Eileen Egan, DNP, FNP-C, BC-ADM, CDCES, FADCES joins The Huddle to share her expertise about the interplay between weight and glycemic management in people with Type 2 diabetes, the importance of meeting glycemic and weight goals early after a Type 2 diabetes diagnosis, as well as best practices for helping people stay motivated and engaged. This episode was made possible with support from Lilly, A Medicine Company.
Eileen Egan, DNP, FNP-C, BC-ADM, CDCES, FADCES joins The Huddle to share her expertise about the interplay between weight and glycemic management in people with Type 2 diabetes, the importance of meeting glycemic and weight goals early after a Type 2 diabetes diagnosis, as well as best practices for helping people stay motivated and engaged. This episode was made possible with support from Lilly, A Medicine Company.
Learn more about this topic in this accompanying patient/client handout (support for the development of this handout was provided by Lilly, A Medicine Company): adces_tipsheet_early_control2.pdf
References:
American Diabetes Association. Obesity and weight management for the prevention and treatment of type 2 diabetes: standards of care in diabetes- 2024. Diabetes Care, 47(1): S145-S157.
Center for Disease Control and Prevention. Adult overweight and obesity. https://www.cdc.gov/obesity/basics/adult-defining.html
DCCT/EDIC study research group. Intensive Diabetes Treatment and Cardiovascular Outcomes in Type 1 Diabetes: The DCCT/EDIC Study 30-Year Follow-up. Diabetes Care. 2016;39(5):686-693.
Gregg E, Jakicic J, Blackburn G, et al. Association of the magnitude of weight loss and changes in physical fitness with long-term cardiovascular disease outcomes in overweight or obese people with type 2 diabetes: a post hoc analysis of the Look AHEAD randomized clinical trial. Lancet Diabetes Endocrinol. 2016; 4(11): 913-921.
Gutiérrez-Cuevas J, Santos A, Armendariz-Borunda J. Pathophysiological Molecular Mechanisms of Obesity: A Link between MAFLD and NASH with Cardiovascular Diseases. Int J Mol Sci. 2021. 27;22(21):11629.
Howard BV, Ruotolo G, Robbins DC. Obesity and dyslipidemia. Endocrinol Metab Clin North Am. 2003;32(4):855-867.
Jin X, et al. Pathophysiology of obesity and its associated diseases. Acta Pharm Sin B. 2023;13(6):2403-2424.
Laiteerapong N, Ham SA, Gao Y, et al. The legacy effect in type 2 diabetes: impact of early glycemic control on future complications (The Diabetes & Aging Study). Diabetes Care. 2019;42(3):416-426.
Lean MEJ, Leslie WS, Barnes AC, et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial.Lancet Diabetes Endocrinol. 2019;7(5):344-355.
Lingvay I, Sumithran P, Cohen RV, le Roux CW. Obesity management as a primary treatment goal for type 2 diabetes: time to reframe the conversation. Lancet. 2022 Jan 22;399(10322):394-405. doi: 10.1016/S0140-6736(21)01919-X. Epub 2021 Sep 30. Erratum in: Lancet. 2022 Jan 22;399(10322):358. PMID: 34600604
Rachel G. Miller, Trevor J. Orchard; Understanding Metabolic Memory: A Tale of Two Studies. Diabetes 1 March 2020; 69 (3): 291–299. https://doi.org/10.2337/db19-0514
Ross, R., Neeland, I.J., Yamashita, S. et al. Waist circumference as a vital sign in clinical practice: a Consensus Statement from the IAS and ICCR Working Group on Visceral Obesity. Nat Rev Endocrinol16, 177–189 (2020). https://doi.org/10.1038/s41574-019-0310-7
Thom G, McIntosh A, Messow CM, et al. Weight loss-induced increase in fasting ghrelin concentration is a predictor of weight regain: Evidence from the Diabetes Remission Clinical Trial (DiRECT). Diabetes Obes Metab. 2021;(23):711-719.
Tsai AG, Bessesen DH. Obesity. Ann Intern Med. 2019;170(5):ITC33-ITC48.
Wing RR, Bolin P, Brancati FL, et al. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med. 2013;369(2):145-154.
World Health Organization. Obesity. https://www.who.int/health-topics/obesity#tab=tab_1
Jodi Lavin-Tompkins (00;00;00 - 00;00;57)
Hello and welcome to ADCES's podcast The Huddle: Conversations with the Diabetes Care Team. In each episode, we speak with guests from across the diabetes care space to bring you perspectives, issues, and updates that elevate your role, inform your practice, and ignite your passion.
I’m Jodi Lavin-Tompkins, Director of Accreditation and Content Development at the Association of Diabetes Care and Education Specialists.
My guest today is Dr. Eileen Egan, an Endocrinology Nurse Practitioner at Tidelands Health in South Carolina.
In this episode, we’ll talk about meeting glycemic and weight goals early after a type 2 diabetes diagnosis and best practices for helping people stay motivated and engaged.
Eileen, welcome to the Huddle.
Eileen Egan (00;00;57 - 00;01;04)
Hi, Jodi. Thank you. I'm so happy to be here today with you to discuss this really important topic for people with diabetes.
Jodi (00;01;05 - 00;01;15)
Well, great. Well, before we get into today's discussion, could you tell our audience a bit more about yourself and your work as it relates to today's topic?
Eileen (00;01;15 - 00;02;02)
Sure, I would love to. I have worked in the field of diabetes in various capacities for a little over 20 years now. Currently, I work at Tidelands Health, which is a community-based hospital system in beautiful South Carolina. As an endocrinology nurse practitioner, one of my goals has always been to provide people with diabetes the necessary education and tools as early as possible to live well with diabetes, and to avoid complications. And Jodi, South Carolina ranked sixth in our nation for highest prevalence of diabetes. So, where I lived, like so many other places across the country, there is so much opportunity for the diabetes care and education specialists to assist people with diabetes.
Jodi (00;02;02 - 00;02;20)
Absolutely. And Eileen, we know that there's an interplay between weight, glycemic management and related complications. So, I think it's important to first understand the prevalence of obesity in people with type 2 diabetes. So can you tell us a little bit about that?
Eileen (00;02;20 - 00;04;19)
Sure. First, I think it's important to start by defining obesity. The World Health Organization defines obesity as excess or abnormal fat accumulation that presents a risk to health.
The American Diabetes Association expands a bit further upon that definition by adding that obesity is a chronic, relapsing disease with numerous metabolic complications, physical and psychosocial complications, in particular, type 2 diabetes. Obesity, and potentially abnormal adipose pathology can result in adipose hypertrophy, visceral adiposity, and ectopic fat distribution. These things Jodi, can be associated with systemic inflammation and metabolic dysfunction and ultimately increase the risk for both microvascular and macro vascular complications.
Now, as far as diagnosis of obesity, typically we do this by measuring a BMI and greater than or equal to 30 is consistent with a diagnosis of obesity, although there are important race and ethnic considerations with BMI. So, a diagnosis of obesity should also include not only BMI to assess overall mass, but also waist circumference or waist to height ratio to assess adipose distribution, as well as the assessment for the presence of associated health or well-being consequences. And within the US, Jodi, as many as 85 to 90% of people with diabetes have overweight or obesity. But obesity and type two diabetes are heterogeneous, meaning not all people with obesity have type two diabetes, and not all people with diabetes have obesity. So, an individualized approach implemented early on is key to help reduce the future risk of complications associated with these conditions.
Jodi (00;04;19 - 00;04;42)
Yes, of course, individualization. We hear a lot about that and all the guidelines and everything we read. So, we know it's very important. And it seems like this is a very big issue for people with type two diabetes. So how does reducing obesity have the potential to reduce micro and macro vascular complications of type 2 diabetes?
Eileen (00;04;42 - 00;05;15)
That's a really important question, Jodi. So excess adiposity is a key driver in the development of cardiovascular disease, chronic kidney disease, and an increase in all-cause mortality risk and has been associated to negatively impact quality of life. On the flip side, weight loss can reduce cardiovascular risk factors like hyperlipidemia and hypertension, which contribute to the development of complications associated with excess weight in people with type 2 diabetes.
So, a weight loss of 3 to 7%, can improve complications related to adiposity by improving glycemia and reducing cardiovascular risk factors and a sustained and weight loss of greater than 10% confers greater benefits with disease modifying effects and the potential for diabetes remission.
Jodi (00;05;37 - 00;05;46)
Well, Eileen, you've talked about the importance of weight loss and risk reduction. Is there a role of timing to that?
Eileen (00;05;46- 00;06;59)
Well, the short answer is yes, definitely yes. We have some great studies to back that up. The Diabetes Remission Clinical Trial, or DIRECT, was a randomized clinical trial to assess the effects of early weight loss on type 2 diabetes remission. In the direct trial, early weight loss reduction was associated with improvement in A1C, with individuals achieving weight loss at 24 months more likely to achieve diabetes remission than those who did not have early weight loss.
Unfortunately, most people aren't able to maintain the weight loss at the two-year point. So, we have more work to do to learn about early weight loss and long-term benefits. Another key trial, Jodi, was a look ahead study. In this trial, individuals with type two diabetes who were randomized to intensive lifestyle modifications with a goal of achieving sustained weight loss did not have any significant difference in major adverse cardiovascular events compared to those who received diabetes support and education alone.
But for a participant who lost at least 10% of body weight, there was a significant reduction in these cardiovascular events.
Jodi (00;06;59 - 00;07;12)
Eileen, thank you for reviewing the evidence for weight loss early and risk reduction. Now, what about achieving A1C targets early after the diagnosis of type 2 diabetes?
Eileen (00;07;12 - 00;09;06)
Yeah, another good question. So here too, we have great studies that support achieving A1C targets early are beneficial.
Landmark trials such as DCCT/ EDIC and type 1 diabetes and the UKPDS trial in individuals with newly diagnosed type 2 diabetes have shown that A1 C of less than 7% early on is associated with enduring reductions for several important diabetes related complications, including microvascular and macro vascular complications for at least ten years. The Diabetes and Aging Study, Jodi, was a more recent large observational study in which A1 C levels of greater than 6.5% within the first year of diagnosis of type 2 diabetes were associated with increased microvascular and macro vascular events as compared to A1 C levels less than 6.5% over the same time period.
So we have learned that achieving A1 C targets early on translates into reduced risk for complications down the road. This is referred to as metabolic memory or legacy effects. This perspective on being A1 C targets early having the potential long term benefits is analogous to investing in a savings account, where an investment is made in the present and can have long term benefits that can be accrued in the future.
Actually, Jodi, as an add on to this podcast, there's a tip sheet that you can find in the show notes that the listeners can use with their patients to illustrate this analogy. So when we consider these data and current guidelines, the key role in addressing and achieving glycemic and weight management targets early on is really important to consider.
Jodi (00;09;06- 00;09;24)
Well, I'm glad to hear there is a tool that our listeners can use with the people they see that's always really helpful. So, thank you for that. And so, Eileen, when you're creating these treatment plans early after the type 2 diagnosis, then how do you incorporate weight management.
Eileen (00;09;24- 00;10;34)
So, I think it's important to make the connection for the person. And what I mean by this is that I offer education about excess weight. People do not always make the link between overweight and obesity and health risks that these conditions are associated with, such as increased morbidity and mortality. I provide education regarding the potential for weight loss, to reverse underlying abnormalities of type 2 diabetes, and reverse or slow down disease progression. Highlighting that weight loss is the most significant predictor of type two diabetes remission.
Also, I emphasize the importance of intensifying efforts early on to achieve individualized goals and reduce the risk of complications later on. And then, of course, we need to discuss lifestyle modifications that are evidence based. So, we incorporate discussion regarding nutrition changes, physical activity, behavioral health counseling as the literature supports that each of these factors is important in diabetes management. So, with the patient at the center, we set small goals using shared decision making to drive these goals.
Jodi (00;10;34 - 00;10;51)
Yes, I agree, Eileen, that lifestyle modifications are always critical and are very helpful. So, I'm wondering if you have an example from your practice of someone that you worked with that might bring this to life that you could share with our audience?
Eileen (00;10;51 - 00;12;30)
I met a gentleman who had been diagnosed with diabetes six months earlier, type two diabetes. He also had obesity. He was already on to oral medications, and his A1C was 8 percent. He was not making progress in losing weight despite trying to improve his eating pattern and increase his physical activity. He felt really defeated and scared. He had not received any diabetes education. So we talked a lot about the impact of obesity on his diabetes and overall health. And I shared with him how weight loss and lowering his A1C early in his diagnosis of diabetes had the potential to significantly reduce risk for several important complications, such as microvascular and macrovascular disease as he aged. He felt really hopeful, and he was willing to make changes in his meal plan and begin a walking program.
At the next visit, he had lost 10 pounds but was feeling that his weight loss had stalled. He wanted to attend his niece's wedding in four months, but could not quite fit into his only suit. So there was his personal motivation. We spoke about the different treatment options available to him and came up with a plan based on shared decision making, which included an individualized nutrition and activity plan, and using a medication for his blood glucose that would also help with his weight loss.
He was able to lose additional weight, lower his A1 C to 6.3%, and fit into his suit, so he was feeling good. So in summary, early intervention in this situation will certainly help this gentleman reduce his risk of complications moving forward.
Jodi (00;12;30 - 00;12;43)
Oh thank you for sharing that story. That's always nice to hear, especially with positive outcomes. So, what do you think the best way is to help people stay motivated until they reach their goal?
Eileen (00;12;44 - 00;13;36)
Well, getting to know the patient and making the connection, I think is the key. And the diabetes care and education specialist is so skilled at doing this. We want to learn what's most important to the person with diabetes. And what's driving them? What makes them want to improve their health? Educate on the importance of weight and glycemic management early on, which can ultimately improve their diabetes and reduce their risk for complications.
So in summary, Jodi, Diabetes care and education specialists and other members of the health care team are in a great position to help people. If we can make that personal connection and we can stress the importance of doing the work now early on to impact their trajectory with diabetes in the long term, I find it gives them a lot of hope and helps to keep them motivated.
Jodi (00;13;36 - 00;13;46)
Well, Eileen, thank you so much for joining us for this episode of The Huddle. This topic is really important and we appreciate you sharing your insights with us.
Eileen (00;13;46 - 00;13;47)
My pleasure.
Jodi (00;13;36 - 00;13;46)
Thank you for listening to this week’s episode of The Huddle. I also want to thank Lilly for partnering on this episode.
Make sure to download the resources discussed in today’s episode. You can find them linked in the show notes at adces.org/Podcast.
And remember, ADCES membership gets you free access to resources, education, and networking that improve your practice and optimize outcomes for your clients. Learn more about what ADCES can do for you at adces.org/Join.
The information in this podcast is for informational purposes only and may not be appropriate or applicable to your individual circumstances. This podcast does not provide medical or professional advice and is not a substitute for consultation with a healthcare professional. Please consult your healthcare professional for any medical questions.