Liverpool — Weight loss on the NHS Type 2 Diabetes Path to Remission Programme was an average of 11 kg after 1 year, and 13 kg after the first 3 months, according to early findings.
The initial weight loss, achieved with total diet replacement – comprised of shakes and soups for the first 3 months – was maintained up to 6 months.
Formerly known as the NHS Low Calorie Diet Programme, the results were presented by Chirag Bakhai, GP and primary care advisor to the NHS Diabetes Programme, at the Diabetes UK Professional Conference (DUKPC) in Liverpool from 26-28 April.
They comprised a first look at the 12-month (end of programme) analysis with figures relating to referral, uptake, retention, and weight loss. Remission figures will follow at a later date.
The early results follow on from those of the Diabetes Remission Clinical Trial (DiRECT), which found losing weight can put type 2 diabetes into remission for at least 5 years in some people.
"Weight loss is not dissimilar to what we saw in the randomised controlled trials which informed the design of the programme, suggesting that the programme may lead to similar remission rates," reported Dr Bakhai.
"Although our analysis has reported some inequalities, there have been various changes to the upcoming specification to try reduce those inequalities in uptake, retention and weight loss," he added, reflected on some of the learning points to date .
Programme participants had to have type 2 diabetes diagnosed in the previous 6 years, aged 18-65 years, and have a BMI of 27 kg/m2 or greater, adjusted to 25 kg/m2 or greater if Black, Asian or other ethnic minority (mean baseline weight was 107 kg).
For the first 3 months on the programme, weight loss is given a boost through low-calorie (800-900 calories per day) total diet replacement. Then, healthy foods were reintroduced and participants were guided to adopt a healthy lifestyle and maintain weight loss through regular sessions with coaches, which could be in-person or delivered digitally.
Referrals, Uptake, Retention, and Weight Loss
Of initial eligible referrals between September 2020 to December 2022, 68% (4184 people )
started the first 3-month stage of total diet replacement.
Of referrals, 45% were under 50 years, with 57% female; 26% were in the most deprived quintile, with only 14% in the least deprived; 64% were White, and 18% Asian.
Uptake was highest in the 18-34 age group at 76%. In the 35-39 age group it was 71%, and was lowest in 60-65 age group at 64%. Of the most deprived group, 62% took up the programme, while 77% of the least deprived did so.
Regarding ethnicity, there was a 74% uptake among White participants, while this dropped to 60% and 67% among Asians and Black participants, respectively .
"People in the least deprived areas had greater uptake than those in the most deprived areas, and people of Asian ethnicity had lower levels of uptake than those of White ethnicity," reported Dr Bakhai.
The qualitative evaluation of the programme has provided insights which have fed into the updated specification, such as offering a choice between in-person and digital delivery and strengthening the approach to tailoring content based on individual cultural and culinary context, explained Dr Bakhai.
Turning to retention on the programme, he reported that: "Despite some preconceptions that there would be high drop-out rates in the first few weeks, the data tell a different story with 90% of those who start the total diet replacement staying with it for the first 3 months, while over 50% were still there at programme end [12 months]."
The researchers also saw a different pattern for retention by age than that for uptake. "Older ages were more likely to stay on the programme for 12 months [65% of 55- to 65-year-olds compared with 43% of those aged 18-44]," reported Dr Bakhai.
By 12 months, participants in the least deprived quintile showed greatest retention at 65%, compared with 52% of participants in the most deprived. By ethnicity, 59% of Black people stayed with the programme at 12 months compared with 56% and 55% of Asian and White ethnicities, respectively .
Regarding mean weight loss, across the 12 months, data recorded a loss of 7.1 kg in month one, 13.2 kg by month three, and 10.9 kg by month 12, representing 6.6%, 12.2%, and 9.8% mean body weight loss, respectively.
"People of White ethnicity lost significantly more weight than those of any other ethnicity," said Dr Bakhai, with 10.3% of body weight loss by 12 months, while people of Asian ethnicity lost 6.8%. "After adjusting for other variables in the multivariable logical regression, we see that having White ethnicity was still associated with significant greater weight loss than having Asian or Black ethnicity.”
By age, the 55-65 age group lost 9.8% body weight, compared with 8.4% in the 18-44 age group. People in the least deprived group showed greatest weight loss at a mean of -10.1% compared with the most deprived at 9.0%.
"We have made changes to the specification to address inequalities in uptake, retention and weight loss," said Dr Bakhai, adding that "we are also linking the programme data to national diabetes audit data to support analysis of remission".
There are plans to expand to full coverage across England by April 2024. Professor Jonathan Valabhji, NHS National Clinical Director for Diabetes and Obesity, said: "Research is clear that weight loss where indicated goes a long way to helping people stay well and avoiding preventable illness, and in many cases it can be the trigger for putting type 2 diabetes into remission," he said.
"I am delighted that thousands more people are making use of this programme with thousands more set to benefit across England in the coming year."
Success of Any Diet Depends on Real-World Practicality
Dr Roy Taylor, professor of medicine and metabolism, Newcastle University, commented on the findings and specifically the value of this diet compared to others available for people living with type 2 diabetes. He highlighted that success with any weight-loss diet rests with it being practical in the real world and suiting most people.
"That is exactly why the low-calorie diet was developed in the first place. It has achieved 12-15 kg weight loss in repeated research studies, and for this reason was adopted by NHS England for the Type 2 Diabetes Pathways to Remission programme."
"The results of that programme at 1 year speak loudly – it is effective," Prof Taylor asserted, adding that the total diet replacement initial phase, "importantly is followed by support to focus on avoidance of weight regain".
"However, any diet that can be sustained could achieve similar results – in theory. In practice, all fall short," he added.
Asked how this diet fared against low carb and intermittent fasting diets, which have garnered a lot of attention in recent years, Dr Taylor said: "Low carbohydrate diets can achieve good results for those who actually like this pattern of eating and that is fine. But in general, low carb is difficult for most people to sustain and simply does not match up to the hype."
"Intermittent fasting is excellent for a small minority of people, but again does not suit enough people to justify widespread use. In the matter of weight loss, one 'size’ does not fit all – but the low calorie approach of rapid weight loss is by a large margin, the most successful way for most people," he concluded.
The programme ends at 12 months; however, some people continue receiving support from other local and national services, Dr Bakhai noted.
The programme was first piloted by the NHS in 2020 as part of its Long-Term Plan and will expand so that it can provide access to patients in each of the 42 Integrated Care Systems in England by April 2024 – it is currently available in 21 Integrated Care Systems.
No relevant financial disclosures declared other than Professor Taylor who was a member of the Scientific Advisory Committee on Nutrition Group which evaluated published evidence on low carbohydrate diets. Also, Professor Taylor devised and tested the low-calorie diet rapid weight loss then weight maintenance. He is also author of the book Life Without Diabetes.