Special Issues in Diabetes 207Pi-Sunyer, 1997). Even mild to modest weight losses (5 to
10 kg/10 to 20 pounds) greatly enhances physical status and
improves metabolic control (ADA, 1997b). Thus, obese indi-
viduals with type 2 diabetes do not need to reach ideal weight
to experience the bene“ts from weight loss (Redmon et al.,
1999). Weight loss treatment also helps in the prevention of
diabetes in those with impaired glucose tolerance, as well as
in the treatment of weight gain in patients with type 1 diabetes
who are using intensive insulin therapy (Wing, 1996).
Weight Loss Interventions
The research on weight loss in diabetes re”ects patterns of
“ndings in the general population, namely, that behavioral
weight management programs lead to modest weight losses,
and interventions should be tailored to the speci“c needs of
the individual (Ruggiero, 1998). Findings of a recent study
employing obese women with type 2 diabetes indicate that
combining a 16-week standard behavioral treatment program
with a motivational interviewing component (e.g., personal-
izing goals) enhances adherence to program recommenda-
tions and glycemic control (D. Smith, Heckemeyer, Kratt, &
Mason, 1997). Overall, the results of behavioral research
with obese individuals with type 2 diabetes emphasize di-
etary and exercise behaviors as important factors in improved
weight loss (Wing, 1993). Traditionally, diets have been iden-
ti“ed as the treatment of choice in obese patients with type 2
diabetes (Maggio & Pi-Sunyer, 1997), but several studies
have found little or no bene“t to dieting (e.g., Milne, Mann,
Chisolm, & Williams, 1994), perhaps because of failure to
adhere to dietary recommendations. Additionally, physiolog-
ical changes occur with dieting (e.g., increased activity of the
fat storage enzyme lipoprotein lipase; Eckel & Yost, 1987),
which may impede weight loss.
Very low calorie diets (VLCD) have been found to be a
safe method of attaining greater and more rapid weight losses
than traditional standard low calorie diets (e.g., Maggio &
Pi-Sunyer, 1997). In obese patients with type 2 diabetes,
VLCD treatments have been generally associated with large
improvements in major metabolic control variables (e.g.,
Brown, Upchurch, Anding, Winter, & Ramirez, 1996; Wing,
Marcus, Salata, et al., 1991). Findings from another study that
randomized 93 obese type 2 diabetes patients to different
levels of caloric restriction (400 versus 1,000 kcal/day) sug-
gest that caloric restriction rather than actual weight loss con-
tributes to the initial, rapid change in metabolic control (Wing
et al., 1994). Furthermore, the group that initiated the treat-
ment program with 1,000 kcal/day and maintained this
caloric intake for 15 weeks experienced further improve-
ments in blood glucose and insulin sensitivity. In contrast, the
group that increased caloric intake from 400 to 1,000 kcal/day
throughout the study had worse fasting glycemic control de-
spite their continued weight loss. These “ndings suggest that
the amount of calorie restriction and weight loss have differ-
ential effects on improvements in metabolic control and in-
sulin sensitivity.
Dietary interventions have not been effective in achieving
long-term weight loss to date. The ADA (1997b) proposes
that emphasis be placed instead on glucose and lipid goals as
opposed to traditional weight loss goals. Individuals with
type 2 diabetes who follow the ADA dietary guidelines expe-
rience signi“cant improvements in glycemic control and car-
diovascular risk factors (Pi-Sunyer et al., 1999). In addition
to a nutritionally adequate diet, ideal metabolic goals can also
be achieved by exercise and/or using medication (ADA,
1997a).
Exercise is also a key ingredient in the management of dia-
betes and should be used as an adjunct to nutrition and/or drug
therapy (ADA, 1997a). The bene“ts of exercise in type 2 dia-
betes patients are extensive and include improved insulin
sensitivity and action (Wing, 1991), glycemic control (Blake,
1992), cardiovascular bene“ts (Schneider, Khachadurian,
Amorosa, Clemow, & Ruderman, 1992), short- and long-term
weight loss (Wing, 1993), reduced need for insulin and/or
hypoglycemic agents (Marrero & Sizemore, 1996), and psy-
chological bene“ts including improvements in mood, self-
esteem, well-being, and quality of life (Rodin & Plante, 1989).
In addition, exercise has been found to increase muscle mass,
leading to improvements in insulin and glucose levels
(Schneider et al., 1992). Outcomes of studies have also re-
vealed the protective bene“t of exercise against developing
type 2 diabetes (Pan et al., 1997). Unfortunately, nonadher-
ence is common and naturally limits the degree to which indi-
viduals may bene“t from exercise (Marcus et al., 2000). Thus,
a prominent role for the health care team is to motivate pa-
tients and personalize goals that incorporate patients• speci“c
physical activity needs while accounting for their tolerable
level of strength and aerobic capacity.
The use of medication is considered an adjunct to diet and
exercise treatment approaches particularly for obese individu-
als with type 2 diabetes who have been unable to achieve and
maintain weight loss (North American Association for the
Study of Obesity, 1995). Similar to other weight loss ap-
proaches, individuals tend to gain weight once the medication
is discontinued (National Task Force on the Prevention
and Treatment of Obesity, 1996), thus, negatively affect-
ing glycemic control (Wing, 1995). Catecholaminergic
agents (e.g., phentermine) have been shown to effect greater
weight losses than placebo groups but with no improvement
in glycemic control (e.g., Crommelin, 1974). Results of