Weight Management as Effective as Medication Intensification for Glycemic Control among Veterans with Type 2 Diabetes
Group medical visits (GMVs) are designed for patients with a common chronic condition to receive education, self-management skills, and medication management to improve outcomes. Weight management (WM) is one of the factors most associated with glycemic control – and is associated with lower risk of diabetes complications independent of glycemic control. This randomized clinical trial sought to determine whether adding intensive WM to group medical visits (WM/GMV) improves glycemia compared with GMV alone, while enhancing weight loss and decreasing medication intensity in patients with uncontrolled type 2 diabetes. The trial included 263 VA outpatients enrolled between January 2015 and May 2017 and followed for up to 48 weeks. Veterans were assigned to one of two study arms: 1) the GMV arm, designed to enhance overall diabetes management (n = 136), or 2) the WM/GMV arm that included weight management counseling (i.e., low-carbohydrate nutrition) in addition to help with diabetes management (n = 127). Outcome measurements included hemoglobin A1c, weight, hypoglycemic events, diabetes-related emotional distress, and diabetes medication use. Investigators also examined the cost of delivery for each intervention.
- For Veterans with diabetes who attended group medical visits, adding intensive weight management using low-carbohydrate nutrition counseling showed comparable glycemic improvement in addition to other clinical advantages (i.e., reduced weight, medication burden, and hypoglycemic events).
- The largest differences between the GMV vs. the WM/GMV arms occurred at 16 weeks after the intensive initial phase of the WM/GMV 48-week program. The WM/GMV intervention decreased HbA1c levels by 1.7% from baseline, which was 0.7% lower than the GMV arm. The intervention also led to a 5.6 point difference in diabetes distress symptoms (i.e., stress, depression).
- The estimated intervention cost per patient was $1,513.42 for patients in the WM/GMV arm, and $1,264.49 for patients in the GMV arm.
- Weight management using a low-carbohydrate diet can be as effective for glycemic improvement as medication intensification, with additional benefits (i.e., weight reduction, fewer hypoglycemic events, less medication use); strategies are needed to help patients sustain these improvements.
- There was a different frequency of meetings in the two arms, with more frequent meetings taking place in the WM/GMV arm, which could lead to participants feeling increased attention or burden.
This study was supported by HSR&D (IIR 13-053); Drs. Maciejewski and Voils are supported by HSR&D Research Career Scientist awards. Drs. Yancy, Crowley, Coffman, Jeffreys, Maciejewski, and Edelman are part of HSR&D’s Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) in Durham, NC.
Yancy W, Crowley M, Dar M, Coffman C, Jeffreys A, Maciejewski M, Voils C, Bradley A, Edelman D. Comparison of Group Medical Visits Combined with Intensive Weight Management vs. Group Medical Visits Alone for Glycemia in Patients with Type 2 Diabetes: A Noninferiority Randomized Clinical Trial. JAMA Internal Medicine. November 4, 2019; Epub ahead of print.