Journal Reading Safuar

7/29/2019 Journal Reading Safuar

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LOGO

Presented by : SYARIFAH S SAFUAR

NIM: I111 07 044

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Background

Adults with type 2 diabetes mellitus oftenhave limitations in mobility that increase withage.

An intensive lifestyle intervention thatproduces weight loss and improves fitnesscould slow the loss of mobility in suchpatients.

2The New England Journal of Medicine


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Introduction

The growing prevalence of type 2 diabetesmellitus is an ominous health threat in the UnitedStates and globally.

An insidious consequence of aging in personswith type 2 diabetes is physical disability,particularly the loss of mobility.

Reduced mobility puts patients at risk for loss ofindependence, leads to muscle loss (whichcompromises glucose storage and clearance),and compromises the quality of life.



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The ongoing Look AHEAD (Action for Health inDiabetes) study, a multicenter, randomized,controlled trial enrolling more than 5000

overweight or obese persons with type 2 diabetes,was designed to determine whether intentionalweight loss would reduce morbidity and mortalityfrom cardiovascular causes.

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Introduction

The New England Journal of Medicine


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Methods

We randomly assigned 5145 overweight or obese adultsbetween the ages of 45 and 74 years with type 2diabetes to either an intensive lifestyle intervention ordiabetes Support-and-education program; 5016

participants contributed data.

We used hidden Markov models to characterizedisability states and mixed-effects ordinal logisticregression to estimate the probability of functional

decline. The primary outcome was self-reportedlimitation in mobility, with annual assessments for 4years.



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Study Design

From 2001-2004, we randomly assignedparticipants to an intensive lifestyle intervention orto a diabetes support-and-education program.

The two primary goals were to induce a meanweight loss from baseline of more than 7% and toincrease the duration of physical activity to morethan 175 minutes a week.

Diabetes support and education involved threegroup sessions a year focusing on nutrition,physical activity, and support.



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Status Assessment

Mobility Mobility was assessed on the basis of 6 of 11 items on

the Medical Outcomes Study 36-Item Short- FormHealth Survey (SF-36) Physical Functioning subscale.

The items included vigorous activity, such as runningand lifting heavy objects; moderate activity, such aspushing a vacuum cleaner or playing golf; climbing oneflight of stairs; bending, kneeling, or stooping; walkingmore than a mile; and walking one block.

Participants were assigned a score of 1 on items forwhich they reported not being limited at all or a score of0 on items for which they indicated having anylimitation.



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Status Assessment

Weight Loss and Fitness

Weight was assessed at each annual visit, and peak

metabolic-equivalent (MET) capacity was estimated

from performance on a graded exercise treadmilltest administered at baseline, year 1, and year 4.

METs were estimated from treadmill speed and

elevation with the use of standardized equations.

The New England Journal of Medicine 8


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Four States of Disability

Criteria for Each State State 1 (good mobility), participants were somewhat

unable to perform vigorous physical activities.

State 2 (mild mobility-related disability), participantshad problems in bending and long-distance walking.

State 3 (moderate mobility-related disability),

participants had deficits in many tasks and somedeterioration in the ability to climb stairs and engage inmoderately demanding activities.

State 4 participants had severe limitations, withdifficulty in nearly all tasks.



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Model of four states of clinical disability



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Risk of Loss of Mobility

A higher proportion of participants in the lifestyle-intervention group who had good mobility than inthe support group during all 4 years.

After adjustment for baselineprevalence, numbers ofsubjects with severe mobility-related disability in thelifestyle-intervention group were 308 of 2514(12.3%) at 1 year and 517 of 2514 (20.6%) at 4years, as compared with 474 of 2502 (18.9%) at 1

year and 656 of 2502 (26.2%) at 4 years,respectively, in the support group.



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Prevalence of the four states of clinical dasabilityduring the 4-year study




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At year 4, the prevalence of good mobility was38.5% in the lifestyle-intervention group, ascompared with 31.9% in the support group.

When expressed as a summary odds ratio,participants in the lifestyl intervention grouphad a 48% reduction in mobility-relateddisability, as compared with those in the

support group (odds ratio, 0.52; 95%confidence interval, 0.44 to 0.63; P


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Test of Mediation

Step A intensive lifestyle interventionresulted in significant weight loss andimproved fitness during the 4-year studyperiod.

Step B loss of weight and improved fitnessboth resulted in a lower risk of loss of mobility(P


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Tests of the effects of mediation on mobility

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Test of Mediation

Both loss of weight and improved fitness weresignificant mediators for the effect of the lifestyleintervention on slowing the loss of mobility(P


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Discussion

Among overweight and obese adults with type 2 diabetes,an intensive lifestyle intervention led to a relative reductionof 48% in the severity of mobilityrelated disability, ascompared with diabetes support and education.

Prevalence rates in the good-mobility category during all 4years of thestudy, participants in the lifestyle- interventiongroup also retained higher levels of healthy functioningthan those in the support group.

Deficits in mobility are a risk factor for the onset andprogression of most chronic diseases, includingcardiovascular disease.



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Summary

Weight loss and improved fitness slowed the decline inmobility in overweight adults with type 2 diabetes

In summary, our findings confirm the clinicalimportance of declining mobility as adults with type 2

diabetes age. Although our measure of mobility was not based on

performance, it had considerable clinical relevance withexpected relationships to BMI, coexisting illnesses,baseline estimated metabolic equivalents, and sex.

Furthermore, both weight loss and improved fitnesswere determinants of this effect.



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