Background: DiRECT reported diabetes remission at one year for 46% of participants allocated to an integrated structured weight management programme. We now assess two-year findings. Methods: DiRECT is an open-label, cluster-randomised, controlled trial in primary care practices randomised to a weight management programme (intervention) or best-practice care by guidelines (control). We recruited individuals aged 20–65 years, with <6 years duration of type 2 diabetes, body-mass index 27–45 kg/m, and not receiving insulin. The intervention comprised withdrawal of anti-diabetes and antihypertensive drugs, total diet replacement (825–853 kcal/day formula diet) for 12-20 weeks, stepped food reintroduction (2–8 weeks), and then structured support for weight loss maintenance. Co-primary outcomes, analysed hierarchically, were weight loss >15 kg, and remission of diabetes, defined as HbA1c <6·5% (<48 mmol/mol) with no anti-diabetes medications. Findings: At 24 months, 53/149 (35·6%) of those commencing the intervention and 5/149 (3·4%) in the control group (adjusted odds ratio 25·8, 95% CI 8·3,80·8; p<0·0001) had remission, and 11·4% of intervention and 2·0% of the control group (adjusted odds ratio 8·2 (2·2,30·0), p=0·0015) had weight loss ≥15kg. Of those maintaining ≥10kg weight loss (45/272), 64% (29/45) achieved remission, and 24.2% (36/149) of the intervention group maintained ≥10kg weight loss. Adjusted mean differences between groups were, in changes in body weight -5·4 kg, (-6·9,-4·0), p<0·0001, in HbA1c -4·8 mmol/mol, (-8·3,-1·4), p=0·0063 despite >50% fewer anti-diabetes agent use in intervention group, and SBP -3·4 mmHg, (-6·7,-0·2), p=0·0397. Serious adverse events were similar at 12 months, but fewer occurred in intervention than control in the second year (9 vs. 22). Quality of life improved more from baseline in the intervention than the control group, adjusted mean difference 4·6 (0·4,8·9, p=0·032). Interpretation: This programme sustained remissions at 24 months for over a third of people with type 2 diabetes. Weight loss of ≥10 kg provides remission for two thirds. Funding: Diabetes UK.

SummaryLow‐carbohydrate diets are being widely recommended, but with apparently conflicting evidence. We have conducted a formal systematic review of the published systematic reviews of RCTs between low‐carbohydrate vs. control (low‐fat/energy‐restricted) diets in adults with overweight and obesity. In MEDLINE, Embase, Web of Knowledge and Cochrane Database of Systematic Reviews, searched from inception to September 2017, we identified 12 systematic reviews, 10 with meta‐analyses. Differences in methods, study quality, weight change and citations of published systematic reviews were assessed by AMSTAR‐2. Review methods varied in definitions of low‐carbohydrate diet, databases searched and bias assessment. Overall review quality was high in two, moderate in three, critically low in seven. Among meta‐analyses, 4/5 with critically low quality showed low‐carbohydrate diet superiority for weight loss (0.7–4.0 kg), while high quality meta‐analyses reported little or no difference between diets. Greater numbers of participants correlated with smaller differences in weight loss (r = 0.73, p = 0.03). More citations correlated with lower review quality (rho = −0.9, p = 0.037), with larger differences in weight loss (rho = −0.9, p = 0.037), and with journal impact factor (rho = 1.0, p = 0.01). In conclusion, publication acceptance and citations appear to favour apparently larger effect sizes above methodological quality. Better quality reviews and RCTs are needed, before recommending low‐carbohydrate diets as preferred to other approaches for energy restriction.

Rationale: Low-carbohydrate diets (LCDs) can improve blood glucose control in patients with diabetes, but this is confounded by weight loss. Meanwhile, long-term prospective studies demonstrated that LCDs are associated with an increased risk of type 2 diabetes (T2DM). Here, we assess the association between LCDs, scored according to the percentages of energy derived from carbohydrate, fat and protein, and glycated haemoglobin (HbA1c) in a sample of the general UK population.

Obesity is associated with elevated risks of developing major costly medical complications and impaired quality of life. The objective of this study was to create a core obesity model to compare weight management interventions, by assessing impacts on BMI and patho-physiological parameters to estimate long-term complications. We developed a life-time Markov model with health states reflective of complications which: 1) are highly related to obesity according to the World Health Organization; 2) respond to weight loss, 3) have substantial consequences on costs, quality of life and/or life expectancy. Selected complications were: type 2 diabetes (T2D), obstructive sleep apnoea, cardiovascular disease (acute coronary syndrome [ACS], stroke), cancers (colorectal, endometrial and breast) and osteoarthritis resulting in knee replacement. Actual short-term effects of specific interventions on BMI, blood pressure, lipids and HbA1c observed in clinical trials were translated into long-term risks of obesity complications, using published or newly developed risk-prediction equations. As an example, in a European cohort, mean age 45 years and BMI 37 kg/m2, over a 10-year horizon the model predicted 5.0% mortality, 5.8% ACS and 2.1% stroke. Knee replacement occurred in 6.3% of the cohort and the proportion alive with T2D was 5.0%. Following a reduction of 3 BMI units, all other factors remaining unchanged, mortality dropped to 4.8%, with ACS and stroke incidences decreasing to 5.5% and 2.0%. The incidence of knee replacement was reduced to 4.4% and the proportion alive with T2D was 3.8%. The presented Core Obesity Model is novel in assessing the long-term effects of weight management interventions on such a comprehensive set of obesity medical complications. This model can therefore be used to inform cost-effectiveness analyses on the treatment of adult patients with obesity, with the usual limitations as no prospective long-term data exist on hard outcomes after intentional weight changes.

Consumption of fish is associated with significant health benefits, particularly improvements of cardiovascular risk, but natural supply from the wild is limited. Salmon farming is a successful alternative. The aim of this chapter is to review the evidence from studies examining the health effects of salmon eating in adult subjects. A systematic review of the literature identified 11 studies. Evaluation of such evidence indicates that eating salmon is significantly and consistently associated with improvements on well-established vascular risk factors such as triglycerides and HDL-cholesterol but not total-cholesterol or LDL-cholesterol. The impact of eating salmon on novel markers of vascular risk is less well studied. Although some concerns have been expressed over the health risks of environmental contaminants found in some fish species, there is an overall agreement on the fact that the health benefits of eating fish exceed its potential risks, and farmed salmon appears to be a good option.

Barasi's Human Nutrition: A Health Perspective, Third Edition, provides a comprehensive introduction to the principles and practice of nutrition. Thoroughly revised, restructured, and updated, this new edition presents up-to-date scientific information in an accessible and reader-friendly format, emphasising how important nutrition is for evidence across the full translational health spectrum, from epidemiology and basic sciences through clinical and public heath applications, and ultimately into sustainable public policy. This third edition places more emphasis on applied nutrition than previous editions. Specifically, sections relating to clinical nutrition, public health nutrition, and improving foods for better health are now separate chapters with new chapters on sport nutrition, obesity, and weight management, and each section has a dedicated table of contents to better highlight the subject covered. The book also focuses on nutritional issues related to globally important, potentially preventable, major diseases, such as coronary heart disease, cancer, and diabetes, and discusses methods for studying nutrition and relevant essential dietary principles for intervention. This textbook is written from the perspective of experienced teachers at the undergraduate and graduate levels and is an invaluable resource for students in health and nutrition and for those pursuing further qualifications in food science. While containing substantial detail on some interesting topics, this book is written in an ‘easy-read’ style, which makes potentially complicated subjects accessible to general readers as well as to the more specialised user. It provides both an entry-level introduction to human nutrition for introductory or intermediate undergraduate students and also sufficient comprehensive detail to serve as a reference book for Masters or PhD students.

Citation for published version: Bhopal, RS, Douglas, A, Wallia, S, Forbes, JF, Lean, MEJ, Gill, JMR, McKnight, JA, Sattar, N, Sheikh, A, Wild, SH, Tuomilehto, J, Sharma, A, Bhopal, R, Smith, JBE, Butcher, I & Murray, GD 2014, 'Effect of a lifestyle intervention on weight change in south Asian individuals in the UK at high risk of type 2 diabetes: A family-cluster randomised controlled trial' The Lancet Diabetes and Endocrinology, vol 2, no. 3, pp. 218227., 10.1016/S2213-8587(13)70204-3

Clinical ObesityVolume 6, Issue 6 p. 361-364 Editorial Who wants weight loss? What do they need? Time to re-think non-surgical approaches in obesity management G. Thom, G. Thom Department of Human Nutrition, University of Glasgow, Glasgow, UKSearch for more papers by this authorM. Lean, M. Lean Department of Human Nutrition, University of Glasgow, Glasgow, UKSearch for more papers by this author G. Thom, G. Thom Department of Human Nutrition, University of Glasgow, Glasgow, UKSearch for more papers by this authorM. Lean, M. Lean Department of Human Nutrition, University of Glasgow, Glasgow, UKSearch for more papers by this author First published: 16 December 2016 https://doi.org/10.1111/cob.12172Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume6, Issue6December 2016Pages 361-364 RelatedInformation

Type 2 diabetes is extremely common in South Asians, e.g. in men from Pakistani and Indian populations it is about three times as likely as in the general population in England, despite similarities in body mass index. Lifestyle interventions reduce the incidence of diabetes. Trials in Europe and North America have not, however, reported on the impact on South Asian populations separately or provided the details of their cross-cultural adaptation processes. Prevention of diabetes and obesity in South Asians (PODOSA) is a randomized, controlled trial in Scotland of an adapted, lifestyle intervention aimed at reducing weight and increasing physical activity to reduce type 2 diabetes in Indians and Pakistanis. The trial was adapted from the Finnish Diabetes Prevention Study. We describe, reflect on and discuss the following key issues: The core adaptations to the trial design, particularly the delivery of the intervention in homes by dietitians rather than in clinics. The use of both a multilingual panel and professional translators to help translate and/or develop materials. The processes and challenges of phonetic translation. How intervention resources were adapted, modified, newly developed and translated into Urdu and Gurmukhi (written Punjabi). The insights gained in PODOSA (including time pressures on investigators, imperfections in the adaptation process, the power of verbal rather than written information, the utilization of English and the mother-tongue languages simultaneously by participants and the costs) might help the research community, given the challenge of health promotion in multi-ethnic, urban societies.

Summary Burden of disease studies typically classify individuals with a body mass index ( BMI ) ≥ 30 kg m −2 as a single group (‘obese’) and make comparisons to those with lower BMIs. Here, we review the literature on the additional economic burden associated with severe obesity or classes 3 and 4 obesity ( BMI ≥ 40 kg m −2 ), the fastest growing category of obesity, with the aim of exploring and disaggregating differences in resource use as BMI increases beyond 40 kg m −2 . We recognize the importance of comparing classes 3 and 4 obesity to less severe obesity (classes 1 and 2) as well as quantifying the single sub‐class impacts (classes 3 and 4). Although the latter analysis is the aim of this review, we include results, where found in the literature, for movement between the recognized subclasses and within classes 3 and 4 obesity. Articles presenting data on the economic burden associated with severe obesity were identified from a search of O vid MEDLINE , EMBASE , EBSCO CINAHL and C ochrane L ibrary databases. Data were extracted on the direct costs, productivity costs and resource use associated with severe obesity along with estimates of the multiplier effects associated with increasing BMI . Fifteen studies were identified, of which four disaggregated resource use for BMI ≥ 40 kg m −2 . The multiplier effects derived for a variety of different types of costs incurred by the severely obese compared with those of normal weight (18.5 kg m −2 < BMI < 25 kg m −2 ) ranged from 1.5 to 3.9 for direct costs, and from 1.7 to 8.0 for productivity costs. There are few published data on the economic burden of obesity disaggregated by BMI ≥ 40 kg m −2 . By grouping people homogenously above a threshold of BMI 40 kg m −2 , the multiplier effects for those at the highest end of the spectrum are likely to be underestimated. This will, in turn, impact on the estimates of cost‐effectiveness for interventions and policies aimed at the severely obese.

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