Clinical guidelines type 2 diabetes mellitus vs,jan 10 2011,gcse questions on probability - .

A modest weight loss of 5% to 10% of initial body weight can substantially improve glycemic control and cardiovascular disease risk factors.
Comprehensive health behaviour intervention should be implemented in overweight and obese people with diabetes or those at risk for diabetes to prevent weight gain and to achieve and maintain a reduced body weight.
Bariatric surgery may be considered for appropriate patients when other interventions fail to achieve and maintain a healthy body weight. Obesity is widely considered a chronic health problem that is often progressive and difficult to treat. Assessment of overweight and obese patients should include determining reasons for the previous or current positive energy balance that led them to become overweight or obese, or to continually gain weight. The program provides individualized nutritional, exercise and behavioral programs and counselling. The goals of therapy for overweight and obese people with diabetes are to achieve optimal glycemic and metabolic control initially through health behaviour intervention. The National Institutes of Health (NIH)-sponsored multicenter Look AHEAD (Action for Health in Diabetes) trial, whose design is based largely on the United States (US) Diabetes Prevention Program, investigated the effects of lifestyle intervention on changes in weight, fitness, and CVD risk factors and events in people with type 2 diabetes (30).
The overall goal of health behaviour intervention in people with diabetes who are overweight or obese is to improve health status and quality of life (32,33). Health behaviour interventions that combine dietary modification, increased and regular physical activity and behaviour therapy are the most effective (34–37).
All weight-loss diets must be well balanced and nutritionally adequate to ensure optimal health. As understanding and adhering to healthy and nutritionally balanced meal plans can be challenging, people with diabetes should be counselled by qualified professionals on appropriate serving sizes, caloric and carbohydrate intake and how to select nutrient-rich meals (38,39). Two large-scale reviews of >100 individual studies evaluating behaviour modification techniques support their effectiveness in promoting weight loss (40,41). Members of the healthcare team should consider using a structured approach to providing advice and feedback on physical activity, healthy eating habits and weight loss (42–45). A longitudinal (sleeve) resection of the stomach reduces the functional capacity of the stomac and eliminates the ghrelin-rich gastric fundus.
Orlistat is currently the only approved medication in Canada for long-term management of obesity (Table 5) (47). However, pharmacotherapy options are limited in weight management, and many approved agents have been discontinued by the developers or rejected by government drug approval boards due to unacceptable side effects (18). Orlistat leads to greater weight loss when coupled with healthy behaviour interventions (47). Some antihyperglycemic medications are associated with weight gain (insulin, insulin secretagogues, thiazolidinediones), and the magnitude of weight gain can vary from 4 to 9 kg or more, depending on the choice of drugs (Table 6 ) (18). Other available anti-obesity drugs, such as diethylpropion and phentermine, are sympathomimetic noradrenergic appetite suppressants that are approved only for short-term use of a few weeks.
Bariatric surgery has emerged as an innovative alternative option in the management of type 2 diabetes.
In overweight or obese adults with type 2 diabetes, the effect of antihyperglycemic agents on body weight should be taken into account [Grade D, Consensus]. 32 The American Diabetes Association's (ADA) evidence-based practice guidelines, standards, and related recommendations and documents for diabetes care.
Recognize is your reminder to consider diabetes risk factors for all of your patients, and screen appropriately for type 2 diabetes. Screen every 3 years in individuals > 40 years of age or in individuals at high risk using a risk calculator. SGLT-2 inhibitors are the first class of drugs to target renal glucose reabsorption as a means of reducing hyperglycemia in type 2 diabetes mellitus. Developed by a faculty of renowned, international diabetes experts led by Julio Rosenstock, MD, this 2-part educational activity will provide clinicians with an interpretation of recent clinical data, and explore the potential role of SGLT-2 inhibitors in diabetes care.

This continuing medical education activity is jointly sponsored by Albert Einstein College of Medicine of Yeshiva University and Haymarket Medical Education and supported by an educational grant from Bristol-Myers Squibb. The first component of this 2-part educational activity, the clinical monograph will provide endocrinologists, cardiologists, and general practitioners who manage the care of patients with type 2 diabetes with the latest data on the SGLT-2 inhibitors.
Four international diabetes experts will further elucidate the future role of the SGLT-2 inhibitors in the T2DM treatment arsenal. Higher body mass index in people with diabetes is associated with increased overall mortality.
Many classes of antihyperglycemic medications are associated with weight gain, while some are weight neutral or associated with weight loss. Metabolic comorbidities, such as hypertension, dyslipidemia and CVD risk factors, should also be assessed since they are highly correlated with increasing BMI (10,11). An etiological approach assessing causes of lower metabolic rates, such as medications and hormonal imbalances, should be considered (17). Attaining and maintaining a healthy body weight and preventing weight regain are the short- and long-term goals. The 1- and 4-year interim data reported beneficial effects of modest weight loss of 5% to 10% in improving glycemic control, lowering of CV risk markers, BP and lipid levels (30,31). Structured interdisciplinary programs have demonstrated better short- and long-term results (36). Programs and clinics dedicated to weight management may be beneficial, particularly those that adhere to the checklist in Table 4 (46). Secretion and function of gastrointestinal hormones after bariatric surgery: their role in type 2 diabetes. Ingested food bypasses ∼95% of the stomach, the entire duodenum and a portion of the jejunum.
When used to treat overweight and obese people with diabetes, orlistat has been demonstrated to improve glycemic control and to reduce the doses of antihyperglycemic agents that can promote weight gain (47).
Orlistat has been shown to be effective at improving glycemic and metabolic control in obese people with type 2 diabetes (47,49,50). Insulin is associated with the most weight gain, whereas metformin, glucosidase inhibitors and the incretin class of antihyperglycemic agents typically are weight neutral or associated with a weight loss of about 3 kg (18). These procedures can result in sustained body weight loss and significant improvement in obesity-related comorbidities (52).
Emerging data strongly suggest that this novel drug class will, in the very near future, have a role to play in diabetes management. A detailed explanation of the unique mechanisms of action and the safety and tolerability profiles of this drug class will be provided, and the results of key clinical trials will be discussed.
Obesity is also becoming more prevalent in people with type 1 diabetes; a study has indicated a 7-fold increase in obesity in 20 years (2). Excessive abdominal adiposity is a strong independent predictor of metabolic comorbidities (12,13). People with diabetes often take medications that are associated with weight gain; these include antihyperglycemic, antihypertensive, pain relief and antidepressant agents (18). In general, obese people with diabetes have greater difficulty with weight loss compared to similarly obese people without diabetes (22). Antiobesity drug therapy may be considered as an adjunct to nutrition therapy, physical activity and behaviour modification to achieve a target weight loss of 5% to 10% of initial body weight and for weight maintenance (32,48).
In obese people with impaired glucose tolerance, orlistat also improves glucose tolerance and reduces the progression to type 2 diabetes (51).
Thus, it is important that health care providers who treat patients with diabetes are aware of the most recent data on these agents and the implications for clinical practice.
Furthermore, intensive insulin therapy and some glucose-lowering medications are associated with weight gain (3,4).

Psychological aspects of eating behaviours, such as emotional eating, binge eating and depression, also should be assessed (19). Many antihyperglycemic medications are associated with weight gain, and attempts should be made to minimize these medications without compromising glycemic control or to switch to alternative agents not associated with weight gain (18).
There was some expected weight regain at 4 years, yet there continued to be beneficial metabolic effects. Adequate protein intake is required to maintain lean body mass and other essential physiological processes.
There are several new antiobesity agents that may be available within the near future and that may have a beneficial impact on diabetes management. Clinical trials with antiobesity agents have confirmed a smaller degree of weight loss in people with diabetes compared with obese people who do not have diabetes (22,38). Individuals who are candidates for surgical procedures should be selected after evaluation by an interdisciplinary team with medical, surgical, psychiatric and nutritional expertise. Walker-Thurmond Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. Despres The association of cardiovascular disease risk factors with abdominal obesity in Canada. Weight loss has been shown to improve glycemic control by increasing insulin sensitivity and glucose uptake and diminishing hepatic glucose output (5). Table 2 (14,15) lists National Cholesterol and Education Program Adult Treatment Panel III (NCEP-ATP III) WC values. Physical parameters that impede activity, such as osteoarthritis or dyspnea, should be assessed (20).
For many patients, prevention of weight gain can be considered a realistic and sustainable outcome. Long-term, if not lifelong, medical surveillance after surgical therapy is necessary for most people.
The risk of death from all causes, cardiovascular disease (CVD) and some forms of cancer increases with excessive body fat (6). The International Diabetes Federation has proposed population specific WC cutoff values (Table 3) (16). Comorbid conditions, such as osteoarthritis and obstructive sleep apnea, can also impact the ability to lose weight (21). A modest weight loss of 5% to 10% of initial body weight can substantially improve insulin sensitivity, glycemic control, high blood pressure (BP) and dyslipidemia (23–27).
Bariatric surgery procedures can be classified as restrictive, malabsorptive or combined restrictive and malabsorptive. This relationship between increasing body fat accumulation and adverse health outcomes exists throughout the range of overweight and obese men and women in all age groups, including those ≥75 years of age (7). These guidelines have not been fully validated against the development of clinical events, and considerable population-based research is needed in this area. Biliopancreatic diversion with duodenal switch procedure (Figure 1), roux-en-Y gastric bypass (Figure 2), gastric sleeve (Figure 3) and laparoscopic adjustable gastric banding (Figure 4 ) have all demonstrated significant improvements and even remission in type 2 diabetes (53–55). As individuals lose weight, adjustment in antihyperglycemic medications may be required to avoid hypoglycemia.

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