Why WAIT for Diabetes Control?
Source Newsroom: Joslin Diabetes Center
Newswise — "Weight loss is emerging as one of the best and safest ways to treat type 2 diabetes," asserts Osama Hamdy, M.D., Ph.D., Medical Director of the Obesity Clinical Program at Joslin Diabetes Center.
In a study concluded last year, 115 people with type 2 diabetes who participated in Joslin's Why WAIT (Weight Achievement and Intensive Treatment) program lost an average of 10.3 percent of their initial weight (or 24 pounds) and an average of 3.7 inches from their waists after 12 weeks. They maintained an average loss of 7.6 percent (or 18.8 pounds) on their own for at least a year and a half afterwards.
Participants' risk for coronary artery disease was down significantly and their blood glucose control so improved that fewer medications--and in some cases, no medications--are now necessary.
These results and related scientific studies have convinced Dr. Hamdy that weight loss is the best way to treat type 2 diabetes.
"For 30 years, the treatment for type 2 diabetes has been to add more medications to get blood glucose under control," points out Dr. Hamdy. "Many of those medications cause weight gain, so people end up with too much medicine and more weight."
A recent study showed that patients with diabetes who gain weight while taking diabetes medications have an additional health care cost of $1,719 per year compared to patients who don't gain weight.
Weight gain is particularly undesirable because about 85 to 90 percent of those with type 2 diabetes are already overweight or obese to start with. Excess weight, particularly around the waist, is a major risk factor for diabetes and one of its most deadly complications, cardiovascular events such as heart attacks and strokes.
Clinical studies conducted by Dr. Hamdy and his colleagues at Joslin and elsewhere have clearly shown that a 7 percent weight loss, combined with moderately intensive exercise, improves insulin sensitivity, lowers blood glucose levels, improves the function of blood vessels, and reduces the inflammation in these vessels that can lead to heart disease. A 7 percent loss of weight for someone who starts at 250 pounds, for example, is a modest 17.5 pounds.
Weight loss-guided by a structured diet, a gradual increase of daily exercise and adjustment of diabetes medications-helps control diabetes, says Dr. Hamdy, and if accomplished in the early stages, can even reverse the disease process, causing remission of the diabetes. About 20 percent of Why WAIT participants no longer require diabetes medication.
Surveys have found that one-third to one-half of primary care physicians don't recommend weight management to their overweight or obese patients. They don't believe patients are motivated enough or they think it will be too costly, as health care insurers don't typically cover the cost of weight loss programs. Studies also find that despite initial weight loss success, people typically regain the weight and only 25 percent can maintain the weight loss for a year
Is it possible to take what has been learned about making lifestyle changes in large clinical research trials like the Diabetes Prevention Program, in which people are intensively supported for six months and longer, and apply it to everyday clinical practice in a shorter timeframe? And what is the best way to help people reach that long-term goal: keeping the weight off?
These are the challenges that Dr. Hamdy and his multidisciplinary Why WAIT team set out to conquer. They developed a three-month program, mostly covered by insurance, and began to enroll 10 to 15 people per session in 2005. Participants come into Joslin once a week for two evening hours and apply what they learn at home.
The Why WAIT team reported on how the participants fared a year and a half after finishing the program at the American Diabetes Association's annual scientific meeting in June, 2009.
Though some had gained back some of the weight they lost, the average loss was 7.6 percent--still above the golden percentage it takes to achieve health benefits.
Just over half (51 percent) of the participants continued to lose weight; typically those who stuck with the program's meal and exercise plans. They were also the ones who maintained excellent blood pressure and diabetes control, and did it using less medication.
Over the course of the program, A1C levels dropped from a starting average of 7.5 percent to 6.6 percent. (Tests of A1C--short for "glycoslated hemoglobin A1C"--measure the glucose that clings to hemoglobin molecules in red blood cells. They are commonly employed in diabetes management to give a good indication of how much extra glucose has been in the bloodstream over the previous few months.) Almost 70 percent of participants lowered their A1C to below 6.5 percent and 82 percent to below 7 percent, which is within Joslin's Clinical Guidelines. Those who maintained their weight loss over the first year also maintained the lower A1C.
The program also resulted in positive changes in participants' cardiovascular disease risk profile-reflected in their improved levels of lipids, blood pressure, and C-reactive protein (a marker for inflammation linked to cardiovascular disease).
The reduction in diabetes medications saved an average of $561.37 per patient per year. Additionally, a recent study showed that just 1% of weight loss in patients with diabetes saved $256 on total health care cost and $131 on diabetes-related cost in a year. A 7.6% weight loss in the Why WAIT program could save $1,946 (or 27%) of the health care cost and $996 (or 44%) of the diabetes-related cost.
How They Did It
A key innovation of the Why WAIT model is how diabetes medications are managed. "We begin by switching participants from medications that cause weight gain to ones that either maintain body weight or help weight loss," says Dr. Hamdy. Every week patients' blood glucose values are reviewed and their diabetes medications are adjusted.
"In our model, the focus is on body weight as the core of diabetes treatment," says Dr. Hamdy. "We've allowed the weight loss itself to help people achieve blood glucose control."
Rooting for the participants and every pound lost along the way are a dietitian, an exercise physiologist, a behavioral psychologist and a nurse educator.
As a team, they deliver five major components of the Why WAIT program:
• Adjustment of diabetes medications
• Structured and modified diet plan
• Gradual, individualized and balanced exercise plan
• Behavioral support to maintain motivation and prevent relapse
• Weekly group education sessions
The principle is simple: eat less and properly and exercise more. "But doing these things and sticking to them is hard," admits Ann Goebel-Fabbri, Ph.D., a Joslin psychologist. "We're requiring people to make multiple changes in their lives simultaneously."
There are no eliminations or rejection like on a television show. There is no blame or shame, as overweight people can sometimes feel in the healthcare or gym environment. But there is gradual, steady weight loss.
Recipes for Success
In the Why WAIT program, calories per day are only cut down by 250 to 500-the equivalent of one-half to a full cup of rich ice cream. In concert with gradually increasing exercise, people lose about one to two pounds every week.
A big part of the program's success, Dr. Hamdy believes, is that the diet is high-protein and low-carb. It strictly follows Joslin's "Clinical Nutrition Guideline for Overweight and Obese Adults with Type 2 Diabetes, Prediabetes or Those at High Risk for Developing Type 2 Diabetes," which recommends the ratio of nutrients to be consumed in a day as 20-30 percent protein, around 40 percent carbohydrate higher in fiber and lower in glycemic index, and 30 percent fat (mono or polyunsaturated fat with less saturated fat and no transfat).
This is a higher percentage of protein and a lower percentage of carbohydrate than has been typically recommended for those with diabetes. "Our guidelines were developed to achieve slow but steady weight loss and better diabetes control, and especially to prevent cardiovascular complications," points out Dr. Hamdy. "It is safe and effective for weight loss, helps people feel more full, results in higher energy levels, and helps reduce blood pressure."
Protein should come from lean sources such as poultry or fish, rather than meat, which is higher in saturated fats, says Gillian Arathuzik, RD, CDE, the program dietitian.
Dealing with Set-Backs
A central theme is that improvement doesn't have to be all or nothing. "There are so many ways to slip up in eating, or by not exercising or monitoring enough," points out Dr. Goebel-Fabbri. "When this happens, it's very easy to move right into self-blame and negative thinking that this is never going to work."
The team uses a highway metaphor to turn this thinking around: If you are trying to drive to Boston and end up in Hartford, Conn., you don't say I'm going to have to get out and stay here; you get right back in the car and head in the direction you want to go.
A large part of what the team does is to help everyone stay motivated. But the "big bang" of motivation is the weight change people see every week. They find that they feel better; their blood glucose numbers are dropping and their energy, lung capacity and flexibility are improving.
On the Right Track
The average age of Why WAIT participants is 54, but 20 percent of them are over age 70. "One participant completed the program at age 81," says Joan Beaton, program coordinator. Most of them have never exercised before. So the emphasis is on gradually introducing varied exercise into their lives, from 20 to 30 minutes a day three to four times a week, to eventually 45 to 60 minutes a day six times a week.
During the program, Why WAIT participants go once a week to the gym at Joslin, a friendly "teaching gym" with equipment designed for larger bodies and those with orthopedic complications. "They experience different exercises, build confidence and become more comfortable with their bodies," explains Jacqueline Shahar, M.Ed., R.C.E.P., C.D.E., Joslin's Manager of Exercise Physiology.
The key is for participants to take home what they've learned. Not everybody has access to a gym. "Everyone leaves with an exercise program that is adapted to their particular lifestyle and medical needs," says Shahar.
The Million-Dollar Question
"Weight-based diabetes management through Why WAIT is a revolutionary new model for managing diabetes," says Dr. Hamdy. "It is totally different from classic model of medication-based diabetes management. The novel model results in less medication, better control, reduced cost, healthier weight, lower cardiovascular risk and above all improved quality of life."
Even those who are severely obese and choose bariatric surgery for weight loss would benefit from first losing weight through a program like this, Hamdy believes. He and his colleagues are about to start a study to compare the Why WAIT model to bariatric surgery.
But the million-dollar question is how to help people maintain weight loss beyond one to five years. "We know people need consistent support afterwards and we are trying to create the best maintenance program," he says.
"Our recent study among Why WAIT participants showed that people who exercised most after the program are those who maintained the weight loss for 18 month," says Shahar.
The team offers each "graduate" a case manager who checks in with them monthly and is available for questions any time. Hamdy says this is like a booster shot to help with barriers to staying on track--be it fitting enough exercise in their lives or sticking to the diet at holidays.