Discussant Michael G. Perri, Ph.D., a pioneer in developing intensive behavioral weight loss programs, said he really likes the stepped-care approach because it’s practical and efficient, and it lends itself to implementation in a variety of health care settings.
“I can tell you, one of the biggest barriers to dissemination is that the length and intensity of the kinds of programs we do is too high for adoption in most community settings. We have to find ways to make them more efficient,” said Dr. Perri, professor of clinical and health psychology and dean of the college of public health and health professions at the University of Florida, Gainesville.
Another “terrific” aspect of the STEP-UP trial, he continued, is that the weight loss was achieved with lower cost and markedly fewer sessions than were entailed in standard therapy.
“It tells us that maybe we need to be looking at more of a triage kind of approach: You could set it up so that if somebody doesn’t do well, they get more care, and if they do worse they get even more care. But at some point, I think it really needs to be triage, where we say, ‘Enough is enough – this person is not going to benefit from anything more and we don’t waste more resources on him,’ ” Dr. Perri commented.
As for the FRESH START trial, in which he was a coinvestigator, Dr. Perri raised the possibility that the novel, maintenance-first intervention merely delayed weight regain rather than preventing it. This is suggested by the weight loss trend over time: During months 6-12, the maintenance-first group gained a mean of only 0.4 pounds, whereas in months 12-18, the group put on 2.5 pounds, which wasn’t significantly different from the mean 3.3-pound gain in the control group during that late phase of the study.
Michael G. Perri
Still, delaying weight regain is not to be shrugged off. It confers long-term health benefits, as was recently shown in the 10-year follow-up of the landmark Diabetes Prevention Program (DPP), the psychologist asserted.
The DPP randomized more than 3,000 subjects with impaired glucose tolerance to an intensive diet and exercise lifestyle intervention, to metformin, or to placebo. The results were truly heartening: At 4 years of follow-up, the biggest average weight loss – about 4 kg – was seen in the lifestyle modification group. Moreover, the primary study end point, which was the development of type 2 diabetes, was reduced by 58% in the lifestyle intervention group, compared with placebo, which was a significantly greater benefit than the 31% risk reduction with metformin (N. Engl. J. Med. 2002;346:393-403).
Then came the initially disheartening DPP 10-year follow-up report. At 10 years, there was no longer any difference between the three study arms in terms of weight loss, which stood at about 2 kg in each group. Yet, surprisingly, there was still a 34% reduction in the incidence of type 2 diabetes in the lifestyle arm, compared with placebo, and an 18% reduction with metformin. The incidence was 11.0 cases per 100 person-years with placebo, 7.8 with metformin, and 4.8 with lifestyle modification (Lancet 2009;374:1677-86).
“One of the things that’s instructive about this is that even though we’re worried about the maintenance problem, the DPP shows that if somebody is able to lose weight and keep it off for a few years, that’s likely to have some beneficial impact on their health that can be observed long term, even if they do regain weight,” Dr. Perri observed.
The FRESH START and STEP-UP trials were funded by the National Institutes of Health. Dr. Kiernan, Dr. Tate, and Dr. Perri reported having no financial conflicts.