Predictors of type 2 diabetes remission in the Diabetes Remission Clinical Trial (DiRECT).

AIM: To identify predictors of type 2 diabetes remission in the intervention arm of DiRECT (Diabetes Remission Clinical Trial). METHODS: Participants were aged 20-65 years, with type 2 diabetes duration of <6 years and BMI 27-45 kg/m2 , and were not receiving insulin. Weight loss was initiated by total diet replacement (825-853 kcal/day, 3-5 months, shakes/soups), and weight loss maintenance support was provided for 2 years. Remissions (HbA1c <48 mmol/mol [<6.5%], without antidiabetes medications) in the intervention group (n = 149, mean age 53 years, BMI 35 kg/m2 ) were achieved by 68/149 participants (46%) at 12 months and by 53/149 participants (36%) at 24 months. Potential predictors were examined by logistic regression analyses, with adjustments for weight loss and effects independent of weight loss. RESULTS: Baseline predictors of remission at 12 and 24 months included being prescribed fewer antidiabetes medications, having lower triglyceride and gamma-glutamyl transferase levels, and reporting better quality of life with less anxiety/depression. Lower baseline HbA1c was a predictor at 12 months, and older age and male sex were predictors at 24 months. Being prescribed antidepressants predicted non-remission. Some, but not all effects were explained by weight loss. Weight loss was the strongest predictor of remission at 12 months (adjusted odds ratio per kg weight loss 1.24, 95% CI 1.14, 1.34; P < 0.0001) and 24 months (adjusted odds ratio 1.23, 95% CI 1.13, 1.35; P <0.0001). Weight loss in kilograms and percentage weight loss were equally good predictors. Early weight loss and higher programme attendance predicted more remissions. Baseline BMI, fasting insulin, fasting C-peptide and diabetes duration did not predict remission. CONCLUSIONS: Other than weight loss, most predictors were modest, and not sufficient to identify subgroups for which remission was not a worthwhile target.

'I have been all in, I have been all out and I have been everything in-between': A 2-year longitudinal qualitative study of weight loss maintenance.

BACKGROUND: Qualitative studies investigating weight management experiences are usually cross-sectional or of short duration, which limits understanding of the long-term challenges. METHODS: Eleven women [mean (SD) age 44.9 (9.8) years; body mass index 40.3 (4.0) kg m-2 ] participated in this longitudinal qualitative study, which included up to 20 weeks of total diet replacement (825-853 kcal day-1 ) and ongoing support for weight loss maintenance (WLM), to 2 years. Semi-structured interviews were conducted at baseline and programme end, as well as at key intervals during the intervention. Questions examined five theoretical themes: motivation, self-regulation, habits, psychological resources and social/environmental influences. Data were coded and analysed in nvivo (https://qsrinternational.com/nvivo) using the framework method. RESULTS: In total, 64 interviews were completed (median, n = 6 per participant). Mean (SD) weight loss was 15.7 (9.6) kg (14.6% body weight) at 6 months and 9.6 (9.9) kg (8.8% body weight) at 2 years. The prespecified theoretical model offered a useful framework to capture the variability of experiences. Negative aspects of obesity were strong motivations for weight loss and maintenance. Perceiving new routines as sustainable and developing a 'maintenance mindset' was characteristic of 'Maintainers', whereas meeting emotional needs at the expense of WLM goals during periods of stress and negative mood states was reported more often by 'Regainers'. Optimistic beliefs about maintaining weight losses appeared to interfere with barrier identification and coping planning for most participants. CONCLUSIONS: People tended to be very optimistic about WLM without acknowledging barriers and this may undermine longer-term outcomes. The potential for regain remained over time, mainly as a result of emotion-triggered eating to alleviate stress and negative feelings. More active self-regulation during these circumstances may improve WLM, and these situations represent important targets for intervention.

Filling the intervention gap: service evaluation of an intensive nonsurgical weight management programme for severe and complex obesity.

BACKGROUND: Weight management including formula total diet replacement (TDR) is emerging as an effective intervention for severe and complex obesity, particularly with respect to type 2 diabetes (T2DM). However, no prospective audit and service evaluation of such programmes have been reported. METHODS: Following initial feasibility piloting, the Counterweight-Plus programme was commissioned across a variety of healthcare providers. The programme includes: Screening, TDR (formula low energy diet), food reintroduction and weight loss maintenance, all delivered by staff with 8 h of training, in-service mentoring, ongoing specialist support and access to medical consultant expertise. Anonymised data are returned centrally for clinical evaluation. RESULTS: Up to December 2016, 288 patients commenced the programme. Mean (SD) baseline characteristics were: age 47.5 (12.7) years, weight 128.0 (32.0) kg, body mass index 45.7 (10.1) kg m-2 , n = 76 (26.5%) were male and n = 99 (34.5%) had T2DM. On an intention-to-treat (ITT) basis, a loss of ≥15 kg at 12 months was achieved by 48 patients, representing 22.1% of all who started and 40% of those who maintained engagement. For complete cases, mean (95% confidence interval) weight loss was 13.3 (12.1-14.4) kg at 3 months, 16.0 (14.4-17.6) kg at 6 months and 14.2 (12.1-16.3) kg at 12 months (all P < 0.001), with losses to follow-up of 10.8%, 29.3% and 44.2%, respectively. Mean loss at 12 months by ITT analyses was: single imputation -10.5 (9.5) kg, last observation carried forward -10.9 (11.6) kg and baseline observation carried forward -7.9 (11.1) kg. The presence of diabetes had no significant impact on weight change outcomes. CONCLUSIONS: This nonsurgical approach is effective for many individuals with severe and complex obesity, representing an option before considering surgery. The results are equally effective in terms of weight loss for people with T2DM.