Barriers to Diabetes and Weight Management

Educational Objectives

The goal of this program is to improve support of diabetes self-management. After hearing and assimilating this program, the clinician will better be able to:

1.   Identify patients with maladaptive eating behaviors and refer them for appropriate interven­tions or support.

2.   Compare the neural responses to food and drugs of abuse with regard to activation of the re­ward circuitry of the brain.

3.   Describe the effects of diabetes on functional exercise capacity.

4.   Improve patient education by implementing principles of clear communication.

5.   Advocate for improved access to healthy options related to diet and physical activity.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following was disclosed: Dr. Kendall reported relationships with Amylin (C,G), Bayer Diabetes Care (C,G), Daiichi-Sankyo (C), Dexcom (G), Eli Lilly & Co (C,G), Health Partners (C), Intarcia (C), Medtronic/MiniMed (G), Merck & Co (C,G), Novo Nordisk (G), Roche (A,G), sanofi-aventis (G), Takeda (C), and UnitedHealth Group (C); his spouse is a current employee of Genentech (a member of the Roche Group); Dr. Reusch disclosed relationships with Amylin/Eli Lilly & Co (G), Bristol-Myers Squibb (G), and GlaxoSmithKline (C,G); Ms. Wolff and Drs. Dietz, Ozier, Reyes, and Wallace and the members of the planning committee reported nothing to disclose.

A=Advisory panel  B=Speakers bureau  C=Consultant  G=Grant or other research

Emotional Eating

Interview with:

Amy Ozier, PhD, RD, Assistant Professor and Facilitator, Graduate Certificate Program in Eating Disorders and Obesity, Northern Illinois University, School of Family, Consumer, and Nutrition Sciences, Dekalb, IL

Limits of the calorie balance equation

The calorie balance equation is a tool that dietitians commonly use for facilitating behavior change and weight loss. Weight loss occurs only when energy expenditure exceeds calorie intake. Though the equation is simple, the reality of weight loss is not. Because many factors may influence why and how much people eat, focusing only on intake and output may leave patients frustrated.

Transactional model of stress and coping

Developed by Richard Lazarus and Susan Folkman, the transactional model of stress and coping describes stress as the result of an imbalance between demands and resources or of the perceived inability to cope. Some researchers have applied this model to better understand maladaptive eating behaviors such as emotional eating.

The EADES questionnaire

Goal: Dr. Amy Ozier developed the Eating and Appraisal Due to Emotions and Stress (EADES)** questionnaire as an instrument to assess how individuals use eating as a coping mechanism.

Content: 54 questions; 24 questions specifically address how individuals use food to cope with emotions or stress.

Relationship with obesity: Low scores indicate maladaptive eating behaviors. Individuals with low scores are 13 times more likely to be overweight or obese, compared to those with high scores.

**For more information about the EADES questionnaire, contact Dr. Ozier at Northern Illinois University

Barriers to addressing emotional eating

Practitioners: Dietitians and other clinicians are trained in the concepts of energy balance and macronutrient compo­sition but not in addressing issues related to emotions and coping.

Time constraints: It may be challenging enough for clinicians to find the time to calculate body mass index (BMI) and to discuss the importance of weight loss. In the interest of time, weight-loss counseling may get stripped down to “eat less; move more” — hollow advice for those struggling with their weight. If issues related to emotional eating and coping mechanisms remain unaddressed, the efficacy of any weight-loss effort is likely to be compromised.

Implications for clinical practice

Clinicians who are dedicated to helping their patients lose weight should consider using a tool such as the EADES questionnaire to assess coping skills and maladaptive eating behaviors. Once a patient is found to engage in emotional eating or to otherwise have poor coping skills, efforts may be made to identify triggers and to develop healthier strat­egies for dealing with stress. In addition to referral to a mental health professional (eg, for cognitive behavioral ther­apy), clinicians may want to consider providing educational materials about emotional eating and stress management.

Food on the Brain

Interview with:

Teresa Reyes, PhD, Research Assistant Professor of Pharmacology, Institute for Translational Medicine and Thera­peutics, University of Pennsylvania, Philadelphia, PA

Food as reward

Although the precise mechanisms are unclear, consumption of palatable (ie, high-fat and/or high-sugar) foods acti­vates the reward circuitry of the brain. This is the same reward circuitry activated by drugs of abuse (eg, cocaine; opi­oids). It includes the ventral tegmental area, the nucleus accumbens (striatum), and the prefrontal cortex, which use the dopaminergic and endogenous opioid systems to encode reward.

In a surprising twist, it appears that taste is not critical for encoding reward (at least in mice), as food continues to ac­tivate the reward circuitry in mice whose taste receptors have been eliminated. Other factors associated with palatabil­ity (eg, caloric content) may be responsible for activating the reward pathways.

Food addiction

In humans, eating and food selection are complicated. Food may be associated with positive memories and behavioral and social rewards. Eating may be a response to stress, boredom, or simple availability. And, although it may be ar­gued whether food is truly addictive, the activation and dysregulation of the reward system are similar, whether the substance of abuse is sugar, cocaine, or heroin.

Another parallel to addiction is the observation of reward hyporesponse. If the neural response to a substance (eg, drugs, palatable food) is decreased, the animal may increase intake of that substance in order to achieve the expected reward. A study in mice found that cycling between regular and high-fat diets resulted in reward hypofunction and a depressive-like phenotype, similar to that seen in mice exposed to chronic cycling in drug exposure.

Evidence for reward hypofunction also is seen in humans. For example, type 2 dopamine (D2) receptors, which seem to be important for setting reward tone, are down-regulated with chronic intake of a high-fat diet. In addition, allelic variation results in different concentrations of D2 receptors within the striatum. This difference has been associated with increased risk for drug use and overeating.

Clinical implications

The regulation of food intake is a critical factor in the development and reversal of obesity, yet there are few effective pharmacotherapies that support healthier eating. Research in this field is beginning to elucidate neural pathways and feedback mechanisms involved in the reward circuitry of the brain. Understanding how the brain perceives food as a reward and learning how to manipulate that perception may identify new therapeutic targets and develop new inter­ventions for losing weight.

Functional Exercise Capacity

Interview with:

Jane Reusch, MD, Professor of Medicine and Biochemistry, University of Colorado, Denver, and Denver Veterans Affairs Medical Center, Denver, CO

Exercise and mortality

Epidemiologic studies suggest that physical activity directly correlates with longevity. A single bout of exercise per week may decrease cardiovascular (CV) and all-cause mortality by 30% to 50% — a greater decrease than that achieved with statin therapy.

Diabetes and exercise impairment

Maximal exercise capacity: Typically assessed by exercising (eg, using a treadmill) until physical exhaustion. Individ­uals with diabetes have a lower maximum exercise capacity compared to matched controls.

Exercise kinetics: One measure is the time required for heart rate and oxygen use to adapt to physical exertion (eg, go­ing from seated to walking across a room). This time is longer (ie, exercise kinetics are significantly impaired) in in­dividuals with diabetes.

Obesity vs diabetes: Although many individuals with type 2 diabetes are overweight or obese, the effect of diabetes on exercise kinetics is additive. That is, matched for BMI, participants with diabetes had greater impairments in functional exercise capacity and slower exercise kinetics than those without.

Implications: Impaired ability to exercise and increased exertion required for modest activity may lead to voluntary reductions in physical activity by individuals with diabetes.

Mechanisms

Insulin sensitivity: Insulin resistance, as measured using euglycemic insulin clamps, is directly correlated with im­paired exercise kinetics.

Endothelial function: Blood vessel response to physical exertion, as measured with a blood cuff, is reduced in individ­uals with diabetes. This reduced endothelial response is directly correlated with impaired exercise kinetics.

Potential role of pharmacotherapy

Some insulin sensitizing agents (eg, thiazolidinediones [TZDs]) not only improve insulin sensitivity but also increase endothelial function. Studies using proglitazone and rosiglitazone*** showed that maximal exercise capacity and re­sponse to exercise challenge were improved with pharmacotherapy alone. These improvements occurred despite weight gain (commonly associated with TZD therapy).

Researchers hope to replicate these exciting findings in studies with other agents (eg, glucagon-like peptide 1 receptor agonists; resveratrol). Ideally, the improvements in functional exercise capacity would translate to increases in physi­cal activity in individuals with diabetes.

***Proglitazone is no longer available; use of rosiglitazone was recently restricted by the Food and Drug Adminis­tration.

Counseling patients about exercise

•   Encourage exercise as a primary intervention in the management of type 1 and type 2 diabetes

•   Instruct patients on how to reduce risk for exercise-induced hypoglycemia

•   Educate patients about the many benefits associated with exercise

•   Prevent discouragement by explaining that exercise alone is generally not sufficient for weight loss

•   Reiterate the importance of exercise for maintaining weight loss

•   Recognize that exercise may be more difficult for individuals with diabetes and work with them to find creative ways to increase their physical activity

Literacy and Numeracy as Barriers to Diabetes Management

Interview with:

Andrea Wallace, PhD, RN, Assistant Professor, University of Iowa, College of Nursing, Iowa City, IA, and Nurse Faculty Scholar, Robert Wood Johnson Foundation

Kathleen Wolff, MSN, Diabetes Nurse Practitioner, Vanderbilt Diabetes Center, and Instructor, Vanderbilt Univer­sity, School of Nursing, Nashville, TN

Health literacy and numeracy

Although health literacy and numeracy affect many aspects of self-care, including diabetes self-management, they are not easy to assess in a typical office visit. Even well-educated professionals may have trouble understanding medical information or performing the mathematic calculations that are commonly required in the setting of diabetes. Compli­cating matters is the stress and anxiety associated with an acute health crisis or chronic disease, which may impair one’s ability to make well-informed decisions.

Effect on health outcomes

Many patients with diabetes have difficulty performing tasks related to diabetes management (eg, understanding por­tion size, estimating carbohydrate intake, calculating insulin doses). Not surprisingly, then, studies have shown that literacy and numeracy skills affect health outcomes. Among patients with diabetes, risks for renal failure and vascular disease have been linked to health literacy and numeracy. In children with diabetes, health outcomes have been linked to the literacy levels of their parents.

“Universal precautions” for literacy and numeracy

Health literacy experts debate the importance of assessing literacy and numeracy. The alternative is to use principles of clear communication with all patients — akin to the universal precaution of wearing gloves with all patients.

Principles of clear communication include:

•   Avoid using medical jargon

•   Break down complicated concepts into simplified forms

•   Focus on practical information

•   When possible, limit instruction to no more than three messages per visit

•   Confirm patient’s understanding of newly introduced information

Use of low-literacy educational materials

A randomized controlled trial found that using low-literacy materials related to diabetes self-management was ini­tially associated with improvements in hemoglobin A_1c, compared to those patients who received standard instruc­tion. At 6 months, however, the difference between the groups disappeared (although individuals in the intervention group maintained a greater sense of self-efficacy than did those in the control group). The findings of this study not only speak to the complicated nature of diabetes self-management but also highlight the importance of comprehen­sive diabetes programs.

New models of health care

Most health care related to diabetes is delivered by primary care practitioners. Evolving approaches to patient care in­clude the chronic care model and the medical home model, both of which integrate primary care, specialist services, and nonmedical support services with informed, proactive self-care.

Vulnerable populations

Populations with low levels of health literacy also have less access to health care services and higher rates of chronic disease. In addition, barriers related to transportation, access to high-quality food, and safe places to exercise make it difficult to tease out the impact of the individual factors on health outcomes. Although it appears that health literacy and numeracy are important in explaining health care disparities, more research must be devoted to understanding these complicated issues.

Curbing the Obesity Epidemic: Legislation to Litigation

Interview with:

William Dietz, MD, PhD, Director, Division of Nutrition, Physical Activity, and Obesity, Centers for Disease Control and Prevention, Atlanta, GA

Childhood obesity

Pediatric obesity, as defined as BMI >95th percentile, appears to be holding steady at 17%. The plateau is occurring in the three major ethnic groups (white, black, Hispanic) and across ages. There is, however, a gender difference, with rates of severe obesity (BMI >97th percentile) continuing to increase among boys aged 6 to 19.

Analogy: trends in tobacco use

Although the first reports linking smoking and lung cancer began to appear in the 1950s, tobacco consumption con­tinued to rise until 1964, when the Surgeon General’s warning was issued. At that point, rates held steady for 10 to 15 years before beginning to decrease. The decline in tobacco use probably resulted from a combination of public health education and public policy initiatives (eg, restricting sale to minors, banning tobacco advertisements on television, and increasing taxes on tobacco products), which generally were initiated at the state and local levels.

Similarly, community-level initiatives have been directed at reducing rates of obesity. In addition, a number of efforts — including legislation and program funding —are being made at the federal level, with the hope that these efforts will help reverse the obesity epidemic.

Targeting sugar-sweetened drinks

Consumption of sodas, 10% juices, and other beverages sweetened with sugar or high-fructose corn syrup has been identified as a factor contributing to the obesity epidemic. Because sugared drinks contribute 200 to 300 calories/day in the average child’s diet, their consumption has been the target of a number of interventions. Approaches have in­cluded restricting access (eg, decreasing availability of sugared drinks in schools) and increasing access to or compet­itively pricing healthier options (eg, water, skim milk).

A new definition of food?

Unlike the very successful litigation against the tobacco industry, lawsuits against the fast food industry have been largely ineffective. The different outcomes may be due in part to the fact that food is necessary for survival, whereas tobacco is not. But, it has been countered that unhealthful items such as sugared drinks should not be classified as food.

Legal approaches: litigation to legislation

The Centers for Disease Control and Prevention and the Institute of
Medicine have convened summits on legal approaches to obesity. Although no consensus was reached, there was a general inclination toward legislative approaches (eg, enhanced nutritional labeling) to help consumers make more in­formed choices. In addition, federal legislation such as the Childhood Nutrition Reauthorization Act, which will af­fect meal programs at public schools, focuses on providing healthier options for children.

Focus on physical activity

Trends in childhood physical activity have been tracked far less closely than have trends in the food environment. One notable trend is related to walking to school — an activity that is becoming less and less common. Some of the rea­sons for the trend are anchored in community design and zoning regulations that affect where a school may be built. Physical activity within the school setting also has decreased, with reduced access to recess, quality physical educa­tion programs, and after-school sports.

Although some aspects of community design may be difficult to reverse, community-level initiatives (eg, Safe Routes to School) are attempting to ameliorate the problem. Furthermore, improvements have been seen in unexpected places. For example, a new light rail system built in Charlotte, North Carolina, led to increased physical activity and (in a subpopulation) decreased rates of obesity.

“Physical activity not only has a role in obesity prevention, but increases in physical activity reduce risk for obe­sity-associated comorbidities… Because of these benefits, this is something we need to restore to people’s lives.”

Online Resources

American Dietetic Association
www.eatright.org

Let’s Move!
www.letsmove.gov

National Center for Health Statistics
http://www.cdc.gov/nchs

National Diabetes Education Program
http://www.ndep.nih.gov

American Diabetes Association’s 58th Annual
Advanced Postgraduate Course

February 25-27, 2011, in New York, NY

Plan to join your colleagues and leading diabetes experts for cutting-edge clinical research in
diabetes treatment and management. The 58th Annual Advanced Postgraduate Course 
will offer the latest advances in diabetes management in general sessions and interactive
Meet the Expert sessions. For more information, go to:

http://professional.diabetes.org

Suggested Reading

Bermudez OI, Gao X: Greater consumption of sweetened beverages and added sugars is associated with obesity among US young adults. Ann Nutr Metab 57:211, 2010; Booth DA, Booth P: Targeting cultural changes supportive of the healthiest lifestyle patterns. A biosocial evidence-base for prevention of obesity. Appetite Dec 8, 2010 [Epub ahead of print]; Branscum P, Sharma M: A systematic analysis of childhood obesity prevention interventions targeting Hispanic children: lessons learned from the previous decade. Obes Rev Oct 26, 2010 [Epub ahead of print]; Cavanaugh K et al: Addressing literacy and numeracy to improve diabetes care: two ran­domized controlled trials. Diabetes Care 32:2149, 2009; Fortuna JL: Sweet preference, sugar addiction and the familial history of al­cohol dependence: shared neural pathway and genes. J Psychoactive Drugs 42:147, 2010; Greenway FL et al: Effect of naltrexone plus bupropion on weight loss in overweight and obese adults (COR-I): a multicentre, randomized, double-blind, placebo-controlled, phase 3 trial. Lancet 376:595, 2010; Johnson PM, Kenny PJ: Dopamine D2 receptors in addiction-like reward dysfunction and com­pulsive eating in obese rats. Nature Neuroscience 13:635, 2010; Konttinen H et al: Emotional eating and physical activity self-effi­cacy as pathways in the association between depressive symptoms and adiposity indicators. Am J Clin Nutr 92:1031, 2010; Liu Y et al: Food addiction and obesity: evidence from bench to bedside. J Psychoactive Drugs 42:133, 2010; Meex RC et al: Restoration of muscle mitochondrial function and metabolic flexibility in type 2 diabetes by exercise training is paralleled by increased myocellular fat storage and improved insulin sensitivity. Diabetes 59:572, 2010; Nadeau KJ et al: Insulin resistance in adolescents with type 2 di­abetes is associated with impaired exercise capacity. J Clin Endocrinol Metab 94:3687, 2009; Osborn CY et al: Self-efficacy links health literacy and numeracy to glycemic control. J Health Commun 15(Suppl 2):146, 2010; Ozier AD et al: The Eating and Ap­praisal Due to Emotions and Stress (EADES) questionnaire: development and validation. J Am Diet Assoc 107:619, 2007; Ozier AD et al: Overweight and obesity are associated with emotion- and stress-related eating as measured by the Eating and Appraisal Due to Emotions and Stress questionnaire. J Am Diet Assoc 108:49, 2008; Regensteiner JG et al: Rosiglitazone improves exercise capacity in individuals with type 2 diabetes. Diabetes Care 28:2877, 2005; Regensteiner JG et al: Cardiac dysfunction during exercise in un­complicated type 2 diabetes. Med Sci Sports Exerc 41:977, 2009; Tucker S et al: A school based community partnership for promot­ing healthy habits for life. J Community Health Oct 26, 2010 [Epub ahead of print].