Article by Sandra Melloni RN, BSN, BA: Can be found on DiabetesCare.net
Most patients with type 2 come into my office wanting to lose weight. Often, their goals are lofty: “Nurse, I really need to lose 130 lbs.” or “Nurse, I’ve gained 80 pounds over the past decade; I need to lose it all.” They are often frustrated and overwhelmed. Where do they begin?
We know that weight gain is a major risk factor for developing type 2 diabetes, and that more than 80% of type 2s are overweight. If we study the incidence of type 2 diabetes in America, the statistics are staggering. With over 29 million people with diabetes in the U.S., the disease is booming. Past forecasts and studies predicted 30 million diabetics in the US by the year 2030, so we are well ahead of schedule. The truth is Americans are becoming increasingly less active and consuming more calories. The result? Our waistlines have increased and so has the incidence of type 2 diabetes.
We have long known that obesity is responsible for the development of hypertension, diabetes, and hyperlipidemia. Weight gain exacerbates these conditions. Has your patient put on an extra twenty pounds? Chances are they will need an adjustment in their diabetes medication, often a dose increase or the addition of another pill. The same goes for their cholesterol and blood pressure.
During the 2013 meeting of the ADA, Philipp Scherer, PhD, professor and director of the Touchstone Diabetes Center at the University of Texas Southwest Medical Center in Dallas, was interviewed on his latest research. He studies diabetes on a cellular level, and obesity’s effects on diabetes, describing fat tissue as a “solid tumor,” containing adipose cells. He explains that when a patient gains weight, fat tissue expands rapidly. This rapid expansion does not allow time for proper vascularization--in other words, the blood supply cannot keep up. The adipose tissues become hypoxic (lack of oxygen) leading to fibrosis of the tissue, and eventually, cell death. This cell death produces surrounding inflammation, which in turn, damages pancreatic beta cells and causes insulin resistance. Insulin resistance is the main mode of pathophysiology in type 2 diabetes. (1)
And if weight gain compromises patient health, certainly weight loss will improve it. However, striving for your patient’s weight as a high school junior just isn’t realistic. Sheri Colberg, PhD, author, exercise physiologist and professor at Old Dominion University discusses in a recent article about weight loss and insulin resistance. “Just a 7% loss of body weight (only 14 lbs if you are 200 lbs) will improve insulin action by 57%. That is a bigger benefit than a patient would get from most diabetes pills.” (2) The American Diabetes Association confirms that a 10-15 pound reduction in body weight will lower blood glucose, blood pressure, cholesterol, and reduce stress on knees and hips. And a 10% weight loss may decrease the risk of certain complications like sleep apnea or particular cancers.
In my diabetes self-management classes, I often suggest to patients that they view healthy eating, exercise, and weight loss as importantly as taking their prescribed medications. These are the tools we have to control diabetes, and overlooking them is like not using all the weapons in our arsenal.
Setting a goal to lose 80 pounds can be overwhelming, but requesting they lose just 10% of their body weight is definitely achieveable. I often ask a patient to mentally calculate what 10% of their body weight is. So if a patient weighs 230 pounds, then a 10% weight loss would be about 23 pounds, certainly an achievable goal over a one year time period. Weight loss would average about two pounds per month or a half pound per week. Most projects in life are better managed by splitting them into smaller tasks. At the end of the year, your patient would realize an improvement in blood sugar and no new additional medications.
So let’s imagine that 23 pounds is our patient’s weight loss goal. This could be achieved with a reduction in calories of about 230 per day. That might be a small bowl of ice cream or a can of soda with some chips. These small changes will add up. Add some physical activity to the mix, and your patient may only need to reduce their calories by 100 per day.
First there are some considerations, particularly if your patient is taking certain medications like insulin or insulin secretagogues, like Glimepiride or Glipizide. Losing weight and eating less may require a change to those medications in order to prevent hypoglycemia. I often suggest that those patients meet with their dietician or diabetes nurse educator before embarking on their weight loss journey. Below are some tips that my colleagues and I often share for weight loss. Remember, your patient doesn’t have to be perfect but make small changes which will add up.
Weight Loss Tips for Diabetes Patients:
- Think Do, not Don’t. If I tell a patient to quit eating chips, it’s often the first thing they crave when they get home. They begin to focus on the “forbidden goodies.” But when we ask them to add 3 vegetables and 2 fruits per day, they don’t feel cheated. Mixing it up with some frozen grapes or some crunchy snow peas with dressing with their lunch will keep things interesting.
- Water, Water, everywhere. We know water is great but try having your patient drink a tall glass ten minutes before meals.
- Lose the tube. When we watch TV and eat simultaneously, we eat more due to the distraction. Ask them to shut off the television and sit at a table.
- Eat to Live. We have all heard the saying “Eat to live, don’t live to eat.” Ask your patient which hobbies they miss. If food is the only source of pleasure, it’s a recipe for disaster. Suggest music, drawing, volunteering or calling an old friend. Yes, even sex. To read more about how food can replace sex and intimacy in some relationships, check out a recent DiabetesCare.net blog here.
- Park Farther and Take the Stairs! Old, but good advice.
- Don’t forget Fido. Just walking the dog twice daily for fifteen minutes each time will help your patient reach their goal of 150 minutes per week of exercise.
- Choose an Exercise you like. If you hate walking, don’t choose it as your exercise. Aqua classes, biking, and Zumba are becoming more popular for men and women alike. Remind patients that gardening and raking burn calories, so put that leaf blower away!
- Put the box down and back away. Everyone is going to cheat sometimes. If they want some ice cream or chips, have your patient measure it out and put the box away.
- Catch some ZZZZZ’s. Lack of sleep can increase stress hormones and cause overeating during the day.
- Sugar-free gum. If you have a chewing fix, break out the gum and save on calories.
- Keep a food diary. We all know it—we eat more than we think we do. Writing it down in black and white can help to think more about what and how much you consume.
- What’s Eating You? If your patient suspects that he or she is an emotional eater, you may want to ask them to keep a journal for one week. Before eating or binging, they might record how they feel, what happened at work, any conversations replaying in their mind and then what they ate. It can certainly be a reflective exercise in why we eat and a great way to become more conscious of the connection between food and emotions.
Again, most people with type 2 want to lose weight. This doesn’t have to be a formidable task or race. Ask patients to “give you 10.”
Sources: 1, 2