In-person and virtual multidisciplinary intensive lifestyle interventions are equally effective in patients with type 2 diabetes and obesity

Telephone Virtual Versus In-Person Pharmacotherapy-Based Obesity Care: A COVID-19-Related Experience at a Veterans Administration Facility

Background: Most of the Veterans Administration (VA) population is either overweight or obese, which is a serious health concern. Medical weight management visits have traditionally occurred through in-person clinics. However, the COVID-19 pandemic forced care delivery to virtual platforms. Methods: We compared weight loss with in-person versus telephone-based medical weight management (lifestyle counseling coupled with pharmacotherapy) delivered by physician and nurse practitioner visits during the pandemic. We designed a program evaluation utilizing a naturalistic (pragmatic) observational study structure, including both newly enrolled and previously established participants in the Minneapolis VA MOVE! program between 2017 and 2021. A "transition" cohort (n = 74) received in-person care from March 2019 to March 2020, and then transitioned to virtual care. A "new start" virtual care cohort (n = 149) enrolled after March 2020 was compared to a separate historical group (n = 180) that received in-person care between January 2017 and December 2019. Weight loss was accessed over a 9-month period in both cohorts. Results: Mean weight loss over 9 months was -6.5 ± 18.2 and -2.5 ± 13.3 lbs in the in-person and virtual phases of the transition cohort, respectively, without significant difference between the two phases (p = 0.22). Mean weight loss over 9 months in the new start (virtual) cohort was -14.4 ± 17.0 lbs compared to -16.7 ± 21.0 lbs in the historical cohort, without significant difference between groups (p = 0.44). Conclusions: In our naturalistic study in a single-site VA clinic setting, weight loss with telephone-based medical weight management during the pandemic was comparable to in-person care. These findings are important for veterans living in rural and/or underserved areas.

Evaluation of hybrid closed-loop insulin delivery system in type 1 diabetes in real-world clinical practice: One-year observational study

BACKGROUND

In 2016, the Food and Drug Administration approved the first hybrid closed-loop (HCL) insulin delivery system for adults with type 1 diabetes (T1D). There is limited information on the impact of using HCL systems on patient-reported outcomes (PROs) in patients with T1D in real-world clinical practice. In this independent study, we evaluated glycemic parameters and PROs over one year of continuous use of Medtronic's 670G HCL in real-world clinical practice.

AIM

To assess the effects of hybrid closed loop system on glycemic control and quality of life in adults with T1D.

METHODS

We evaluated 71 patients with T1D (mean age: 45.5 ± 12.1 years; 59% females; body weight: 83.8 ± 18.7 kg, body mass index: 28.7 ± 5.6 kg/m2, A1C: 7.6% ± 0.8%) who were treated with HCL at Joslin Clinic from 2017 to 2019. We measured A1C and percent of glucose time-in-range (%TIR) at baseline and 12 months. We measured percent time in auto mode (%TiAM) for the last two weeks preceding the final visit and assessed PROs through several validated quality-of-life surveys related to general health and diabetes management.

RESULTS

At 12 mo, A1C decreased by 0.3% ± 0.1% (P = 0.001) and %TIR increased by 8.1% ± 2.5% (P = 0.002). The average %TiAM was only 64.3% ± 32.8% and was not associated with A1C, %TIR or PROs. PROs, provided at baseline and at the end of the study, showed that the physical functioning submodule of 36Item Short-Form Health Survey increased significantly by 22.9% (P < 0.001). Hypoglycemia fear survey/worry scale decreased significantly by 24.9% (P < 0.000); Problem Areas In Diabetes reduced significantly by -17.2% (P = 0.002). The emotional burden submodules of dietary diversity score reduced significantly by -44.7% (P = 0.001). Furthermore, analysis of Clarke questionnaire showed no increase in awareness of hypoglycemic episodes. WHO-5 showed no improvements in subject's wellbeing among participants after starting the 670G HCL system. Finally, analysis of Pittsburgh Sleep Quality Index showed no difference in sleep quality, sleep latency, or duration of sleep from baseline to 12 mo.

CONCLUSION

The use of HCL in real-world clinical practice for one year was associated with significant improvements in A1C, %TIR, physical functioning, hypoglycemia fear, emotional distress, and emotional burden related to diabetes management. However, these changes were not associated with time in auto mode.

Qualitative evaluation of a Salutogenic Healthy Eating Programme for Dutch people with type 2 diabetes

The salutogenic model of health (SMH) is a health-promoting theory that focuses on resources, strengths, and coping capacities in everyday life as a way to improve health and wellbeing. The SMH was applied to develop a programme for enabling healthy eating practices among people with type 2 diabetes mellitus (T2DM): the SALUD programme. This study aims to gain insight in how participants with T2DM experienced the content and meaning of the SALUD programme. Three focus groups with participants (six to eight participants/group) that finished the SALUD programme were conducted. The focus groups were video-recorded, transcribed ad verbatim and thematically analysed. The SALUD programme was perceived by the participants as a positive, meaningful learning experience. Key factors why the participants described the programme as positive were that they felt a sense of social-belonging and (emotionally) safe (theme 1). The SALUD programme's positive encouraging approach presented by the coach invited participants to join an active learning process (theme 2). Performing trial-and-error experiments and weekly reflecting on goals is what characterized active learning. The meaningfulness of the learning process (theme 3) was derived from (i) positive self-confrontation; (ii) exploring mind-body connections and perceiving improved health and (iii) noticing positive changes in their social environment (theme 3). To conclude, the study uncovered that the SALUD programme incited a positive, meaningful learning process for healthy eating and the contextual factors important in this. Potential leads to further improve the SALUD programme are discussed in order to maximize the chance of inciting an inclusive, active learning process.

Type 2 Diabetes Mellitus and Sarcopenia as Comorbid Chronic Diseases in Older Adults: Established and Emerging Treatments and Therapies

Type 2 diabetes mellitus (T2DM) and sarcopenia (low skeletal muscle mass and function) share a bidirectional relationship. The prevalence of these diseases increases with age and they share common risk factors. Skeletal muscle fat infiltration, commonly referred to as myosteatosis, may be a major contributor to both T2DM and sarcopenia in older adults via independent effects on insulin resistance and muscle health. Many strategies to manage T2DM result in energy restriction and subsequent weight loss, and this can lead to significant declines in muscle mass in the absence of resistance exercise, which is also a first-line treatment for sarcopenia. In this review, we highlight recent evidence on established treatments and emerging therapies targeting weight loss and muscle mass and function improvements in older adults with, or at risk of, T2DM and/or sarcopenia. This includes dietary, physical activity and exercise interventions, new generation incretin-based agonists and myostatin-based antagonists, and endoscopic bariatric therapies. We also highlight how digital health technologies and health literacy interventions can increase uptake of, and adherence to, established and emerging treatments and therapies in older adults with T2DM and/or sarcopenia.

Effect of telehealth-based versus in-person nutritional and exercise intervention on type II diabetes mellitus improvement and efficiency of human resources utilization in patients with obesity

Aims

Telehealth became a patient necessity during the COVID pandemic and evolved into a patient preference in the post-COVID era. This study compared the % total body weight loss (%TBWL), HbA1c reduction, and resource utilization among patients with obesity and diabetes who participated in lifestyle interventions with or without telehealth.

Methods

A total of 150 patients with obesity and diabetes who were followed every 4-6 weeks either in-person (n = 83) or via telehealth (n = 67), were included. All patients were provided with an individualized nutritional plan that included a weight-based daily protein intake from protein supplements and food, an activity/sleep schedule-based meal times, and an aerobic exercise goal of a 2000-calorie burn/week, customized to patient's preferences, physical abilities, and comorbidities. The goal was to lose 10%TBWL. Telehealth-based follow-up required transmission via texting of weekly body composition measurements and any blood glucose levels below 100 mg/dl for medication adjustments. Weight, BMI, %TBWL, HbA1c (%), and medication effect score (MES) were compared. Patient no-show rates, number of visits, program duration, and drop-out rate were used to assess resource utilization based on cumulative staff and provider time spent (CSPTS), provider lost time (PLT) and patient spent time (PST).

Results

Mean age was 47.2 ± 10.6 years and 74.6% were women. Mean Body Mass Index (BMI) decreased from 44.1 ± 7.7-39.7 ± 6.7 kg/m2 (p < 0.0001). Mean program duration was 189.4 ± 169.3 days. An HbA1c% unit decline of 1.3 ± 1.5 was achieved with a 10.1 ± 5.1%TBWL. Diabetes was cured in 16% (24/150) of patients. %TBWL was similar in regards to telehealth or in-person appointments (10.6% ± 5.1 vs. 9.6% ± 4.9, p = 0.14). Age, initial BMI, MES, %TBWL, and baseline HbA1c had a significant independent effect on HbA1c reduction (p < 0.0001). Program duration was longer for in-person follow-up (213.8 ± 194 vs. 159.3 ± 127, p = 0.019). The mean annual telehealth and in-person no-show rates were 2.7% and 11.2%, respectively (p < 0.0001). Mean number of visits (5.7 ± 3.0 vs. 8.6 ± 5.1) and drop-out rates (16.49% vs. 25.83%) were lower in telehealth group (p < 0.0001). The CSPTS (440.4 ± 267.5 min vs. 200.6 ± 110.8 min), PLT (28.9 ± 17.5 min vs. 3.1 ± 1.6 min), and PST (1033 ± 628 min vs. 113.7 ± 61.4 min) were significantly longer (p < 0.0001) for the in-person group.

Conclusions

Telehealth offered comparable %TBWL and HbA1c decline as in-person follow-up, but with a shorter follow-up, fewer appointments, and no-shows. If improved resource utilization is validated by other studies, telehealth should become the standard of care for the management of obesity and diabetes.

Telenursing needs and influencing factors in patients with type 2 diabetes mellitus: A cross-sectional study

AIMS AND OBJECTIVES

This study aimed to determine the relationship between the demand for telenursing and the chronic illness resources available to patients with type 2 diabetes mellitus (T2DM), as well as the factors that affect this requirement.

DESIGN

Cross-sectional.

METHODS

This study included 586 participants with T2DM. A telenursing needs questionnaire developed by the research team was used to assess the telenursing needs of patients with T2DM, and the Chinese version of the Chronic Illness Resources Survey was used to assess the participants' community chronic disease resources. A one-way ANOVA and multiple regression analysis were used to determine the factors influencing the demand for telenursing and to estimate the relationship between chronic illness resources and the need for telenursing. The STROBE checklist was followed.

RESULTS

The patients' telenursing needs, ranked from high to low, are as follows: individualized skills and safety; basic disease care; psychological and spiritual needs; respect and social support; and high-level health management. The chronic disease resource score was 3.47 ± .02, which suggested that patients with T2DM have relatively rich disease resources. Multiple regression analyses showed that resources for chronic diseases, the course of diabetes and complications, family income and other chronic diseases accounted for 79.6% of the variance in T2DM patients' telenursing needs.

CONCLUSIONS

The telenursing needs of patients with T2DM are prominent, and primarily focus on basic nursing needs for the disease. To some extent, chronic disease resources affect the telenursing needs of patients with T2DM.

RELEVANCE TO CLINICAL PRACTICE

It is crucial to pay attention to research on telenursing for T2DM patients from the patients' perspective. Enhancing resources for chronic diseases may help meet the telenursing needs of T2DM patients.

PATIENT OR PUBLIC CONTRIBUTION

Parents and diabetes management specialists participated in designing the telenursing needs questionnaire.

Is Type 2 Diabetes Mellitus a Behavioural Disorder? An Evidence Review for Type 2 Diabetes Mellitus Prevention and Remission through Lifestyle Modification

The prevalence of type 2 diabetes mellitus (T2DM) is steadily rising worldwide due to an increasingly sedentary lifestyle combined with unhealthy food habits. Currently, the burden of diabetes on healthcare systems is unprecedented and rising daily. Several observational studies and randomized controlled trials provide clinical evidence that T2DM remission is possible by adopting dietary interventions and a strict exercise training protocol. Notably, these studies provide ample evidence for remission in patients with T2DM or for prevention in those with risk factors for the disease through various non-pharmacological behavioural interventions. In this article, we present two clinical cases of individuals who showed remission from T2DM/prediabetes via behavioural changes, especially through the adoption of a low-energy diet and exercise. We also discuss the recent advances in T2DM and obesity research, focusing on nutritional interventions and exercise and their benefits for weight loss, improved metabolic profile, enhanced glycaemic control and remission of diabetes.

Long-term effect of intensive lifestyle intervention on cardiometabolic risk factors and microvascular complications in patients with diabetes in real-world clinical practice: a 10-year longitudinal study

INTRODUCTION

Intensive lifestyle intervention (ILI) has significantly reduced incidence of diabetes and improved many cardiovascular disease risk factors. We evaluated long-term effects of ILI on cardiometabolic risk factors, and microvascular and macrovascular complications among patients with diabetes in real-world clinical practice.

RESEARCH DESIGN AND METHODS

We evaluated 129 patients with diabetes and obesity enrolled in a 12-week translational model of ILI. At 1 year, we divided participants into group A, who maintained <7% weight loss (n=61, 47.7%), and group B, who maintained ≥7% weight loss (n=67, 52.3%). We continued to follow them for 10 years.

RESULTS

The total cohort lost an average of 10.8±4.6 kg (-9.7%) at 12 weeks and maintained an average weight loss of 7.7±10 kg (-6.9%) at 10 years. Group A maintained 4.3±9.5 kg (-4.3%) and group B maintained 10.8±9.3 kg (-9.3%) of weight loss at 10 years (p<0.001 between groups). In group A, A1c decreased from 7.5±1.3% to 6.7±0.9% at 12 weeks but rebounded to 7.7±1.4% at 1 year and 8.0±1.9% at 10 years. In group B, A1c decreased from 7.4±1.2% to 6.4±0.9% at 12 weeks then increased to 6.8±1.2% at 1 year and 7.3±1.5% at 10 years (p<0.05 between groups). Maintenance of ≥7% weight loss at 1 year was associated with a 68% lower risk of developing nephropathy for up to 10 years compared with maintenance of <7% weight loss (adjusted HR for group B: 0.32, 95% CI 0.11, 0.9, p=0.007).

CONCLUSIONS

Weight reduction in patients with diabetes can be maintained for up to 10 years in real-world clinical practice. Sustained weight loss is associated with significantly lower A1c at 10 years and improvement in lipid profile. Maintenance of ≥7% weight loss at 1 year is associated with decreased incidence of diabetic nephropathy at 10 years.

Hybrid model of intensive lifestyle intervention is potentially effective in patients with diabetes & obesity for post-COVID era

The Weight Achievement and Intensive Treatment (Why WAIT) program is a 12-week multidisciplinary intensive lifestyle intervention (ILI) for patients with diabetes and obesity in real-world clinical practice that has led to long-term weight loss maintenance for up to 10 years. During COVID-19, we reported that a virtual model (VM) of the program was equally effective in reducing body weight and improving glycemic control. Here, we test a newly-introduced hybrid model (HM), to accommodate ongoing restrictions of the pandemic. We evaluated 56 participants: 18 from HM, 16 from VM and 22 from the in-person model (iPM). At 12 weeks, mean change in body weight from baseline for HM was -8.2 ± 5.0 kg; p<0.001. Mean change in A1C for HM was -0.6 ± 0.6%; p=0.002. There were no significant differences in body weight reduction (p=0.7) or A1C reduction (p=0.6) between groups. Blood pressure, lipid profile, and all other parameters showed improvements without significant differences between groups. Overall, HM is as effective as VM and iPM in reducing body weight and A1C after 12 weeks. Given its scalability, HM could be offered to more patients with diabetes and obesity who may benefit from its increased flexibility and enhanced accountability without compromising the multidisciplinary approach for a post-COVID era.