Health care providers (HCPs) and their overweight and obese clients with prediabetes and type 2 diabetes have been struggling for years with unsuccessful attempts to lose weight and maintain the weight loss with traditional hypocaloric weight loss plans, along with a physical activity component and, in some cases, implementation of a variety of behavioral strategies. We are learning more each day about the complex integration of neurological, endocrine, and gastrointestinal feedback mechanisms that regulate appetite and weight, in addition to the effects of comorbidities and medication on body weight in individuals with type 2 diabetes (1). Despite the well-known relationship between obesity and concomitant risk of type 2 diabetes in people with prediabetes, weight loss and weight maintenance remain elusive in the majority of our overweight and obese clients. This has prompted some to ask: are we focusing too much on an outcome that is unachievable in most of our clients?

This Diabetes Spectrum From Research to Practice section begins with an article in which Guest Editor Marion J. Franz discusses the evidence supporting the benefits of moderate weight loss (5–10% of weight) in obese individuals without diabetes (p. 149). The potential for weight regain is addressed, as well as the types of interventions that have generally been required to facilitate weight maintenance. Ms. Franz then reviews the effectiveness of modest weight loss and regular physical activity in individuals with prediabetes relative to the results of the Diabetes Prevention Program and its 10-year follow-up. The use of medications to prevent progression from prediabetes to diabetes and metabolic surgery to reduce the incidence of type 2 diabetes are also discussed. For individuals with type 2 diabetes, Ms. Franz points out that the goals of medical nutrition therapy shift from weight loss to control of glucose, lipids, and blood pressure. She provides an excellent review of the effectiveness of weight loss interventions for type 2 diabetes and highlights the necessary changes to the focus of nutrition intervention as diabetes progresses.

The high rate of recidivism among overweight or obese clients is frustrating, to say the least, to HCPs striving to help them achieve their weight loss goals. Feelings of failure and embarrassment often result in these clients not returning for follow-up visits. Alison B. Evert and Ms. Franz present a very interesting article (p. 153) discussing the contribution of genetics versus environment to weight variance and the currently identified factors that can reduce the likelihood of successfully achieving and maintaining a healthy body weight. The authors explain the hormonal, metabolic, and neural factors that play a role in weight regulation and how the body responds to food deprivation, giving us insight into some of the reasons obese individuals have difficulty maintaining weight loss over time. Ms. Evert and Ms. Franz also explain that the lack of awareness by HCPs of the factors that affect outcomes may result in negative attitudes due to frustration about poor weight loss outcomes. This, the authors state, has been suggested to affect their willingness to provide weight intervention.

One important lifestyle issue we have all pondered is the contribution of physical activity to weight loss and weight maintenance. Most of us are aware of the glycemic benefit of regular physical activity in type 2 diabetes, but what about the effect on weight control? In her excellent article starting on p. 157, Carla E. Cox discusses the evidence regarding exercise in and of itself to improve weight loss efforts, outside of dietary restriction. She reviews the evidence and discusses the potential explanations for less weight loss than might be predicted from exercise alone. Dr. Cox also addresses the question of whether individuals utilizing exercise alone for weight reduction compensate for exercise by either eating more or reducing their nonexercise activity thermogenesis. Studies addressing the potential difference between aerobic training and resistance training in achieving weight loss or weight maintenance are also discussed, and exercise/physical activity guidelines from the major health care organizations are compared to study results.

Diabetes HCPs are well aware of the many challenges facing people attempting to lose weight and are eagerly seeking new behavioral strategies that might prove successful in helping people with diabetes reach their weight loss goals. In their article starting on p. 161, Tenisha L. Hill and Jeffrey J. VanWormer discuss evidence indicating that weight loss from lifestyle interventions may prove to be even more challenging for individuals with diabetes than for the general population, and they cite the absence of studies addressing the effectiveness of intensive behavioral therapy (IBT) in adults with diabetes. Ms. Hill and Dr. VanWormer discuss a 1-year study they conducted to examine the effectiveness of IBT specifically in adults with type 2 diabetes. Their study utilized primarily registered dietitian nutritionists to deliver IBT, focusing on behavioral aspects of weight management, including nutrition and physical activity recommendations, along with counseling on behavioral self-management techniques such as goal-setting, self-monitoring, and problem-solving. They compared weight change over 1 year in obese adults with type 2 diabetes who received IBT to that of those who did not.

In her article starting on p. 166, Meg G. Salvia discusses the significance of the results of the Look AHEAD (Action for Health in Diabetes) trial, given its size (>5,000 overweight or obese people with type 2 diabetes) and duration (>8 years). Look AHEAD evaluated the impact of a very intensive lifestyle intervention on health outcomes, including cardiovascular morbidity and mortality, weight, and glycemic control, compared to a control group that received standard diabetes support and education. Ms. Salvia explains that, although the trial did not find significant differences in cardiovascular morbidity and mortality between the two groups, there were a number of positive outcomes resulting from the interventions from which HCPs can learn. As in all clinical studies, the question arises as to whether these outcomes could be replicated in nonresearch settings.

Wrapping up this issue, Joseph B. Nelson discusses the behavioral approach of mindful eating that has gained popularity in recent years (p. 171). Mr. Nelson explains that mindfulness refers to “paying attention in a particular way, on purpose, in the present moment and nonjudgmentally.” Mindful eating focuses on an individual’s sensual awareness and experience of food rather than on the type or amount of food consumed. This approach has been shown to help individuals with type 2 diabetes change their eating behaviors.

I hope the articles in this Diabetes Spectrum From Research to Practice section will expand readers’ knowledge of the challenges and complexity of losing weight and maintaining weight loss for individuals with type 2 diabetes and their understanding that relying on weight loss as a primary outcome may prevent HCPs from acknowledging other positive metabolic outcomes arising from healthy lifestyle changes. I wish to thank Ms. Franz for all of her hard work in serving as both Guest Editor and an expert author for this research section. It is always a delight to work with and learn from her.

No potential conflicts of interest relevant to this article were reported.

Halving your cake and eating it, too: a case-based discussion and review of metabolic rehabilitation for obese adults with diabetes
Curr Diabetes Rev
Epub ahead of print (DOI: 10.2174/1573399813666170329154902)
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