Body Weight and Energy Balance

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There is a general consensus among the various scientific organizations that weight loss is an important therapeutic strategy in all overweight or obese individuals who have type-2 diabetes or are at risk of developing type-2 diabetes. The primary approach to achieving weight loss, in the vast majority of cases, is a therapeutic lifestyle change, which includes a reduction in energy intake and an increase in physical activity.

The ADA recommends a moderate decrease in caloric balance (by 500-1,000 kcal/day) that will result in a slow but progressive weight loss of about 1-2 lb/week. For most patients, a weight loss diet is advised to provide at least 1,000-1,200 kcal/day for women and 1,200-1,600 kcal/day for men.

The DNSG of the EASD does not make specific caloric recommendations, but stresses that a weight reduction of as little as 10% of the initial body weight will have very beneficial effects on insulin sensitivity, blood pressure and lipid levels in overweight diabetic persons. The goal should be to decrease BMI under 25kg/m2 and to prevent weight regain thereafter. They also stress that overweight patients with type-1 diabetes may also become insulin resistant and weight loss may lead to a reduction in insulin dose and improved glycemic control.

The Joslin Diabetes Center and Joslin Clinic recommends a modest and gradual weight reduction of 1 lb every 1-2 weeks as an optimal therapeutic target, with a reduction of daily caloric intake by 250-500 kcal. Total daily caloric intake should not be less than 1,000-1,200 kcal/day for women and 1,200-1,600 kcal/day for men.

The AACE emphasizes the fact that simply a negative caloric balance can decrease insulin resistance in type-2 diabetes and that loss of as few as 10-20lb (4.5-9kg) will be helpful. For patients with type-1 diabetes, the patient must understand the action and duration of the insulin being used as well as the effect of the timing of the intake of food on the insulin action. Flexibility of insulin dosing and timing must be taught to the patient.

Diabetes UK recommends that a loss of 1-2 kg per month by means of a sustained energy deficit of approximately 500 kcal/day should be regarded as satisfactory. Furthermore, given the fact that body weight tends to increase with aging up to the sixth decade, avoidance of further weight gain may be considered a success in some patients.

The Canadian Diabetes Association does not have specific recommendations regarding the total amount of energy that needs to be consumed by diabetic persons in order to lose weight.

It should be noted that although weight loss is a major objective in the guidelines of all scientific organizations, there is actually a lack of prospective trials with hard end points (mortality). Also, no specific recommendations are provided on how to lose weight. Consequently, there is obviously a need for long-term, well-designed trials in order to assess the benefit from weight management in patients with diabetes. In this regard, the Look AHEAD: Action for Health in Diabetes Program aims to examine, in overweight volunteers with type-2 diabetes, the long-term effects of an intensive lifestyle intervention program, designed to achieve and maintain weight loss by decreased caloric intake and increased physical activity. The composite end point includes: cardiovascular death (including fatal myocardial infarction and stroke), nonfatal myocardial infarction, and nonfatal stroke.

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