Message from our Medical Director, Prof Tony Leeds
A message from our Medical Director, Professor Anthony Leeds, who is attending the International Diabetes Federation meeting in Abu Dhabi.
The results of the Diabetes remission trial (DiRECT) that has been going on in GP practices around Glasgow and Newcastle from July 2014 to August 2016 have been presented today 5th December and published in the Lancet medical journal. Two hundred and ninety-eight people with type 2 diabetes (up to 6 years since diagnosis, not treated with insulin and with BMI’s 27-45) were randomised to either best-practice care (best NHS care) or the Counterweight-Plus programme, a total diet replacement – TDR - (~825 to 853kcal/d using 4 Cambridge Weight Plan-manufactured products). The Counterweight-Plus group lost on average 10kg at 12 months compared to 1 kg in the best-practice control group and in the TDR group remission of diabetes occurred in 46% compared to 4% in the control group. Among those who lost greater amounts of weight 28% achieved maintenance of more than 15kg weight loss at 12 months compared to none in the control group. Greater amounts of weight loss were associated with an increased proportion of people going into diabetes remission: more than 15kg: 86% achieved remission; 10-15kg: 57%; 5-10kg: 34%; and less than 5kg: 4%. This last finding is consistent with the work of other scientists and shows that delivering an initial large weight loss is a critical part of achieving diabetes remission, but it must be followed by a structured maintenance programme with stepped food re-introduction (in this study done over 2 to 8 weeks) and structured support for weight-loss maintenance. Maintenance was achieved using a conventional food programme but there was also a structured relapse management programme: If weight increased by more than 2kg (or diabetes returned) the participants were offered one or two, Cambridge Weight Plan manufactured, meal-replacement products to replace one or two conventional meals for four weeks. If weight increased by more than 4kg or to less than 15kg below the starting weight, or if diabetes recurred, then participants were offered 4 weeks of total diet replacement. The weight-loss medication, orlistat was also offered, but not necessarily used, as an option in these cases. Not surprisingly those who weighed more than 110kg (just over 17 stone) at the beginning were more likely to have lost and maintained a 15kg weight loss at 12 months than those who weighed under 90kg (14 stone) and men were more likely to have maintained a 15kg weight loss at one year than women (33% compared to 14%). The side effect pattern was similar to those from previous trials with constipation, sensitivity to cold, headache and dizziness being the most common effects. The TDR and best- practice programmes were provided by practice nurses and dietitians trained in the Counter-Weight Plus programme. During the programme participants were seen weekly or fortnightly, during stepped food- reintroduction they were seen fortnightly and during the weight-loss maintenance phase they were seen monthly and the focus was on maintaining lifestyle changes and preventing weight regain.
This new study adds to the existing portfolio of evidence, all of which was obtained in research settings in hospital clinics with delivery of the Cambridge Weight Plan programme by dietitians with some local variation in the nutrition education and weight maintenance components. In elderly obese people with knee osteoarthritis maintenance was achieved for a total of four years in over 50% of those who started, following intense education in groups during the TDR programme followed by either one meal replacement daily for three years but with monthly support from the dietitian, and in the studies on people with other weight related conditions dietitians delivered the programmes.