ADA 2008: Putting weight loss into clinical practice

Translating weight loss research into clinical programs is not easy. Too many clinical protocols exist in isolation, according to Donald Williamson, PhD, Pennington Biomedical Research Center, Baton Rouge, LA. The key gap is extending methods that contribute to weight loss into programs that maintain weight loss.

"Weight loss is not a curative effort," Dr. Williamson said. "This is not a situation where you do something to the patient and then say goodbye. Losing weight is a life-long, significant effort."

The typical patient loses weight, then regains it. The problem: Too many patients and clinicians assess weight and produce a program that results in weight loss, but neglect to create a management strategy to keep those lost pounds from returning.

Separate weight lossinto two goals
The more effective approach, he said, is to separate weight loss into two goals, one for the initial loss and another for long-term weight management. Weight loss typically happens in 6 to 12 months, he said. Weight management is a life-long process.

Weight management is also more complex than weight loss. Management is not just management of the patient, diet and exercise, but management of all of the risk factors that to favor weight gain, especially the environment."Put that patient who just lost 10% in an environment with easy access to food and low levels of exercise and you have a recipe for problems. You need to get the home and work environments structured in ways that support healthy eating and exercise."

Obesity typically precedes diabetes, Dr. Williamson noted. The most effective time to intervene is before insulin resistance fully develops and insulin secretion plummets. Once diabetes is well-established, it is too late to reap the full benefits of early weight loss.

Patients with a body mass index (BMI) of 30 or above are obese under current guidelines. These obese patients, as well patients who are overweight (BMI between 25 and 30) and have two additional risk factors for diabetes, should lose about 10% of body weight. Patients with a BMI between 25 and 30 who do not have additional risk factors should focus on weight management to avoid becoming obese.

Dr. Williamson said most studies suggest that a weight loss of 1 to 2 pounds per week is optimal. In clinical practice, most patients actually lose closer to 1 pound weekly.

A 10% weight loss may be the goal, but a smaller weight loss may also bring benefits. The DPP study found that even a 7% weight loss reduced the development of type 2 diabetes by 58%. Weight loss was more effective at preventing the development of diabetes than metformin, which showed a 31% reduction compared to placebo.