QJM Advance Access originally published online on August 31, 2007
QJM 2007 100(10):665-666; doi:10.1093/qjmed/hcm084
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Response
Department of Human Nutrition
University of Glasgow
Glasgow Royal Infirmary
Glasgow
UK
email: lean{at}clinmed.gla.ac.uk
Sir,
We agree with much of Dr Hockaday's letter, at least beyond his first sentence. We included type 2 diabetes in our systematic review to draw attention to the need for weight management in the majority of cases who are overweight, particularly when that need is amplified by weight gain (via fat gain) as a consequence of treatment with hypoglycaemic drugs. Even now, many diabetic patients are not warned that weight gain is an expected side-effect, or given advice by dietitians to help them avoid it. Treatment of untreated type 1 diabetes with insulin is accompanied by fluid and general resuscitation, which leads to weight gain that has nothing to do with obesity, so this was excluded on the basis of a very different confounder.
The UKPDS cannot provide a comparison between the values of glycaemic control and weight management in the treatment of type 2 diabetes. UKPDS was designed to establish whether aggressive pursuit of normoglycaemia could improve health outcomes, and has shown some important but quite modest benefits, mainly for microvascular complications. It did not include active or aggressive weight management (not all UKPDS centres even had a dietitian at the start). It remains very possible that aggressive weight management, with improvement in all the cardiovascular risk cascade, would achieve greater clinical outcome benefit for overweight people with newly diagnosed type 2 diabetes than better glycaemic control alone. Observational studies have shown major increases in life expectancy for overweight diabetic patients who have lost weight intentionally1,2. We thus agree wholeheartedly with Dr Hockaday's final conclusion ('Obesity needs therapy rather than exhortation'), and would urge a well-designed prospective CVD-endpoint study to explore this.
References
1. Lean ME, Powrie JK, Anderson AS, Garthwaite PH. Obesity weight loss and prognosis in type 2 diabetes. Diabet Med (1990) 7:228–33.[Web of Science][Medline]
2. Williamson DF, Pamuk E, Thum M, Flanders D, Byers T, Heath C. Prospective study of intentional weight loss and mortality in overweight white men aged 40–64 years. Am J Epidemiol (1999) 149:491–503.
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