Field Notes

Short-Term Intensive Weight-Loss Program Valid Alternative to Bariatric Surgery

A study by a team of clinicians and researchers at the Joslin Diabetes Center in Boston has shown for the first time that patients with diabetes who enrolled in a short-term intensive weight management program were able to lose weight and keep it off on their own for four years. The findings suggest an alternative course to bariatric surgery in the fight against type 2 diabetes.

The study, presented at the American Diabetes Association’s 72nd Scientific Sessions, strongly counters the popular view that people generally can’t maintain weight loss achieved during lifestyle intervention programs for the long term.

“The notion that most people in the medical field have is that when you apply intensive lifestyle interventions, the majority of patients gain all or most of the weight back in a year,” says Osama Hamdy, MD, PhD, medical director of the obesity clinical program, director of inpatient diabetes management at Joslin, and lead author of the paper.

“People have been pessimistic,” he adds. “They think they may need bariatric surgery, but we’re sending an optimistic message: Think again. There is something else that can work effectively in real-world clinical practice and save money too. This is a very important observation.”

The study showed that around 50% of the 120 patients who enrolled in the Weight Achievement and Intensive Treatment (Why WAIT) program for 12 weeks were able to maintain an average of 9.5% weight loss at four years, while the total group maintained 6.3% at four years.

Why WAIT is a multidisciplinary diabetes weight management program designed for clinical practice. The program included a change in diabetes medications to enhance weight reduction, structured dietary intervention with lower carbohydrates and higher protein and meal replacement, an exercise program with emphasis on strength training, and weekly educational and support sessions.

Although subjects in this study were followed for four years, they were on their own after the initial 12-week program. The study found that about one-half of the subjects didn’t regain the weight—on average 24 lbs—after four years. This group also maintained a significant improvement in their metabolic control as measured by hemoglobin A1c and the improvement in other vascular risk factors, such as blood pressure and lipids.

It also found that those who maintained at least 7% of their weight loss at one year were most likely to continue the weight reduction over the long term.

“This is very important information,” Hamdy says. “It tells us not everyone gains the weight back. In reality, these are similar numbers to the weight loss gained by some bariatric surgeries at that time frame.”

Those who had lost at least 7% of their body weight after one year lost an average of 29 lbs (11.9% of their body weight) at 12 weeks and maintained an average loss of 31.5 lbs (12.6%) at one year.

A second group included those who lost an average of 19.6 lbs (8%) at 12 weeks but were down to a loss of just 5.6 lbs (2.3%) at one year.

Those in the first group maintained weight losses of 23.9 lbs at two years, 23.5 lbs at three years, and 24.1 lbs at four years. Those in the second group only maintained losses of 6.9 lbs at two years, 6.3 lbs at three years, and 8 lbs at four years.

Blood sugar levels in the first group dropped over the four-year period, but levels in the second group rebounded after dropping initially. However, there were no differences in the groups when reductions in blood pressure, HDL cholesterol, and triglyceride levels were compared at the end of the four years.

“Those who gained the weight back still got some benefits,” Hamdy says.

Patients in the Why WAIT study received an optimal intensive lifestyle intervention, which included close evaluation at the outset and that all interventions were in a group format. In addition, diabetes medications were adjusted by diabetologists at the start and during the follow-up, and patients were fed fewer carbohydrates and exercised more—up to 300 minutes per week, he says.

Subjects in Why WAIT were able to cut their diabetes medications by one-half on average at the end of the 12-week program. It saved them $561 per year on diabetes medications alone, he says. Based on other valid cost-effective analysis, patients in the program saved $2,000 per year in overall healthcare costs and around $1,000 in diabetes-related costs, he adds.

Hamdy says the study proves that intensive lifestyle intervention is at least as effective as some common bariatric surgeries in helping people lose weight and deal with their diabetes issues, with less cost and fewer short- and long-term side effects.

“Surgery carries a lot of long-term risks,” he says. “And a significant number of surgical patients gain their weight back after one or two years.”

He also says that bariatric surgery costs in the range of $20,000, while the optimal intensive lifestyle intervention through the Why WAIT model costs just $2,700. After those results, “We’re ready to debate them on the long-term value,” he adds.

“So many physicians have been telling the governmental authorities that weight loss in clinical practice is a waste of money and that they will never keep the weight off,” he concluds. “We now have a message for them. It’s very effective in at least half of people in terms of weight loss and cost savings. Intensive lifestyle intervention can be a very valid option.”

— Source: Joslin Diabetes Center


Study Debunks Belief Insulin Puts People With Diabetes at Risk of Heart Disease

Researchers at McMaster University in Canada have discovered that long-term insulin use doesn’t harm people with diabetes or prediabetes or put them at risk of heart attacks, strokes, or cancer.

This is contrary to concerns that long-term use of insulin may cause heart disease, says Hertzel Gerstein, MD, principal investigator of the study, a professor of medicine at McMaster’s Michael G. DeGroote School of Medicine, and deputy director of the Population Health Research Institute at McMaster University and Hamilton Health Sciences.

“People have been debating the question of whether there are adverse consequences to long-term insulin use for years,” he says. “This study provides the clearest answer yet to that question: No, there are not.”

Gerstein presented the findings of the ORIGIN study (Outcome Reduction with an Initial Glargine Intervention study) at the scientific sessions of the American Diabetes Association. The results are also published in two papers in The New England Journal of Medicine.

A second important finding of the study is that people with prediabetes who received daily basal insulin injections with insulin glargine had a 28% lower chance of developing type 2 diabetes, even after the injections stopped.

In the ORIGIN study, more than 12,500 people at 537 sites in 40 countries with an average age of 64 at high risk of or in the early stages of type 2 diabetes were randomized to either one daily injection of insulin (glargine) or no insulin (standard care) for an average of six years.

Researchers found no difference among the two groups in cardiovascular outcomes or the development of any type of cancer. This suggests daily insulin injections (with insulin glargine) to normalize glucose levels aren’t harmful when taken over long periods of time. Throughout the study, most of the participants given insulin maintained normal fasting glucose levels (below 6 mmol/L).

The study confirmed the presence of two previously known side effects of insulin: hypoglycemia and modest weight gain. Both were considered minor from a medical point of view, with participants gaining an average of 3.5 lbs during the study and experiencing a low, 0.7% higher risk of severe hypoglycemia per year than the people not on insulin.

“We now know what the risks are of taking insulin on a long-term basis, and they are low,” Gerstein says.

— Source: McMaster University