Amy Hess Fischl MS, RD, LDN, BC-ADM, CDE joins the Huddle to share her expertise and experiences providing support to patients with type 2 diabetes as they are experiencing weight reduction while on injectable, non-insulin therapies. We will cover topics like patient experiences with changes in appetite and food intake, nutritional counseling for people experiencing weight reduction and emphasizing the importance of exercise as well. Disclosures: Speaker for Abbott Diabetes Care, Insulet, Xeris Pharmaceuticals This podcast was developed in partnership with Eli Lilly and Company. Resources: Download a patient-focused tipsheet that complements the topics covered in this Huddle podcast. https://www.adces.org/docs/default-source/handouts/cvd/59-23_tipsheet-losingweight-7.pdf?sfvrsn=c4201759_5 1. El Sayed et al., Diabetes Care. 2023;46:S128 2. Galgani & Ravussin Int J Obesity. 2008;32:S109 3. Morselli et al., Best Practice & Research Clinical Endocrinology & Metabolism. 2010;24:687 4. Garber. DOM. 2012;14:399 5. Hall & Kahan. Med Clin North Am. 2018;102(1):183 6. El Sayed et al., Diabetes Care. 2023;46:S68 7. El Sayed et al., Diabetes Care. 2023;46:S140 8. https://pi.lilly.com/us/trulicity-uspi.pdf 9. https://www.bydureon.com/bydureon-bcise.html 10. https://www.novo-pi.com/victoza.pdf 11. https://www.novo-pi.com/ozempic.pdf 12. https://www.novo-pi.com/rybelsus.pdf 13. https://pi.lilly.com/us/mounjaro-uspi.pdf?s=pi 14. Heise et al., Diabetes Care. 2023;46(5):998 15. ten Kulve et al., Diabetes Care. 2016;39:214 16. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. 9th Edition. December 2020
Amy Hess Fischl MS, RD, LDN, BC-ADM, CDE joins the Huddle to share her expertise and experiences providing support to patients with type 2 diabetes as they are experiencing weight reduction while on injectable, non-insulin therapies. We will cover topics like patient experiences with changes in appetite and food intake, nutritional counseling for people experiencing weight reduction and emphasizing the importance of exercise as well.
Disclosures: Speaker for Abbott Diabetes Care, Insulet, Xeris Pharmaceuticals
This podcast was developed in partnership with Eli Lilly and Company.
Resources:
Download a patient-focused tipsheet that complements the topics covered in this Huddle podcast. 59-23_tipsheet-losingweight-7.pdf (adces.org)
Jodi:
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-Tomkins, Director of Accreditation and Content Development at the Association of Diabetes Care and Education Specialists.
Our guest today is Amy Hess-Fischl, a dietician and certified diabetes care and education specialist, who is also board certified in advanced diabetes management. Amy works with both adult and pediatric populations at the University of Chicago's Kovler Diabetes Center.
I also want to thank Eli Lilly for their partnership on this episode, in which we discuss the complexities around weight reduction in people with type 2 diabetes, which can include lifestyle and medication choices.
Amy, welcome to The Huddle.
Amy:
Such a pleasure to be here, Jodi.
Jodi:
Before we get into today's discussion, would you like to tell our audience a bit more about yourself and your work and how it relates to this topic?
Amy:
Well, of course. I have been a registered dietician nutritionist for 25 years, working with people with diabetes for that same amount of time. And during my 25 years, weight reduction has been a conversation that is first and foremost on most people's minds. So it's something that I'm very comfortable having a discussion with, and an honest conversation with people with diabetes how to successfully do that.
Jodi:
Well, thank you for that, Amy. And I know it is a common discussion people have. And as we know, people with type 2 diabetes and obesity are at higher risk for cardiovascular events. So is there any evidence that weight reduction in this population has benefits? And can you tell our audience more about this?
Amy:
Oh, absolutely. And I think that we don't really talk about this enough. But of course, the American Diabetes Association Standards of Medical Care for Diabetes recommends that people with type 2 that we see that weight reduction of just 3 to 7% - so just to kind of put that into perspective, the average person who's 200 pounds, we're talking 6 to 14 pound reduction - is associated with an improvement of glycemic management.
Also, the Look AHEAD or the Action for Health and Diabetes study really just focused on lifestyle intervention, really showed us that for people with overweight or obesity with type 2 diabetes, they found that weight reduction was associated with reducing their medication burden for all their other conditions, as well as improvements in their mobility and their quality of life. So of course, this study really just highlighted what we knew, but really just solidified the fact that just small reductions really have an impact.
Now finally, we know that weight reduction of 10% - so take that 200 pound person, we're talking 20 pound plus - is associated with significant health benefits and a reduction in cardiovascular risk. So really, really highlighting the fact that we want to quantify that amount for people with diabetes to just understand that just these small amounts are going to have a really big difference in their overall health and quality of life.
Jodi:
Well, Amy, I know you've just described the benefits of weight reduction, but some people may find it challenging to lose weight with type 2 diabetes. So why do you think that is?
Amy:
Well, this is not an easy topic to have a discussion about. It's not as clear cut as we really want to have when it comes to somebody, "This is what you do and all is right with the world." One thing that we have to acknowledge is that weight is regulated by a fine balance of several factors. So, the first is metabolism.
So one thing that we have to acknowledge is that as people lose weight, there is a reduction in that metabolic rate as well. Also, hormones and our central nervous system. So it's a really fine balance of all of these things that are going on that we can't always pinpoint.
So we also have to think of other factors that we have no control over. So we could be talking about someone's gender or their genetics, but we do have some control over the other things like our glucose management. You know, again, treating hypoglycemia or the amount of hypoglycemia that somebody has because that's going to add lots of calories as well that people may not necessarily consider. We also have to take into consideration things that they can control is the amount of sleep that they're having as well as their food intake, which are the two biggies that a lot of people aren't necessarily thinking about as much.
Now, the other piece that we have to talk about is weight regaining. And this is so very common. So in people with overweight or obesity and type 2 diabetes, we see that after they've reduced their weight, almost 80 percent of them are going to regain in the absence of lifestyle changes.
So it's crucial that lifestyle is still the cornerstone of diabetes self-management. And it should be continued even when starting any types of other medications. So we can see that successful weight reduction. Also, hormones and the central nervous system are all working together when it comes to weight. So it's not as easy of a conversation as we'd like to see.
Jodi:
Well, Amy, you mentioned the challenges for weight reduction as well as the benefits and the importance of continuing to work on lifestyle. But what about weight reduction associated with incretin-based type 2 diabetes medications? Why is now a good time to talk about that?
Amy:
Well, you took the words right out of my mouth is that weight reduction for people with type 2 diabetes, heck, for anyone, is challenging. And that's why we're talking about it, because of that challenge. Now, thanks to the progress in scientific research, we see now that the addition of pharmacological tools that may make for the first time a significant impact in weight reduction outcomes as part of people's diabetes self-management. And this is really exciting.
Jodi:
So if we do start someone with type 2 diabetes on an incretin-based diabetes medication that has the potential for weight reduction, is there anything we need to pay attention to or be aware of?
Amy:
Of course. When starting someone on these medications, it's really helpful to know that they can delay gastric emptying as well as increase satiety. Now, why does that matter? You know, some considerations that we really have to focus on is that people are going to feel less of the need to want to eat. I mean, some people are going to find that they want to eliminate meals altogether, which, of course, is going to reduce their overall healthfulness of their eating plants.
Now, what I've commonly seen is that when people take these medications, you know, they're mentioning that they just don't feel like eating all their regular meals or they're eating a lot smaller portions. And so really the conversation should be surrounding the selection of nutrient-dense foods. Now, what do I mean by nutrient-dense foods? You know, the foods that really have the most bang for their buck, you know, again, those that are going to have more vitamins and minerals. So we're talking kind of whole foods, fruits, vegetables, you know. So think Dietary Guidelines for Americans.
You know, again, that's, you know, what we really want to try and be focusing. And I think this is a good time to kind of reassess because a lot of people kind of forget what they should be eating. In fact, you know, just yesterday in clinic, I had three separate conversations with people that are on medications. And they said, you know, one said, you know, I'm just skipping meals. I just, I only want to eat one meal a day. But I am interested in making sure that I am eating healthfully. So how can I incorporate, you know, some healthful snacks because I'm willing to do that? Whereas two others are saying, you know, I'm just eating smaller portions. Let's kind of go over what am I supposed to be eating? Because again, because I'm eating smaller portions, I'm not eating as much. I want to make sure that what I am eating is going to meet my needs.
So again, it's really all about the person that's in front of us and individualizing for their goals and needs. But, you know, again, really starting that conversation. And I'm lucky that, you know, a lot of my patients are saying, hey, let's talk about this. But we also have to acknowledge that there are a lot of people that aren't going to want to start the conversation. So, we have to right?
Jodi:
So, Amy, thank you for sharing those experiences, because your experiences are really interesting. And it sounds like you're emphasizing protein, micronutrients, fiber and fluids. But can you expand for our audience more on how you counsel people who have reported these changes in their eating patterns?
Amy:
Of course. And again, as a registered dietitian nutritionist, I am lucky, you know, and a certified diabetes care and education specialist that I can spend a lot more time with patients. So, we can really kind of dig in and talk. But once they've started therapy, you know, I really want to assess their food intake overall. And you know what they eat and drink just to confirm what is their nutrient status. And, you know, all that really means is just how much are you eating? When are you eating? You know, why are you eating? And really just to identify, do we need to make some adjustments to reduce their risk of nutrient deficiencies?
Now, as I mentioned before, you know, nutrient dense foods is kind of the buzzword, but it really is just foods that are rich in vitamins, minerals and other nutrients that are important for health. And, you know, again, we want to go back to the Dietary Guidelines for Americans and say, all right, let's reduce our saturated fat, our added sugars, our sodium. You know, and so what we're really kind of talking about with people is, you know, again, how many fruits and vegetables are you eating? What are your whole grains? Are you having nonfat and low fat dairy? You know, are you having more fish and seafood than, you know, other, you know, higher fat types of meats? You know, are you having unprocessed lean meats and poultry, nuts and legumes? So we do know that, you know, as a society, Americans just don't eat enough fruits and vegetables. And so that's really where I kind of like to say, all right, can we increase those fruits and vegetables on a daily basis and just start where they are? Can we just add one? That would be fabulous.
Again, really looking at grains. But again, the serving size, I think that we really do have to hone in a little bit more that a lot of people think an entire plate of pasta or rice is a serving. Where, you know, again, if you put your fist together, that's pretty much, you know, what a typical serving is. So we do want to kind of step back a little bit and say, hey, you can get all of these and still have those smaller portions that you're eating. But again, it's all about the planning that we're doing. So it's, you know, kind of making that concerted effort to focus on, again, is my eating pattern as a whole, meeting those minimum requirements to make sure that we're getting all the nutrients that we need.
Now, also one thing that we sometimes forget, because if somebody is forgetting to eat, they might be forgetting to drink as well. So we want to make sure that people are incorporating fluids into their life, not enough that they're going to float out of their office or out of their home. But, you know, again, making sure that they're consuming enough. However, you know, again, we do want to make sure that somebody has any kidney concerns or any any renal issues that we're making sure that we're individualizing for their needs as well.
Also, we know that if patients are really struggling to maintain kind of that quality in their eating patterns, it's important that they reach out to their health care providers and really see if it's necessary to have supplements. Now, dietary supplements are not for everyone. And I want to be very clear about that. But again, it is just important that we do assess that if somebody is truly missing many meals and there's not any chance that they're going to be able to incorporate the minimum requirements that they're supposed to be having per day. It's a really good idea that we kind of reassess that. And again, it's important to either talk to the registered dietitian, a nutritionist or your health care provider to see what is going to be right for you depending on that person's needs.
And also, there is a tip sheet that kind of goes over a lot of the things that we've just discussed that is found in the resource section of this page.
Jodi:
Well, Amy, this has been a great discussion about nutritional considerations. But what does our audience need to know about the role of activity in all of this?
Amy:
Well, we have good evidence that aerobic activity, as well as muscle strengthening and bone strengthening activities, should be a part of the overall lifestyle of somebody with diabetes, as well as during weight reduction. You want to stress activities that help strengthen their muscles while they're losing weight and remind them that exercise can also aid in glycemic management, which we don't always focus on. And that is independent of weight loss.
So, we want to really show that there is a one-two punch that any type of activity that they're doing is going to help their glucose. Aerobic exercises can also help lower mortality risks as well as heart failure. Resistance training improves strength, balance, and activities of daily life. So we want to incorporate all of these together on a weekly basis. But it's important that all of you, for those with type 2 diabetes that you're seeing, really do a pre-exercise evaluation just to assess for any conditions that might be contraindicated for certain types of activity. So, of course, you know, looking at ulcers, peripheral neuropathy, kidney disease, and then you can kind of fine tune and individualize for what their needs are.
Jodi:
Okay, so it sounds like it's really important to keep active and make sure that the people that we see include both aerobic and muscle strengthening and bone strengthening activities. So great to hear your take on that. And now I want to move into the best way to start the conversation about weight reduction.
Amy:
Well, you know, it's with all of us how we have our conversations with all of our patients that we see. You know, again, we need to build a trusting relationship and really focusing on no judgment. You know, again, I'm trying to think yesterday in clinic how many times I said that. Because, you know, we have to kind of acknowledge that, you know, people do feel like they may be judged. And we need to keep it to be an honest, open dialogue. Ideally, people with diabetes are going to advocate for their own health. You know, they're going to come with their own questions and agenda. But we know that that's not always going to be the case. So we have to find ways of how do we ask and discuss weight reduction with people. We certainly want to identify if they've already considered any options already.
And, you know, in fact, you know, when I think of all of my clinic days, it really just comes down to starting the conversation of if they haven't brought it up, I usually say, "What do you think about your vitals? Are there any concerns that you've seen in your vitals? Your blood pressure, your pulse, your glucose level, your weight?" You know, is there any changes that you've seen? Or are you seeing something different on your scale? And that sometimes just opens up the conversation to be able to say, "Yeah, you know, I have noticed I've gained some weight." And then I can at least say, "All right, can we talk about weight?"
You know, but if, you know, somebody is kind of bringing it up already saying, "You know what? I have seen that I've increased my weight and it's a little frustrating to me." And that just kind of opens the door to be able to say, "What do you find frustrating?" You know, again, what are your goals? What have you really tried to meet them already? And, you know, looking at those short and long-term goals and kind of going back to our previous conversation of 3% to 7% reduction, you know, really putting in and quantifying in their goals that, you know, again, yes, weight reduction is important, but even any small amount of weight reduction that you're going to have is still going to improve your overall health. And we have to really hit that home with people. But really having that honest discussion that we want to help them to make their goals a reality.
Jodi:
Well, Amy, you've made some great points in this conversation and given us a lot of information. Do you have any other closing thoughts for our listeners?
Amy:
Absolutely. Yeah, I think that first and foremost, we have to acknowledge the complexities of weight reduction in people with type 2 diabetes, as well as the factors that are actionable for your patients. Again, quantifying the weight reduction that can be attained or expected. But just be sure that your patients understand that it does go hand in hand with healthful eating choices. As I said already, having a honest conversation about weight reduction and discuss that diabetes medications are just one facet of overall treatment and health management. And finally, include that discussion of healthful eating by choosing those nutrient dense foods and using that cheat sheet as well to reduce the risk of nutrient deficiencies and remind them that lifestyle changes are the cornerstone of diabetes self-management and successful use of the medications depends on their healthy eating.
Jodi:
Well, Amy, thank you for taking the time to join us for this episode of The Huddle and for sharing your knowledge and experience with our audience. As a diabetes care and education specialist, I know how useful this information is for practice. So I'm sure our listeners really appreciate hearing your firsthand experience.
Amy:
It has been a pleasure. I hope it is helpful.
Jodi:
Absolutely. And thank you all for listening to this week's episode of The Huddle. I also want to thank Lilly for their partnership on this episode. Make sure to download the resources discussed in today's episode. You can find them linked in the show notes at diabeteseducator.org forward slash 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 diabeteseducator.org forward slash 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 health care professional. Please consult your health care professional for any medical questions.