A Randomized Control Trial
Am J Public Health. 2016;106(5):918-920.
Abstract and Introduction
Abstract
Objectives. To determine if a widely available weight-management program (Weight Watchers) could achieve sufficient weight loss in persons with prediabetes compared with a Diabetes Prevention Program–based individual counseling program supported by National Diabetes Education Program materials.
Methods. We conducted an individual, randomized intervention trial in Indianapolis, Indiana, in 2013 to 2014, in 225 persons with prediabetes. We compared the Weight Watchers weight-management program (n = 112) with Your Game Plan to Prevent Type 2 Diabetes, a program developed by the National Diabetes Education Program. Outcomes were weight and metabolic markers measured at baseline, 6 months, and 12 months.
Results. Intervention participants lost significantly more weight than controls at 6 months (5.5% vs 0.8%) and 12 months (5.5% vs 0.2%; both P < .001). The intervention group also had significantly greater improvements in hemoglobin A1c and high-density lipoprotein cholesterol level than did controls.
Conclusions. A large weight-management program is effective for achieving lifestyle changes associated with diabetes prevention. Such programs could significantly increase the availability of diabetes prevention programs worldwide making an immediate and significant public health impact.
Introduction
Type 2 diabetes is one of the most significant public health crises of our time. Both incidence and prevalence have reached epidemic proportions, affecting more than 29 million Americans[1] with costs exceeding $245 billion annually.[2] Of particular concern is the estimated 86 million persons with prediabetes in the United States, a metabolic condition that significantly increases the risk for developing type 2 diabetes.[2,3] If left unchallenged, there will be a significant increase in the number of persons burdened by type 2 diabetes with concomitant social and fiscal costs associated with the disease.
Fortunately, the Diabetes Prevention Program (DPP) demonstrated that type 2 diabetes risk can be reduced through modest weight loss and increased physical activity achieved through lifestyle change programs.[4] Unfortunately, the DPP addressed efficacy, with little regard to the feasibility or costs required to implement prevention programs into the broader public health. There are programs targeting the translation of the DPP to the broader public health.[5–9] These programs have been shown to be effective in addressing the primary risk factor for developing type 2 diabetes—weight reduction in persons with prediabetes.[5–14] In spite of more than a decade of evidence that diabetes prevention is feasible, the speed at which programs have become available is still relatively slow.
There are limits to the scalability of programs that use the DPP curriculum format. They are “disease specific” (i.e., they target only persons with prediabetes). Although this is consistent with the evidence base that demonstrates the effectiveness of the DPP format curriculum only for those with prediabetes, given that excessive weight is the prime risk factor, this may limit interest and availability for persons who do not know they have prediabetes—a condition that is still not routinely assessed in primary care.[15] Thus, disease-specific programs may fail to reach the critical mass required to start and scale a cohort-based program (i.e., all participants have to start at same time).
In addition, the DPP-based curriculum has some inherent limitations that potentially have an impact on the development of the program on a broad public health scale. The DPP uses a 16 weekly session sequential curriculum in which each session is only offered once. If a session is missed, it is difficult to make it up. Increasing evidence illustrates that it is difficult for many persons to commit to a 4-month weekly program.[5–9] By contrast, many weight-loss programs use “loop” models in which sessions are repeated frequently and at a wide range of times and locations, often within the same week. Such programs are easy to restart when needed if life events or scheduling conflicts interrupt program attendance. This feature may offer important alternatives to consumers in terms of “user friendliness.”
There is clearly a need to identify mechanisms that can more quickly implement cost-effective, evidence-based intervention programs. In this context, the role that widely available commercial weight-loss programs might play has not been fully explored. There are many scalable weight-management programs available in the commercial space. Most incorporate the central components used in the DPP—monitoring of food intake, modification in food selection to reduce calories, focus on social and psychological factors that influence eating behavior, and the use of regular physical activity to help with weight loss and maintenance. None of these programs, however, has been tested among those with prediabetes to determine if they can achieve weight loss consistent with risk reduction. If such programs can produce weight loss among persons with prediabetes comparable to that seen in the DPP and derivative programs, and do so at a reasonable cost, they could provide a valuable approach to diabetes prevention without the need for creating additional infrastructure, disseminating complex treatment programs, and training new treatment providers.
To explore the potential of a widely available weight-loss program to contribute to the primary prevention of type 2 diabetes, we investigated if the Weight Watchers program, when combined with a single session to address prediabetes, could effectively reduce weight at levels similar to the DPP-based community programs.
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