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 (lt;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

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)

Predictors of type 2 diabetes 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

A simplified (modified) Duke Activity Status Index (M-DASI) to characterise functional capacity: A secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) study

Background Accurate assessment of functional capacity, a predictor of postoperative morbidity and mortality, is essential to improving surgical planning and outcomes. We assessed if all 12 items of the Duke Activity Status Index (DASI) were equally important in reflecting exercise capacity. Methods In this secondary cross-sectional analysis of the international, multicentre Measurement of Exercise Tolerance before Surgery (METS) study, we assessed cardiopulmonary exercise testing and DASI data from 1455 participants. Multivariable regression analyses were used to revise the DASI model in predicting an anaerobic threshold (AT) >11 ml kg −1 min −1 and peak oxygen consumption (VO 2 peak) >16 ml kg −1 min −1, cut-points that represent a reduced risk of postoperative complications. Results Five questions were identified to have dominance in predicting AT>11 ml kg −1 min −1 and VO 2 peak>16 ml.kg −1min −1. These items were included in the M-DASI-5Q and retained utility in predicting AT>11 ml.kg −1.min −1 (area under the receiver-operating-characteristic [AUROC]-AT: M-DASI-5Q=0.67 vs original 12-question DASI=0.66) and VO 2 peak (AUROC-VO2 peak: M-DASI-5Q 0.73 vs original 12-question DASI 0.71). Conversely, in a sensitivity analysis we removed one potentially sensitive question related to the ability to have sexual relations, and the ability of the remaining four questions (M-DASI-4Q) to predict an adequate functional threshold remained no worse than the original 12-question DASI model. Adding a dynamic component to the M-DASI-4Q by assessing the chronotropic response to exercise improved its ability to discriminate between those with VO 2 peak>16 ml.kg −1.min −1 and VO 2 peak<16 ml.kg −1.min −1. Conclusions The M-DASI provides a simple screening tool for further preoperative evaluation, including with cardiopulmonary exercise testing, to guide perioperative management

Genetics of coronary artery calcification among African Americans, a meta-analysis

Background: Coronary heart disease (CHD) is the major cause of death in the United States. Coronary artery calcification (CAC) scores are independent predictors of CHD. African Americans (AA) have higher rates of CHD but are less well-studied in genomic studies. We assembled the largest AA data resource currently available with measured CAC to identify associated genetic variants.Methods: We analyzed log transformed CAC quantity (ln(CAC + 1)), for association with ~2.5 million single nucleotide polymorphisms (SNPs) and performed an inverse-variance weighted meta-analysis on results for 5,823 AA from 8 studies. Heritability was calculated using family studies. The most significant SNPs among AAs were evaluated in European Ancestry (EA) CAC data; conversely, the significance of published SNPs for CAC/CHD in EA was queried within our AA meta-analysis.Results: Heritability of CAC was lower in AA (~30%) than previously reported for EA (~50%). No SNP reached genome wide significance (p < 5E-08). Of 67 SNPs with p < 1E-05 in AA there was no evidence of association in EA CAC data. Four SNPs in regions previously implicated in CAC/CHD (at 9p21 and PHACTR1) in EA reached

Improving the dietary intake of under nourished older people in residential care homes using an energy-enriching food approach: a cluster randomised controlled study

Background: To examine whether the nutritional status of aged undernourished residents in care could be improved through dietary modification to increase energy intake but not portion size.&lt;p&gt;&lt;/p&gt; Methods: A 12-week cluster randomised controlled trial was carried out in 21 residential care homes. Participants comprised undernourished residents with a body mass index (BMI) &#60;18.5 kg m–2. All menus were analysed to evaluate nutrient provision. Energy and macronutrient intakes of undernourished residents were estimated using 3-day weighed food intake diaries. Those resident in homes randomised to intervention had their usual meals enriched with energy-dense foods to a maximum of +1673 kJ day−1.&lt;p&gt;&lt;/p&gt; Results: Of 445 residents screened, 41 (9%) had a BMI &#60;18.5 kg m–2 and entered the study. Despite adequate food provision, energy and macronutrient intakes were below UK dietary reference values. Mean (SEM) energy intake increased [+556 (372) kJ, P = 0.154] in residents allocated to intervention but fell in those residents in ‘control homes’ receiving usual care [−151 (351) kJ, P = 0.676]. Weight change [+1.3 (0.53) kg, P = 0.03] was seen in intervention residents but not in controls [−0.2 (1.5) kg, P = 0.536]. Between-group differences for changes in weight and energy intake were not significant (P = 0.08 and 0.20, respectively). Six residents allocated to the intervention increased their BMI &#62;18.5 kg m–2 (P = 0.018).&lt;p&gt;&lt;/p&gt; Conclusions: Achieving weight gain in frail older people is difficult. These results suggest that enriching food could help address undernutrition and slow chronic weight loss. Interventions of a longer duration are needed to confirm or exclude the value of food enrichment.&lt;p&gt;&lt;/p&gt