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.

Type 2 diabetes remission: economic evaluation of the DiRECT/Counterweight-Plus weight management programme within a primary care randomized controlled trial.

AIM: The Counterweight-Plus weight management programme achieved 46% remission of Type 2 diabetes at 1 year in the DiRECT trial. We estimated the implementation costs of the Counterweight-Plus programme and its 1-year cost-effectiveness in terms of diabetes remission, compared with usual care, from the UK National Health Service (NHS) perspective. METHODS: Within-trial total costs included programme set-up and running costs (practitioner appointment visits, low-energy formula diet sachets and training), oral anti-diabetes and anti-hypertensive medications, and healthcare contacts. Total costs were calculated for aggregated resource use for each participant and 95% confidence intervals (CI) were based on 1000 non-parametric bootstrap iterations. RESULTS: One-year programme costs under trial conditions were estimated at £1137 per participant (95% CI £1071, £1205). The intervention led to a significant cost-saving of £120 (95% CI £78, £163) for the oral anti-diabetes drugs and £14 (95% CI £7.9, £22) for anti-hypertensive medications compared with the control. Deducting the cost-savings of all healthcare contacts from the intervention cost resulted an incremental cost of £982 (95% CI £732, £1258). Cost per 1 year of diabetes remission was £2359 (95% CI £1668, £3250). CONCLUSIONS: Remission of Type 2 diabetes within 1-year can be achieved at a cost below the annual cost of diabetes (including complications). Providing a reasonable proportion of remissions can be maintained over time, with multiple medical gains expected, as well as immediate social benefits, there is a case for shifting resources within diabetes care budgets to offer support for people with Type 2 diabetes to attempt remission. (Clinical Trial Registry No.: ISRCTN03267836).

Associations of BMI, waist circumference, body fat, and skeletal muscle with type 2 diabetes in adults.

AIMS: Type 2 diabetes (T2D) is known to be associated with high BMI and waist circumference (WC). These measures do not discriminate well between skeletal muscle (SM) and body fat (BF), which may have opposite influences. METHODS: We conducted a secondary analysis of population-based data from 58,128 aged 18-85 yrs from Scottish Health Surveys (2003, 2008-2011) and Health Surveys for England (2003-2006, 2008-2013), excluding pregnant women and insulin-treated diabetes. Logistic regression was used to assess associations of known T2D, and of screened HbA1c > 48 mmol/mol (> 6.5%), with sex-specific quintiles of BMI, WC, and BF% and SM% estimated by validated anthropometric equations, adjusted for age, sex, smoking, ethnicity, country, and survey year. RESULTS: As expected, ORs for having known T2D rose with quintiles of BMI (1, 1.5, 2.3, 3.1, and 6.5) and WC (1, 1.8, 2.5, 3.5, and 8.7). Compared to the lowest BF% quintile, OR for having T2D in highest BF% quintile was 11.1 (95% CI = 8.4-14.6). Compared to the highest SM% quintile, OR for having T2D in lowest SM% quintile was 2.0 (1.7-2.4). Of 72 adults with T2D/HbA1c > 6.5% in the lowest quintile of BF%, 27 (37.5%) were in quintile 1 of SM%. Similar patterns of OR were observed for having HbA1c > 6.5% in those without known T2D. CONCLUSIONS: Estimated BF% associates strongly with T2D. Low SM% also has a significant association, suggesting a neglected aspect of aetiology within T2D. These two simple measures with biological relevance, available from data collected in most health surveys, may be more useful than the purely statistical terms BMI.

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.

Low-carbohydrate diets for overweight and obesity: a systematic review of the systematic reviews.

Low-carbohydrate diets are being widely recommended, but with apparently conflicting evidence. We have conducted a formal systematic review of the published systematic reviews of RCTs between low-carbohydrate vs. control (low-fat/energy-restricted) diets in adults with overweight and obesity. In MEDLINE, Embase, Web of Knowledge and Cochrane Database of Systematic Reviews, searched from inception to September 2017, we identified 12 systematic reviews, 10 with meta-analyses. Differences in methods, study quality, weight change and citations of published systematic reviews were assessed by AMSTAR-2. Review methods varied in definitions of low-carbohydrate diet, databases searched and bias assessment. Overall review quality was high in two, moderate in three, critically low in seven. Among meta-analyses, 4/5 with critically low quality showed low-carbohydrate diet superiority for weight loss (0.7-4.0 kg), while high quality meta-analyses reported little or no difference between diets. Greater numbers of participants correlated with smaller differences in weight loss (r = 0.73, p = 0.03). More citations correlated with lower review quality (rho = -0.9, p = 0.037), with larger differences in weight loss (rho = -0.9, p = 0.037), and with journal impact factor (rho = 1.0, p = 0.01). In conclusion, publication acceptance and citations appear to favour apparently larger effect sizes above methodological quality. Better quality reviews and RCTs are needed, before recommending low-carbohydrate diets as preferred to other approaches for energy restriction.

Different associations between body composition and alcohol when assessed by exposure frequency or by quantitative estimates of consumption.

BACKGROUND: Alcohol intake is widely assumed to contribute to excess body fatness, especially among young men; however, the evidence is inconsistent. We have addressed this research question by investigating associations between reported alcohol consumption and body composition from large representative national surveys in a high alcohol-consuming country with a high obesity prevalence. METHODS: The present study comprised a secondary analysis of combined cross-sectional nationally representative Scottish Health Surveys (1995-2010). Reported alcohol-drinking frequency was divided into five groups: from 'nonfrequent drinking' (reference) to daily/'almost every day' among 35 837 representative adults [mean (SD) age: 42.7 (12.7) years (range 18-64 years)]. Quantitative alcohol consumption was categorised into seven groups: from '1-7 to ≥50 10 g units per week'. Regression models against measured body mass index (BMI) and waist circumference (WC) were adjusted for age, physical activity, income, smoking, deprivation category and economic status. RESULTS: Among alcohol-consuming men, heavier drinking (21-28 units per week) was associated with a higher BMI by +1.4 kg m-2 [95% confidence interval (CI) = 1.38-1.43] and higher WC by +3.4 cm (95% CI = 3.2-3.6) than drinking 1-7 units per week. However, those who reported daily drinking frequency were associated with a lower BMI by -2.45 kg m-2 (95% CI = -2.4 to -2.5) and lower WC by -3.7 cm (95% CI = -3.3 to -4.0) than those who reported less-frequent drinking. Similar associations were found for women. Most of these associations were restricted to subjects aged >30 years. Unexplained variances in BMI and WC are large. CONCLUSIONS: Quantitative alcohol consumption and frequency of consumption were positively and inversely associated, respectively, with both BMI and WC among alcohol-consuming adults. Surveys are needed that evaluate both the quantity and frequency of consumption. The lowest BMI and WC were associated with a 'Mediterranean' drinking style (i.e. relatively little, but more frequently).

Contemporary challenges to iodine status and nutrition: the role of foods, dietary recommendations, fortification and supplementation.

Iodine deficiency (ID) in women of childbearing age remains a global public health concern, mainly through its impact on fetal and infant neurodevelopment. While iodine status is improving globally, ID is still prevalent in pregnancy, when requirements increase. More than 120 countries have implemented salt iodisation and food fortification, strategies that have been partially successful. Supplementation during pregnancy is recommended in some countries and supported by the WHO when mandatory salt iodisation is not present. The UK is listed as one of the ten countries with the lowest iodine status globally, with approximately 60 % of pregnant women not meeting the WHO recommended intake. Without mandatory iodine fortification or recommendation for supplementation in pregnancy, the UK population depends on dietary sources of iodine. Both women and healthcare professionals have low knowledge and awareness of iodine, its sources or its role for health. Dairy and seafood products are the richest sources of iodine and their consumption is essential to support adequate iodine status. Increasing iodine through the diet might be possible if iodine-rich foods get repositioned in the diet, as they now contribute towards only about 13 % of the average energy intake of adult women. This review examines the use of iodine-rich foods in parallel with other public health strategies, to increase iodine intake and highlights the rare opportunity in the UK for randomised trials, due to the lack of mandatory fortification programmes.

Association of neutrophil morphology with bacterial isolates in equine tracheal wash samples.

BACKGROUND: Tracheal wash sample neutrophilia is common in lower airway inflammation of various causes; however, relevance of cytomorphological features to culture of bacterial pathogens has not been established. OBJECTIVES: To investigate whether the presence of nondegenerate or degenerate neutrophils in tracheal washes is associated with culture of bacteria and, if so, whether this is influenced by age or temporal factors. STUDY DESIGN: Cross-sectional study. METHODS: Tracheal wash samples submitted to Rossdales LLP from 1/1/2013 to 31/7/2015 were evaluated using set criteria. Neutrophilia and degenerate neutrophilia (graded ≥2/4 on Rossdales cytological scale [0-4]) were analysed in relation to bacterial isolates considered potentially pathogenic in respiratory disease. Statistical analyses included multivariable logistic regression to identify associations between two separate outcomes: 1) the presence of neutrophilia compared with no neutrophilia and 2) the presence of degenerate neutrophilia compared with nondegenerate neutrophilia and four independent variables. RESULTS: Sufficient data for inclusion in the multivariable model for nondegenerate neutrophilia were available from 1100 horses. Culture of potentially pathogenic bacteria was associated with increased odds of degenerate neutrophilia compared with samples with negative culture (OR 4.5, 95% CI 3.1, 6.4, P-value<0.001). Horses over 9 years old had lower odds of having degenerate neutrophilia than those aged 1-3 years (OR 0.6, 95% CI 0.4, 0.9, P-value<0.02). In the spring/summer, horses had reduced odds of a degenerate neutrophilia compared with winter (OR 0.4, 95% CI 0.3, 0.7, P-value <0.001). MAIN LIMITATIONS: The study relied on routine laboratory submissions, with no control over sample collection or submitted clinical history. CONCLUSIONS: Cytological evaluation of tracheal washes should include cytomorphological features of the neutrophil response. The presence of degenerate neutrophils, especially in young horses, indicates added value of culture and sensitivity for antimicrobial therapeutics. The absence of degenerate changes, in combination with clinical factors, can help support diagnosis of a nonseptic cause of airway neutrophilia.

Fludrocortisone therapy for persistent hyperkalaemia.

BACKGROUND: Type 4 renal tubular acidosis causes hyperkalaemia, for which diabetes and medications commonly used in this patient group are aetiological factors. Here we describe the novel use of fludrocortisone in this difficult condition. CASE REPORT: A 55-year-old woman with complex co-morbidities, including Type 2 diabetes (HbA1c 37 mmol/mol 5.5%), was admitted with renal failure. Bloods on admission: eGFR 25 ml/min, creatinine 184 ?mol/L, urea 35.9 mmol/L, sodium 128 mmol/L, potassium 5.6 mmol/L, bicarbonate 15 mmol/L, and albumin 30 g/L. Her admission was prolonged, complicated by hospital-acquired sepsis (lower respiratory tract, urinary tract, and infected leg ulcers), poor venous access and severe depression. She had recurrent hyperkalaemia and deteriorating renal function, from presumed Type 4 renal tubular acidosis and excessive fluid losses from leg ulcers. Her renal function recurrently deteriorated, despite conventional treatment methods. After 69 days, she was commenced on fludrocortisone 50 mcg/day. Her renal function and serum potassium stabilized and she was discharged with potassium 4.3 mmol/L, eGFR 42 ml/min, and bicarbonate 23 mmol/L. She has remained stable on this treatment, without requiring further hospital admission for over 6 months, with eGFR 40 ml/min, and potassium 5.5 mmol/L, and albumin 26 g/L. CONCLUSION: This woman was presumed to have Type 4 renal tubular acidosis and recurrent hyperkalaemia due to renal insufficiency, in the context of underlying diabetes and chronic kidney disease, which was poorly responsive to conventional management. There is limited evidence for using fludrocortisone in this setting. Our case suggests that fludrocortisone might offer a novel therapeutic strategy when conventional management is not working.

Weight losses with low-energy formula diets in obese patients with and without type 2 diabetes: systematic review and meta-analysis.

This corrects the article DOI: 10.1038/ijo.2016.175.

Time spent in sedentary posture is associated with waist circumference and cardiovascular risk.

BACKGROUND: The relationship between metabolic risk and time spent sitting, standing and stepping has not been well established. The present study aimed to determine associations of objectively measured time spent siting, standing and stepping, with coronary heart disease (CHD) risk. METHODS: A cross-sectional study of healthy non-smoking Glasgow postal workers, n=111 (55 office workers, 5 women, and 56 walking/delivery workers, 10 women), who wore activPAL physical activity monitors for 7 days. Cardiovascular risks were assessed by metabolic syndrome categorisation and 10-year PROCAM (prospective cardiovascular Munster) risk. RESULTS: Mean (s.d.) age was 40 (8) years, body mass index 26.9 (3.9) kg m-2 and waist circumference 95.4 (11.9) cm. Mean (s.d.) high-density lipoprotein cholesterol (HDL cholesterol) 1.33 (0.31), low-density lipoprotein cholesterol 3.11 (0.87), triglycerides 1.23 (0.64) mmol l-1 and 10-year PROCAM risk 1.8 (1.7)%. The participants spent mean (s.d.) 9.1 (1.8) h per day sedentary, 7.6 (1.2) h per day sleeping, 3.9 (1.1) h per day standing and 3.3 (0.9) h per day stepping, accumulating 14 708 (4984) steps per day in 61 (25) sit-to-stand transitions per day. In univariate regressions-adjusting for age, sex, family history of CHD, shift worked, job type and socioeconomic status-waist circumference (P=0.005), fasting triglycerides (P=0.002), HDL cholesterol (P=0.001) and PROCAM risk (P=0.047) were detrimentally associated with sedentary time. These associations remained significant after further adjustment for sleep, standing and stepping in stepwise regression models. However, after further adjustment for waist circumference, the associations were not significant. Compared with those without the metabolic syndrome, participants with the metabolic syndrome were significantly less active-fewer steps, shorter stepping duration and longer time sitting. Those with no metabolic syndrome features walked >15 000 steps per day or spent >7 h per day upright. CONCLUSIONS: Longer time spent in sedentary posture is significantly associated with higher CHD risk and larger waist circumference.

Mobile applications for obesity and weight management: current market characteristics.

Mobile-Health (mHealth) is the fastest-developing eHealth sector, with over 100 000 health applications (apps) currently available. Overweight/obesity is a problem of wide public concern that is potentially treatable/preventable through mHealth. This study describes the current weight-management app-market. Five app stores (Apple, Google, Amazon, Windows and Blackberry) in UK, US, Russia, Japan and Germany, Italy, France, China, Australia and Canada were searched for keywords: 'weight', 'calorie', 'weight-loss', 'slimming', 'diet', 'dietitian' and 'overweight' in January/February 2016 using App-Annie software. The 10 most downloaded apps in the lifetime of an app were recorded. Developers' lists and the app descriptions were searched to identify any professional input with keywords 'professional', 'dietitian' and 'nutritionist'. A total of 28 905 relevant apps were identified as follows: Apple iTunes=8559 (4634, 54% paid), Google Play=1762 (597, 33.9% paid), Amazon App=13569 (4821, 35.5% paid), Windows=2419 (819, 17% paid) and Blackberry=2596 (940, 36% paid). The 28 905 identified apps focused mainly on physical activity (34%), diet (31%), and recording/monitoring of exercise, calorie intake and body weight (23%). Only 17 apps (0.05%) were developed with identifiable professional input. Apps on weight management are widely available and very popular but currently lack professional content expertise. Encouraging app development based on evidence-based online approaches would assure content quality, allowing healthcare professionals to recommend their use.

Weight losses with low-energy formula diets in obese patients with and without type 2 diabetes: systematic review and meta-analysis.

AIM: To provide a systematic review, of published data, to compare weight losses following very low calorie (<800 kcal per day VLCD) or low-energy liquid-formula (>800 kcal per day LELD) diets, in people with and without type 2 diabetes mellitus (T2DM). METHODS: Systematic electronic searches of Medline (1946-2015) and Embase (1947-2015) to identify published studies using formula total diet replacement diets (VLCD/LELD). Random effects meta-analysis using weighted mean difference (WMD) in body weight between groups (with and without diabetes) as the summary estimate. RESULTS: Final weight loss, in the five included studies, weighted for study sizes, (n=569, mean BMI=35.5-42.6 kg/m2), was not significantly different between participants with and without T2DM: -1.2 kg; 95% CI: -4.1 to 1.6 kg). Rates of weight loss were also similar in the two groups -0.6 kg per week (T2DM) and 0.5 kg per week (no diabetes), and for VLCD (<800 kcal per day) and LELD (>800 kcal per day). CONCLUSIONS: Weight losses with liquid-formula diets are very similar for VLCD and LELD and for obese subjects with or without T2DM. They can potentially achieve new weight loss/ maintenance targets of >15-20% for people with severe and medically complicated obesity.

Lower bone turnover and relative bone deficits in men with metabolic syndrome: a matter of insulin sensitivity? The European Male Ageing Study.

We examined cross-sectional associations of metabolic syndrome and its components with male bone turnover, density and structure. Greater bone mass in men with metabolic syndrome was related to their greater body mass, whereas hyperglycaemia, hypertriglyceridaemia or impaired insulin sensitivity were associated with lower bone turnover and relative bone mass deficits. INTRODUCTION: Metabolic syndrome (MetS) has been associated with lower bone turnover and relative bone mass or strength deficits (i.e. not proportionate to body mass index, BMI), but the relative contributions of MetS components related to insulin sensitivity or obesity to male bone health remain unclear. METHODS: We determined cross-sectional associations of MetS, its components and insulin sensitivity (by homeostatic model assessment-insulin sensitivity (HOMA-S)) using linear regression models adjusted for age, centre, smoking, alcohol, and BMI. Bone turnover markers and heel broadband ultrasound attenuation (BUA) were measured in 3129 men aged 40-79. Two centres measured total hip, femoral neck, and lumbar spine areal bone mineral density (aBMD, n = 527) and performed radius peripheral quantitative computed tomography (pQCT, n = 595). RESULTS: MetS was present in 975 men (31.2 %). Men with MetS had lower ß C-terminal cross-linked telopeptide (ß-CTX), N-terminal propeptide of type I procollagen (PINP) and osteocalcin (P < 0.0001) and higher total hip, femoral neck, and lumbar spine aBMD (P ≤ 0.03). Among MetS components, only hypertriglyceridaemia and hyperglycaemia were independently associated with PINP and ß-CTX. Hyperglycaemia was negatively associated with BUA, hypertriglyceridaemia with hip aBMD and radius cross-sectional area (CSA) and stress-strain index. HOMA-S was similarly associated with PINP and ß-CTX, BUA, and radius CSA in BMI-adjusted models. CONCLUSIONS: Men with MetS have higher aBMD in association with their greater body mass, while their lower bone turnover and relative deficits in heel BUA and radius CSA are mainly related to correlates of insulin sensitivity. Our findings support the hypothesis that underlying metabolic complications may be involved in the bone's failure to adapt to increasing bodily loads in men with MetS.

Associations between weight change and biomarkers of cardiometabolic risk in South Asians: secondary analyses of the PODOSA trial.

BACKGROUND/OBJECTIVES: The association of weight changes with cardiometabolic biomarkers in South Asians has been sparsely studied. SUBJECTS/METHODS: We measured cardiometabolic biomarkers at baseline and after 3 years in the Prevention of Diabetes and Obesity in South Asians Trial. We investigated the effect of a lifestyle intervention on biomarkers in the randomized groups. In addition, treating the population as a single cohort, we estimated the association between change in weight and change in biomarkers. RESULTS: Complete data were available at baseline and after 3 years in 151 participants. At 3 years, there was an adjusted mean reduction of 1·44 kg (95% confidence interval (95% CI): 0.18-2.71) in weight and 1.59 cm (95% CI: 0.08-3.09) in waist circumference in the intervention arm as compared with the control arm. There was no clear evidence of difference between the intervention and control arms in change of mean value of any biomarker. As a single cohort, every 1 kg weight reduction during follow-up was associated with a reduction in triglycerides (-1.3%, P=0.048), alanine aminotransferase (-2.5%, P=0.032), gamma-glutamyl transferase (-2.2%, P=0.040), leptin (-6.5%, P<0.0001), insulin (-3.7%, P=0.0005), fasting glucose (-0.8%, P=0.0071), 2-h glucose (-2.3%, P=0.0002) and Homeostatic Model Assessment of insulin resistance (HOMA-IR: -4.5%, P=0.0002). There was no evidence of associations with other lipid measures, tissue plasminogen activator, markers of inflammation or blood pressure. CONCLUSIONS: We demonstrate that modest weight decrease in SAs is associated with improvements in markers of total and ectopic fat as well as insulin resistance and glycaemia in South Asians at risk of diabetes. Future trials with more intensive weight change are needed to extend these findings.

Changing guards: time to move beyond body mass index for population monitoring of excess adiposity.

With the obesity epidemic, and the effects of aging populations, human phenotypes have changed over two generations, possibly more dramatically than in other species previously. As obesity is an important and growing hazard for population health, we recommend a systematic evaluation of the optimal measure(s) for population-level excess body fat. Ideal measure(s) for monitoring body composition and obesity should be simple, as accurate and sensitive as possible, and provide good categorization of related health risks. Combinations of anthropometric markers or predictive equations may facilitate better use of anthropometric data than single measures to estimate body composition for populations. Here, we provide new evidence that increasing proportions of aging populations are at high health-risk according to waist circumference, but not body mass index (BMI), so continued use of BMI as the principal population-level measure substantially underestimates the health-burden from excess adiposity.