Overcoming Obesity
Obesity's Effect on Specific Conditions
According to Dr. Pi-Sunyer, the mechanism of obesity in diabetes is related to ectopic fat distribution. "Basically, obese patients with diabetes have fat in the wrong places, not just in fat cells but in the abdominal organs, such as the liver, and in muscles. These fatty deposits can lead to insulin resistance because glucose is inhibited from entering the cells."
How obesity contributes to hypertension and CVD is less clear, says Dr. Pi-Sunyer. "Greater activation of the sympathetic nervous system contributes to some instances of hypertension. Other cases of hypertension are caused by retention of sodium in response to higher insulin levels, which can increase blood volume. In patients with CVD, increased release of lipids from fat cells causes elevated blood lipids and can lead to atherosclerosis; the insulin doesn't do its job appropriately in fat cells. Patients have higher circulating fatty acids, which are converted into triglycerides. The resulting high triglyceride levels can lead to low HDL-C levels and small LDL-C particles, which are atherogenic. In the setting of type 2 diabetes where risks and consequences of hypertension and CVD are considerably heightened, the management of weight becomes a greater clinical issue."
Therapeutic Thresholds
The National Heart, Lung and Blood Institute (NHLBI), the American Diabetes Association (ADA), the American Heart Association (AHA), and the American Dietetic Association have established therapeutic threshold recommendations for physicians to follow when treating obesity in patients with diabetes (see Figure 1). "Physicians can prescribe pharmacotherapy if a patient with diabetes has a BMI [body mass index] above 27 kg/m2 and two risk factors for CVD or if a patient has a BMI of 30 kg/m2 or higher without risk factors, according to FDA regulations," Dr. Pi-Sunyer says. "Traditionally, obesity surgery has been reserved for people with a BMI of 40 kg/m2 or higher, but many patients are having the procedure once their BMI is higher than 35 kg/m2 because they also have congestive heart failure, uncontrolled diabetes or hypertension, severe coronary artery disease, or other significant risk factors.
"Physicians are now armed with good resources and practical guidelines that provide background information on the condition," continues Dr. Pi-Sunyer. "Additionally, findings from recent studies explain some of the newer approaches to treating patients who are obese. Much of this information can be downloaded from the internet for the physician to use and share with their patients." The ADA is providing a free toolkit (see Figure 2) that is designed to encourage physicians to take a more active role in managing diabetic patients and obesity. The websites for the NHLBI, the AHA, and the American Academy of Family Physicians also provide educational materials for physicians on obesity management (see Readings & Resources).
Diabetes Self-Management Education (DSME) centers have also been established throughout the United States to aid in educating patients with diabetes about their condition. Patients can receive reimbursement through most healthcare plans to attend these centers and have access to specialized diabetes educators and nutritionists, but Dr. Pi-Sunyer says that many patients are unaware of these resources. "Physicians need to do a better job of promoting the use of DSME centers because they are good resources that can have a significant impact on our patients' lives. Many primary care physicians are not paying enough attention to obesity because they are extremely busy and have limited time to spend with their patients. This leads to a sense of futility about what they can accomplish in such a short period of time. Physicians may also be reluctant to discuss nutrition and provide dietary counseling because it's not their forte. Primary care physicians need to recognize that obesity is not a situation where we can simply write a prescription and the problem will go away."…. CONTINUES……….www.physweekly.com
Depãºirea Obezitate - Overcoming Obesity - articole medicale engleza - startsanatate