Does Intensive Lifestyle Intervention Reverse Type 2 Diabetes?

Abstract & Commentary

By Jeff Unger, MD, Director, Metabolic Studies, Catalina Research Institute, Chino, CA. Dr. Unger reports no financial relationships relevant to this field of study.

Synopsis: After 4 years, the intensive lifestyle intervention resulted in a greater likelihood of “partial remission” of type 2 diabetes.

Source: Gregg EW, et al. Association of an intensive lifestyle intervention with remission of type 2 diabetes. JAMA 2012;38: 2489-2496.

A total of 5145 patients with type 2 diabetes were randomized to receive either diabetes support and education (DSE), including three group sessions annually focusing on diet, physical activity, and social support, or intensive lifestyle intervention (ILI), including weekly group and individual counseling for the first 6 months followed by three sessions monthly with frequent contact sessions over 4 years. The ILI group also aimed to reduce total caloric intake to 1200-1800 kcal/day and encourage exercising 175 minutes weekly.

At 4 years, the ILI cohort experienced more weight loss vs the DSE group (-4.7% vs -4.4% from baseline). The prevalence of complete remission (defined as glucose normalization without the need for pharmacologic intervention at year 4) was low, yet more common among members of the ILI cohort (0.7% vs 0.2% of patients in the DSE cohort). Thirty percent of the patients experiencing any remission in the ILI cohort progressed to clinical diabetes each year whereas 50% of the DSE patients returned to clinical diabetes status once they achieved remission. Positive predictors for remission included: a) patients who developed any remission during the first year of the clinical trial, b) patients experiencing substantial weight loss or an increase in fitness status, c) shorter duration of diabetes prior to randomization, d) lower baseline A1c, and e) patients who were not insulin dependent.

Commentary

Although the large database in this study supports a favorable relationship between intensive lifestyle intervention and diabetes remission, some critics may consider this “old news.” In 2009, Perreault et al enrolled participants in the Diabetes Prevention Program (DPP) and they experienced a 16% reduction in diabetes risk progression for each 1 kg of weight loss they experienced using ILI.1 The study also demonstrated the importance of early intensive intervention in the cohort of patients with prediabetes. Those individuals who achieved normal glucose regulation during the first year of randomization were less likely to progress toward clinical diabetes due to pancreatic beta cell preservation.

More recently, Mingrone et al demonstrated that patients undergoing bariatric surgery lost, on average, 33% of their baseline weight after 2 years.2 No patient in this study who underwent ILI and pharmacotherapy achieved diabetes remission whereas 75% of gastric bypass and 95% of bilio-pancreatic diversion patients were diabetes free just 2 years following their surgical procedures.

ILI is not readily available to all patients. ILI patients were provided with 90 individual or group training sessions over a 4-year period. Assuming that a certified diabetes educator charges $35 per hour, 4 years of intensive lifestyle training may cost each patient $3150. Yet, less than 1% of ILI patients actually were able to experience complete remission. Although bariatric surgery is more expensive, the odds that one will lose more weight more rapidly and achieve remission sooner would suggest that qualifying patients may choose surgery over ILI coaching.

References

1. Perreault L, et al. Regression from pre-diabetes to normal glucose regulation in the Diabetes Prevention Program. Diabetes Care 2009;32:1583-1588.

2. Mingrone G, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med 2012; 366:1577-1585.