From ADA 2012: Diabetes and Obesity - Why WAIT?

Philadelphia—It’s not easy but it’s not impossible: weight reduction and metabolic improvements can be achieved in a real-world clinical practice setting. Yes, it requires intensive lifestyle intervention, but the benefits are maintained long term, according to Osama Hamdy, MD, director of the obesity clinic at Joslin Diabetes Center, in Boston, and assistant professor of medicine at Harvard Medical School.

Dr. Hamdy presented results of the Why WAIT? program at the 72nd Annual Scientific Sessions of the American Diabetes Association in Philadelphia last month. The acronym stands for Weight Achievement and Intensive Treatment, a 12-week multidisciplinary intensive intervention program for weight control and diabetes management offered to individuals with type 1 or 2 diabetes.

“The concept is out there,” Dr. Hamdy said in an interview with CSWN, “that when people lose weight by intensive lifestyle intervention, most of them gain that weight back within a year.” Dr. Hamdy and colleagues followed patients in the Why WAIT? program for a year and stratified them according to whether they had (Group A) or had not (Group B) lost and maintained 7% or more of body weight. “We know that losing 7% of body weight is usually a cutoff to (detect) metabolic improvement,” he said. All patients were then reassessed after 4 years.

Eligible participants had diabetes, BMI of 30-45 kg/m2, were able to exercise, had normal kidney function (serum creatinine <1.5 mg/dL, no severe microalbuminuria), and no active fundus bleeding.

Reality Bites

Participants underwent a comprehensive evaluation before enrollment by a team consisting of a diabetologist, a registered dietician, an exercise physiologist, and a psychologist. The program included weekly group (12-15 patients) interventions, adjustment of diabetes medications by an endocrinologist with emphasis on weight-neutral or weight-negative agents, and a structured dietary intervention (~40-50% low glycemic index carbohydrates, 20-30% protein, <35% fat [<7% saturated fat, no trans fat], and ~30g fiber/day).

“We formulated menus from an American diet so that people don’t feel like they are being deprived,” Dr. Hamdy said. The reality, he said, is this: “People can’t maintain extremely low-fat diets,” he added. “You need something that people can do!”

The program also includes:

  • adjustments to diabetes medications to enhance weight reduction;
  • weekly learning sessions;
  • and an individualized exercise plan that gradually increases from 20-30 minutes/day (3-4 times/week) to 45-60 minutes/day (6 times/week)

An essential component of the program is designed to counteract sarcopenic obesity. “When people lose weight,” Dr. Hamdy said, “usually 27% of it is muscle mass loss. People with diabetes lose muscle mass at an even higher rate. As people get older, they lose muscle mass and gain fat mass. We are able to reduce this muscle mass loss down to 12%.” The key: strength exercises and extra protein. The exercise component includes stretching, resistance training, and cardiovascular exercise. A target of about 300 minutes of exercise per week is the goal.

Dr. Hamdy reported that Group A (55 patients, mean baseline weight = 249.8 lbs) lost an average of 29.2 lbs (-11.9%) at 12 weeks, and maintained 31.5 (-12.6%) of weight loss after 1 year. Subjects in Group B (64 patients, mean baseline weight = 241.5 lbs) lost an average of 19.6 lbs (-8.0%) at 12 weeks, but their weight loss had diminished to just 5.59 lbs (-2.6%) at 1 year. At 4 years, Group A maintained a weight loss of 24.1 lbs, while Group B maintained only 8.0 lbs (Top Figure).

In Group A, glycosated hemoglobin A1c (A1c) dropped from 7.29 to 6.26 at 12 weeks (p < 0.001) and was 6.9 at 4 years (p < 0.001). In Group B, there was a similar short-term benefit seen as A1c dropped from 7.42 to 6.54 (p < 0.001) but there was a rebound to 8.0 at 4 years (p < 0.05) (Bottom Figure). At 4 years, Group A had a higher percent weight loss (-9.6% vs. -3.4%; p < 0.001) and A1c reduction (-0.36% vs. 0.55%; p = 0.002).

One differentiating factor between the groups, aside from initial weight loss, was duration of exercise during the study: 300+ minutes versus 175 minutes in the Group B patients. Other significant benefits for Group A: a 27% savings in total healthcare costs and a 44% savings in diabetes costs.

“This now looks like a very good, solid option in real clinical practice,” Dr. Hamdy concluded. An ongoing study is comparing the Why WAIT? model with bariatric surgery, and models are being developed for primary care physicians and for community settings (NIH-funded). The Why WAIT? program, Dr. Hamdy said, is covered by most insurance plans, including Medicare.



Keywords: Bariatric Surgery, Weight Loss, Exercise, Physicians, Primary Care, Glycemic Index, Health Care Costs, Creatinine, Resistance Training, Carbohydrates, Hemoglobins, Body Mass Index, Obesity, Diet, Fat-Restricted, Nutritionists, Medicare, United States, Diabetes Mellitus

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