Alex Kolesar Diabetes Information

Dietary Approaches

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The gold standard in the dietary treatment of obese patients with type 2 diabetes is a balanced moderately energy-restricted diet. The energy deficit is between 500 and 800 kcal/day. The most important single measure is the reduction in fat intake, particularly in saturated fatty acids. It is generally recommended to prefer a high-carbohydrate low-fat diet. As shown

TABLE 5 Obesity Prevention and Treatment Flowchart

Health status

Treatment goals

Treatment steps

Normal weight (BMI

18.5-24.9) Normal weight (BMI 18.5-24.9) plus risk factors(s) and/or comorbidity(ies) Pre-obesity (BMI 25-29.9)

Pre-obesity (BMI 25-29.9) plus risk factors(s) and/or comorbidity(ies)

Obesity Class I (BMI

30-34.9) Obesity Class I (BMI 30-34.9) plus risk factors (s) and/or comorbidity(ies)

Obesity Class II (BMI

35-39.9) Obesity Class II (BMI 35-39.9) plus risk factors (s) and/or comorbidity(ies)

Weight maintenance

Weight maintenance. Prevention of a >3 kg weight gain. Risk factor management, e.g. smoking cessation, healthy lifestyle

Prevention of further weight gain or, preferably, induction of modest weight loss

5-10% weight reduction in 3-6 months (especially if success in controlling risk factors is only moderate after 3 months) and weight maintenance thereafter

5-10% sustained weight reduction

5-10% sustained weight reduction

> 10% sustained weight reduction 10-20% sustained weight reduction

Obesity Class III (BMI >40) 10-30% sustained weight reduction

Consider periodic weight monitoring

Weight monitoring, risk-factor management, treatment of comorbidities, advice for a healthy lifestyle Best practice program3

Best practice program3, risk-factor management, treatment of comorbidities

Best practice program3

Best practice program", risk-factor management, treatment of comorbidities If not successful, consider additional drug therapy no earlier than after 12 weeks Best practice program3

Best practice program", risk-factor management, treatment of comorbidities If not successful, consider additional drug therapy no earlier than 12 weeks If conservative treatment is not successful, consider surgical treatment Best practice program3, risk factor management, treatment of comorbidities If conservative treatment is not successful, consider surgical treatment a The best practice program consists of a combination of dietary therapy, increased physical activity, and behavioral modification. Source: From Ref. 26.

recently, a diet rich in fiber and complex carbohydrates has some beneficial effects on parameters of glucose and lipid metabolism but these effects may be small and possibly of limited clinical importance (34). The concept of a high-carbohydrate, low-fat diet was, however, challenged by clinical studies showing that replacement of saturated fat by monounsaturated fat compared to high-carbohydrate intake is equally favorable or has even some minor advantages with regard to glycemic response and lipids (35). For these reasons, there is convincing evidence that energy content rather than nutrient composition is the major determinant of weight reduction in obese subjects with type 2 diabetes.

From a practical point of view it is extremely important to carefully assess the habitual diet of a patient with type 2 diabetes and to focus counselling on punctual changes of his/her eating habits in order to get close to current dietary recommendations (36,37). It should be stressed that all efforts for dietary changes should be made as simple as possible for the patients as they are burdened by many requirements to manage their diabetes (28). For obese subjects with type 2 diabetes the frequent recommendation to distribute their allowed calories over 5 to 6 meals is difficult to be met and may even hinder weight loss without being of any advantage for metabolic control (38). Therefore, in most cases 3 to 4 meals a day may be more appropriate to reach the individual dietary goals.

Another possible dietary approach is the use of a very-low-calorie diet (VLCD) for initial weight loss. This option may be particularly valuable for patients with poor metabolic control and/or "dietary failure." Usually, there is a rapid improvement of insulin resistance and glycemic control after even short periods of VLCD. However, this approach can only be applied for a limited number of weeks and requires intense medical care. Nevertheless, a recent review concluded with the statement that the long-term results of VLCD are better than those of conventional diets (39). There is certainly a need for new sophisticated solutions such as intermittent VLCD in combination with conventional hypocaloric diets to obtain better long-term results (40). Another potentially promising strategy is to establish a long-term meal-replacement concept, which substitutes 1 or 2 meals daily by balanced formula diets of reduced calorie content, as recently demonstrated in a 4-year clinical study in nondiabetic obese subjects (41). In a recent study in obese type 2 diabetic patients, percentage weight loss by meal replacement was significantly greater than under the diet recommended by the American Diabetes Association (4.57% vs. 2.25%, p< 0.05) including a greater reduction of fasting plasma glucose and HbA1c and a greater reduction in the use and dosage of oral hypoglycemic agents (42). Further progress in this field can also be expected from the ongoing Look AHEAD study which is aiming at substantial weight loss in obese diabetic subjects to reduce the high cardiovascular risk of these patients (43). There is no doubt that more research is urgently required to develop strategies that may help to provide better individual solutions and to manage the weight problem of many patients more efficiently.

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