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## Complete Summary

#### GUIDELINE TITLE

Weight management through lifestyle modification for the prevention and
management of type 2 diabetes: rationale and strategies.

#### BIBLIOGRAPHIC SOURCE(S)

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.
Diabetes Care 2004 Aug;27(8):2067-73. \[105 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15277443)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Type 2 diabetes mellitus

-   Overweight (body mass index \[BMI\] 25.0-29.9 kilograms per meter
    squared \[kg/m^2^\])

-   Obesity (BMI [\>]{.underline}30.0 kg/m^2^)

#### GUIDELINE CATEGORY

Management\
Prevention

#### CLINICAL SPECIALTY

Endocrinology\
Family Practice\
Internal Medicine\
Nutrition\
Preventive Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Dietitians\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To review the important role of weight management in the prevention and
management of type 2 diabetes and to describe strategies for achieving
and maintaining a healthy body weight through lifestyle modification

#### TARGET POPULATION

Overweight and obese individuals at risk of or with type 2 diabetes

#### INTERVENTIONS AND PRACTICES CONSIDERED

Weight management through lifestyle modification including:

-   Diet

-   Physical activity

#### MAJOR OUTCOMES CONSIDERED

-   Weight loss

-   Glycemic control (fasting blood glucose concentrations)

-   Use of diabetes medications

-   Risk factors for cardiovascular disease (blood pressure, lipid
    concentrations, serum markers of inflammation)

-   Development of type 2 diabetes in high-risk groups

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review\
Review of Published Meta-Analyses

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

American Diabetes Association Statements are reviewed externally and
also by the Professional Practice Committee for overall content.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Overweight and obesity are strongly linked to the development of type 2
diabetes and can complicate its management. Obesity is also an
independent risk factor for hypertension and dyslipidemia as well as
cardiovascular disease, which is the major cause of death in those with
diabetes. Moderate weight loss improves glycemic control, reduces
cardiovascular disease risk, and can prevent the development of type 2
diabetes in those with pre-diabetes. Therefore, weight loss is an
important therapeutic strategy in all overweight or obese persons who
have type 2 diabetes or are at risk for developing diabetes.

**Specific Recommendations**

-   Weight loss is recommended for all overweight (body mass index
    \[BMI\] 25.0-29.9 kilograms per meter squared \[kg/m^2^\]) or obese
    (BMI [\>]{.underline}30.0 kg/m^2^) adults who have, or who are at
    risk for developing, type 2 diabetes.

-   The primary approach for achieving weight loss is therapeutic
    lifestyle change, which includes a reduction in energy intake and an
    increase in physical activity.

-   A moderate decrease in caloric intake (500-1,000 kilocalories per
    day \[kcal/day\]) will result in a slow but progressive weight loss
    (1-2 pounds per week). For most patients, weight loss diets should
    supply at least 1,000-1,200 kcal/day for women and 1,200-1,600
    kcal/day for men.

-   Overweight or obese patients with diabetes are encouraged to adopt
    the dietary recommendations known to reduce the risk of coronary
    heart disease (outlined in Tables 3 and 4 of the original guideline
    document). In conjunction with a moderate reduction in caloric
    intake (500-1,000 kcal/day), this diet is likely to result in
    moderate weight loss as well as improvement in cardiovascular risk
    factors. Dietary guidance should be tailored to each person,
    allowing for individual food preferences and approaches to reducing
    caloric intake.

-   Physical activity is an important component of a comprehensive
    weight management program. Regular, moderate-intensity physical
    activity enhances long-term weight maintenance. Regular activity
    also improves insulin sensitivity, glycemic control, and selected
    risk factors for cardiovascular disease (i.e., hypertension and
    dyslipidemia), and increased aerobic fitness decreases the risk of
    coronary heart disease.

-   Initial physical activity recommendations should be modest, based on
    the patient\'s willingness and ability, gradually increasing the
    duration and frequency to 30 to 45 minutes of moderate aerobic
    activity, 3 to 5 days per week, when possible. Greater activity
    levels of at least 1 hour per day of moderate (walking) or 30
    minutes per day of vigorous (jogging) activity may be needed to
    achieve successful long-term weight loss.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each
recommendation.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

**Benefits of Weight Loss**

-   Moderate weight loss (5% of body weight) can improve insulin action,
    decrease fasting blood glucose concentrations, and reduce the need
    for diabetes medications.

-   Weight loss has important additional health benefits in patients
    with diabetes because it improves other risk factors for
    cardiovascular disease by decreasing blood pressure, improving serum
    lipid concentrations (decrease in serum triglycerides, total
    cholesterol, and low-density lipoprotein \[LDL\] cholesterol and
    increase in serum high-density lipoprotein \[HDL\] cholesterol
    concentrations), and reducing serum markers of inflammation.

**Benefits of Physical Activity**

Regular exercise and aerobic fitness improve insulin sensitivity and
glycemic control, may decrease the risk of developing diabetes, and may
reduce overall mortality in patients who have type 2 diabetes.

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

Although many different dietary approaches may result in short-term
weight loss, the limitation of most diets is poor long-term compliance
and weight regain. The optimal dietary macronutrient composition that
facilitates lasting and safe weight loss is not known.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

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.
Diabetes Care 2004 Aug;27(8):2067-73. \[105 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15277443)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2004 Aug

#### GUIDELINE DEVELOPER(S)

American Diabetes Association - Professional Association\
American Society for Clinical Nutrition - Professional Association\
North American Association for the Study of Obesity - Professional
Association

#### SOURCE(S) OF FUNDING

American Diabetes Association (ADA)

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Primary Authors*: Samuel Klein, MD, Division of Geriatrics and
Nutritional Sciences and Center for Human Nutrition, Washington
University School of Medicine, St. Louis, Missouri; Nancy F. Sheard,
SCD, RD, Department of Family Practice, University of Vermont,
Burlington, Vermont; Xavier Pi-Sunyer, MD, MPH, Division of
Endocrinology, Diabetes and Nutrition, St. Luke\'s---Roosevelt Hospital
Center, Columbia University College of Physicians and Surgeons, New York
New York; Anne Daly, MS, RD, BC-ADM, CDE, Springfield Diabetes &
Endocrine Center, Springfield, Illinois; Judith Wylie-Rosett, EDD, RD,
Division of Health, Behavior and Nutrition, Albert Einstein College of
Medicine, Bronx, New York; Karmeen Kulkarni, MS, RD, BC-ADM, CDE, St
Mark\'s Diabetes Center, Salt Lake City, Utah; Nathaniel G. Clark, MD,
MS, RD, American Diabetes Association, Alexandria, Virginia

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Samuel Klein, MD is a member of the Obesity and Diabetes Educational
Council, which is funded by an unrestricted educational grant provided
by Roche Laboratories, is on the Enteromedics Medical Advisory Board,
has received honoraria from Merck, and has received research support
from Transneuronix.

Judith Wylie-Rosett, EDD, RD has received research funding from the Dr.
Robert C. Atkins Foundation.

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [American Diabetes Association
(ADA) Web
site](http://care.diabetesjournals.org/cgi/content/full/27/8/2067).

Print copies: Available from the American Diabetes Association, 1701
North Beauregard Street, Alexandria, VA 22311.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on April 18, 2005.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is
copyrighted by the American Diabetes Association (ADA).

For information on guideline reproduction, please contact Alison Favors,
Manager, Rights and Permissions by e-mail at <permissions@diabetes.org>.

For information about the use of the guidelines, please contact the
Clinical Affairs Department at (703) 549-1500 ext. 1692.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008