ADA: Lifestyle Changes Don’t Protect Diabetic Heart

 

English: The blue circle is the global symbol for diabetes, introduced by the International Diabetes Federation with the aim of giving diabetes a common identity, supporting existing efforts to raise awareness of diabetes and placing the diabetes epidemic firmly in the public spotlight. (Photo credit: Wikipedia)

An intense lifestyle intervention for patients with type 2 diabetes that was focused on diet and exercise failed to protect patients against heart problems according to AHEAD Trial.  
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In terms of retention, early numbers suggest success. The 1-year exam was attended by 96.4% of participants, which was only slightly, but statistically significant between the two study arms (Intensive Lifestyle Intervention 97.1% versus DSEI 95.7%; p = 0.004) [17]. The 4-year exam was attended by 93.6% of participants. There was no significant difference between the two study arms (Intensive Lifestyle Intervention 94.1% versus DSEI 93.0%; p = 0.11) [18]. Such high 1-year and 4-year retention rates in a weight loss trial are remarkable. Furthermore, there was a significant stepwise trend between attending a greater number of DSEI sessions and higher retention at the 1-year visit, with only 85% of those participants who attended no DSEI sessions the first year completing data collection, compared to 99% of those attending all three DSEI classes (p < 0.001). While this does not prove causality, it provides face validity that the DSEI sessions were valuable in enhancing retention in the comparison group. The years 1 and 4 retention data in Look AHEAD equal or exceed those of other large multi-center lifestyle intervention trials (Table 4). The Weight Loss Maintenance trial retained 94.7% of its Self-Directed control group after 30 months; however, this study randomized only patients who had lost 4 kg during a 6-month intervention period [15]. The Diabetes Prevention Program retained 92.4% of its participants at the end of the study (2.8 years); however, the control group in that study was a placebo control group designed in comparison to the metformin and troglitazone arms of the study [19]. Perhaps most similarly, the Finnish Diabetes Prevention Study had an overall retention rate of 97.1% at 1 year, but only 90.1% at 2 years [20]; furthermore, the retention rates by study arm were not reported clearly. Prior to Look AHEAD, the longest lifestyle intervention trial was the Women’s Health Initiative which reported an overall retention rate of 90.8% (90.4% for lifestyle and 91.1% for the comparison group) at 8 years of follow-up [21]. Look AHEAD is currently in year 8 of data collection, so comparison at that time point will be available in the future.

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Population-wide weight loss and regain in relation to diabetes burden and cardiovascular mortality in Cuba 1980-2010: repeated cross sectional surveys and ecological comparison of secular trends

English: Prevalence of diabetes worldwide in 2000 (per 1000 inhabitants). World average was 28.23‰. no data less than 7.5 7.5-15 15-22.5 22.5-30 30-37.5 37.5-45 45-52.5 52.5-60 60-67.5 67.5-75 75-82.5 more than 82.5 Note: I interpreted France in the data as including the overseas departments of Reunion, Guadeloupe, Martinique, and French Guiana as they are integral parts of France. China includes the SARs of Hong Kong and Macao. (Photo credit: Wikipedia)

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f1515 (Published 9 April 2013)

Cite this as: BMJ 2013;346:f1515

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Abstract

Objective To evaluate the associations between population-wide loss and gain in weight with diabetes prevalence, incidence, and mortality, as well as cardiovascular and cancer mortality trends, in Cuba over a 30 year interval.

Design Repeated cross sectional surveys and ecological comparison of secular trends.

Setting Cuba and the province of Cienfuegos, from 1980 to 2010.

Participants Measurements in Cienfuegos included a representative sample of 1657, 1351, 1667, and 1492 adults in 1991, 1995, 2001, and 2010, respectively. National surveys included a representative sample of 14 304, 22 851, and 8031 participants in 1995, 2001, and 2010, respectively.

Main outcome measures Changes in smoking, daily energy intake, physical activity, and body weight were tracked from 1980 to 2010 using national and regional surveys. Data for diabetes prevalence and incidence were obtained from national population based registries. Mortality trends were modelled using national vital statistics.

Results Rapid declines in diabetes and heart disease accompanied an average population-wide loss of 5.5 kg in weight, driven by an economic crisis in the mid-1990s. A rebound in population weight followed in 1995 (33.5% prevalence of overweight and obesity) and exceeded pre-crisis levels by 2010 (52.9% prevalence). The population-wide increase in weight was immediately followed by a 116% increase in diabetes prevalence and 140% increase in diabetes incidence. Six years into the weight rebound phase, diabetes mortality increased by 49% (from 9.3 deaths per 10 000 people in 2002 to 13.9 deaths per 10 000 people in 2010). A deceleration in the rate of decline in mortality from coronary heart disease was also observed.

Conclusions In relation to the Cuban experience in 1980-2010, there is an association at the population level between weight reduction and death from diabetes and cardiovascular disease; the opposite effect on the diabetes and cardiovascular burden was seen on population-wide weight gain.

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Weight in the world

Source: Digg

Weight of the World infographic by b_willers.

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Obesity Treatment in Primary Care — Are We There Yet?

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The U.S. Preventive Services Task Force recommends that clinicians arrange for their obese patients to receive intensive, multicomponent behavioral weight-loss counseling.1 However, less than 50% of primary care physicians (PCPs) report that they consistently provide diet and weight-control advice to their adult patients with weight-related disease, and less than 25% regularly refer patients for further management or track their weight-control behaviors over time.2

Recognizing the need for effective weight-management treatments that can be implemented in the primary care setting, the National Heart, Lung, and Blood Institute funded the Practice-based Opportunities for Weight Reduction consortium,3 a group of independent but coordinated comparative-effectiveness trials of weight-loss interventions delivered in primary care settings to obese patients with cardiovascular risk factors. The primary outcome was weight change at 2 years. In this issue of the Journal, the results of two of these studies4,5 are presented.

In the study by Wadden et al.,4 usual care (counseling provided at quarterly PCP office visits) was compared with the addition of brief lifestyle counseling (monthly, 15-minute, in-person counseling visits by trained medical assistants) and with enhanced lifestyle counseling (brief lifestyle counseling plus a toolbox that included meal replacements and weight-loss medications). Although weight loss in the brief-lifestyle-counseling group (2.9 kg) and the usual-care group (1.7 kg) did not differ significantly at 2 years, participants in the enhanced-lifestyle-counseling group lost significantly more weight (4.6 kg) than did those in either of the other two groups and were more likely to lose at least 5% of their initial body weight (35% in the enhanced-lifestyle-counseling group, vs. 26% in the brief-lifestyle-counseling group and 22% in the usual-care group).

In the study by Appel et al.,5 participants from six primary care practices were randomly assigned to a self-directed weight-loss program (control group); to in-person individual sessions plus group sessions, along with electronic and telephone contacts delivered by office-based lifestyle coaches (in-person support); or to a commercial call center–directed group in which coaches delivered all lifestyle interventions by telephone, Internet, and e-mail (remote support). Physicians supported the delivery of the interventions, reviewed participants' weight status, and at routine medical visits encouraged participants to be engaged with the weight-loss treatment. Weight loss at 2 years was similar in the groups that received in-person support (5.1 kg) and remote support (4.5 kg) and was significantly greater than the weight loss in the control group (0.8 kg). Participants assigned to either the in-person or the remote lifestyle intervention were twice as likely as those assigned to the control group to have lost 5% or more of their initial body weight at 2 years (41% for the in-person group and 38% for the remote group, vs. 19% for the control group).

A well-recognized issue that affects the sustainability of behavioral interventions is that attendance at face-to-face counseling sessions decreases substantially over time. In the study by Wadden et al., participants in both the brief-lifestyle-counseling and the enhanced-lifestyle-counseling groups attended fewer than half the scheduled counseling visits during year 2. Similarly, in the study by Appel et al., those assigned to the in-person group participated in only 2 of 24 recommended face-to-face individual and group sessions between month 7 and the end of the trial. In contrast, those assigned to the remote group participated in a median of 16 of 18 recommended telephone contacts during that time. Given that remotely delivered coaching resulted in weight-loss outcomes similar to those of in-person visits, the use of mobile technologies to deliver behavioral weight-loss treatment in primary care appears to be promising. Such interventions may present fewer barriers to adherence than interventions delivered in person, since they allow for greater scheduling flexibility, decreased travel time, and lower transportation costs. In addition, a telephone-based coaching program has the potential for widespread implementation in multiple practice settings, including geographically isolated areas.

Both these studies provide evidence that PCPs can deliver safe and effective weight-loss interventions in primary care settings. However, there are important caveats. Although described as “effectiveness” rather than “efficacy” studies, both studies provided treatments (including lifestyle coaching, counseling, and, in the case of the Wadden study, meal replacements and medications) at no cost to the participants. Whether patients would be willing to pay for these therapies, or insurers would be willing to reimburse for them, is not known. Determining the costs and cost-effectiveness of these and other treatments in primary care settings is crucial. In addition, these two studies were not powered to detect differences in cardiovascular risk reduction, and there were no consistent between-group differences with respect to lipid levels, glucose levels, or blood pressure at 2 years. Particularly when one is augmenting behavioral treatments with medication, it is critical to assess the impact of such interventions on obesity-related coexisting conditions.

Finally, although more than one third of patients may respond to lifestyle counseling with weight loss of at least 5% of their baseline weight, many obese persons do not successfully achieve or maintain weight losses sufficient to improve their health by means of lifestyle changes alone. Some patients will require additional treatments (e.g., medications or bariatric surgery) as an adjunct to, but not a replacement for, lifestyle interventions. Continued research on ways to enhance patients' adherence to long-term lifestyle changes should improve the reach and effectiveness of behavioral treatments for obesity in primary care settings.

The opinions expressed herein are those of the author and do not necessarily reflect the views of the National Institutes of Health or the Department of Health and Human Services.

Disclosure forms provided by the author are available with the full text of this article at NEJM.org.

This article (10.1056/NEJMe1111487) was published on November 15, 2011, at NEJM.org.

SOURCE INFORMATION

From the Office of Obesity Research, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD.

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