Low-Carb Advice in Group Visits Lowers Hypos, Meds in Diabetes

Becky McCall

November 05, 2019

Advice on low-carbohydrate diets incorporated into group medical visits for patients with difficult to treat type 2 diabetes was associated with less use of diabetes medication and, surprisingly, less hypoglycemia, as well as greater weight loss, compared to group visits without such advice.

Both approaches led to a similar improvement in glycemic control, however.

William S. Yancy Jr, MD, from the Duke Diet and Fitness Center, Durham, North Carolina, and colleagues report the findings of the randomized controlled trial in an article published online November 4 in JAMA Internal Medicine.  

"Weight management group visits using a low-carbohydrate diet can be as effective for blood sugar improvement while actually lowering medications," as well as reducing hypoglycemia, and weight, said Yancy, who reports receiving personal fees as a consultant from Guideline Central and dietdoctor.com.

"We know that lifestyle changes can be difficult to maintain, but this study shows that group meetings can be an efficient and effective strategy that helps patients sustain these improvements," he noted in a press release from his institution.

"These two group visit strategies were embedded in outpatient clinics and led by nurses, dietitians, and physicians, so it should be quite feasible to incorporate the new strategy into clinical practice," Yancy pointed out.

Over the total study follow-up of 48 weeks, those in the low carbohydrate diet group had a 50% decrease in hypoglycemic episodes, an almost 8 lbs weight loss, and a decline in diabetes medication use compared with those in the standard group.

Group Medical Visits: A Growing Trend That's Easy to Implement

Group medical visits are increasingly being used to help patients manage their diabetes, and patients and medical providers welcome them, explained Yancy in an interview with Medscape Medical News.

"Group medical visits typically increase diabetes medications to control blood sugar, but in contrast, we have noticed in our low carbohydrate dietary weight loss programs that blood sugar improves and we are able to reduce medications, and since many patients were interested in losing weight and reducing medications, it made sense to test this strategy against the traditional group medical visit [without such intensive weight management advice]," he explained.

The study compared two outpatient group medical visit approaches for diabetes management in 263 people with uncontrolled type 2 diabetes. One approach focused on diabetes-related topics plus medication management for glycemic control (standard group; n = 136). they met every 4 weeks for 16 weeks and then every 8 weeks.

The other group comprised diabetes medication management for glycemic control plus intensive weight management counseling using a low-carbohydrate diet (n = 127). They met every 2 weeks for 16 weeks and then received a similar intervention to the other group, meeting every 8 weeks until study end at 48 weeks.

Sessions for both groups lasted approximately 1.5 to 2 hours and started with outcome data collection by research staff, followed by group counseling led by a registered nurse or registered dietitian.

Sessions ended with a one-on-one meeting with a study physician assigned to the group. The study physicians included two general internists and four endocrinologists. Participants in both groups received a nutrient handbook and similar information emphasizing adequate hydration and physical activity.

Hemoglobin A1c levels, hypoglycemic events, diabetes medication effect score, and weight at 48 weeks were measured.

Patients had a mean body mass index of 35.3 kg/m2 and a mean baseline A1c level of 9.1%.

The group medical visits that included weight management were assessed for noninferiority to the standard group visits for change in A1c at 48 weeks, as well as for superiority to group medical visits alone for hypoglycemic events, diabetes medication intensity, and weight loss.

Glycemic Control Similar, but Weight and Hypoglycemic Events Differed

Patients in the intensive weight management group showed greater initial improvement in glycemic control, but by 48 weeks, A1c level was similarly improved in the weight management and standard groups (8.2% and 8.3%, respectively).

Those in the weight management group lost 3.7 kg more than those in the standard group (–4.1 vs –0.4 kg).

And there was a significantly lower number of hypoglycemic events in the weight management versus the standard group over the 48 weeks (3.2 vs 6.6 events; incidence rate ratio, 0.49; P < .001).

The authors say they didn't expect to see a lower rate of hypoglycemic events in the weight management group.

"Hypoglycemia is commonly identified by people with diabetes as a cause for apprehension and is correlated with lower quality of life. In addition, fear of hypoglycemia can interfere with efforts at more intensive glycemic control," they observe.

Asked whether the low carbohydrate diet alone drove the observed benefits, Yancy said, "because we did not have a third study group that taught the low carbohydrate diet to patients one-on-one, we were unable to tease this out."

However, he noted that prior studies have shown greater reductions in blood glucose and diabetes medications when comparing a low versus a higher carbohydrate diet, "so the diet certainly is a contributor."

Yancy also commented on the generalizability of the findings. "I think this study would generalize quite well to other...primary care and endocrinology clinic settings, as long as staff was trained in teaching the low-carbohydrate diet," adjusting medications and monitoring patients, he concluded.

JAMA Intern Med. Published online November 4, 2019. Abstract

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