Q: My patient with type 2 diabetes is motivated to lose weight; however, he wants to use partial meal replacements to help him achieve his weight loss goal. I am concerned that this is not healthy. What are the current recommendations for patients with diabetes who are interested in losing weight?

When discussing weight loss diet options with your patient, it is important to remember that diets that provide the same caloric restriction but differ in protein, carbohydrate, and fat content (such as high-fat or high-carbohydrate foods) are effective in achieving weight loss (American Diabetes Association [ADA], 2017). For example, the ADA indicates that use of meal replacement plans prescribed by trained practitioners, with close patient monitoring, can be beneficial. Moreover, when weight loss strategies are individualized to meet patient preferences this may help the patient achieve the desired weight loss goal. The key message here is that all aspects of diabetes management should be individualized to meet the unique needs of the patient, including weight loss goals and intervention strategies.

Weight loss approaches that are designed to achieve >5% weight loss are recommended. Examples include high-intensity lifestyle modification sessions (>=16 within 6 months) that focus on diet, increased physical activity, and behavioral therapy. The overall aim of these interventions is to achieve a 500-750 kcal/day energy deficit (approximately 1,200-1,500 kcal/day for women and 1,500-1,800 kcal/day for men, adjusted for the individual's baseline body weight). For patients who are overweight or obese and have inadequate glycemic, blood pressure, and lipid control and/or other obesity-related medical conditions, modest and sustained weight loss (~5% of body weight) can produce clinically meaningful reductions in blood glucose, A1C, and triglycerides. This is important to note because there is an increased risk of cardiovascular disease and all-cause mortality in patients with type 2 diabetes who are overweight or obese (ADA, 2017).

Even though as little as 5% weight can produce some health benefits, sustained weight loss of >=7% is ideal. With even greater weight loss results, patients can see reductions in blood pressure, low-density lipoprotein and high-density lipoprotein cholesterol, and sometimes reductions in the need for medications to control blood glucose, blood pressure, and cholesterol levels. Keep in mind improvement in glycemic control due to weight loss is most likely to occur early in the natural history of type 2 diabetes when obesity associated insulin resistance has caused reversible b-cell dysfunction but insulin secretory capacity remains relatively preserved (ADA, 2017, p. S57).

Once short-term weight loss goals have been achieved, then a long-term (>=1-year) comprehensive weight maintenance program should be introduced. These programs offer at least monthly contact with ongoing monitoring of body weight. Strategies for successful weight loss maintenance include continued adherence to a low-calorie diet and participation in high levels of physical activity (200-300 min/week) (ADA, 2017).

Diabetes self-management can be arduous process for patients; and when the need for weight loss is added to the mix it can be overwhelming. Therefore, it is imperative that healthcare professionals support patients in their efforts to lose weight by individualizing weight loss strategies to align with patient preferences.

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