Changes in health state utilities with changes in body mass in the Diabetes Prevention Program

The effects of carbohydrate-restricted diet on psychological outcomes: a systematic review of randomized controlled trials

CONTEXT

Carbohydrate-restricted diets are widely used as an effective treatment tool for many chronic diseases. The impact of these diets on physical health is well known, but their impact on psychological health is less well described in the scientific literature. This is an important aspect to focus on, especially if the diets are to be sustainable in the long term.

OBJECTIVE

The objective of this study was to systematically review the scientific literature describing the effect of carbohydrate-restricted diets and ketogenic diets on psychological outcomes, as observed in randomized controlled trials. Additionally, the potential synergistic effect of carbohydrate-restricted diets and exercise or social factors on these outcomes was researched.

DATA SOURCES

Five databases (Web of Science, PubMed, Scopus, ScienceDirect, and MEDLINE Complete) were searched without restriction of publication date.

DATA EXTRACTION

The first data extraction was made in October 2020 and the second in May 2022. Abstract screening was performed by 3 independent reviewers. The quality of studies was assessed using the Jadad scale.

DATA ANALYSIS

Sixteen randomized controlled studies were included in the analysis. Five studies focused on clinical populations, 9 on obese/overweight populations, and 2 on healthy populations; all studies examined adult people. Four psychological outcomes were identified (quality of life, mental health, mood, and fatigue), and they were examined in connection with a very low-carbohydrate or ketogenic diet.

CONCLUSION

Daily low-carbohydrate intake may not negatively affect psychological well-being, and low-carbohydrate diets and ketogenic diets are no worse than other diets in this respect. An intervention of 12 weeks or longer can bring benefits in psychological well-being. The synergistic effect of diet and exercise or social factors was not reviewed due to lack of evidence.

Loss of Health State Utilities Attributable to Obesity

OBJECTIVES

This study aimed to quantify the association between the loss of health state utilities (LHSU) and obesity, considering different obesity categories. This is relevant to interventions economic evaluations and for public policy decision planning.

METHODS

Using data from the Chilean National Health Survey, this study uses linear regression models and counterfactual scenarios to calculate the prevalent burden, population averages, and total sum of LHSU attributable to obesity for the Chilean national level on people older than 15 years, year 2017. Adjustments for socioeconomic status and associated noncommunicable diseases (NCDs) are considered. Calculating the LHSU using these methods enables the approximation of loss of prevalent quality-adjusted life-years (QALYs).

RESULTS

The raw obesity LHSU burden was 9.1% (95% uncertainty interval [UI] 5.1-13). When adjustment is considered, the LHSU attributable to obesity reaches 4.6% (95% UI 0.6-8.5) being responsible for 121 045 prevalent QALYs. Socioeconomic status adjusted analysis of higher body mass index (BMI, in kg/m²) categories of obesity shows a dose-response effect for LHSU, being the BMI ≥ 40 category with the highest population average of attributable LHSU (10.1; 95% UI 5.5-14.5, scale 0 [full health] to 100 [dead]). Burden for BMI ≥ 35 categories showed the biggest change after NCD adjustment.

CONCLUSIONS

Obesity carries a significant burden of QALY loss. Policy decision-making addressing obesity should focus specially on the BMI ≥ 40 group. NCD comorbidity should be considered for policies addressing the BMI ≥ 35 group.

Association of metformin and depression in patients with type 2 diabetes

BACKGROUND

Emerging evidence showed metformin may have pleiotropic effects on ameliorating depression. However, whether metformin was associated with decreased risk of depression remains unclear.

METHODS

A historical cohort study was conducted based on a medical claim database from 2010 to 2017 in Beijing, China. Patients newly diagnosed with T2D were classified into the metformin and non-metformin groups according to their initial antidiabetic prescription. The incidences of depression between the groups were compared using Cox proportional regression model.

RESULTS

There were 193,624 (37.4 %) and 323,930 (62.6 %) T2D patients in the metformin and non-metformin groups. The mean age was 54.9 (SD: 13.1) years and 53.9% were females. With a median follow-up of 3.2 years, 64,963 patients developed depression. The adjusted incidence of depression in the metformin group (30.6, 95 % CI: 30.1, 31.0 per 1000 person-years) was significantly lower than in the non-metformin group (39.6, 95 % CI: 39.3, 40.0 per 1000 person-years, P < 0.001). The metformin group was significantly associated with a lower risk of depression compared with the overall non-metformin group (HR: 0.77, 95% CI: 0.75, 0.78), as well as compared with α-glucosidase inhibitors (HR: 0.73, 95 % CI: 0.71, 0.74), sulfonylureas (HR: 0.84, 95 % CI: 0.82, 0.86), and glinides (HR: 0.85, 95 % CI: 0.82, 0.88), except for thiazolidinediones (HR: 0.96, 95 % CI: 0.91, 1.01). The association between metformin and lower depression risk was significant in all the age and sex subgroups.

CONCLUSIONS

Metformin was associated with a lower risk of depression compared with other oral hypoglycemic agents, indicating a potential pleiotropic effect on depression.

The role of metformin as a treatment for neuropsychiatric illness

Advances in psychopharmacology have been significantly slower to evolve than in other disciplines of medicine and therefore investigation into novel therapeutic approaches is required. Additionally, concurrent metabolic conditions are prevalent among people with mental disorders. Metformin is a widely used hypoglycaemic agent that is now being studied for use beyond diabetes management. Evidence is emerging that metformin has multiple effects on diverse neurobiological pathways and consequently may be repurposed for treating mental illness. Metformin may have beneficial neuroimmunological, neuroplastic, neuro-oxidative and neuro-nitrosative effects across a range of psychiatric and neurodegenerative illnesses. Mechanisms include glucose lowering effects and effects on AMP-activated protein kinase (AMPK) signalling, however the best evidence for clinical benefit is through the glucose lowering effects, with other mechanisms less supported by the current evidence base. This narrative review aims to draw together the existing evidence for use of metformin as a psychopharmaceutical and present the role of metformin in the context of physical and psychiatric ill health, including metabolic, endocrinological and cancer domains. It not only has therapeutic potential in medical comorbidity but may have potential in core illness domains.

Investigating the pro-cognitive and anti-depressant efficacy of metformin: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

The preclinical and clinical data regarding the efficacy of metformin as a pro-cognitive and anti-depressant therapy is mixed. We conducted a systematic review and meta-analysis of randomised controlled trials investigating the effects of metformin on cognition and depressive symptoms.

METHODS

The study was conducted in accordance with PRISMA guidelines (PROSPERO identifier: CRD42020184547). PubMed and Web of Science were searched (inception through to May 6, 2020) for trials which measured the effects (change from baseline to end-of-treatment) of metformin on cognition and depressive symptoms, compared to either placebo or other oral antidiabetic therapies. When feasible, pooled meta-analytic estimates were provided using a random-effects model.

RESULTS

Eight studies met the inclusion criteria: four assessed only cognition, three assessed only depressive symptoms, and one study assessed both cognition and depressive symptoms. Results suggested that metformin was significantly superior to placebo in improving cognitive function in patients suffering with clinical conditions associated with cognitive impairment (SMD: 0.80; 95%CI: 0.46 to 1.15; p < 0.001; N = 2 studies; I² = 0.0%). One study reported an association between improved cognition and depressive symptoms in a cohort of patients with type 2 diabetes mellitus and depression. Two studies investigating metformin versus pioglitazone showed a superior, but not significant, effect of pioglitazone on depressive symptoms (SMD: 1.56; 95%CI: -0.52 to 3.56; p = 0.13;I² = 94.9%; N = 2 studies).

LIMITATIONS

Assessment of risk of bias identified two studies as having "some concerns".

CONCLUSIONS

Our findings suggest that metformin might be re-purposed for the treatment of cognitive deficits in select clinical conditions.

Actions of Metformin in the Brain: A New Perspective of Metformin Treatments in Related Neurological Disorders

Metformin is a first-line drug for treating type 2 diabetes mellitus (T2DM) and one of the most commonly prescribed drugs in the world. Besides its hypoglycemic effects, metformin also can improve cognitive or mood functions in some T2DM patients; moreover, it has been reported that metformin exerts beneficial effects on many neurological disorders, including major depressive disorder (MDD), Alzheimer’s disease (AD) and Fragile X syndrome (FXS); however, the mechanism underlying metformin in the brain is not fully understood. Neurotransmission between neurons is fundamental for brain functions, and its defects have been implicated in many neurological disorders. Recent studies suggest that metformin appears not only to regulate synaptic transmission or plasticity in pathological conditions but also to regulate the balance of excitation and inhibition (E/I balance) in neural networks. In this review, we focused on and reviewed the roles of metformin in brain functions and related neurological disorders, which would give us a deeper understanding of the actions of metformin in the brain.

Effects of Metabolic Medicine and Metabolic Surgery on Patient-Reported Outcomes Among Patients with Type 2 Diabetes

The assessment and management of patient-reported outcomes (PROs) is considered secondary to that of cardiometabolic outcomes. When assessed, health-related quality of life (HRQOL), a PRO, can yield pertinent information that cannot be obtained from cardiometabolic assessments. For instance, physical and mental distress can be quantified and treated. Moreover, treatment convenience and satisfaction can be gaged. Behavioral modification, bariatric surgery, and pharmacotherapy can improve PROs. Typically, HRQOL is responsive to changes in weight. Specifically, weight loss and weight gain are associated with positive and negative changes in quality of life, respectively. In addition, patient satisfaction can be influenced by glycemic control. Therefore, hypoglycemia and hyperglycemic episodes can negatively affect patient satisfaction. When managing type 2 diabetes (T2D), it is important to consider how therapies impact PROs. Generally, changes in clinical outcomes mirror changes in PROs. To best manage T2D, integrating the assessment of PROs with clinical outcomes is needed.

Exercise as a Moderator of Persistent Neuroendocrine Symptoms of COVID-19

Precipitated by chronic psychological stress, immune system dysregulation, and a hyperinflammatory state, the sequelae of postacute COVID-19 (long COVID) include depression and new-onset diabetes. We hypothesize that exercise counters the neuropsychiatric and endocrine sequelae of long COVID by inducing the release of circulating factors that mediate the anti-inflammatory response, support brain homeostasis, and increase insulin sensitivity.

What is clinically relevant weight loss for your patients and how can it be achieved? A narrative review

Obesity is a chronic disease with increasing prevalence. It affects quality of life and renders those affected at increased risk of mortality. For people living with obesity, weight loss is one of the most important strategies to improve health outcomes and prevent or reverse obesity-related complications. In line with newly released clinical practice guidelines, weight loss targets for people living with obesity should be defined individually based on their clinical profile, and progress measured in the context of improvements in health outcomes, rather than weight loss alone. We outline current treatment options for clinically meaningful weight loss and briefly discuss pharmacological agents and devices under development. Numerous studies have shown that weight loss of ≥5% results in significant improvements in cardiometabolic risk factors associated with obesity; this degree of weight loss is also required for the approval of novel anti-obesity medications by the US Food and Drug Administration. However, some obesity-related comorbidities and complications, such as non-alcoholic steatohepatitis, obstructive sleep apnea, gastroesophageal reflux disease and remission of type 2 diabetes, require a greater magnitude of weight loss to achieve clinically meaningful improvements. In this review, we assessed the available literature describing the effect of categorical weight losses of ≥5%, ≥10%, and ≥15% on obesity-related comorbidities and complications, and challenge the concept of clinically meaningful weight loss to go beyond percentage change in total body weight. We discuss weight-loss interventions including lifestyle interventions and therapeutic options including devices, and pharmacological and surgical approaches as assessed from the available literature.

Health state utilities associated with weight loss in type 2 diabetes and obesity

INTRODUCTION

Health state utilities associated with weight change are needed as inputs for cost-utility analyses (CUAs) examining the value of treatments for obesity and type 2 diabetes (T2D). Although some pharmaceutical treatments currently in development are associated with substantial weight loss, little is known about the utility impact of weight decreases greater than 10%. The purpose of this study was to estimate utilities associated with body weight decreases up to 20% based on preferences of individuals with obesity, with and without T2D.

METHODS

Health state vignettes were developed to represent respondents' own current weight and weight decreases of 2.5, 5, 10, 15, and 20%. Health state utilities were elicited in time trade-off interviews in two UK locations (Edinburgh and London) with a sample of participants with obesity, with and without T2D. Mean utility increases associated with each amount of weight decrease were calculated. Regression analyses were performed to derive a method for estimating utility change associated with weight decreases.

RESULTS

Analyses were conducted with data from 405 individuals with obesity (202 with T2D, 203 without T2D). Utility increases associated with various levels of weight decrease ranged from 0.011 to 0.060 in the subgroup with T2D and 0.015 to 0.077 in the subgroup without T2D. All regression models found that the percentage of weight decrease was a highly significant predictor of change in utility (p < .0001). The relationship between weight change and utility change did not appear to be linear. Equations are recommended for estimating utility change based on the natural logarithm of percentage of weight decrease.

DISCUSSION

Results of this study may be used to provide inputs for CUAs examining and comparing the value of treatments that are associated with substantial amounts of weight loss in patients with obesity, with or without T2D.

Shared metabolic and neuroimmune mechanisms underlying Type 2 Diabetes Mellitus and Major Depressive Disorder

Type 2 Diabetes Mellitus (T2DM) is a chronic metabolic disease with symptoms that go beyond the domain of glucose metabolism. In fact, research has shown that T2DM is accompanied by neurodegeneration and neuroinflammation. Interestingly, Major Depressive Disorder (MDD), a mood disorder characterized mainly by depressed mood and anhedonia is a key feature of T2DM. A body of evidence demonstrates that there are many shared neuroimmune mechanisms underlying the pathophysiology of T2DM and MDD. Therefore, here we review the state-of-art regarding the underlying factors common to both T2DM and MDD. Furthermore, we briefly discuss how depressive symptoms in diabetic patients could be tackled by using novel therapeutic approaches uncovered by these shared mechanisms. Understanding the comorbidity of depression in diabetic patients is essential to fully address T2DM pathophysiology and treatment.

Impact of elevated BMI and types of comorbid conditions on health-related quality of life in a nationally representative US sample

OBJECTIVE

Elevated BMI is associated with multiple chronic conditions including diabetes and CVD. Patients with overweight or obesity may also suffer from comorbidities not directly related to the pathophysiology of elevated BMI. The current study sought to determine the impact of BMI and different types of chronic conditions on health-related quality of life (HRQoL) outcomes.

DESIGN

Six weight categories by BMI were identified: underweight, normal weight, overweight, Class-I obesity, Class-II obesity and Class-III obesity. Twenty chronic conditions were considered and categorised as elevated BMI-related (concordant) or -unrelated (discordant) conditions. HRQoL outcomes were measured using Short Form-6 Dimensions (SF-6D). Multivariable regression models were performed to examine the impact of type, number of comorbid conditions and BMI categories on SF-6D scores.

SETTING

Medical Expenditure Panel Survey (2013-2015).

PARTICIPANTS

Nationally representative sample of US population; 18 years or older (n 58 960).

RESULTS

Of the sample, 1·7 %, 32·9 %, 34·0 % and 31·4 % were classified as underweight, normal weight, overweight and obese, respectively. The SF-6D scores were significantly decreased across all obesity classes, with the largest reduction in Class-III obesity (0·033; P < 0·001). Additionally, individuals with obesity having one or more concordant or discordant comorbidities further reduced SF-6D scores between 0·031 and 0·148 (P-values < 0·001) or between 0·080 and 0·212 (P-values < 0·001), respectively.

CONCLUSIONS

Individuals with obesity had a significant reduction in HRQoL outcomes compared to those with normal BMI. Importantly, discordant comorbidity resulted in greater reduction in HRQoL outcomes compared to concordant comorbidity in subjects with elevated BMI.

Decreased efficacy of the ketamine and scopolamine-induced sustained antidepressant-like effects in rats receiving metformin

BACKGROUND

Metformin is the most widely used drug for treating type 2 diabetes mellitus (DM), which frequently co-occurs with depressive disorders. Thus, patients with depression are likely to receive metformin. Metformin activates AMP-activated kinase (AMPK), which inhibits mechanistic target of rapamycin complex 1 (mTORC1) signaling. mTORC1 activation is essential for the antidepressant effects of ketamine and scopolamine. Thus, we hypothesized that metformin may attenuate ketamine- or scopolamine-induced antidepressant efficacies by blocking their mTORC1 activation.

METHODS

We assessed the acute and sustained antidepressant-like actions of ketamine and scopolamine in male Sprague-Dawley rats subjected to the forced swim test with or without metformin pretreatment. The expressions of AMPK, mTORC1, and brain-derived neurotrophic factor (BDNF) in their prefrontal cortex were assessed.

RESULTS

Metformin (50 mg/kg) attenuated the sustained, but not acute, antidepressant-like effects of ketamine (10 mg/kg) and scopolamine (25 μg/kg). Although metformin reduced mTORC1 downstream activated P70S6K, it did not significantly alter mTORser2448 activation and even increased BDNF expression. Notably, ketamine, scopolamine, and metformin all exerted significant antidepressant-like actions, as evidenced by increased AMPK phosphorylation and BDNF expression.

CONCLUSIONS

Metformin-induced attenuation of sustained antidepressant-like effects are not directly dependent on AMPK-deactivated mTORC1. Our results indicate the complexity of interactions between AMPK, BDNF, and mTORC1. Further research, including mechanistic studies, is warranted to comprehensively evaluate the application of metformin in patients receiving mTORC1-based antidepressants.

Diets and drugs for weight loss and health in obesity - An update

Numerous combinations of diets and pharmacological agents, including lifestyle changes, have been launched to treat obesity. There are still ambiguities regarding the efficacies of different approaches despite many clinical trials and the use of animal models to study physiological mechanisms in weight management and obesity comorbidities, Here, we present an update on promising diets and pharmacological aids. Literature published after the year 2005 was searched in PubMed, Medline and Google scholar. Among recommended diets are low-fat (LF) and low-carbohydrate (LC) diets, in addition to the Mediterranean diet and the intermittent fasting approach, all of which presumably being optimized by adequate contents of dietary fibers. A basic point for weight loss is to adopt a diet that creates a permanently negative and acceptable energy balance, and prolonged dietary adherence is a crucial factor. As for pharmacological aids, obese patients with type 2 diabetes or insulin resistance seem to benefit from LC diet combined with a GLP-1 agonist, e.g. semaglutide, which may improve glycemic control, stimulate satiety, and suppress appetite. The lipase inhibitor orlistat is still used to maintain a low-fat approach, which may be favorable e.g. in hypercholesterolemia. The bupropion-naltrexone-combination appears promising for interruption of the vicious cycle of addictive over-eating. Successful weight loss seems to improve almost all biomarkers of obesity comorbidities. Until more support for specific strategies is available, clinicians should recommend an adapted lifestyle, and when necessary, a drug combination tailored to individual needs and comorbidities. Different diets may change hormonal secretion, gut-brain signaling, and influence hunger, satiety and energy expenditure. Further research is needed to clarify mechanisms and how such knowledge can be used in weight management.

Antidiabetes Agents and Incident Depression: A Nationwide Population-Based Study

OBJECTIVE

Diabetes is associated with an increased risk of depression. Some antidiabetes agents, specifically metformin and pioglitazone, have been suggested to have beneficial effects on depression, but associations between antidiabetes drugs and depression have not been systematically investigated.

RESEARCH DESIGN AND METHODS

We combined four Danish population-based registers to investigate whether the 20 most widely used orally administered antidiabetes drugs were associated with an altered risk of incident depression. Analyses of insulin were included for comparisons. All persons in Denmark in 2005 were included in the study and followed until 2015. Two different outcome measures of incident depression were included: 1) a diagnosis of depressive disorder at a psychiatric hospital as an inpatient or outpatient and 2) a combined measure of a diagnosis of depression or use of antidepressants. Data were analyzed using Cox regression models.

RESULTS

A total of 360,205 individuals using orally administered antidiabetes drugs and 64,582 using insulin at any time during the study period were included in the analyses. Continued use of metformin and combinations of drugs including metformin were associated with decreased rates of incident depression. Pioglitazone was not associated with a decreased rate of incident depression. No other antidiabetes drugs or insulin showed significant associations with depression.

CONCLUSIONS

Real-life population-based data suggest a positive effect of metformin on depression rates. This evidence should be used in guiding prescriptions for patients with type 2 diabetes who are at risk for developing depression, including those with prior depression or anxiety and patients with a family history of depression.

Clinical Evidence of Antidepressant Effects of Insulin and Anti-Hyperglycemic Agents and Implications for the Pathophysiology of Depression-A Literature Review

Close connections between depression and type 2 diabetes (T2DM) have been suggested by many epidemiological and experimental studies. Disturbances in insulin sensitivity due to the disruption of various molecular pathways cause insulin resistance, which underpins many metabolic disorders, including diabetes, as well as depression. Several anti-hyperglycemic agents have demonstrated antidepressant properties in clinical trials, probably due to their action on brain targets based on the shared pathophysiology of depression and T2DM. In this article, we review reports of clinical trials examining the antidepressant effect of these medications, including insulin, metformin, glucagon like peptide-1 receptor agonists (GLP-1RA), and peroxisome proliferator-activated receptor (PPAR)-γ agonists, and briefly consider possible molecular mechanisms underlying the associations between amelioration of insulin resistance and improvement of depressive symptoms. In doing so, we intend to suggest an integrative perspective for understanding the pathophysiology of depression.

Depression as an Immunometabolic Disorder: Exploring Shared Pharmacotherapeutics with Cardiovascular Disease

Modern times have seen depression and cardiovascular disease (CVD) become notorious public health concerns, corresponding to alarming proportions of morbidity, mortality, decreased quality of life, and economic costs. Expanding comprehension of the pathogenesis of depression as an immunometabolic disorder has identified numerous pathophysiologic phenomena in common with CVD, including chronic inflammation, insulin resistance, and oxidative stress. These shared components could be exploited to offer improved alternatives in the joint management of these conditions. Abundant preclinical and clinical data on the impact of established treatments for CVD in the management of depression have allowed for potential candidates to be proposed for the joint management of depression and CVD as immunometabolic disorders. However, a large proportion of the clinical investigation currently available exhibits marked methodological flaws which preclude the formulation of concrete recommendations in many cases. This situation may be a reflection of pervasive problems present in clinical research in psychiatry, especially pertaining to study homogeneity. Therefore, further high-quality research is essential in the future in this regard.

Cost-Effectiveness of a Weight Loss Intervention: An Adaptation of the Look AHEAD Lifestyle Intervention in the US Military

OBJECTIVE

This study aimed to assess whether a counselor-initiated (CI) adaptation of the Look AHEAD (Action for Health in Diabetes) intensive lifestyle intervention in a military setting was cost-effective relative to a self-paced (SP) adaptation.

METHODS

A cost-effectiveness analysis from a payer perspective was performed alongside a 2014-2017 randomized behavioral weight loss trial among 248 active-duty military personnel stationed at a US Air Force base in Texas. Incremental cost-effectiveness ratios were calculated for weight loss, reductions in waist circumference, and quality-adjusted life-years (QALYs).

RESULTS

After 12 months, the CI adaptation cost more per participant compared with the SP adaptation ($1,081 vs. $120) but achieved greater weight loss (1.86 kg vs. 0.06 kg), greater reductions in waist circumference (1.85 cm vs. 0.48 cm), and more QALYs (0.871 vs. 0.856). The incremental cost-effectiveness ratio for the CI adaptation relative to the SP adaptation was $61,268 per additional QALY. At willingness-to-pay thresholds of $50,000 and $100,000 per QALY, the CI adaptation was 45% and 49% likely to be cost-effective, respectively.

CONCLUSIONS

The CI delivery of the Look AHEAD Intensive Lifestyle Intervention may offer a cost-effective approach to tackle excess weight in the US military.

Effect on Health Care Expenditures During Nationwide Implementation of the Diabetes Prevention Program as a Health Insurance Benefit

OBJECTIVE

Lifestyle interventions slow development of type 2 diabetes by half, but the impact of health payer reimbursement for delivery of intervention programs is not well known. We evaluated net commercial health payer expenditures when offering reimbursement for access to YMCA's Diabetes Prevention Program (YDPP) in 42 states.

RESEARCH DESIGN AND METHODS

We used a nonequivalent comparison group design to evaluate net health care expenditures for adults with prediabetes who attended one or more YDPP visit between 1 July 2009 and 31 May 2013 ("YDPP users"). Rolling, 1:1 nearest neighbor propensity score (PS) matching was used to identify a comparison group of nonusers. Administrative data provided measures of YDPP attendance, body weight at YDPP visits, and health care expenditures. Random effects, difference-in-difference regression was used to estimate quarterly health care expenditures before and after participants' first visit to YDPP.

RESULTS

Worksite screening identified 9.7% of the target population; 39.1% of those identified (19,933 participants through June 2015) became YDPP users. Mean weight loss for YDPP users enrolled before June 2013 (n = 1,725) was 7.5 lb (3.4%); 29% achieved ≥5% weight loss. Inclusive of added costs to offer YDPP, there were no statistically significant differences in mean per-person net health care expenditures between YDPP users and PS-matched nonusers over 2 years ($0.2 lower [95% CI $56 lower to $56 higher]). Mean reimbursement to the YMCA was $212 per YDPP user, with 92.8% of all expenditures made for those who attended at a high rate (≥9 completed YDPP visits).

CONCLUSIONS

Worksite screening was inefficient for identifying the population with prediabetes, but those identified achieved modest YDPP attendance and clinically meaningful weight loss. Over 2 years, added costs to offer the intervention were modest, with neutral effects on net health care costs.

A randomized controlled trial on the effectiveness of 8-week high-intensity interval exercise on intrahepatic triglycerides, visceral lipids, and health-related quality of life in diabetic obese patients with nonalcoholic fatty liver disease

BACKGROUND

Medications are limited for patients with nonalcoholic fatty liver disease (NAFLD). It has been reported that aerobic exercise is effective in reducing the characteristics of NAFLD, although unclear data have ascertained the effects of high-intensity interval aerobic exercise on health-related quality of life (HRQoL) in diabetic obese patients with NAFLD.

OBJECTIVES

This a randomized controlled trial aimed to ascertain the effectiveness of 8-week high-intensity interval exercise on intrahepatic triglycerides (IHTG), visceral lipids and HRQoL in diabetic obese patients with NAFLD.

STUDY DESIGN

Between August and December 2017, 32 diabetic obese patients with NAFLD aged 45 to 60 years (21 men and 11 women) were enrolled in this study. They were randomly assigned to 2 groups, 16 patients in each group, high-intensity interval (HII) exercise and control groups. The HII group received a program of HII aerobic exercise for 8 weeks with medications of NAFLD and the control group received only medications without any type of exercise intervention. The test of IHTG, visceral lipids, and HRQoL were recorded at the initial assessment and at the end of the program after 8 weeks.

RESULTS

There were significant differences between the 2 groups at the end of the study. These study findings exhibited significant improvements in IHTG, VO2peak, visceral lipids, glycohemoglobin, plasma glucose, and all dimensions of HRQoL in the HII group (P <.05), But there was non-significant improvement in any measure in the control group (P >.05) after the 8-week intervention.

CONCLUSION

Eight-week high-intensity interval aerobic exercise has a beneficial effect on IHTG, visceral lipids, and HRQoL in diabetic obese patients with NAFLD. Effort and awareness should be dedicated to encouraging the active lifestyle among different population, especially diabetic obese patients with NAFLD.

Cost-effectiveness and quality of life of a diet intervention postpartum: 2-year results from a randomized controlled trial

Background

Pregnancy has been identified as a contributor to obesity. We have shown that a diet intervention postpartum produced a 2-y weight loss of 8%. Here, we present the impact of the diet intervention on cost-effectiveness and explore changes in quality of life (QOL).

Methods

A total of 110 postpartum women with overweight/obesity were randomly assigned to diet (D-group) or control (C-group). D-group received a 12-wk diet intervention within primary health care followed by monthly emails up to the 1-y follow-up. C-group received a brochure. Changes in QOL were measured using the 36-item Short Form Health Survey and EQ-5D. The analysis of cost-effectiveness was a cost-utility analysis with a health care perspective and included costs of intervention for stakeholder, quality-adjusted life-years (QALYs) gained and savings in health care. The likelihood of cost-effectiveness was examined using the net monetary benefit method.

Results

The D-group increased their QOL more than the C-group at 12 wk. and 1 y, with pronounced differences for the dimensions general health and mental health, and the mental component summary score (all p < 0.05). Cost per gained QALY was 1704–7889 USD. The likelihood for cost-effectiveness, based on a willingness to pay 50,000 USD per QALY, was 0.77–1.00.

Conclusions

A diet intervention that produced clinically relevant postpartum weight loss also resulted in increased QOL and was cost-effective.

Trial registration

Clinical trials, NCT01949558, 2013-09-24

Insulin Resistance as a Shared Pathogenic Mechanism Between Depression and Type 2 Diabetes

Neuropsychiatric disorders and type 2 diabetes (T2D) are major public health concerns proposed to be intimately connected. T2D is associated with increased risk of dementia, neuropsychiatric and mood disorders. Evidences of the involvement of insulin signaling on brain mechanisms related to depression indicate that insulin resistance, a hallmark of type 2 diabetes, could develop in the brains of depressive patients. In this article, we briefly review possible molecular mechanisms associating defective brain insulin signaling with reward system, neurogenesis, synaptic plasticity and hypothalamic-pituitary-adrenal (HPA) stress axis in depression. We further discuss the involvement of tumor necrosis factor α (TNFα) promoting defective insulin signaling and depressive-like behavior in rodent models. Finally, due to the high resistant rate of anti-depressants, novel insights into the link between insulin resistance and depression may advance the development of alternative treatments for this disease.

Effects of lifestyle changes on adults with prediabetes: A systematic review and meta-analysis

AIMS

To assess the efficacy, safety, and cost-effectiveness of lifestyle intervention, compared with treatment as usual in people with prediabetes as defined by the American Diabetes Association. For older studies, we used the 1985 World Health Organization definition.

METHODS

We systematically searched multiple electronic databases and referenced lists of pertinent review articles from January 1980 through November 2015. We performed an update search in MEDLINE on April 26, 2017. Based on a priori established eligibility criteria, we dually reviewed the literature, extracted data, and rated the risk of bias of included studies with validated checklists. To assess the efficacy of lifestyle intervention to prevent or delay further progression to type 2 diabetes, we conducted a random-effects meta-analysis. We assessed the certainty of evidence using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.

RESULT

Pooled results of 16 randomized controlled trials showed that people with prediabetes who received lifestyle intervention had a lower rate of progression to type 2 diabetes after one (4% vs. 10%, RR 0.46 [CI 0.32, 0.66]) and three years of follow-up (14% vs. 23%, RR 0.64 [95% CI 0.53, 0.77]). The majority of the studies also showed a greater weight loss in lifestyle intervention participants, with a great variation between studies. Costs per quality-adjusted life-year were lower when the benefits of lifestyle intervention were analyzed over a lifelong time horizon compared to only the period of lifestyle intervention (three years) or to modeling over a ten-year period.

CONCLUSION

Lifestyle intervention is an efficacious, safe, and cost-effective measure to reduce the risk of progression to type 2 diabetes in people diagnosed with prediabetes. More research is necessary to compare the efficacy of various modes, frequencies, and intensities of lifestyle intervention across studies.

Behavioral and Pharmacotherapy Weight Loss Interventions to Prevent Obesity-Related Morbidity and Mortality in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Overweight and obesity have been associated with adverse health effects.

OBJECTIVE

To systematically review evidence on benefits and harms of behavioral and pharmacotherapy weight loss and weight loss maintenance interventions in adults to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, PubMed Publisher-Supplied Records, PsycINFO, and the Cochrane Central Register of Controlled Trials for studies published through June 6, 2017; ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials through August 2017; and ongoing surveillance in targeted publications through March 23, 2018. Studies from previous reviews were reevaluated for inclusion.

STUDY SELECTION

Randomized clinical trials (RCTs) focusing on weight loss or weight loss maintenance in adults.

DATA EXTRACTION AND SYNTHESIS

Data were abstracted by one reviewer and confirmed by another. Random-effects meta-analyses were conducted for weight loss outcomes in behavior-based interventions.

MAIN OUTCOMES AND MEASURES

Health outcomes, weight loss or weight loss maintenance, reduction in obesity-related conditions, and adverse events.

RESULTS

A total of 122 RCTs (N = 62 533) and 2 observational studies (N = 209 993) were identified. Compared with controls, participants in behavior-based interventions had greater mean weight loss at 12 to 18 months (-2.39 kg [95% CI, -2.86 to -1.93]; 67 studies [n = 22065]) and less weight regain (-1.59 kg [95% CI, -2.38 to -0.79]; 8 studies [n = 1408]). Studies of medication-based weight loss and maintenance interventions also reported greater weight loss or less weight regain in intervention compared with placebo groups at 12 to 18 months (range, -0.6 to -5.8 kg; no meta-analysis). Participants with prediabetes in weight loss interventions had a lower risk of developing diabetes compared with controls (relative risk, 0.67 [95% CI, 0.51 to 0.89]). There was no evidence of other benefits, but most health outcomes such as mortality, cardiovascular disease, and cancer were infrequently reported. Small improvements in quality of life in some medication trials were noted but were of unclear clinical significance. There was no evidence of harm such as cardiovascular disease from behavior-based interventions; higher rates of adverse events were associated with higher dropout rates in medication groups than in placebo groups.

CONCLUSIONS AND RELEVANCE

Behavior-based weight loss interventions with or without weight loss medications were associated with more weight loss and a lower risk of developing diabetes than control conditions. Weight loss medications, but not behavior-based interventions, were associated with higher rates of harms. Long-term weight and health outcomes data, as well as data on important subgroups, were limited.

Repositioning of diabetes treatments for depressive symptoms: A systematic review and meta-analysis of clinical trials

Depression is a common comorbidity in diabetes but conventional antidepressant treatments do not consistently improve outcomes. We tested whether established diabetes treatments can also improve depressive symptoms and examined biological correlates of response. We performed a multi-database systematic search of all clinical trials, which measured the effect of licensed diabetes treatments on depressive symptoms using a validated questionnaire. Results of randomised controlled trials (RCT's) were pooled for meta-analysis. Data were also collected on insulin resistance (HOMA-IR), C-reactive protein (CRP) and fasting blood glucose (FBG) as correlates of response. Nineteen studies (n = 3369 patients) were included in the qualitative synthesis, 9 testing thiazolidenediones, 5 metformin, 2 thiazolidenediones against metformin, 2 incretin-based therapies and 1 insulin. Most studies were of good quality. In random-effects meta-analysis of RCT's, pioglitazone improved depressive symptoms compared to controls (pooled effect size = -0.68 (95% C.I. -1.12 to -0.24), p = .003, N_studies = 8, I² = 83.2%). Conversely, metformin was comparable to controls overall (pooled effect size = +0.32 (95% C.I. -0.23 to 0.88), p = .25, N_studies = 6, I² = 94.2%), although inferior to active controls (pooled effect size = +1.32 (95% C.I. 0.31-2.34), p < 0.001, N_studies = 3, I² = 90.1%). In random-effects meta-regression, female sex (β = -0.023, (95% C.I.-0.041 to -0.0041), p = .016, N_studies = 8) predicted reduction in depressive symptoms with pioglitazone, but baseline HOMA-IR, FBG and severity of depressive symptoms did not. In conclusion, pioglitazone was associated with improvement in depressive symptoms, an effect more marked in women and poorly explained by effects on glycaemia and insulin resistance. Metformin had no consistent benefit on depressive symptoms. Further mechanistc trials of diabetes treatments as potential antidepressants are needed, stratified by sex and including serial measures of innate inflammation.

A peer-support lifestyle intervention for preventing type 2 diabetes in India: A cluster-randomized controlled trial of the Kerala Diabetes Prevention Program

BACKGROUND

The major efficacy trials on diabetes prevention have used resource-intensive approaches to identify high-risk individuals and deliver lifestyle interventions. Such strategies are not feasible for wider implementation in low- and middle-income countries (LMICs). We aimed to evaluate the effectiveness of a peer-support lifestyle intervention in preventing type 2 diabetes among high-risk individuals identified on the basis of a simple diabetes risk score.

METHODS AND FINDINGS

The Kerala Diabetes Prevention Program was a cluster-randomized controlled trial conducted in 60 polling areas (clusters) of Neyyattinkara taluk (subdistrict) in Trivandrum district, Kerala state, India. Participants (age 30-60 years) were those with an Indian Diabetes Risk Score (IDRS) ≥60 and were free of diabetes on an oral glucose tolerance test (OGTT). A total of 1,007 participants (47.2% female) were enrolled (507 in the control group and 500 in the intervention group). Participants from intervention clusters participated in a 12-month community-based peer-support program comprising 15 group sessions (12 of which were led by trained lay peer leaders) and a range of community activities to support lifestyle change. Participants from control clusters received an education booklet with lifestyle change advice. The primary outcome was the incidence of diabetes at 24 months, diagnosed by an annual OGTT. Secondary outcomes were behavioral, clinical, and biochemical characteristics and health-related quality of life (HRQoL). A total of 964 (95.7%) participants were followed up at 24 months. Baseline characteristics of clusters and participants were similar between the study groups. After a median follow-up of 24 months, diabetes developed in 17.1% (79/463) of control participants and 14.9% (68/456) of intervention participants (relative risk [RR] 0.88, 95% CI 0.66-1.16, p = 0.36). At 24 months, compared with the control group, intervention participants had a greater reduction in IDRS score (mean difference: -1.50 points, p = 0.022) and alcohol use (RR 0.77, p = 0.018) and a greater increase in fruit and vegetable intake (≥5 servings/day) (RR 1.83, p = 0.008) and physical functioning score of the HRQoL scale (mean difference: 3.9 score, p = 0.016). The cost of delivering the peer-support intervention was US$22.5 per participant. There were no adverse events related to the intervention. We did not adjust for multiple comparisons, which may have increased the overall type I error rate.

CONCLUSIONS

A low-cost community-based peer-support lifestyle intervention resulted in a nonsignificant reduction in diabetes incidence in this high-risk population at 24 months. However, there were significant improvements in some cardiovascular risk factors and physical functioning score of the HRQoL scale.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry ACTRN12611000262909.

A Fresh Perspective on a Familiar Problem: Examining Disparities in Knee Osteoarthritis Using a Markov Model

Supplemental Digital Content is available in the text.

Background:

Disparities in the presentation of knee osteoarthritis (OA) and in the utilization of treatment across sex, racial, and ethnic groups in the United States are well documented.

Objectives:

We used a Markov model to calculate lifetime costs of knee OA treatment. We then used the model results to compute costs of disparities in treatment by race, ethnicity, sex, and socioeconomic status.

Research Design:

We used the literature to construct a Markov Model of knee OA and publicly available data to create the model parameters and patient populations of interest. An expert panel of physicians, who treated a large number of patients with knee OA, constructed treatment pathways. Direct costs were based on the literature and indirect costs were derived from the Medical Expenditure Panel Survey.

Results:

We found that failing to obtain effective treatment increased costs and limited benefits for all groups. Delaying treatment imposed a greater cost across all groups and decreased benefits. Lost income because of lower labor market productivity comprised a substantial proportion of the lifetime costs of knee OA. Population simulations demonstrated that as the diversity of the US population increases, the societal costs of racial and ethnic disparities in treatment utilization for knee OA will increase.

Conclusions:

Our results show that disparities in treatment of knee OA are costly. All stakeholders involved in treatment decisions for knee OA patients should consider costs associated with delaying and forgoing treatment, especially for disadvantaged populations. Such decisions may lead to higher costs and worse health outcomes.

A systematic review of reviews: exploring the relationship between obesity, weight loss and health-related quality of life

This is the first systematic review of reviews to assess the effect of obesity and weight loss on health-related quality of life (HRQoL). We identified 12 meta-analyses/systematic reviews published between January 2001 and July 2016. They addressed the following themes: (i) the relationship between weight/body mass index and HRQoL (baseline/pre-intervention; n = 2). (ii) HRQoL after weight loss (varied interventions and/or study design; n = 2). (iii) HRQoL after weight loss (randomized controlled trials only; n = 2). (iv) HRQoL after bariatric surgery (n = 6). We found that in all populations, obesity was associated with significantly lower generic and obesity-specific HRQoL. The relationship between weight loss and improved HRQoL was consistently demonstrated after bariatric surgery, perhaps due to a greater than average weight loss compared with other treatments. Improved HRQoL was evident after non-surgical weight loss, but was not consistently demonstrated, even in randomized controlled trials. This inconsistency may be attributed to variation in quality of reporting, assessment measures, study populations and weight-loss interventions. We recommend longer-term studies, using both generic and obesity-specific measures, which go beyond HRQoL in isolation to exploring mediators of HRQoL changes and interactions with other variables, such as comorbidities, fitness level and body image.

Lifestyle intervention using the psychoeducational approach is associated with greater cardiometabolic benefits and retention of individuals with worse health status

OBJECTIVE

This study aimed to compare the effects of two lifestyle intervention programs for type 2 diabetes mellitus (T2DM) prevention - traditional or interdisciplinary psychoeducation-based intervention - in daily habits and cardiometabolic risk factors and investigate the role of the psychoeducational approach for the retention of individuals in the program.

SUBJECTS AND METHODS

Between 2008 and 2010, in a public health service, 183 pre-diabetic individuals were allocated to two 18-month interventions involving diet and physical activity. Physical activity, diet, quality of life (QOL) and depression and biochemical measurements were obtained. Linear mixed-effect models were used to assess the effect of the interventions. A student t test was used to compare dropouts versus non-dropouts.

RESULTS

Improvements in energy intake and physical activity were greater in the interdisciplinary than the traditional intervention. A decrease in fat mass and blood pressure was more pronounced with interdisciplinary intervention. Dropouts from the traditional intervention only had higher BMI and lower fiber intake and QOL than non-dropouts.

CONCLUSION

The interdisciplinary psychoeducation-based intervention revealed useful for reducing cardiometabolic risk and retaining individuals with worse health profiles. This approach represents a feasible strategy for motivating high-risk individuals to adopt a long-term healthy lifestyle.

A Prospective Programmatic Cost Analysis of Fuel Your Life: A Worksite Translation of DPP

OBJECTIVE

An accounting of the resources necessary for implementation of efficacious programs is important for economic evaluations and dissemination.

METHODS

A programmatic costs analysis was conducted prospectively in conjunction with an efficacy trial of Fuel Your Life (FYL), a worksite translation of the Diabetes Prevention Program. FYL was implemented through three different modalities, Group, Phone, and Self-study, using a micro-costing approach from both the employer and societal perspectives.

RESULTS

The Phone modality was the most costly at $354.6 per participant, compared with $154.6 and $75.5 for the Group and Self-study modalities, respectively. With the inclusion of participant-related costs, the Phone modality was still more expensive than the Group modality but with a smaller incremental difference ($461.4 vs $368.1).

CONCLUSIONS

This level of cost-related detail for a preventive intervention is rare, and our analysis can aid in the transparency of future economic evaluations.

Testosterone and depressive symptoms among men in the Diabetes Prevention Program

OBJECTIVE

We examined associations between intensive lifestyle intervention (ILS) and changes in testosterone and associations with mood among middle-aged men.

DESIGN

Secondary analysis of men (n=886) participating in the Diabetes Prevention Program which randomized glucose-intolerant, overweight men to ILS, metformin, or placebo between 1996 and 1999.

MAIN OUTCOME MEASURES

Changes in testosterone between baseline and 1-year follow-up asnd associations of these changes with mood measures (Beck Depression Inventory [BDI-II], Beck Anxiety Inventory [BAI]).

RESULTS

Median baseline testosterone was 10.98nmol/l and 44% (n=385) had testosterone<10.41nmol/l or 300ng/dl. Testosterone increases were greater among men randomized to ILS vs. metformin vs. placebo (1.15nmol/l vs. -0.12nmol/l vs. -0.27nmol/l, p<0.001). The association between changes in testosterone and mood differed by study arm (p<0.001 for interaction); there were no significant associations between changes in testosterone and mood changes among men in the ILS or placebo arms. Among men in the metformin arm, increases in testosterone were significantly associated with decreases in BDI-II (improved depressive symptoms) (β-coefficient -0.2336, p=0.0002) indicating a 0.23 decrease in BDI-II for every 1nmol/l increase in testosterone and decreases in BAI (improved anxiety symptoms) (β-coefficient -0.2147, p=0.0014). Similar patterns were observed for bioavailable testosterone.

CONCLUSIONS

Among overweight middle-aged men with glucose-intolerance, ILS increased endogenous testosterone slightly but without significant improvements in mood. Metformin did not increase testosterone, but among metformin users, testosterone increases were associated with improvements in mood. Thus, interventions that increase endogenous testosterone may not also improve mood.

Cost-effectiveness of SHINE: A Telephone Translation of the Diabetes Prevention Program

BACKGROUND

The Support, Health Information, Nutrition, and Exercise (SHINE) trial recently showed that a telephone adaptation of the Diabetes Prevention Program (DPP) lifestyle intervention was effective in reducing weight among patients with metabolic syndrome. The aim of this study is to determine whether a conference call (CC) adaptation was cost effective relative to an individual call (IC) adaptation of the DPP lifestyle intervention in the primary care setting.

METHODS

We performed a stochastic cost-effectiveness analysis alongside a clinical trial comparing two telephone adaptations of the DPP lifestyle intervention. The primary outcomes were incremental cost-effectiveness ratios estimated for weight loss, body mass index (BMI), waist circumference, and quality-adjusted life years (QALYs). Costs were estimated from the perspective of society and included direct medical costs, indirect costs, and intervention costs.

RESULTS

After one year, participants receiving the CC intervention accumulated fewer costs ($2,831 vs. $2,933) than the IC group, lost more weight (6.2 kg vs. 5.1 kg), had greater reduction in BMI (2.1 vs. 1.9), and had greater reduction in waist circumference (6.5 cm vs. 5.9 cm). However, participants in the CC group had fewer QALYs than those in the IC group (0.635 vs. 0.646). The incremental cost-effectiveness ratio for CC vs. IC was $9,250/QALY, with a 48% probability of being cost-effective at a willingness-to-pay of $100,000/QALY.

CONCLUSIONS

CC delivery of the DPP was cost effective relative to IC delivery in the first year in terms of cost per clinical measure (weight lost, BMI, and waist circumference) but not in terms of cost per QALY, most likely because of the short time horizon.

Lipidomic risk score independently and cost-effectively predicts risk of future type 2 diabetes: results from diverse cohorts

Background

Detection of type 2 diabetes (T2D) is routinely based on the presence of dysglycemia. Although disturbed lipid metabolism is a hallmark of T2D, the potential of plasma lipidomics as a biomarker of future T2D is unknown. Our objective was to develop and validate a plasma lipidomic risk score (LRS) as a biomarker of future type 2 diabetes and to evaluate its cost-effectiveness for T2D screening.

Methods

Plasma LRS, based on significantly associated lipid species from an array of 319 lipid species, was developed in a cohort of initially T2D-free individuals from the San Antonio Family Heart Study (SAFHS). The LRS derived from SAFHS as well as its recalibrated version were validated in an independent cohort from Australia – the AusDiab cohort. The participants were T2D-free at baseline and followed for 9197 person-years in the SAFHS cohort (n = 771) and 5930 person-years in the AusDiab cohort (n = 644). Statistically and clinically improved T2D prediction was evaluated with established statistical parameters in both cohorts. Modeling studies were conducted to determine whether the use of LRS would be cost-effective for T2D screening. The main outcome measures included accuracy and incremental value of the LRS over routinely used clinical predictors of T2D risk; validation of these results in an independent cohort and cost-effectiveness of including LRS in screening/intervention programs for T2D.

Results

The LRS was based on plasma concentration of dihydroceramide 18:0, lysoalkylphosphatidylcholine 22:1 and triacyglycerol 16:0/18:0/18:1. The score predicted future T2D independently of prediabetes with an accuracy of 76 %. Even in the subset of initially euglycemic individuals, the LRS improved T2D prediction. In the AusDiab cohort, the LRS continued to predict T2D significantly and independently. When combined with risk-stratification methods currently used in clinical practice, the LRS significantly improved the model fit (p < 0.001), information content (p < 0.001), discrimination (p < 0.001) and reclassification (p < 0.001) in both cohorts. Modeling studies demonstrated that LRS-based risk-stratification combined with metformin supplementation for high-risk individuals was the most cost-effective strategy for T2D prevention.

Conclusions

Considering the novelty, incremental value and cost-effectiveness of LRS it should be used for risk-stratification of future T2D.

Electronic supplementary material

The online version of this article (doi:10.1186/s12944-016-0234-3) contains supplementary material, which is available to authorized users.

Weight loss results in significant improvements in quality of life for patients with nonalcoholic fatty liver disease: A prospective cohort study

Nonalcoholic fatty liver disease (NAFLD) is highly prevalent and associated with decreased quality of life (QOL). The currently available treatment is weight loss through lifestyle modification. However, longitudinal QOL data are lacking on whether weight loss improves QOL. We prospectively enrolled 151 patients with NAFLD from 2009 to 2014. All patients received a liver biopsy, lifestyle assessment, blood tests, and QOL tools, including the Chronic Liver Disease Questionnaire (CLDQ), a validated health-related quality of life measurement. All patients were followed with a repeat CLDQ at 6 months. The cohort included 91 (60%) men, ages 51.5 ± 12.6 years, 46 (30%) of whom were diabetic. Thirty (21%) had advanced fibrosis or cirrhosis and 67 (47%) had a NAFLD Activity Score >4. Overall, 47 (31%) patients achieved at least a 5% reduction in weight. The cohort's median baseline total CLDQ value was 5.6 (interquartile range: 4.8-6.2). Those who achieved at least a 5% reduction in weight had a 0.45 (95% confidence interval [CI]: 0.24-0.66; P < 0.0001) point improvement in the total CLDQ, compared to 0.003 (95% CI: -0.12-0.12; P = 0.95) in those who did not. Nondiabetic patients with nonalcoholic steatohepatitis and without advanced fibrosis are most likely to achieve QOL benefits from weight loss. For every decrement in body mass index (BMI), there was a corresponding increase of 0.09 (95% CI: 0.03-0.16) points in the CLDQ scale (P = 0.005), adjusting for histology, diabetes, sex, age, and change in alanine aminotransferase level and change in FIB-4 index. A decrease by 5 points in BMI leads to a 10% adjusted improvement in QOL.

CONCLUSION

Patients with NAFLD can experience significant improvements in QOL that appear specific to weight loss and not biochemical improvements.

Impact of weight change on quality of life in adults with overweight/obesity in the United States: a systematic review

OBJECTIVE

To review published evidence on the impact of weight/BMI change on health-related quality of life (HRQoL) in adults from the US with overweight/obesity.

METHODS

The systematic review was conducted in accordance with PRISMA guidelines. MEDLINE, Embase, EconLit, and Cochrane Library databases were reviewed using pre-defined eligibility criteria to identify relevant US studies in adults with overweight/obesity, with ≥1 year follow-up, quantified weight change, and measured HRQoL. This manuscript focuses on HRQoL derived using the Short-Form 36 (SF-36) and Impact of Weight on Quality of Life-Lite (IWQOL-Lite) instruments.

RESULTS

In total, 32 of 6793 identified publications reported HRQoL according to SF-36 or IWQOL-Lite; 20 provided adequate data for inclusion in this review. Although study design and outcomes were heterogeneous, improvements in HRQoL were generally observed with weight loss. Bariatric surgery studies provided the most evidence (12 publications) and demonstrated dramatic (≥20%) weight loss and associated HRQoL improvements. Sustained weight loss was associated with maintenance of HRQoL improvements out to 6 years in some studies. In lifestyle and pharmaceutical intervention studies showing weight loss of 5%-10%, some aspects of HRQoL improved, although the association with weight was not typically explored. Across the 20 publications, physical versus mental HRQoL improvements were more commonly statistically significant.

CONCLUSION

Overweight/obesity is typically associated with poorer HRQoL than normal weight (BMI 18.5-24.9 kg/m(2)). This systematic review of US literature demonstrated that significant weight loss after bariatric surgery may be associated with improvements in HRQoL. In non-bariatric studies with weight loss of ≥5%, improvements in some aspects of HRQoL were noted, although the causal nature of the relationship is uncertain. Although many SF-36 and IWQOL-Lite domain scores increased, improvements were typically only significant for physical, rather than mental, HRQoL. This systematic review provides evidence supporting that weight loss may improve HRQoL in people with overweight/obesity.

The feasibility, acceptability, and preliminary effectiveness of a Promotora-Led Diabetes Prevention Program (PL-DPP) in Latinas: a pilot study

PURPOSE

The purpose of this pilot study is to test the feasibility, acceptability, and preliminary effectiveness of a Promotora-Led Diabetes Prevention Program (PL-DPP) in Hispanic women (Latinas).

METHODS

Twenty Latina adults with prediabetes were enrolled in this single-arm pilot trial of PL-DPP. Participants underwent a year-long lifestyle intervention consisting of 24 sessions divided into 14 weekly core sessions and 10 post-core sessions offered either biweekly or monthly. Each session was led by a promotora in Spanish. The primary outcome was weight change over the 12-month study period.

RESULTS

The study participants were socioeconomically challenged, middle-aged Latinas with limited access to health care. Eighteen participants (90%) completed at least 12 sessions, and 1 was lost to follow-up. Overall, participants reported high levels of satisfaction with PL-DPP. At 12 months, the participants achieved a mean weight loss of 10.8 pounds, which corresponded to 5.6% of initial body weight. Significant pre-post reductions in waist circumference, diastolic blood pressure, LDL cholesterol, and insulin levels were also observed. Modest reductions in A1C and fasting plasma glucose were not significant.

CONCLUSIONS

The PL-DPP demonstrated feasibility, acceptability, and preliminary effectiveness in a high-risk population of Latinas. Future research examining this intervention in a randomized clinical trial should explore factors impacting its effects using both qualitative and quantitative methods.

Medicare's intensive behavioral therapy for obesity: an exploratory cost-effectiveness analysis

INTRODUCTION

Medicare coverage recently was expanded to include intensive behavioral therapy for obese individuals in primary care settings.

PURPOSE

To examine the potential cost effectiveness of Medicare's intensive behavioral therapy for obesity, accounting for uncertainty in effectiveness and utilization.

METHODS

A Markov simulation model of type 2 diabetes was used to estimate long-term health benefits and healthcare system costs of intensive behavioral therapy for obesity in the Medicare population without diabetes relative to an alternative of usual care. Cohort statistics were based on the 2005-2008 National Health and Nutrition Examination Survey. Model parameters were derived from the literature. Analyses were conducted in 2014 and reported in 2012 U.S. dollars.

RESULTS

Based on assumptions for the maximal intervention effectiveness, intensive behavioral therapy is likely to be cost saving if costs per session equal the current reimbursement rate ($25.19) and will provide a cost-effectiveness ratio of $20,912 per quality-adjusted life-year if costs equal the rate for routine office visits. The intervention is less cost effective if it is less effective in primary care settings or if fewer intervention sessions are supplied by providers or used by participants.

CONCLUSIONS

If the effectiveness of the intervention is similar to lifestyle interventions tested in other settings and costs per session equal the current reimbursement rate, intensive behavioral therapy for obesity offers good value. However, intervention effectiveness and the pattern of implementation and utilization strongly influence cost effectiveness. Given uncertainty regarding these factors, additional data might be collected to validate the modeling results.

Predicting successful long-term weight loss from short-term weight-loss outcomes: new insights from a dynamic energy balance model (the POUNDS Lost study)

BACKGROUND

Currently, early weight-loss predictions of long-term weight-loss success rely on fixed percent-weight-loss thresholds.

OBJECTIVE

The objective was to develop thresholds during the first 3 mo of intervention that include the influence of age, sex, baseline weight, percent weight loss, and deviations from expected weight to predict whether a participant is likely to lose 5% or more body weight by year 1.

DESIGN

Data consisting of month 1, 2, 3, and 12 treatment weights were obtained from the 2-y Preventing Obesity Using Novel Dietary Strategies (POUNDS Lost) intervention. Logistic regression models that included covariates of age, height, sex, baseline weight, target energy intake, percent weight loss, and deviation of actual weight from expected were developed for months 1, 2, and 3 that predicted the probability of losing <5% of body weight in 1 y. Receiver operating characteristic (ROC) curves, area under the curve (AUC), and thresholds were calculated for each model. The AUC statistic quantified the ROC curve's capacity to classify participants likely to lose <5% of their body weight at the end of 1 y. The models yielding the highest AUC were retained as optimal. For comparison with current practice, ROC curves relying solely on percent weight loss were also calculated.

RESULTS

Optimal models for months 1, 2, and 3 yielded ROC curves with AUCs of 0.68 (95% CI: 0.63, 0.74), 0.75 (95% CI: 0.71, 0.81), and 0.79 (95% CI: 0.74, 0.84), respectively. Percent weight loss alone was not better at identifying true positives than random chance (AUC ≤0.50).

CONCLUSIONS

The newly derived models provide a personalized prediction of long-term success from early weight-loss variables. The predictions improve on existing fixed percent-weight-loss thresholds. Future research is needed to explore model application for informing treatment approaches during early intervention.

Health-related quality of life for pre-diabetic states and type 2 diabetes mellitus: a cross-sectional study in Västerbotten Sweden

BACKGROUND

Type 2 diabetes (T2D) decreases health-related quality of life, but there is a lack of information about the health status of people in pre-diabetic states. However, information on health utility weights (HUWs) for pre-diabetic states and T2D are essential to estimate the effect of prevention initiatives. We estimated and compared HUWs for healthy individuals, those with pre-diabetes and those with T2D in a Swedish population and evaluated the influence of age, sex, education and body mass index on HUWs.

METHODS

Participants of the Västerbotten Intervention Program, Sweden, between 2002 and 2012, who underwent an oral glucose tolerance test or indicated they had T2D and who filled in the Short Form-36 questionnaire (SF-36) were included. Individuals were categorized as healthy, being in any of three different pre-diabetic states, or as T2D. The pre-diabetic states are impaired fasting glucose (IFG), impaired glucose tolerance (IGT) or a combination of both (IFG&IGT). The SF-6D index was used to convert SF-36 responses to HUWs. HUWs were stratified by age, sex, education and body mass index. Beta regression analyses were conducted to estimate the effect of multiple risk factors on the HUWs.

RESULTS

In total, 55 882 individuals were included in the analysis. The overall mean HUW was 0.764. The mean HUW of healthy individuals was 0.768, 0.759 for those with IFG, 0.746 for those with IGT, 0.745 for those with IFG&IGT, and 0.738 for those with T2D. In the overall model, all variables except underweight vs. normal weight were significantly associated with HUW. Younger age, male sex, and higher education were associated with increased HUW. Normal weight, or being overweight was associated with elevated HUW, while obesity was associated with lower HUW.

CONCLUSIONS

Healthy individuals had higher HUWs than participants with T2D, while individuals with IFG, IGT or IFG&IGT had HUWs that ranged between those for NGT and T2D. Therefore, preventing the development of pre-diabetic states would improve health-related quality of life in addition to lowering the risk of developing T2D.

Changes in body weight and health-related quality of life: 2 cohorts of US women

Studies have shown that body weight is a determinant of health-related quality of life (HRQoL). However, few studies have examined long-term weight change with changes in HRQoL. We followed 52,682 women aged 46-71 years in the Nurses' Health Study (in 1992-2000) and 52,587 women aged 29-46 years in the Nurses' Health Study II (in 1993-2001). Body weight was self-reported, HRQoL was measured by the Medical Outcomes Study's 36-Item Short Form Health Survey, and both were updated every 4 years. The relationship between changes in weight and HRQoL scores was evaluated at 4-year intervals by using a generalized linear regression model with multivariate adjustment for baseline age, ethnicity, menopausal status, and changes in comorbidities and lifestyle factors. Weight gain of 15 lbs (1 lb = 0.45 kg) or more over a 4-year period was associated with 2.05-point lower (95% confidence interval: 2.14, 1.95) physical component scores, whereas weight loss of 15 lbs or more was associated with 0.89-point higher (95% confidence interval: 0.75, 1.03) physical component scores. Inverse associations were also found between weight change and physical function, role limitations due to physical problems, bodily pain, general health, and vitality. However, the relations of weight change with mental component scores, social functioning, mental health, and role limitations due to emotional problems were small.

Design and methods of "diaBEAT-it!": a hybrid preference/randomized control trial design using the RE-AIM framework

BACKGROUND

Diabetes prevention is a public health priority that is dependent upon the reach, effectiveness, and cost of intervention strategies. However, understanding each of these outcomes within the context of randomized controlled trials is problematic.

PURPOSE

To describe the methods and design of a hybrid preference/randomized control trial using the RE-AIM framework.

METHODS

The trial, which was developed using the RE-AIM framework, will contrast the effects of 3 interventions: (1) a standard care, small group, diabetes prevention education class (SG), (2) the small group intervention plus 12 months of interactive voice response telephone follow-up (SG-IVR), and (3) a DVD version of the small group intervention with the same IVR follow-up (DVD-IVR). Each intervention includes personal action planning with a focus on key elements of the lifestyle intervention from the Diabetes Prevention Program (DPP). Adult patients at risk for diabetes will be randomly assigned to either choice or RCT. Those assigned to choice (n=240) will have the opportunity to choose between SG-IVR and DVD-IVR. Those assigned to RCT group (n=360) will be randomly assigned to SG, SG-IVR, or DVD-IRV. Assessment of primary (weight loss, reach, & cost) and secondary (physical activity, & dietary intake) outcomes will occur at baseline, 6, 12, and 18 months.

CONCLUSION

This will be the first diabetes prevention trial that will allow the research team to determine the relationships between reach, effectiveness, and cost of different interventions.

Impact of intensive lifestyle intervention on depression and health-related quality of life in type 2 diabetes: the Look AHEAD Trial

OBJECTIVE

We examined the effects of an intensive lifestyle intervention (ILI), compared with a diabetes support and education (DSE) control intervention, on long-term changes in depression symptoms, antidepressant medication (ADM) use, and health-related quality of life (HRQoL) in overweight/obese individuals with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Look AHEAD was a multisite randomized controlled trial of 5,145 overweight/obese participants assigned to ILI (designed to produce weight loss) or DSE and followed for a median of 9.6 years. The Beck Depression Inventory (BDI) was administered at baseline, annually at years 1-4, and again at year 8. Mean BDI scores and incidence of BDI scores ≥10, indicative of likely mild or greater depression, were examined. Annually through year 10, participants reported their ADM use and completed the Medical Outcomes Study Short Form 36 (SF-36) questionnaire, which yields physical component summary (PCS) and mental component summary (MCS) scores.

RESULTS

ILI significantly reduced the incidence of mild or greater depression symptoms (BDI scores ≥10) compared with DSE (hazard ratio [HR] = 0.85; 95% CI 0.75-0.97; P = 0.0145). Although SF-36 PCS scores worsened over time in both groups, ILI participants reported better physical function than DSE throughout the first 8 years (all P values <0.01). There were no significant differences between treatment arms in the proportion of participants who used ADMs or in SF-36 MCS scores.

CONCLUSIONS

ILI for overweight/obese patients with type 2 diabetes may reduce the risk of developing clinically significant symptoms of depression and preserve physical HRQoL. These findings should be considered when evaluating the potential benefits of ILIs.

Predictors of health-related quality of life changes after lifestyle intervention in persons at risk of type 2 diabetes mellitus

PURPOSE

To assess health-related quality of life (HRQOL) of subjects at risk of type 2 diabetes undergoing lifestyle intervention, and predictors for improved HRQOL.

METHODS

The Finnish Diabetes Risk Score was used by general practitioners to identify individuals at risk. Low-intensity interventions with an 18-month follow-up were employed. HRQOL was assessed using the SF-36 at baseline and compared with results from a general Norwegian population survey and further at 6 and 18 months. Simple and multiple linear regression analyses were applied to identify predictors of changes in HRQOL of clinical importance.

RESULTS

Two hundred and thirteen participants (50 % women; mean age: 46 years, mean body mass index: 37) were included: 182 returned for 18-month follow-up, of whom 172 completed the HRQOL questionnaire. HRQOL was reduced with clinical significance compared with general Norwegians. The mean changes in HRQOL from the baseline to the follow-up were not of clinical importance. However, one out of three individuals achieved a moderate or large clinical improvement in HRQOL. The best determinant for improved HRQOL was obtained for a composite, clinically significant lifestyle change, i.e. both a weight reduction of at least 5 % and an improvement in exercise capacity of at least 10 %, which was associated with an improvement in five out of the eight SF-36 domains.

CONCLUSION

Subjects at risk of type 2 diabetes report a clinically important reduction in HRQOL compared with general Norwegians. The best predictor of improved HRQOL was a small weight loss combined with a small improvement in aerobic capacity.

Health-related quality of life (EQ-5D) among type 2 diabetes mellitus patients treated with dapagliflozin over 2 years

AIMS

This study evaluated health status and health-related quality of life (HRQOL) among patients with type 2 diabetes mellitus (T2DM) treated with dapagliflozin, a highly selective sodium-glucose co-transporter 2 (SGLT2) inhibitor that lowers blood glucose by increasing glucose excretion, in a double-blind, randomised clinical trial.

METHODS

Subjects with T2DM who had inadequate glycaemic control on metformin alone were enrolled in a 24-week, double-blind, randomised, placebo-controlled study with a 78-week extension period to evaluate the effect of dapagliflozin in combination with metformin. Subjects treated with dapagliflozin 10 mg + metformin (n = 89) were compared with subjects treated with placebo + metformin (n = 91) at baseline and at weeks 24, 50 and 102. EQ-5D change from baseline was derived from a repeated-measures mixed model, adjusting for baseline EQ-5D, treatment group, time point and use of rescue medication.

RESULTS

Mean (SD) EQ-5D index was 0.85 (0.16) and 0.82 (0.15) at baseline and 0.85 (0.19) and 0.84 (0.19) at week 102 for dapagliflozin and placebo, respectively. The model indicated no change over 102 weeks in EQ-5D index scores in either treatment group. Mean (SD) EQ-5D visual analogue scale (VAS) was 72.5 (19.5) and 73.7 (15.6) at baseline and 79.8 (13.3) and 78.2 (12.1) at week 102 for dapagliflozin and placebo, respectively. The model indicated similar small improvements in EQ-5D VAS scores in both groups over 102 weeks.

CONCLUSION

Patients maintained high HRQOL scores from baseline through week 102 in both treatment groups. Dapagliflozin, a novel SGLT2 inhibitor, did not adversely affect HRQOL over 2 years of treatment.

The effect of weight loss on health-related quality of life: systematic review and meta-analysis of randomized trials

The aim of this study was to examine the effect of weight loss on health-related quality of life (HRQL) in randomized controlled intervention trials (RCTs). MEDLINE, HealthStar and PsycINFO were searched. RCTs of any weight loss intervention and 20 HRQL instruments were examined. Contingency tables were constructed to examine the association between statistically significant weight loss and statistically significant HRQL improvement within five HRQL categories. In addition, Short Form-36 (SF-36) outcomes were pooled using random-effects models. Fifty-three trials were included. Seventeen studies reported statistically significant weight loss and HRQL improvement. No statistically significant associations between weight loss and HRQL improvement were found in any contingency table. Because of suboptimal endpoint reporting, quantitative data pooling could only be performed using 25% of SF-36 trials in any one model. Significant improvements in physical health were found: mean difference 2.83 points, 95% CI 0.55-5.1, for the physical component score, and mean difference 6.81 points, 95% CI 2.99-10.63, for the physical functioning domain score. Conversely, no significant improvements in mental health were found. No significant association was found between weight loss and overall HRQL improvement. Weight loss may be associated with modest improvements in physical, but not mental, health.

Dietary interventions and quality of life: a systematic review of the literature

OBJECTIVE

To systematically review the literature to examine whether there has been adequate assessment of the effects of dietary intervention on quality of life (QOL) independent of weight loss, assess which instruments are being used to measure nutrition-related QOL, identify gaps in the literature, and suggest future directions.

DESIGN

Systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement.

RESULTS

A total of 24 studies were eligible for inclusion. The Short Form-36 Health Survey was the most widely used instrument to assess QOL. Other disease-specific instruments were used. Several different dietary approaches (eg, low carbohydrate, low calorie, low fat, combinations) were recommended. Across studies, QOL generally improved after participating in behavioral weight loss interventions, but findings revealed a lack of evidence to definitively determine whether reported changes in QOL were a result of weight loss or independent of it.

CONCLUSIONS AND IMPLICATIONS

It is important to consider how making broad dietary recommendations for all individuals might affect overall QOL in both positive and negative directions when considering factors other than weight loss and health improvement. If dietary interventions are adversely affecting QOL in other domains (eg, social, economic) and this relationship is not being detected or reported by current research practices, barriers for successful and sustainable dietary changes may not be fully understood.

Patient-reported outcomes in the practice-based opportunities for weight reduction (POWER) trial

PURPOSE

To evaluate effects of two behavioral weight-loss interventions (in-person, remote) on health-related quality of life (HRQOL) compared to a control intervention.

METHODS

Four hundred and fifty-one obese US adults with at least one cardiovascular risk factor completed five measures of HRQOL and depression: MOS SF-12 physical component summary (PCS) and mental component summary; EuroQoL-5 dimensions single index and visual analog scale; PHQ-8 depression symptoms; and PSQI sleep quality scores at baseline and 6 and 24 months after randomization. Change in each outcome was analyzed using outcome-specific mixed-effects models controlling for participant demographic characteristics.

RESULTS

PCS-12 scores over 24 months improved more among participants in the in-person active intervention arm than among control arm participants (P < 0.05, ES = 0.21); there were no other statistically significant treatment arm differences in HRQOL change. Greater weight loss was associated with improvements in most outcomes (P < 0.05 to < 0.0001).

CONCLUSIONS

Participants in the in-person active intervention improved more in physical function HRQOL than participants in the control arm did. Greater weight loss during the study was associated with greater improvement in all PRO except for sleep quality, suggesting that weight loss is a key factor in improving HRQOL.