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Treating Obesity In People With Prediabetes Could Save Billions



Today, as I attend the 47th European Association for the Study of Diabetes (EASD) Annual Meeting here in Lisbon, I cannot help but discuss an article by Kenneth E. Thorpe and Zhou Yang, Emory University, Atlanta, Georgia, published in the latest issue of Health Affairs.

Based on their analysis of the significant impact of even modest sustained weight reduction on the incidence of type 2 diabetes, these authors suggest that enrolling overweight and obese pre-diabetic US adults aged 60–64 into a proven, community-based weight loss program nationwide could save Medicare $1.8–$2.3 billion over the following ten years.

Estimated savings would be even higher ($3.0–$3.7 billion) if equally overweight people at risk for cardiovascular disease were also enrolled.

Thus, lifetime Medicare savings could range from approximately $7 billion to $15 billion, depending on how broadly program eligibility was defined and actual levels of program participation, for a single “wave” of eligible people.

A key assumption in their proposal, is that a fully funded sixteen-twenty week community program (perhaps delivered by the YMCA), would deliver about 4% weight loss and replicate the almost 50-70% reduction in progression to diabetes seen in some diabetes prevention studies.

Using our Edmonton Obesity Staging System definitions – this program would target Stage 1 patients (pre-diabetes) or Stage 2 patients (with hypertension or dyslipidemia).

There is no doubt that community based ‘lifestyle’ interventions are the only plausible way in which any program can be delivered to millions of eligible individuals. There is also little doubt that in randomised controlled trials, considerable benefits have been demonstrated.

The question remains, however, whether enough eligible participants will in fact participate and persist with these ‘lifestyle’ changes without continuing and ongoing support (which is generally what the clinical trials have delivered). The notion that an intervention of limited duration (even twenty weeks) will lead to sustainable effects, may be a bit over optimistic, even if 10 year follow-up data from some diabetes preventions studies suggest long-term benefits even after the end of the trials.

It is also worth discussing whether or not success is actually dependent on losing weight (not a behaviour) rather than simply increasing physical activity and eating better (which are behaviours).

Whether or not there is indeed a realistic chance that millions of people can be enrolled in community based interventions programs will remain to be seen, but it is certain that, if feasible, savings would indeed be substantial.

This is why, in the recently announced Alberta Health Services Obesity Initiative, there is a significant emphasis on the importance of community based programs (such as Thr!ve on Wellness, a joint initiative from Alberta Health Services and the Alberta Cancer Foundation, which will soon be expanded to over 100 Alberta communities).

If successfully adopted, these programs should have benefits far beyond diabetes prevention and reduce rates of heart disease, cancers, musculoskeletal problems and hopefully also improve mental health and well being.

Perhaps this is when we can truly claim to be moving towards a ‘health care’ rather than a ‘sickness care’ system.

AMS
Lisbon, Portugal

Thorpe KE, & Yang Z (2011). Enrolling people with prediabetes ages 60-64 in a proven weight loss program could save medicare $7 billion or more. Health affairs (Project Hope), 30 (9), 1673-9 PMID: 21900657

6 Comments

  1. I’ve been having a hard time grasping how this will save billions with the appalling failure rate of diets. The much-vaunted Weight Watchers success was tracked only for a year, not five. If 95% of people regain the weight in five years, worsening their health measures, and one-third of those gain even more, how is this cost-effective in the long-run?

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  2. A 4% weight reduction? As you point out, when you’re talking about a 5-15 pound weight loss, you’re probably talking about the impact of healthier habits, not the impact of reduced weight. This is where HAES (health at every size) is probably much more effective than a focus on weight, because studies have indicated that people are more likely to maintain healthy habits when weight loss was never the goal.

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  3. People in the age group 60 and older were children during the second world war. What they learned from their families and society is that food is precious, eat when you can, don’t waste anything, eat now or you may not get something later, and if it tastes good, you should be grateful. This mindset is very difficult to overcome.

    In my experience as a dietitian I have noticed over and over the inability to let go of these dysfunctional attitudes and beliefs about food and I hear things like “if you can’t enjoy food, what can you enjoy?”, “it’s not good to be too skinny”, or ” I will look old and wrinkly if I am thinner”.

    I doubt that we are ever going to get aging folks to be successful at losing weight and maintaining any kind of loss unless we address these attitudes, especially given that keeping weight off is so difficult and that “eating is to enjoy life” . The question is really about rewiring the brain to be able to accept today’s reality ( a toxic food environment) and not see today through the filter of what once was (scarcity and hunger and suffereing) . So…… will enrolling a cohort of people into a weight program without addressing the underlying beliefs they have about food be successful. This is a theorectical exercise which requires a lot more insight into the complexities of what we are dealing with.
    Incidentally, having been brought up by these folks means that the repercussions just as important as attitudes are learned.

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  4. Education is always a good idea and at any age. Great proposal to get people talking and engaged towards mindful health care! I agree that behaviour change is key, but these programs could empower the early stages as long as there isn’t that rebound effect. Also, not so sure the baby boomers and on will be much for going to the YMCA! That said, children are now habitually ruining their heels and knees at the indoor soccer centres being coached about great plays, socializing and playing their best – practice practice practice so they can play their best! — while coaching kids to eat their best is a bit taboo as pizza parties are the norm.

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  5. Dr Sharma has got me thinking:

    “”The question remains, however, whether enough eligible participants will in fact participate and persist with these ‘lifestyle’ changes without continuing and ongoing support (which is generally what the clinical trials have delivered). The notion that an intervention of limited duration (even twenty weeks) will lead to sustainable effects, may be a bit over optimistic, even if 10 year follow-up data from some diabetes preventions studies suggest long-term benefits even after the end of the trials.

    It is also worth discussing whether or not success is actually dependent on losing weight (not a behaviour) rather than simply increasing physical activity and eating better (which are behaviours).””

    I have hung around OA for a long time, and around TOPS for a while. There is no doubt that these weekly programs help, and that people will come back as long as they obtain benefit from the weekly meetings. Those programs assisted me in changing my thinking, then my lifestyle, followed by a measurable result in weight loss. Changing my knowledge about food, my thinking and attitude toward food was my key to weight loss success.

    I will volunteer to assemble a program and deliver the first series if you or anyone will provide the space in South Edmonton, as a trial to see if if actually helps. I will suggest Thursdays evenings at the Gray Nuns in one of the class rooms. It would require some promotion, which Weight Wise could provide. It would need to have ongoing development, as what I believe are the needs may prove to be wrong. All I know is what I require. I would even be willing to work with any group of other people needing to maintain recovery. I will require an knowledgeable editor, and someone to dress up a few graphics, as my abilities in those areas are deficient.

    The objective must be to foster lifestyle change in a positive manner, to assist in weight loss and living at a lower weight. Much of my recovery has come as a result of self directed study of information freely available on the internet and various diet books. I know some of it is actually wrong, but the results work. aka doing the right thing for the wrong reasons. The whole thing must be educational.

    Dr. Sharma’s time frame is of twenty week is not particularly supportive, for some will require years of support to recover and ongoing occasional support for the remainder of there life; however, they will be able to provide support to others in other areas. It must support all diet concepts, including LCHF in some form, not just your government approved plan.

    Absolutes must be supported, like no sugar, no grains, no Omega 6. Support does not mean recommending. The participants must be free to choose, not be dictated to. There is nothing that will destroy a weekly group faster than a control freak in charge.

    There should be an educational feature at each meeting, ranging from someone like Jim telling the lessons they learned during there weight loss, to professional who struggles with the weight control issue, or basic bio-chemistry, bio-physics, psychology solutions, to philosophy. There message may not agree with your approach, but education is not always correct. It would need to be open to the public, anyone who was in the need of losing substantial weight, or has lost considerable weight. It need to be an all encompassing altruistic movement.

    This is just a proposal. Should anyone want such a thing, or to be part of movement or the development, you know how to contact me.

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  6. @katja — what I find dysfunctional is the idea that food is NOT to be enjoyed and that the pursuit of a lower weight on the scale is the be-all, end-all of health.

    While I do think there are some toxic aspects of our food culture that can certainly be addressed, I think the HAES approach is the most sane.

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