From Research to Practice

Multidisciplinary Team–Based Obesity Treatment in Patients With Diabetes: Current Practices and the State of the Science

  1. Daniel Foster1,*,
  2. Shakira Sanchez-Collins2,* and
  3. Lawrence J. Cheskin3
  1. Johns Hopkins 1Bloomberg School of Public Health
  2. 2Department of Internal Medicine, and
  3. 3Weight Management Center, Baltimore, MD
  1. Corresponding author: Lawrence J. Cheskin, cheskin{at}jhu.edu
Diabetes Spectrum 2017 Nov; 30(4): 244-249. https://doi.org/10.2337/ds17-0045

This article has a correction. Please see:

Abstract

IN BRIEF Rates of obesity and diabetes are growing, as are their costs. Because the two diseases share many key determinants, the paradigms for their treatment overlap. For both, optimal treatment involves a multidisciplinary team following the Chronic Care Model of health care delivery. Combined treatment programs that include 1) a low-calorie diet individualized to patients’ preferences, 2) structured exercise that is also tailored to each patient, and 3) psychotherapy induce the largest weight changes in patients with diabetes. Although diet alone can achieve weight loss, exercise and cognitive behavioral therapy components can enhance the effects of dietary modification. A multidisciplinary team that includes a physician with expertise in pharmacotherapy, a nurse and/or nurse practitioner, a dietitian, an exercise physiologist, and a psychologist can provide a comprehensive weight loss program combining the most effective interventions from each discipline.

Obesity is a serious clinical and public health issue. More than one-third of the adult population in the United States has a BMI >30 kg/m2 (1). This condition shortens life expectancy by 2–10 years and accounts for 15% of excess deaths in America, mostly from negative cardiovascular and metabolic effects (2,3). Obesity affects not only life span, but also health span, contributing to physical pain, immobility, and depression, among many other comorbidities (4). In the United States, direct medical costs for obesity have risen to ∼$147 billion annually, with newer analyses estimating even higher costs (1,5,6).

Diabetes is another major health threat and is intimately related to obesity. Nearly 10% of Americans suffer from diabetes (7). Chronically elevated blood glucose shortens life expectancy by almost 9 years and accounts for 12–16% of adult deaths in the United States (8,9). Although most mortality accompanying diabetes stems from vascular disease, several different conditions contribute to the increased morbidity of people with diabetes, including blindness, amputations, and kidney failure (10). The human cost of diabetes is great and so is the economic cost—an estimated $176 billion annually for direct medical care (5).

Diabetes and Obesity: Shared Key Determinants

Diabetes and obesity share many key determinants. Both are progressive, multifactorial diseases that are amplified by a Western diet and physical inactivity (11–14). These two key factors, which lead to a positive energy imbalance, have many socioeconomic and environmental roots. Diabetes and obesity also share pathophysiological links. Lipid overflow, lipotoxicity, and pathogenic adipocytokines are mechanisms through which excess adiposity causes hyperglycemia (15,16).

Weight gain and obesity increase diabetes risk—3-fold for people who are overweight, 7-fold for those who are obese, and 60-fold for those with severe obesity (17). Fortunately, this risk decreases with weight loss. Bariatric surgery trials, including the landmark Swedish Obesity Study, found that such surgeries, and especially the Roux-en-Y gastric bypass procedure, prevent or reverse diabetes (18,19).

The relationship between excess weight and high blood glucose is imperfect. Most, but not all, people with type 2 diabetes are overweight. Most, but not all, people with obesity eventually develop type 2 diabetes. Overall, though, excess body fat is the most important reversible risk factor for type 2 diabetes.

Diabetes and Obesity: Common Treatment Solutions

Losing weight and keeping it off can be daunting for anyone, and people with obesity and diabetes have greater difficulty losing weight than those who do not have diabetes. However, trials such as the Finnish Diabetes Prevention Study (20), the National Institutes of Health’s Diabetes Prevention Program (21), and the Look AHEAD (Action for Health in Diabetes) trial (22) showed that intensive lifestyle interventions can reduce weight and prevent or mitigate diabetes and its comorbidities. Such interventions have been successfully replicated in academic settings and endorsed by numerous obesity and diabetes professional societies (23–25).

Intensive lifestyle intervention was based in part on the Chronic Care Model (CCM) of health care delivery (26–30), the core principles of which include:

  • Long-term commitment: acknowledgment that the condition is lifelong; that it requires sustainable lifestyle and behavior changes plus maintenance of these changes; and that this often requires motivational interviewing by the health care provider and integration of the clinic with community resources

  • Patient-centered care: focused on patient participation, patient goal-setting, patient skill-building, and patient self-management

  • Multidisciplinary team: including specialists who are socialized to each other and who have defined roles, harmonized messages, and a common focus

  • Evidence-based and protocol-driven care: decisional aids and algorithms based on best practices to decrease harmful variations in care

Multidisciplinary obesity clinics and multidisciplinary diabetes clinics share not only the general CCM philosophy, but also specific goals and methods. They both aim for realistic, modest weight loss targets (5–10% during 6 months) (31). Both view weight as an indirect indicator of metabolic disease, cardiovascular disease, and poor quality of life (32); in the later stages of diabetes, however, the emphasis may shift from weight loss to glucocentric strategies while avoiding further weight gain.

The weight loss goals and plans are often quite similar for people with obesity and those with diabetes (33). Weight is lost primarily through various low-calorie diets. Regular aerobic exercise augments this loss and mitigates the underlying cardiovascular and metabolic derangements (34,35).

Many of the same team members are found in multidisciplinary obesity clinics and multidisciplinary diabetes clinics. Patients are at the center of both types of team, assisted by a primary physician, nurse and/or nurse practitioner, dietitian, exercise physiologist, and behaviorist (36,37). This core group may be complemented by a pharmacist (drug management currently plays a larger role in diabetes care than in obesity care), and perhaps a case manager.

One of the biggest differences between obesity and diabetes multidisciplinary clinics involves referrals to outside specialty physicians. Obesity centers often refer patients for bariatric surgery, psychiatry, and gastroenterology services (38). Diabetes centers more commonly refer for ophthalmology, podiatry, vascular surgery, cardiology, nephrology, and endocrinology (39,40).

Weight Loss Challenges of People With Diabetes

For people with both obesity and diabetes, the greater degree of difficulty in achieving weight loss stems from multiple factors. One study found that overweight patients with diabetes lost less weight than their spouse without diabetes following the same program. However, the differences could be explained by poorer dietary adherence and higher reports of dysphoria among the participants with diabetes (41). Another study showed that an intensive lifestyle program for women with obesity was equally effective in the short term for people with and without diabetes. However, those with diabetes had greater weight gain in the year after the program ended (42).

One possible explanation is the effect of diabetes medications such as insulin and sulfonylureas, which enhance anabolic activity (43). In the U.K. Prospective Diabetes Study, patients with diabetes who were treated with insulin or sulfonylureas gained significantly more weight during 10 years than those treated with diet alone (44).

People with poor glycemic control also have a high energy expenditure, higher metabolic rate, more protein turnover, and glycosuria with calories excreted in the urine (45,46). These catabolic processes are reversed by adequate glycemic control achieved through medication and weight loss itself.

Furthermore, diabetes complications such as neuropathy, heart disease, and foot ulcers can limit physical activity (43). In response to these multiple challenges, a multidisciplinary weight-management team must provide a multifaceted approach that includes effective diet options, specialized exercise programs, and supportive behavioral therapy.

Core Elements of Weight Loss Programs for Obesity and Diabetes

Diet

People with diabetes and obesity have multiple diet options that have been proven effective for weight loss. Common options include low–glycemic index, Mediterranean-style, low-carbohydrate Mediterranean-style, very-low-calorie ketogenic, low-fat, and low-fat vegan eating patterns.

These eating patterns differ in macronutrient content (i.e., amount of carbohydrates, proteins, and fats). The Institute of Medicine recommends that adults in general should get 45–65% of their energy from carbohydrates, 10–35% from protein, and 20–35% from fats (47). Although the evidence is mixed regarding the macronutrient proportions that are most effective for weight loss (48), there is some evidence that low-carbohydrate diets yield greater initial mean weight loss, both in general and for people with diabetes. In people with or without diabetes, reduced caloric intake over time is essential for achieving weight loss (48,49). Low-carbohydrate diets tend to have either a high protein content such as the very-low-calorie ketogenic diet or a high fat content such as the low-carbohydrate Mediterranean-style eating pattern. Furthermore, high protein content has been found to be safe in people with diabetes and does not increase albuminuria or worsen kidney function (50).

In comparison to the 2003 American Diabetes Association (ADA) nutrition recommendations (50–55% carbohydrate, 30% fats, and 20% protein) and the Mediterranean-style diet (50–55% carbohydrate, 30% fats, 15–20% protein), the low-carbohydrate Mediterranean-style diet (35% carbohydrate, 45% fats, and 15–20% protein) was found to achieve the greatest weight loss (51). Both the traditional Mediterranean and the low-carbohydrate Mediterranean diets only included low–glycemic index carbohydrates, whereas the ADA diet included mixed–glycemic index carbohydrates. The low-carbohydrate diet had a reduced percentage of carbohydrates and an increased percentage of fat (51). Other eating patterns such as the low-fat vegan, standard low-fat, and low–glycemic index diets induce significant reductions in A1C, but there are no significant differences among them in weight loss achieved (52,53).

Given that different macronutrient combinations can lead to successful weight loss, clinicians should consider patients’ preferences when choosing a specific eating pattern. In a study comparing low-fat and low-carbohydrate diets, only the low-carbohydrate group had improvements in health-related quality of life; these improvements were seen in physical function and general health, but not in mental health (54). Thus, diet alone may achieve weight loss but may not address the mental health issues that also affect the long-term management of diabetes and obesity.

Exercise

People with obesity and diabetes lose minimal weight through exercise (aerobic or a combination of aerobic and resistance) alone (55,56). The Studies of a Targeted Risk Reduction Intervention Through Defined Exercise (57) found weight loss ranging from 0.2 to 1.5 kg during a 6-month period from exercise alone. However, exercise appears to augment the effects of diet on weight loss. Specifically, the addition of aerobic exercise to a low-calorie diet leads to a loss of fat mass but not necessarily a loss of weight (58). Resistance training combined with virtually any diet (i.e., energy-restricted standard carbohydrate, low-protein, or low-fat) leads to greater weight loss than with diet alone (59).

Recently published ADA exercise guidelines recommend a goal of 150 min/week of moderate-vigorous physical activity and lapses of no more than 2 days between exercise sessions. This exercise can be either structured exercise or general physical activity. Structured exercise programs include prescriptions for planned and individualized exercise. Structured exercise programs have been found to lead to greater reductions in A1C than general physical activity advice given by the physician (60).

The level of energy expenditure affects the degree of observed weight loss. Energy expenditures >20 metabolic equivalent [MET]-hours/week can achieve significant changes in body weight, BMI, waist circumference, heart rate, and LDL cholesterol. Energy expenditures in the range of 11–19 MET-hours/week do not lead to significant weight loss but still induce reduction in the A1C, blood pressure, triglycerides, total cholesterol, and 10-year coronary heart disease risk. Energy expenditures <11 MET-hours/week do not cause significant changes in any parameters (61). As part of the multidisciplinary team, an exercise physiologist can design personalized exercise regimens based on patients’ specific needs.

Psychotherapy

For obesity management, there are two main psychological methods: behavioral therapy and cognitive therapy. Behavioral therapy teaches patients how to act differently around food, whereas cognitive therapy teaches patients how to change their thoughts and emotions related to food (62,63). Among other things, behavioral therapy for weight loss teaches the skills of problem-solving and awareness of negative thought processes. Topics addressed during sessions include self-control, self-esteem, stress management, and relapse prevention (64,65). When unrealistic weight goals are not achieved, patients’ motivation for long-term behavior change tends to decline. Cognitive therapy can help guide patients to set more realistic goals and thus maintain the motivation that is essential for long-term success (62).

One study showed that obese patients with binge-eating disorder who underwent cognitive behavioral therapy (CBT) followed by behavioral weight loss treatment (such as diet and exercise) had a greater percentage BMI reduction than those who received CBT or behavioral weight loss treatment alone (66,67). In many cases, group sessions have a greater weight loss effect than individual sessions (68). This result may be because patients in group treatment benefit from the support they receive from each other and the positive peer influence to maintain the group norm of losing weight (69).

Pharmacology

Multidisciplinary clinics use a patient-centered approach to medication counseling for weight loss. Although physicians are ultimately responsible for choosing the appropriate appetite-suppressant medications, they incorporate the expertise and input of other team members, who may have insights into the need for and likely effect of the various medications based on their observations of patients. Team members consider how a drug may affect patients’ overall long-term goals through their own specialty lens. Dietitians consider drug-nutrient interactions (e.g., metformin-induced cobalamin deficiency) (70). Exercise physiologists consider how to coordinate patients’ insulin timing and doses with episodes of aerobic exercise to avoid hypoglycemia (71). Behavioral therapists consider the psychological and social aspects of patients’ medication adherence. As with other chronic conditions, treating depression with psychopharmacology can improve diabetes medication adherence (72–74).

Understanding the patient, provider, and prescription factors related to adherence with weight loss medications is also a job shared by all members of the weight loss team (75,76). Adherence is a key factor in the effectiveness of medications. It is also fundamental to every aspect of patient self-care for both diabetes and obesity and therefore demands a team approach.

Bariatric Surgery

According to the American Society for Metabolic and Bariatric Surgery, bariatric surgery is a treatment option for patients with morbid or severe obesity and obesity-related comorbidities such as diabetes for whom nonsurgical attempts at weight loss have failed. Multiple studies have shown that bariatric surgery leads to similar weight loss results for patients with obesity regardless of their diabetes status (77). For patients with diabetes, clinical trials have shown that bariatric surgery can lead to greater weight loss and greater improvement in diabetes than intensive medical therapy alone (78). Likewise, bariatric surgery followed by lifestyle interventions, including diet and exercise, results in more weight loss than bariatric surgery alone (79,80).

Bariatric surgery leads to diabetes remission through several mechanisms, including alteration of gut microbiota (81). Of the two main types of bariatric surgery, gastric restrictive procedures (i.e., laparoscopic adjustable gastric banding and sleeve gastrectomy) bring about a quicker remission of diabetes than intestinal bypass procedures (i.e., Roux-en-Y gastric bypass) (82,83). However, further research is required to determine the long-term sustainability of diabetes remission after bariatric surgery.

Conclusion

Combination programs that focus on a low-calorie diet, adequate physical activity, and psychotherapy induce the greatest weight losses in patients with diabetes (84). Although dietary modification alone can achieve weight loss, exercise and CBT enhance the effects of dietary treatment. Multidisciplinary teams that include a physician with expertise in pharmacotherapy, a nurse and/or nurse practitioner, a dietitian, an exercise physiologist, and a psychologist can provide a comprehensive weight loss program that uses the most effective interventions from each discipline.

Duality of Interest

L.J.C. is chair of the scientific advisory board of Medifast, Inc., a commercial weight-loss program. No other potential conflicts of interest relevant to this article were reported.

Footnotes

  • ↵* D.F. and S.S.-C. were co-primary authors and contributed equally to this work.

Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/licenses/by-nc-nd/3.0 for details.

References

  1. 1.↵
    1. Ogden C,
    2. Carroll M,
    3. Fryar C,
    4. Flegal K
    . Prevalence of obesity among adults and youth: United States 2011–2014. NCHS Data Brief 2015;Nov;1–8
  2. 2.↵
    1. Fontaine KR,
    2. Redden DT,
    3. Wang C,
    4. Westfall AO,
    5. Allison DB
    . Years of life lost due to obesity. JAMA 2017;289:187–193
    OpenUrl
  3. 3.↵
    1. Flegal KM,
    2. Kit BK,
    3. Orpana H
    . Association of all-cause mortality with overweight and obesity using standard body mass index categories. JAMA 2017;309:71–82
    OpenUrl
  4. 4.↵
    1. Hruby A,
    2. Hu FB
    . The epidemiology of obesity: a big picture. Pharmacoeconomics 2015;33:673–689
    OpenUrlPubMed
  5. 5.↵
    1. Mallory Leung M,
    2. Carlsson NP,
    3. Colditz GA,
    4. Chang S
    . The burden of obesity on diabetes in the United States: medical expenditure panel survey, 2008 to 2012. Value Health 2017;20:77–84
    OpenUrl
  6. 6.↵
    1. Finkelstein EA,
    2. Trogdon JG,
    3. Cohen JW,
    4. Dietz W
    . Annual medical spending attributable to obesity: payer and service specific estimates. Health Aff (Millwood) 2009;28:822–831
    OpenUrlCrossRef
  7. 7.↵
    1. Centers for Disease Control and Prevention
    . National diabetes statistics report: estimates of diabetes and its burden in the United States, 2014. Atlanta, Ga., U.S. Department of Health and Human Services, 2014
  8. 8.↵
    1. Stokes A,
    2. Preston SH
    . Deaths attributable to diabetes in the United States: comparison of data sources and estimation approaches. PLoS One 2017;12:e0170219
  9. 9.↵
    1. Roglic G,
    2. Unwin N
    . Mortality attributable to diabetes: estimates for the year 2010. Diabetes Res Clin Pract 2010;87:15–19
    OpenUrlCrossRefPubMedWeb of Science
  10. 10.↵
    1. Deshpande A,
    2. Harris-Haynes M,
    3. Schootman M
    . Epidemiology of diabetes and diabetes-related complications. Phys Ther 2008;88:1254–1264
    OpenUrlAbstract/FREE Full Text
  11. 11.↵
    1. Cordain L,
    2. Eaton SB,
    3. Sebastian A, et al
    . Origins and evolution of the Western diet: health implications for the 21st century. Am J Clin Nutr 2005;81:341–354
    OpenUrlAbstract/FREE Full Text
  12. 12.
    1. McEvoy CT,
    2. Cardwell CR,
    3. Woodside JV,
    4. Young IS,
    5. Hunter SJ,
    6. Mckinley MC
    . A posteriori dietary patterns are related to risk of type 2 diabetes: findings from a systematic review and meta-analysis. J Acad Nutr Diet 2014;114:1759–1775.e4
    OpenUrlCrossRefPubMed
  13. 13.
    1. Cefalu WT,
    2. Bray GA,
    3. Home PD, et al
    . Advances in the science, treatment, and prevention of the disease of obesity: reflections from a Diabetes Care editors’ expert forum. Diabetes Care 2015;38:1567–1582
    OpenUrlAbstract/FREE Full Text
  14. 14.↵
    1. Astrup A,
    2. Finer N
    . Redefining type 2 diabetes: “diabesity” or “obesity dependent diabetes mellitus”? Obes Rev 2000;20:57–59
    OpenUrl
  15. 15.↵
    1. Aucott L,
    2. Poobalan A,
    3. Smith WCS, et al
    . Weight loss in obese diabetic and non-diabetic individuals and long-term diabetes outcomes: a systematic review. Diabetes Obes Metab 2004;6:85–94
    OpenUrlCrossRefPubMedWeb of Science
  16. 16.↵
    1. Dixon JB
    . Advances in managing obesity. Nature 2016;12:215–216
    OpenUrl
  17. 17.↵
    1. Mooradian AD
    . Obesity: a rational target for managing diabetes mellitus. Growth Horm IGF Res 2001;11(Suppl. A):S79–S83
    OpenUrl
  18. 18.↵
    1. Sjostrom L
    . Review of the key results from the Swedish Obese Subjects (SOS) trial: a prospective controlled intervention study of bariatric surgery. J Intern Med 2013;273:219–234
    OpenUrlCrossRefPubMed
  19. 19.↵
    1. Sjöholm K,
    2. Pajunen P,
    3. Jacobson P, et al
    . Incidence and remission of type 2 diabetes in relation to degree of obesity at baseline and 2 year weight change: the Swedish Obese Subjects (SOS) study. Diabetologia 2015;58:1448–1453
    OpenUrlCrossRefPubMed
  20. 20.↵
    1. Lindstrom J,
    2. Ilanne-Parikka P,
    3. Peltonen M, et al
    .; Finnish Diabetes Prevention Study Group. Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. Lancet 2006;368:1673–1679
    OpenUrlCrossRefPubMedWeb of Science
  21. 21.↵
    1. Diabetes Prevention Program Research Group
    . The Diabetes Prevention Program: description of lifestyle intervention. Diabetes Care 2005;25:2165–2171
    OpenUrl
  22. 22.↵
    1. Gregg EW,
    2. Chen H,
    3. Wagenknecht LE, et al
    . Association of an intensive lifestyle intervention with remission of type 2 diabetes. JAMA 2012;308:2489–2496
    OpenUrlCrossRefPubMedWeb of Science
  23. 23.↵
    1. Jensen MD,
    2. Ryan DH,
    3. Apovian CM, et al
    . AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation 2014;129(Suppl. 2):S102–S138
    OpenUrlFREE Full Text
  24. 24.
    1. McGill M,
    2. Felton A-M
    . New global recommendations: a multidisciplinary approach to improving outcomes in diabetes. Prim Care Diabetes 2007;1:49–55
    OpenUrl
  25. 25.↵
    1. Chamberlain JJ,
    2. Rhinehart AS,
    3. Shaefer CF Jr.,
    4. Neuman A
    . Diagnosis and management of diabetes: synopsis of the 2016 American Diabetes Association standards of medical care in diabetes. Ann Intern Med 2016;164:542–552
    OpenUrlCrossRefPubMed
  26. 26.↵
    1. Coleman K,
    2. Austin BT,
    3. Brach C,
    4. Wagner EH
    . Evidence on the Chronic Care Model in the new millennium. Health Aff (Millwood) 2009;28:75–86
    OpenUrlAbstract/FREE Full Text
  27. 27.
    1. Isaacs S,
    2. Knickman J
    1. Wielawski IM
    . Improving chronic illness care. In To Improve Health and Health Care. Isaacs S, Knickman J, Eds. San Francisco, Calif., Jossey-Bass, 2006, p. 1–17
  28. 28.
    1. McCallin A
    . Interdisciplinary practice: a matter of teamwork: an integrated literature review. J Clin Nurs 2001;10:419–428
    OpenUrlCrossRefPubMedWeb of Science
  29. 29.
    1. Ouwens M,
    2. Wollersheim HUB,
    3. Hermens R,
    4. Hulscher M
    . Integrated care programmes for chronically ill patients: a review of systematic reviews. Int J Qual Health Care 2005;17:141–146
    OpenUrlCrossRefPubMedWeb of Science
  30. 30.↵
    1. Mickan SM,
    2. Rodger SA
    . Effective health care teams: a model of six characteristics developed from shared perceptions. J Interprof Care 2005;19:358–370
    OpenUrlCrossRefPubMed
  31. 31.↵
    1. Aschner P,
    2. Lasalle J,
    3. Mcgill M
    ; Global Partnership for Effective Diabetes Management. The team approach to diabetes management: partnering with patients. Int J Clin Pract Suppl 2007;61:22–30
    OpenUrl
  32. 32.↵
    1. VanGaal L,
    2. Scheen A
    . Weight management in type 2 diabetes: current and emerging approaches to treatment. Diabetes Care 2015;38:1161–1172
    OpenUrlAbstract/FREE Full Text
  33. 33.↵
    1. Franz MJ
    . The dilemma of weight loss in diabetes. Diabetes Spectr 2007;20:133–136
    OpenUrlFREE Full Text
  34. 34.↵
    1. Bray GA,
    2. Frühbeck G,
    3. Ryan DH,
    4. Wilding JPH
    . Management of obesity. Lancet 2016;387:1947–1956
    OpenUrlCrossRefPubMed
  35. 35.↵
    1. Yu GC,
    2. Beresford R
    . Implementation of a chronic illness model for diabetes care in a family medicine residency program. J Gen Intern Med 2010;25:615–619
    OpenUrl
  36. 36.↵
    1. Golay A,
    2. Fossati M,
    3. Deletraz M,
    4. De Luzy F,
    5. Howles MN,
    6. Ybarra J
    . Multidisciplinary approach to obesity treatment. Diabetes Obes Metab 2003;5:274–279
    OpenUrlPubMed
  37. 37.↵
    1. Bernstein KM,
    2. Manning DA,
    3. Julian RM
    . Multidisciplinary teams and obesity: role of the modern patient-centered medical home. Prim Care 2016;43:53–59
    OpenUrl
  38. 38.↵
    1. Ryan DH
    . Guidelines for obesity management. Endocrinol Metab Clin North Am 2016;45:501–510
    OpenUrl
  39. 39.↵
    1. De Feo P,
    2. Fatone C,
    3. Burani P, et al
    . An innovative model for changing the lifestyles of persons with obesity and/or type 2 diabetes mellitus. J Endocrinol Invest 2011;34:e349–e354.
    OpenUrlCrossRefPubMed
  40. 40.↵
    1. Pappachan JM,
    2. Viswanath AK
    . Medical management of diabesity: do we have realistic targets? Curr Diab Rep 2017;17:4
    OpenUrl
  41. 41.↵
    1. Wing R,
    2. Marcus MP,
    3. Epstein LH,
    4. Salata R
    . Type II diabetic subjects lose less weight than their overweight nondiabetic spouses. Diabetes Care 1987;10:563–566
    OpenUrlAbstract/FREE Full Text
  42. 42.↵
    1. Guare JC,
    2. Wing RR,
    3. Grant A
    . Comparison of obese NIDDM and nondiabetic women: short- and long-term weight loss. Obes Res 1995;3:329–335
    OpenUrlPubMedWeb of Science
  43. 43.↵
    1. Pi-Sunyer FX
    . Weight loss in type 2 diabetic patients. Diabetes Care 2005;28:1526–1527
    OpenUrlFREE Full Text
  44. 44.↵
    U.K. Prospective Diabetes Study Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes. Lancet 1998;352:837–853
    OpenUrlCrossRefPubMedWeb of Science
  45. 45.↵
    1. Nair KS,
    2. Halliday D,
    3. Garrow JS
    . Increased energy expenditure in poorly controlled type 1 (insulin-dependent) diabetic patients. Diabetologia 1984;27:13–16
    OpenUrlPubMedWeb of Science
  46. 46.↵
    1. Bogardus C,
    2. Taskinen MR,
    3. Zawadzki J,
    4. Lillioja S,
    5. Mott D,
    6. Howard BV
    . Increased resting metabolic rates in obese subjects with non-insulin-dependent diabetes mellitus and the effect of sulfonylurea therapy. Diabetes 1986;35:1–5
    OpenUrlAbstract/FREE Full Text
  47. 47.↵
    1. Panel on Macronutrients
    2. Panel on the Definition of Dietary Fiber
    3. Subcommittee on Upper Reference Levels of Nutrients
    4. Subcommittee on Interpretation and Uses of Dietary Reference Intakes
    5. Standing Committee on the Scientific Evaluation of Dietary Reference Intakes
    6. Food and Nutrition Board
    7. Institute of Medicine
    . Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids. Washington, D.C., National Academies Press, 2002
  48. 48.↵
    1. U.S. Department of Health and Human Services
    . 2008 Physical Activity Guidelines for Americans [Internet]. Available from https://health.gov/paguidelines/pdf/paguide.pdf. Accessed 8 February 2017
  49. 49.↵
    1. American Diabetes Association
    . Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Diabetes Care 2008;31(Suppl. 1):S61–S78
    OpenUrlFREE Full Text
  50. 50.↵
    1. Goday A,
    2. Bellido D,
    3. Sajoux I, et al
    . Short-term safety, tolerability and efficacy of a very low-calorie-ketogenic diet interventional weight loss program versus hypocaloric diet in patients with type 2 diabetes mellitus. Nutr Diabetes 2016;6:e230
  51. 51.↵
    1. Elhayany A,
    2. Lustman A,
    3. Abel R,
    4. Attal-Singer J,
    5. Vinker S
    . A low carbohydrate Mediterranean diet improves cardiovascular risk factors and diabetes control among overweight patients with type 2 diabetes mellitus: a 1-year prospective randomized intervention study. Diabetes Obes Metab 2010;12:204–209
    OpenUrlCrossRefPubMedWeb of Science
  52. 52.↵
    1. Barnard ND,
    2. Cohen J,
    3. Jenkins DJ, et al
    . A low-fat vegan diet and a conventional diabetes diet in the treatment of type 2 diabetes: a randomized, controlled, 74-wk clinical trial. Am J Clin Nutr 2009;89:1588S–1596S
    OpenUrlAbstract/FREE Full Text
  53. 53.↵
    1. Fabricatore AN,
    2. Wadden TA,
    3. Ebbeling CB, et al
    . Targeting dietary fat or glycemic load in the treatment of obesity and type 2 diabetes: a randomized controlled trial. Diabetes Res Clin Pract 2011;92:37–45
    OpenUrlCrossRefPubMed
  54. 54.↵
    1. Guldbrand H,
    2. Lindström T,
    3. Dizdar B, et al
    . Randomization to a low-carbohydrate diet advice improves health related quality of life compared with a low-fat diet at similar weight-loss in type 2 diabetes mellitus. Diabetes Res Clin Pract 2014;106:221–227
    OpenUrl
  55. 55.↵
    1. Sigal RJ,
    2. Kenny GP,
    3. Boulé NG, et al
    . Effects of aerobic training, resistance training, or both on glycemic control in type 2 diabetes. Ann Intern Med 2007;147:357–369
    OpenUrlCrossRefPubMedWeb of Science
  56. 56.↵
    1. Lucotti P,
    2. Monti LD,
    3. Setola E, et al
    . Aerobic and resistance training effects compared to aerobic training alone in obese type 2 diabetic patients on diet treatment. Diabetes Res Clin Pract 2011;94:395–403
    OpenUrlPubMed
  57. 57.↵
    1. Kraus WE,
    2. Houmard JA,
    3. Duscha BD, et al
    . Effects of the amount and intensity of exercise on plasma lipoproteins. N Engl J Med 2002;347:1483–1492
    OpenUrlCrossRefPubMedWeb of Science
  58. 58.↵
    1. Snel M,
    2. Gastaldelli A,
    3. Ouwens DM, et al
    . Effects of adding exercise to a 16-week very low-calorie diet in obese, insulin-dependent type 2 diabetes mellitus patients. J Clin Endocrinol Metab 2012;97:2512–2520
    OpenUrlCrossRefPubMed
  59. 59.↵
    1. Wycherley TP,
    2. Noakes M,
    3. Clifton P,
    4. Cleanthous X,
    5. Keogh JB,
    6. Brinkworth GD
    . A high-protein diet with resistance exercise training improves weight loss and body composition in overweight and obese patients with type 2 diabetes. Diabetes Care 2010;33:969–976
    OpenUrlAbstract/FREE Full Text
  60. 60.↵
    1. Di Loreto C,
    2. Fanelli C,
    3. Lucidi P, et al
    . Make your diabetic patients walk: long-term impact of different amounts of physical activity on type 2 diabetes. Diabetes Care 2005;28:1295–1302
    OpenUrlAbstract/FREE Full Text
  61. 61.↵
    1. Umpierre D,
    2. Ribeiro PAB,
    3. Kramer CK, et al
    . Physical activity advice only or structured exercise training and association with HbA 1c levels in type 2 diabetes. JAMA 2011;305:1790–1799
    OpenUrlCrossRefPubMedWeb of Science
  62. 62.↵
    1. Fabricatore AN
    . Behavior therapy and cognitive-behavioral therapy of obesity: is there a difference? J Am Diet Assoc 2007;107:92–99
    OpenUrlCrossRefPubMed
  63. 63.↵
    1. Hollon SD
    . What is cognitive behavioural therapy and does it work? Curr Opin Neurobiol 1998;8:289–292
    OpenUrlCrossRefPubMedWeb of Science
  64. 64.↵
    1. Dorsten BVan,
    2. Lindley EM
    . Cognitive and behavioral approaches in the treatment of obesity. Med Clin North Am 2011;95:971–988
    OpenUrlCrossRefPubMed
  65. 65.↵
    1. Kelley CP,
    2. Sbrocco G,
    3. Sbrocco T
    . Behavioral modification for the management of obesity. Prim Care 2016;43:159–175
    OpenUrl
  66. 66.↵
    1. Grilo CM,
    2. Masheb RM,
    3. Wilson GT,
    4. Gueorguieva R,
    5. White MA
    . Cognitive-behavioral therapy, behavioral weight loss, and sequential treatment for obese patients with binge-eating disorder: a randomized controlled trial. J Consult Clin Psychol 2011;79:675–685
    OpenUrlPubMed
  67. 67.↵
    1. Painot D,
    2. Jotterand S,
    3. Kammer A,
    4. Fossati M,
    5. Golay A
    . Simultaneous nutritional cognitive-behavioural therapy in obese patients. Patient Educ Couns 2001;42:47–52
    OpenUrlCrossRefPubMed
  68. 68.↵
    1. Cresci B,
    2. Tesi F,
    3. La Ferlita T, et al
    . Group versus individual cognitive-behavioural treatment for obesity: results after 36 months. Eat Weight Disord 2007;12:147–153
    OpenUrlPubMed
  69. 69.↵
    1. Wadden TA,
    2. Stunkard AJ
    1. Wadden T,
    2. Osei S
    . The treatment of obesity: an overview. In Handbook of Obesity Treatment. Wadden TA, Stunkard AJ, Eds. New York, Guilford Press, 2002, p. 229–248
  70. 70.↵
    1. Triplitt C
    . Drug interactions of medications commonly used in diabetes. Diabetes Spectr 2006;19:202–211
    OpenUrlFREE Full Text
  71. 71.↵
    1. Flood BL,
    2. Constance A
    . Diabetes exercise safety. Am J Nurs 2002;102:47–55
    OpenUrlPubMedWeb of Science
  72. 72.↵
    1. Rubin RR
    . Adherence to pharmacologic therapy in patients with type 2 diabetes mellitus. Am J Med 2005;118(Suppl. 5):27S–34S
    OpenUrlPubMedWeb of Science
  73. 73.
    1. Yun LWH,
    2. Maravi M,
    3. Kobayashi JS,
    4. Barton PL,
    5. Davidson AJ
    . Antidepressant treatment improves adherence to antiretroviral therapy among depressed HIV-infected patients. J Acquir Immune Defic Syndr 2005;38:432–438
    OpenUrlCrossRefPubMedWeb of Science
  74. 74.↵
    1. Gatto N,
    2. Mohr DC,
    3. Goodkin DE,
    4. Baumann KA,
    5. Rudick RA
    . Treatment of depression improves adherence to interferon beta-1b therapy for multiple sclerosis. Arch Neurol 1997;54:531–533
    OpenUrlCrossRefPubMedWeb of Science
  75. 75.↵
    1. DiMatteo M
    . Social support and patient adherence to medical treatment: a meta-analysis. Heal Psychol 2004;23:207–218
    OpenUrl
  76. 76.↵
    1. Vlasnik J,
    2. Aliotta S,
    3. Bonnie D
    . Medication adherence: factors influencing compliance with prescribed medication plans. Case Manager 2005;16:47–51
    OpenUrlPubMed
  77. 77.↵
    1. Pham S,
    2. Gancel A,
    3. Scotte M, et al
    . Comparison of the effectiveness of four bariatric surgery procedures in obese patients with type 2 diabetes: a retrospective study. J Obes 2014;2014:638203
    OpenUrl
  78. 78.↵
    1. Kumar AA,
    2. Palamaner Subash Shantha G,
    3. Kahan S,
    4. Samson RJ,
    5. Boddu ND,
    6. Cheskin LJ
    . Intentional weight loss and dose reductions of anti-diabetic medications: a retrospective cohort study. PLoS One 2012;7:e32395
    OpenUrlPubMed
  79. 79.↵
    1. Herring LY,
    2. Stevinson C,
    3. Carter P, et al
    . The effects of supervised exercise training 12–24 months after bariatric surgery on physical function and body composition: a randomised controlled trial. Int J Obes (Lond) 2017;41:909–916
    OpenUrl
  80. 80.↵
    1. Kalarchian M,
    2. Turk M,
    3. Elliott J,
    4. Gourash W
    . Lifestyle management for enhancing outcomes after bariatric surgery. Curr Diab Rep 2014;14:540
    OpenUrl
  81. 81.↵
    1. Liu H,
    2. Hu C,
    3. Zhang X,
    4. Jia W
    . Role of gut microbiota, bile acids and their cross-talk in the effects of bariatric surgery on obesity and type 2 diabetes. J Diabetes Investig. Epub ahead of print on 23 April 2017 (DOI: 10.1111/jdi.12687)
  82. 82.↵
    1. Kashyap SR,
    2. Gatmaitan P,
    3. Brethauer S,
    4. Schauer P
    . Bariatric surgery for type 2 diabetes: weighing the impact for obese patients. Cleve Clin J Med 2010;77:468–476
    OpenUrlAbstract/FREE Full Text
  83. 83.↵
    1. Ardestani A,
    2. Rhoads D,
    3. Tavakkoli A
    . Insulin cessation and diabetes remission after bariatric surgery in adults with insulin-treated type 2 diabetes. Diabetes Care 2015;38:659–664
    OpenUrlAbstract/FREE Full Text
  84. 84.↵
    1. Norris SL,
    2. Zhang X,
    3. Avenell A, et al
    . Long-term effectiveness of lifestyle and behavioral weight loss interventions in adults with type 2 diabetes: a meta-analysis. Am J Med 2004;117:762–774
    OpenUrlCrossRefPubMedWeb of Science
Back to top
View Selected Citations (0)
Print
Download PDF
Article Alerts
Email Article
Citation Tools
Add to Selected Citations

Multidisciplinary Team–Based Obesity Treatment in Patients With Diabetes: Current Practices and the State of the Science
Daniel Foster, Shakira Sanchez-Collins, Lawrence J. Cheskin
Diabetes Spectrum Nov 2017, 30 (4) 244-249; DOI: 10.2337/ds17-0045
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo

Jump to section