June 21, 2017
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Lifestyle intervention improves diabetes outcomes in veterans

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Veterans with diabetes and overweight or obesity who participated in a lifestyle intervention program that emphasized physical activity, proper nutrition and goal setting were less likely to develop diabetic eye and renal diseases over 6 years than eligible veterans who did not participate in the program, study findings show.

“Randomized clinical trials indicate that lifestyle change programs improve weight and glycemic control, reduce medication use, and may reduce microvascular complications,” Sandra J. Jackson, PhD, MPH, of the Clinical Studies Center of the Atlanta VA Medical Center in Decatur, Georgia, and colleagues wrote. “However, the failure to translate research into practice and policy has prevented patients from benefiting fully from lifestyle change programs. The dissemination of effective interventions, particularly to those disproportionately burdened by diabetes and its complications, requires translation research in settings that reach subpopulations at highest risk of diabetes.”

In a longitudinal, retrospective study, Jackson and colleagues analyzed data from 87,366 veterans with overweight or obesity and diabetes at baseline who were receiving care at a VA clinic (yearly outpatient visits for at least 3 consecutive years) between 2005 and 2012, who were participating in the MOVE! Program (mean age, 58 years; 95.9% men; 77.1% white; mean baseline BMI, 34 kg/m²; mean HbA1c, 7.5%), as well as 400,170 eligible patients with diabetes who did not participate in the program. The program’s curriculum includes an orientation session and 10 core modules that emphasize improved nutrition, portion sizes, walking with a pedometer or physical activity modifications for wheelchair users, goal setting and motivation strategies. The researchers noted that organization and delivery of the MOVE! Program varies by site; however, a study of best practices emphasizes the importance of utilizing the standard curriculum and offering a group-based format. Researchers assessed body weight and HbA1c, diabetic eye disease and renal disease incidences and the initiation of oral diabetes medications and insulin, as well as medication intensification, defined as prescription of a new oral diabetes medication or initiation of insulin after baseline. Researchers used least-squares means through linear models to calculate the average body weight, random plasma glucose level and HbA1c of program participants compared with nonparticipants, and they used Cox proportional hazard models to estimate HRs for diabetic eye disease (among those without eye disease at baseline), diabetic renal disease (among those without renal disease at baseline) and medication intensification. The cohort was followed for a median of 69 months.

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Within the cohort of both participants and nonparticipants, patients had a median of four clinic visits per year and sustained a median 10 years of care. Compared with nonparticipants, the MOVE! group included more women (7.2% vs. 3.3%) and more black (22.9% vs. 17.1%) participants, and more participants with obesity (88.7% vs. 66.7%) and eye (25.5% vs. 14.6%) or renal (12.7% vs. 4.9%) disease at baseline and prescribed oral diabetes medications (78.9% vs. 66.7%) or insulin therapy (32.3% vs. 19.2%).

Researchers found that patients who participated in the MOVE! program saw a greater change in mean body weight (–0.6 kg), random plasma glucose concentration (–2.8 mg/dL) and HbA1c (–0.1%) at 12 months vs. nonparticipants; results persisted after adjusting for age, sex, race, baseline values and the use of oral diabetes medications and insulin. The differences became smaller between months 12 and 36, but remained significant.

“Participants who met VA criteria for ‘intense and sustained’ participation (9.5% of participants) had larger reductions in weight (–2.1 kg), [random plasma glucose] (–7.8 mg/dL) and HbA1c (–0.3%) compared to nonparticipants at 12 months,” the researchers wrote.

Incidence of diabetic eye and renal disease was 52 and 30 per 1,000 person-years, respectively, among those without diabetes at baseline. Researchers found that participation in the MOVE! program was associated with a lower incidence of eye disease (HR = 0.8; 95% CI, 0.75-0.84) and renal disease (HR = 0.89; 95% CI, 0.86-0.92) over 69 months. Results remained significant after adjusting for baseline HbA1c and systolic blood pressure.

During follow-up, medication intensification occurred at a rate of 157 new medications per 1,000 person-years. Participants in the MOVE! program were more likely to reduce their medication use compared with nonparticipants (HR = 0.82; 95% CI, 0.8-0.84). In addition, MOVE! participation was more strongly associated with lower oral diabetes medication intensification (HR = 0.81; 95% CI, 0.78-0.85) than insulin initiation (HR = 0.95; 95% CI, 0.92-0.98).

“This study demonstrates that participation of patients with diabetes in a health care system-based lifestyle change program was associated with reduced incidence of diabetes complications,” the researchers wrote. “In addition, participation was associated with improved weight, [BP] and HbA1c levels despite reduced intensification of diabetes medications. Broad implementation of lifestyle change programs within large health care systems might have widespread beneficial effects on the growing population of people with diabetes.” – by Regina Schaffer

Disclosures: Jackson reports receiving previous financial support from Amylin. Please see the full study for the other authors’ relevant financial disclosures.