Very-low-energy diet for type 2 diabetes: An underutilized therapy?

https://doi.org/10.1016/j.jdiacomp.2014.03.014Get rights and content

Abstract

Background

Current approaches to the management of type 2 diabetes focus on the early initiation of novel pharmacologic therapies and bariatric surgery.

Objective

The purpose of this study was to revisit the use of intensive, outpatient, behavioral weight management programs for the management of type 2 diabetes.

Design

Prospective observational study of 66 patients with type 2 diabetes and BMI 32 kg/m2 who enrolled in a program designed to produce 15% weight reduction over 12 weeks using total meal replacement and low- to moderate-intensity physical activity.

Results

Patients were 53 ± 7 years of age (mean ± SD) and 53% were men. After 12 weeks, BMI fell from 40.1 ± 6.6 to 35.1 ± 6.5 kg/m2. HbA1c fell from 7.4% ± 1.3% to 6.5% ± 1.2% (57.4 ± 12.3 to 47.7 ± 12.9 mmol/mol) in patients with established diabetes: 76% of patients with established diabetes and 100% of patients with newly diagnosed diabetes achieved HbA1c < 7.0% (53.0 mmol/mol). Improvement in HbA1c over 12 weeks was associated with higher baseline HbA1c and greater reduction in BMI.

Conclusions

An intensive, outpatient, behavioral weight management program significantly improved HbA1c in patients with type 2 diabetes over 12 weeks. The use of such programs should be encouraged among obese patients with type 2 diabetes.

Introduction

In response to the evidence that near-normal glycemia can reduce the long-term complications of type 2 diabetes and the approval of new classes of antihyperglycemic medications, consensus guidelines have been published for the management of type 2 diabetes. Although essentially all of them recognize the role of overnutrition, physical inactivity, and obesity in the pathogenesis of type 2 diabetes, few, if any, recommend lifestyle intervention as first line therapy for its management. Indeed, in 2008, the American Diabetes Association and the European Association for the Study of Diabetes concluded that because lifestyle interventions often fail to achieve or maintain glycemic goals either because of failure to lose weight, weight regain, progressive disease, or a combination of factors, metformin therapy should be initiated at the diagnosis of type 2 diabetes (Nathan et al., 2009). More recently, Roux-en-Y gastric bypass (RYGB), now termed “metabolic surgery”, has been proposed as first line therapy for obese patients (body mass index (BMI) > 30 kg/m2) with type 2 diabetes (Cohen et al., 2012, Pories et al., 1995). Although a recent trial demonstrated that 12 months of medical therapy plus bariatric surgery achieved better glycemic outcomes than medical therapy alone in obese patients with uncontrolled type 2 diabetes (Schauer et al., 2012), another small, short-term, clinical trial suggested that a very-low-energy diet, similar to those consumed by patients following RYGB, can produce similar improvements in glycemia, beta-cell function, and insulin sensitivity as RYGB (Jackness et al., 2013).

The purpose of this study was to determine if 12 weeks of a very-low-energy diet combined with physical activity of low- to moderate-intensity was effective for the management of type 2 diabetes. Our hypothesis was that although traditional low intensity lifestyle interventions may fail to achieve glycemic goals, more intensive, outpatient, multidisciplinary, behavioral obesity management programs may be an appropriate first-line treatment for type 2 diabetes.

Section snippets

Methods

The University of Michigan Investigational Weight Management Program is a 2-year, outpatient, multidisciplinary, behavioral, obesity management program. The program is offered to obese members of a managed care health plan who are required to participate in one of three weight management programs in order to receive enhanced benefits (Rothberg, McEwen, Fraser, Burant, & Herman, 2013) and to patients referred by University of Michigan-affiliated health care providers. To be eligible, patients

Results

Between 2010 and 2013, 367 patients enrolled in the Investigational Weight Management Program and completed at least 12 weeks of follow-up. Of these, 93 (25%) were diagnosed with type 2 diabetes. Sixty-six (71%) had baseline HbA1c or blood glucose levels and HbA1c levels measured 3 to 6 months after baseline and are the focus of this study. Twenty-seven (29%) were missing baseline or follow-up measures of glycemia and were excluded from the study. Those excluded did not differ from those included

Discussion

With the focus on metformin as first line therapy for type 2 diabetes, the promotion of new classes of oral antihyperglycemic medications, and the near-universal enthusiasm for bariatric or “metabolic” surgery for the treatment for type 2 diabetes, the role of intensive, outpatient, behavioral weight management programs for the management of type 2 diabetes has been largely overlooked. Others have previously demonstrated that 12 weeks of very-low-energy diet improves insulin secretion, insulin

Acknowledgment

Additional support was provided by the A. Alfred Taubman Medical Institute and the Robert C. and Veronica Atkins Foundation.

AER has received consulting fees from NovoNordisk and WHH has received consulting fees from sanofi. LNM, ATK, and CEF have no potential conflicts of interest to report.

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    Citation Excerpt :

    An estimated 463 million adults aged 20–79 years are currently living with diabetes, representing 9.3% of the world’s population in this age group (IDF), and Obesity and diabetes have reached epidemic proportions [10,11]. Managing obesity efficiently can delay the progression from prediabetes to T2DM [12,13] and may also prove beneficial in T2DM treatment [14–19]. According to previous small studies, a severely energy-restricted diet (ERD) can reduce glycated hemoglobin (HbA1C) to <6.5% (48 mmol/mol) and fasting plasma glucose (FPG) to <126 mg/dL (7.0 mmol/L) in the absence of any pharmacological treatment in obese patients with T2DM and MS [18–21].

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Conflicts of Interest: A.E.R. has received consulting fees from NovoNordisk and W.H.H. has received consulting fees from Sanofi. L.N.M., A.T.K., and C.E.F. have no potential conflicts of interest to report.

Reprints: Reprints will not be available from the author.

Support: The work was supported by the Michigan Nutrition and Obesity Research Center (Grant Number DK089503), the Michigan Center for Diabetes Translational Research (Grant Number P30DK092926), and the Chemistry Laboratory of the Michigan Diabetes Research Center (Grant Number P30DK020572) from the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health. Health Management Resources (HMR), Inc. (Boston, MA) donated Healthy Solutions meal replacement products used in this study.

Clinical Trial Registry: NCT02043457

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