COMMENTARY

Getting to 'A-ha!' With Obese Patients

Anne L. Peters, MD, CDE

Disclosures

April 21, 2014

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The Dual Struggle of Obesity and Diabetes

Anne L. Peters, MD, CDE: Hi. My name is Dr. Anne Peters, from the University of Southern California, and today I am going to talk about the treatment of obesity in type 2 diabetes. This is going to be a special video because part of it will include a patient of mine named Marde, discussing her own struggle with obesity in the setting of type 2 diabetes.

The reason for this topic is because I was asked to give a talk on this subject at the American Diabetes Association postgraduate course. That required me to go through all of the literature in this field and make up my own mind as to what I thought the best approach should be. It's not really a headline, but the key, obviously, is to change a person's lifestyle. We can try to do that in a variety of different ways. We can use medications or bariatric surgery; we have all sorts of approaches. But from my perspective -- and as you are going to hear from Marde -- you can really overeat anything if you put your mind to it and you haven't really changed your habits.

The key in how we approach our patients is to continuously reinforce lifestyle changes and give them whatever resources we can to encourage them to do that. Second, I find that it's vitally important to use medications for treating type 2 diabetes that do not promote weight gain. Obviously there are drugs such as insulin and sulfonylurea agents that lower blood sugar levels, but my patients tend to have the most success when they are treated with drugs such as metformin or the DPP-4 inhibitors, which are weight-neutral. Drugs such as the GLP-1 receptor agonist class, as well as the new SGLT2 inhibitor class, are actually associated with weight loss.

Getting Off Insulin and Other Benefits

Dr. Peters: I am able to take patients who may be on some amount of basal insulin and add in drugs -- for example, a SGLT2 inhibitor such as canagliflozin or dapagliflozin -- to help them reduce their blood sugars, reduce their weight, and potentially get off that basal insulin. If I can get a patient to target using drugs that don't promote weight gain, I seem to do better in this struggle with obesity that many of our patients with type 2 diabetes face.

Additionally, there are weight loss drugs that are approved for patients both with and without diabetes, and those medications work. The problem is that once you stop those medications, patients often regain the weight. There is also bariatric surgery, which I recommend for nearly everybody whose body mass index is > 35 kg/m2, but as I mentioned earlier, you can overeat even after gastric bypass surgery, and for many people it's not a realistic option.

I'm going to let you see Marde and learn from her, but there are a couple of caveats. First of all, she is unusual in how aggressively she pursued the treatment of her obesity, and for all of our patients, hopefully they are going to reach a point. Maybe you call it reaching bottom or having that "a-ha" moment (as Dr. Bill Polonsky says) when, for some reason, something changes within them that allows them to succeed when perhaps they have not been successful in the past.

She uses [exenatide injection] at a point in her treatment, and it makes her nauseous. She liked feeling nauseated but it's not my goal to have patients develop gastrointestinal side effects from these medications, so I would argue that creating nausea is not necessarily a first choice, but enhancing satiety is.

Finally, at the very end of this video, she discusses her relationship with me, which is very sweet and slightly embarrassing. But I believe that we should all have a partnership that allows us to help patients grow and find their own solutions, because telling patients what to do never works unless they internalize it and use me as a partner to improve their health.

So, with that, I'll show you the video.

A Patient Tells Her Tale of Weight Loss

Marde Gregory: My name is Marde Gregory and my current weight -- I'm very proud to say -- is 136 pounds. I have been as heavy as 280 pounds and I was fat for a good number of years. I had endometriosis. I stayed in bed for 6 months and my husband wanted to please me, so he would bring home all of these ridiculous things for me to eat, and I would eat them all day and all night and lay in bed and get fat.

I have tried just about every diet out there, and that is why I don't like the word "diet." I did the all-fruits-and-vegetables diet, the all-protein diet, the no-fat diet, Weight Watchers, the watermelon diet, and even a liquid diet. Diets don't work because they are artificial. If you could go on a diet and stay on it for your entire life, you would be fine, but I don't know anybody who has done that. You need to find a program that you can, will, and want to do for the rest of your life.

I woke up one morning, went to school (I am a teacher), and could barely get to my classroom. I was so slow and so heavy that it took me 20 minutes to get to where I should have been able to get to in 5 minutes. I recognized at that time that I was slowing down because I was dying, and I was going to do one of 2 things: I was either going to die or I was going to get this weight off of me, and I just shook my head and said, "No. I am going to take my pretty good brain and apply it to losing weight."

The first thing that I did when I decided to lose weight was to go for it. I was going to boldly go out there once again and lose all the weight -- which is what I had tried to do with diet -- so I decided to have surgery. I had complete gastric bypass surgery. I lost 100 pounds. As soon as I lost 100 pounds, I started gaining weight. Now, I know what I was doing; I was eating the wrong foods in the wrong amounts. I decided to create 4 steps to get my weight off, and the first step was [exenatide], which was a new drug at the time. It made me entirely and utterly nauseous, but that gave me the time to put the other 3 steps in place. The second step was finding a food shrink. That was Dr. Kathy Quinn, and she helped me enormously. The third step was putting together a team of doctors and making sure that they were on my team. I was in control of that team; they weren't in control of me. That was the hardest part -- putting together a group of doctors who would recognize that I needed to talk about and work on food issues. The fourth step was a wonderful book called Volumetrics,[1] which was written by a woman who got her PhD in general nutrition. That book taught me everything I needed to know to change my taste buds, which was the key element and ingredient in ensuring that I could lose weight. I changed my taste buds.

Understanding the disease elements of obesity is going to be terribly helpful for doctors because it is going to lead to very good discussions between doctors and patients. It also means that it is the patient who is in control. The patient must be in control.

Dr. Peters and I are a team and I adore her. She is open to me as a human being and that allows me to open up to her as a human being, and we have a perfectly reciprocal teamship. That's what I would call it, and let me tell you that she is the only one who has allowed me to tell my story to others. Thank you, Dr. Peters.

Dr. Peters: I hope that you enjoyed watching Marde discuss her own particular challenges with weight loss and that you enjoyed learning from her, as I frankly did. I hope that you can encourage your patients to "change their taste buds," because I love how she puts it. That was her solution for herself. She said that she is never going to not think about food and want food, but she has changed how she eats, how she fills herself up, and her cravings and desires for unhealthy food. She has replaced these things with better food choices, and as a result has attained a much healthier weight.

This has been Dr. Anne Peters for Medscape. Thank you.

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