Program May Match Gastric-Band Benefits, Up Glycemic Control

Marlene Busko

June 25, 2015

BOSTON — Obese patients with type 2 diabetes who follow the 12-week Weight Achievement and Intensive Treatment (Why WAIT) program may attain similar 1-year health benefits as those who undergo laparoscopic gastric banding, a new study suggests.

In a second, related study, one in 20 obese patients with type 2 diabetes who followed this weight-management program had a major improvement in glycemic control, defined as achieving an HbA1c < 6.5% with or without antihyperglycemic agents after one year.

These findings were reported in two posters at the recent American Diabetes Association (ADA) 2015 Scientific Sessions.

The first one reported outcomes from the Surgery or Lifestyle With Intensive Medical Management in Treatment of Type 2 Diabetes (SLIMM-T2D) randomized controlled trial.

The findings suggest that both treatment strategies lead to similar improvements in diabetes control, cardiometabolic risk factors, and quality-of-life parameters, Dr Osama Hamdy, MD, PhD, from the Joslin Diabetes Center, Boston, Massachusetts, and colleagues said. "These results may be useful in guiding obese patients with type 2 diabetes when they explore their weight-management options," they note.

The second study, which looked at diabetes remission, identified certain characteristics that predicted which patients were more likely to have improved glycemic control a year after following the medical management program. These included those who had had diabetes for a short time (< 5 years), a body mass index (BMI) < 40 kg/m2, and an HbA1c < 7.5%, were taking two or fewer oral antihyperglycemic agents, and had achieved a > 7% weight loss at 3 months.

"We think that if we focus on [patients who fit] these criteria, we may be able to not cure, but to induce diabetes remission," coauthor of the poster about diabetes remission, Adham Mottalib, MD, from the Joslin Diabetes Center told Medscape Medical News.

The first study, with lead author Su-Ann Ding, MD, from Harvard Medical School, Boston, Massachusetts, was also published online in April (J Clin Endocrinol Metab. 2015; DOI:10.1210/jc.2015-1443) The second study was also been published online, in May (J Diabetes Res. 2015; Article ID 468704).

Group Counseling Sessions vs Gastric Banding

In the Why WAIT program, which has been specifically designed to manage weight in obese patients with diabetes, about 12 to 15 individuals attend weekly group meetings where they learn about diet, exercise, and behavior-modification techniques. Key components of the program are strength-building exercises and a diet consisting of 30% protein, Dr Hamby stressed to Medscape Medical News.

The researchers randomized 45 obese patients with type 2 diabetes to receive the Why WAIT program or laparoscopic gastric banding. After five patients dropped out, this left 13 men and nine women who followed the lifestyle program and nine men and nine women who underwent gastric banding.

On average, at study entry, the participants were aged 51, had an HbA1c of 8.2%, weighed 109 kg, had a BMI of 36.5, and had had diabetes for about 9 years.

At 3 months, patients in both groups had lost a similar amount of weight: 38% of participants in the Why WAIT program and 41% of participants who had undergone gastric banding had shed 10% of their initial weight.

However, at 1 year, patients who had undergone gastric banding had kept off more weight than those who had participated in the program (-13.5 kg vs -8.5 kg, respectively, P < .05).

Nevertheless, at 1 year, patients in both groups had similar improvements in cardiovascular risk factors: HbA1c levels dropped 1.2% with gastric banding vs 1.0% with the lifestyle program, and they had similar improvements in blood pressure, triglycerides, and LDL cholesterol.

Thus, patients in both groups had similar improvements in cardiovascular risk, as determined by the United Kingdom Prospective Diabetes Study (UKPDS) risk scores.

The 5-year risk of coronary heart disease (CHD) decreased from 9.7% to 9.0% in patients in the lifestyle-intervention arm and from 10.5% to 9.2% in those who received a gastric band. Similarly, the 5-year risk of having a fatal CHD event decreased from 5.8% to 5.5% in the lifestyle-intervention group and from 6.5% to 5.9% among gastric-banding recipients.

At the same time, patients in both groups reported similar improvements in quality of life, as assessed by the Short-Form 36, the Impact of Weight on Quality of Life (IWQOL), and the Problem Areas in Diabetes (PAID) questionnaires. Patients in both groups lost weight and so they were happier, Dr Hamby said.

"Obesity is a 'brain problem,' and to treat it we need to target the brain," he added. Thus, the cognitive behavioral part of Why WAIT teaches patients about things such as a hunger scale and the 20-minute delay before the brain realizes the stomach is full. The program provides patients with all the tools to help them succeed in losing weight and maintaining the weight loss, he stressed.

Can Lifestyle Changes Induce Diabetes Remission?

In the second poster, the authors note that partial or complete remission from type 2 diabetes — defined as an HbA1c < 6.5% and HbA1c <5.7%, respectively, with no antihyperglycemic medications after 1 year — "is a new and intriguing concept" that was recently observed after bariatric surgery.

But little is known about possible diabetes remission after an intensive medical-management program for weight reduction, they explain.

They looked at data from patients with type 2 diabetes who participated in the Why WAIT program between September 2005 and June 2008. Of 126 patients who were enrolled in the program, 120 completed the program, and 88 patients returned for the 1-year checkup.

Of these 88 participants, 15 patients (17.3%) had major improvements in glycemic control (HbA1c < 6.5%) with one antihyperglycemic medication; two patients (2.3%) achieved partial remission of diabetes; and two patients (2.3%) achieved complete remission of diabetes, at 1 year.

These findings suggest that patients may benefit from an early, intensive lifestyle-counseling program. "Growing evidence, including this study, indicates that lifestyle intervention plays a prime role in diabetes management, and the effort to implement it should be more than the general advice to lose weight and to increase physical activity," the researchers say.

However, this was a retrospective, observational study, so more research is needed to confirm the possibility of diabetes remission in a minority of certain obese patients with type 2 diabetes who follow an intensive lifestyle intervention.

They call for "a randomized controlled prospective study that is designed specifically to evaluate diabetes remission, [with] patients with similar characteristics to those who achieved diabetes remission in this study."

Dr Hamdy is on the advisory panel for Metagenics and receives research support from Metagenics and Neurometrix; he is also a consultant for Abbott Nutrition and Merck. Dr Sakr, Dr Shehab Eldin, and Dr Mottalib have no relevant financial relationships.

American Diabetes Association 2015 Scientific Sessions; June 7, 2015; Boston, Massachusetts. Abstract 2215-P, Abstract 2239-P



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