Conference over coffee: The importance of weight loss

Banting Memorial Lecture – Type 2 management: “weighing” up the options

Naveed Sattar
Professor of Cardiovascular and Metabolic Health, University of Glasgow

●  There are individual differences in a person’s subcutaneous fat capacity. Once this is exceeded, fat is deposited around the internal organs (visceral or ectopic fat), and this can result in type 2 diabetes.

●  Men tend to develop type 2 diabetes at a lower BMI than women, likely because of lower subcutaneous fat capacity and increased storage in other tissues, increasing insulin resistance.

• They also tend to develop diabetes 15 years earlier than women.

●  For similar reasons, Black, Asian and minority ethnic individuals also develop type 2 diabetes at lower BMI and earlier than those of white European ethnicity.

●  However, white people who develop type 2 diabetes earlier tend to lose more years of life due to greater adiposity:

• This is because adiposity is a major cause of heart failure, non-alcoholic steatohepatitis, end-stage renal disease, etc., even in people without type 2 diabetes.

●  Therefore, weight loss should be considered its own goal, independent of its effects on HbA_1c and, potentially, diabetes remission.

• In addition to diabetes outcomes, patient-reported outcomes (e.g. functional mobility, pain, body image and quality of life) are increasingly being used to confirm benefits of weight loss.

Translating research into practice: The NHS Type 2 Diabetes Path to Remission programme

Jonathan Valabhji
National Clinical Director for Diabetes and Obesity, NHS England

●  As of December 2022, there have been 7554 referrals to the (newly renamed) NHS Type 2 Diabetes Path to Remission programme.

• The highest referral rates have been in the most deprived areas, and there are higher rates among minority ethnic groups. This highlights the benefits of GP referral versus self-referral: underserved communities are being served.

●  Of eligible referrals, 75% have attended for an initial assessment and 68% have started on the meal-replacement diet.

• Uptake has been highest in the youngest age groups, which is encouraging as they have the greatest potential benefit.
• However, uptake was lowest in the most deprived areas (direct inverse relationship between deprivation and uptake).

●  Retention rates have been encouraging: 90% at 3 months (start of weight maintenance phase) and 55% at 1 year.

• Retention rates were lowest in younger ages and deprived areas, and were reduced in those with BMI ≥45. No differences by sex, ethnicity or diabetes duration.

●  Weight change outcomes: –12.2% at 3 months; –12.0% at 6 months; –9.8% at 1 year.

●  Weight change outcomes: –12.2% at 3 months; –12.0% at 6 months; –9.8% at 1 year.

●  Weight loss findings, therefore, reflect those of the original DiRECT randomised controlled trial at 1 year.

●  Remission data are yet to be published.

5-year follow-up weight, remission and clinical outcomes from the DiRECT intervention

Mike Lean, Roy Taylor
Clinical Senior Research Fellow, University of Glasgow; Professor of Medicine and Metabolism, University of Newcastle

●  In the original DiRECT study, 46% of participants in the intervention group achieved remission at 1 year, and 36% at 2 years.

●  Thereafter, the study has been extended: 95 of the original intervention group (48 in remission at extension start) received continued weight maintenance support over years 3–5.

• Reviewed every 3 months in primary care; those who regained >2 kg offered an additional package of support (available once per year), consisting of a 4-week meal-replacement diet plus food reintroduction support.

●  Control group: 82 participants from original control group, who did not receive 3-monthly reviews or supplemental support over the study extension period.

●  Weight loss in the intervention group (n=85 with outcomes data) was attenuated after 2 years but stabilised at a substantial 6.1 kg in year 5.

●  Positive metabolic effects persisted in the study group: decreased triglycerides, decreased insulin levels, decreased liver fat.

●  Interestingly, the control group also achieved weight loss of 4.6 kg over the same interval.

●  At 5 years, in the intervention vs control groups:

• Remission rates: 13% vs 5%.
• Off all diabetes medications: 40% vs 13% (greater weight loss correlated with decreases in HbA_1c).
• Quality of life (EQ-5D score) almost 10% higher in intervention group (same as at 1 year).

●  Of the 48 participants who were in remission at the start of the extension period, 11 (23%) were still in remission, with an average weight loss of 8.9 kg, at 5 years.

●  54% fewer serious adverse events in the intervention group:

• Sudden death, stroke and TIA all lower. However, there were more cardiovascular events in the intervention group (possibly associated with discontinuation of statins, which is not advised).
• Gallstones, DKA and bacterial infections all lower.
• No new cases of weight-associated cancers in intervention group, versus eight in controls – further evaluation needed as numbers are small.

●  Further research is needed to improve weight loss maintenance outcomes and optimise cost efficiency.