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Joslin Diabetes CenterPrimary Care Congress for Cardiometabolic Health 2013Long-Term Weight Management in Obese Patients With Diabetes
Copyright © 2013 by Joslin Diabetes Center, Inc. All rights reserved. These materials may be used for personal use only. Any distribution or reuse of this presentation or any part of it in any form for other than personal use without the express writtenpermission of Joslin Diabetes Center is prohibited.
Long‐term Weight Management in Obese Diabetic Patients
Osama Hamdy, MD, PhD, FACE
Medical Director, Obesity Clinical Program,Director of Inpatient Diabetes Management,Joslin Diabetes CenterAssistant Professor of MedicineHarvard Medical SchoolBoston, Massachusetts, USA
2
3
Obesity and Diabetes: the Twin Epidemics
Rates of diabetes and obesity are dramatically high worldwide,with an average of
– 17% of people suffering from obesity
– 7% of people with diabetes
% %
Diabetes prevalence rates (2010)Obesity prevalence rates (2009)
OECD (2011), “Overweight and obesity among adults”, in Health at a Glance 2011: OECD Indicators, OECD Publishing. http://dx.doi.org/10.1787/health_glance-2011-18-enOECD (2011), “Diabetes prevalence and incidence”, in Health at a Glance 2011: OECD Indicators, OECD Publishing. http://dx.doi.org/10.1787/health_glance-2011-13-en
4
Nu
mb
er in
Mil
lion
s
CDC/NCHS, National Health and Nutrition Examination Survey, 2009–2010
Number of US Individuals with Obesity
37.5
5.5
40.6
7
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
Age >20 ys Age 2-19
WomenMen
5
1‐ Can long‐term weight loss be achieved?
2‐What are the keys for long‐term maintenance of weight loss?
3‐ Is non‐surgical weight reduction cost‐effective?
Objectives
6
Type of Intervention
Short‐term Weight Loss (< 1 year)Advice to change lifestyle……………………….. +/‐ 5 lbs (2%)Lifestyle intervention program…………………… ‐ 5‐10 lbs (2‐5%)Intensive lifestyle intervention program………… ‐10‐20 lbs (5‐7%)Optimal intensive lifestyle intervention program ‐20‐30 lbs (10‐15%)
Long‐term Weight Loss (4‐8 years)Intensive lifestyle intervention program ‐ 4.7%Optimal intensive lifestyle intervention program ‐ 6.3%
1
Joslin Diabetes CenterPrimary Care Congress for Cardiometabolic Health 2013Long-Term Weight Management in Obese Patients With Diabetes
Copyright © 2013 by Joslin Diabetes Center, Inc. All rights reserved. These materials may be used for personal use only. Any distribution or reuse of this presentation or any part of it in any form for other than personal use without the express writtenpermission of Joslin Diabetes Center is prohibited.
7
Weight Losses in ILI were Significantly Greater Than in DSE and Sustained Over a 4‐year Period (Look AHEAD Study)
Wei
gh
t ch
ang
e fr
om
bas
elin
e (%
)
*P <0.001
* *
Look Ahead Research Group. Arch Intern Med. 2010;170(17):1566–1575.
*
*
Time (years)
8
Weight Loss Through Year 8 (Look AHEAD study)
Years
0
-2
-4
-6
-8
-100 1 2 3 4 5 6 7 8
P<.001 for comparisons at all years
Percen
t Red
uction in In
itial W
eight
-4.7%
-2.1%ILI
DSE
Adapted with permission from Wadden TA, et al. Obesity. 2011;19:1987.
9
N=174(19.6%)
+2
0
2
4
6
8
10
12
14
16
18
1 2 3 4
Percentage W
eight Loss
Four‐Year Weight Loss Trajectories of 887 ILI Participants Who Had Lost ≥ 10% Initial Weight at Year 1
Years
0-5%
5-6.9%
7-10%
≥ 10%
Gained
N=374
(42.2%)
N=152(17.1%)
N=99(11.2%)
N=88
(9.9%)
+4
Wadden TA et al. Obesity 2011;19:1987
10
0 12 W 3 M 6 M 9 M 12 M 15 M 18 M 21 M 24 M 27 M 30 M 33 M 36 M 39 M 42 M 45 M 48 M
Total 0 -24.2 -23.9 -23.5 -19.9 -17.9 -17.3 -15.95 -14.3 -14.99 -13.6 -14.65 -14.4 -14.5 -14.4 -14.85 -14.7 -15.6
-30
-25
-20
-15
-10
-5
0
Wei
ght L
oss
in P
ound
s
Long‐term Reduction in Body Weight after Optimal Lifestyle Intervention in Clinical Practice
-15.6(-6.3%)
N= 120
Hamdy O. et al. ADA, Philadelphia, 2012
11
0 12 W 3 M 6 M 9 M 12 M 15 M 18 M 21 M 24 M 27 M 30 M 33 M 36 M 39 M 42 M 45 M 48 M
Group A 0 -29.2 -31.98 -34.3 -32.8 -31.5 -29.4 -27.1 -26.6 -23.9 -22.8 -23.98 -22.4 -23.5 -23.8 -24.6 -23.8 -24.1
Group B 0 -19.6 -16.66 -13.88 -8.2 -5.59 -6.4 -5.9 -3.3 -6.9 -5.3 -6.2 -7.3 -6.3 -5.9 -5.99 -6.4 -8
Total 0 -24.2 -23.9 -23.5 -19.9 -17.9 -17.3 -15.95 -14.3 -14.99 -13.6 -14.65 -14.4 -14.5 -14.4 -14.85 -14.7 -15.6
-40
-35
-30
-25
-20
-15
-10
-5
0
Wei
ght L
oss
in P
ound
s
Long‐term Reduction in Body Weight after Optimal Lifestyle Intervention in Clinical Practice
**
**********
****
* **** ***
******
-8.0(-3.3%)
-15.6(-6.3%)
-24.1(-9.5%)
Weight Maintenance (48% of Participants)
Weight Regain (52% of Participants)
Total Group
N= 120 (Group A 57, Group B 63)
Hamdy O. et al. ADA, Philadelphia, 2012A versus B * p<0.05, ** P<0.01, *** P<0.001
12
Distribution of Levels of Weight Maintenance at 1 Year and 2 Year Follow‐up Assessments by Method of Initial Weight Loss
Year 1 Year 2
Bond DS et al. Int J Obes. 2009 Jan;33(1):173-80.
Lost >5.0 Kg Maintain +4.9 Kg Gain >5 Kg Lost >5.0 Kg Maintain +4.9 Kg Gain >5 Kg
NWCR registry: Weight loss >13.6 and maintaining ≥ 13.6 kg for a yearAverage weight loss 56 kg and maintenance of >13.6 kg for 5.5 years
2
Joslin Diabetes CenterPrimary Care Congress for Cardiometabolic Health 2013Long-Term Weight Management in Obese Patients With Diabetes
Copyright © 2013 by Joslin Diabetes Center, Inc. All rights reserved. These materials may be used for personal use only. Any distribution or reuse of this presentation or any part of it in any form for other than personal use without the express writtenpermission of Joslin Diabetes Center is prohibited.
13
Keys to Optimal Lifestyle Intervention for Long‐term Weight Reduction
1. Aim for meaningful weight loss goal (5‐10%)
2. Gradual and balanced and individualized physical activity
1. Duration of exercise
2. Type of exercise
3. Exercise records
3. Structured dietary intervention & modified macronutrient composition
1. Relatively higher protein, LGI & higher fibers
2. Provided menus
3. Food records
4. Diabetes specific meal replacement (GTSN)
4. Medication adjustment and frequent BG monitoring
5. Counseling and cognitive behavioral change
6. Group intervention and frequent participant contact
7. Daily weighing 14
Effect of weight loss on insulin sensitivity
Weight Insulin Sensitivity
BMI = body mass index; W/H = waist-to-hip-ratio.
*P<0.001Hamdy O, et al. Diabetes Care. 2003;26:2119-2125
Chan
ge From Baseline (%
)
BMI W/H
* * *
*
1‐ Aim for Modest Weight Loss through Defining a SMART Goal
15
Visceral FatVisceral Fat
BP & lipids BP & lipids
Metabolic ControlPhysical Fitness & QOLMaintenance of Weight Loss
Metabolic ControlPhysical Fitness & QOLMaintenance of Weight Loss
Vascular ResistanceVascular Resistance
The benefits of Exercise and or
Increased Physical Activity include
2‐ Gradual, balanced and individualized physical activity‐ Duration of exercise‐ Type of exercise‐ Short versus long‐bouts of exercise‐ Exercise records/exercise monitor
16
Diabetes, a Common Comorbidity, Significantly Accelerates Loss of Muscle Mass, Strength and Quality
p<0.05*Park SW, et al. Diabetes Care 2009;32:1993-1997.
Loss of Total Muscle Mass[g/ year]
Loss of Muscle M
ass (gm
/year)
*
*
17
Loss of Muscle M
ass
(As % of Total W
eight Loss)
Men
Women
*P<0.05
Ballor DL and Poehlman ET. Int J Obes Relat Metab Disord. 1994;18(1):35-40.
Exercise Preserves Muscle Mass During Weight Reduction
Diet Diet + Exercise
18
Balanced Exercise Model
Flexibility Strength
Strength exercise is particularly important during weight reduction
Aerobic
Walking
Swimming
Biking
Dancing
Resistance tubing
Weight lifting
Yoga
Stretching
Yoga
3
Joslin Diabetes CenterPrimary Care Congress for Cardiometabolic Health 2013Long-Term Weight Management in Obese Patients With Diabetes
Copyright © 2013 by Joslin Diabetes Center, Inc. All rights reserved. These materials may be used for personal use only. Any distribution or reuse of this presentation or any part of it in any form for other than personal use without the express writtenpermission of Joslin Diabetes Center is prohibited.
19
Week Frequency of Exercise* Duration of Exercise Type of Exercise
1‐4 4 days /wk 20‐40 min AEX + STCH + CST + CT
5‐8 5 days /wk 40‐45 min AEX + CT+ IT + STCH + Y + CSE
9‐12 6 days /wk 50‐60 min IT + CT + CSE +SS + Y + STCH
AEX – Aerobic Exercise CT – Circuit Training SS ‐Superset Training STCH – Stretching Exercise IT – Interval Training CST‐ Cross Training CSE ‐ Core Stability Exercise Y‐ Yoga (Vinyasa flow)
Shahar J et al, ADA 2009
Independent Exercise ProgressionGradual and balanced exercise intervention*
* Model used in the Why WAIT program
20
Changes in % Body Fat, Fat Mass & Lean/Fat Ratio after 12 Weeks of Balanced Exercise Plan
Bod
y F
at M
ass
in lb
s
Fat Mass (lbs) Body Fat (%) Lean/Fat Ratio
***
***
n = 85 * p <0.05 ** p <0.01 *** p <0.001
*
Hamdy O et al Obesity Management J. 2008; 4(4):176-183
21
Percent Weight Loss for Categories of 24‐month Physical Activity
(N = 170)
Jakicic JM et alArch Intern Med. 2008; 168(14): 1550–1560
22
Effect of Long vs. Short Bouts of Exercise on Adherence and Weight Loss
Long bout = one 40-min session.Short bout = four 10-min sessions.
Activity (m
in/w
eek)
LongBouts
ShortBouts
10
8
6
4
2
0
Weigh
t Loss (kg)
Jakicic et al. J Obes Relat Metab Disord 1995;19:893.
LongBouts
ShortBouts
23
3‐ Structured dietary intervention & modified macronutrient composition
‐ Relatively higher protein, LGI & higher fibers‐ Provide structure menus ‐ Calorie replacements ‐ Food records
Calorie intakeCarbs to 40-45%Calorie intakeCarbs to 40-45%
Glycemic indexGlycemic index
Protein intake to 30%FiberMUFA
Protein intake to 30%FiberMUFA
Saturated fat and sodiumSaturated fat and sodium
Natural food (dinner menus and snacks) and
Calorie Replacement
24
Diets with High or Low Protein Content and Glycemic Index for Weight‐Loss Maintenance (26 weeks)
Larsen TM et al. N Engl J Med 2010;363:2102-13.
n= 773Initial weight loss >8%
13% protein (LGI/HGI) versus 25% protein (LGI/HGI)
4
Joslin Diabetes CenterPrimary Care Congress for Cardiometabolic Health 2013Long-Term Weight Management in Obese Patients With Diabetes
Copyright © 2013 by Joslin Diabetes Center, Inc. All rights reserved. These materials may be used for personal use only. Any distribution or reuse of this presentation or any part of it in any form for other than personal use without the express writtenpermission of Joslin Diabetes Center is prohibited.
25
Total glycated hemoglobin response of subjects to the control (15% protein) and high-protein (30% protein) diets over the 5-wk study period.
*Significantly different from the control diet, P < 0.05 The rate of decline was also significantly greater after the high-protein diet, P < 0.001
-0.3%
-0.8%
Adapted from Gannon MC et al. Amer J Clin Nutr 2003;78:734-741
The Metabolic Effect of Different Protein/Carbohydrates Ratios in Type 2 DM
Protein to carbohydrate to fat: 30:40:30 Versus 15:55:30
26
Strong Correlation Between Calorie Replacement and Weight Loss (Look AHEAD Study)
Number in the bar is mean number of MRs used in that quartile
Red
uctio
n in
Initi
al W
eigh
t in
ill pa
rtici
pant
s (%
)
MRs = meal replacements.Reproduced with permission from Wadden TA et al. Obesitiy 2009; 17:713-722
117 277 406 608MRs
27
Avoid weight promoting medications
4‐ Adjusting medications that affect the body weight
‐ Diabetes medications‐ Antidepressants‐ Weight loss medications
Diabetes Medications and Body Weight
Weight Gain Weight Neutral Weight Loss
Significant Modest
Pioglitazone
SUsGlyburideGlipizide
InsulinNPHGlargineRegularAspartLisproGlulisine
SUsGlimepirideGlipizide XL
GlinidesRepaglinideNateglinide
InsulinDetemirGlulisine (PP)
Metformin
DPP‐4 InhibitorsSitagliptinSaxaglipitinLinagliptin
‐glucosidase InhibitorsAcarboseMiglitol
Colesevelam
Bromocriptine
GLP‐1 AnalogesExenatideExenatide ERLiraglutide
Pramlintide
Stop, Reduce or Switch Continue Add
1‐ Identify
2‐ Plan
3‐ Change
List A List B
29
Results of Optimal Intensive Lifestyle Intervention (OILI)
Before After
7.5
6.6
HbA1c (%
)
Hamdy O, et al. Curr Diab Rep. 2008;8(5):413–420
n = 115
*
Changes in Metabolic& CV Outcomes
* P<0.001
30
Cost‐effectiveness of non‐surgical and surgical weight management
Health Care Cost and Diabetes‐Related Cost
Cost utilization (Hospitalization, Clinic visits)
5
Joslin Diabetes CenterPrimary Care Congress for Cardiometabolic Health 2013Long-Term Weight Management in Obese Patients With Diabetes
Copyright © 2013 by Joslin Diabetes Center, Inc. All rights reserved. These materials may be used for personal use only. Any distribution or reuse of this presentation or any part of it in any form for other than personal use without the express writtenpermission of Joslin Diabetes Center is prohibited.
31
Cost‐effectiveness of Intensive Lifestyle Intervention
A 10‐year analysis of the Diabetes Prevention Program trial showed lifestyle intervention was cost‐effective compared with placebo in prevention of diabetes in high‐risk adults
From a payer perspective, investment in lifestyle management for diabetes prevention provides good value
The Diabetes Prevention Program Research Group. Diabetes Care. 2012;35:723-730.
32
Economic Impact of Non‐Surgical Weight Loss in One Year in Patients With Diabetes
Cost Saving(1% wt loss)
Cos
t sav
ing
per y
ear
(-3.6%)1*
(-5.8%)2*
(-27%)
(-44%)
Estimated Saving with(7% wt loss)
1) p<0.5 2) p<001
YU AP et al. Curr Med Res Opin. 2007;23(9):2157-69
Health Care Cost Diabetes Related Cost
33
Impact of Bariatric Surgery on Healthcare Utilization & Costs in Patients with DM over 6 Years
Odds of Hospitalization Ratio of Counts of PCP Visits
Ratio of Counts of Specialist
ConclusionIn the six years following bariatric surgery, individuals with type 2 diabetes did not have lower healthcare costs than before surgery.
Bleich SN et al. Med Care. 2012, 50(1):58-65
7,806 patients with diabetes who received bariatric surgery
34
In Conclusion
Long-term weight reduction can be achieved through non-surgical weight management
1
Exercise type and duration significantly impact long-term weight maintenance
2
Changing macronutrient compositions, providing structured meal plan plus adding calorie replacements are effective dietary intervention
3 4
Adjusting diabetes medications is important for effective long-term weight reduction in patients with diabetes
5
Long-term weight reduction is cost-effective for prevention and treatment of diabetes
6
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