Intensive weight management in primary care improved weight loss and remission of type 2 diabetes

The author of an ACP Journal Club commentary said that the intervention effect was strong enough to prompt a reconsideration of primary care management of obesity and that the results of the trial may motivate patients to lose enough weight to reverse diabetes.

An intensive weight management program in primary care resulted in greater rates of weight loss and diabetes remission than usual care in the DiRECT study, a cluster-randomized trial conducted in 49 British primary care practices. The program entailed replacing type 2 diabetes patients' diets with formula (about 850 kcal/d) for three to five months, and then reintroducing food over a period of two to eight weeks before providing structured support for long-term weight-loss maintenance.

The study was published online Dec. 5, 2017, by The Lancet and in the Feb. 10, 2018 print issue. It was summarized in the January ACP Diabetes Monthly. The following commentary by Anupam Goel, MD, FACP, was published in the ACP Journal Club section of the March 20 Annals of Internal Medicine.

Adult weight gain is strongly associated with developing type 2 diabetes. In the Look AHEAD trial, a mean 6.4-kg weight loss in patients with diabetes was not associated with fewer cardiovascular events after 10 years. The DiRECT trial by Lean and colleagues suggests that a more intensive behavioral intervention may be needed to affect patient-oriented outcomes.

The study, however, raises additional questions. What proportion of patients relapse after the first year? With <30% of eligible patients agreeing to participate in the DiRECT trial, how might patients be motivated to adopt behaviors to help lose weight? Could patients lose this much weight without a proprietary very low-calorie formula?

This intervention effect is strong enough for us to rethink primary care management of obesity. Perhaps overweight or obese patients without diabetes should be offered behavioral modifications to lose ≥7% body weight. Those with diabetes not receiving insulin or without diabetes-related complications should be offered the DiRECT trial intervention. The results of the trial may motivate patients to lose enough weight to reverse diabetes. Patients with diabetes-related complications receiving insulin or other pharmaceutical agents that cause weight gain could consider bariatric surgery if they qualify.