1 Helping People Make Healthy Lifestyle Changes: What Works, Why? Hope S. Warshaw, MMSc, RD, CDE, BC-ADM Owner, Hope Warshaw Associates, LLC Twitter: @HopeWarshaw facebook.com/EatHealthyLiveWell 17 th Annual Montana Diabetes Professional Conference October 24, 2014 Presenters Disclosures* • Food and nutrition clients: – McNeil Nutritionals, LLC (Splenda ® Brand Sweeteners) – Beneo Institute (dietary fibers) • Diabetes clients: – Insulet Corporation – Locemia Solutions, ULC • Online weight management coaching: – DPS Health *As of 10/14 Program Goals 1. Detail clinical impact of weight loss/maintenance to prevent/delay progression preD, T2D with recent research evidence. 2. Identify factors for successful weight loss/maintenance from recent research evidence. 3. Through dialog with successful “losers” and HCP counselors/coaches challenge and/or reinforce HCP strategies, tools, and techniques to support clients’ weight management efforts.
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Helping People Make Healthy Lifestyle Changes: What Works, Why?
1. Detail clinical impact of weight loss/maintenance to prevent/delay progression preD, T2D with recent research evidence.
2. Identify factors for successful weight loss/maintenance from recent research evidence.
3. Through dialog with successful “losers” and HCP counselors/coaches challenge and/or reinforce HCP strategies, tools, and techniques to support clients’ weight management efforts.
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Time Program
10:00 – 11:00 am Presentation
11:00 – 11:45 am Panel discussion
11:45 am - noon Q & A and recap
BIG Applause to Montana!
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Diabetes Prevention Program Delivery in Montana• Adapted in 2008 for group‐based implementation and telehealth delivery to rural/frontier areas.
• Enrolled over 5,300 participants since 2008.
• Reimbursed by MT Medicaid in 2012 for Medicaid beneficiaries.
Table. Outcomes at 4 months among participants in the Montana Diabetes Prevention Program, 2008‐2013.
All participants, 2008‐2012
(n=3,804)
Medicaid only, 2012‐2013
(n=118)
Mean (SD) Mean (SD)
Age (years) 52.5 (11.9) 46.7 (12.9)
Baseline BMI (kg/m2) 36.2 (7.2) 40.2 (9.7)
Number of core sessions attended 13.7 (3.8) 11.2 (4.8)
Achieved 150 min physical activity per week 64 (2,072) 59 (70)
Achieved 7% weight loss 34 (1,300) 17 (20)
Data Source: Diabetes Prevention Program, Montana, 2008‐2013.Data Notes: Enrolled defined as attending at least one visit.
Completed program defined as attending at least 4 core and 3 post core visits.
Prediabetes to Type 2 = Progressive
Overweight Begets, Prediabetes & T2D
• Diabetes (US): – 29 mil1 (9%) (21 mil dx)
• ~95% T2
• ~85% T2 overweight
• Future glimpse– 40% of population, 2 out of 5 to develop in lifetime2
1. CDC, National Diabetes Statistics Report – 2014 http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf.2. Gregg EW, et al., Trends in lifetime risk and years of life lost due to diabetes in the USA, 1985—2011: a modelling study. Lancet
Diab and Endo. e-pub 8/13/14. http://www.thelancet.com/journals/landia/article/PIIS2213-8587(14)70161-5/fulltext
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Overweight Begets, Prediabetes & T2D
• Prediabetes (US)– 86 mil1, majority overweight
• 37% of adults >20 yr; 51% over 65 yrs1
• Only 11% aware2 ( from 8%3)
• Progression PreD to T2D: – 70% will develop T24
– Annually 11% preD not engaged in healthy lifestyle develop T2D following 3 yrs5
1. CDC, National Diabetes Statistics Report – 2014 http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf.2. Li Y, Geiss LS, Burrows NR, Rolka DB, Albright A, Awareness of Prediabetes:United States, 2005–2010. Morbidity and Mortality
Weekly. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6211a4.htm?s_cid=mm6211a4_w.3. Geiss LS. Diabetes risk reduction behaviors among U.S. adults with prediabetes. Am J Prev Med. 2010;38(4):403-409.4. Narayan KMV, et al. Lifetime risk for diabetes in US. JAMA. 2003;290:1884-1890. 5. Knowler WC, Barrett-Conner E, Fowler SE, et al; Diabetes Prevention Program Research Group. Reduction in the incidence of
type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393–403.
Detail clinical impact of weight loss/maintenance to prevent/delay progression preD, T2D with recent
research evidence.
Natural History: Wt Gain, Loss, Regain
Eckel RH et al: Obesity and type 2 diabetes: What can be unified and what needs to be individualized? Diabetes Care 34:1424-1430, 2011
Years YearsMonths
Prevention Therapeutic Space
Body Weight
Age-related Wt Gain
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Diabetes Prevention Program (DPP):Trial Basics1
• DPP initiated: 1998, stopped 2001
• RCT, multi-site in U.S.
– ~3000 subjects
• 4 arms to 3 arms: metformin w/ std care, placebo/stdcare, Intensive Lifestyle Intervention (ILI)
• Wt loss: 5 – 7% from initial
• Exercise: 150 min; 30 min, 5x/wk
• DPP Outcomes Study (DPPOS) extension, ongoing: Does further reduction in diabetes development reduce complications?
1. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393-403.
DPP/DPPOS Results to Date –Reduction of Incidence of T2D in
High Risk Population
ILI* Metformin/Std Care*
DPP1 58% 31%
DPPOS at 10 yrs2 34% 18%
DPPOS at 15 yrs3 27% 17%
1. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393-403.
2. Diabetes Prevention Program Research Group 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. The Lancet. 2009;374(9702):1677–1686.
3. American Diabetes Assoc. 2014 Scientific Sessions. Long-term follow-up of DPP show continued reduction in diabetes development. http://www.diabetes.org/newsroom/press-releases/2014/long-term-follow-up-of-diabetes-prevention-program-shows-reduction-in-diabetes-development.html
*Compared to placebo/std care. All DPP participants offered lifestyle intervention post DPP, leading to reduction in differences over time.3
DPP Lifestyle Changes: Weight Loss or Physical Activity?
• DPP Findings:– Weight loss = dominant predictor of
reduced T2 incidence and return to normoglycemia1
• For each kg weight loss = 16% reduction in risk for T22
• Subjects who lost > 5 – 7% reduced T2 risk > 90%2
– Physical activity helps sustains weight loss – plays “supporting role”
1. Perreault et al. Regression from pre-diabetes to normal glucose regulation in the DPP. Diabetes Care. 2009;32(9):1583-1588.2. Hamman, et al. Diabetes Care. 2008;29(9). 3. Delahanty L, Nathan D: Implications of the DPP and Look AHEAD clinical trials for lifestyle interventions. J Am Diet Assoc.
2008;108 (4 Suppl 1): S66-72.
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DPPOS – 15 yr F/U1
• Conclusions1: – Can prevent/delay T2D with ILI or metformin over long term
– Regardless of DPP treatment type, participants w/ out T2D at 15 yrshad 28% lower occurrence of microvascular disease
– Minimal incidence of CVD (HA, stroke) (young, healthy population)
– HTN improved in ILI, less in metformin DPP group
– Metformin: DPPOS largest, longest trial using drug, safe and well-tolerated; small increase in B-12 deficiency
• Summary: Weight loss key factor in preventing progression of prediabetes to type 2 and in restoring normoglycemia to some.2
1. American Diabetes Assoc. 2014 Scientific Sessions. Long-term follow-up of DPP show continued reduction in diabetes development. http://www.diabetes.org/newsroom/press-releases/2014/long-term-follow-up-of-diabetes-prevention-program-shows-reduction-in-diabetes-development.html
2. Diabetes Prevention Program Research Group 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. The Lancet. 2009;374(9702):1677–1686.
Look AHEAD Trial
• Study details: – Long term (start ~2000), multicenter, RCT,
study extended to 2014 (ended early 10/19/12)1,2
– > 5,137 (55-76 yrs), overwt or obese individuals2
– T2 diabetes for 6.8 + 6.5 yrs (range 3 mos – 13 yrs)3
– Median follow up 9.6 yrs4
• Primary Outcome: – Will intentional weight loss reduce the incidence of fatal and
nonfatal cardiovascular and cerebrovascular events?
1. http://www.nih.gov/news/health/oct2012/niddk-19.htm 2. Look AHEAD Research Group. Reduction in weight and cardiovascular disease risk factors in individuals with type 2
diabetes. Diabetes Care. 2007;30(6):1374-13833. Bertoni, et al. Journal of Diabetes and its Complications. 2008;22(1-9). 4. Look AHEAD Research Group. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J
Med 2013;369:145–154.
Look AHEAD Trial – Groups Defined• Intensive Lifestyle Intervention (ILI):1,2
– Goals: 7% or greater wt loss at one year, >175 minutes physical activity/week
– Calorie goal: 1200-1800 cals/day, < 30% of cals as fat, (<10% sat fat), minimum 15% cals as protein, use portion-controlled meals and meal replacements
• Remainder of trial: regular with decreasing frequency2
• Diabetes Support and Education (DSE)/(control):– Support: invite 3 group sessions/yr (not mixed)
– Standardized protocol for eating plan, physical activity, social support.
– No focus on behavioral strategies
1. Look AHEAD Research Group. Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes. Diabetes Care. 2007;30(6):1374-1383
2. Look AHEAD Research Group. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med 2013;369:145–154.
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Look AHEAD: Changes in Weight1,2
Mean wt loss from baseline 8.6% ILI,
0.7% control1,2
1. Look AHEAD Research Group. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med 2013;369:145–154.2. Delahanty L. The Look AHEAD Study: implications for clinical practice go beyond the headlines. J Acad Nutr Diet. 2014;114(4):537-542.
Mean wt loss from baseline 6% ILI, 3.5% control1,2
• Mean wt loss from baseline 6% ILI, 3.5% control1
• A1c lowering ILI group 0.2%1
• Primary outcome: Failed to reduce CVD events in ILI vs. control
• Other health benefits: • Reduced sleep apnea, depression, urinary incontinence and improved QOL3
• Subjects with early stage disease = most health benefits• Shortest duration
• Not on insulin
• Good baseline glycemic control
1. Look AHEAD Research Group. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med 2013;369:145–154.2. Delahanty L. The Look AHEAD Study: implications for clinical practice go beyond the headlines. J Acad Nutr Diet. 2014;114(4):537-542.3. Warshaw HS. The Look AHEAD Trial: Look beyond the headlines. Wt Mgmt Matters/WMDPG. 2014;12(4):2-3. Diab Care and Ed DPG
• Financial analysis2:– ILI produced mean relative per-person 10-year healthcare cost
savings of $5,280; not evident in ppl w/ hx of CVD
– Average annual savings ~$600/participant
– ILI used fewer medications (7%), had fewer hospitalizations (11%)
• Look AHEAD continues as observational trial
1. Look AHEAD Research Group. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med 2013;369:145–154.2. Espeland MA, et al., Impact of an intensive lfestyle intervention on use and cost of medical services among overweight and obese adults with
But Healthy Eating is continuously important and can always assist
glucose, BP, lipid control!
ADA 2013 -Optimal Macronutrient Mix?1,2
• No one ideal % calories from carb, pro and fat for all
• No optimal mix to achieve wt loss• Wide variety of eating patterns shown modestly effective; all acceptable
to achieve positive metabolic outcomes
• Base mix around healthy eating goals, personal habits and metabolic goals
1. Evert A, Boucher J, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care: 2013;36(11):3821-3842.
2. Wheeler M, Dunbar S: Macronutrient, Food groups, and eating patterns in the management of diabetes. A systematic review of the literature, 2010. Diabetes Care. 2012;35;434-445.
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POUNDS LOST Study1
• Study details: – NIH - 2 yr wt loss trial, 800+ subjects, 2 sites– Overwt adults, BMI: 25 - 40– 4 diets, varying % calories:
• CHO - Low 35% to high of 65%
1. Sacks, F, et al. Comparison of Weight-Loss Diets with Different Compositions of Fat, Protein, and Carbohydrates. New Eng J Med. 2009;360(9):859-873.
POUNDS LOST Study1
Results:• No one nutrient composition faired better than another (subjects
modified towards diet goal, but didn’t reach diet’s goal)
• Weight loss: • 6 months: similar weight loss - 7% (6 kg/13 lbs) • 12 months: regained similar amounts of weight• 2 years weight loss remained similar: 4 kg/9 lbs • Subjects attending 2/3rd of sessions lost: 9 kg/20 lbs
• Clinical improvements: • Reduced cardiovascular disease and type 2 diabetes risk factors including
lower LDL-cholesterol, BG and serum insulin levels; and slightly lower BP
1. Sacks, F, et al. Comparison of Weight-Loss Diets with Different Compositions of Fat, Protein, and Carbohydrates. New Eng J Med. 2009;360(9):859-873.
ADA 2013 – Weight Management1
• Modest weight loss >6 kg (7-8.5%) may provide metabolic benefits (for some), esp early in disease
• Regular physical activity, and frequent contact with RDs (counseling/support) necessary for consistent, long term beneficial effects
• Reframe “success”:
– Minimize weight regain, maintain maximum of lost weight
– Prevent further weight gain, slow trajectory
1. Evert A, Boucher J, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care: 2013;36(11):3821-3842.
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Guidelines for the Management of Overweight and Obesity in Adults1
• Jointly published 2013: American Heart Association (AHA), American College of Cardiology (ACC), The Obesity Society (TOS)
• Part of update, integration of BP, cholesterol and obesity guidelines previously researched, disseminated through NHLBI
1. Jensen MD, et al. Guideline for the Management of Overweight and Obesity in Adults: A Report of the ACC, AHA, TOS Task Force on Practice Guidelines.Circulation. https://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437739.71477.ee.full.pdf+html?sid=6af28578-67b4-4bb1-9a4d-91ebab818a98 (published in 3 association journals)
2. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. Jour Am Med Assoc. 2012;307(5):491–507.
15 Dietary Approaches Associated
with Weight Loss by Expert Panel1
Among 15, range of options:* • Higher protein (25%), fat (30%), carbohydrate (45%)
• Lacto-ovo-vegetarian-style
• Low-fat (10% to 25% of total calories from fat) vegan-style
• Mediterranean-style diet with prescribed energy restriction
• Provision of high-glycemic load or low-glycemic load meals
1. Jensen MD, et al. Guideline for the Management of Overweight and Obesity in Adults: A Report of the ACC, AHA, TOS Task Force on Practice Guidelines.Circulation. https://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437739.71477.ee.full.pdf+html?sid=6af28578-67b4-4bb1-9a4d-91ebab818a98 (published in 3 association journals)
*If reduction in dietary energy intake is achieved.
Weight Management or Do Nothing?
1. Hill JO, Wyatt HR, Reed GW, Peters JC. Obesity and the environment: Where do we go from here? Science. 2003; 299:853-855.
2. Knowler WC, Barrett-Conner E, Fowler SE, et al; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393–403.
Average American adult gains 1 to 2 pounds per year.1 If a person at the end of 2, 5 or 10 years (eg DPPOS, Look AHEAD) is at a lower body weight than they were at when they began their weight loss efforts, have they avoided gaining those 1 to 2 pounds per year and the health consequences? Gained potential health benefits?
From: Martin, C: WMDPG Symposium, April 2013
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BG-Lowering Meds: New Choices Can Support Wt Loss
• Start BG lowering meds (for most) at dx of T2 (e.g., metformin)
• Goal: treat insulin resistance1,2
– Choose meds to support wt loss/wt neutral vs. those can cause wt gain, stimulate hunger, cause hypo/eat
• Reframe PWD-T2 mindset on meds
– Not “diet failure,” it’s beta cell failure
– Meds work concert to treat progression of disease, newer ones can prevent wt gain, assist w/ wt loss
1. Position Statement American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD): Management of HyperglycemiainType2 Diabetes: A Patient-Centered Approach. Diabetes Care. 2012;35:1364-1379.
1. Graham Thomas J et al: Weight-loss maintenance for 10 yrs in NWCR. Am J Prev Med. 2014;46(1):17-23.
• Magnitude of initial wt loss and duration
• Increased physical activity
• Low calorie and low fat intake
• High restraint and low disinhibition around food
• Self-weighing > several times/wk
1. Graham Thomas J et al: Weight-loss maintenance for 10 yrs in NWCR. Am J Prev Med. 2014;46(1):17-23.
NWCR - 10 yearsPredictors of Success
“Continued adherence to each behavior can improve long term outcomes.”
Weight Loss: Successful Strategies
• Ready, willing and able?1,2
• Focus, don’t overwhelm1,2
• Choose behaviors most ready to change1,2
• Reduce total fat to < 30% fat (don’t focus on carb)2,3
• Use of meal replacements/structure3
• Include physical activity2-5
• Early success (wt loss) predicts later success (frequent contact early)5,6
1. Bissett. Lessons from the DPP, On the Cutting Edge, Diabetes Care and Education. 2008;29(4). 2. Delahanty L, Nathan D. J Am Diet Assoc.1 2008;108(Suppl1):S66-72. 3. Wadden TA, et al. The Look AHEAD Research Group): One-year weight losses in the Look AHEAD study: Factors associated with success. Obesity. 2009;17(4):713-722. 4.Wadden, TA, Neiberg, RH, Wing, RR, et al., The Look AHEAD Research Group (2011), Four-Year Weight Losses in the Look AHEAD Study: Factors Associated With Long-Term Success. Obesity. 2011;19:1987–1998. 5. Look AHEAD Research Group. Eight-year weight losses with an ILI: The Look AHEAD Study. Obesity 2014;22(1):5-13. 6. Graham Thomas J et al: Weight-loss maintenance for 10 yrs in NWCR. Am J Prev Med. 2014;46(1):17-23.
1.Rosenbaum M: Weight Management DPG Symposium, 2013.2. Fletcher, On the Cutting Edge, Diabetes Care and Education. 2008;29(4). 3. Wadden, TA, Neiberg, RH, Wing, RR, et al., The Look AHEAD Research Group (2011), Four-Year Weight Losses in the Look AHEAD Study: Factors Associated With Long-Term Success. Obesity. 2011;19:1987–1998.4. Look AHEAD Research Group. Eight-year weight losses with an ILI: The Look AHEAD Study. Obesity 2014;22(1):5-13. 5. Graham Thomas J et al: Weight-loss maintenance for 10 yrs in NWCR. Am J Prev Med. 2014;46(1):17-23.
Panel Discussion
Recap Panel DiscussionTwo questions for you: 1. What were the most important points you
heard today?
2. What is one change you will make in your work with your overweight/at risk clients based on what you heard today?
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Themes - Success Stories PreD, T2D1
• Light bulb moments: – Hitting certain high weight
– Seeing photo of self/looking unhealthy
– Observing health consequences, dx preD, T2D
Warshaw, HS. Diabetic Living magazine. Eat to Beat Diabetes Bookazine 2015. (In press)
Themes - Success Stories PreD, T2D1
• Kick start into action/tools:– Program/facility for assistance
– Accountability to self, group members
– Using food scale
– Decrease restaurant eating, time spent in kitchen
– Less regular soda, use diet beverages, water, etc.
– Make exercise regular part of life, vary it
• Challenges: Life’s hurdles!
Warshaw, HS. Diabetic Living magazine. Eat to Beat Diabetes Bookazine 2015. (In press)
Themes - Success Stories PreD, T2D1
• Words of wisdom: – “Don’t beat yourself up if you ‘mess up’, get right back on track.”
– “Believe in yourself.” “Develop self-confidence.”
– “Be willing to take the first step, experience success, then another.”
– “Just jump in, do something positive for yourself.”
– “Believe food that’s healthy for you can taste good too.”
– “Discover what motivates you long term.”
Warshaw, HS. Diabetic Living magazine. Eat to Beat Diabetes Bookazine 2015. (In press)
• Our goal should NOT be to help people get thinner, but to help people get healthier. Take the attention off of weight.
• “I only care about the weight you can keep off.”
AADE 2013, http://www.presentdiabetes.com/ezines/#ezine413.Chair in Obesity Research and Management at the University of Alberta in Edmonton and Director of the Alberta Health Services Obesity Program. http://www.drsharma.ca/. Twitter: @drsharma.
M (motivation) + A (ability to make the change) + T (the trigger).
– Tie new behavior to existing, easier to accomplish
• Build “success momentum” - make one tiny habit change after another
• Can’t break bad habits thinking if you break it once, it will be fixed. We can, overtime, “untangle” bad habits
• Behavior change mastery occurs due to continual practice. Eventually “healthy reflexes” emerge
• “Help people change what they already want to change, not what they know they should change but don’t really want to.”
AADE 2013, http://www.presentdiabetes.com/ezines/#ezine413. BJ Fogg is a professor at Stanford University in California, where he runs the Persuasive Technology Lab. http://www.bjfogg.com/. Twitter: @bjfogg.
Reads and Resources• The conscienhealth blog: http://conscienhealth.org/. Daily blog capturing latest
obesity research and puts in perspective with links to research.
• David Allison/UAB weekly recap/e-mail Obesity & Energetic Offerings. Recap of latest publications/articles on hot obesity topics. Link to subscribe: http://www.obesityandenergetics.org/subscribe
• David Katz, MD: (regular blogs)
• diatribe: monthly e-newsletter from Close Concerns: subscribe at diatribe.us