune-modulating tube feed formulas remains a subject of controversy. In cases of acute critical illness, septic shock, or acute respiratory distress syndrome, initial clinical trials demonstrate benefit with specific immune-modulating formulas, while subsequent studies show no effect. In contrast, six separate, recently published trials investigating the use of arginine-fortified tube feeds among subjects with head and neck squamous cell cancer consistently demonstrate improved outcomes including reduced surgical complications, reduced fistula formation, and reduced length of hospitalization. Based on these findings, administration of tube feeds enriched with arginine is most appropriate in the patient presented here.
In the same patient, tube feeds are started. After 36 hours, the patient develops mild lower extremity edema, and bloodwork demonstrates an electrolyte abnormality. Refeeding syndrome is suspected.
Which of the following serum electrolyte abnormalities is most often seen in refeeding sydrome?
Refeeding syndrome is marked by electrolyte abnormalities that occur in severely malnourished patients as nutrition support is re-introduced. In some cases, edema, diarrhea, tachycardia, and weakness can develop. Any form of nutrition including oral diet, tube feeds, or parenteral nutrition can lead to refeeding syndrome.
During times of fasting or scarce nutritional intake, circulating insulin levels are low and glucagon levels are elevated. Intracellular potassium, magnesium, and phosphate stores are continually utilized, becoming depleted. As intake of food suddenly increases, insulin levels rise significantly. Potassium, magnesium, and phosphate shift into the intracellular space, leading to low serum levels of these electrolytes.Hypophosphatemia is the most commonly described electrolyte abnormality, with a reported prevalence of 96% in a review of 27 refeeding syndrome cases. This results from a sudden increase in phosphate utilization, e.g., the intracellular phosphorylation of newly ingested glucose to glucose-6-phosphate, and through an abrupt increase in synthesis of adenosine triphosphate (ATP).
When severe, the hypophosphatemia in refeeding syndrome can lead to muscle weakness, paralysis, and even death from diaphragmatic weakness and subsequent respiratory failure. Hypokalemia and hypomagnesemia are also commonly observed in approximately half of individuals with refeeding syndrome, stimulated by intracellular shifts of these electrolytes as nutrients are given and insulin levels rise. Serum calcium levels, when corrected for low circulating levels of albumin, are usually not affected.
To avoid refeeding syndrome, nutrients should be introduced slowly, depending on the severity of malnutrition. Electrolyte disturbances can be anticipated: phosphate, potassium, and magnesium supplementation may be given along with the initial nutrition support to avoid refeeding syndrome. Thiamine, which functions as a cofactor in glucose metabolism, should also be empirically administered to address potential thiamine deficiency that can be exacerbated as dietary carbohydrate intake suddenly rises. Careful monitoring of serum electrolyte levels should guide the adjustment of electrolyte supplementation over the initial days of nutrition support in cases of severe malnutrition.
Obesity Case 3
- A 42 year-old woman who presently weighs 215 lbs (99 kg) and has undergone Roux-en-Y gastric bypass surgery two years prior. Postoperatively, she sustained a weight loss of 110 lb (50 kg) over 20 months, though she has gained 2.5 lbs (1 kg) in the past month. She continues to experience intermittent loose bowel movements and hair loss.
- A 56 year-old otherwise healthy man presents to the emergency department with two days of fevers, severe abdominal pain, nausea, and an inability to tolerate food by mouth. Diverticulitis is confirmed on computerized tomography (CT) scan. Serum pre-albumin is measured to be 16 mg/dL (normal, 20-40 mg/dL)
- A 37 year-old male with history of Crohn’s disease has sustained four exacerbations in the past year, requiring bowel rest and corticosteroids. He continues to have 5-10 bowel movements daily and has lost 15 lbs (7 kg) over the past 3 months. His current weight is 132 lbs (60 kg), with a body mass index of 20 kg/m 2 (normal, 18.5 to 24.9 kg/m 2 ).
- A 72 year-old female with a history of chronic obstructive pulmonary disease (COPD) and hypertension is transferred to the intensive care unit (ICU) for sepsis and respiratory failure two days after she was admitted to the hospital for a COPD exacerbation. She requires mechanical ventilation through an endotracheal tube. Due to hypotension, she requires continuous infusion of adrenergic agonists (pressors) and her glomerular filtration rate has declined by 30% since admission. Her weight is 165 lbs (75 kg), and her body mass index is 26 kg/m 2 (normal, 18.5 to 24.9 kg/m 2 ).
Which of the following clinical scenarios represents patients who are at high risk for malnutrition?
The prevalence of malnutrition has been reported as 20-50% among hospitalized patients and is secondary to chronic disease, acute illness or exacerbation, and aging populations. Screening for malnutrition in all hospitalized patients is mandated in the United States by the Joint Commission for Accreditation of Healthcare Organizations, and addressing concerns raised regarding nutritional status is integral for patient care and improved inpatient outcomes.A large number of nutritional scoring systems have been published that identify patients at risk for malnutrition. Most of these systems involve a measure of unintentional weight loss, severity of current illness, presence of chronic illness, and gastrointestinal tract function. Three of the most commonly used models are summarized in the table below.
FIGURE 1 In Scenario I, the patient underwent bariatric surgery, and her postoperative course of intentional weight loss over 12-20 months is typical of patients following this procedure. Although reduced intestinal surface area is present following Roux-en-Y gastric bypass, frank malabsorption leading to malnutrition is a rare adverse effect of this procedure, with a prevalence of approximately 1%. Individuals who suffer from malabsorption following gastric bypass typically have weight loss that continues beyond 20 months postoperatively. While hair loss can be a clinical sign of micronutrient deficiency, it is common following malabsorptive bariatric surgery and is nonspecific in this setting. Often hair loss for up to two years during the postoperative phase of a malabsorptive bariatric procedure cannot be attributed to a specific micronutrient deficiency.
Scenario II depicts an otherwise healthy individual with sudden onset of acute diverticulitis. Prior to this acute illness, he was well nourished. Though his dietary intake for the two days leading to hospitalization is poor and he is likely to be dehydrated, his internal nutrient stores are sufficient to compensate for this short duration of poor intake. Like many serum proteins, pre-albumin acts as an inverse acute phase reactant. Hepatic synthesis of pre-albumin is diminished during acute illness. Thus, the low serum pre-albumin levels in this scenario do not reflect low protein stores. Depending on his subsequent hospital course, he may develop malnutrition, which warrants continued evaluation. He does not presently meet criteria for malnutrition.
In Scenario III, the patient had several exacerbations of Crohn's disease, which can lead to malabsorption. In addition, individuals with gastrointestinal illness, such as Crohn's disease, may self-restrict their oral dietary intake in between flares due to persistence of abdominal pain, loose bowel movements, or fear of inducing another exacerbation. This patient lost over 10% of his body weight in the past 3 months. He also has a low body mass index and demonstrates varying tolerance of oral diet. These findings meet criteria for high nutritional risk or severe malnutrition by nearly any published classification method.
Scenario IV clearly represents an individual at high risk of malnutrition for several reasons: 1) She has a prolonged hospitalization; 2) She has acute critical illness; and 3) She has chronic illness – COPD – that can lead to malnutrition through reduced appetite, increased protein degradation, and increased autophagy secondary to chronic, low-grade systemic inflammation. She is considered at high risk for malnutrition by NUTRIC criteria, which is recommended for use in critically ill patients. Identifying patients such as the one in scenario IV emphasizes the need for aggressive provision of nutritional support for improved outcomes.
Obesity Case 2
A 47 year-old white man of Italian descent with a strong family history of type 2 diabetes and cardiovascular disease was recently diagnosed with prediabetes. He has always been proud that he does not have any chronic disease and has never needed to take any medications, despite having a weight problem. He does not follow any specific diet plan, but is very active. He is currently doing 150 minutes of moderate intensity physical activity every week. He cooks most of his meals and rarely dines out. His meals, in general, are high in carbohydrates as he loves pasta, pizza, and bread. He also adds olive oil to most of his meals and eats fatty fish two times per week. He does not eat much red meat, but eats a lot of processed meat and cheese. During his last visit to his primary care physician, his fasting plasma glucose was 110 mg/dL (normal, 70-100 mg/dL), and his glycated hemoglobin (HbA1c) was 6.1% (normal, <5.7%). He was shocked by the results. Except for obesity, he does not have any other health problems. When your dietitian reviewed his 3-day food log, she found that he consumes approximately 2800 calories per day with total carbohydrates comprising 60% of his diet.
- Weight: 206 lbs (93.6 kg)
- Height: 67 inches (170 cm)
- Body mass index (BMI): 32 kg/m 2 (normal, 18.5 to 24.9 kg/m 2 )
- Waist circumference: 40 inches
- Blood pressure: 130/80 mm Hg
- Low density lipoprotein cholesterol (LDL-C): 98 mg/dL (desirable, <100 mg/dL)
- High density lipoprotein cholesterol (HDL-C): 42 mg/dL (desirable, ≥60 mg/dL)
- Triglycerides (TG): 186 mg/dL (desirable, <150 mg/dL)
His internet search led him to read the results of the diabetes prevention program, which showed that weight loss reduces type 2 diabetes risk by 58%. He stated that he was in the best shape, and he would like to reach that goal over the next 8 weeks by reducing total caloric intake to 1000-1200 calories/day and increasing his activity to 50 minutes on 5 days of the week to a total of 250 minutes/week. He came to you for advice regarding healthy eating patterns and physical activity that will help him to prevent type 2 diabetes.
In helping this individual to achieve and maintain his target weight loss, which of the following advice is BEST?
For weight management, consistency is more important than speed of weight changes. Weight losses of 0.5 to 2 lbs (0.2-0.9 kg) per 1-2 weeks are acceptable and safe. You can calculate basal metabolic rate (BMR) using the Harris-Benedict equations (For men BMR = 88.362 + (13.397 x weight in kg) + (4.799 x height in cm) - (5.677 x age in years). The answer can then be multiplied by an activity factor (i.e., 1.375 for light exercise 1-3 days per week; 1.55 for moderate exercise 3-5 days per week). Using this patient as an example: BMR = 88.362 + (13.397 x 93.6) + (4.799 x 170) – (5.677 x 47) = (88 + 1254 + 816)-266 = 1892 x 1.55 = 2932- 500 = 2432 kcal. Thus, reducing caloric intake by 250-500 is reasonable and tolerated, making option A the correct response.Weight loss of around 7% significantly improves insulin sensitivity and helps individuals with prediabetes to prevent diabetes. A goal of 5-10% weight loss maintained for a year is an optimal target for patients with obesity and prediabetes.
For an individual who consumes 2800 calories per day, reducing caloric intake to 1200 calories per day may not be doable and is frequently associated with rapid weight regain. Thus, option B is incorrect.
People who are overweight and obese may choose to increase the percentage of calorie intake from protein and decrease the percentage from carbohydrates to around 40-45% when they reduce caloric intake for weight reduction. It is particularly important to maintain the absolute protein intake at not less than 1.2 gm/kg of adjusted body weight when the total caloric intake is reduced to 1200-1500 calories to avoid protein malnutrition. Recommended protein intake is around 15-20% of total caloric intake. However, when caloric reduction is recommended for weight reduction, the use of percentages to calculate protein intake may result in a serious reduction in absolute protein intake. For this reason, individuals who seek weight reduction through caloric restriction should calculate protein intake based on gram/kg body weight. Adequate intake is 0.8 gm/kg of body weight, but for people who are overweight, 0.8-1.5 gm/kg of adjusted body weight [Adjusted Body Weight = IBW (Ideal Body Weight) + 0.25 (Current Weight - IBW) can be used to calculate appropriate intake. Thus, protein intake of 1.5 g/kg of actual body weight is too high, making option C incorrect.
Regular physical activity, including a balanced mix of stretching, cardiovascular exercise, and progressive resistance exercise for at least 30 minutes most days of the week, has health benefits and is needed to control body weight. Exercise has been shown to help overweight and obese patients to maintain weight loss over the long-term. About 60 minutes a day of moderate intensity exercise for at least 5 days/week (300 minutes/week) may be needed to prevent weight regain. Thus, option D is also incorrect.
Although a traditional weight loss diet is generally low in calories and fat, several meta-analyses comparing low-fat versus low-carbohydrates diets have consistently shown that a diet lower in calories and carbohydrates is superior to a diet low in fat and higher in carbohydrates. The percentage of carbohydrates in a weight loss diet should not be higher than 40-45%, but not less than 130 g/day. Carbohydrates of lower glycemic index like non-starchy vegetables, fruits, and whole grains are the preferred source of carbohydrates. Thus, option E is also an incorrect response.
Obesity Case 1
A 45 year-old female who is “health conscious” came to your clinic for advice about healthy eating and lifestyle. She is an editor of a shopping magazine and frequently reads articles about diets, nutrients, supplements, and healthy lifestyles. She found that much of the information she recently read is contradictory, which made her confused about what to eat and do. Her mother had type 2 diabetes and died at age 61 from a fatal myocardial infarction. The death of her mother at such young age compelled her to eat healthier and to walk for 30 minutes most days of the week.
She is now eating three regular meals per day and does not eat snacks. She tries to read all of her food labels and to keep her food intake to 1,800 calories per day. Although she dines out approximately 5 days per week, she controls her food portions as much as she can. She has maintained her weight for the last 5 years. She likes good wine and drinks 1-2 glasses when she dines out. She takes several over-the-counter supplements including vitamin D, calcium, magnesium, vitamin B12, and cinnamon. She does not have any gastro-intestinal symptoms, and she sleeps 6-7 hours every night. Recent results of lab work are below.
- Weight: 172 lbs
- Body mass index (BMI): 28 kg/m 2 (normal, 18.5 to 24.9 kg/m 2 )
- Waist circumference: 32 inches
- Blood pressure: 124/72 mm Hg
- Serum low density lipoprotein cholesterol (LDL-C): 122 mg/dL (desirable, <100 mg/dL)
- Serum high density lipoprotein cholesterol (HDL-C): 39 mg/dL (desirable, ≥60 mg/dL)
- Serum triglycerides (TG): 280 mg/dL (desirable, <150 mg/dL)
- Fasting plasma glucose: 92 mg/dL (normal, 70-100 mg/dL)
- Glycated hemoglobin (HbA1c): 5.6% (normal, <5.7%)
She told you that she would like to follow a strict vegetarian dietary pattern since she heard that it is the best lifestyle. She would also like to follow a gluten-free diet to shed few pounds.
Regarding her current lifestyle and her intentions to change it, which of the following is correct advice?
Alcohol, especially red wine increases HDL-C. If a person chooses to drink alcohol, the consumption must be moderate (no more than one drink a day for women and no more than two drinks a day for men). Additionally, it is not advisable that one actually increases alcohol consumption to these levels to derive a health benefit. One drink is equal to 12 ounces of regular beer, 5 ounces of wine, or 1.5 ounces of 80-proof distilled alcohol. So, option A is incorrect as women should not exceed one drink per day.
Celiac disease or gluten sensitive enteropathy is an autoimmune disease in which there is an abnormal response to gluten, the protein contained in wheat, barley, and rye. Ingestion causes damage to the intestinal lining and malabsorption of micronutrients as well as varying degrees of symptoms, which may include diarrhea, bloating, weight loss, and fatigue. The treatment for celiac disease is a gluten-free diet. Some people without celiac disease report similar gastrointestinal symptoms when eating gluten-containing foods, although it is controversial whether these symptoms are due to the gluten itself. Regardless, gluten-free diets have become popular over the last few years, and many people are using them to lose weight. Some people lose weight because they end up eliminating high carbohydrate foods that they previously over consumed. Other people who choose to omit gluten replace gluten-containing carbohydrates with another type of carbohydrates like corn, rice, tapioca, and/or potato. In fact, many people on gluten-free diets gain weight. Since this patient does not have any gastrointestinal symptoms, she is unlikely to have gluten sensitivity. Thus, adopting a gluten-free diet is unnecessary, and option B is therefore incorrect.
A vegetarian eating plan is a relatively healthy eating pattern and has been associated with reductions in type 2 diabetes and cardiovascular risk in several observational studies. However, a strict vegan diet is associated with significant deficiency in many essential amino acids that only come from animal sources like milk, eggs, fish, meat, and poultry. If a person elects to follow a vegan diet, the diet should be supplemented with ketogenic essential amino acids to be balanced in nutrition. Therefore, option C is incorrect.
Due to the recognition of the benefit of “healthier” fats, restriction of dietary fat to Reducing daily caloric intake by 250-500 calories will help most people with overweight or obesity problems to lose weight. Since the patient in this case is overweight, a target BMI of 20-25 kg/m2may be advised to reduce her cardiovascular disease and type 2 diabetes risk. Regular physical activity, including a balanced mix of stretching, cardiovascular exercise, and progressive resistance exercise for at least 30 minutes most days of the week, has health benefits and is needed to control body weight. This new advice replaced the old recommendation of doing only aerobic exercise like walking 10,000 steps per day. Thus, option E is the correct answer.
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Case study: a patient with diabetes and weight-loss surgery.
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Sue Cummings; Case Study: A Patient With Diabetes and Weight-Loss Surgery. Diabetes Spectr 1 July 2007; 20 (3): 173–176. https://doi.org/10.2337/diaspect.20.3.173
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A.W. is a 65-year-old man with type 2 diabetes who was referred by his primary care physician to the weight center for an evaluation of his obesity and recommendations for treatment options, including weight-loss surgery. The weight center has a team of obesity specialists, including an internist, a registered dietitian (RD), and a psychologist, who perform a comprehensive initial evaluation and make recommendations for obesity treatment. A.W. presented to the weight center team reluctant to consider weight-loss surgery;he is a radiologist and has seen patients who have had complications from bariatric surgery.
Pertinent medical history. A.W.'s current medications include 30 and 70 units of NPH insulin before breakfast and before or after dinner, respectively, 850 mg of metformin twice daily, atorvastatin,lisinopril, nifedipine, allopurinol, aspirin, and an over-the-counter vitamin B 12 supplement. He has sleep apnea but is not using his continuous positive airway pressure machine. He reports that his morning blood glucose levels are 100–130 mg/dl, his hemoglobin A 1c (A1C) level is 6.1%, which is within normal limits, his triglyceride level is 201 mg/dl, and serum insulin is 19 ulU/ml. He weighs 343 lb and is 72 inches tall, giving him a BMI of 46.6 kg/m 2 .
Weight history. A.W. developed obesity as a child and reports having gained weight every decade. He is at his highest adult weight with no indication that medications or medical complications contributed to his obesity. His family history is positive for obesity; his father and one sister are also obese.
Dieting history. A.W. has participated in both commercial and medical weight-loss programs but has regained any weight lost within months of discontinuing the programs. He has seen an RD for weight loss in the past and has also participated in a hospital-based, dietitian-led, group weight-loss program in which he lost some weight but regained it all. He has tried many self-directed diets, but has had no significant weight losses with these.
Food intake. A.W. eats three meals a day. Dinner, his largest meal of the day, is at 7:30 p . m . He usually does not plan a mid-afternoon snack but will eat food if it is left over from work meetings. He also eats an evening snack to avoid hypoglycemia. He reports eating in restaurants two or three times a week but says his fast-food consumption is limited to an occasional breakfast sandwich from Dunkin'Donuts. His alcohol intake consists of only an occasional glass of wine. He reports binge eating (described as eating an entire large package of cookies or a large amount of food at work lunches even if he is not hungry) about once a month, and says it is triggered by stress.
Social history. Recently divorced, A.W. is feeling depressed about his life situation and has financial problems and stressful changes occurring at work. He recently started living with his girlfriend, who does all of the cooking and grocery shopping for their household.
Motivation for weight loss. A.W. says he is concerned about his health and wants to get his life back under control. His girlfriend, who is thin and a healthy eater, has also been concerned about his weight. His primary care physician has been encouraging him to explore weight-loss surgery; he is now willing to learn more about surgical options. He says that if the weight center team's primary recommendation is for weight-loss surgery,he will consider it.
Does A.W. have contraindications to weight-loss surgery, and, if not, does he meet the criteria for weight-loss surgery?
What type of weight-loss surgery would be best for A.W.?
Roles of the obesity specialist team members
The role of the physician as an obesity specialist is to identify and evaluate obesity-related comorbidities and to exclude medically treatable causes of obesity. The physician assesses any need to adjust medications and,if possible, determines if the patient is on a weight-promoting medication that may be switched to a less weight-promoting medication.
The psychologist evaluates weight-loss surgery candidates for a multitude of factors, including the impact of weight on functioning, current psychological symptoms and stressors, psychosocial history, eating disorders,patients' treatment preferences and expectations, motivation, interpersonal consequences of weight loss, and issues of adherence to medical therapies.
The RD conducts a nutritional evaluation, which incorporates anthropometric measurements including height (every 5 years), weight (using standardized techniques and involving scales in a private location that can measure patients who weigh > 350 lb), neck circumference (a screening tool for sleep apnea), and waist circumference for patients with a BMI < 35 kg/m 2 . Other assessments include family weight history,environmental influences, eating patterns, and the nutritional quality of the diet. A thorough weight and dieting history is taken, including age of onset of overweight or obesity, highest and lowest adult weight, usual weight, types of diets and/or previous weight-loss medications, and the amount of weight lost and regained with each attempt. 1
Importance of type of obesity
Childhood- and adolescent-onset obesity lead to hyperplasic obesity (large numbers of fat cells); patients presenting with hyperplasic and hypertrophic obesity (large-sized fat cells), as opposed to patients with hypertrophic obesity alone, are less likely to be able to maintain a BMI < 25 kg/m 2 , because fat cells can only be shrunk and not eliminated. This is true even after weight-loss surgery and may contribute to the variability in weight loss outcomes after weight loss surgery. Less than 5% of patients lose 100% of their excess body weight. 2 , 3
Criteria and contraindications for weight-loss surgery
In 1998, the “Clinical Guidelines on the Identification, Evaluation,and Treatment of Overweight and Obesity in Adults: The Evidence Report” 4 recommended that weight-loss surgery be considered an option for carefully selected patients:
with clinically severe obesity (BMI ≥ 40 kg/m 2 or ≥ 35 kg/m 2 with comorbid conditions);
when less invasive methods of weight loss have failed; and
the patient is at high risk for obesity-associated morbidity or mortality.
Contraindications for weight-loss surgery include end-stage lung disease,unstable cardiovascular disease, multi-organ failure, gastric verices,uncontrolled psychiatric disorders, ongoing substance abuse, and noncompliance with current regimens.
A.W. had no contraindications for surgery and met the criteria for surgery,with a BMI of 46.6 kg/m 2 . He had made numerous previous attempts at weight loss, and he had obesity-related comorbidities, including diabetes,sleep apnea, hypertension, and hypercholesterolemia.
Types of procedures
The roux-en-Y gastric bypass (RYGB) surgery is the most common weight-loss procedure performed in the United States. However, the laparoscopic adjustable gastric band (LAGB) procedure has been gaining popularity among surgeons. Both procedures are restrictive, with no malabsorption of macronutrients. There is,however, malabsorption of micronutrients with the RYGB resulting from the bypassing of a major portion of the stomach and duodenum. The bypassed portion of the stomach produces the intrinsic factor needed for the absorption of vitamin B 12 . The duodenum is where many of the fat-soluble vitamins, B vitamins, calcium, and iron are absorbed. Patients undergoing RYGB must agree to take daily vitamin and mineral supplementation and to have yearly monitoring of nutritional status for life.
Weight loss after RYGB and LAGB
The goal of weight-loss surgery is to achieve and maintain a healthier body weight. Mean weight loss 2 years after gastric bypass is ∼ 65% of excess weight loss (EWL), which is defined as the number of pounds lost divided by the pounds of overweight before surgery. 5 When reviewing studies of weight-loss procedures, it is important to know whether EWL or total body weight loss is being measured. EWL is about double the percentage of total body weight loss; a 65% EWL represents about 32% loss of total body weight.
Most of the weight loss occurs in the first 6 months after surgery, with a continuation of gradual loss throughout the first 18–24 months. Many patients will regain 10–15% of the lost weight; a small number of patients regain a significant portion of their lost weight. 6 Data on long-term weight maintenance after surgery indicate that if weight loss has been maintained for 5 years, there is a > 95% likelihood that the patient will keep the weight off over the long term.
The mean percentage of EWL for LAGB is 47.5%. 3 Although the LAGB is considered a lower-risk surgery, initial weight loss and health benefits from the procedure are also lower than those of RYGB.
Weight-loss surgery and diabetes
After gastric bypass surgery, there is evidence of resolution of type 2 diabetes in some individuals, which has led some to suggest that surgery is a cure. 7 Two published studies by Schauer et al. 8 and Sugarman et al. 9 reported resolution in 83 and 86% of patients, respectively. Sjoström et al. 10 published 2-and 10-year data from the Swedish Obese Subjects (SOS) study of 4,047 morbidly obese subjects who underwent bariatric surgery and matched control subjects. At the end of 2 years, the incidence of diabetes in subjects who underwent bariatric surgery was 1.0%, compared to 8.0% in the control subjects. At 10 years, the incidence was 7.0 and 24.0%, respectively.
The resolution of diabetes often occurs before marked weight loss is achieved, often days after the surgery. Resolution of diabetes is more prevalent after gastric bypass than after gastric banding (83.7% for gastric bypass and 47.9% for gastric banding). 5 The LAGB requires adjusting (filling the band through a port placed under the skin),usually five to six times per year. Meta-analysis of available data shows slower weight loss and less improvement in comorbidities including diabetes compared to RYGB. 5
A.W. had diabetes; therefore, the weight center team recommended the RYGB procedure.
Case study follow-up
A.W. had strong medical indications for surgery and met all other criteria outlined in current guidelines. 4 He attended a surgical orientation session that described his surgical options,reviewed the procedures (including their risks and possible complications),and provided him the opportunity to ask questions. This orientation was led by an RD, with surgeons and post–weight-loss surgical patients available to answer questions. After attending the orientation, A.W. felt better informed about the surgery and motivated to pursue this treatment.
The weight center evaluation team referred him to the surgeon for surgical evaluation. The surgeon agreed with the recommendation for RYGB surgery, and presurgical appointments and the surgery date were set. The surgeon encouraged A.W. to try to lose weight before surgery. 11
Immediately post-surgery. The surgery went well. A.W.'s blood glucose levels on postoperative day 2 were 156 mg/dl at 9:15 a . m . and 147 mg/dl at 11:15 a . m . He was discharged from the hospital on that day on no diabetes medications and encouraged to follow a Stage II clear and full liquid diet( Table 1 ). 12
Diet Stages After RYBG Surgery
On postoperative day 10, he returned to the weight center. He reported consuming 16 oz of Lactaid milk mixed with sugar-free Carnation Instant Breakfast and 8 oz of light yogurt, spread out over three to six meals per day. In addition, he was consuming 24 oz per day of clear liquids containing no sugar, calories, or carbonation. A.W.'s diet was advanced to Stage III,which included soft foods consisting primarily of protein sources (diced,ground, moist meat, fish, or poultry; beans; and/or dairy) and well-cooked vegetables. He also attended a nutrition group every 3 weeks, at which the RD assisted him in advancing his diet.
Two months post-surgery. A.W. was recovering well; he denied nausea, vomiting, diarrhea, or constipation. He was eating without difficulty and reported feeling no hunger. His fasting and pre-dinner blood glucose levels were consistently < 120 mg/dl, with no diabetes medications. He continued on allopurinol and atorvastatin and was taking a chewable daily multivitamin and chewable calcium citrate (1,000 mg/day in divided doses) with vitamin D (400 units). His weight was 293 lb, down 50 lb since the surgery. A pathology report from a liver biopsy showed mild to moderate steatatosis without hepatitis.
One year post-surgery. A.W.'s weight was 265 lb, down 78 lb since the surgery, and his weight loss had significantly slowed, as expected. He was no longer taking nifedipine or lisinipril but was restarted at 5 mg daily to achieve a systolic blood pressure < 120 mmHg. His atorvastatin was stopped because his blood lipid levels were appropriate (total cholesterol 117 mg/dl, triglycerides 77 mg/dl, HDL cholesterol 55 mg/dl, and LDL cholesterol 47 mg/dl). His gastroesophageal reflux disease has been resolved, and he continued on allopurinol for gout but had had no flare-ups since surgery. Knee pain caused by osteoarthritis was well controlled without anti-inflammatory medications, and he had no evidence of sleep apnea. Annual medical follow-up and nutritional laboratory measurements will include electrolytes, glucose,A1C, albumin, total protein, complete blood count, ferritin, iron, total iron binding capacity, calcium, parathyroid hormone, vitamin D, magnesium, vitamins B 1 and B 12 , and folate, as well as thyroid, liver, and kidney function tests and lipid measurements.
In summary, A.W. significantly benefited from undergoing RYBP surgery. By 1 year post-surgery, his BMI had decreased from 46.6 to 35.8 kg/m 2 ,and he continues to lose weight at a rate of ∼ 2 lb per month. His diabetes, sleep apnea, and hypercholesterolemia were resolved and he was able to control his blood pressure with one medication.
Clinical Pearls
Individuals considering weight loss surgery require rigorous presurgical evaluation, education, and preparation, as well as a comprehensive long-term postoperative program of surgical, medical, nutritional, and psychological follow-up.
Individuals with diabetes should consider the RYBP procedure because the data on resolution or significant improvement of diabetes after this procedure are very strong, and such improvements occur immediately. Resolution in or improvement of diabetes with the LAGB procedure are more likely to occur only after excess weight has been lost.
Individuals with diabetes undergoing weight loss surgery should be closely monitored; an inpatient protocol should be written regarding insulin regimens and sliding-scale use of insulin if needed. Patients should be educated regarding self-monitoring of blood glucose and the signs and symptoms of hypoglycemia. They should be given instructions on stopping or reducing medications as blood glucose levels normalize.
Patient undergoing RYGB must have lifetime multivitamin supplementation,including vitamins B 1 , B 12 , and D, biotin, and iron, as well as a calcium citrate supplement containing vitamin D (1,000–1,500 mg calcium per day). Nutritional laboratory measurements should be conducted yearly and deficiencies repleted as indicated for the duration of the patient's life.
Sue Cummings, MS, RD, LDN, is the clinical programs coordinator at the MGH Weight Center in Boston, Mass.
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A case study of liraglutide in an obese diabetic patient in a District General Hospital
Global Journal of Diabetes, Endocrinology & Metabolic Disorders
Volume 1, Issue 1, June 2020, Pages: 12-15 Received: Aug 8, 2020, Reviewed: Aug 31, 2020; Accepted: Oct 1, 2020; Published: April 1, 2021
Unified Citation Journals, Diabetes 2021, 1(2) 12-15; https://doi.org/10.52402/Diabetes701 ISSN : 2752-6283
Eastbourne District General Hospital
*Author to whom correspondence should be addressed.
Introduction: Diabetes mellitus is increasing rapidly worldwide, and treatment comes with many challenges. It is estimated that in 2030, approximately 500 million people will live with diabetes across the world—most of which will be type 2 diabetes mellitus (T2DM). Obesity often coincides with T2DM and has been linked to increased insulin resistance, high blood pressure, and high blood lipids. Thus, pharmacological management should be aimed at promoting weight loss or at very least be weight neutral. In many cases, the risks of hypoglycaemia and weight gain may delay titration of diabetic agents to HbA1C targets.
Both insulin and sulfonylureas are proven medications that are beneficial for tight glycemic control but with an increased risk of weight gain and hypoglycaemia. Newer agents under the drug class glucagon-like peptide receptor antagonists (GLP-1RA) are increasingly being used. Various randomized clinical trials support that obese T2DM patients treated with GLP-1RA lead to better glycaemic control, weight reduction, and reduced risk of hypoglycaemia.
Keywords: T2DM, Liraglutide, GLP-1 RA, Obesity
Case Summary : A 56-year-old female was diagnosed with T2DM in 2003 and had been regularly followed up in a diabetes clinic since 2014. During the initial clinic review, she had a bodyweight of 114.9 kg (BMI 40.7), fasting blood glucose was 8 – 9, 2-hour CBG 11-13, and HbA1c of 87. At that time, she was taking insulin glargine (Lantus) 36 units once daily, gliclazide 40 mg in the morning / 120 mg in the evening, metformin slow release 2 g in the evening, and simvastatin 20 mg at bedtime. After discussion with her, she was started on the GLP-1RA liraglutide subcutaneously. She had no diabetic-related complications. She continued liraglutide since then. Her HbA1c started to improve and also noticed a change in body weight which had gradually decreased from 114.9 to 109 kg. Her liraglutide was held at the latter end of 2018 as her glucose control and weight had been maintained. It was noticed that after stopping liraglutide her blood glucose and weight started to go up again even though her other medications remained the same. Her case was discussed at Diabetes MDT and liraglutide1.8mg restarted in September 2019 and since then she able to lose around 5% of her body weight and HBA1C also started to drop.
It is noticed that since the starting of her liraglutide her HBA1C level and weight fall by around 1% and 4% respectively. In late 2018 once she stopped liraglutide her HbA1C and weight started to rise again. In 2019 liraglutide was restarted and she managed to reduce body weight by 5kg and HbA1C by 2%. During the whole time period, she maintained lifestyle intervention.
Discussion:
Excessive fat accumulation with potential impairing effects on health know as overweight and obesity is a major risk factor for type 2 diabetes mellitus. Most T2DM people around 80-90% fall in mild to moderate obesity or overweight need either behavior or medication-based weight loss programme. In these patients losing as little as 5% of body weight positively affect their cardiovascular mortality and glycemic control. There is no need to mention that losing body weight and maintaining it is a challenge for the majority of diabetic patients and it is especially true for those who are on oral hypoglycaemic agents such as insulin, sulfonylurea, and thiazolidinediones, and insulin. In that case GLP-! Receptor agonists (GLP-1 Ras) is exceptional and it is proven benefit in reducing weight in T2DM obese patients.
Liraglutide is first approved in 2010 as an adjunct therapy to diet and exercise for the management of type 2 diabetes. Liraglutide is a derivative of GLP-1, a polypeptide incretin hormone secreted by the L-cell of the gastrointestinal tract. It stimulates glucose-dependent insulin secretion causing a decrease in plasma glucagon concentrations, delayed gastric emptying, suppress appetite, and increased heart rate. It is believed that the weight-lowering effect of GLP-1RA is due to appetite suppression and delayed gastric emptying.
After liraglutide administration peak absorption occurs at 11 hours and its absolute bioavailability is 55%. Its half-life in 13 hours, allowing it once-daily administration. It eliminates through the liver and kidneys and does not interfere with cytochrome p450 system. Most common side effects are nausea, hypoglycaemia, diarrhoea, constipation, abdominal pain and increased serum lipase. Gastrointestinal intolerance is the most common reason for drug discontinuation in patients. There is also an increased correlation with acute pancreatitis, serious hypoglycaemic episodes, tachycardia, and suicidal behaviour. Liraglutide is contraindicated in pregnancy and should be avoided in nursing mothers, children, and coincident use with other GLP-1 agonists.
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To citation of this article: Dr. Mohammed Ashfaqul Ghani , A case study of liraglutide in an obese diabetic patient in a District General Hospital, Global Journal of Diabetes, Endocrinology & Metabolic Disorders
References:
- Gan, S., Dawed, A., Donnelly, L., Nair, A., Palmer, C., Mohan, V. and Pearson, E., 2021. Efficacy of Modern Diabetes Treatments DPP-4i, SGLT-2i, and GLP-1RA in White and Asian Patients With Diabetes: A Systematic Review and Meta-analysis of Randomized Controlled Trials.
- Mehta, A., Marso, S. and Neeland, I., 2021. Liraglutide for weight management: a critical review of the evidence .
- Montanya, E. and Sesti, G., 2021. A review of efficacy and safety data regarding the use of liraglutide, a once-daily human glucagon-like peptide 1 analogue, in the treatment of type 2 diabetes mellitus.
- Mirabelli, M., Chiefari, E., Caroleo, P., Arcidiacono, B., Corigliano, D., Giuliano, S., Brunetti, F., Tanyolaç, S., Foti, D., Puccio, L. and Brunetti, A., 2021. Long-Term Effectiveness of Liraglutide for Weight Management and Glycemic Control in Type 2 Diabetes .
Dr. Mohammed Ghani
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