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<strong>American</strong> <strong>Journal</strong> <strong>of</strong> <strong>Lifestyle</strong> <strong>Medicine</strong>http://ajl.sagepub.com/Type 2 Diabetes Risk Reduction in Overweight and Obese Adults Through Multidisciplinary GroupSessions: Effects <strong>of</strong> Meeting AttendanceKathleen J. Melanson and Joshua LowndesAMERICAN JOURNAL OF LIFESTYLE MEDICINE 2010 4: 275 originally published online 16 February 2010DOI: 10.1177/1559827609361013The online version <strong>of</strong> this article can be found at:http://ajl.sagepub.com/content/4/3/275Published by:http://www.sagepublications.comAdditional services and information for <strong>American</strong> <strong>Journal</strong> <strong>of</strong> <strong>Lifestyle</strong> <strong>Medicine</strong> can be found at:Email Alerts: http://ajl.sagepub.com/cgi/alertsSubscriptions: http://ajl.sagepub.com/subscriptionsReprints: http://www.sagepub.com/journalsReprints.navPermissions: http://www.sagepub.com/journalsPermissions.navCitations: http://ajl.sagepub.com/content/4/3/275.refs.htmlDownloaded from ajl.sagepub.com at HUNTER COLLEGE LIB on December 1, 2010
vol. 4 • no. 3<strong>American</strong> <strong>Journal</strong> <strong>of</strong> <strong>Lifestyle</strong> <strong>Medicine</strong>Kathleen J. Melanson, PhD, RD, LD,and Joshua Lowndes, MAType 2 Diabetes Risk Reductionin Overweight and ObeseAdults Through MultidisciplinaryGroup Sessions: Effects <strong>of</strong>Meeting AttendanceAbstract: This study evaluated theimportance <strong>of</strong> attendance in a commercialweight loss program for type 2diabetes risk reduction in normoglycemicmen (n = 8) and women (n = 53)aged 25 to 50 years (38.7 ± 6.0 years),with a body mass index (BMI) <strong>of</strong> 27 to35 kg/m 2 (31.6 ± 2.3 kg/m 2 ). The singlegroup24-week intervention consisted<strong>of</strong> food, activity, and behavior modificationplans within weekly meetings.Weight, waist circumference,meeting attendance, and glucose handlingwere measured before and after.Relationships between meeting attendanceand outcomes were analyzedvia Pearson correlation. Quartiles formeeting attendance were calculated(quartile 1: 30.0% ± 10.4%; quartile2: 52.1% ± 5.8%; quartile 3: 65.5%± 3.8%; quartile 4: 82.4% ± 4.6%),and between-group differences wereassessed via 1-way analysis <strong>of</strong> variance.Meeting attendance was correlatedwith decreases in weight, BMI,and waist circumference (r = 0.476,0.492, and 0.455; P = .002, .001, and.003, respectively). Quartile 1 lost significantlyless weight than quartile 4(–1.0 ± 3.5 kg vs –6.70 ± 3.58 kg). Inquartiles 3 and 4, fasting insulin andHOMA-IR decreased (both P < .05),but not in quartiles 1 and 2. Fastingglucose decreased in all groups (P
vol. 4 • no. 3<strong>American</strong> <strong>Journal</strong> <strong>of</strong> <strong>Lifestyle</strong> <strong>Medicine</strong>followed the current guidelines from the<strong>American</strong> College <strong>of</strong> Sports <strong>Medicine</strong>. 25Weekly group meetings lasting approximately1 hour were led by successfulgraduates <strong>of</strong> this program who act as rolemodels and provide written educationalmaterials, social support, and a weeklyweigh-in session.Attendance was taken at the weeklygroup meetings, although results <strong>of</strong> thisattendance were not known to the researchteam until the conclusion <strong>of</strong> week 24data collection. Individuals who missedmore than 2 consecutive weeks were sentreminder cards by the group leader.Subjects were assessed in the researchlaboratory at baseline and again at 24weeks. Baseline determinations includedcomplete blood count, blood chemistrypanel (SMAC-12), urinalysis, lipid pr<strong>of</strong>ile,C-reactive protein, and blood pressure.BMI was calculated from fasting weightand height measures, and waist circumferencewas measured using standardizedtechniques. Body composition was determinedby validated 26 air displacement plethysmographyin a self-contained systemcomposed <strong>of</strong> a computer-integrated dualchamberair plethysmograph equippedwith a digital scale (Model 2000 A; LifeMeasurements, Inc, Concord, California).This methodology is sensitive to moderatechanges in body composition. 26 Fastingstatemultiple measurements were taken,and percentage body fat and lean bodymass were calculated from body volumeusing the Siri equation, as with otherdensiometric methods. 26 A standardized2-hour oral glucose tolerance test (OGTT)was also performed to assess responses toa glucose challenge. Insulin sensitivity andglucose disposal were determined usingthe respective AUCs and standardizedhomeostasis model assessment <strong>of</strong> insulinresistance (HOMA-IR) during the OGTT.AnalysisParticipants were separated into quartilesbased on weekly meeting attendance. Theeffect <strong>of</strong> meeting attendance on changesin various anthropometric variables anddiabetic and cardiovascular risk factorswas assessed by performing multiple 2(pretest vs posttest) × 4 (attendance quartile)analyses <strong>of</strong> variance with repeatedTable 1.Baseline Characteristics <strong>of</strong> Study ParticipantsCharacteristicGenderFemaleMalemeasures. Within-group differences wereassessed for each group independently viapaired sample t tests as a result <strong>of</strong> a significantinteraction F ratio. All data were analyzedwith SPSS version 12.0, with an αlevel for all analyses set at .05.ResultsParticipant CharacteristicsOver the 6-month study period, a total<strong>of</strong> 61 individuals were enrolled in thecomprehensive weight loss program.Baseline characteristics <strong>of</strong> these individualsare shown in Table 1. During thestudy, 19 individuals dropped out <strong>of</strong> theintervention (30% drop out). Reasonsgiven for drop out included personal reasons(family issues, job issues, relocating)and time and distance issues. There wereno significant differences between completersand noncompleters in any measuredvariables (P > .05).Attendance at MeetingsThe cohort was separated into quartilesbased on percentage <strong>of</strong> meetingsattended. Mean attendance for the quartileswas as follows:All Participants(N = 61)CompletedParticipants (n = 42)Age, y 38.7 ± 6.0 38.8 ± 6.0RaceWhiteBlackHispanicAsianOther538346181237525412Height, m 162.8 ± 7.4 162.6 ± 7.1Weight, kg 84.4 ± 9.3 84.6 ± 8.6Body mass index, kg/m 2 31.7 ± 2.3 32.0 ± 2.1• Quartile 1: 30.0% ± 10.4%• Quartile 2: 52.1% ± 7.8%• Quartile 3: 65.5% ± 3.8%• Quartile 4: 82.4% ± 4.6%Weight, Body Mass Index,Body Composition, andWaist CircumferenceData regarding weight, BMI, waist circumference,and body composition can befound in Table 2. Significant group interactionswere seen for all <strong>of</strong> these variablesexcept fat-free mass. All groups increasedfat-free mass, most likely because <strong>of</strong> theheightened physical activity. Quartiles 3and 4 also decreased body weight, BMI,waist circumference, and body fat significantly,but quartiles 1 and 2 did not.As illustrated in Figure 1, individuals inquartile 1 who attended the least number<strong>of</strong> meetings lost an average <strong>of</strong> 1.01 ±3.49 kg (2.24 ± 7.71 lb, P > .05) in contrast,individuals who attended the highestpercentage <strong>of</strong> meetings lost an average<strong>of</strong> 6.72 ± 3.58 kg (14.78 ± 7.98 lb; P =.02). Significant correlations were foundbetween attendance <strong>of</strong> weekly meetingsand decreases in body weight (r = 0.476,P = .002), BMI (r = 0.492, P = .001), andwaist circumference (r = 0.455, P =.003).1277Downloaded from ajl.sagepub.com at HUNTER COLLEGE LIB on December 1, 2010
<strong>American</strong> <strong>Journal</strong> <strong>of</strong> <strong>Lifestyle</strong> <strong>Medicine</strong> May • June 2010Table 2.Anthropometrics and Body Composition by Quartiles <strong>of</strong> Weight Management Group Meeting Attendance Over 24 WeeksQuartile 1 Quartile 2 Quartile 3 Quartile 4InteractionP ValueBody mass, kgBaselineWeek 2483.04 ± 10.5782.03 ± 10.7188.19 ± 6.5385.79 ± 6.7383.43 ± 5.58 84.05 ± 12.43 .01877.61 ± 4.60 a 77.33 ± 10.81 aBody massindex, kg/m 2BaselineWeek 2431.00 ± 2.3330.66 ± 3.1432.82 ± 1.9531.94 ± 2.2331.81 ± 1.79 31.83 ± 2.49 .01329.65 ± 2.38 a 29.34 ± 2.80 aWaistcircumference, cmBaselineWeek 2488.31 ± 11.8886.92 ± 11.4791.95 ± 5.3189.63 ± 6.4991.19 ± 6.03 93.87 ± 10.00 .01986.35 ± 5.98 a 88.10 ± 9.71 aPercentagebody fatBaselineWeek 2445.13 ± 6.6543.23 ± 7.5548.97 ± 4.5747.01 ± 3.0647.56 ± 7.12 45.99 ± 4.75 .03242.89 ± 9.26 a 40.43 ± 6.09 aFat mass, kgBaselineWeek 2437.07 ± 4.6945.97 ± 11.0943.20 ± 5.3940.31 ± 4.0739.62 ± 6.18 38.35 ± 4.88 .01730.78 ± 7.13 b 30.99 ± 4.66 aFat-free mass, kgBaselineWeek 2445.97 ± 11.09 44.98 ± 4.93 43.81 ± 7.45 45.68 ± 9.65 .89046.81 ± 10.64 b 45.47 ± 4.49 b 44.28 ± 7.51 b 46.34 ± 9.92 baDifferent within group from baseline, P < .001.bDifferent within group from baseline, P < .01.Figure 1.Changes in body mass after 24 weeks <strong>of</strong> a commercial multidisciplinary weightmanagement program, which includes weekly group meetings; subjects groupedaccording to meeting attendance.Change in Body Weight (kg)0–5–10–15*Significantly different than lowest, P < .05.Lowest Low Moderate HighestInsulin and Glucose HandlingData related to glucose handling andinsulin resistance are presented in Table 3.Baseline values were normal and did notdiffer among the 4 quartiles. Group interactionswere significant for HOMA-IRand approached significance for fastinginsulin. Fasting insulin increased significantlyin quartile 1 but decreased significantlyin quartiles 3 and 4. HOMA-IRdecreased only in quartiles 3 and 4. Allgroups decreased fasting glucose similarly.Glucose AUC increased significantlyin quartile 1 but decreased significantly inquartiles 2, 3, and 4, although there wasno group interaction. Significant correlationswere found between attendance<strong>of</strong> weekly meetings and change in fastinginsulin (r = 0.389, P = .012) and fastingglucose (r = 0.354, P = .023) andHOMA-IR (r = 0.436, P = .004).ConclusionsThe main finding <strong>of</strong> this study was thatif normoglycemic overweight and obeseadults attend at least 65% <strong>of</strong> weeklygroup meetings (∼16 <strong>of</strong> 24) in a commercialmultidisciplinary weight lossprogram, risk for type 2 diabetes canbe significantly reduced. The program,which included plans for a hypocaloricdiet, increased physical activity, andcognitive restructuring, also resulted insignificant improvements in BMI, waistcircumference, and body compositionfor individuals who attended the greatest278Downloaded from ajl.sagepub.com at HUNTER COLLEGE LIB on December 1, 2010
vol. 4 • no. 3<strong>American</strong> <strong>Journal</strong> <strong>of</strong> <strong>Lifestyle</strong> <strong>Medicine</strong>Table 3.Indices <strong>of</strong> Glucose Handling by Quartiles <strong>of</strong> Weight Management Group Meeting Attendance Over 24 WeeksQuartile 1 Quartile 2 Quartile 3 Quartile 4InteractionP ValueInsulin, uIU/mLBaselineWeek 249.85 ± 7.45 9.11 ± 4.67 10.21 ± 3.91 11.32 ± 7.02 .05110.18 ± 8.03 a 9.13 ± 5.01 a 7.72 ± 3.26 a 7.29 ± 3.48 aGlucose, mg/dL(mmol/L)BaselineWeek 2490.30 ± 9.38(4.97 ± 0.52)86.90 ± 13.82 b(4.78 ± 0.76)85.58 ± 7.08(4.71 ± 0.39)84.33 ± 4.14 b(4.64 ± 0.23)91.90 ± 14.55(5.05 ± 0.80)82.10 ± 10.35 b(4.52 ± 0.57)91.00 ± 10.55(5.01 ± 0.58)82.22 ± 7.33 b(4.52 ± 0.40).103HOMA-IRBaselineWeek 242.14 ± 1.492.19 ± 1.771.93 ± 1.041.91 ± 1.052.42 ± 1.26 2.60 ± 1.72 .0241.59 ± 0.78 a 1.51 ± 0.81 aGlucose AUC,mg.min/dLBaselineWeek 247.90 ± 2.03 7.75 ± 1.77 9.02 ± 1.80 8.70 ± 2.29 .5097.95 ± 2.09 a 6.99 ± 1.59 a 8.14 ± 2.70 a 7.71 ± 1.90 aAbbreviation: AUC, area under the curve during a 2-hour oral glucose tolerance test.aDifferent within group from baseline, P < .05.bDifferent within group from baseline, P < .001.percentage <strong>of</strong> group meetings. Benefitsmay be even greater with 82% attendance(∼20 <strong>of</strong> 24 weekly meetings). Weight lossin quartiles 3 and 4 were 7% and 8%,respectively, which is within the 5% to10% range recommended for chronic diseaserisk reduction. 10Numerous studies have supportedthe concept that comprehensive lifestylemanagement approaches to weightloss including structured food and activityplans and behavioral strategies suchas group support are effective both forshort-term weight loss and longer termmaintenance <strong>of</strong> weight loss. 21-23,27-29 Thedata presented here specifically demonstratethat individuals who participate inthe highest percentage <strong>of</strong> group meetingsachieve the greatest degree <strong>of</strong> weightloss, decrease in waist circumference,and improvement in glucose handling.Such dose-response results can serve asmotivators for individuals who wouldotherwise tend to skip meals.Previous studies have shown that lifestyleinterventions are highly effective inreducing the incidence <strong>of</strong> type 2 diabetesin obese individuals. 11-13,24 These studies,which focused on individuals withbaseline insulin resistance, show that lifestyleinterventions that resulted in weightloss comparable with those reported inthe current investigation are effective inat-risk populations for lowering the incidence<strong>of</strong> type 2 diabetes. The presentfindings extend the results <strong>of</strong> previousstudies because this population <strong>of</strong> obeseindividuals had normal fasting blood glucoseand showed significant improvementin insulin resistance along withweight loss. These benefits were stronglyassociated with meeting attendance whenthe data were analyzed both categoricallyand continuously.Research has shown that a variety <strong>of</strong>behavioral strategies involving maintenancegroups can serve as effectivecomponents <strong>of</strong> comprehensive weightmanagement. 16,17,19,22,29 This study furthersupports the value <strong>of</strong> such maintenancegroups and provides more specificinformation concerning the relationshipbetween meeting attendance and bothweight loss and glucose handling. Whilethe current study explores social supportin the context <strong>of</strong> a commercially availablegroup meeting, it is likely that expandingthe circle <strong>of</strong> support (ie, to include family,friends, coworkers, etc) may enhancethe findings. 14,24The dramatic rise <strong>of</strong> overweight andobesity worldwide, 3 along with theassociated sharp increase in the prevalence<strong>of</strong> diabetes, 2,3 mandates innovativeapproaches to helping peoplelose weight and improve early stages <strong>of</strong>abnormalities <strong>of</strong> glucose handling. 10,14,24Data presented herein suggest that awidely available commercial weight lossprogram can fill that mandate. A particularlyattractive potential benefit <strong>of</strong> thecurrent study relates to the economicefficiency <strong>of</strong> commercially availableprograms. It has been estimated that participationin this program costs approximately$56 per month. 17 This is wellbelow the estimated cost <strong>of</strong> the interventionin the DPP. In a study that exploredhigh-risk individuals’ willingness to payfor diabetes risk reduction programs, 15 itwas found that individuals were willingto pay $1510 over 3 years (approximately$42 per month to participate in a lifestyleintervention program similar to that<strong>of</strong> the DPP). Thus, the estimated cost <strong>of</strong>the current intervention is consistent withwhat individuals who are at high risk fordiabetes appear willing to pay for thistype <strong>of</strong> program. In addition to money,time is an important consideration,279Downloaded from ajl.sagepub.com at HUNTER COLLEGE LIB on December 1, 2010
<strong>American</strong> <strong>Journal</strong> <strong>of</strong> <strong>Lifestyle</strong> <strong>Medicine</strong> May • June 2010because most clinical health pr<strong>of</strong>essionalshave limited time to devote to individualswho would benefit from a weekly 1-hourdiabetes prevention program. 14,24 The programin the current study was implementedby trained successful programcompleters who were able to devote thetime required for social support, weighins,and plans relating to a hypocaloricdiet, physical activity, and cognitiverestructuring behavior modification.One limitation <strong>of</strong> this study is the lack<strong>of</strong> a control group, but the design didallow for comparison among similar individualswho undertook the same weightloss program but differed in their frequency<strong>of</strong> meeting attendance. This studyis also limited by following individualsfor only 24 weeks. Whether weight losscan be maintained over longer periods<strong>of</strong> time by attending more group meetingscannot be answered by the currentresearch trial. However, a recent largeclinical trial showed that 2-year weightloss was strongly predicted by meetingattendance, 29 although this programwas implemented by credentialed healthpr<strong>of</strong>essionals rather than through a lesscostly commercial program. Furthermore,relationships between attendance anddiabetes risk factors were not reported asin the present study. Previous researchon commercially available programsdemonstrated significant weight loss at2 years among individuals who attendedmore than 78% <strong>of</strong> group meetings. 27Future research should also examine awider range <strong>of</strong> subjects, including differentethnicities, because the present samplewas composed largely <strong>of</strong> whites.Implications/Relevancefor Diabetes EducatorsEvidence-based, cost-effective, and feasiblediabetes prevention programs are <strong>of</strong>critical importance. 10,14,24 Further researchis needed to examine whether meetingattendance in cost-effective programsduring active weight loss is associatedwith long-term maintenance <strong>of</strong> improvementsin insulin resistance and diabetesprevention. 10,24 Practicing clinicians withpatients who plan to decrease diabetesrisk through commercial weight loss programsshould encourage such patients toattend as many meetings as possible tomaximize effectiveness.AcknowledgmentFinancial support was provided byWeight Watchers International. 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