Building Competency in Diabetes Education THE ESSENTIALS

TREATMENT MODALITIES: LIFESTYLE| 5-29

weight, regardless of starting weight, should be sufficient to improve metabolic parameters (11). If weight loss does not seem possible, then prevention of further weight gain should be attempted. Lifestyle interventions remain the cornerstone of the treatment of obesity, yet adherence is poor and long-term success is modest due to significant barriers on the part of both the patient and the health-care professionals responsible for treatment. Often people with obesity and diabetes have greater difficulty achieving weight loss compared to people with obesity but without diabetes (116). The Canadian clinical practice guidelines on the management and prevention of obesity in adults and children have developed an algorithm for the assessment and stepwise management of the overweight or obese adult. Included in this algorithm is the recommendation to assess and screen for depression, eating and mood disorders (115), recognizing the significant effects of psychosocial barriers. People with diabetes often take medications that are associated with weight gain; these include antihyperglycemic, antihypertensive, pain relief and antidepressant agents (117). Health-care providers should attempt to minimize the use of weight-inducing agents. Assessing psychological aspects of eating behaviours, such as emotional eating, binge eating, attention deficit and hyperactivity disorder (ADHD) and depression, is important for determining reasons for weight gain (118). Physical factors that impede activity, such as osteoarthritis or dyspnea, can contribute to obesity (119). Comorbid conditions, such as osteoarthritis and obstructive sleep apnea (OSA), can also impact the ability to lose weight (120). Healthy behaviour interventions are essential components of successful weight management. Interventions that include dietary modification, regular physical activity and behaviour therapy are the most effective at improving health outcomes (121). Structured interprofessional programs and group programs have demonstrated better results (122) compared to individual health-care professional-based interventions (123). When considering dietary changes, obvious sources of excess energy should be modified first (i.e. regular pop; large portions of juice; large amounts of carbohydrate, protein or fat). Carbohydrate, regardless of its source, may be tolerated to different degrees depending on insulin availability/insulin resistance. Those who use insulin can adjust their insulin dose to accommodate more carbohydrate than those treated with oral agents or diet and exercise alone. A restriction in saturated fat will reduce energy intake and also reduce the risk of heart disease and some forms of cancer; this is considered to be a better strategy for promoting weight loss than a general energy restriction (124). The many health benefits of exercise for the general population (125) apply equally to people with diabetes . Members of the health care team should consider using a structured approach to providing feedback and advice on