We are pleased to present the first in a three-part series on weight management and diabetes sponsored by Lilly and written by Amy Hess Fischl, MS, RD, LDN, BC-ADM, CDCES. Content is provided for information only; please consult with your healthcare provider before making changes to your diabetes management.

Imagine you're in your healthcare provider's office, and the medical staff is completing your initial vitals. They review your medications, take your blood pressure, and then ask you to hop on the scale to check your weight. That last request fills many people with dread since there is a possibility that a conversation will ensue that may be construed as judgmental about weight gain, why it was gained, and the unrealistic goals of how many pounds to lose. If this has not happened to you, consider yourself lucky. With weight gain being a primary reason for higher blood pressure and cholesterol, risk of heart disease, stroke, gallbladder disease, and nonfatty liver disease (to name a few), it is often a top-of-mind discussion point during a healthcare provider (HCP) visit. Since losing weight is a battle fraught with guilt and feelings of failure that many face, the types of conversations regarding our weight and the potential need to reduce it are the difference between taking action and taking offense.

While having a negative connotation, weight management is a term that refers to behaviors, techniques, and physiological processes that contribute to a person's ability to attain and maintain a healthy weight. Most weight management techniques encompass long-term lifestyle strategies promoting healthy eating and physical activity¹. Think of it in terms of being a healthier self instead of a diet or an exercise regimen. The key is making lasting behavior changes that you can stick to without feeling like you are reducing your quality of life. These specific changes are unique to each of us, which is why this is a more complex conversation.

Speaking as a patient myself, I prefer to bring up the topic of weight management strategies instead of hearing my HCP tell me what I need to do. You may feel the same, and this article is meant to empower you to be in the driver’s seat. I strongly advocate for every patient I see to come armed with a plan of attack for a visit: questions they want to be answered and goals they would like to implement. If weight management is on your mind, be prepared to bring it up first so YOU direct the conversation.

Before having that conversation with your HCP, consider some situations that may thwart weight management strategies. If you use insulin therapy, think about the following:

• How often are you treating hypoglycemia? If you are experiencing multiple hypoglycemic events per day, you could effectively be consuming an extra 200-500 calories daily. That alone will stop any potential weight loss in its tracks.
• Why are you experiencing hypoglycemia? If it occurs without added activity and there is no discernible reason, your medication doses could be too high, and you essentially have to “feed” the medications. Have a discussion with your HCP to create a plan to make adjustments in between your visits.
• What sources of food and beverages are you using to treat hypoglycemia? We know that a pure glucose source like glucose tabs is ideal, but fructose (juice) and sucrose (sugar-based candy like Starburst, Skittles, and Sour Patch kids) have been used in their place if glucose tablets are not available. The “Rule of 15” suggests that 15 grams of carbohydrate should be used if your glucose is under 70 mg/dL, raising the glucose by 30-50 points. However, in a state of panic, many people may consume two to three times as much, leading to increased calories and far higher than expected glucose. Also, some people turn to cookies, candies, and other treats containing protein and fat, leading to a much slower glucose rise and a need to eat more to feel better in response.

For those on insulin, reducing hypoglycemia and re-evaluating your treatment options can increase the success of your weight management strategies. However, for those not taking insulin, some other key considerations should also be addressed:

• Have you assessed how often you are eating? It is a misconception that we should all consume three meals with snacks daily. We really should only be eating when we are hungry. So, if you are consuming calories “because you think you need to,” that can make it more challenging to achieve your weight management goals.
• How much are you consuming at one time? Remember that it takes 15-20 minutes for our brains to realize we are full. To reduce the risk of overeating, try to slow down while eating and enjoy the experience. If necessary, set a timer to work on making your meal last at least 15 to 20 minutes.

When assessing weight management needs, you must be realistic regarding the amount of weight that needs to be lost – we all need to stop thinking we should get back to our high school weight. A weight loss goal of 5% (or 9 pounds for a person weighing 180) is recommended and has many benefits, including reductions in blood pressure, LDL cholesterol, and liver enzymes. The research shows that a 2-5% weight reduction can get the ball rolling and aid in reducing glucose. That amount of weight loss can lead to an A1C reduction of 0.5%, with the most significant impact on fasting levels^2-5. This may require a decrease in various diabetes medications (including basal insulin, especially for those taking basal insulin injections at dinner or bedtime and those on insulin pumps). It has also been found that weight loss of 10% starts to impact postprandial levels. But, any weight loss is helpful and requires reducing medications to reduce the risk of hypoglycemia^6,7.

Healthy lifestyle behavior changes are the first line of treatment, so it is essential to start by focusing on meal composition and its impact on glucose. Changing how much and how often you eat will aid in reducing glucose. Reducing the portions of higher carbohydrate foods and beverages will lead to lower post-meal glucose readings. It also will reduce how high the readings rise after a meal.

I hate to burst anyone’s bubble, but most types of physical activity may not play as big of a factor in losing weight. Still, exercise is an incredible tool for weight maintenance and aiding in reducing glucose levels, especially surrounding meals. Taking a quick walk after a meal helps the body utilize the glucose more efficiently, leading to more in-range readings after meals and hours later. Also, breaking up long periods of sitting with standing and moving around can improve post-meal glucose. If you have a desk job, try incorporating just a few minutes of movement every hour^8,9.

Bottom line – weight management strategies should be lifelong habits incorporated into our lives. Think of it as if everything is related – one small change can affect everything else. Set the stage and think about weight management in a different light. It does not have to be a bad thing. Our weight fluctuates, and that should not equate to failure. We need to focus on the big picture. All the lifestyle changes that you make are helping to reduce the risks of other health issues. So, it is the sum of all the parts, not just the number we see when we step on the scale. Weight management strategies CAN lead to in-range glucose levels more often, but it is a work in progress. Do not get frustrated if you do not see the results you expect. If at first you don’t succeed, try, try again. ALL changes you make, no matter how small, are positive ones.

References:
¹https://www.niddk.nih.gov/health-information/weight-management
²Pak J Med Sci. 2020;36(7):1523-1528. doi: https://doi.org/10.12669/pjms.36.7.3027
³Diabetes Care 2023;46(Suppl. 1):S140–S157 | https://doi.org/10.2337/dc23-S009
⁴Diabetes Care 34:1481–1486, 2011. DOI: 10.2337/dc10-2415
⁵Diabetes Care 34:2152–2157, 2011. DOI: 10.2337/dc11-0874
⁶Curr Obes_Rep._2017;6(2):187–194. doi:10.1007/s13679-017-0262-y
⁷Obesity Reviews. 2022;23:e13357. https://doi.org/10.1111/obr.13357
⁸Nutrients 2018, 10, 1743; doi:10.3390/nu10111743
⁹Sports Medicine (2022) 52:1765–1787

 

Amy Hess Fischl, MS, RD, LDN, BC-ADM, CDCES, is an advanced practice dietitian and diabetes care and education specialist at the University of Chicago within the departments of pediatric and adult endocrinology. She speaks internationally on all diabetes topics, especially meal plan options for type 1 diabetes, insulin pumps, and continuous glucose monitors. She is actively involved in the American Diabetes Association, the Academy of Diabetes Care and Education Specialists, and the Academy of Nutrition and Dietetics, as well as several international groups for diabetes and pre-diabetes. She was named 2018 IL AADE Diabetes Educator of the Year and also received the 2018 Pan Arab Congress on Diabetes Award of Excellence for her contributions to diabetes care and education. Her dream vacation always includes diving with sharks.