Effects of lifestyle intervention on health care costs: Improving Control with Activity and Nutrition (ICAN)

Health Economic Evaluation of a Controlled Lifestyle Intervention: The Healthy Lifestyle Community Program (Cohort 2; HLCP-2)

Non-communicable diseases (NCD) are associated with high costs for healthcare systems. We evaluated changes in total costs, comprising direct and indirect costs, due to a 24-month non-randomized, controlled lifestyle intervention trial with six measurement time points aiming to improve the risk profile for NCDs. Overall, 187 individuals from the general population aged ≥18 years were assigned to either the intervention group (IG; n = 112), receiving a 10-week intensive lifestyle intervention focusing on a healthy, plant-based diet; physical activity; stress management; and community support, followed by a 22-month follow-up phase including monthly seminars, or a control group (CG; n = 75) without intervention. The complete data sets of 118 participants (IG: n = 79; CG: n = 39) were analyzed. At baseline, total costs per person amounted to 67.80 ± 69.17 EUR in the IG and 48.73 ± 54.41 EUR in the CG per week. The reduction in total costs was significantly greater in the IG compared to the CG after 10 weeks (p = 0.012) and 6 months (p = 0.004), whereas direct costs differed significantly after 10 weeks (p = 0.017), 6 months (p = 0.041) and 12 months (p = 0.012) between the groups. The HLCP-2 was able to reduce health-related economic costs, primarily due to the reduction in direct costs.

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update

OBJECTIVE

The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.

METHODS

The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RESULTS

This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.

CONCLUSIONS

This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.

Cost-Effectiveness Analysis of Group vs. Weblog Telecommunication (Web Tel) Nutrition Education Program on Glycemic Indices in Patients With Non-Insulin Dependent Diabetes Mellitus Type 2: A Randomized Controlled Trial

This a randomized controlled trial study with a cost-effectiveness analysis that aimed to compare the cost-effectiveness of group nutrition education with that of Web-Tel nutrition education in the glycemic control of patients with non-insulin-dependent type 2 diabetes mellitus (T2DM). The study was conducted on 105 patients with T2DM for 3 months in Quds health centre of Bushehr province, Iran. The participants were classified based on age and disease severity (hemoglobin A1c level); then, they were randomly assigned to one of the three groups: group education, Web-Tel education, and the control group using block randomization method. The clinical (intermediate) outcome was changes in hemoglobin A1c (HbA1c). Patients' perspective was adopted, and a deterministic one-way sensitivity analysis was conducted to identify the effects of uncertainties. The results indicated that the expected effectiveness was 0.46, 0.63, and 0.4; the mean costs was 27,188, 5,335, and 634 purchasing power parity (PPP) dollars for group education, Web-Tel education, and the control group, respectively. The incremental cost-effectiveness ratio (ICER) of Web-Tel education vs. the control group was positive and equal to $21, 613.04 PPP; since it was less than three times of the threshold, the Web-Tel education method was considered as a more cost-effective method than the control group. On the other hand, the ICER of group education vs. control group was $447,067 PPP and above the threshold, so group education was considered as a dominated method compared with the control group. In conclusion, considering the ICER, Web-Tel education is a more cost-effective method than the other two and can be used as the first priority in educating patients with T2DM. The present study was registered in Thailand Clinical Trials Registry (TCTR20210331001).

Economic Impact and Health Care Utilization Outcomes of Diabetes Self-Management Education and Support Interventions for Persons With Diabetes: A Systematic Review and Recommendations for Future Research

PURPOSE

Value-driven outcomes are important because health systems determine sustainability of diabetes self-management education and support (DSMES) programming. Health care utilization and clinical outcomes are critical factors when considering the impact of DSMES programs.

OBJECTIVE

The aim of this systematic review was to describe studies that report on the economic and health care utilization outcomes of diabetes self-management programs.

METHODS

A systematic literature review was performed in multiple databases. Studies reporting economic and health care utilization outcomes related to DSMES and including 1 or more of the ADCES7 Self-Care BehaviorsTM from January 2006 to May 2020 were included. Eligible articles needed to compare the intervention and comparison group and report on economic impact. The methodological quality was assessed with the Joanna Briggs Institute Critical Appraisal Checklist specific to each individual study design.

RESULTS

A total of 22 of 14 556 articles published between 2007 and 2020 were included. Cost benefits varied, and there were considerable methodological heterogeneity among design, economic measures, population, perspective, intervention, and biophysical outcomes.

CONCLUSION

DSMES interventions may positively impact economic outcomes and/or health care utilization, although not all studies showed consistent benefit. This review highlights an evidence gap, and future health economic evaluations are warranted.

Does Lifestyle Intervention Improve Health of Adults with Overweight/Obesity and Type 2 Diabetes? Findings from the Look AHEAD Randomized Trial

This paper reviews the main findings from the Action for Health in Diabetes (Look AHEAD) Trial, a randomized trial testing the long-term health effects of intensive lifestyle interventions (ILIs) in 5,145 persons with overweight/obesity and type 2 diabetes. Although the primary outcome originally focused on cardiovascular morbidity and mortality, secondary outcomes included a broad range of health parameters related to diabetes and obesity. As the cohort aged, study outcomes were expanded to include health problems affecting geriatric populations, such as cognitive impairment and disability.This review summarizes the history of this trial and presents findings related to a wide range of health outcomes. Studies are reviewed that showed positive impact of ILI on diabetes control and complications, depression, physical health-related quality of life, sleep apnea, incontinence, brain structure, and health care use and costs. Several composite indices were also positively impacted by ILI, including multimorbidity, geriatric syndromes, and disability-free life years. However, there are also some important outcomes that did not show significant differences between the intervention and control, including cardiovascular morbidity and mortality, cancer, cognitive function, and cognitive impairment; for several of these nonsignificant effects, post hoc analyses suggested that there may be differences among subgroups, raising the possibility that ILI may be beneficial to some but potentially harmful to others. The only adverse effects of ILI relative to diabetes support and education were on frailty fractures and the related negative effects on body composition and bone density. Through this review, the manuscript seeks to determine whether weight loss should be encouraged in this population; given the large number of beneficial effects, relative to the small number of adverse effects, the answer appears to be yes.

Real-world impact of ongoing regular exercise in overweight and obese US adults with diabetes on health care utilization and expenses

AIMS

To assess the effect of regular exercise on health care utilization patterns and expenses in a real-world national sample of overweight and obese US adults with diabetes.

METHODS

Medical Expenditure Panel Survey data (2010-2015) identified adults with diabetes and a body mass index (kg/m²) ≥25. Two groups were created: exercise (moderate or vigorous physical activity >30min at least five times weekly) and non-exercise groups.

OUTCOMES MEASURED

average total health care expenses (per-person per-annum) and the likelihood of hospitalization.

RESULTS

Among 5140 overweight and obese adults with diabetes, 49.1% reported exercising at least five times weekly. The exercise group showed lower medical care and prescription drug utilization than the non-exercise group (p<0.001). Total unadjusted health expenses in the exercise group were $5651 lower than the non-exercise group (p<0.001). After controlling for socioeconomic and health-related variables, regular exercise reduced total health care expenses by 22.1% (p<0.001) and the likelihood of hospitalization by 28% (p=0.001).

CONCLUSIONS

Reduced hospitalization and health care expenses were associated with regular exercise (≥30min at least five times weekly) in overweight and obese adults with diabetes.

A cross-sectional survey of general practice health workers' perceptions of their provision of culturally competent services to ethnic minority people with diabetes

AIMS

To explore General Practice teams cultural-competence, in particular, ethnicity, linguistic skillset and cultural awareness. The practice teams' access to diabetes-training, and overall perception of cultural-competence were also assessed.

METHODS

A cross-sectional single-city-survey with one in three people with diabetes from an ethnic minority group, using 35 semi-structured questions was completed. Self-reported data analysed using descriptive statistics, interpreted with reference to the Culturally-Competent-Assessment-Tool.

RESULTS

Thirty-four (52%) of all 66 practices in Coventry responded between November 2011 and January 2012.

KEY FINDINGS

(1) One in five practice staff was from a minority group in contrast with one in ten of Coventry's population, (2) 164 practice staff (32%) spoke a second language relevant to the practice's minority population, (3) 56% of practices were highly culturally-competent at providing diabetes services for minority populations, (4) 94% of practices reported the ethnicity of their populations, and (5) the most frequently stated barriers to culturally-competent service delivery were language and knowledge of nutritional habits.

CONCLUSIONS

Culturally-competent diabetes care is widespread across the city. Language barriers are being addressed, cultural knowledge of diabetes-related-nutrition requires further improvement. Further studies should investigate if structured cultural-competence training for diabetes service providers produces positive effects in diabetes-related outcome-measures in minority populations.

Quantified patient preferences for lifestyle intervention programs for diabetes prevention-a protocol for a systematic review

BACKGROUND

The 20-70% participation of diabetes patients in lifestyle interventions (LSI) worldwide seems to be rather sub-optimal, in spite of all intents of such interventions to delay further progress of the disease. Positive effects through LSI are expected in particular for patients who suffer less from diabetes-related limitations or other chronic diseases. Seeing that diabetes prevalence and with it mortality are increasing, LSI have become an inherent part of diabetes treatment standards. Various qualitative studies have been carried out to identify participation barriers for LSI. However, these have not resulted in more detailed knowledge about the relative importance of factors with an inhibiting impact on participation. Since it cannot be assumed that all of the influencing factors have equivalent values, it is necessary to investigate their individual importance with regard to a positive or negative decision about participating. There are no systematic reviews on patient preferences for LSI programs in diabetes prevention. As a result, the main objectives of this systematic review are to (i) identify existing patient preference elicitation studies related to LSI for diabetic patients, (ii) summarize the methods applied and findings, and (iii) appraise the reporting and methodological quality of such studies.

METHODS

We will perform systematic literature searches to identify suitable studies from 14 electronic databases. Retrieved study records will be included based on predefined eligibility criteria as defined in this protocol. We will run abstract and full-text screenings and then extract data from all selected studies by filling in a predefined data extraction spreadsheet. We will undertake a descriptive, narrative synthesis of findings to address the study objectives, since no pooling for quantified preferences is for methodological reasons implementable. We will pay special attention to aspects of methodological quality of preference elicitation by applying established evaluation criteria of the ISPOR and some own developed criteria for different elicitation techniques. All critical stages within the screening, data extraction, and synthesis processes will be conducted by two pairs of authors. This protocol adheres to PRISMA and PRISMA-P standards.

DISCUSSION

The proposed systematic review will provide an overview of the methods used and current practice in the elicitation and quantification of patients' preferences for diabetes prevention lifestyle interventions. Furthermore, the methodological quality of the identified studies will be appraised as well.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018086988.

Achievement of Target Blood Pressure Levels among Japanese Workers with Hypertension and Healthy Lifestyle Characteristics Associated with Therapeutic Failure

BACKGROUND

Few studies have examined Japanese with regard to the achievement rates for target blood pressure levels, or the relationship between these rates and healthy lifestyle characteristics in patients with hypertension as defined by the newly established hypertension management guidelines (JSH2014). The aim of this study was to elucidate achievement rates and examine healthy lifestyle characteristics associated with achievement status among Japanese.

METHODS

This cross-sectional study, conducted in January-December 2012, examined blood pressure control and healthy lifestyle characteristics in 8,001 Japanese workers with hypertension (mean age, 57.0 years; 78.8% were men) who participated in a workplace health checkup. Data were collected from workplace medical checkup records and participants' self-administered questionnaires. We divided into 5 groups [G1; young, middle-aged, and early-phase elderly patients (65-74 years old) without diabetes mellitus or chronic kidney disease (CKD) (<140/90 mmHg), G2; late-phase elderly patients (≥75 years old) without diabetes mellitus or CKD (<150/90 mmHg), G3; diabetic patients (<130/80 mmHg), G4; patients with CKD (<130/80 mmHg), and G5; patients with cerebrovascular and/or coronary artery diseases (<140/90 mmHg)] according to JSH2014. And then, achievement rates were calculated in each group. Multivariate analysis identified healthy lifestyle characteristics associated with "therapeutic failure" of target blood pressure.

RESULTS

Target blood pressures were achieved by 60.2% of young, middle-aged, and early-phase elderly patients (G1), 71.4% of late-phase elderly patients (G2), 30.5% of diabetic patients (G3), 33.4% of those with chronic kidney disease (G4), and 66.0% of those with cerebrovascular and/or coronary artery diseases (G5). A body mass index of 18.5-24.9 and non-daily alcohol consumption were protective factors, and adequate sleep was found to contribute to therapeutic success.

DISCUSSION

We found low achievement rates for treatment goals among patients with chronic kidney disease and diabetes mellitus. Maintaining an ideal body weight and adequate alcohol consumption may help with blood pressure control. Lifestyle modification may be necessary for better management of hypertension.

Medication costs during an 18 month clinical trial of obesity treatment among patients encountered in primary care

BACKGROUND

Weight loss often leads to reductions in medication costs, particularly for weight-related conditions. We aimed to evaluate changes in medication costs from an 18 month study of weight loss among patients recruited from primary care.

METHODS

Study participants (n = 79, average age = 56.3; 75.7 % female) with average BMI of 39.5 kg/m(2), plus one co-morbid condition of either diabetes/pre-diabetes, hypertension, abnormal cholesterol, or sleep apnea, were recruited from 2 internal medicine practices. All participants received intensive behavioral and dietary treatment during months 0-6, including subsidized access to portion-controlled foods for weight loss. From months 7-18, all participants were offered continued access to subsidized foods, and half of participants were randomly assigned to continue in-person visits ("Intensified Maintenance"), while the other half received materials by mail or e-mail ("Standard Maintenance"). Medication costs were evaluated at months 0, 6, and 18.

RESULTS

Participants assigned to Intensified Maintenance maintained nearly all their lost weight, whereas those assigned to Standard Maintenance regained weight. However, no significant differences in medication costs were observed within or between groups during the 18 months of the trial. A reduction of nearly $30 per month (12.9 %) was observed among all participants from month 0 to month 6 (active weight loss phase), but this difference did not reach statistical significance.

CONCLUSIONS

A behavioral intervention that led to clinically significant weight loss did not lead to statistically significant reductions in medication costs. Substantial variability in medication costs and lack of a systematic approach by the study team to reduce medications may explain the lack of effect.

TRIAL REGISTRATION

The trial was registered at (NCT01220089) on September 23, 2010.

Economic simulation of canagliflozin and sitagliptin treatment outcomes in patients with type 2 diabetes mellitus with inadequate glycemic control

OBJECTIVES

This study examines the association between changes in diabetes-related quality measures (QMs) (HbA1c, systolic and diastolic blood pressure [BP], low-density lipoprotein cholesterol [LDL-C], and body weight) and healthcare costs in Type 2 diabetes mellitus (T2DM) patients. It also performs an economic simulation that evaluates the cost implications of the changes in QMs and of the incidence rates (IRs) of adverse events (AEs) associated with canagliflozin (CANA) and sitagliptin (SITA) treatments in a real-world setting.

METHODS

Health-insurance claims and electronic medical records from the Reliant Medical Group database (2007-2011) were used to identify adult patients with T2DM receiving metformin and sulfonylurea who did not achieve adequate glycemic control. The association between the changes in QMs and healthcare costs was evaluated using multivariate regression and non-parametric bootstrap methods. AE-related costs were taken from the literature. The cost impact of CANA and SITA outcomes was evaluated using the aforementioned costs and the changes in QMs and the IRs of AEs observed in a recent phase 3 trial comparing CANA and SITA as third oral agent (DIA3015).

RESULTS

Eight hundred and fifty-six T2DM patients were identified (mean age = 65.8; female 45.4%). The regression analysis found that increases of 1 percentage point in HbA1C and 1% in systolic and diastolic BP, LDL-C, or weight were associated with a per patient per year (PPPY) cost increase of $4476 (p = 0.028) and $566 (p = 0.006), a decrease of $362 (p = 0.070) and $7 (p = 0.817), and an increase of $241 (p = 0.481), respectively. The economic simulation showed that changes in QMs and IRs of AEs equivalent to those reported in DIA3015 would be associated with a reduction in PPPY healthcare costs of $6061 (p = 0.036) for CANA and $2190 (p = 0.098) for SITA.

CONCLUSIONS

This study suggests that integrated approaches that manage to control a combination of quality measures are most successful at reducing downstream healthcare costs.

Impact of an intensive lifestyle intervention on use and cost of medical services among overweight and obese adults with type 2 diabetes: the action for health in diabetes

OBJECTIVE

To assess the relative impact of an intensive lifestyle intervention (ILI) on use and costs of health care within the Look AHEAD trial.

RESEARCH DESIGN AND METHODS

A total of 5,121 overweight or obese adults with type 2 diabetes were randomly assigned to an ILI that promoted weight loss or to a comparison condition of diabetes support and education (DSE). Use and costs of health-care services were recorded across an average of 10 years.

RESULTS

ILI led to reductions in annual hospitalizations (11%, P = 0.004), hospital days (15%, P = 0.01), and number of medications (6%, P < 0.001), resulting in cost savings for hospitalization (10%, P = 0.04) and medication (7%, P < 0.001). ILI produced a mean relative per-person 10-year cost savings of $5,280 (95% CI 3,385-7,175); however, these were not evident among individuals with a history of cardiovascular disease.

CONCLUSIONS

Compared with DSE over 10 years, ILI participants had fewer hospitalizations, fewer medications, and lower health-care costs.

Cost-effectiveness of a primary care intervention to treat obesity

BACKGROUND

Data on the cost-effectiveness of the behavioral treatment of obesity are not conclusive. The cost-effectiveness of treatment in primary care settings is particularly relevant.

METHODS

We conducted a within-trial cost-effectiveness analysis of a primary care-based obesity intervention. Study participants were randomized to: Usual Care (UC; quarterly visits with their primary care provider); Brief Lifestyle Counseling (BLC; quarterly provider visits plus monthly weight loss counseling visits) or Enhanced Brief Lifestyle Counseling (EBLC; all above interventions, plus choice of meal replacements or weight loss medication). A health-care payer perspective was used. Intervention costs were estimated from tracking data obtained prospectively. Quality-adjusted life years (QALYs) were estimated with the EuroQol-5D. We estimated cost per kilogram-year of weight loss and cost per QALY.

RESULTS

Weight losses after 2 years were 1.7, 2.9 and 4.6 kg for UC, BLC and EBLC, respectively (P=0.003 for comparison of EBLC vs UC). The incremental cost per kilogram-year lost was $292 for EBLC compared with UC (95% confidence interval (CI): $219-$437). The short-term incremental cost per QALY was $115,397, but the 95% CI were undefined. Comparison of short-term cost per kg with published estimates of longer-term cost per QALY suggested that the intervention could be cost-effective over the long term (≥ 10 years).

CONCLUSIONS

A primary care intervention that includes monthly counseling visits and a choice of meal replacements or weight loss medication could be a cost-effective treatment for obesity over the long term. However, additional studies are needed on the cost-effectiveness of behavioral treatment of obesity.

The role of glucagon-like peptide-1 impairment in obesity and potential therapeutic implications

The hormone glucagon-like peptide-1 (GLP-1) is released from the gut in response to food intake. It acts as a satiety signal, leading to reduced food intake, and also as a regulator of gastric emptying. Furthermore, GLP-1 functions as an incretin hormone, stimulating insulin release and inhibiting glucagon secretion from the pancreas in response to food ingestion. Evidence suggests that the action or effect of GLP-1 may be impaired in obese subjects, even in those with normal glucose tolerance. GLP-1 impairment may help explain the increased gastric emptying and decreased satiety signalling seen in obesity. Incretin impairment, probably associated with reduced insulinotropic potency of GLP-1, is also characteristic of type 2 diabetes (T2D). Therefore, it is possible that incretin impairment may contribute to the pathophysiological bridge between obesity and T2D. This review summarises current knowledge about the pathophysiology and consequences of GLP-1 and incretin impairment in obesity, and examines the evidence for an incretin-related link between obesity and T2D. It also considers the current literature surrounding the novel use of GLP-1 receptor agonists as a treatment for obesity in patients with normoglycaemia, prediabetes and T2D.

Comparison of two self-directed weight loss interventions: Limited weekly support vs. no outside support

SUMMARY

OBJECTIVE

The purpose of this study was to compare the efficacy of two home-based weight loss interventions that differ only in the amount of outside support provided.

METHODS

This was a 12-week, randomized, controlled trial. One group received limited support (LWS, n = 35) via a single 10 min phone call each week while another group received no weekly support (NWS, n = 28). Both the LWS and NWS received pre-packaged meals (PM) and shakes. A third group served as control (CON, n = 30) and received no components of the intervention. Weight loss at 12 weeks was the primary outcome. Diet (PM, shake, and fruit/vegetable (F/V) intake) and physical activity (PA) were self-monitored, recorded daily and reported weekly. An exit survey was completed by participants in the intervention groups upon completion of the study.

RESULTS

Weight loss and percent weight loss in the LWS, NWS, and CON groups were 7.7 ± 4.4 kg (8.5 ± 4.2%), 5.9 ± 4.1 kg (6.0 ± 4.2%), and 0.3 ± 1.9 kg (0.4 ± 1.2%), respectively. The decrease in body weight and percent weight loss was significantly greater in the LWS and NWS groups when compared to the CON group and the percent weight loss was significantly greater in the LWS when compared to both the NWS and CON groups.

CONCLUSION

A home-based weight loss program utilizing PM and shakes results in clinically significant percent weight loss and the addition of a brief weekly call promotes additional percent weight loss.

Position of the Academy of Nutrition and Dietetics: the role of nutrition in health promotion and chronic disease prevention

It is the position of the Academy of Nutrition and Dietetics that primary prevention is the most effective and affordable method to prevent chronic disease, and that dietary intervention positively impacts health outcomes across the life span. Registered dietitians and dietetic technicians, registered are critical members of health care teams and are essential to delivering nutrition-focused preventive services in clinical and community settings, advocating for policy and programmatic initiatives, and leading research in disease prevention and health promotion. Health-promotion and disease-prevention strategies are effective at reducing morbidity and mortality and improving quality of life, and have a significant impact on the leading causes of disease. By applying these principles within a social ecological theoretical framework, positive influence can be applied across the spectrum of engagement: at intrapersonal, interpersonal, institutional, community, and public policy levels. Through the application of efficacious and cost-effective interventions, registered dietitians and dietetic technicians, registered, can positively impact public health as well as health outcomes for the individuals that they counsel. This position paper supports the "Practice Paper of the Academy of Nutrition and Dietetics: The Role of Nutrition in Health Promotion and Chronic Disease Prevention" published on the Academy's website at: www.eatright.org/positions.

A novel endocrinology-based wellness program to reduce medication expenditures and improve glycemic outcomes

AIMS

The purpose of this study was to determine the difference in diabetes-related medication expenditures as a result of a 16-week lifestyle intervention program. Medical expenditures for patients with diabetes are twice as high compared to patients without this condition. Secondary objectives were changes in HbA1C, BMI, weight, body fat, and program satisfaction.

METHODS

The Wellness Life! Program includes educational sessions focused on nutrition, fitness, and behavioral therapy. Medication costs were based on Average Wholesale Prices, tabulated from the 2010 Red Book.

RESULTS

A total of 36 patients (49-80 years old) enrolled, of which 27 patients have diabetes mellitus (Type 2=26, Type 1=1). Mean 30-day anti-diabetic medication costs decreased by $142.92. Clinical mean parameters improved in both the overall group and the diabetic subgroup, respectively: HbA1C (%) -0.69, -0.82; weight (lbs) -16.94, -17.11; BMI -2.73, -2.88; and body fat (%) -1.71, -1.79. Participants were generally satisfied with the program.

CONCLUSIONS

Employing a multidisciplinary wellness program within an endocrinology practice can reduce anti-diabetic medication expenses; however, long term follow-up is needed to determine if medication reductions and improved clinical parameters persist.

The impact of culturally competent diabetes care interventions for improving diabetes-related outcomes in ethnic minority groups: a systematic review

AIM

To examine the evidence on culturally competent interventions tailored to the needs of people with diabetes from ethnic minority groups.

METHODS

MEDLINE (NHS Evidence), CINAHL and reference lists of retrieved papers were searched from inception to September 2011; two National Health Service specialist libraries were also searched. Google, Cochrane and DARE databases were interrogated and experts consulted. Studies were included if they reported primary research on the impact of culturally competent interventions on outcome measures of any ethnic minority group with diabetes. Paper selection and appraisal were conducted independently by two reviewers. The heterogeneity of the studies required narrative analysis. A novel culturally competent assessment tool was used to systematically assess the cultural competency of each intervention.

RESULTS

Three hundred and twenty papers were retrieved and 11 included. Study designs varied with a diverse range of service providers. Of the interventions, 64% were found to be highly culturally competent (scoring 90-100%) and 36% moderately culturally competent (70-89%). Data were collected from 2616 participants on 22 patient-reported outcome measures. A consistent finding from 10 of the studies was that any structured intervention, tailored to ethnic minority groups by integrating elements of culture, language, religion and health literacy skills, produced a positive impact on a range of patient-important outcomes.

CONCLUSIONS

Benefits in using culturally competent interventions with ethnic minority groups with diabetes were identified. The majority of interventions described as culturally competent were confirmed as so, when assessed using the culturally competent assessment tool. Further good quality research is required to determine effectiveness and cost-effectiveness of culturally competent interventions to influence diabetes service commissioners.

Multiple point-of-testing nutrition counseling sessions reduce risk factors for chronic disease among older adults

The objectives of this study were to explore the relationships of baseline dietary intakes and frequency of attendance at point-of-testing nutrition counseling sessions to selected risk factors for chronic diseases during a 3-year intervention. This study was part of a large multidisciplinary, community-based health outreach project conducted in a rural community of northern Louisiana. Screenings, point-of-testing counseling, weekly group exercise sessions, and group nutrition education sessions were provided over a period of 3 years. Outcome variables assessed at 6-month intervals over 3 years were body mass index (BMI), systolic and diastolic blood pressure, fasting blood glucose, and total and LDL cholesterol and dietary intake. Repeated measure analysis of variance was used to investigate the impact of the frequency of counseling sessions on outcome variables. Paired t-tests were used to identify points at which significant changes occurred. A total of 159 subjects ages 65 years and older participated in this study. The majority of the participants were female (62%) and White (82%). Attending the point of testing counseling for more than two sessions was important for a significant improvement in BMI (p ≤ 0.001), LDL cholesterol (p ≤ 0.03), blood glucose (p ≤ 0.03), and diastolic blood pressure (p ≤ 0.045). Participants who attended at least three sessions had significant reductions in risk factors for obesity and related chronic diseases, underscoring the importance of follow-up sessions after health screening.

Willingness to pay for diabetes drug therapy in type 2 diabetes patients: based on LEAD clinical programme results

OBJECTIVE

The purpose of this study was to investigate the preferences of people with diabetes for liraglutide vs other glucose lowering drugs, based on outcomes of clinical trials.

METHODS

Willingness to pay (WTP) for diabetes drug treatment was assessed by combining results from a recent WTP study with analysis of results from the Liraglutide Effect and Action in Diabetes (LEAD) programme. The LEAD programme included six randomised clinical trials with 3967 participants analysing efficacy and safety of liraglutide 1.2 mg (LEAD 1-6 trials), rosiglitazone (LEAD 1 trial), glimepiride (LEAD 2-3 trials), insulin glargine (LEAD 5 trial), and exenatide (LEAD 6 trial). The WTP survey used discrete choice experimental (DCE) methodology to evaluate the convenience and clinical effects of glucose lowering treatments.

RESULTS

People with type 2 diabetes were prepared to pay an extra €2.64/day for liraglutide compared with rosiglitazone, an extra €1.94/day compared with glimepiride, an extra €3.36/day compared with insulin glargine, and an extra €0.81/day compared with exenatide. Weight loss was the largest component of WTP for liraglutide compared with rosiglitazone, glimepiride, and insulin glargine. Differences in the administration of the two drugs was the largest component of WTP for liraglutide (once daily anytime) compared with exenatide (twice daily with meals). A limitation of the study was that it was based on six clinical trials where liraglutide was the test drug, but each trial had a different comparator, therefore the clinical effects of liraglutide were much better documented than the comparators.

CONCLUSIONS

WTP analyses of the clinical results from the LEAD programme suggested that participants with type 2 diabetes were willing to pay appreciably more for liraglutide than other glucose lowering treatments. This was driven by the relative advantage of weight loss compared with rosiglitazone, glimepiride, and insulin glargine, and administration frequency compared with exenatide.

Obesity - an indication for GLP-1 treatment? Obesity pathophysiology and GLP-1 treatment potential

Obesity is common and associated with a high rate of morbidity and mortality; therefore, treatment is of great interest. At present, bariatric surgery is the only truly successful treatment of severe obesity. Mimicking one of the effects of bariatric surgery, namely the increased secretion of glucagon-like peptide (GLP)-1, by artificially increasing the levels of GLP-1 might prove successful as obesity treatment. Recent studies have shown that GLP-1 is a physiological regulator of appetite and food intake. The effect on food intake and satiety is preserved in obese subjects and GLP-1 may therefore have a therapeutic potential. The GLP-1 analogues result in a moderate average weight loss, which is clinically relevant in relation to reducing the risk of type 2 diabetes and cardiovascular disease. Inspired by the hormone profile after gastric bypass, a future strategy in obesity drug development could be to combine several hormones, and thereby produce a superior appetite suppressing hormone profile that may result in a weight loss exceeding that seen in single-agent trials. In conclusion, with the GLP-1 analogues combining a moderate weight loss with beneficial effects on metabolic and cardiovascular risk factors, it seems that we are on the right track for future treatment of obesity.

Active living--the perception of older people with chronic conditions

OBJECTIVES

To describe and understand factors which enhance and impede participation in physical activity for older adults with and without chronic illness and develop a framework of health behaviours for 'active living'.

METHODS

A contrasting group framework was used to compare discussions in two sets of focus groups with relatively healthy and less healthy older adults. The thematic analysis was informed by the Transtheoretical Model, the Health Belief Model and Social Cognitive Theory.

RESULTS

All participants affirmed the health benefits of physical activity and there was broad agreement that social support and conductive environments contributed to the promotion of opportunities for physical activity. However, perceptions of specific factors needed to maintain and promote good health differed between healthy and less healthy participants. Connection to community, sense of place and 'walkability' of neighbourhoods were identified as motivators for undertaking physical activity, whilst barriers were associated with health, the environment, family and attitudes to physical activity.

DISCUSSIONS

The focus groups highlighted the importance of social, behavioural and contextual factors in promoting opportunities for physical activity in older adults with and without chronic illness. The findings were used to propose an Active Living Framework which is the subject of ongoing research.

Optimizing weight control in diabetes: antidiabetic drug selection

CLINICAL QUESTION

Which antidiabetic drugs provide optimal weight control in patients with type 2 diabetes?

RESULTS

Metformin reduces weight gain, and may cause weight loss, when given alone or in combination with other drugs. Pioglitazone and rosiglitazone use is associated with weight gain. Use of the glucagon-like peptide-1 (GLP-1) analogs, liraglutide and exenatide, is associated with weight loss. Dipeptidyl peptidase-4 (DPP-4) inhibitors are considered weight-neutral. Results with insulin therapy are conflicting. Insulin detemir provides weight control along with glycemic control.

IMPLEMENTATION

Weight gain is considered an inevitable part of good glycemic control using conventional modalities of treatment such as sulfonylureas.1Use of metformin, weight-sparing insulin analogs such as insulin detemir, and liraglutide, should be encouraged as monotherapy, or in combination with other drugs.

Physical activity, health status and risk of hospitalization in patients with severe chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a leading cause of death and 70% of the cost of COPD is due to hospitalizations. Self-reported daily physical activity and health status have been reported as predictors of a hospitalization in COPD but are not routinely assessed.

OBJECTIVES

We tested the hypothesis that self-reported daily physical activity and health status assessed by a simple question were predictors of a hospitalization in a well-characterized cohort of patients with severe emphysema.

METHODS

Investigators gathered daily physical activity and health status data assessed by a simple question in 597 patients with severe emphysema and tested the association of those patient-reported outcomes to the occurrence of a hospitalization in the following year. Multiple logistic regression analyses were used to determine predictors of hospitalization during the first 12 months after randomization.

RESULTS

The two variables tested in the hypothesis were significant predictors of a hospitalization after adjusting for all univariable significant predictors: >2 h of physical activity per week had a protective effect [odds ratio (OR) 0.60; 95% confidence interval (95% CI) 0.41-0.88] and self-reported health status as fair or poor had a deleterious effect (OR 1.57; 95% CI 1.10-2.23). In addition, two other variables became significant in the multivariate model: total lung capacity (every 10% increase) had a protective effect (OR 0.88; 95% CI 0.78-0.99) and self-reported anxiety had a deleterious effect (OR 1.75; 95% CI 1.13-2.70).

CONCLUSION

Self-reported daily physical activity and health status are independently associated with COPD hospitalizations. Our findings, assessed by simple questions, suggest the value of patient-reported outcomes in developing risk assessment tools that are easy to use.

Benefits of moderate weight loss in patients with type 2 diabetes

Weight loss is a primary goal of therapy in overweight patients with type 2 diabetes. This review examines whether positive patient outcomes are observed even after relatively small amounts of weight loss, that is, weight loss being more easily attainable in practice. Clinical studies demonstrate that therapeutic benefit rises with increasing weight loss, but that losses as low as 0.45-4 kg (1-9 lb) have positive effects on metabolic control, cardiovascular risk factors and mortality rates. Even the intention to lose weight, without significant success, can improve outcomes in patients with diabetes, presumably because of the healthy behaviours associated with the attempt. The current data support a continued focus on weight loss, including moderate weight loss, as a key component of good care for overweight patients with type 2 diabetes.

High BMI and waist circumference are associated with a high prevalence of comorbidities in older Americans Act programs in Georgia senior centers

OBJECTIVE

This study characterized the relationship of body mass index (BMI) and high waist circumference (WC) with the prevalence of selected comorbidities among older adults receiving nutrition and wellness services from Georgia's Older Americans Act programs at senior centers.

METHODS

Participants were a convenience sample (N = 759, mean age = 75 years, 81% female, 63% white, 36% black). Correction factors were applied to measured WC and to measured and self-reported height and weight.

RESULTS

The prevalence of several comorbidities showed striking relationships with WC and BMI, independent of age, gender, and race.

CONCLUSION

The health burden of overweight/obesity is very high in these older adults creating an urgent need for evidence-based nutrition, physical activity programs, and therapeutic lifestyle counseling to prevent and manage weight-related comorbidities.

Obesity on the rise

The prevalence of obesity has increased markedly during recent years with the burden of obesity higher in minority groups in the United States. Rates of obesity vary according to age and employment, although the effect by socioeconomic strata is diminishing. Body mass index (BMI) and waist circumference (WC) are the primary anthropometric measures of obesity, but waist-to-height is increasingly being used as a measure that identifies both overweight and metabolic risk. BMI should be interpreted with caution in the elderly, children, and some Asian populations.

Impact of lifestyle intervention on lost productivity and disability: improving control with activity and nutrition

OBJECTIVE

To evaluate the effectiveness of a lifestyle intervention (LI) in reducing work loss and disability days.

METHODS

One year randomized controlled trial of health plan members (n = 147) with type 2 diabetes and obesity. Members were randomized to modest-cost LI or usual care (UC). Outcomes were group differences in cumulative days either missed at work or with disability using Mann-Whitney U-tests and Poisson regression models.

RESULTS

LI reduced the risk of workdays lost by 64.3% (P <or= 0.001) compared to UC (annual accumulation: UC: 3.49 days vs LI: 0.92 days, P = 0.01). LI decreased the risk of disability days by 87.2% (P = 0.0003) compared to UC (annual accumulation: UC: 5.3 days vs LI: 0.94 days, P <or= 0.001). Similar trends were observed among the subset of people with depression.

CONCLUSION

LIs reduce work loss and disability days associated with diabetes and obesity.

Use of a real time continuous glucose monitoring system as a motivational device for poorly controlled type 2 diabetes

OBJECTIVE

The use of a real time continuous glucose monitoring system (RT-CGM) was studied as a behavior modification tool and the effectiveness of a RT-CGM in glucose control for patients with type 2 diabetes was determined.

METHODS

We conducted a prospective, open-label, randomized, controlled clinical trial in 65 patients with poorly controlled type 2 diabetes (8.0</=HbA1c</=10%) over a 3-month period. The intervention group was monitored monthly with a RT-CGM (three days at a time for 3 months) and the control group continued self-monitoring blood glucose (SMBG) at least four times a week for 3 months.

RESULTS

The HbA1c of the RT-CGM group was significantly reduced after 12 weeks compared with the SMBG group (9.1+/-1.0% to 8.0+/-1.2% vs. 8.7+/-0.7% to 8.3+/-1.1%, respectively; P=0.004). In the RT-CGM group, there was a significant reduction in total daily calorie intake, weight, body mass index (BMI), and postprandial glucose level, and a significant increase in total exercise time per week after 3 months.

CONCLUSIONS

We demonstrated that the RT-CGM was useful in modifying a patient's diet and exercise habits and could induce better glycemic control than SMBG for patients with type 2 diabetes.

Bioimpedance for severe obesity: comparing research methods for total body water and resting energy expenditure

OBJECTIVE

As the acceptance of surgical procedures for weight loss in morbid obesity is increasing, clinically useful baseline and follow-up measures of total body water (TBW) and resting energy expenditure (REE) are important. Research methods such as deuterium (D(2)O) dilution and metabolic carts are problematic in the clinical setting. We compared bioimpedance analysis (BIA) predicted (Tanita TBF-310) and measured TBW and REE.

METHODS AND PROCEDURES

Forty-two paired presurgery studies were completed using BIA and D(2)O in patients with BMI (mean +/- s.d.) 50.2 +/- 8.8 kg/m(2) for TBW, and 30 patients with BMI 51.0 +/- 13 kg/m(2) completed paired determinations of REE with metabolic carts and the Tanita balance with weight, height, sex, and age modifiers. Regression analysis and Bland-Altman plots were applied.

RESULTS

When regression analysis was completed for TBW, regression line was consistent with the identity line "y = x." The intercept was not different from 0 (95% confidence interval -2.5 +/- 7.0). The slope of the line was not different from 1.0 +/- 0.1. The measured TBW 51.2 +/- 10.1 l had a correlation with the predicted 49.5 +/- 11.27 l of 0.92. There also was no significant difference (P = 0.33) between predicted (2,316 +/- 559 kcal/day) and measured REE (2,383 +/- 576 kcal/day);delta 66.7 +/- 273 kcal/day. The two measures were highly correlated (r = 0.88) with no bias detected.

DISCUSSION

These observations support the use of the BIA system calibration in subjects with severe obesity. Without the use of complex, costly equipment and invasive procedures, BIA measurements can easily be obtained in clinical practice to monitor patient responses to treatment.