Impact of an intensive lifestyle intervention on use and cost of medical services among overweight and obese adults with type 2 diabetes: the action for health in diabetes

The past, present, and future of behavioral obesity treatment

Over the last century, hundreds of evaluations have been conducted to examine weight-management interventions related to diet, physical activity, and behavior therapy. These investigations have contributed to a growing body of knowledge that has consistently advanced the field of obesity treatment, while also revealing some persistent challenges. This narrative review summarizes key findings from randomized controlled trials conducted in adults that have combined diet, physical activity, and behavior therapy, an approach variously referred to as behavioral treatment, comprehensive lifestyle modification, or intensive lifestyle intervention. The review shows that current behavioral approaches induce average reductions in baseline body weight of 5 to 10% at 6 to 12 months. Such losses have proven effective in reducing the risk of type 2 diabetes in persons with impaired glucose tolerance and in improving other obesity-related complications. These benefits have also been associated with reductions in healthcare costs. Despite these advances, behavioral treatment is challenged by the need for larger losses to achieve optimal improvements in health, by difficulties associated with maintaining weight loss, and by barriers limiting access to treatment. New anti-obesity medications, when combined with behavioral obesity treatment, hold promise of addressing the first two issues.

Medical Nutrition Therapy, In-Person, or Telephone Group Lifestyle Intervention for Type 2 Diabetes? A Qualitative Study of Patient Perceptions and Treatment Preferences

PURPOSE

The purpose of the study was to explore the thoughts, feelings, motivations, and assignment preferences of community health center patients with type 2 diabetes considering participation in a 2-year lifestyle intervention trial aimed at weight loss and increased physical activity. The reasons for patients' delivery mode preferences were also explored to aid in the design of future interventions for controlled trials.

METHODS

Using structured telephone interview guides, 57 patients with type 2 diabetes receiving primary care at 3 community health centers affiliated with an academic medical center were interviewed regarding the perceived pros and cons of each of the 3 possible treatment assignments: telephone conference group, in-person group, or individual medical nutrition therapy. The interview data were organized using NVIVO and analyzed using content analysis. Findings on whether preferences varied by age, gender, or diabetes duration were also examined.

RESULTS

Six categories related to patient treatment preferences were identified: (1) perception of time, (2) learning style, (3) comfort, (4) prior experience with weight loss programs and conference calls, (5) desire for support/idea exchange, and (6) accountability. Preferences did not seem to vary by age, gender, or diabetes duration.

CONCLUSIONS

Key factors influencing preference of treatment assignment included schedule demands, belief about learning style, and past experiences. These findings demonstrate the importance of having a variety of nutrition and lifestyle treatment options available to meet the needs of people with type 2 diabetes.

Lifestyle Coaching May Be an Effective Treatment for Schizophrenia

This commentary critiques the Danish CHANGE trial, which evaluated 3 levels of outpatient intervention intensity, in a group of outpatients with obesity and schizophrenia. Neither adding care coordination with weekly nurse contacts alone nor combining this treatment with assertive community lifestyle coaching as compared to treatment as usual improved outcomes, which included cardiovascular disease risk calculation, cardiorespiratory fitness, weight, and self-reported behaviors such as smoking, physical activity, and diet. The CHANGE trial investigators appear strongly averse to recommending the development and implementation of lifestyle medicine programs as a major component when treating outpatients with severe mental disorders. The potential dismissal of lifestyle medicine as a component of treatment for severe mental disorders is problematic. Valuable lessons can be learned from more thoroughly analyzing secondary outcomes such as medical and psychiatric hospitalization rates and total health care cost. The CHANGE trial data analysis needs to be expanded beyond the focus on changes in weight and serum cholesterol. Insulin resistance and high refined carbohydrate intake may be major factors in determining both the medical and psychiatric clinical course of schizophrenia. Assertive community lifestyle coaching is a novel treatment modality. Evidence strongly suggests assertive community lifestyle coaching substantially decreases both psychiatric and medical hospitalization rates.

Long-term Impact of a 10-Year Intensive Lifestyle Intervention on a Deficit Accumulation Frailty Index: Action for Health in Diabetes Trial

BACKGROUND

Multidomain lifestyle interventions may slow aging as captured by deficit accumulation frailty indices; however, it is unknown whether benefits extend beyond intervention delivery.

METHODS

We developed a deficit accumulation frailty index (FI-E) to span the 10 years that the Action for Health in Diabetes (Look AHEAD) randomized controlled clinical trial delivered interventions (a multidomain lifestyle intervention focused on caloric restriction, increased physical activity, and diet compared to a control condition) and to extend across an additional 8 years post-delivery. The study cohort included 5 145 individuals, aged 45-76 years at enrollment, who had type 2 diabetes and either obesity or overweight.

RESULTS

Overall, FI-E scores were relatively lower among lifestyle participants throughout follow-up, averaging 0.0130 [95% confidence interval: 0.0104, 0.0156] (p < .001) less across the 18 years. During Years 1-8, the mean relative difference between control and lifestyle participants' FI-E scores was 0.0139 [0.0115, 0.0163], approximately 10% of the baseline level. During Years 9-18, this average difference was 0.0107 [0.0066, 0.0148]. Benefits were comparable for individuals grouped by baseline age and body mass index and sex but were not evident for those entering the trial with a history of cardiovascular disease.

CONCLUSIONS

Multidomain lifestyle intervention may slow biological aging long term, as captured by an FI-E. Clinical Trials Registration Number: NCT00017953.

The (cost) effectiveness of a very low-energy diet intervention with the use of eHealth in patients with type 2 diabetes and obesity: study protocol for a randomised controlled non-inferiority trial (E-diet trial)

BACKGROUND

Despite preventive measures, the number of people with type 2 diabetes and obesity is increasing. Obesity increases morbidity and mortality in people with type 2 diabetes, making weight loss a cornerstone of treatment. We previously developed a very low energy diet (VLED) intervention that effectively reduced weight in people with type 2 diabetes in the long term. However, this intervention requires considerable time and manpower, which reduces the number of people who can benefit from it. eHealth offers more efficient solutions but has proven to be less effective than face-to-face interventions. Therefore, we want to investigate whether a blended version of our VLED intervention (in which face-to-face contact is partly replaced by an eHealth (mobile) application (E-VLED)) would be more cost-effective than the current face-to-face intervention.

METHODS

We will conduct a randomised, controlled trial with non-inferiority design in patients with type 2 diabetes and obesity (BMI > 30 kg/m2), aged 18-75 years. The control group will receive the usual care VLED intervention, while the intervention group will receive the E-VLED intervention for 1 year, where face-to-face contact will be partly replaced by an eHealth (mobile) application. The main study endpoint is the difference in weight (% change) between the control and intervention group after 1 year, plus the difference between the total costs (euro) of the treatment in the control and intervention groups. The secondary aims are to investigate the effectiveness of the E-VLED diet intervention regarding cardiovascular risk factors, quality of life, patient satisfaction, compliance, and to study whether there is a difference in effectiveness in pre-specified subgroups. General linear models for repeated measurements will be applied for the statistical analysis of the data.

DISCUSSION

We hypothesise that the E-VLED intervention will be equally effective compared to the usual care VLED but lower in costs due to less time invested by the dietician. This will enable to help more people with type 2 diabetes and obesity to effectively lose weight and improve their health-related quality of life.

TRIAL REGISTRATION

Netherlands Trial Register, NL7832, registered on 26 June 2019.

Rationale, design, and cohort characteristics of the Action for Health in Diabetes Aging study

INTRODUCTION

Diabetes and overweight/obesity are described as accelerating aging processes, yet many individuals with these conditions maintain high levels of cognitive and physical function and independence late into life. The Look AHEAD Aging study is designed to identify 20-year trajectories of behaviors, risk factors, and medical history associated with resilience against geriatric syndromes and aging-related cognitive and physical functional deficits among individuals with these conditions.

METHODS

Look AHEAD Aging extends follow-up of the cohort of the former 10-year Look AHEAD trial. The original cohort (N = 5145) was enrolled in 2001 to 2004 when participants were aged 45 to 76 years and randomly assigned to a multidomain intensive lifestyle intervention (ILI) or a diabetes support and education (DSE) condition. The trial interventions ceased in 2012. Clinic-based follow-up continued through 2020. In 2021, the cohort was invited to enroll in Look AHEAD Aging, an additional 4-year telephone-based follow-up (every 6 months) enhanced with Medicare linkage. Standardized protocols assess multimorbidity, physical and cognitive function, health care utilization, and health-related quality of life.

RESULTS

Of the original N = 5145 Look AHEAD participants, N = 1552 active survivors agreed to participate in Look AHEAD Aging. At consent, the cohort's mean age was 76 (range 63 to 94) years and participants had been followed for a mean of 20 years. Of the original Look AHEAD enrollees, those who were younger, female, or with no history of cardiovascular disease were more likely to be represented in the Look AHEAD Aging cohort. Intervention groups were comparable with respect to age, diabetes duration, body mass index, insulin use, hypertension, cardiovascular disease, and cognitive function. ILI participants had significantly lower deficit accumulation index scores.

DISCUSSION

By continuing the long-term follow-up of an extensively characterized cohort of older individuals with type 2 diabetes, Look AHEAD Aging is well positioned to identify factors associated with resilience against aging-related conditions.

The Inauguration of the First High School Lifestyle Medicine Club

Montverde Academy is home to our country's first Lifestyle Medicine Club, a novel approach to Lifestyle Medicine outreach amongst teenagers. A high-school student-driven initiative, the club successfully completed its first year in existence by focusing on growing its membership and teaching high school students about the 6 pillars of Lifestyle Medicine. This article describes the inception of the club, its first events, and its future directions.

Effect of a controlled lifestyle intervention on medication use and costs: The Healthy Lifestyle Community Program (cohort 2)

TRIAL REGISTRATION

German Clinical Trials Register DRKS (www.drks.de; reference: DRKS00018775).

Effect of Yearly Exercise on Medication Expense and Benefit-Cost Ratio in Individuals with Metabolic Syndrome: A Randomized Clinical Trial

INTRODUCTION

Lifestyle modification through incorporation of exercise training could improve metabolic syndrome (MetS) clinical components (hypertension, dyslipidemia, hyperglycemia, and visceral abdominal obesity). We aimed to assess if long-term exercise training could restrain the increased pharmacological cost of the clinical management of the MetS.

METHODS

Medicine cost during a 5-yr-long randomized controlled exercise intervention trial was analyzed. After a per-protocol analysis, a group of 64 individuals 53 ± 2 yr old, with overweight (body mass index, 33.4 ± 0.9 kg·m -2 ) and MetS (3.6 ± 0.2 factors) were randomized to a training (4 months·yr -1 for 5 yr; EXERCISE, n = 25) or to a control group (CONTROL, n = 26). Subjects were studied on three occasions during the 5-yr follow-up. Participants continued their routine medication managed by their general practitioner. The main outcome is the 5-yr evolution of medication cost to treat MetS (hyperglycemia, hypertension, and hyperlipidemia). A secondary outcome is the benefit-cost ratio of the exercise intervention.

RESULTS

In CONTROL, medicine cost increased 160% from baseline ( P < 0.001), whereas in EXERCISE, it remained unchanged (33%; P = 0.25). After the 5-yr follow-up, medicine use was 60% and medicine cost 74% higher in CONTROL than EXERCISE ( P < 0.05 in both cases). However, MetS z score was similarly reduced over time in both groups ( P = 0.244 for group-time interaction). The number of prescribed medications increased after 5 yr in CONTROL (89%; P < 0.001), whereas it remained stable with yearly training (17%; P = 0.72 in EXERCISE). Ten-year atherosclerotic cardiovascular disease risk estimation increased only in CONTROL (15%; P = 0.05 for group-time interaction). The benefit in medicine savings (€153 per year and patient) triplicated the estimated cost (€50.8 per year and patient) of the exercise intervention.

CONCLUSIONS

A 5-yr-long supervised exercise training program in middle-age individuals with MetS prevents the need for increasing medicine use. The savings in pharmacological therapy outweighs the estimated costs of implementing the exercise program.

Individual patient-centered target-driven intervention to improve clinical outcomes of diabetes, health literacy, and self-care practices in Nepal: A randomized controlled trial

PURPOSE

To examine the effectiveness of a culturally and linguistically appropriate, patient-centered, target-driven lifestyle intervention with video education training in improving clinical outcomes, health literacy, and diabetic self-care practices in newly diagnosed patients in Nepal.

METHODS

A total of 110 participants with newly and consequently diagnosed Type 2 were randomly allocated into intervention (mean age = 45 ± 9.7 years) and control (mean age = 47 ± 12.5 years) groups. Intervention group participants were trained on a culturally and linguistically appropriate diabetic video education program and were given a customized dietary and physical activity plan with specific targets to practice at home. Participants' compliance was monitored weekly via telephone calls. Both groups received the usual treatment from their doctor and were followed up after three months. Outcome measures included changes in: i. diabetic health literacy, diet, and physical activity measured using self-reported questionnaires; and ii. blood glucose (glycated hemoglobin, HbA1c), cholesterol, blood pressure, body mass index, and visual acuity. Clinical outcome measures were blinded from randomization and intervention allocation.

RESULTS

After three months, HbA1c decreased to 6.1% from the baseline value of 7.2% in the intervention group compared to 6.6% in the control group from the baseline value of 7.1% (p <0.05). The intervention group had mean total cholesterol and low-density lipoprotein of 174 and 95.5 mg/dL, which were significantly lower than 186 and 107.5 mg/dL in the control group. Daily white rice consumption decreased by 36.5% in the intervention vs. 4% in the control group (p <0.05). After three months, the intervention group participants exercised more than the control group (p <0.05). All intervention group participants self-initiated retinal screening checks since the baseline visit among which 13% showed early diabetic retinopathy signs compared to 0% in the control group. Health literacy improvement in the intervention group was found to be sustained after three months too.

CONCLUSIONS

A culturally appropriate, target-driven lifestyle intervention with video education training is effective in improving clinical outcomes, health literacy, and self-care practice in newly diagnosed diabetic patients in Nepal, i.e., at a time period when effective diabetes control is vital to prevent further complications. The training intervention could be rolled out nationwide in order to reduce the risk of diabetic-related complications and improve people's quality of life and productivity.

Assessment of the Knowledge and Self- Care Practice on Hypoglycemia among Patients with Diabetic Mellitus Attending Medical Opd at Smch

Introduction: Hypoglycemia is a clinical emergency that needs to be recognized and treated promptly to avoid organ damage and death. Knowledge of hypoglycemia prevention is an essential step in self-care practices due to the fact knowledgeable individuals are much more likely to practice hypoglycemia prevention. Prevention of hypoglycemia relies on adequate awareness and rightself-care. Objectives: To evaluate the level of knowledge and to self - care practice of hypoglycemia with their selected demographic variables among diabetic patients. Methods: A cross sectional descriptive research design was adopted with hundred samples who met the inclusion criteria in the hospital setting. Self-structured questionnaire method was used to acquire the data. Data have been through descriptive and inferential statistics. Result: Of 100 samples, 76(76%) had adequate knowledge and 63(63%)had good self-care practice on hypoglycemia. Spearman’s correlation showed positive relationship between knowledge and self-care practice of hypoglycemia (r value = 0.720, p<0.001). In respect to level of knowledge, there was a significant association noted among age, education, occupation, income, religion, marital status, family history and with regards to self-care practice along with all variables including gender is significant at p<0.05. Conclusion: This study result emphasized that majority of the diabetic patients had adequate knowledge and good self-care practice on hypoglycemia. Enlightening the patients further with regular self-monitoring of blood glucose level and obtain medical guidance and support may help the patients to stay fit.

Examining the evidence for weight management in individuals with type 2 diabetes

The obesity epidemic has been linked to the worsening diabetes epidemic. Despite this, weight reduction for individuals with obesity is seen as a secondary, or even tertiary, consideration in the treatment of type 2 diabetes (T2D). The aim of this review is to examine the benefits of weight management in individuals with T2D. A literature review of current available published data on the benefits of weight reduction in individuals with T2D was conducted. In individuals with T2D who have obesity or overweight, modest and sustained weight reduction results in improvement in glycaemic control and decreased utilization of glucose-lowering medication. A total body weight loss of 5% or higher reduces HbA1c levels and contributes to mitigating risk factors of cardiovascular disease, such as hyperlipidaemia and hypertension, as well as other disease-related complications of obesity. Progressive improvements in glycaemic control and cardiometabolic risk factors can occur when the total body weight loss increases to 10% or more. In the approach to treating patients with T2D and obesity, prioritizing weight management and the use of therapeutics that offer glycaemic control as well as the additional weight loss should be emphasized given their potential to attenuate the progression and severity of T2D.

Effectiveness of a personal health coaching intervention (diabetescoach) in patients with type 2 diabetes: protocol for an open-label, pragmatic randomised controlled trial

INTRODUCTION

The widespread prevalence of type 2 diabetes (T2D) not only influences patients' daily lives but also has an economic impact on society. Increasing physical activity and a healthy diet can delay the progression of T2D. Although there are evidence-based recommendations on diet and physical activity, patients with T2D have difficulties implementing them. An appropriate lifestyle intervention can address this problem.

METHODS AND ANALYSIS

This study is based on the need to develop an intervention that helps patients to establish behavioural changes in order to achieve glycaemic control. The intervention will be evaluated in a monocentric, open-label, pragmatic, two-arm randomised controlled trial with a sample ratio of 1:1 and a parallel design. This superiority study will be conducted in Switzerland. All enrolled patients (n=90) will receive the standard medical treatment for T2D. The intervention group will receive personal health coaching by telephone and access to a smartphone and web application for 1 year. The control group will receive access to the application for 1 year and a one-time written diet and exercise recommendation. The primary outcomes are objectively measured physical activity and glycated haemoglobin. Secondary outcomes are self-reported physical activity, nutrition, cognitive mediators of changes in sport-related behaviour, blood values, medication and nutritional supplements, anthropometric data, quality of life, neuropathy and cost-effectiveness. All outcomes will be measured at baseline, at 27 weeks after inclusion and at 54 weeks after inclusion. The recruitment of participants and the measurements will be completed after 2 years. Linear mixed-effects models will be applied for each outcome variable to analyse the intervention effects.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee North-western and Central Switzerland in February 2021 (ref: 2020-02755). All participants will be required to provide written informed consent. The results will be published in international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN79457541.

Dietary intake and physical activity in Japanese patients with type 2 diabetes: the Japan Diabetes Complication and its Prevention prospective study (JDCP study 8)

Medical nutrition therapy and exercise therapy are the cornerstones of treatment for patients with type 2 diabetes; however, there has not been a nationwide study on the actual dietary intake and physical activity status of patients since the 2000s. We aimed to clarify this in Japanese patients with type 2 diabetes using data from the Japan Diabetes Complication and its Prevention prospective (JDCP), a nationwide study launched in 2007. A total of 1992 patients with type 2 diabetes, aged 40-75 years, completed either the Brief-type, self-administered Diet History Questionnaire (1643 patients) or International Physical Activity Questionnaire (1834 patients), and their data were analyzed in this study. Mean daily energy intake for all participants was 1686.8 kcal/day, and the mean proportions of carbohydrate, protein, and fat comprising total energy intake were 60.2, 16.2, and 23.6%, respectively. The patients in this study had similar energy and nutrient intake status to patients in the 1996 Japan Diabetes Complications Study; however, Japanese patients still had higher carbohydrate and lower fat consumption than patients with diabetes in Western countries. The physical activity questionnaire reported that 31.0% of patients did not have exercise habits; this was particularly noticeable in female patients and patients under the age of 65. BMI increased from 22.7 to 24.1 kg/m² in men and 23.2 to 24.8 kg/m² in women from 1996 to 2007, respectively. Further research is required to investigate how dietary intake and physical activity associates with the risk of developing complications in type 2 diabetes patients.

Centering the Strengths of American Indian Culture, Families and Communities to Overcome Type 2 Diabetes

Type 2 diabetes (T2D) is a critical Indigenous health inequity rooted in experiences of colonization and marginalization including disproportionate exposure to stressors, disruption of traditional family and food systems, and attacks on cultural practices that have led to more sedentary lifestyles. Thus, an important step in redressing inequities is building awareness of and interventions attuned to unique Indigenous contexts influencing T2D and Indigenous culture as a pathway to community wellbeing. Using a dynamic, stage-based model of intervention development and evaluation, we detail the creation and evolution of a family-based, culturally centered T2D preventive intervention: Together on Diabetes (later Together Overcoming Diabetes) (TOD). The TOD program was built by and for Indigenous communities via community-based participatory research and has been implemented across diverse cultural contexts. The TOD curriculum approaches health through a holistic lens of spiritual, mental, physical and emotional wellness. Preliminary evidence suggests TOD is effective in reducing diabetes risk factors including lowering BMI and depressive symptoms, and the program is viewed favorably by participants and community members. We discuss lessons learned regarding collaborative intervention development and adaptation across Indigenous cultures, as well as future directions for TOD.

Exercise/Physical Activity in Individuals with Type 2 Diabetes: A Consensus Statement from the American College of Sports Medicine

ABSTRACT

This consensus statement is an update of the 2010 American College of Sports Medicine position stand on exercise and type 2 diabetes. Since then, a substantial amount of research on select topics in exercise in individuals of various ages with type 2 diabetes has been published while diabetes prevalence has continued to expand worldwide. This consensus statement provides a brief summary of the current evidence and extends and updates the prior recommendations. The document has been expanded to include physical activity, a broader, more comprehensive definition of human movement than planned exercise, and reducing sedentary time. Various types of physical activity enhance health and glycemic management in people with type 2 diabetes, including flexibility and balance exercise, and the importance of each recommended type or mode are discussed. In general, the 2018 Physical Activity Guidelines for Americans apply to all individuals with type 2 diabetes, with a few exceptions and modifications. People with type 2 diabetes should engage in physical activity regularly and be encouraged to reduce sedentary time and break up sitting time with frequent activity breaks. Any activities undertaken with acute and chronic health complications related to diabetes may require accommodations to ensure safe and effective participation. Other topics addressed are exercise timing to maximize its glucose-lowering effects and barriers to and inequities in physical activity adoption and maintenance.

A Behavioral Lifestyle Intervention to Improve Frailty in Overweight or Obese Older Adults with Type 2 Diabetes: A Feasibility Study

BACKGROUND

Older adults with Type 2 diabetes (T2D) are more likely to be frail, which increases the risk for disability and mortality.

OBJECTIVES

To determine the feasibility of a behavioral lifestyle intervention, enhanced with mobile health technology for self-monitoring of diet and activity, to improve frailty in overweight/obese older adults (≥65 years) diagnosed with T2D.

DESIGN, SETTING, AND PARTICIPANTS

Single arm, 6-month study of a behavioral lifestyle intervention in 20 overweight/obese (BMI>25) older adults (≥ 65 years) with self-reported T2D diagnosis who owned a smartphone. A Fitbit tracker was provided to all participants for self-monitoring of diet and physical activity. Our primary outcome of feasibility was measured by session attendance, adherence to Fitbit usage to self-monitor diet and physical activity, and study retention. Secondary outcomes included the preliminary efficacy of the intervention on frailty, physical function, quality of life, and T2D-related outcomes.

RESULTS

Eighteen participants completed the study. The mean age was 71.5 (SD ± 5.3) years, 56% were female, and half were Hispanic. At baseline, 13 (72%) were pre-frail, 4 (22%) were frail, and 1 (6%) were non-frail. At follow-up, frailty scores improved significantly from 1.61 ± 1.15 to 0.94 ± 0.94 (p=0.01) and bodyweight improved from 205.66 ± 45.52 lbs. to 198.33 ± 43.6 lbs. (p=<0.001).

CONCLUSION

This study provides evidence for the feasibility of a behavioral lifestyle intervention in overweight/obese older adults with T2D and preliminary results support its potential efficacy in improving frailty score.

A systematic review of adherence to physical activity interventions in individuals with type 2 diabetes

Lifestyle interventions are pivotal for successful management of type 2 diabetes (T2D), however, the proportion of people with T2D adhering to physical activity advice has not been thoroughly studied. The purpose of this systematic review was to summarise the evidence on adherence to exercise or physical activity components in lifestyle interventions in those with T2D. We searched MEDLINE EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and Scopus on 12 November 2019. Eligible studies enrolled adults with T2D and reported the proportion of adherence to lifestyle interventions as a primary or secondary outcome. We included 11 studies (nine randomised controlled trials (RCTs) enrolling 1717 patients and two nonrandomised studies enrolling 62 patients). Only one of the studies had low risk of bias. The proportion of participants adhering to physical activity varied from 32% to 100% with a median of 58%. Adherence was higher in interventions using supervised training and lowest in interventions using remote coaching and the adherence rate in observational studies was higher compared to RCTs (92% vs. 55%; p < 0.01). Study duration, risk of bias, or participants' sex, were not associated with adherence to physical activity. The proportion of those with T2D adhering to physical activity interventions for T2D varies widely and most of the included studies had a high risk of bias. These findings have important implications for planning and power analysis of future trials and when counselling patients about lifestyle interventions including physical activity or exercise components.

Cost-effectiveness of bariatric surgery and non-surgical weight management programmes for adults with severe obesity: a decision analysis model

OBJECTIVES

To determine the most cost-effective weight management programmes (WMPs) for adults, in England with severe obesity (BMI ≥ 35 kg/m2), who are more at risk of obesity related diseases.

METHODS

An economic evaluation of five different WMPs: 1) low intensity (WMP1); 2) very low calorie diets (VLCD) added to WMP1; 3) moderate intensity (WMP2); 4) high intensity (Look AHEAD); and 5) Roux-en-Y gastric bypass (RYGB) surgery, all compared to a baseline scenario representing no WMP. We also compare a VLCD added to WMP1 vs. WMP1 alone. A microsimulation decision analysis model was used to extrapolate the impact of changes in BMI, obtained from a systematic review and meta-analysis of randomised controlled trials (RCTs) of WMPs and bariatric surgery, on long-term risks of obesity related disease, costs, quality adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) measured as incremental cost per QALY gained over a 30-year time horizon from a UK National Health Service (NHS) perspective. Sensitivity analyses explored the impact of long-term weight regain assumptions on results.

RESULTS

RYGB was the most costly intervention but also generated the lowest incidence of obesity related disease and hence the highest QALY gains. Base case ICERs for WMP1, a VLCD added to WMP1, WMP2, Look AHEAD, and RYGB compared to no WMP were £557, £6628, £1540, £23,725 and £10,126 per QALY gained respectively. Adding a VLCD to WMP1 generated an ICER of over £121,000 per QALY compared to WMP1 alone. Sensitivity analysis found that all ICERs were sensitive to the modelled base case, five year post intervention cessation, weight regain assumption.

CONCLUSIONS

RYGB surgery was the most effective and cost-effective use of scarce NHS funding resources. However, where fixed healthcare budgets or patient preferences exclude surgery as an option, a standard 12 week behavioural WMP (WMP1) was the next most cost-effective intervention.

Association of Cycling With All-Cause and Cardiovascular Disease Mortality Among Persons With Diabetes: The European Prospective Investigation Into Cancer and Nutrition (EPIC) Study

Importance

Premature death from all causes and cardiovascular disease (CVD) causes is higher among persons with diabetes.

Objective

To investigate the association between time spent cycling and all-cause and CVD mortality among persons with diabetes, as well as to evaluate the association between change in time spent cycling and risk of all-cause and CVD mortality.

Design, Setting, and Participants

This prospective cohort study included 7459 adults with diabetes from the European Prospective Investigation into Cancer and Nutrition study. Questionnaires regarding medical history, sociodemographic, and lifestyle information were administered in 10 Western European countries from 1992 through 2000 (baseline examination) and at a second examination 5 years after baseline. A total of 5423 participants with diabetes completed both examinations. The final updated primary analysis was conducted on November 13, 2020.

Exposures

The primary exposure was self-reported time spent cycling per week at the baseline examination. The secondary exposure was change in cycling status from baseline to the second examination.

Main Outcomes and Measures

The primary and secondary outcomes were all-cause and CVD mortality, respectively, adjusted for other physical activity modalities, diabetes duration, and sociodemographic and lifestyle factors.

Results

Of the 7459 adults with diabetes included in the analysis, the mean (SD) age was 55.9 (7.7) years, and 3924 (52.6%) were female. During 110 944 person-years of follow-up, 1673 deaths from all causes were registered. Compared with the reference group of people who reported no cycling at baseline (0 min/wk), the multivariable-adjusted hazard ratios for all-cause mortality were 0.78 (95% CI, 0.61-0.99), 0.76 (95% CI, 0.65-0.88), 0.68 (95% CI, 0.57-0.82), and 0.76 (95% CI, 0.63-0.91) for cycling 1 to 59, 60 to 149, 150 to 299, and 300 or more min/wk, respectively. In an analysis of change in time spent cycling with 57 802 person-years of follow-up, a total of 975 deaths from all causes were recorded. Compared with people who reported no cycling at both examinations, the multivariable-adjusted hazard ratios for all-cause mortality were 0.90 (95% CI, 0.71-1.14) in those who cycled and then stopped, 0.65 (95% CI, 0.46-0.92) in initial noncyclists who started cycling, and 0.65 (95% CI, 0.53-0.80) for people who reported cycling at both examinations. Similar results were observed for CVD mortality.

Conclusion and Relevance

In this cohort study, cycling was associated with lower all-cause and CVD mortality risk among people with diabetes independent of practicing other types of physical activity. Participants who took up cycling between the baseline and second examination had a considerably lower risk of both all-cause and CVD mortality compared with consistent noncyclists.

Does Lifestyle Intervention Improve Health of Adults with Overweight/Obesity and Type 2 Diabetes? Findings from the Look AHEAD Randomized Trial

This paper reviews the main findings from the Action for Health in Diabetes (Look AHEAD) Trial, a randomized trial testing the long-term health effects of intensive lifestyle interventions (ILIs) in 5,145 persons with overweight/obesity and type 2 diabetes. Although the primary outcome originally focused on cardiovascular morbidity and mortality, secondary outcomes included a broad range of health parameters related to diabetes and obesity. As the cohort aged, study outcomes were expanded to include health problems affecting geriatric populations, such as cognitive impairment and disability.This review summarizes the history of this trial and presents findings related to a wide range of health outcomes. Studies are reviewed that showed positive impact of ILI on diabetes control and complications, depression, physical health-related quality of life, sleep apnea, incontinence, brain structure, and health care use and costs. Several composite indices were also positively impacted by ILI, including multimorbidity, geriatric syndromes, and disability-free life years. However, there are also some important outcomes that did not show significant differences between the intervention and control, including cardiovascular morbidity and mortality, cancer, cognitive function, and cognitive impairment; for several of these nonsignificant effects, post hoc analyses suggested that there may be differences among subgroups, raising the possibility that ILI may be beneficial to some but potentially harmful to others. The only adverse effects of ILI relative to diabetes support and education were on frailty fractures and the related negative effects on body composition and bone density. Through this review, the manuscript seeks to determine whether weight loss should be encouraged in this population; given the large number of beneficial effects, relative to the small number of adverse effects, the answer appears to be yes.

Does the Impact of Intensive Lifestyle Intervention on Cardiovascular Disease Risk Vary According to Frailty as Measured via Deficit Accumulation?

BACKGROUND

Individuals are often counseled to use behavioral weight loss strategies to reduce risk for cardiovascular disease (CVD). We examined whether any benefits for CVD risk from weight loss intervention extend uniformly to individuals across a range of underlying health states.

METHODS

The time until first occurrence of a composite of fatal and nonfatal myocardial infarction and stroke, hospitalized angina, or CVD death was analyzed from 8 to 11 years of follow-up of 4,859 adults who were overweight or obese, aged 45-76 years with Type 2 diabetes. Individuals had been randomly assigned to either an intensive lifestyle intervention (ILI) or diabetes support and education (DSE). Participants were grouped by intervention assignment and a frailty index (FI) based on deficit accumulation, ordered from fewer (first tertile) to more (third tertile) deficits.

RESULTS

Baseline FI scores were unrelated to intervention-induced weight losses and increased physical activity. The relative effectiveness of ILI on CVD incidence was inversely related to baseline FI in a graded fashion (p = .01), with relative benefit (hazard ratio = 0.73 [95% CI 0.55,0.98]) for individuals in the first FI tertile to no benefit (hazard ratio = 1.15 [0.94,1.42]) among those in the third FI tertile. This graded relationship was not seen for individuals ordered by age tertile (p = .52), and was stronger among participants aged 45-59 years (three-way interaction p = .04).

CONCLUSIONS

In overweight/obese adults with diabetes, multidomain lifestyle interventions may be most effective in reducing CVD if administered before individuals have accrued many age-related health deficits. However, these exploratory analyses require confirmation by other studies.

CLINICAL TRIAL REGISTRATION

NCT00017953.

Exercise Reduces Medication for Metabolic Syndrome Management: A 5-Year Follow-up Study

PURPOSE

This study aimed to determine the effects of a 5-yr exercise intervention on metabolic syndrome (MetS) and health-related variables and medication use for MetS management.

METHODS

Participants were randomly assigned to an exercise intervention (n = 25, 54 ± 2 yr, 20% women) or control group (n = 26, 54 ± 2 yr, 38% women). The intervention lasted 4 months per year and consisted of high-intensity interval training on a cycloergometer thrice a week. Outcomes were MetS z-score and medication use score, MetS-related variables (including blood pressure, blood glucose homeostasis, and lipid profile), and cardiorespiratory fitness (CRF, as determined by maximal oxygen uptake).

RESULTS

MetS z-score was similarly reduced over time in both groups (P = 0.244 for group-time interaction). A quasi-significant and significant group-time interaction was found for MetS number of factors (P = 0.004) and CRF (P < 0.001), respectively. Thus, MetS factors tended to decrease over time only in the exercise group with no change in the control group, whereas CRF increased from baseline to 5-yr assessment in the exercise group (by 1.1 MET, P < 0.001) but decreased in the control group (-0.5 MET, P = 0.025). Medicine use score increased twofold from baseline to 5-yr follow-up in the control group (P < 0.001) but did not significantly change (10%, P = 0.52) in the exercise group (P < 0.001 for group-time interaction). The proportion of medicated patients who had to increase antihypertensive (P < 0.001), glucose-lowering (P = 0.036), or total medication (P < 0.0001) over the 5-yr period was lower in the exercise than that in the control group.

CONCLUSIONS

Exercise training can attenuate the increase in medication that would be otherwise required to manage MetS over a 5-yr period.

Patient Outcomes Associated With Utilization of Education, Case Management, and Advanced Practice Pharmacy Services by American Indian and Alaska Native Peoples With Diabetes

BACKGROUND

The burden of diabetes is exceptionally high among American Indian and Alaska Native (AI/AN) peoples. The Indian Health Service (IHS) and Tribal health programs provide education, case management, and advanced practice pharmacy (ECP) services for AI/ANs with diabetes to improve their health outcomes.

OBJECTIVE

The objective of this study was to evaluate patient outcomes associated with ECP use by AI/AN adults with diabetes.

RESEARCH DESIGN

This observational study included the analysis of IHS data for fiscal years (FY) 2011-2013. Using propensity score models, we assessed FY2013 patient outcomes associated with FY2012 ECP use, controlling for FY2011 baseline characteristics.

SUBJECTS

AI/AN adults with diabetes who used IHS and Tribal health services (n=28,578).

MEASURES

We compared health status and hospital utilization outcomes for ECP users and nonusers.

RESULTS

Among adults with diabetes, ECP users, compared with nonusers, had lower odds of high systolic blood pressure [odds ratio (OR)=0.85, P<0.001] and high low-density lipoprotein cholesterol (OR=0.89, P<0.01). Among adults with diabetes absent cardiovascular disease (CVD) at baseline, 3 or more ECP visits, compared with no visits, was associated with lower odds of CVD onset (OR=0.79, P<0.05). Among adults with diabetes and CVD, any ECP use was associated with lower odds of end-stage renal disease onset (OR=0.60, P<0.05). ECP users had lower odds of 1 or more hospitalizations (OR=0.80, P<0.001).

CONCLUSIONS

Findings on positive patient outcomes associated with ECP use by adults with diabetes may inform IHS and Tribal policies, funding, and enhancements to ECP services to reduce disparities between AI/ANs and other populations in diabetes-related morbidity and mortality.

The daily Self-Weighing for Obesity Management in Primary Care Study: Rationale, design and methodology

Background Daily self-weighing (DSW) may be an effective harm-reduction intervention to disrupt continued weight gain. Self-Weighing for Obesity Management in Primary Care (SWOP) is a 24-month randomized controlled trial in 400 adults with obesity (BMI: kg/m² ≥ 30) receiving primary care through a clinical network affiliated with an academic medical center. Objective To test DSW as a potentially scalable way to deter age-related weight gain among primary care patients with obesity. Methods Randomized-controlled trial with two conditions: DSW (instruction to weigh daily and provision of a web-enabled digital scale with graphical weight feedback) or Standard Care (receive a monetary gift card equivalent to value of the scale). Both groups receive standardized weight management educational material. SWOP will test the causal effect of assignment to DSW (Aim 1) and adherence to DSW (Aim 2) on weight (primary outcome) and adoption of weight management practices (secondary outcomes), as well as evaluate the cost-effectiveness of DSW compared to standard care (Aim 3). Findings may inform clinical guidelines for weight management by providing evidence that DSW attenuates continued age-related weight gain among adults with obesity. This trial is registered with ClinicalTrials.gov (NCT04044794).

Does the impact of intensive lifestyle intervention on cognitive function vary depending baseline level of frailty? An ancillary study to the Action for Health in Diabetes (Look AHEAD) Trial

AIMS

To assess whether there is an opportune window when intensive lifestyle intervention (ILI) benefits cognitive function.

METHODS

Standardized cognitive assessments were collected following ≥8 years of either ILI or a control condition of diabetes support and education (DSE) in 3708 individuals, ages 45-76 years at enrollment, with type 2 diabetes and overweight or obesity. Frailty index (FI) scores were used to group individuals at baseline into tertiles according to their age-related health status. Linear models were used to describe intervention adherence and cognitive function, with interaction terms to examine the consistency of relationships among tertiles.

RESULTS

Worse baseline FI scores were associated with poorer subsequent performance in tests of attention, processing speed, and executive function. No differences in any measure of cognitive function were observed between intervention groups within any FI tertile (all p > 0.10). Among individuals with worse baseline FI scores, weight gain was associated with poorer global cognitive function among participants assigned to DSE. There was no association between weight changes and cognitive function among participants assigned to ILI.

CONCLUSIONS

Among adults with type 2 diabetes and overweight/obesity, we found no evidence that there is a window of opportunity based on FI when ILI benefits cognitive function.

Return on Investment: Medical Savings of an Employer-Sponsored Digital Intensive Lifestyle Intervention, Weight Loss

OBJECTIVE

This study aimed to determine the medical cost impact and return on investment (ROI) of a large, commercial, digital, weight-management intensive lifestyle intervention (ILI) program (Real Appeal).

METHODS

Participants in this program were compared with a control group matched by age, sex, geographic region, health risk, baseline medical costs, and chronic conditions. Medical costs were defined as the total amount paid for all medical expenses, inclusive of both the insurers' and the study participants' responsibility.

RESULTS

In the 3 years following program registration, the intent-to-treat (ITT) cohort had significantly lower medical expenditures than the matched controls, with an average of -$771 or 12% lower costs (P = 0.002). Among 4,790 ITT participants, a total savings of $3,693,090 compared with total program costs of $1,639,961 translated into a 2.3:1 ROI. Program completers (n = 3,990), who attended more sessions than the overall ITT group, had greater mean weight loss (-4.4%), greater cost savings (-$956 or 14%), and an ROI of 2.0:1 over the 3-year time frame compared with matched controls.

CONCLUSIONS

The findings demonstrated that the digital weight-management ILI was associated with a significantly positive ROI. Employers and payers willing to cover the cost of an ILI that produces both weight loss and demonstrated cost benefits can improve health and save money for their population with overweight or obesity.

Impact of Multidomain Lifestyle Intervention on Frailty Through the Lens of Deficit Accumulation in Adults with Type 2 Diabetes Mellitus

BACKGROUND

Type 2 diabetes and obesity increase the accumulation of health deficits and may accelerate biological aging. Multidomain lifestyle interventions may mitigate against this.

METHODS

Within a large, randomized clinical trial of intensive lifestyle intervention including caloric restriction, increased physical activity, dietary counseling, and risk factor monitoring compared with diabetes support and education, we examined the accumulation of health deficits across 8 years. We used two complementary frailty indices (FIs) based on deficit accumulation, one modeled on work in the Systolic Blood Pressure Intervention Trial and the other including additional deficits related to obesity and type 2 diabetes mellitus. Differences between intervention groups and their consistency among subgroups were assessed with re-randomization tests.

RESULTS

Data from 4,859 adults (45-76 years at baseline, 59% female) were analyzed. Random assignment to intensive lifestyle intervention was associated with lower FI scores throughout follow-up as captured by areas under curves traced by longitudinal means (p ≤ .001), over which time mean (SE) differences between intervention groups averaged 5.8% (0.9%) and 5.4% (0.9%) for the two indices. At year 8, the percentage of participants classified as frail (FI > 0.21) was lower among intensive lifestyle intervention (39.8% and 54.5%) compared with diabetes support and education (42.7% and 60.9%) for both FIs (both p < .001). Intervention benefits were relatively greater for participants who were older, not obese, and without history of cardiovascular disease at baseline.

CONCLUSIONS

Eight years of multidomain lifestyle intervention create a buffer against the accumulation of age-related health deficits in overweight or obese adults with type 2 diabetes.ClinicalTrials.gov Identifier: NCT00017953.

Within-Trial Cost-Effectiveness of a Structured Lifestyle Intervention in Adults With Overweight/Obesity and Type 2 Diabetes: Results From the Action for Health in Diabetes (Look AHEAD) Study

OBJECTIVE

To assess the cost-effectiveness (CE) of an intensive lifestyle intervention (ILI) compared with standard diabetes support and education (DSE) in adults with overweight/obesity and type 2 diabetes, as implemented in the Action for Health in Diabetes study.

RESEARCH DESIGN AND METHODS

Data were from 4,827 participants during their first 9 years of study participation from 2001 to 2012. Information on Health Utilities Index Mark 2 (HUI-2) and HUI-3, Short-Form 6D (SF-6D), and Feeling Thermometer (FT), cost of delivering the interventions, and health expenditures was collected during the study. CE was measured by incremental CE ratios (ICERs) in costs per quality-adjusted life year (QALY). Future costs and QALYs were discounted at 3% annually. Costs were in 2012 U.S. dollars.

RESULTS

Over the 9 years studied, the mean cumulative intervention costs and mean cumulative health care expenditures were $11,275 and $64,453 per person for ILI and $887 and $68,174 for DSE. Thus, ILI cost $6,666 more per person than DSE. Additional QALYs gained by ILI were not statistically significant measured by the HUIs and were 0.07 and 0.15, respectively, measured by SF-6D and FT. The ICERs ranged from no health benefit with a higher cost based on HUIs to $96,458/QALY and $43,169/QALY, respectively, based on SF-6D and FT.

CONCLUSIONS

Whether ILI was cost-effective over the 9-year period is unclear because different health utility measures led to different conclusions.

Associations of Intensive Lifestyle Intervention in Type 2 Diabetes With Health Care Use, Spending, and Disability: An Ancillary Study of the Look AHEAD Study

IMPORTANCE

Intensive lifestyle interventions focused on diet and exercise can reduce weight and improve diabetes management. However, the long-term effects on health care use and spending are unclear, especially for public payers.

OBJECTIVE

To estimate the association of effective intensive lifestyle intervention for weight loss with long-term health care use and Medicare spending.

DESIGN, SETTING, AND PARTICIPANTS

This ancillary study used data from the Look AHEAD randomized clinical trial, which randomized participants with type 2 diabetes to an intensive lifestyle intervention or control group (ie, diabetes support and education), provided ongoing intervention from 2001 to 2012, and demonstrated improved diabetes management and reduced health care costs during the intervention. This study compared Medicare data between study arms from 2012 to 2015 to determine whether the intervention was associated with persistent reductions in health care spending.

EXPOSURE

Starting in 2001, Look AHEAD's intervention group participated in sessions with lifestyle counselors, dieticians, exercise specialists, and behavioral therapists with the goal of reducing weight 7% in the first year. Sessions occurred weekly in the first 6 months of the intervention and decreased over the intervention period. The controls participated in periodic group education sessions that occurred 3 times per year in the first year and decreased to 1 time per year later in the trial.

MAIN OUTCOMES AND MEASURES

Outcomes included total Medicare spending, Part D prescription drug costs, Part A and Part B Medicare spending, hospital admissions, emergency department visits, and disability-related Medicare eligibility.

RESULTS

This study matched Medicare administrative records for 2796 Look AHEAD study participants (54% of 5145 participants initially randomized and 86% of 3246 participants consenting to linkages). Linked intervention and control participants were of a similar age (mean [SD] age, 59.6 [5.4] years vs 59.6 [5.5] years at randomization) and sex (818 [58.1%] women vs 822 [59.3%] women). There was no statistically significant difference in total Medicare spending between groups (difference, -$133 [95% CI, -$1946 to $1681]; P = .89). In the intervention group, compared with the control group, there was statistically significantly higher Part B spending (difference, $513 [95% CI, $70 to $955]; P = .02) but lower prescription drug costs (difference, -$803 [95% CI, -$1522 to -$83]; P = .03).

CONCLUSIONS AND RELEVANCE

This ancillary study of a randomized clinical trial found that reductions in health care use and spending associated with an intensive lifestyle intervention for type 2 diabetes diminished as participants aged. Intensive lifestyle interventions may need to be sustained to reduce long-term health care spending.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03952728.

Impact of an 8-Year Intensive Lifestyle Intervention on an Index of Multimorbidity

BACKGROUND/OBJECTIVES

Type 2 diabetes mellitus and obesity are sometimes described as conditions that accelerate aging. Multidomain lifestyle interventions have shown promise to slow the accumulation of age-related diseases, a hallmark of aging. However, they have not been assessed among at-risk individuals with these two conditions. We examined the relative impact of 8 years of a multidomain lifestyle intervention on an index of multimorbidity.

DESIGN

Randomized controlled clinical trial comparing an intensive lifestyle intervention (ILI) that targeted weight loss through caloric restriction and increased physical activity with a control condition of diabetes support and education (DSE).

SETTING

Sixteen U.S. academic centers.

PARTICIPANTS

A total of 5,145 volunteers, aged 45 to 76, with established type 2 diabetes mellitus and overweight or obesity who met eligibility criteria for a randomized controlled clinical trial.

MEASUREMENTS

A multimorbidity index that included nine age-related chronic diseases and death was tracked over 8 years of intervention delivery.

RESULTS

Among individuals assigned to DSE, the multimorbidity index scores increased by an average of .98 (95% confidence interval [CI] = .94-1.02) over 8 years, compared with .89 (95% CI = .85-.93) among those in the multidomain ILI, which was a 9% difference (P = .003). Relative intervention effects were similar among individuals grouped by baseline body mass index, age, and sex, and they were greater for those with lower levels of multimorbidity index scores at baseline.

CONCLUSIONS

Increases in multimorbidity over time among adults with overweight or obesity and type 2 diabetes mellitus may be slowed by multidomain ILI. J Am Geriatr Soc 68:2249-2256, 2020.

Exercise capacity is associated with hospital readmission among patients with diabetes

INTRODUCTION

Patients with diabetes are at greater risk of hospital readmission than patients without diabetes. There is a need to identify more modifiable risk factors for readmission as potential targets for intervention. Cardiorespiratory fitness is a predictor of morbidity and mortality. The purpose of this study was to examine whether there is an association between exercise capacity based on the maximal workload achieved during treadmill stress testing and readmission among patients with diabetes.

RESEARCH DESIGN AND METHODS

This retrospective cohort study included adult patients with diabetes discharged from an academic medical center between July 1, 2012 and December 31, 2018 who had a stress test documented before the index discharge. Univariate analysis and multinomial multivariable logistic regressions were used to evaluate associations with readmission within 30 days, 6 months, and 1 year of discharge. Exercise capacity was measured as metabolic equivalents (METs).

RESULTS

A total of 580 patients with 1598 hospitalizations were analyzed. Mean METs of readmitted patients were significantly lower than for non-readmitted patients (5.7 (2.6) vs 6.7 (2.6), p<0.001). After adjustment for confounders, a low METs level (<5) was associated with higher odds of readmission within 30 days (OR 5.46 (2.22-13.45), p<0.001), 6 months (OR 2.78 (1.36-5.65), p=0.005), and 1 year (OR 2.16 (1.12-4.16), p=0.022) compared with medium (5-7) and high (>7) METs level. During the 6.5-year study period, patients with low METs had a mean of 3.2±3.6 hospitalizations, while those with high METs had 2.5±2.4 hospitalizations (p=0.007).

CONCLUSIONS

Lower exercise capacity is associated with a higher risk of readmission within 30 days, 6 months, and 1 year, as well as a greater incidence of hospitalization, in patients with diabetes. Future studies are needed to explore whether exercise reduces readmission risk in this population.

Practical guidance for use of oral semaglutide in primary care: a narrative review

As the cornerstone of type 2 diabetes (T2D) management within the community, primary care providers are now faced with the challenge of not only managing diabetes itself, but also preventing hypoglycemia and weight gain associated with intensive disease management, and reducing cardiovascular risk. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are well established as efficacious treatments for T2D, and the safety/tolerability profile of this drug class is well defined. However, despite their beneficial effects, GLP-1RAs are under-utilized, highlighting the need for novel approaches to increase their use in primary care. Oral semaglutide is the first oral GLP-1RA approved for the treatment of T2D, offering glucose lowering and body weight loss, a low risk of hypoglycemia, and no increase in cardiovascular risk. Oral semaglutide represents an additional treatment option for patients not achieving their glycemic goal despite treatment with metformin, either alone or with other hypoglycemic agents. Oral semaglutide has the potential to increase usage of GLP-1RAs in the primary care setting by addressing clinician and patient concerns about injections, and may facilitate earlier initiation of GLP-1RA therapy in T2D. Due to the formulation of oral semaglutide, clinicians need to be aware of specific considerations in order to ensure optimal use. Such considerations include dosing conditions and use of concomitant medications. This article provides practical guidance on the use of oral semaglutide in the primary care setting, based on evidence from clinical studies, including the phase 3a PIONEER program, and the authors' clinical experience.

Barriers and Solutions for Prescribing Obesity Pharmacotherapy

There are many valid reasons why health care providers are reluctant to use pharmacotherapy for weight management: the negative track record of weight loss medications has led to numerous safety concerns, and there is lack of formal training in obesity medicine and a general discomfort with using these medications. New medications have improved safety profiles, and their mechanisms are based on recent discoveries of how humans regulate weight. This, combined with a change in American health coverage, has slowly increased the use weight loss medication. This article examines the barriers and changes that are increasing the use of anti-obesity medications.

Dose-Response Effects of Exercise on Glucose-Lowering Medications for Type 2 Diabetes: A Secondary Analysis of a Randomized Clinical Trial

OBJECTIVE

To investigate whether a dose-response relationship exists between volume of exercise and discontinuation of glucose-lowering medication treatment in patients with type 2 diabetes.

PATIENTS AND METHODS

Secondary analyses of a randomized controlled exercise-based lifestyle intervention trial (April 29, 2015 to August 17, 2016). Patients with non-insulin-dependent type 2 diabetes were randomly assigned to an intensive lifestyle intervention (U-TURN) or standard-care group. Both groups received lifestyle advice and objective target-driven medical regulation. Additionally, the U-TURN group received supervised exercise and individualized dietary counseling. Of the 98 randomly assigned participants, 92 were included in the analysis (U-TURN, n=61, standard care, n=31). Participants in the U-TURN group were stratified into tertiles based on accumulated volumes of exercise completed during the 1-year intervention.

RESULTS

Median exercise levels of 178 (interquartile range [IQR], 121-213; lower tertile), 296 (IQR, 261-310; intermediate tertile), and 380 minutes per week (IQR, 355-446; upper tertile) were associated with higher odds of discontinuing treatment with glucose-lowering medication, with corresponding odds ratios of 12.1 (95% CI, 1.2-119; number needed to treat: 4), 30.2 (95% CI, 2.9-318.5; 3), and 34.4 (95% CI, 4.1-290.1; 2), respectively, when comparing with standard care. Cardiovascular risk factors such as glycated hemoglobin A_1c levels, fitness, 2-hour glucose levels, and triglyceride levels were improved significantly in the intermediate and upper tertiles, but not the lower tertile, compared with the standard-care group.

CONCLUSION

Exercise volume is associated with discontinuation of glucose-lowering medication treatment in a dose-dependent manner, as are important cardiovascular risk factors in well-treated participants with type 2 diabetes and disease duration less than 10 years. Further studies are needed to support these findings.

STUDY REGISTRATION

ClinicalTrials.gov registration (NCT02417012).

Real-world impact of ongoing regular exercise in overweight and obese US adults with diabetes on health care utilization and expenses

AIMS

To assess the effect of regular exercise on health care utilization patterns and expenses in a real-world national sample of overweight and obese US adults with diabetes.

METHODS

Medical Expenditure Panel Survey data (2010-2015) identified adults with diabetes and a body mass index (kg/m²) ≥25. Two groups were created: exercise (moderate or vigorous physical activity >30min at least five times weekly) and non-exercise groups.

OUTCOMES MEASURED

average total health care expenses (per-person per-annum) and the likelihood of hospitalization.

RESULTS

Among 5140 overweight and obese adults with diabetes, 49.1% reported exercising at least five times weekly. The exercise group showed lower medical care and prescription drug utilization than the non-exercise group (p<0.001). Total unadjusted health expenses in the exercise group were $5651 lower than the non-exercise group (p<0.001). After controlling for socioeconomic and health-related variables, regular exercise reduced total health care expenses by 22.1% (p<0.001) and the likelihood of hospitalization by 28% (p=0.001).

CONCLUSIONS

Reduced hospitalization and health care expenses were associated with regular exercise (≥30min at least five times weekly) in overweight and obese adults with diabetes.

Prevalence of overweight and obesity and associated risk factors among adult residents of northwest China: a cross-sectional study

OBJECTIVE

Overweight and obesity have been shown to be related to multiple chronic conditions, leading to a heavy economic burden on society throughout the world. This study aims to estimate the prevalence of overweight and obesity and determine potential influencing factors among adults in Xinjiang, northwest China.

DESIGN

A community-based observational study.

SETTING

The First Affiliated Hospital of Xinjiang Medical University.

METHODS

In total, 14 618 adult participants (7799 males; 6819 females) aged over 35 years were recruited from the Cardiovascular Risk Survey conducted in 2010. Data were obtained from face-to-face interviews and physical examinations. The sample was used to estimate the prevalence of overweight (body mass index (BMI) 24-28 kg/m²) and obesity (BMI ≥28 kg/m²) in Xinjiang Province. Influencing factors were analysed based on statistical methods.

RESULTS

In Xinjiang Province, the overall prevalence of overweight was 36.5% (male 40.1%; female 33.4%), and the prevalence of obesity was 26.5% (male 27.2%; female 25.8%). The prevalence of both overweight and obesity were higher in women than in men (p<0.001). The main influencing factors for overweight and obesity were sex, age, race, marital status, education level, occupation, smoking, drinking, hypertension, diabetes and dyslipidaemia (p<0.05).

CONCLUSIONS

This study estimated that the prevalence of overweight and obesity among adult residents of Xinjiang Province, northwest China, was high. These data suggest that efforts related to the prevention and control of overweight and obesity should be a public health priority in northwest China.

Cardiorespiratory Fitness and Health Care Costs in Diabetes: The Veterans Exercise Testing Study

BACKGROUND

This study aimed to determine the association between cardiorespiratory fitness and healthcare expenditures among individuals with and without diabetes.

METHODS

Health care costs were quantified among 3924 consecutive men (mean age 58 ± 11 years) referred for a maximal exercise test, and compared according to presence (n = 2457) and absence (n = 1467) of diabetes and fitness. Fitness was classified into 4 categories based on age-stratified quartiles of peak metabolic equivalents: least-fit (5.1 ± 1.5 metabolic equivalents; n = 1044), moderately-fit (7.6 ± 1.5 metabolic equivalents; n = 938), fit (9.4 ± 1.5 metabolic equivalents; n = 988), and highly-fit (12.4 ± 2.2 metabolic equivalents; n = 954). Annual costs per subject were quantified over an 8-year period.

RESULTS

Age, BMI, and presence of cardiovascular disease (CVD) were similar between subjects with and without diabetes. After adjusting for age and presence of CVD, annual costs per person were higher among diabetics vs. non-diabetics. Individuals with and without diabetes in the highly-fit category had annual costs (US dollars x 10³) (mean ± standard deviation) that were on average $32,178 and $30,816 lower, respectively, than individuals in the least-fit category. For each 1-metabolic equivalent higher fitness, annual cost savings per person were $5,193 and $3,603 for individuals with and without diabetes, respectively.

CONCLUSIONS

Higher fitness is associated with lower health care costs. Cost savings associated with higher fitness are particularly evident among individuals with diabetes. The economic burden of diabetes may be reduced through interventions that target improvements in fitness.

Weight Loss Experiences of African American, Hispanic, and Non-Hispanic White Men and Women with Type 2 Diabetes: The Look AHEAD Trial

OBJECTIVE

The aim of this study was to characterize weight loss, treatment engagement, and weight control strategies utilized by African American, Hispanic, and non-Hispanic white participants in the Action for Health in Diabetes (Look AHEAD) Intensive Lifestyle Intervention by racial/ethnic and sex subgroups.

METHODS

Weight losses at 1, 4, and 8 years among 2,361 adults with obesity and type 2 diabetes randomized to intervention (31% minority; 42% men) are reported by subgroup. Multivariable models within subgroups examine relative contributions of treatment engagement variables and self-reported weight control behaviors.

RESULTS

All subgroups averaged weight losses ≥ 5% in year 1 but experienced regain; losses ≥ 5% were sustained at year 8 by non-Hispanic white participants and minority women (but not men). Session attendance was high (≥ 86%) in year 1 and exceeded protocol-specified minimum levels into year 8. Individual session attendance had stronger associations with weight loss among Hispanic and African American participants than non-Hispanic white participants at 4 years (P = 0.04) and 8 years (P = 0.001). Daily self-weighing uptake was considerable in all subgroups and was a prominent factor associated with year 1 weight loss among African American men and women. Greater meal replacement use was strongly associated with poorer 1-year weight losses among African American women.

CONCLUSIONS

Experiences of minority men and women with diabetes in lifestyle interventions fill important gaps in the literature that can inform treatment delivery.

Addressing Lifestyle Management During Visits Involving Patients with Prediabetes: NAMCS 2013-2015

BACKGROUND

The gap between treatment guidelines and clinical practice in prediabetes management has been identified in previous studies. The knowledge related to addressing lifestyle change during office visits in clinical practice to manage prediabetes is limited.

OBJECTIVE

To describe patterns of lifestyle management addressed during office-based visits involving patients with prediabetes and identify factors associated with addressing lifestyle management during physician office visits in the USA.

DESIGN

Cross-sectional study PARTICIPANTS: US National Ambulatory Medical Care Survey (NAMCS) data from 2013 to 2015 were combined to identify office-based visits involving patients with prediabetes.

MAIN MEASURES

The major outcome is lifestyle management including diet/nutrition, exercise, and/or weight reduction. Patient and physician characteristics were collected for analysis. The prevalence and patterns of addressing lifestyle management during visits were estimated and described. Multivariate logistic regression model identified significant factors associated with lifestyle management. The patient visit weight was applied to all analyses to achieve nationally representative estimates.

KEY RESULTS

Among 4039 office-based visits involving patients with prediabetes between 2013 and 2015, 22.8% indicated lifestyle management was addressed during the visits. Diet/nutrition, exercise, and weight reduction accounted for 86.1%, 62.6%, and 34.1% of the visits with lifestyle management addressed, respectively. Lifestyle management was more likely to be addressed during the visits involving patients with hyperlipidemia (OR = 1.74, 95% CI 1.24-2.46) and obesity (OR = 4.03, 95% CI 2.91-5.56), seeing primary physicians (vs. other specialties, OR = 1.46, 95% CI 1.03-2.08), and living in the southern region (vs. northeast, OR = 1.96, 95% CI 1.20-3.19).

CONCLUSIONS

The prevalence of addressing lifestyle management during office visits involving patients with prediabetes remained low in the USA. Patients' clinical characteristics, geographic region, and physician's specialty were associated with addressing lifestyle management during the visits.

Effects of one-legged high-intensity interval training on insulin-mediated skeletal muscle glucose homeostasis in patients with type 2 diabetes

AIM

To examine the effect of high-intensity interval training (HIIT) on glucose clearance rates in skeletal muscle and explore the mechanism within the muscle.

METHODS

Ten males with type 2 diabetes mellitus (T2DM) and ten matched healthy subjects performed 2 weeks of one-legged HIIT (total of eight sessions, each comprised of 10 × 1 minute ergometer bicycle exercise at >80% of maximal heart rate, interspersed with one min of rest). Insulin sensitivity was assessed by an isoglycaemic, hyperinsulinaemic clamp combined with arteriovenous leg balance technique of the trained (T) and the untrained (UT) leg and muscle biopsies of both legs.

RESULTS

Insulin-stimulated glucose clearance in T legs was ~30% higher compared with UT legs in both groups due to increased blood flow in T vs UT legs and maintained glucose extraction. With each training session, muscle glycogen content decreased only in the training leg, and after the training, glycogen synthase and citrate synthase activities were higher in T vs UT legs. No major changes occurred in the expression of proteins in the insulin signalling cascade. Mitochondrial respiratory capacity was similar in T2DM and healthy subjects, and unchanged by HIIT.

CONCLUSION

HIIT improves skeletal muscle insulin sensitivity. With HIIT, the skeletal muscle of patients with T2DM becomes just as insulin sensitive as untrained muscle in healthy subjects. The mechanism includes oscillations in muscle glycogen stores and a maintained ability to extract glucose from the blood in the face of increased blood flow in the trained leg.

End-of-Trial Health Outcomes in Look AHEAD Participants who Elected to have Bariatric Surgery

OBJECTIVE

This study examined end-of-trial health outcomes in participants in the Action for Health in Diabetes (Look AHEAD) trial who had bariatric surgery during the approximately 10-year randomized intervention.

METHODS

Data were obtained from the Look AHEAD public access database of 4,901 individuals with type 2 diabetes and overweight/obesity who were assigned to intensive lifestyle intervention (ILI) or a diabetes support and education (DSE) control group. Changes in outcomes in participants who had bariatric surgery were compared with those in participants with BMI ≥ 30 kg/m2 who remained in the ILI and DSE groups.

RESULTS

A total of 99 DSE and 97 ILI participants had bariatric surgery. At randomization, these 196 participants were significantly younger and more likely to be female and to have higher BMI than the remaining ILI (N = 1,972) and DSE (N = 2,009) participants. At trial's end, surgically treated participants lost 19.3% of baseline weight, compared with 5.8% and 3.3% for the ILI and DSE groups, respectively, and were more likely to achieve partial or full remission of their diabetes.

CONCLUSIONS

The large, sustained improvements in weight and diabetes observed in this self-selected sample of surgically treated participants are consistent with results of multiple randomized trials.

Behavior Modification in Prediabetes and Diabetes: Potential Use of Real-Time Continuous Glucose Monitoring

Real-time continuous glucose monitoring (RT-CGM) provides real time glucose readings to participants wearing the device. The ability to see changes in glucose has the potential to provide immediate feedback to users on food choices and physical activity. The National Diabetes Prevention Program is currently the only reimbursable intervention for diabetes prevention and weight loss. The purpose of this article is to review the CGM literature on measurements other than Hemoglobin A1c (HbA1c) changes and hypoglycemia and discuss RT-CGM potential use as a behavior modification tool for lifestyle changes and weight reduction in people with prediabetes and type 2 diabetes (T2D).

Forecasting the amount and cost of medicine to treat type 2 diabetes mellitus in Nepal using knowledge on medicine usage from a developed country

Objectives

This research was aimed to forecast the amount and cost of medicines required to treat people with type 2 diabetes mellitus (T2DM) in Nepal over 30 years.

Methods

We modelled the financial burden of T2DM medicines by estimating the cost of medicines to treat all cases of T2DM in Nepal over three decades based on the prevalence of T2DM in Nepal, the Nepalese costs of medicine and the T2DM medicine use profile of Australia.

Key findings

With the current T2DM prevalence trend, it would cost US$63–95 million in 2013 to purchase T2DM medicines for Nepal, if Nepalese receive the same mix of T2DM medicines as used in Australia. This cost is almost one-quarter of the total health budget of Nepal (US$308 million). The cost of medicines to treat T2DM is projected to triple between 2013 and 2043.

Conclusions

With the medicines for only T2DM projected to cost about 25% of the entire health budget, the planned health insurance seems unaffordable if patients are treated with the same medicines as those in one of the best healthcare systems in the world. The government needs to stimulate rational prescribing and secure additional funding through taxation, health insurance or health levy to provide such medicines and services.