Introduction

Effective weight management programmes for patients with type 2 diabetes are vital to help tackle the escalating rise in obesity. Patients with type 2 diabetes who are started on insulin are known to gain weight. This article will discuss a pilot project that was set up to evaluate a weight management programme specifically targeted at this group of patients. Outcomes of weight loss, Hb[A.sub.1c] reduction and patient-reported benefits of taking part will be discussed. Finally, recommendations for future development of a weight management programme will be considered.

KEY WORDS

* Weight management programme

* Obesity

* Insulin

* Weight loss

* Support

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Patients converted to insulin will in the short-term gain improved glycaemic control. One of the side-effects of this is usually weight gain, which poses increased health risks (Laville M et al, 2000). Direct evidence shows that insulin therapy can reduce the risk of macrovascular events by improving glycaemic control and diabetes associated dyslipidaemias (Boyne et al, 1999). However, these beneficial effects may be significantly compromised by excessive weight gain (Boyne et al, 1999). Most studies report an average 6 kg weight gain in patients with type 2 diabetes following the first year of taking insulin (UKPDS, 1998; Laville et al, 2000).

The prevalence of patients newly diagnosed with type 2 diabetes who are overweight or obese is known to be at least 90% (Davies et al, 2003). The rising levels of obesity present society and healthcare providers with major challenges. Treatments to help patients lose weight are being developed by many individual centres, but at present there appears to be no consensus about the best way to provide patients with both the educational and behavioural techniques to lead to long lasting and achievable weight loss. The recent Cochrane review on obesity discusses the current evidence available for different approaches to caring for patients who are overweight and obese. In its introduction, the review states that 'the approach to obesity management in the NHS is patchy, and that work is needed to develop and implement effective strategies to prevent and treat obesity at policy and provider level' (Harvey et al, 2002). The review also strongly points to the need for cost-effective management of obesity and that dietitian-led treatments may be well worth further investigation.

Weight management

The Royal College of Physicians guidelines (RCP, 1998) state that a weight loss of 10% is associated with positive health benefits, such as reduction in fasting blood glucose, cholesterol, blood pressure and mortality. A clinical review by Noel et al (2002) states that for motivated patients a gradual and modest weight loss of 5-10% should be aimed for and that this should be achieved by caloric restriction, increased physical activity and behaviour therapy.

The National Weight Control Registry established by Klem et al (1997) in the US is a valuable resource which gives us a clear view of how people who have successfully lost weight have been able to maintain that loss. Important components to highlight are self-monitoring, physical activity and caloric restriction, especially from fat.

Aims of project

The aim of this project was to set up, run and evaluate a dietitian-led weight management programme for patients with type 2 diabetes who were taking insulin. The primary outcome from this project was weight. Hb[A.sub.1c] levels and patient-reported benefits of taking part were also measured. Sessions were held at the diabetes centre in a seminar room at Broomfield hospital in Chelmsford between January and May 2003.

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The diabetes centre patient database was searched to identify all patients with type 2 diabetes with a BMI>30 and a Hb[A.sub.1c]>7% and who had been converted onto insulin in the past 4 years. A questionnaire and covering letter was then sent to a random selection of 100 of these patients to gauge interest in a weight management group. Half the questionnaires were returned. The sessions were designed according to the responses to the questionnaire and participants were invited to attend the group.

The weight management programme consisted of eight sessions taking place on a fortnightly basis and was attended by 23 patients divided into two groups; one group of males and females and one group of all males. Figure 1 illustrates the breakdown of the groups.

The main purpose of the weight management sessions was to use behavioural techniques, along with education on a wide range of topics, to help patients work towards changing some of their eating, exercise and diabetes care behaviours. Emphasis was given to patient-led discussion, enabling people to share their experiences of managing their diabetes and their weight. The programme was delivered using goal setting, food diaries, relapse prevention, achievements and motivational approaches. Other members of the diabetes team were involved with some of the teaching sessions on insulin adjustment and physical activity.

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A brief outline of the topics covered in each session is detailed in Figure 2. It is beyond the scope of this article to go into detail of each session, but it is important to note that although each session had stated learning outcomes, these were achieved within the needs of the group and the learning environment remained informal and where possible fun. Each session lasted between 1-1.5h.

Results

Of the 16 patients who started in the morning group, four dropped out before the final session and one was admitted to hospital for a below knee amputation. One other patient has been excluded from the results as he was started on a special low calorie diet for medical reasons and therefore the weight loss for this patient would bias the results. The evening group had one patient drop out. Therefore the total number of patients included in the results is 16.

Figure 3 shows the weight at the start and end of the weight management programme for each individual patient, broken down by sex. The mean average weight loss for males and females was 3.2kg and 1.8kg, respectively. Mean average weight loss for all participants was 2.9kg over the 16-week period.

Figure 4 shows the total percentage weight loss for each patient. The greatest weight loss was 7.7%. The average weight loss was just under 3%. Five patients lost less than 1% in weight and one patient gained just under 2% in weight.

Figure 5 shows Hb[A.sub.1c] results before and after the weight management sessions. Two patients did not have their Hb[A.sub.1c] taken so results are given for 14 of the 16 participants. Mean average Hb[A.sub.1c] reduction for males and females was 0.86% and 1.8%, respectively. The total mean average reduction in Hb[A.sub.1c] for all participants was 1.07%.

Participant feedback

Comments from the participants are shown in Table 1. Some patients did not answer all the questions and one patient did not answer any. Group participant feedback was very positive, with most patients agreeing or strongly agreeing that their diabetes control, knowledge, confidence and eating behaviours had improved. It is also interesting to note that only one patient felt that they would gain weight after completing the programme. 71% of patients also reported they were doing more physical activity than before.

Some of the individual comments are listed below to give a general feeling of patient perceptions.

  'The programme ran very well, would like to carry on--it has improved
  my standard of living.'

  'Found all sessions useful mainly because of the other people in the
  group sharing their same problems.'

  'I know so much more about diabetes, the sessions have been excellent
  and extremely informative.'

  'These sessions have been most useful, most of all they keep you in
  touch with the clinic and its staff.'

Discussion

The results from the programme show that all but one patient lost weight. The weight loss ranged from 0.2-9.3kg with the majority of patients losing between 3-5% of their total body weight. This is a very encouraging result considering this weight loss was seen in a 3 month period. Most patients also reported that it was the first time since starting insulin that they had either not gained or had managed to maintain their weight. A fall was also seen in most patients' Hb[A.sub.1c] levels indicating improved blood glucose control.

Although the results from this project were encouraging, it is important to highlight the limitations. Only a relatively small number of patients were involved and there was no control group. The evaluation form was not a validated tool and therefore reporter bias must be considered.