AACE-logoThe problem of obesity and its relationship to diabetes has been inextricably linked. However, more recently, the focus has changed. Healthcare providers, especially CDEs, have long realized that the frustrating cycle of weight loss and weight regain can exacerbate diabetes, its complications, as well as be discouraging for patients.

Endocrinologists and bariatricians are two medical specialties which address this conundrum of obesity and diabetes. This year, both the Endocrine Society and the American Association of Clinical Endocrinologists (AACE) meetings offered many presentations, symposia, abstracts, and exhibitions on this topic. (1,2,3,4,5)

At the recent AACE meeting, the 24th Annual Scientific and Clinical Congress in Nashville, there were numerous discussions and presentations on diabetes and obesity for providers, including: 4 symposia, 5 sessions directly focusing on diabetes and weight, 6 sessions indirectly addressing this subject, as well as numerous posters. Here are some notable sessions at this year’s AACE meeting:

New Players in the Study of Appetite-Regulating Hormones?

Ralph DeFronzo, MD, reported about the role of glucagon and oxyntomodulin  in weight regulation in his presentation on “The Role Of Glucagon In Fasting And Postprandial Hyperglycemia In Diabetes Mellitus: An Update in Diabetes.” The role of glucagon in weight regulation has been documented, but additional research is needed to elucidate clearly its actions. 

Oxyntomodulin is a natural occurring, 37-amino acid produced in fundic mucosa. Although the mechanisms of actions are not fully understood, it’s been documented that the amino acid binds with both GLP-1 and glucagon receptors. It also has several additional relevant actions:

  • inhibits gastric secretion;
  • increases energy expenditure;
  • blocks the orexigenic effects of ghrelin; and
  • inhibits the hunger center in the hypothalamus.
 

Practical Use of Obesity Medications for Diabetes Patients

Caroline Apovian, MD, FACP, FACN reported on the use of pharmacotherapy as one of the tools for obesity treatment. Dr. Apovian positioned obesity medication use after lifestyle interventions of “diet, exercise, and behavior modifications,” but before bariatric surgery.

Recommendations for use of medications to treat obesity include:

  • treating weight first, not last;
  • transitioning patients off weight increasing medications to weight decreasing or weight-neutral medications;
  • prescribing medication type and dose based on co-morbidities with obesity;
  • positioning lifestyle change as the foundation of all approaches for effective weight loss; and
  • following patients frequently is also key for sustained weight loss.

Details of her recommendations can be found in the Endocrine Society's Clinical Practice Guidelines. (6)

The Mind’s Role in Obesity

Josh Thayler, MD, provided a thorough overview of the complex role of the brain in weight and appetite regulation. Some key concepts from the presentation include:

  • there is an extremely complex interrelationship between the hypothalamus and peripheral tissues (i.e., various regions of the brain enable different aspects of energy balance);
  • high fat diets negatively impact brain cell function, repair,  and regeneration;
  • just 3 days of high fat intake significantly inflames the hypothalamus; and
  • excessive caloric intake results in hypothalamus inflammation, and therefore decreased regulation of metabolism and increased obesity.

Sleep, Weight Management and Diabetes

In  Eve Van Cauter's, PhD, lecture “Sleep and Health,”  she presented numerous data on the crucial relationship between sleep quality, quantity, and metabolic disruptions. Some interesting notes from it include:

  • there is a high percentage of diabetes patients who also have obstructive sleep apnea (OSA): between 58% and 86% from various recent studies;
  • there’s a high correlation between OSA and decreased insulin sensitivity;
  • lack of sleep duration significantly disrupts ghrelin and leptin, regulation of appetite and hunger, and increases caloric intake, with no change in expenditure;
  • short sleep duration also: increases diabetes risk, by decreasing insulin sensitivity and response; disrupts fat metabolism in studied subjects; anddisrupts glucose metabolism in healthy young subjects;
  • Abnormal timing of sleep (working night shifts and rotating shift work), significantly affects overall metabolism resulting in weight gain and higher incidence of diabetes; and
  • sleep timing, quality, and quantity are often overlooked as the core contributor to metabolic disruptions (i.e., diabetes, obesity, cancer).

What’s the Relationship of Diabetes, Obesity, and Cancer?

In her presentation, “The Year in Diabetes, ” Claresa Levetan, MD, reported on the increasing (1.2 – 2 fold) risk of many types of cancer in both type 1 and type 2 diabetes.  Several studies indicate that pancreatic cancer patients are glucose intolerant or diabetic.

Francisco Pasquel, MD, in his presentation, “Obesidad, Diabetes y Cancer,” stated that there may be similar mechanisms for development of the disorders of diabetes, obesity, and cancer.

What’s Next?

It’s anticipated that additional healthcare organizations such as the American Diabetes Association (ADA), The Obesity Society, American Heart Association, etc., will increasingly fund studies specific to the quandary of diabetes and weight.  

For example, the AACE announced during this meeting that they will be working on this topic in the next edition of their practice guidelines.

Diabetes and obesity will continue to be a growing area of interest in healthcare. I will bring you more information and how fellow providers can address these topics with their patients.


References:

1 Endo Soc meeting.

2. Apovian C, et. al. Pharmacological Management of Obesity: An Endocrine Society Clinical Practice Guideline, J Clin Endocrinol Metab, February 2015, 100(2):342–362.

3. AACE 24th Annual Scientific and Clinical Congress 24th Annual Scientific and Clinical Congress.

4. AACE Practice Guidelines.

5. Garvey, WT, et.al. American Association Of Clinical Endocrinologists And American College Of Endocrinology Position Statement On The 2014 Advanced Framework For A New Diagnosis Of Obesity As A Chronic Disease. Endo Prac, 2014, 20(9):977-989.

6. Apovian C, et.al. J Clin Endocrinol Metab. January  2015, jc20143415.