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

Num

ber i

n M

illio

ns

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

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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

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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%

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Weight Losses in ILI were Significantly Greater Than in DSE and Sustained Over a 4‐year Period (Look AHEAD Study)

Wei

ght c

hang

e fr

om b

asel

ine

(%)

*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 yearsPercen

t Red

uctio

n 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

024

681012141618

1 2 3 4

Percen

tage 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 MTotal 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

Weig

ht L

oss i

n Po

unds

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

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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 MGroup 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 -24.1Group 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 -8Total 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

Weig

ht L

oss i

n Po

unds

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

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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

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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 

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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

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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

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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 M

uscle Mass (gm/year)

*

*

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Loss of M

uscle Mass

(As %

 of Total W

eight Loss)

MenWomen

*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

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Balanced Exercise Model

Flexibility Strength

Strength exercise is particularly important during weight reduction

Aerobic

WalkingSwimming

Biking Dancing

Resistance tubing Weight lifting

Yoga

StretchingYoga

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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

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Changes in % Body Fat, Fat Mass & Lean/Fat Ratio after 12 Weeks of Balanced Exercise Plan 

Bod

y Fa

t Mas

s in

lbs

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

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Percent Weight Loss for Categories of 24‐month Physical Activity 

(N = 170)

Jakicic JM et alArch Intern Med. 2008; 168(14): 1550–1560

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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.

Activ

ity (m

in/w

eek)

LongBouts

ShortBouts

10

8

6

4

2

0

Weight Loss (kg)

Jakicic et al. J Obes Relat Metab Disord 1995;19:893.

LongBouts

ShortBouts

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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

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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)

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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

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Strong Correlation Between Calorie Replacement and Weight Loss (Look AHEAD Study)

Number in the bar is mean number of MRs used in that quartile

Redu

ction

in In

itial W

eight

inill

partic

ipants

(%)

MRs = meal replacements.Reproduced with permission from Wadden TA et al. Obesitiy 2009; 17:713-722

117 277 406 608MRs

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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         

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Results of Optimal Intensive Lifestyle Intervention (OILI)

Before After

7.5

6.6

HbA

1c (%

)

Hamdy O, et al. Curr Diab Rep. 2008;8(5):413–420

n = 115

*

Changes in Metabolic& CV Outcomes

* P<0.001

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Cost‐effectiveness of non‐surgical and surgical weight management

Health Care Cost and Diabetes‐Related Cost

Cost utilization (Hospitalization, Clinic visits)

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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.

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Economic Impact of Non‐Surgical Weight Loss in One Year in Patients With Diabetes

Cost Saving(1% wt loss)

Cost

savin

g per

year (-3.6%)1*

(-5.8%)2*

(-27%)

(-44%)

Estimated Saving with(7% wt loss)

1) p<0.5 2) p<001YU AP et al. Curr Med Res Opin. 2007;23(9):2157-69

Health Care Cost Diabetes Related Cost

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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

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In Conclusion

Long-term weight reduction can be achieved through non-surgical weight management

1Exercise type and duration significantly impact long-term weight maintenance

2Changing macronutrient compositions, providing structured meal plan plus adding calorie replacements are effective dietary intervention

3 4Adjusting diabetes medications is important for effective long-term weight reduction in patients with diabetes

5Long-term weight reduction is cost-effective for prevention and treatment of diabetes