Month: May 2022

On 12^th April at TDMR Europe’s online seminar “Diabetes Remission: Maintenance after weight loss with total diet replacement (TDR)”, health experts demonstrated that weight maintenance is possible after rapid weight loss with TDR and showed its crucial role in delivering diabetes remission  type 2 diabetes.

Professor Gary Frost (Chair in Nutrition and Dietetics – Imperial College London) participated in the webinar providing key-insights on the challenges and potential solutions related to successful weight loss maintenance and diabetes remission. Professor Frost stressed that biological, behavioural, and environmental factors conspire to resist weight loss and promote regain, and that effective treatment of obesity requires ongoing attention and support, and weight maintenance-specific counselling, to deliver better long-term weight management.

Maintenance of weight loss and diabetes remission: barriers and solutions

Professor Gary Frost, Imperial College London, England

Long term weight loss and maintenance of weight loss over the life course remains a major unachieved goal (1).  Only 20% of people meet the criteria of long-term weight loss (10% of their initial body weight for one year) (2).  This disappointing statistic is common across all dietary profiles.  There are a number of common traits that are associated with maintenance of weight loss include positive emotional regulation such as low levels of dietary disinhibition and low levels of depression, dietary consistency, weight gain management and high contact with a councillor.  Unfortunately, evidence suggest that physiology starts to work against the maintenance of weight loss maintenance.  Energy balance starts to favour weight regain (1); appetite regulation favours a low appetite suppression tone (3).  In recent year my team have used some of these observations to design a method to nudge anorectic systems to prevent weight gain.  We had achieved this using a short chain fatty acid propionate.  Short chain fatty acids are produced by the microbiome in the human colon.  We have developed a method to deliver propionate to the colon and demonstrated positive effects on appetite regulation, hedonic wanting and liking of food and energy expenditure (4). It is possible such systems could impact on weight loss maintenance.

At the present time there is no high-quality evidenced based guidelines to enhance weight loss maintenance.  There is a number of good practice points that may enhance weight loss maintenance.

1. Maintaining contact with professional support
2. The use of corrective intervention
3. Realistic but clinically important targets
4. Physiological support
5. Methods to support appetite regulation

 

References

• Hall KD, Kahan S. Maintenance of lost weight and long-term management of obesity. Med Clin North Am [Internet] NIH Public Access; 2018 [cited 2022 Apr 12];102:183. Available from: /pmc/articles/PMC5764193/

 

• Wing RR, Phelan S. Long-term weight loss maintenance. Am J Clin Nutr [Internet] Oxford Academic; 2005 [cited 2022 Apr 12];82:222S-225S. Available from: https://academic.oup.com/ajcn/article/82/1/222S/4863393

 

• Sumithran P, Prendergast LA, Delbridge E, Purcell K, Shulkes A, Kriketos A, Proietto J. Long-term persistence of hormonal adaptations to weight loss. N Engl J Med [Internet] 2011 [cited 2014 May 7];365:1597–604. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22029981

 

• Chambers ES, Morrison DJ, Tedford MC, Frost G. A novel dietary strategy to increase colonic propionate production in humans and improve appetite regulation and bodyweight management. Nutr Bull 2015;40

If you would like to contact TDMR Europe to discuss the webinar or any other matter, please email secretariat@tdmr-europe.com.

TDMR Europe organises educational seminars on TDRs and MRPs. Our events bring together industry stakeholders, academics, policymakers and others to review and raise awareness of the increasing evidence base within the scientific literature regarding the efficacy and potential of TDRs and MRPs to address effectively the challenge of obesity and related diseases in Europe. Find out more about TDMR Europe in our media pack and membership leaflet.

Sleep duration and sleep quality were significantly improved by 8 weeks Total Diet Replacement (TDR) 810kcal/d diet in 195 adults with obesity as reported at the European Congress on Obesity (ECO May 2022) by Prof Signe Torekov’s group from the University of Copenhagen.  The presentation (Bogh A et al 2022) reported preliminary data from accelerometry measurements and the Pittsburgh Sleep Quality Index (PSQI) scores on participants in the ‘S-LITE‘ study.  After the initial 8-week preparatory weight loss with TDR participants were randomised to a maintenance dietary regimen with a daily Liraglutide injection in one group, a daily placebo injection in the second, an exercise programme for the third group and exercise and Liraglutide for the fourth group. Weight outcomes have already been fully reported (Lundgren J R et al 2021) and showed an initial average loss of 13.1kg (12%) after 8 weeks TDR.  Accelerometry recordings of sleep duration and PSQI scores were made at baseline, after 8 weeks TDR and 26 and 52 weeks after weight loss.

Baseline sleep status influenced weight maintenance.  Poor sleepers, who at baseline slept for less than 6 hours regained more weight than those who slept for 6-7 hours/night.  Those who exercised maintained sleep quality improvements better than those who did not exercise.

These preliminary results suggest that improved sleep can be listed alongside diabetes remission, reduced blood pressure, reduced cardiovascular risk, reduced pain in osteoarthritis and reduced inflammatory markers as potential beneficial effects of weight loss with TDR.

In another recently published study (Tasali et al 2021) 80 young adults with overweight (BMI 25 to 29.9) aged 21 to 40 years and who habitually slept for less than 6.5 hours/night were randomised to either continuing their habitual sleep pattern or were entered into sleep hygiene counselling intended to extend sleep to 8.5 hours/night for two weeks. Dietary energy intake, energy expenditure (doubly labelled water method), body composition (DEXA scanning) and sleep duration (by actigraphy) were measured. Sleep duration increased by 1.2 hours/night in the sleep extension group in whom dietary energy intake decreased significantly by an average 270kcal/d compared to the control group. The sleep extension group lost an average 0.87kg in two weeks, significantly different from the habitual sleep group in whom an average 0.39kg body weight was gained.  The authors concluded ‘Improving and maintaining healthy sleep duration over longer periods could be part of obesity prevention and weight loss programs’.

The results from Copenhagen suggest that there would be merit in giving sleep hygiene guidance at the beginning of a TDR weight loss programme in order to facilitate better weight loss maintenance, however this would need to be tested in a specific study.  None the less since little or no harm can be done by following guidance to improve sleep duration and quality, there is no good reason why this should not be done anyway.  Key points of advice given would include:

• Do get to bed at a regular time every night and get up at a regular time;
• Do not read, eat or watch TV in bed;
• Do limit or avoid all screen use for 1-2 hours before bedtime and especially avoid stimulating computer games;
• Avoid caffeine containing drinks for up to 6 hours before sleep;
• Avoid smoking and drinking alcohol for at least an hour before going to bed;
• Avoid excessive exercise for a few hours before going to bed;
• Do arrange a warm bed and a cool uncluttered room with low lighting (warm light rather than blue/white light);
• Do write a list of worries and/or a ‘to-do’ list before going to bed.

Anthony Leeds, chairman of TDMR Europe said ‘I welcome these preliminary findings that provide some scientific support for what I and some colleagues had long suspected: that a good weight loss of 10kg or 10% improves sleep in people who are overweight or obese even in the absence of a specific sleep disorder.  People with obesity (or overweight) who are troubled by poor sleep should consider losing 10% body weight with TDR and follow simple sleep hygiene guidance now.  While more research will be helpful, we do not need to wait another 5 years before giving guidance, meanwhile I eagerly await publication of the full results from this study.’

Anthony R Leeds

The  S-LITE study was funded by the Novo Nordisk Foundation and TDR products and accelerometers were provided by Cambridge Weight Plan Ltd UK.

Refs:

Bogh A H et al 2022 Short Sleep Duration is Associated with Weight Regain – PAGE 134 in Obes Facts 2022;15(suppl 1):1–240 DOI: 10.1159/000524469

Lundgren J R et al Healthy Weight Loss Maintenance with Exercise, Liraglutide, or Both Combined  N Engl J Med 2021;384:1719-30. DOI: 10.1056/NEJMoa2028198

Tasali E et al Effect of sleep extension on objectively assessed energy intake among adults with overweight in real-life settings: a randomized clinical trial. JAMA Intern Med doi: 10.1001/jamainternmed.2021.8098

On 12th April, TDMR Europe’s online seminar brought together speakers from Scotland, England and Cyprus to focus on weight maintenance and diabetes remission maintenance after weight loss with total diet replacement.

The webinar was opened by Professor Mike Lean, Professor of Human Nutrition at the University of Glasgow who reviewed research evidence including the DiRECT trial of Total Diet Replacement (TDR) weight loss with behavioural and lifestyle guidance followed by weight maintenance to achieve diabetes remission in people with type 2 diabetes.  Prof Lean also reviewed the extent to which current guidelines refer to the evidence for diabetes remission and forthcoming plans for further guidelines later in 2022.

Introducing the webinar TDMR Europe chair Professor Anthony Leeds said ‘European countries face levels of obesity and diabetes that will overwhelm capacity for healthcare provision. Weight loss has been recognised as the key component for diabetes prevention and key to effective diabetes prevention. All European countries require effective programmes for diabetes prevention, diabetes remission and obesity prevention and reduction and diabetes remission programmes based on the DiRECT research results may help contribute to this.’

TDMR Europe’s online seminar brought together industry stakeholders, academics and others and showed the potential role of TDR in contributing to diabetes remission and prevention and considered the issues relating to weight maintenance, including whether or not dietary glycaemic index and glycaemic load could play a part.

The recording of the webinar will is available here.

More information on TDR is available here.

Professor Mike Lean is a principal investigator of the DiRECT study, chair of the department of human nutrition at the University of Glasgow, visiting professor at Otago University and visiting professor at the University of Sydney. He is a keen fiddle-player and climbs mountains.

FUNDING – The DiRECT trial was funded as a Strategic Research Initiative by Diabetes UK and Cambridge Weight Plan donated all formula diet products.

Abstract

An update on development of guidelines for diabetes remission – remission possible!

Professor Mike Lean, University of Glasgow, Scotland

Until very recently, ‘remission ‘ of type 2 diabetes (T2D) was an unknown concept.  Results from the UK Diabetes Remission Clinical Trial (DiRECT), supported by near-identical findings from DIADEM-1 in Qatar, have challenged and changed the old paradigm of T2D being a permanent condition, treatable by life-long glucose-lowering drugs, an inconvenience of ageing.  The new evidence reveals T2D as a very serious life-shortening and disabling disease, part of the disease-process of ‘obesity’ in genetically predisposed people, but preventable and reversible at an early stage.

DiRECT included people with T2D up to 6 years from diagnosis. A structured dietary programme (Counterweight-Plus: Total Diet Replacement for 12 weeks, transferring to a food-based maintenance diet with about 50% energy from carbohydrate) achieved remission (HbA1c <48mmol/mol (<6.5%) for 46% of all participants randomized to the intervention, with mean 12m weight loss 10kg.  Those who maintained >15kg loss had over 80% remissions at both 12 and 24 months, and >10kg loss brought remissions for over 70%.

With slightly younger participants and shorter diabetes duration, using similar total Diet Replacement and food-based maintenance, DIADEM-1 achieved 61% remissions at 12m.

These are the only randomized controlled trials of diet interventions reporting remissions of diabetes.  Several observational studies have employed low-carbohydrate diets, but while some have led to good weight losses, the remission rates are rather lower.  The large VIRTA-Health study in US achieved 13kg weight loss, but only 19% remissions. A failure to withdraw glucose lowering drugs may have obscured some more remissions, but these results are in, one with evidence that lower carbohydrate diets are associated with higher, not lower HbA1c.

Criteria for remission of T2D entail (1) a cut-off of HbA1c to denote freedom from diabetes, and (2) a duration of non-diabetic HbA1c without glucose-lowering medication.  There are now internationally agreed criteria, by ADA, EASD, Diabetes UK, the Endocrine Society, and the Diabetes Surgery Summit (2021): HbA1c <48mmol/mol (6.5%), >3 months without glucose-lowering medication.

Following publication of DiRECT, the wishes of people with T2D seeking freedom from the disease have been important in stimulating adoption of remission programmes, for local services, in national Clinical Guidelines (eg Australia, New Zealand) and from international organisations such as forthcoming 2022 evidence-based Guidelines from the Diabetes Nutrition Study Group of EASD.

References:

1. Churuangsuk C., et al Diets for weight management in adults with type 2 diabetes: an umbrella review of published meta-analyses and systematic review of trials of diets for diabetes remission. Diabetologia (2022) 65, 14–36 https://doi.org/10.1007/s00125-021-05577-2
2. Lean MEJ, et al,. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet (2018) 391(10120) 541-551
3. Thom, G. et al. (2021) Predictors of type 2 diabetes in the Diabetes Remission Clinical Trial (DiRECT). Diabetic Medicine, 38(8), e14395. (doi: 10.1111/dme.14395) (PMID:32870520)
4. Riddle M, et al; Consensus Report: Definition and Interpretation of Remission in Type 2 Diabetes. Diabetes Care 1 October 2021; 44 (10): 2438–2444. https://doi.org/10.2337/dci21-0034