I reckon it's well worth reading the paper presenting the 2 year DiRECT follow-up results in conjunction with this. Article proof here:
https://www.ncl.ac.uk/media/wwwnclacuk/newcastlemagneticresonancecentre/files/DiRECT - 2 year results.pdf
Remission outcomes by weight loss:
At 24 months, 70% of people who lost > 15kg were in remission, down to just 5% who lost less than 5kg - which is just "noise", really. For a real chance, you have to lose 5kg+. Because the study group had a mean baseline weight of ~100kg, that means losing 5%+ of body weight. And that fits perfectly for the general medical view on weight loss: 5%+ is "clinically meaningful".
One of the things I like about this work is that the more you dig into it, the more it fits with a large amount of well-established research. This is one of the major features which distinguishes real research from quackery.
Obviously, the big issue with the approach clinically is the difficulty of maintaining weight loss.
At one year, 24% had 15kg+ loss, declining to 11% at two years. For 10kg weight loss, it was 24% at two years. The previous figure shows that to have a chance much better than 50% of getting to remission, you generally need to aim for 10kg (or approx 10%) weight loss. Of course, you could get lucky with less, or unlucky with more: one thing that these results show is that losing weight isn't a universal cure, at least for the weight loss ranges explored.
One thing highlighted in the results paper and less so in the book, is that about half the participants required at least one "relapse management" intervention when their weight started to go back up inthe first 12 months. This isn't set & forget!
Personally, I went into what I would call "remission" - avg daily BG <= 5.8 mmol/L, fasting BG <= 5.2 mmol/L - after losing about 10kg, or about 12% of body weight, which fits with this picture.
That happened around the beginning of Oct 2018, and the step-down should be pretty obvious from the chart. So about 15 months ago. If I can keep it up for aother 9 months, I guess I will correspond to one of those 60% in remission at 24 months in the DiRECT follow-up.
So what are my chances of being able to maintain the remission? long-term To the extent that it depends on maintaining >= 10kg / ~10% weight loss, it's a bit interesting to look at the well-known "Look AHEAD" trial: 8 year study, finishing in 2012, investigating managed weight-loss program outcomes for a large cohort of T2D's. I think DiRECT was modelled on this to some extent & although the details of the interventions were different, it's probably of some use in trying to extrapolate out from the 2 year DiRECT results.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3904491/pdf/nihms536505.pdf
Over the first 12 months, the Look AHEAD "ILI" intervention achieved an avg weight loss of 8.5%, falling to about 6.5% at year 2 (versus ~10.5% / ~7.5% for DiRECT):
("DSE" = standard care)
By year 8, avg wright loss had reduced to < 5%. This is the same general profile as for any weight loss program, short-term reductions, stacking it back over time, hopefully achieving some modest long term net reduction - even with support, advice, rah-rah email messages, follow-ups etc etc. Even though the DiRECT 2 yr results were a bit better, I haven't seen anything to give confidence that the longer term results won't converge to something like this.
If 5% is the minimum clinically meaningful target, at a population level it's really hard to achieve!
However, I'm not a population so I'm more interested in the subgroup which did achieve 10%+ reduction over 8 years. Interestingly, this looks a lot like DiRECT's 2 year results for the 10kg / ~10% reduction group:
In Look AHEAD, about 27% achieved 10kg+ loss at 8 years and about 11% achieved 15kg+. At 2 years, the corresponding results for DiRECT were 24% / 11%. Pretty much the same.
Other data from Look AHEAD suggest this isn't much of a coincidence: how much you lose in the first year was a big predicter for how much you have lost by year 8. One aspect of this:
39% of people who lost 10%+ in the first year were still at 10%+ loss by year 8, and the higher the first year loss, generally the less you would stack back on and the lower you would be at year 8. Whatever motivation people have for the initial loss is often enough to carry them through for the longer term.
Fingers crossed!
The study identified characteristics of successful maintainers which are completely unsurprising: they check weight often, they check calories often and adjust as needed, they are physically active.
So this further motivates me to continue to be moderately obsessive about managing things
🙂
But for the world as a whole, and for me if I lose motivation, what all this work really demonstrates IMO is that we badly need a cheap, safe, effecive appetite suppressant pill. Sorry, but evolution hasn't equipped us for a world of abundant food and pharma needs to take up the slack. Look: even with the best intervention programs and generally motivated particpants, the avg long-term weight loss is sub 5%, at best marginally clinically significant. How much more proof do we need?
The excellent Kevin Hall has great research illustrating the fundamental problem:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5764193/#!po=2.20588
Appetite changes likely play a more important role than slowing metabolism in explaining the weight loss plateau since the feedback circuit controlling long-term calorie intake has greater overall strength than the feedback circuit controlling calorie expenditure. Specifically, it has been estimated that for each kilogram of lost weight, calorie expenditure decreases by about 20–30 kcal/d whereas appetite increases by about 100 kcal/d above the baseline level prior to weight loss31. Despite these predictable physiologic phenomena, the typical response of the patient is to blame themselves as lazy or lacking in willpower, sentiments that are often reinforced by healthcare providers,
You lose 10kg, on average your appetitie increases by 1,000 cal per day. At the same time, your baseline energy expenditure decreases by about 200 cal per day. Of course there's individual variability in that but of course at a population level maintaining 10kg weight loss is going to be really really difficult - you're going to be feeling constantly like you've eaten 1,200 cal per day too little. I'm probably fortunate in not feeling the full force of that, but I often do feel a big part of it, and not letting fat creep back is going to demand constant vigilance.
Sucks! Bring on the appetitie suppressant implant!
