Weight No More: a randomised controlled trial for people with type 2 diabetes on insulin therapy

Long-Term Effect of Weight Regain Following Behavioral Weight Management Programs on Cardiometabolic Disease Incidence and Risk: Systematic Review and Meta-Analysis

BACKGROUND

Behavioral weight management programs (BWMPs) enhance weight loss in the short term, but longer term cardiometabolic effects are uncertain as weight is commonly regained. We assessed the impact of weight regain after BWMPs on cardiovascular risk factors, diabetes, and cardiovascular disease.

METHODS

Trial registries, 11 databases, and forward-citation searching (latest search, December 19) were used to identify articles published in English, from any geographical region. Randomized trials of BWMPs in adults with overweight/obesity reporting cardiometabolic outcomes at ≥12 months at and after program end were included. Differences between more intensive interventions and comparator groups were synthesized using mixed-effects, meta-regression, and time-to-event models to assess the impact of weight regain on cardiovascular disease incidence and risk.

RESULTS

One hundred twenty-four trials reporting on ≥1 cardiometabolic outcomes with a median follow-up of 28 (range, 11-360) months after program end were included. Median baseline participant body mass index was 33 kg/m2; median age was 51 years. Eight and 15 study arms (7889 and 4202 participants, respectively) examined the incidence of cardiovascular disease and type 2 diabetes, respectively, with imprecise evidence of a lower incidence for at least 5 years. Weight regain in BWMPs relative to comparators reduced these differences. One and 5 years after program end, total cholesterol/HDL (high-density lipoprotein) ratio was 1.5 points lower at both times (82 studies; 19 003 participants), systolic blood pressure was 1.5 mm mercury and 0.4 mm lower (84 studies; 30 836 participants), and HbA1c (%) 0.38 lower at both times (94 studies; 28 083 participants). Of the included studies, 22% were judged at high risk of bias; removing these did not meaningfully change results.

CONCLUSIONS

Despite weight regain, BWMPs reduce cardiometabolic risk factors with effects lasting at least 5 years after program end and dwindling with weight regain. Evidence that they reduce the incidence of cardiovascular disease or diabetes is less certain. Few studies followed participants for ≥5 years.

REGISTRATION

URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42018105744.

Quality improvement strategies enhance primary care dietetics: A systematic review and meta-analysis

BACKGROUND

Quality improvement strategies have been widely applied in health care; however, little is known about their use in primary care dietetics. This review aims to describe and evaluate the effectiveness of quality improvement strategies that seek to improve patient outcomes by enhancing dietetic care compared to standard dietetic care.

METHODS

The study employed a systematic review and meta-analysis design following PRISMA guidelines and included studies up to March 2021. Studies were included if they used a randomised controlled trial (RCT) design to evaluate the effect of a quality improvement strategy applied to care delivered by a dietitian on patient outcomes. A meta-analysis was conducted where there were sufficient studies with homogeneous populations and outcome measures.

RESULTS

Twelve RCTs (n = 1604) met the inclusion criteria for review and five studies (n = 511) were eligible for meta-analysis for glycated haemoglobin in patients with type 2 diabetes. The most frequently reported quality improvement strategies addressed disease management programs (58%), patient education (67%), group care (42%) and patient self-management (42%). A positive intervention effect was reported in 50% of the included studies. A low grade of evidence supported a positive intervention effect for quality improvement intervention by a dietitian for glycated haemoglobin (pooled mean difference = -0.39% with 95% confidence interval = -0.70 to -0.08, p = 0.01) in n = 511 patients with type 2 diabetes mellitus.

CONCLUSIONS

Interventions aimed at enhancing quality in primary care dietetic practice support improvements in patient outcomes. Further research on quality improvement interventions for patient outcomes is required to strengthen the evidence base in this important topic.

Replicating group-based education interventions for the management of type 2 diabetes: a review of intervention reporting

AIMS

To assess the completeness of reporting of group-based education interventions for the management of type 2 diabetes.

METHODS

A previous systematic review of group-based education programmes for adults with type 2 diabetes identified eligible intervention studies. Data were extracted and assessed using the Template for Intervention Description and Replication ('TIDieR') checklist. Missing data were sourced from other published material, or by contacting authors.

RESULTS

Fifty-three publications describing 47 studies were included. No publications sufficiently described all items. Authors of 43 of the 47 included studies (91%) were contacted via e-mail to obtain missing data in order to complete the TIDieR checklist. Seven (16%) did not respond. Additional data were obtained for 33/47 studies (70%). Most studies (45/47, 96%) described the intervention duration and frequency, detailed the procedures and rationale (40/47, 85%), provided a brief intervention name and explained any individual tailoring (38/47, 81%), defined whether providers received training and adequately described how the programme was delivered (37/47, 79%). However, few described any modifications (28/47, 60%), whether the intervention was delivered as planned (27/47, 57%), where it was delivered (21/47, 45%), whether materials were provided (19/47, 40%), and who delivered the intervention (13/47, 28%).

CONCLUSIONS

Group-based education interventions for the management of type 2 diabetes are poorly reported. To translate effective research into practice, practitioners need sufficient detail to implement evidence-based interventions. Researcher adoption of the TIDieR checklist will assist the translation and replication of published interventions.

Tier 3 specialist weight management service and pre-bariatric multicomponent weight management programmes for adults with obesity living in the UK: A systematic review

BACKGROUND

NHS England has recommended a multidisciplinary weight management services (MWMS-Tier 3 services) for patients requiring specialized management of obesity, including bariatric surgery, but clinical and measurable health-related outcomes from these services remains fragmented. We therefore undertook a systematic review to explore the evidence base of effect on body weight loss and comorbidities outcomes of Tier 3 or UK pre-bariatric MWMPs.

METHODS

AMED, CINAHL, EMBASE, HMIC, MEDLINE, PsycINFO, PubMed, HDAS search and Google Scholar were searched from January 2000 to September 2017 in a free-text fashion and crossed-references of included studies to identify potential illegibility. Inclusion criteria were as follows: (a) published Tier 3 original study abstracts/articles; (b) intervention studies with before and after data; (c) studies that included any sort of MWMPs conducted on British residents with obesity; and (d) studies included T2DM measurements in a MWMPs.

RESULTS

In total, 19 studies met the inclusion criteria. The total number of participants analysed was N = 11,735. Baseline accumulative average BMI was calculated at 42.54 kg/m2, weight 117.88 kg and waist circumference 126.9 cm. And at 6 months, 40.73 kg/m2, 112.17 kg and 120.3 cm, respectively. Secondary outcome variables were as improved with reduction in HbA1c, fasting blood sugars, insulin usage and blood pressure. Physical activity increased at 3 months then declined after 6 months with no significant changes in cholesterol levels.

CONCLUSION

Tier 3 and MWMPs have a short to mid-ranged positive effect on obese patients (BMI ≥30 kg/m2) living in the UK regarding accumulated reduction in weight, glycaemic control, blood pressure and with subtle improvements in physical activity.

Exploring the evidence base for Tier 3 weight management interventions for adults: a systematic review

Specialist weight management services provide a treatment option for severe obesity. The objective of the study is to review the characteristics, impact and practice implications of specialist weight management services for adults in the UK. Systematic review: EMBASE, MEDLINE and PsycINFO were searched from January 2005 to March 2016 with supplementary searches. Adults with a body mass index of ≥40 kg m^-2 , or ≥35 kg m^-2 with comorbidity or ≥30 kg m^-2 with type 2 diabetes and any study of multicomponent interventions, in any UK or Ireland setting, delivered by a specialist multidisciplinary team are the inclusion criteria. Fourteen studies in a variety of settings were included: 1 randomized controlled trial, 3 controlled and 10 observational studies. Mean baseline body mass index and age ranged from 40 to 54 kg m^-2 and from 40 to 58 years. The studies were heterogeneous making comparisons of service characteristics difficult. Multidisciplinary team composition and eligibility criteria varied; dropout rates were high (43-62%). Statistically significant reduction in mean body mass index over time ranged from -1.4 to -3.1 kg m^-2 and mean weight changes ranged from -2.2 to -12.4 kg. Completers achieving at least 5% reduction of initial body weight ranged from 32 to 51%. There was evidence for improved outcomes in diabetics. Specialist weight management services can demonstrate clinically significant weight loss and have an important role in supporting adults to manage severe and often complex forms of obesity. This review highlights important variations in provision and strongly indicates the need for further research into effective approaches to support severely obese adults.

Identifying components of self-management interventions that improve health-related quality of life in chronically ill patients: Systematic review and meta-regression analysis

OBJECTIVE

To quantify diversity in components of self-management interventions and explore which components are associated with improvement in health-related quality of life (HRQoL) in patients with chronic heart failure (CHF), chronic obstructive pulmonary disease (COPD), or type 2 diabetes mellitus (T2DM).

METHODS

Systematic literature search was conducted from January 1985 through June 2013. Included studies were randomised trials in patients with CHF, COPD, or T2DM, comparing self-management interventions with usual care, and reporting data on disease-specific HRQoL. Data were analysed with weighted random effects linear regression models.

RESULTS

47 trials were included, representing 10,596 patients. Self-management interventions showed great diversity in mode, content, intensity, and duration. Although self-management interventions overall improved HRQoL at 6 and 12 months, meta-regression showed counterintuitive negative effects of standardised training of interventionists (SMD=-0.16, 95% CI: -0.31 to -0.01) and peer interaction (SMD=-0.23, 95% CI: -0.39 to 0.06) on HRQoL at 6 months.

CONCLUSION

Self-management interventions improve HRQoL at 6 and 12 months, but interventions evaluated are highly heterogeneous. No components were identified that favourably affected HRQoL. Standardised training and peer interaction negatively influenced HRQoL, but the underlying mechanism remains unclear.

PRACTICE IMPLICATIONS

Future research should address process evaluations and study response to self-management on the level of individual patients.

Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults

BACKGROUND

It has been recognized that poor adherence can be a serious risk to the health and wellbeing of patients, and greater adherence to dietary advice is a critical component in preventing and managing chronic diseases.

OBJECTIVES

To assess the effects of interventions for enhancing adherence to dietary advice for preventing and managing chronic diseases in adults.

SEARCH METHODS

We searched the following electronic databases up to 29 September 2010: The Cochrane Library (issue 9 2010), PubMed, EMBASE (Embase.com), CINAHL (Ebsco) and PsycINFO (PsycNET) with no language restrictions. We also reviewed: a) recent years of relevant conferences, symposium and colloquium proceedings and abstracts; b) web-based registries of clinical trials; and c) the bibliographies of included studies.

SELECTION CRITERIA

We included randomized controlled trials that evaluated interventions enhancing adherence to dietary advice for preventing and managing chronic diseases in adults. Studies were eligible if the primary outcome was the client's adherence to dietary advice. We defined 'client' as an adult participating in a chronic disease prevention or chronic disease management study involving dietary advice.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of the studies. They also assessed the risk of bias and extracted data using a modified version of the Cochrane Consumers and Communication Review Group data extraction template. Any discrepancies in judgement were resolved by discussion and consensus, or with a third review author. Because the studies differed widely with respect to interventions, measures of diet adherence, dietary advice, nature of the chronic diseases and duration of interventions and follow-up, we conducted a qualitative analysis. We classified included studies according to the function of the intervention and present results in a narrative table using vote counting for each category of intervention.

MAIN RESULTS

We included 38 studies involving 9445 participants. Among studies that measured diet adherence outcomes between an intervention group and a control/usual care group, 32 out of 123 diet adherence outcomes favoured the intervention group, 4 favoured the control group whereas 62 had no significant difference between groups (assessment was impossible for 25 diet adherence outcomes since data and/or statistical analyses needed for comparison between groups were not provided). Interventions shown to improve at least one diet adherence outcome are: telephone follow-up, video, contract, feedback, nutritional tools and more complex interventions including multiple interventions. However, these interventions also shown no difference in some diet adherence outcomes compared to a control/usual care group making inconclusive results about the most effective intervention to enhance dietary advice. The majority of studies reporting a diet adherence outcome favouring the intervention group compared to the control/usual care group in the short-term also reported no significant effect at later time points. Studies investigating interventions such as a group session, individual session, reminders, restriction and behaviour change techniques reported no diet adherence outcome showing a statistically significant difference favouring the intervention group. Finally, studies were generally of short duration and low quality, and adherence measures varied widely.

AUTHORS' CONCLUSIONS

There is a need for further, long-term, good-quality studies using more standardized and validated measures of adherence to identify the interventions that should be used in practice to enhance adherence to dietary advice in the context of a variety of chronic diseases.

How can structured self-management patient education improve outcomes in people with type 2 diabetes?

Type 2 diabetes (T2DM) is a long-term chronic condition that is complex to manage, with the majority of management being done by the person with diabetes outside of the clinical setting. Because of its complexities, effective self-management requires skills, confidence and the ability to make decisions and choices about treatments and lifestyle on a day-to-day basis. Equipping a person with these self-management skills is in itself challenging and it is now widely accepted that structured education is an integral part of the management of T2DM. This paper explores whether structured self-management education can improve outcomes in people with diabetes. The authors explore what self-management education is, why it is needed and then go on to examine the recent evidence from clinical trials from 2006 onwards.

The Relationship Between Diabetes Mellitus, Depression, and Missed Appointments in a Low-Income Uninsured Population

Purpose

The purpose of this project is to identify rates of depression and document mental health needs of adults with diabetes who obtained care in free clinics. Data were collected to determine if there is a relationship between diabetes and depression and missed appointments in a sample of patients who were low-income, uninsured, and represented a variety of racial groups.

Methods

A sample of 183 adults with diabetes participated by completing paper and computerized questionnaires. Instruments included the Patient Health Questionnaire 9 (to measure prevalence of depression), the RAND 36 Health Survey (to measure quality of health), the Audit of Diabetes Dependent Quality of Life (to measure diabetes-dependent quality of life), and the Diabetes Empowerment Scale (to measure self-efficacy).

Results

The prevalence of depression at a moderate or greater level in the sample was found to be 30.1%. Levels of quality of health and self-efficacy were found to be reduced among those with the presence of depression. A significant increase in the rate of depression was found among those who had attended the free clinic for a longer period. No significant differences were found in diabetes-dependent quality of life and missed appointments among those with depression compared with those without.

Conclusions

Rates of depression among adults with diabetes in a free clinic setting were found to be comparable with the highest rates reported by other studies of insured populations. Results of this study support the need to develop mental health treatment programs for free clinic settings.