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Meal Provision as a Strategy for Supporting Weight Loss and Improving Metabolic Parameters in Type 2 Diabetes

	Presentation

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J.L. is a 65-year-old white woman diagnosed with type 2 diabetes at age 62 years. She has struggled with weight gain during her adult years and has repeatedly attempted to lose weight through various popular diets. Nevertheless, her weight continued to increase, and her glycemic control became increasingly erratic. She reports monitoring her blood glucose infrequently because seeing elevated glucose values causes her to feel "out of control" and depressed. She is generally not physically active and has recently been very inactive because of a leg injury resulting from a fall.

At her last physician visit, J.L.'s height was 5'7'', and her weight was 230 lb (BMI 36 kg/m²), her highest adult weight. Her hemoglobin A_1c (A1C) was 7.2% on 1,000 mg of meformin twice daily taken with breakfast and with her evening meal, plus 8 mg of rosiglitazone once daily. Her blood pressure was 126/82 mmHg on 150 mg of irbesartan daily, and her lipid panel showed an LDL cholesterol of 107 mg/dl, HDL cholesterol of 42 mg/dl, and triglycerides 156 mg/dl on 20 mg of rosuvastatin daily.

J.L.'s physician referred her to a registered dietitian, who determined that J.L. was frustrated and overwhelmed with her attempts to follow multiple dietary recommendations and that meal planning was a considerable stressor for her. This contributed to dietary nonadherence. In addition, J.L.'s leg injury made meal preparation difficult.

The dietitian suggested that J.L. try a portion- and nutrient-controlled meal plan that would provide a high degree of structure and support. This option could enable J.L. to experience success with weight loss and help improve her glycemic control and other metabolic parameters. Also, the meals could be used as a teaching tool to illustrate portion control and demonstrate how to translate dietary recommendations into healthy and appealing meals.

J.L. began a novel, home-delivered meal program that provides three portion- and nutrient-controlled meals each day. All the meals are freshly prepared and integrate nutrition guidelines advocated by various health care associations that link proper diet to disease management and prevention. With input from the dietitians, J.L. selected a 1,200-calorie daily meal plan option that provided a consistent amount of carbohydrate (50 g) at each meal, < 10% of calories from saturated fat, and 2,300 mg of sodium per day. In addition to the meals, internet-based resources and telephone consultations with the dietitian were made available to J.L. to support her adherence with the meals and positive lifestyle changes.

J.L. closely followed the meal plan for 2 months and lost 11.25 lb. She felt positive about her weight loss success and began to feel more in control of her diabetes. She started monitoring her blood glucose four times per day, and 87% of the values on her meter were in the target ranges of 90-130 mg/dl before meals and < 180 mg/dl after meals. Her blood pressure also improved to 122/78 mmHg. Another A1C test and a repeat lipid panel were scheduled in her physician's office.

J.L. also began physical therapy and was able to initiate a pedometer-based walking program. At this point, she felt ready to plan and prepare meals herself. J.L. said she was glad to know the option of portion-controlled meals was available should she need additional structure and support to maintain her weight loss and improve her diabetes control again in the future.

	Questions

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1. Why should weight loss or prevention of weight gain be a primary goal for overweight individuals with diabetes?
   
2. What unique weight-loss challenges do people with diabetes face?
   
3. What strategies can be implemented to support success with weight management?
   

	Commentary

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Weight gain during adulthood is directly correlated with an increased risk of developing type 2 diabetes.¹ Overweight or obesity typically precedes a diagnosis of diabetes, and as BMI increases, so does insulin resistance, glucose intolerance, and the likelihood of developing diabetes.¹ Eighty percent of individuals with type 2 diabetes have a BMI that classifies them as either overweight (25-29.9 kg/m²) or obese ( 30 kg/m²).²

Lifestyle interventions aimed at promoting a moderate weight loss of 5-10% of starting weight can improve insulin resistance and contribute to improved glucose, lipid, and blood pressure control.^2-4 Greater amounts of weight loss are associated with greater improvements in fasting glucose.⁵ Because considerable health risks are associated with obesity and diabetes, weight loss, or at least prevention of further weight gain, is essential for optimal diabetes management.

Although weight loss and maintenance are imperative for overweight individuals with diabetes, achieving significant reductions in weight can be challenging.^2,6 This, in part, is because of metabolic changes that influence energy expenditure. As individuals lose weight, their resting metabolic rate declines, and their nonresting energy expenditure decreases as the amount of body mass that must be moved through space becomes less.⁷ When individuals with poorly controlled diabetes, which is characterized by high protein turnover, achieve improved glycemic control, thermogenesis of protein synthesis decreases, and energy expenditure drops. Calorie "wasting" from urinary excretion of glucose is diminished, and calories are retained. Hypothalamic signals that defend body weight amplify and increase the hunger signals that drive food intake. If this leads to an increase in caloric intake, additional weight loss is prevented.⁶ Also, many of the medications that are aimed at reducing hyperglycemia, including insulin, sulfonylureas, meglitinides, and thiazolidinediones, increase anabolism and can contribute to weight gain.⁶

Beyond these biological and metabolic factors, environment and lifestyle behaviors contribute significantly to the development of overweight and obesity. Today's societal environment limits physical activity and allows easy access to high-calorie, high-fat, nutrient-deficient foods. For many overweight people, poor food choices, overconsumption of calories, and a sedentary lifestyle set the stage for progressive weight gain and the onset of diabetes.

Although vitally important, changing established lifestyle behaviors and food preferences can be difficult. Lifestyle and behavioral approaches such as goal setting and self-monitoring; nutrition and physical activity education and counseling; reinforcement of healthy behaviors; stimulus control; modification of eating habits; and development of problem-solving and coping skills can help modify behaviors and lead to moderate weight loss.^8,9

Food provision is a new trend in the management of overweight and obesity that focuses on directly changing the food environment by providing calorie-, portion-, and nutrient-controlled meals or meal replacements.^8-10 This approach, when combined with education and lifestyle coaching, may be especially effective for several reasons. It is a simple and effective strategy for meeting many complex nutrient recommendations.¹¹ The inherent structure of the meals may improve eating patterns and reduce snacking. The meals demonstrate appropriate portion sizes and illustrate how nutrition recommendations can be translated into healthy and appealing meals. And this strategy minimizes meal planning and preparation, which allows more time to focus on self-monitoring and improving overall self-care.^9,11,12

Following are some resources for meal provision companies with menus that meet generally accepted, health-promoting nutrition guidelines or offer dietitian support.

• Diet Gourmet http://www.dietgourmet.com
  
• Fresh Cuisine http://www.FreshCuisine.com
  
• Good Measure Meals http://www.GoodMeasureMeals.com
  
• Susan's Healthy Gourmet http://susanshealthygourmet.com
  

	Clinical Pearls

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• Overweight and obese individuals with type 2 diabetes are at high absolute health risk. This is especially true for individuals who have multiple additional risk factors, such as hypertension, abnormal lipids, or cardiovascular disease.
  
• Moderate weight loss can improve insulin resistance, glycemic control, and cardiovascular risk factors. Greater amounts of weight loss tend to result in greater improvements in glycemic control. For individuals with diabetes of long duration and impaired ß-cell function, weight loss is imperative to lowering overall health risk, although it may not lead to significant improvements in glycemic control.⁴
  
• Standards of care indicate that lifestyle interventions aimed at diet and physical activity should be first-line treatments for diabetes and should remain essential components of diabetes management as the disease progresses.^4,6
  
• Because multiple factors contribute to the development of overweight and obesity, multiple intervention strategies must be used to effectively treat the disorder. It is important for practitioners to develop a toolkit and to learn about clinical and community resources that can offer overweight or obese patients the guidance and support they need to successfully manage their disease.
  

	Footnotes

 
Charlotte Hayes, MMSc, MS, RD, CDE, is Director of Nutrition Services at Project Open Hand/Atlanta in Georgia.

Note of disclosure: The author's employer, Project Open Hand/Atlanta owns Good Measure Meals, a program that sells home-delivered portion- and nutrient-controlled meals in the Atlanta, Ga., region.

	REFERENCES

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¹ Klein S, Sheard NF, Pi-Sunyer X, Daly A, Wylie-Rosett J, Kulkarni K, Clark NG: Weight management through lifestyle modification for the prevention and management of type 2 diabetes: rationale and strategies: a statement of the American Diabetes Association, the North American Association for the Study of Obesity, and the American Society for the Clinical Nutrition (Review). Diabetes Care 27:2067 -2073, 2004[Free Full Text]

² Hensrud DD: Dietary treatment and long-term weight loss and maintenance in type 2 diabetes. Obesity Res9 : S348-S353,2001[Medline]

³ American Diabetes Association: Nutrition principles and recommendations in diabetes (Position Statement). Diabetes Care 27: S36-S54,2004

⁴ Franz MJ: Type 2 diabetes: a progressive disease requiring progressive treatment. On The Cutting Edge25 : 8-12,2004

⁵ U.K. Prospective Diabetes Study Group: UKPDS 7: response of fasting plasma glucose to diet therapy in newly presenting type II diabetic patients. Metabolism 39:905 -912, 1990[Medline]

⁶ Pi Sunyer FX: Weight loss in type 2 diabetic patients. Diabetes Care 28:1526 -1527, 2005[Free Full Text]

⁷ Leibel RI, Rosenbaum M, Hirsch J: Changes in energy expenditure resulting from altered body weight in man. N Engl J Med 332: 621-628,1995 .[Abstract/Free Full Text]

⁸ Foreyt JP: Trends in the long-term management of obesity. Asia Pac J Clin Nutr 14:S29 , 2005.

⁹ Wing RR, Jeffery RW: Food provision as a strategy to promote weight loss. Obesity Res 9:S271 -S275, 2001[Medline]

¹⁰ Delahanty LM: Evidence-based trends for achieving weight loss and increased physical activity: applications for diabetes prevention and treatment. Diabetes Spectrum15 : 183-189,2002[Abstract/Free Full Text]

¹¹ Metz JA, Kris-Etherton PM, Morris CD, Mustad VA, Stern JS, Oparil S, Chait A, Haynes RB, Resnick LM, Clark S, Hatton DC, McMahon M, Holcomb S, Snyder GW, Pi-Sunyer FX, McCarron DA: Dietary compliance and cardiovascular risk reduction with a prepared meal plan compared with a self-selected diet. Am J Clin Nutr 66:373 -385, 1979

¹² Wing RR: Food provision in dietary intervention studies. Am J Clin Nutr 66:421 -422, 1979

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This Article Extract Full Text (PDF) Purchase Article View Shopping Cart Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Hayes, C. Search for Related Content PubMed Articles by Hayes, C. Social Bookmarking                What's this?