weight management program for individual with prediabetes

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Diabetes & Metabolism 37 (2011) 410–418

Original article

A cost-effective moderate-intensity interdisciplinary weight-managementprogramme for individuals with prediabetes

C. Gagnon , C. Brown , C. Couture , C.N. Kamga-Ngande , M.F. Hivert ,J.P. Baillargeon , A.C. Carpentier , M.F. Langlois∗

Department of medicine, Division of endocrinology, Université de Sherbrooke, centre de recherche clinique Étienne-LeBel,Sherbrooke, Qc J1H 5N4 Quebec, Canada

Received 22 August 2010; received in revised form 26 November 2010; accepted 3 January 2011Available online 13 April 2011

Abstract

Aim. – To compare the effectiveness and cost of two lifestyle-modification programmes in individuals at high risk of developing type 2 diabetes. Methods. – Forty-eight men and women with a body mass index ≥27kg/m2 and prediabetes were randomly assigned to either a 1-year

interdisciplinary intervention including individual counseling every 6 weeks and 25 group seminars (group I; n = 22) or a group interventioncomprising seminars only (group G; n = 26). These interventions were compared in terms of weight loss and improvement of anthropometricmeasures, metabolic variables and costs.

Results. – Participants in group I lost an average of 4.9 kg (95% CI: −7.3, −2.4; P < 0.01) and 5 cm in waist circumference (95% CI: −7.0,−3.0; P < 0.01), whereas no significant change was noted in those assigned to group G. Among the participants in group I, 50 and 27% lost atleast 5 and 10% of their initial weight, respectively, compared with only 12 and 4%, respectively, in group G. Fasting glucose, 2-hour glucose andlipid profiles improved significantly in groupI, and no participant (zero on 22) developed diabetes compared with 11.5% (3/26) in groupG. Mostparticipants (nine on 11) with impaired fasting glucose in groupI returned to normal. The direct cost of the individual intervention was estimatedto be $733.06/year per subject compared with $81.36/year per subject for the group intervention.

Conclusion. – This study demonstrates that a low-cost, moderate-intensity, individual interdisciplinary approach combined with group seminarsleads to clinically significant weight loss and metabolic improvement in people with prediabetes. Group seminars alone were not effective in thispopulation (www.ClinicalTrial.gov , Identifier: NCT00991549).© 2011 Elsevier Masson SAS. All rights reserved.

Keywords: Weight loss; Interdisciplinary programme; Glucose intolerance; Diabetes; Obesity

Résumé

Étude coût-efficacité d’un programme interdisciplinaire de gestion du poids d’intensité modérée chez des individus atteints de prédiabète. But. – Comparer l’efficacité et le coût de deux programmes de modification des habitudes de vie chez des individus à risque de développer un

diabète de type 2. Méthodes. – Quarante-huit hommes et femmes avec un indice de masse corporelle supérieur ou égal à 27 kg/m2 et un prédiabète ont été

randomisés en deux groupes : soit intervention interdisciplinaire d’un an incluant un conseil individuel toutes les six semaines et 25 séminaires degroupe (groupeI ; n = 22), soit intervention de groupe comprenant les seuls séminaires (groupeG ; n = 26). Ces interventions ont été comparées en

termes de perte de poids et d’amélioration des mesures anthropométriques, variables métaboliques et coûts. Résultats. – Les participants du groupe I ont perdu en moyenne 4,9 kg (IC à 95 % [−7,3, −2,4], P <0,01) et 5cm de tour de taille (IC 95%[−7,0, −3,0], P < 0,01) alors qu’aucun changement significatif n’a été observé dans le groupe G. Dans le groupe I, 50 et 27% des participants ontperdu au moins 5 et 10 % de leur poids initial, comparativement à 12 et 4 % dans le groupe G. La glycémie à jeun, la glycémie à deux heures etle profil lipidique se sont significativement améliorés dans le groupeI. Aucun participant dans le groupe I (zéro sur 22) n’a développé de diabètecomparé à 11,5 % (trois sur 26) dans le groupeG. La majorité (neuf sur 11) des sujets avec une glycémie marginale dans le groupeI ont normaliséleur glycémie à jeun. Les coûts directs de l’intervention individuelle ont été estimé à $733,06/année par patient comparativement à $81,36/annéepar sujet pour l’intervention de groupe.

∗ Corresponding author. Tel.: +1 819 564 5223; fax: +1 819 564 5292.E-mail address: Marie-France.Langlois@USherbrooke.ca (M.F. Langlois).

doi:10.1016/j.diabet.2011.01.003

C. Gagnon et al. / Diabetes & Metabolism 37 (2011) 410–418 411

Conclusion. – Cette étude démontre qu’une intervention individuelle interdisciplinaire d’intensité modérée et peu coûteuse, associée à desactivités en groupe, conduit à une perte de poids cliniquement significative et une amélioration métabolique chez les prédiabétiques. Les activitésde groupe seules n’ont pas été efficaces dans cette population (www.ClinicalTrial.gov, Identifier: NCT00991549).© 2011 Elsevier Masson SAS. Tous droits réservés.

Mots clés : Perte de poids ; Programme interdisciplinaire ; Étude longitudinale ; Intolérance au glucose ; Diabète ; Obésité

1. Introduction

The prevalence of type 2 diabetes (T2DM) has risen dra-matically over the past 10 years in Canada to already exceedpredictions by the World Health Organization (WHO) for 2030[1]. Prevention programmes for diabetes, targeting high-riskindividuals, are the key to reducing the continuously growingpublic-health and economic burden of the disease. Lifestyleinterventional strategies have also proven highly effective inpreventing or delaying the progression from impaired glucosetolerance (IGT) to T2DM in overweight and obese individ-uals. Indeed, the Diabetes Prevention Program (DPP) studyhas shown that a weight loss of 5.6kg (6% of initial bodyweight) canreduce the incidenceof diabetes by 58%over 3 years[2]. The beneficial effect of weight loss on diabetes risk wasfurther supported by the results of the Finnish Diabetes Pre-vention Study (DPS) and the Da Qing IGT and Diabetes Study[3,4].

Although these large trials have convincingly demonstratedthe power of a structured, multidisciplinary approach to induceweight loss, multiple factors limit the application of theseinterventions in the current healthcare system. A tailor-madecurriculum including frequent individual encounters with casemanagers who have experience in nutrition, physical activity

and behavioural modification are the cornerstones of the DPPlifestyle intervention.However,the restrictedbudget allocatedtodiabetes prevention and the shortage of well-trained profession-als render this strategy difficult or even impossible to implementin manyclinical settings. Cost-effective interventional strategiessuited to the current healthcare context are, therefore, needed toprevent diabetes in the ever-growing population of people withprediabetes.

The present study compared the efficacy at a 1-year interdis-ciplinary approach, including individual counseling plus groupseminars, compared with group seminars only in inducingweight loss in subjects at high risk of developing T2DM.

2. Patients and methods

2.1. Patient selection

Between November 2004 and March 2006, participants wererecruited through advertisements or by physicians’ referrals.Starting in October 2005, an invitation to take part in the studywas also sent to individuals who had an oral glucose toler-ance test (OGTT) diagnostic of IGT or impaired fasting glucose(IFG) at the Centre hospitalier universitaire de Sherbrooke

(CHUS).

Subjects were eligible if they had a body mass index(BMI) ≥27 kg/m2 and a diagnosis of IFG (fasting glu-cose: 6.1–6.9mmol/L) or IGT confirmed by a 2-hour 75-gOGTT within the last 3 months: fasting plasma glucose(FPG) <7.0 mmol/L; and a post-load glucose between 7.8 and11.0 mmol/L. Subjects were excluded if they were unable tocomply with the proposed intervention, had taken pharma-cological treatment for obesity or any medications known toalter glucose tolerance (including metformin) within the last3 months, or hadpast or planned bariatricsurgery. Subjects plan-ning a pregnancy within a year and those using a pacemakerwere also excluded. The CHUS and University of Sherbrookeethics review board of research on humans approved the studyprotocol, and written informed consent was obtained from eachparticipant.

2.2. Randomization and intervention

Subjects were randomly assigned to one of two weight-management programmes, with stratification according togender and BMI (< or≥35 kg/m2). Participants in the individualinterdisciplinary approach group (I) benefited from our previ-ously described lifestyle recalibration intervention [5]. At the

first visit, a realistic and individualized weight-loss goal wasset for each participant (usually 5–10% of body weight over6–12 months). Participants were invited to return to the clinicevery 6weeks for 12 months. At each visit, the participant indi-vidually met with three members of our interdisciplinary team(15 minutes each):

• the nurse, responsible of assessing the psychosocial contextand providing support, reviewing progress, and identifyingany barriers to change and strategies to overcome them;

• the dietitian, who evaluated the participant’s food intake andhelped to choose two or three nutritional goals (such as por-

tion size, vegetable and wholegrain consumption, fat content,snacks and caloric beverages) to work on until the nextappointment;

• the endocrinologist, responsible for coaching the participantto progressively increase levels of physical activity(long-termobjective of 60 min/day of moderate activity).

Participants were also invited to attend a series of 25 groupseminars of 45 minutes’ duration covering diet, exercise,behavioural modification, and general informationaboutobesityand lifestyle modification. Upon request by the team, individualconsultations with a psychologist or a kinesiologist were also

offered; this offer was taken up by < 10% of participants. Sub-

412 C. Gagnon et al. / Diabetes & Metabolism 37 (2011) 410–418

jects enrolled in the group approach (G) were only invited toparticipate in group seminars every 2 weeks for 1 year.

2.3. Clinical and biochemical assessments

At entry and at the end of the study, assessments wereperformed during two visits. A medical history and physicalexamination were performed, and subjects completed a 3-dayfood diary and a standardized physical-activity questionnaire[6]. Fasting body weight was measured without shoes and wear-ing light clothing to the nearest 0.1 kg, using a mechanical scale,andheight to thenearest 0.1cm,usinga wall-mounted stadiome-ter. Waist circumference (WC) was measured twice at the endof a normal exhalation to the nearest 0.5cm, using a measuringtape placed at the midpoint between the lowermost rib and theupper iliac crest; the mean of the two measurements was usedin the analyses. Body composition was assessed by bioelectricalimpedance analysis (BIA; Hydra ICF/ECF, Xitron Technolo-gies, San Diego, CA, USA). Multiple-frequency BIA has been

shown to accurately assess changes in body composition duringweight loss in overweight and obese individuals [7].

A 6-minute walking test was conducted according to the pro-tocol recommended by the American Thoracic Society [8] andrecently validated to measure physical capacity in obese indi-viduals [9]. An uniaxial accelerometer (CaltracTM) was usedto monitor total energy expenditure, resting metabolism andusual physical activity for 3 days (2 weekdays and 1 weekendday) [10]. Resting energy expenditure (REE) was assessed byindirect calorimetry (Vmax 29n, SensorMedics) for a periodof 30 minutes, as described elsewhere [11]. REE was calcu-lated from the abbreviated Weir equation, where REE = 1440

(3.94×

VO2 + 1.11×

VCO2).Fasting blood was drawn for measurements of baselineglucose, HbA1c and lipid profile (Ortho-Clinical Diagnos-tics Vitros 950 and HDL Direct, Beckman). Serial samplesof glucose (Beckman Coulter Glucose Analyzer 2, BeckmanInstruments) and insulin (Linco Research, St. Charles, MO,USA) were collected for 5 hours after a 75-g glucose load [12].Insulin sensitivity was estimated by homoeostasis model assess-ment of insulin sensitivity (HOMA-S): 22.5/(fasting insulin[IU/L]× fasting glucose [mmol/L]) [13]. When insulin isexpressed in pmol/L, the constant changes to 156.26. Theearly insulin response was calculated as the ratio of thechange in insulin to the change in glucose from 0–30 minutes

(I0-30 / G0-30). The oral disposition index was calculatedas I0-30 / G0-30×HOMA-S [14]. Mean glucose and meaninsulin at times −30 minutes and 0 were used as fasting valuesin the calculations.

Participants in each group were also seen every 3 months forblood pressure and anthropometric measurements (weight andWC). Blood pressure was taken twice after a 5-minute rest, andthe mean of the two measurements used in the analyses.

2.4. Outcome measures

The primary study endpoints were to compare absolute

weight loss between groups and the percentage of subjects who

lost 5, 7 and 10% of their initial body weight. The effect of each intervention on anthropometric measures and metabolicvariables was evaluated as secondary endpoints. In addition, thedirect annual cost of the interventions were calculated, using themiddle salary level for each professional and medical costs asreimbursed by the Régie de l’assurance maladie du Québec (thegovernment health insurance system of Quebec) for 2009, basedon a mean of nine visits/patient per year. Seminar costs includedpreparation and teaching.

2.5. Statistical analyses

Statistical analyses were performed with SPSS software, ver-sion 17.0 (Chicago, IL, USA). The primary analysis followedthe intention-to-treat (ITT) principle, with the last observa-tion carried forward when data were missing during follow-up.Also performed were secondary analyses including only theparticipants who completed the 1-year intervention and thoseparticipants in each group who were adherent to ≥75% of theintervention.

To examine the differences in baseline characteristicsbetween groups, an independent t test(orMann–Whitneytestforvariables without normal distribution) wasperformed for contin-uous variables, and a Chi2 test for categorical variables. Unlessotherwise specified, the data are presented as means±SD forease of presentation. One-year changes in anthropometric mea-sures andmetabolic variables foreach group were assessed usinga paired t test (or Wilcoxon’s signed-rank test for non-normallydistributed data). These data are presented as means of changeswith 95% confidence intervals (CI). To determine differences inproportions, a McNemar test was used. As both weight and WC

had a skewed distribution to the right, the Friedman ANOVA(analysis of variance) by rank was used to determine significantchanges in those variables over time. A two-tailed P-value <0.05was considered statistically significant.

3. Results

3.1. Baseline characteristics and attendance of participants

Altogether, 48 Caucasian men and women participated inthe study. Of these, 41 (85.4%) completed the study – 17 ingroupI and 24 in group G. During the study, one participant

died of metastatic cancer of unknown origin diagnosed afterstudy entry, two moved to another city and four left for personalreasons. Both groups presented similar baseline characteristics(Table 1). The proportion of participants with a BMI≥30kg/m2

was also similar between groups (91% vs 92% in groups I andG, respectively; P = 1.00). In addition, there were no significantdifferences between groups I and G in terms of median weight(89.4 vs 95.5kg, respectively; P = 0.21) and median WC (106vs 110 cm, respectively; P = 0.27) at baseline.

The participation rate in the group seminars was low (44.0and 50.5% for groups I and G, respectively; P = 0.68), with only31% of participants attending at least 75% of the seminars (27%

vs 35% for groupsI and G, respectively; P = 0.58). In contrast,

Table 1Baseline characteristics of the participants.

Characteristics Group I Group G P-valuea

(n = 22) (n =26)

Age, years 54.8± 11.7 58.4± 10.7 0.27

Female, n (%) 13/22 (59.1) 13/26 (50.0) 0.53

Family history of type 2 diabetes, n (%) 13/22 (59.1) 11/24 (45.8) 0.37

Current smoking, n (%) 2/22 (9.1) 2/26 (7.7) 0.90

Weight, kg 91.4± 13.4 100.4± 23.8 0.21

Body mass index, kg/m2 34.1± 4.3 36.0± 6.3 0.58

Waist circumference, cm 105± 12 111± 17 0.27

Body compositionb

Fat body mass, kg 31.3± 6.1 38.7± 14.2 0.09Fat body mass, % 35.8± 7.9 38.1± 8.0 0.39Lean body mass, kg 57.2± 11.7 61.7± 14.2 0.30Lean body mass, % 64.2± 7.9 61.9± 8.0 0.40

Blood pressure, mmHgSystolic 125± 15 121± 13 0.38Diastolic 72± 8 70± 10 0.48Medication use, n (%)c 11/22 (50.0) 17/26 (65.4) 0.28

Plasma glucose, mmol/LFasting 5.8± 0.6 6.0± 0.6 0.422-hour post-75-g glucose 9.3± 1.2 9.6± 1.0 0.43

Glycosylated haemoglobin, % 5.7± 0.5 5.7± 0.5 0.97

HOMA-S 0.26± 0.10 0.30± 0.17 0.68

∆ I 0-30 / ∆G0-30 136.8± 93.9 117.58± 58.71 0.86

Disposition index 31.41± 19.61 30.52± 18.34 0.84

Lipid profile, mmol/LTotal cholesterol (TC) 4.5± 0.8 5.0± 1.1 0.12LDL-C 2.7± 0.7 3.1± 1.0 0.13HDL-C 1.1± 0.2 1.2± 0.3 0.18Triglycerides 1.8± 1.0 1.7± 0.5 0.32TC/HDL-C ratio 4.3± 1.2 4.4± 1.3 0.85Statin use, n (%) 7/22 (31.8) 6/26 (23.1) 0.50Fibrate use, n (%) 1/22 (4.5) 0/26 (0.0) 0.46

6-minute walking test, m 433± 64 401± 64 0.08

Energy expenditure (EE), kcal/dayResting EEd 1904± 275 2046± 439 0.22Leisure-time physical activitye 683± 570 838± 895 0.87Total EEf 2508± 556 2641± 654 0.46

Energy intake, kcal/dayg 1870± 400 1941± 608 0.65From protein, % 18.8± 3.6 18.4± 3.0 0.68From carbohydrates, % 45.5± 8.0 45.5± 8.2 0.98

From fat, % 32.3± 6.6 35.0± 5.4 0.13From saturated fat, % 10.0± 2.1 10.9± 3.3 0.31

Data are presented as means±SD or n(%).HOMA-S: homoeostasis model assessment of insulin sensitivity; LDL-C/HDL-C: low-density/high-density lipoprotein cholesterol.

a Difference between groups using independent t test (or Mann–Whitney) or Chi2 (or Fisher’s) test as appropriate.b By bioimpedance analysis.c Use of at least one antihypertensive medication.d Calculated from the abbreviated Weir equation by indirect calorimetry: REE= 1440 (3.94×VO2 + 1.11×VCO2).e Based on the Canada Fitness Survey questionnaire (1981).f By uniaxial accelerometry.g Based on a 3-day food diary.

Fig. 1. Changes in weight over time by intervention group. Each data pointrepresents a mean change in weight±SEM (P < 0.05 for change in weight ingroup I over time, using Friedman ANOVA by rank). Group I: interdisciplinaryindividual meetings plus group seminars; group G: group seminars only.

attendance to individual counselling was 81%, with 73% attend-ing ≥75% of the scheduled meetings.

3.2. Changes in anthropometry and body composition

Participants taking part in the individual interdisciplinaryintervention lost significantly more weight than those attendingthe group sessions only (P <0.01)(Table 2). Of note, weight lossin group I was continual over the 1-year follow-up (Fig. 1) and,after 1 year, 36% of the participants had reached the objectiveof ≥7% weight loss, 50% had lost ≥5% of their initial weightand 27% had lost ≥10%. In comparison, only 12, 8 and 4%of the participants in group G achieved at least 5, 7 and 10%weight loss, respectively. Of particular interest is the importantreduction in WC observed in subjects assigned to group I vs G.While participants in group G gained significant fat mass, thosewho underwent the individual intervention exhibited a signifi-cant reduction in fat mass. However, a significant decrease inlean mass was noteworthy in both groups. Subjects assigned togroup I significantly reduced their calorie intake and increasedtheir total energy expenditure, as measured by accelerometry.In contrast, those in group G did not change their energy intakeand significantly decreased their energy expenditure.

3.3. Effect on metabolic variables

Fasting and 2-hour OGTT glucose levels significantlyimproved at 1 year compared with baseline levels in groupI(Table 2). On the other hand, HbA1c increased in group G andFPG decreased significantly; however, the change in FPG wasnot significant after excluding a patient who had begun takingmetformin during the study. Of the participants in group I withIFG at baseline, nine on 11 (82%) returned to normal and nonedeveloped diabetes, whereas three on 12 (25%) in group G hadan FPG value in the diabetic range (P = 0.20 for the difference

between groups; Fig. 2A). The effect of both interventions on

Fig. 2. Fasting glucose and glucose tolerance status at 1year by interven-tion group: (A) proportion of participants with impaired fasting glucose (IFG;6.1–6.9mmol/L) at baseline (n = 11 in groupI, n = 12 in groupG) with fastingglucose values in the normal, impaired and diabetes range at 1 year (P < 0.05 forthe difference between groups using Chi2 test); and (B) proportion of partici-pants with post-load glucose values in the normal, impaired glucose tolerance(IGT) and diabetes range at 1 year. All of the participants had IGT at baseline(P < 0.05 for the difference between groups using Chi2 test). GroupI: individualmeetings plus group seminars; group G: group seminars only.

glucosetolerancewaslessstriking,observedinfouron22(18%)

patients in group I vs 3/26 (11.5%) in group G who revertedto a normal glucose-tolerance status (P =0.40 for the differ-ence between groups; Fig. 2B). Insulin sensitivity increased andinsulin secretion decreased significantly in groupI followingthe intervention; however, this did not translate into a signif-icant improvement in beta-cell function, as assessed by theoral disposition index. However, no changes in insulin sensi-tivity, insulin secretion or beta-cell function were observed ingroupG.

Triglyceride levels and total cholesterol (TC)/high-densitylipoprotein cholesterol (HDL-C) ratio improved significantly inboth groups, but was associated with intensification of treat-

ment with statins during the study (23.1% at entry vs 38.5%

Table 2Change in clinical and metabolic variables by group after the 1-year interventions.

Change in variables Group I (n = 22) Group G (n = 26) P-valuea

Weight, kg −4.9 (−7.3, −2.4)c −0.6 (−3.3, 2.1) < 0.01

Body mass index, kg/m2 −1.9 (−2.8, −0.9)b −0.2 (−1.0, 0.7) < 0.01

Waist circumference, cm −5 (−7, −3)c −1 (−3, 1) < 0.01

Body compositione

Fat body mass, kg −2.4 (−3.8, −1.0)c 3.4 (0.2, 6.5)c <0.001Fat body mass, % −0.7 (−1.9, 0.4) 3.6 (1.3, 5.9)c 0.001Lean body mass, kg −2.5 (−4.1, −0.9)c −4.1 (−6.1, −2.0)b 0.24Lean body mass, % 0.8 (−0.4, 1.9) −3.8 (−6.1, −1.4)c 0.001

Blood pressure, mmHgSystolic −6 (−13, 0) 4 (−1, 9) 0.03Diastolic −3 (−7, 1) 0 (−4, 4) 0.30Medication use, %f −4.5 −3.9 0.27

Plasma glucose, mmol/LFasting −0.5 (−0.7, −0.3)b −0.3 (−0.6, 0.0)d 0.312-hour post-75-g glucose −0.5 (−0.9, −0.1)d −0.2 (−1.0, 0.5) 0.54

Glycosylated haemoglobin, % −0.0 (−0.1, 0.0) 0.1 (0.0, 0.2)c 0.02

HOMA-S 0.12 (−0.01, 0.26)d −0.03 (−0.09, 0.04) 0.02

∆ I 0–30 / ∆G0–30 −38.43 (−77.38, 0.52)d −2.08 (−29.63, 25.47) 0.09

Disposition index 0.86 (−11.14, 12.87) −0.99 (−7.88, 5.90) 0.43

Lipid profile, mmol/LTotal cholesterol (TC) −0.3 (−0.5, 0.0) −0.4 (−0.7, 0.0)g 0.56LDL-C −0.1 (−0.3, 0.1) −0.4 (−0.7, 0.0)g 0.17HDL-C 0.0 (−0.0, 0.1) 0.0 (−0.1, 0.1) 0.14Triglycerides −0.4 (−0.7, −0.1)g −0.2 (−0.5, 0.0)g 0.96TC/HDL-C ratio −0.4 (−0.7, −0.1)g −0.4 (−0.7, 0.0) 0.93Statin use, % 4.6 15.4 0.56Fibrate use, % 0.0 0.0 0.21

6-min walking test, m 26 (4, 47)c 37 (13, 61)c 0.77

Energy expenditure (EE), kcal/dayResting EEg −180 (−283, −78)c −164 (−339, 12) 0.28Leisure-time physical activityh 97 (−130, 324) −120 (−315, 74) 0.14Total EEi −65 (−291, 160) −150 (−392, 92) 0.60

Energy intake, kcal/day j −221 (−357, −85)c −140 (−291, 10) 0.42From protein, % 0.9 (−0.6, 2.4) 0.7 (−0.7, 2.0) 0.55From carbohydrates, % 1.5 (−0.5, 3.6) 2.9 (−0.1, 5.8)d 0.77From fat, % −1.3 (−3.7, 1.0) −3.1 (−5.8, −0.5)d 0.42From saturated fat, % −0.3 (−1.3, 0.7) −1.4 (−2.7, −0.2)d 0.42

Data are presented as means (95% CI) or %.HOMA-S: homoeostasis model assessment of insulin sensitivity; LDL-C/HDL-C: low-density/high-density lipoprotein cholesterol.

a Difference between groups using independent t test (or Mann–Whitney) or Chi2 (or Fisher’s) test.b P ≤0.001 for the difference between baseline and 1 year of intervention using paired t (or Wilcoxon’s signed-rank) or McNemar test as appropriate.c

P ≤0.01 for the difference between baseline and 1 year of intervention using paired t (or Wilcoxon’s signed-rank) or McNemar test as appropriate.d P ≤0.05 for the difference between baseline and 1 year of intervention using paired t (or Wilcoxon’s signed-rank) or McNemar test as appropriate.e By bioimpedance analysis.f Use of at least one antihypertensive medication.g Calculated from the abbreviated Weir equation by indirect calorimetry: REE= 1440 (3.94 x VO2 + 1.11 x VCO2).h Based on the Canada Fitness Survey questionnaire (1981).i By uniaxial accelerometry. j Based on a 3-day food diary;

at the end of the study; P = 0.20). Although not significant,a reduction in both systolic and diastolic blood pressure wasobserved in group I together with a decrease in the proportion of subjects taking antihypertensive medication. In contrast, partic-

ipants in group G showedneither significant changes in their use

of antihypertensive medication nor any improvements in bloodpressure.

When the analysis included only those subjects who com-pleted the intervention, the results in groupG were similar to

thoseintheITTanalysis.IngroupI,weightloss(meanof6.6kg)

Table 3Direct annual cost of interdisciplinary intervention per patient.

History and medical examination and medical follow-up $443.90Nurse intervention $84.65Dietitian intervention $82.69Seminars $81.36Receptionist (scheduling, recall) $30.47

Material $10.00Total $733.06

and reduction in WC (mean of 6cm) were greater when theanalysis included the completers vs the ITT group, although themagnitude of the changes in metabolic variables was similarbetween the completers and the ITT group. Finally, in groupG,on comparing the participants who attended at least 75% of the group seminars with those who failed to adhere with theintervention, it was apparent that weight loss at 1 year (−1 kgvs −0.3kg; P = 0.43 for the difference between groups) andchanges in metabolic variables were similar between the two

groups. In group I, adherence to the group seminars was associ-ated with greater weight loss, but was not statistically significant(−6.6kg vs −4.2kg; P = 0.15), with 83% of the participantsachieving 5% weight loss vs 38% (P = 0.06 for the differencebetween groups). However, changes in metabolic variables weresimilar between the two groups. Furthermore, 100% of the par-ticipants adherent to the group seminars attended at least 75%of the clinic visits. Participants who attended at least 75% of theclinicvisits lost a meanof 6.7 kgwhile those who attended<75%of the clinics lost no weight at all (P = 0.01 for the differencebetween groups).

3.4. Cost

Thedirectcostoftheinterventionwasestimatedtobeapprox-imately $735/subject per year in group I, and $80/subject peryear in groupG (Table 3).

4. Discussion

The effectiveness of interdisciplinary weight-managementprogrammes in reducing therisk of T2DM in individuals at high-risk is well-established [2,3]. However, the lack of human andeconomic resources limits widespread implementation of suchprogrammes in thecommunity. The ideal programme has to take

into account the restrictions of the current healthcare system.The present study was undertaken to evaluate whether or nota moderate-intensity interdisciplinary programme and lower-intensity group seminars would result in clinically significantweight loss at a relatively low cost.

In fact, the present study demonstrates that a moderate-intensity intervention (group I) can achieve results similar to themore intensive DPP study and DPS, and highlights the impor-tance of an individual interdisciplinary approach for obtainingclinically significant weight loss in those with prediabetes. Thegroup seminar approach alone was not associated with anyweight loss or improvement in metabolic profile of the partici-

pants. The high rate of non-attendance together with the absence

of individual counselling probably contributed to the lack of efficacy of this type of intervention, as previously reported [15].However,ourpresentresultsrevealedthatadherencetothegroupseminars was not associated with better outcomes in terms of weight loss and metabolic improvements, suggesting that thistype of intervention maynot be suitable for a number of patients.Indeed, other researchers have also shown low efficacy withgroup interventions [16]. The reasons explaining the low adher-ence to the group seminars remain speculative, but perhaps alow motivation of the participants contributed to the failure of this approach [17].

In contrast, our individual interdisciplinary approach wasassociated with weight loss and metabolic improvement similarto those reported in the DPP study and DPS (36% of the partic-ipants achieved the objective of ≥7% weight loss vs ≈50% inthe DPP study and <43% in the DPS at 1 year); it was also asso-ciated with significantly greater weight loss than seen with othermoderate-intensity interventions [2,18,19]. Of utmost impor-tance is the proportion of participants who reverted to normal

FPG (82%) and glucose tolerance status (18%) after only a year,even if these differences were not statistically significant due tothelackofpowerofthestudy.Also,themarkedreductioninWC,an indirect measure of abdominal obesity, that accompanied theintervention has important clinical implications, given its asso-ciation with cardiovascular disease (CVD) [20] and all-cause,CVD and cancer mortality [21].

In addition to its effectiveness, the direct annual medicalcosts per patient of our interdisciplinary intervention were esti-mated at only $735 compared with $1400 in the DPP study[22], which renders our programme attractive from a decision-making perspective. Such an intervention has, in fact, been

implemented at our institution since 2001 [5], and costs havebeen further reduced to $515 by decreasing physicians’ visits toevery 3 months.

Subjects assigned to group I lost fat mass, but they also losta significant amount of lean mass. Thus, physical activity is animportant component of weight management and was stronglyemphasized as part of our intervention. In addition to helpingto sustain long-term weight reduction, physical exercise canpreserve or attenuate the decrease in muscle and bone massthat occurs during weight loss [23–26]. Although significant,the increase in physical activity, as assessed by questionnaire,was minimal compared with the decrease in energy intake inour study, suggesting that weight loss was mainly attributable

to calorie restriction rather than increased energy expenditure.Nevertheless, our results highlight the importance of physicalactivity as part of weight management, and suggest that physicaltherapists/kinesiologists should be part of the multidisciplinaryteam.

The limitations of our present study need to be considered.The inclusion of only Caucasians limits its generalizability.However, the fact that participants had a tailored interventionwith each healthcare professional suggests that the results couldbe extrapolated to other populations. Another limitation was therelatively short follow-up of 1 year. In this regard, the 7-yearfollow-up data of the DPS showed that, even after discontinu-

ation of an active lifestyle intervention, people at high risk of

diabetes had a sustained reduction in the incidence of T2DM(hazard ratio of 0.57) [27]. These results suggest that even anintervention lasting for just a limited time can yield long-termdiabetes risk-reduction benefits.

5. Conclusion

A moderate-intensity intervention comprising individuallifestyle counseling and group seminars is associated with sig-nificant weight loss andimprovements in themetabolic profileof individuals with prediabetes, whereas group seminars alone arenot associated with weight loss. As the implementation of sucha strategy relies on fewer human and economic resources thanwere utilized in the DPP study, it could also possibly increasethe accessibility of our intervention and decrease the burden of T2DM.

Disclosure of interest

The authors declare that they have no conflicts of interestconcerning this article.

Acknowledgements

We thank the other members of the interdisciplinary UETROstaff – Diego Bellabarba, Marie-Josée Bertrand, Anick Cham-poux, Marie-Isabelle Doucet, Ghislaine Houde, Julie Ménardand Caroline Noël – who participated in the care of the studypatients. This work was supported by the Novo NordiskEndocrine Resident Research Award (to Claudia Gagnon) anda grant from the Ministry of Health of Québec (Programmede subventions en santé publique ; Grant Programme in Public

Health). Marie-France Langlois, Jean-Patrice Baillargeon andAndré Carpentier are recipients of career awards from the Fondsde la recherche en santé du Québec (FRSQ; Funding Agencyfor Human Health Research). The Centre de recherche cliniqueÉtienne-Le Bel (Étienne-Le Bel Clinical Research Centre) is aFRSQ-funded research centre.

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