Joslin Diabetes Center Management of Diabetes in 2013: The Need to Combine Art and Science Weight Management in the Patient With Diabetes

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1 Long-term Weight Management in Patients With Diabetes: The Why WAIT Model Osama Hamdy, MD, PhD, FACE Medical Director, Obesity Clinical Program Director of Inpatient Diabetes Management Joslin Diabetes Center Assistant Professor of Medicine Harvard Medical School Boston, Massachusetts, USA Objectives 1. Identify the key factors for long-term success of weight management 2. Review the structure and the long-term results of the Why WAIT program Challenges in Dealing With Diabetes and Obesity Why it is difficult for patients with diabetes to lose weight? What are the barriers for weight loss in patients with diabetes? Other Major Challenges: Sarcopenic obesity Hormonal imbalance Rebound weight gain

2 Type of Lifestyle Intervention Short-term weight loss (3-6 months) Advice to change lifestyle +/ 5 lbs (2%) Lifestyle intervention program 5 to 1 lbs (2 5%) Intensive lifestyle intervention program 1 to 2 lbs (5 7%) Optimal intensive lifestyle intervention program 2 to 3 lbs (1 15%) Long-term weight loss (up to 4 years): Intensive lifestyle intervention program 4.7% Optimal intensive lifestyle intervention program 6.3% Why WAIT Program Why WAIT Program Weight Achievement and Intensive Treatment: the world s first clinical practice program designed to help patients with diabetes lose weight through a novel multidisciplinary approach Hamdy O et al. Curr Diab Rep. 28;8(5): Multidisciplinary Intervention

3 Innovations in the Why WAIT Program: Keys to Long-term Weight Redusction Duration and type of exercise Dietary composition and diabetes-specific meal replacement Group intervention and long-term follow-up Medication adjustment Hamdy O. Curr Diab Rep. 211;11(2):75-6. The Role of Exercise Benefits of Increased Physical Activity and Exercise Body weight and visceral fat The benefits of exercise and/or increased physical activity include Blood pressure and lipids Metabolic control Physical fitness and QOL Maintenance of weight loss Vascular resistance

4 Diabetes Significantly Accelerates Loss of Muscle Mass, Strength and Quality Undiagnosed diabetes Diabetes Without diabetes -5 Loss of Muscle Mass (gm/year) Loss of Total Muscle Mass [g/ year] -5 p<.5 Park SW, et al. Diabetes Care 29;32: Exercise Preserves Muscle Mass During Weight Reduction 35 P <.5 Loss of Muscle Mass (as % of total weight loss) Men Women 11 Diet only Diet + exercise Ballor DL and Poehlman ET. Int J Obes Relat Metab Disord. 1994;18:35-4. Changes in % Body Fat, Fat Mass, and Lean/Fat Ratio After 12 Weeks of the Why WAIT? Program Fat mass (lbs) Body fat (%) Lean/fat ratio Body fat mass (lb) n = 85 P<.5 P<.1 P<.1

5 Percent Weight Loss for Categories of 24-Month Physical Activity (N = 17) Jakicic JM et al. Arch Intern Med. 28;168: Effect of Long vs Short Bouts of Exercise on Adherence and Weight Loss Activity (min/wk) Weight loss (kg) 17 Long bouts Short bouts Long bouts Short bouts Long bout = one 4-min session Short bout = four 1-min sessions Jakicic et al. Int J Obes Relat Metab Disord. 1995;19: Balanced Exercise Model in the Why WAIT Flexibility Aerobic Strength Stretching Yoga Walking Swimming Biking Dancing Resistance tubing Weight lifting Yoga All types of exercise should be considered for patients with diabetes unless contraindicated

6 Gradual Progression of Exercise Intervention in the Why WAIT Week Frequency of Exercise Duration of Exercise Type of Exercise days/wk 2 4 min AEX + STCH + CST + CT days/wk 4 45 min AEX + CT + IT STCH + Y + CSE days/wk 5 6 min IT + CT + CSE +SS + Y + STCH AEX Aerobic Exercise SS Superset Training IT Interval Training CSE Core Stability Exercise CT Circuit Training STCH Stretching Exercise CST Cross Training Y Yoga (Vinyasa Flow) Weekly session at the Joslin gym Shahar J et al. ADA. 29. The Role of Dietary Composition Diets With High or Low Protein Content and Glycemic Index for Weight-Loss Maintenance (26 weeks) n = 773 Initial weight loss 8% 13% protein (LGI/HGI) vs 25% protein (LGI/HGI) Larsen TM et al. N Engl J Med. 21;363:

7 The Metabolic Effect of Different Protein/Carbohydrate Ratios in Type 2 DM Protein to carbohydrate to fat: 3:4:3 versus 15:55:3.3%.8% Total glycated hemoglobin response of subjects to the control (15% protein) and high-protein (3% protein) diets over the 5-week study period. Significantly different from the control diet, P <.5 The rate of decline was also significantly greater after the high-protein diet, P<.1 Adapted from Gannon MC et al. Amer J Clin Nutr. 23;78: Strong Correlation Between Meal Replacement (MR) and Weight Loss 1st 2nd 3rd 4th Reduction in Initial Weight in Ill Participants (%) MRs 5.9% 7.2% 9.4% 11.2% Mean number of MRs in each quartile Reproduced with permission from Wadden TA et al. Obesity. 29;17: Dietary Principles of the Why WAIT Caloric intake Carbohydrates 4-45% Natural food (dinner menus and snacks) + meal replacement Glycemic index Protein 3% Fiber MUFA Saturated fat Sodium Hamdy O. US Endocrinology. 29;4(2),

8 Structured Modified Dietary Intervention 2 Meal Replacements (BOOST Diabetic or BOOST Glucose Control ) Two 2 cal snacks (e.g. Fruit, Nuts) Choice from 14 pre-set dinner menus Hamdy O. US Endocrinology. 29;4(2), Structured Modified Dietary Intervention Meal Plan Carbs Protein Fat Hamdy O. US Endocrinology. 29;4(2), The Role of Diabetes Medications

9 Diabetes Medications and Body Weight List A List B Stop, reduce, or switch Continue Add Weight Gain Weight Neutral Weight Loss Significant Pioglitazone Sulfonylureas Glyburide Glipizide Insulin NPH Glargine Regular Aspart Lispro Glulisine Modest Sulfonylureas Glimepiride Glipizide XL Glinides Repaglinide Nateglinide Insulin Detemir Glulisine (PP) Metformin DPP-4 Inhibitors Sitagliptin Saxaglipitin Linagliptin Alogliptin α-glucosidase Inhibitors Acarbose Miglitol Colesevelam Bromocriptine GLP-1 Analogs Exenatide Exenatide ER Liraglutide Pramlintide SGLT-2 inhibitors Mitri J, Hamdy O. Expert Opin Drug Saf. 29;8(5): Cognitive Behavioral Support 3-6 minute sessions facilitated by psychologist Realistic and attainable goals (Smart Goals) for long-term sustainability Relapse prevention using Logbook Learning and success stories Mastering unique challenges (Delay and distraction, Planning ahead, Problem solving) Managing automatic, negative thoughts ( detour thinking ) Hamdy O. US Endocrinology. 29;4(2), Group Adult-Educational Sessions Let Us Start All Team Balancing the Calorie Scale When Thoughts Get in Your Way Take Action-Be Active Effect of Lifestyle on Diabetes & Vascular Health Making Sense of Portion Distortion Burn the Fat Lapse, Relapse, Collapse Stay Active-Keep it Off Lifestyle and Food: What Science Says Keeping out of the Fast Food Lane Eating for Life: How to Put it All Together RD Psychologist EP MD RD EP Psychologist EP MD RD All Team Hamdy O. US Endocrinology. 29;4(2),

10 Key Differences between Look AHEAD vs Why WAIT Look AHEAD Study Dietary intake: kcal/day < 25 lbs kcal/day > 25 lbs 5% carbs, 2% protein, 3% fat Calorie replacements: (2 liquid meal + one snack bar) Transition at week 2 Menu plans provided Physical activity: Gradual increases Goal of 175 min/week 1, steps Group + Individual sessions Medication changes: PCP Why WAIT Program Dietary intake: 15 kcal/day for women 18 kcal/day for men 4% carbs, 3% protein, 3% fat Calorie replacements: (2 liquid meals + 2 food snacks) Transition at week 6 Menu plans provided Physical activity: Gradual increases Goal of 3 min/week Balanced (more resistance exercises) Group intervention only Medication changes: Endocrinologists Wadden TA et al. Obesity. 29;17: Hamdy O et al. Curr Diab Rep. 28;8(5): Results Why WAIT Results after 12 Weeks -1 Weight Loss in Lbs n =

11 Changes in Waist and Waist/Hip Ratio after 12-Week of Why WAIT? Program Waist -3.7 inches Waist/Hip Ratio Waist in inches n = 85 p <.5 p <.1 p <.1.8 Long-Term Reduction in Body Weight After Optimal Lifestyle Intervention in Clinical Practice -5 Weight Loss (lbs) (-6.3%) W 3 M 6 M 9 M 12 M 15 M 18 M 21 M 24 M 27 M 3 M 33 M 36 M 39 M 42 M 45 M 48 M Total N = 12 Hamdy O et al. Diabetes. 212; 61 (suppl 1A): 125-LB. Long-Term Reduction in Body Weight after Optimal Lifestyle Intervention in Clinical Practice Weight Loss (lbs) Weight regain ~5% Total group -8. (-3.3%) (-6.3%) Weight maintenance ~5% (-9.5%) W 3 M 6 M 9 M 12 M 15 M 18 M 21 M 24 M 27 M 3 M 33 M 36 M 39 M 42 M 45 M 48 M Group A Group B Total N = 12 (Group A 57, Group B 63) A versus B P<.5, P<.1, P<.1 Hamdy O et al. Diabetes. 212; 61 (suppl 1A): 125-LB.

12 The Why WAIT Program 7.5 A1C (%) 82% achieved A1C <7% 69% achieved A1c <6.5 19% achieved A1c of <5.7% 6.6 Before After N = 115 P<.1 Percentage Changes in Lipid Profile after 12-Week of Why WAIT? Program % Change TC Triglycerides LDL HDL -3 n = 85 p <.5 p <.1 p <.1 Changes in Liver Enzymes after Why WAIT? Program AST ALT IU/L 15 IU/L n = 62 p <.5 p <.1 p <.1 5

13 Changes in Urinary Albumin/Creatinine Ratio after 12-Week and One Year of the Why WAIT? Program Urinary Albumin/creatinine Ratio mcg/mg Start 12 Weeks 1 year 25 n = 85 p <.1 p <.1 versus baseline Changes in Blood Pressure after 12-Week and One Year of the Why WAIT? Program Systolic BP Diastolic BP mmhg 12 mmhg Start 12 Ws 1 year n = 85 p <.5 p <.1 p <.1 5 Start 12 Ws 1 year Changes in Diabetes Medications After 12 Weeks Diabetes medication Sulfonylureas Before # patients (dose/day) After # patients (dose/day) % Change (dose change) Glyburide 6 (9.5 mg/day) 2 (6.2 mg/day) 67% ( 35%) Glipizide 8 (11.25 mg/day) 3 (6.6 mg/day) 63% ( 41%) Thiazolidinediones Pioglitazone 8 (28.1 mg/day) 1 (15 mg/day) 88% ( 47%) Rosiglitazone 7 (7.4 mg/day) 2 (5 mg/day) 71% ( 33%) Metformin 46 ( mg/day) 47 (1862 mg/day) 2% (12%) Exenatide 8 (15 mcg/day) 25 (17.6 mcg/day) 213% (17) Insulin NPH 6 (47.5 unit/day) 3 (41.7 unit/day) 5% ( 12%) Long-acting analog 1 (6.9 unit/day) 13 (27.2 unit/day) 3% ( 55%) Short-acting analog 14 (52.1 unit/day) 11 (24.1 unit/day) 21% ( 54%) Pramlintide 2 (45 unit/day) 11 (47.3 unit/day) 45% (5%)

14 Why WAIT?: Changes in hs-crp After 6 Months CRP (mcg/l) After 6 months Hamdy O et al. ADA. 29. Economic Impact of Weight Loss in One Year in Patients With Diabetes Cost saving (1% weight loss) Estimated saving in WW (7.6% weight loss) $256 $131 ( 3.6%) 1 ( 5.8%) 2 Saving in 1.5 years HCC $2919 DRC $1494 $1946 ( 27%) $996 ( 44%) 1) P<.5 2) P<.1 Yu AP et al. Curr Med Res Opin. 27;23: Keys to Optimal Lifestyle Intervention for Long-term Weight Reduction 1. Aim for meaningful weight loss goal (5 1%) 2. Gradual and balanced and individualized physical activity Duration of exercise Type of exercise Exercise records 3. Structured dietary intervention & modified macronutrient composition Relatively higher protein, LGI & higher fibers Provided menus Food records 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

15 In Conclusion 1 Long-term weight reduction can be achieved through the non-surgical weight management model of Why WAIT 2 Exercise type and duration significantly impact long-term weight maintenance 3 4 Changing macronutrient compositions, providing structured meal plan plus adding calorie replacements are effective dietary intervention Adjusting diabetes medications is important for effective long-term weight reduction in patients with diabetes 5 Long-term weight reduction in the Why WAIT is cost-effective for prevention and treatment of diabetes Thank You 44