Look AHEAD – Practical Implications from an Intensive Lifestyle Intervention

by tony sheng

Diet and exercise are usually the first therapies prescribed by health care practitioners for patients newly diagnosed with type 2 diabetes, but what sounds like simple and effective therapies have failed time and time again in the United States. For busy people with cluttered lives and a million things on their minds, allocating that extra hour a day to jog, those extra three hours a week to do groceries, and the extra money to pay for healthier foods-well, it's just too much extra! Even for those who are determined to purge their bodies of junk food and defeat their sedentary lifestyles, behavioral change is hard to sustain. Some previous studies on diet and exercise interventions have demonstrated impressive improvements in weight and diabetes management but have been conducted in unrealistic settings (i.e., eating every meal at the study site). However, we're encouraged by the results of a study called Look AHEAD (Action For Health in Diabetes), which suggest that diet and exercise can be an effective therapy for obesity and type 2 diabetes even without complicated study procedures.

The Look AHEAD trial was designed to see if and how a long-term intensive lifestyle intervention program would affect the risks of cardiovascular disease and death in obese patients with type 2 diabetes. Patients that took part in the intensive lifestyle intervention were given basic education about diabetes and were taught the importance of eating a healthy diet and of being physically active. They were encouraged to lose 10% of their body weight, restrict their diets to around 1,500 calories a day, and to exercise 175 minutes per week. During the first year, participants were seen in clinic weekly with three weight-loss group meetings and one individual counseling session per month. In years two through four, a minimum of two contacts per month was expected. Of the 5,145 patients in the massive trial, around 95% stayed on the program. Many behavioral studies have trouble retaining subjects in part because of unrealistic requirements. Look AHEAD's high retention rate speaks to the adoptability of the program.

More impressive were the improvements in weight, fitness, and cardiovascular risk factors. Patients on the intensive intervention lost weight (8.6% of their body weight in the first year!), improved fitness, glycemic control, systolic blood pressure, and triglyceride levels. Not surprisingly, these patients also required fewer diabetes medications and insulin. Fewer medications needed means less medication purchased, which means less money spent by the patient! The study also showed that physical activity was the most significant factor in explaining the dramatic weight loss. In his talk at the ADA Scientific Sessions in New Orleans, Dr. Thomas A. Wadden of the University of Pennsylvania Medical School suggested that the success of group treatments seen in the Look AHEAD study might be due to the support and competition in the group setting.

Look AHEAD presents what we already knew (that diet and exercise are important and effective diabetes and obesity therapies) and puts a practical twist on it. Many past studies were controlled too tightly and created environments that could not be translated to the real world. Look AHEAD showed real improvements with at least three hours of exercise a week and only two or three meetings per month with a weight-loss. This trial shows that if you can educate yourself on healthy eating and exercise habits, set goals, and find a few other people to lose weight with you, you can (really!) lose weight and improve your diabetes.

Editor’s Note: As always, remember that diaTribe doesn’t give treatment advice. Always consult your doctor before starting a new exercise or treatment program.

insights from Look AHEAD:

Diabetes education is vitally important. All participants in the intensive intervention program attended a one-hour diabetes education class that placed a special emphasis on hypoglycemia, cardiovascular disease symptoms, and foot care.
Setting aggressive goals may help people to lose more weight. Patients in the intensive intervention program set a goal of losing 10% of their body weight. Not everybody met this goal, but the average weight loss was over 8%! It’s the slow, incremental improvements that will add up and make a difference in the long run.
Proper diet is absolutely critical for weight loss. It is important to control portions of food. Think of your stomach as a bathtub, and calories as water. Calories you consume from food enter the tub, and any exercise you do drains the water out. If you don’t exercise enough, the tub will overflow. A constantly overflowing tub leads to obesity, type 2 diabetes, and cardiovascular problems. The diet recommended for patients in the intensive intervention program was based on ADA guidelines and National Cholesterol Education programs and includes a maximum of 30% of total calories from total fat, a maximum of 10% of total calories from saturated fat, and a minimum of 15% of total calories from protein.
According to Dr. Wadden, exercise was the most important factor in achieving weight loss in this study. Patients in the intensive intervention program were encouraged to exercise 175 minutes a week. This translates to 25 minutes a day. Start by taking walks after meals, and count any exercise that lasts longer than 10 minutes towards your goal.
There are benefits of a team approach to weight loss. Dr. Wadden believes that the significant weight loss experienced in this trial might be due in part to the support and competition in the group meetings during the trial.
Quitting smoking improves cardiovascular health. All individuals in the program that smoked were encouraged to stop smoking and were provided with self-help materials and/or referrals to local programs. People with diabetes are already two to three times more likely to die from cardiovascular events, and smoking just increases that risk!