Association of an Intensive Lifestyle Intervention With Remission of Type 2 Diabetes
What is the impact of a long-term intensive weight-loss intervention on the frequency of remission from type 2 diabetes to prediabetes or normoglycemia?
This was an ancillary observational analysis of a 4-year randomized controlled trial (baseline visit, August 2001–April 2004; last follow-up, April 2008) comparing an intensive lifestyle intervention (ILI) with a diabetes support and education control condition (DSE) among 4,503 US adults with a body mass index (BMI) of 25 kg/m2 or higher and type 2 diabetes. Participants were randomly assigned to receive the ILI, which included weekly group and individual counseling in the first 6 months, followed by three sessions per month for the second 6 months and twice-monthly contact and regular refresher group series and campaigns in years 2-4 (n = 2,241), or the DSE, which was an offer of three group sessions per year on diet, physical activity, and social support (n = 2,262).
The groups were well balanced regarding the following: mean age was 59 years, 41% were male; 73% were on oral hypoglycemic, 19% on insulin, and 7% diet only. Median duration of diabetes was 5 years, and mean BMI was 35.8 kg/m2. ILI participants lost significantly more weight than DSE participants, with 1 year net difference -7.9%; and -3.9% at year 4, and had greater fitness increases with net difference 15.4% at 1 year; and 6.4% at 4 years (p < 0.001 for each). The ILI group was significantly more likely to experience any remission (partial or complete), with prevalences of 11.5% during the first year and 7.3% at year 4, compared with 2.0% for the DSE group at both time points (p < 0.001 for each). Among ILI participants, 9.2%, 6.4%, and 3.5% had continuous, sustained remission for at least 2, at least 3, and 4 years, respectively, compared with less than 2% of DSE participants for at least 2 years; 1.3% for at least 3 years; and 0.5% for 4 years. On multivariate analysis, the variables associated with any remission at 1 year included duration of diabetes >2 years, use of hypertension medication, glycated hemoglobin (HgA1c) >6.7%, and use of insulin.
In these exploratory analyses of overweight adults, an ILI associated with a greater likelihood of partial remission of type 2 diabetes compared with diabetes support and education. However, the absolute remission rates were modest.
Both the 1-year and 4-year results are disappointing considering the intensity of the lifestyle intervention and baseline HgA1c. This well-designed study provided a very intense weight loss and exercise regimen to diabetics who represented the obese cohort most likely to benefit. In contrast, following bariatric surgery, most subjects experience improvements in diabetes control, hypertension, dyslipidemia, and other obesity-related conditions. In patients with impaired glucose tolerance, most studies report 99-100% prevention of progression to diabetes, while in subjects with diabetes prior to surgery, resolution of the disease is reported in 64-93% of the cases. It would seem that the ILI should be focused on prediabetes and the metabolic syndrome.
Keywords: Hemoglobin A, Myocardial Infarction, Bariatric Surgery, Insulin, Follow-Up Studies, Weight Loss, Body Weight, Metabolic Syndrome, Prevalence, Glucose Intolerance, Dyslipidemias, Body Mass Index, Cardiology, Cardiovascular Diseases, Obesity, Hypoglycemic Agents, Hypertension, Diabetes Mellitus, Myocardial Reperfusion
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