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The Sugar Buddies: an intervention

programme for obese patients with poorly

controlled diabetes

J. Hughes, V. Todorovic and H. KempDietetic and Nutrition Services, Bassetlaw Hospital, Worksop, Notts, UK

Background: Within the Bassetlaw Diabetes Clinic population a group of obese patients

with poorly controlled diabetes were identified, who appeared to be resistant to standard

intervention. An alternative approach, the Sugar Buddies programme, was developed,

focusing on gradual weight loss and improved glycaemic control. Development of self-care

behaviours such as healthy eating, following prescribed testing and medication routines

was encouraged. Programme participants attended either individual sessions or a

combination of individual sessions and group sessions provided jointly by a diabetes

specialist dietitian and diabetes specialist nurse.

Aims: To evaluate the effectiveness of the Sugar Buddies programme in achieving weight

loss and/or improved glycaemic contol in a group of obese patients with poorly

controlled diabetes.

Method: Measurements of weight and glycosylated haemoglobin (HbA1c)were made at 6,

12 and 18 months on 50 patients participating in the pilot programme. The programme

included patients with Type 1 and Type 2 diabetes. All patients had an initial body mass

index (BMI) 4 30 kg/m2 and HbA1c 4 7%.Outcome measures: The proportion of patients who were able to achieve gradual weight

loss (a minimum of 2.5 kg over 6 months) and sustain this minimum weight loss over 6, 12

and 18 months. The proportion of patients who were able to achieve a reduction in HbA1cof at least 1% against individual baseline measurements over 6 months, and sustain this

reduction over 6, 12 and 18 months.

Results: Patients who achieved an initial minimum weight loss of 2.5 kg at 6 months were

likely to sustain this weight loss at 12 and 18 months. Patients attending group sessions

were more likely to achieve weight loss. Some of the patients who did not achieve weight

loss at 6 months but continued in the programme achieved the minimum weight loss goal

at 12 and/or 18 months. Patients who achieved a reduction in HbA1c at 6 months were

likely to sustain these improvements at 12 and 18 months. Patients attending group

sessions were more likely to sustain improvements in HbA1c values. Length of

participation in sessions had no impact on HbA1c improvements. At 6 months, three

patients (6%) had achieved both a weight loss 5 2.5 kg and a reduction of at least1% in HbA1c.

Conclusions: The programmes focus on making lifestyle changes achieved a measure of

success in weight loss and/or improved glycaemic control among patients previously

resistant to intervention.

Key words: obese patients, diabetes, weight loss, glycaemic control.

Introduction and Background

While obesity, and in particular the increasing

prevalence of obesity, in the general population is

of concern (DH 1992; Knight 1994; Colhoun &Correspondence: Dr V. Todorovic.

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Prescott-Clarke 1996), there is a segment of the

population where obesity has a particularly

detrimental effect. Diabetes is the fourth leading

cause of death in the UK. Approximately 85% of

patients diagnosed with diabetes will be classi-

fied as having type 2 diabetes (Dowse et al. 1989).

Of these, 80% will be overweight or obese (BMI

4 25) and up to 50% will be dyslipidaemic ondiagnosis (De Grauw et al. 1995). Cardiovascular

disease is 24 times more prevalent than in the

general population and is the major cause of

death in Type 2 diabetes (De Grauw et al. 1995).

The Cardiovascular Disease Sub Group report

to the St Vincent Joint Task Force on Diabetes

concluded that weight loss is the most important

change necessary to improve or correct the risk

factors for Coronary Heart Disease in Diabetes

(DH/BDA 1995).

Other benefits of weight loss for obese patients

with type 1 or type 2 diabetes, range from

improvements in blood glucose control to pro-

longed survival (Lean et al. 1990; Ross et al. 1997).

Thus, weight loss becomes an important goal for

obese patients with diabetes. However, weight

loss and in particular sustained weight loss, is an

elusive goal for most patients with type 2

diabetes (Uusitupa et al. 1993).

The Diabetes Control and Complications Trial,

a large multicentre study in North America,

established that tight glycaemic control improved

health outcomes for patients with type 1 diabetes.

In the study report, it was recommended that

tight glycaemic control should be a goal for

patients with type 2 diabetes. The expectation is

that improved control will lead to improved

health outcomes (American Diabetes Association

1998). However, one of the risks of tight control is

weight gain (Wing et al. 1990).

Since 1994, The Bassetlaw Hospital Diabetes

Resource Centre has provided multidisciplinary

care and education to patients with diabetes

within a consultant-led clinic. Standard treat-

ment practice for obese patients with diabetes is

advice from the consultant to lose weight and a

referral for weight loss counselling to the

dietitian working in the clinic. Patients are seen

by the dietitian during the consultant clinic for

initial assessment and then are offered follow-up

care by the dietitian during a consultant clinic or

in their GP surgery, whichever is most appro-

priate for the patient.

Within the clinic population, there are a group

of patients who have been resistant to interven-

tion. These patients are obese, with a body mass

index (BMI) greater than 30 and have elevated

glycated haemoglobin (HbA1c 4 7.0). Thisdifficult group have been given guidance (includ-

ing dietetic counselling), on one or more occa-

sions, to reduce weight. Many have experienced

continued weight gain and/or a reduction in

blood glucose control over the past year with

standard practice. An efficient alternative ap-

proach was considered essential for this group.

Several studies have suggested that, in order to

achieve sustained weight loss and improvement

in metabolic control in diabetes, a continuous

care model with gradual lifestyle changes is likely

to be the most effective strategy (Goodrick &

Foreyt 1991; DCCT Research Group 1993).

In September 1995, The Sugar Buddies pro-

gramme was established to provide an alternative

treatment approach for a difficult cohort who had

not achieved satisfactory outcomes with the

standard treatment approach. The Sugar Buddies

programme encourages the development of self-

care behaviours, the tasks and activities that the

patient takes responsibility for to improve their

level of health care. The initial focus of the

programme, for the majority of patients, was to

stop weight gain and progress to weight loss.

Aim

This study was undertaken to evaluate the

effectiveness of The Sugar Buddies programme

in achieving weight loss and/or improved glycae-

mic control in a group of obese patients with

poorly controlled diabetes.

The Sugar Buddies Programme

The Sugar Buddies Programme is based on a

model of continuing care. It uses a team approach

with a relaxed environment, to assist in the

management and care of patients with diabetes

who have failed to achieve satisfactory outcomes.

The programme is based on current evidence of

effective chronic disease management and incor-

porates behaviour change strategies (DCCT

Research Group 1993; DEramo-Melkus et al.

1992). Weight loss theories that support the

concept of slow but sustained weight loss and

improved glycaemic control formed the basis for

programme development (Raz et al. 1988; Man-

ning et al. 1995; American Dietetic Association

1997; British Dietetic Association 1997).

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Group work was incorporated into the pro-

gramme, as an option, for both peer support and

to provide an efficient means of frequent on-going

contact for large numbers of patients (Wilson &

Pratt 1987; Jones et al. 1989; Campbell et al. 1990).

The main objectives of the programme are:

. to help patients achieve gradual weight lossthrough behaviour changes and to sustain or

improve weight loss over time (Goodrick &

Foreyt 1991; Harris et al. 1988; American

Dietetic Association 1997);

. to help patients achieve a reduction in HbA1cthrough behaviour changes, and sustain or

improve this reduction over time (American

Diabetes Association 1998; American Dietetic

Association 1997).

Programme structure

Process. The consultant diabetologist refers

patients to the programme. Patients typically

present with weight management concerns (BMI

4 30) and a high HbA1c (4 7.0%). Entry into theprogramme is open-ended. Initially, the diabetes

specialist dietitian and the diabetes specialist

nurse see each patient, on an individual basis, in

a combined clinic. A nursing and nutritional

history is completed at initial clinic attendance,

including information on blood glucose or urine

glucose self-monitoring, height, weight, medica-

tions, and usual food and activity patterns.

Patients are offered the option of individual

clinic appointments monthly (unless required

earlier for monitoring of medication therapy),

and/or weekly group education and support

sessions which patients may access as desired.

Patients are encouraged to attend group sessions

as they offer peer support, educational sessions

and increased contact frequency. However, pa-

tients are not required to attend group sessions.

The group sessions have an open continuing

format with topics developed on the basis of

patients need and request. The dietitian facil-

itates most group sessions with the nurse joining

in for the drop-in session. The programme is

flexible, enabling patients who initially may not

have attended group sessions to do so at any

point in their programme of care.

The length of time that patients continue to

come to group sessions is based on the patients

perception of their own needs and interest. The

length of attendance for the individual sessions is

generally a joint decision by the combined clinic

staff and patient.

Programme components

Individual sessions. The Sugar Buddies indivi-

dual sessions are based on work by Laurie

Ruggiero and her interpretation of Prochaska and

DiClementes Stages of Change Model for practical

application to help people with diabetes make

necessary changes (Prochaska & DiClemente 1986;

Ruggiero 1990). The stage of change is identified at

the initial session and barriers to progress and

temptations are discussed. Strategies such as role-

playing situational temptations may be employed

to identify coping strategies. Reducing temptation

and increasing the patients self-confidence in their

ability to make changes are the main focus of the

interventions thus; the program encourages pa-

tients to move through the stages of change.

Group sessions. The Sugar Buddies group

sessions are based on increasing knowledge,

developing skills, and improving attitudes to-

wards diabetes self-care. The sessions include a

mixture of interactive discussions, activities, and

lectures. Each session focuses on a single element

of diabetes self care and is either knowledge-

based or skill-based. During the group sessions,

patients are encouraged to interact, problem-

solve, and provide support and suggestions for

each other. The drop-in portion of the group

sessions provides an opportunity for individual

queries and a weight check.

Increasing knowledge. The educational compo-

nent of the programme focuses on increasing

knowledge of how diabetes affects the body, the

treatment and management of diabetes, the

principles of weight management, and healthy

eating for weight loss.

Developing skills. Group and individual activities

are planned in a manner designed to encourage

the development of skills. Activities such as a

supermarket tour help patients develop the skills

to select appropriate foodstuffs. Label-reading

exercises help patients choose foods with a lower

dietary fat content. Meal planning exercises

based on the patients usual meal habits help

identify areas for change and help patients plan

meals that meet their needs, their budgets, and

their tastes.

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Improving attitudes. Patients are encouraged to

develop confidence in their ability to make

dietary change by keeping records of food intake.

By assessing their own eating habits and accept-

ing recommended dietary changes to reduce

dietary energy intake, patients develop increased

confidence in their ability to manage their

self-care.

Through the process of monitoring blood

glucose or testing urine, patients are encouraged

to interpret tests and respond appropriately to

test results and follow prescribed medication

regimens. Patients begin to understand the

impact that activity and stress can have on

overall diabetes management.

Healthy eating for weight management. The

Healthy Eating for Weight Management compo-

nent of the programme is based on the Healthy

Eating Guidelines for Diabetes (British Diabetic

Association 1992). Throughout the programme, in

both individual and group sessions, patients are

encouraged to focus on lifestyle changes that may

lead to weight loss, rather than to focus on

weight loss.

Healthy eating stresses changing eating beha-

viours by reducing dietary fat intake and

increasing intake of fruit and vegetables. Studies

indicate that most patients with diabetes, con-

sume more than 40% of their energy from dietary

fat (Humphreys et al. 1994) rather than the 35%

recommended in current dietary guidelines (DH

1991). This high intake of fat may occur because

many patients with diabetes continue to focus on

reducing added sugar in the diet rather than

reducing and changing the type of dietary fat

(Pearson 1996). Recent work supports the concept

that reducing dietary fat may lead to sustained

weight loss (Carmichael et al. 1988).

Programme evaluation

In 1997, an evaluation of The Sugar Buddies

programme was undertaken to determine the

effectiveness of the overall programme and to

determine whether there were differences in

outcomes for patients attending both group and

individual sessions compared to those only

attending individual sessions.

The outcome measures used to determine

programme effectiveness were:

. the proportion of patients who achieved aminimum weight loss of at least 2.5 kg over

6 months and sustained this weight loss at

1 year and 18 months;

. the proportion of patients who reduced theirHbA1c by 1% against individual baseline

measurements over 6 months and sustained

this at 1 year and 18 months;

. the proportion of patients who achieved aminimum weight loss of at least 2.5 kg in 6

months and a reduction in HbA1c of at least

1% against individual baseline measurements

over 6 months and sustained this at 1 year and

18 months.

Methods

The patient population

The evaluation included all adult patients

(n=50) involved in The Sugar Buddies pro-

gramme from January 1996 to December 1997. All

patients had diabetes, a BMI greater than 30 and

glycosylated haemoglobin (HbA1c) greater than

7%. Characteristics of the patient group are

described in Table 1.

Table 1. Patient Characteristics at entry to the programme

Age, range in years 2249.9 5064.9 6575

Number (%) 14 (28%) 27 (54%) 9 (18%)

BMI Mean (range), kg/m2 36.6 (30.345.2) 35.5 (30.545.3) 35.0 (30.744.0)

HbA1c Mean (range),% 8.4 (7.39.8) 8.3 (7.011.1) 8.5 (7.110.8)

Sex M/F 8/6 14/13 3/6

Treatment:

Diet only 1 0 1

Oral hypoglycaemic agents (OHA) 2 10 1

OHA & insulin or insulin only 11 17 7

Type of Diabetes:

Type 1 4 2 0

Type 2 10 25 9

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Measures

Anthropometric. Patient heights and weights

were recorded at initial visit. BMI was calculated

from height and weight data. The clinic staff

nurse, using a Seca height meter attached to the

wall, measured height on all participants. Pa-

tients were weighed on Seca Alpha Model 770

scales on an uncarpeted floor. The scales are

under an annual maintenance contract.

Weights were also taken at 6, 12, and 18

months follow-ups.

Somatic. HbA1c assay measurements were

collected at the beginning of the programme.

Further HbA1c assay samples collections

were scheduled for patients at dates close to 6-,

12-and 18-month programme anniversaries.

HbA1c assay was measured using a Corning

Glycomat 765 Analyser with standardized

laboratory procedures.

In addition, telephone interviews were under-

taken to obtain qualitative data on experience of

group sessions and identify reported dietary

changes. These results are not presented in

this paper.

Data analysis

Analysis of quantitative data were completed

using SPSS for Windows (1993) Version 6.

Relative risk (RR) were calculated using Epi Info.

(Dean et al. 1994).

Results

The data were analysed according to the length of

time the patient had been involved in the

programme. Because the programme is open-

ended and continuing, separate results are

reported for 6 months, 12 months, and 18 months

of participation. At the point of evaluation, 22

patients had participated in the programme for

18 months, a further 16 had completed 12 months

and a further 12 patients had completed

6 months. This provides both a snapshot of

programme effectiveness after different lengths of

participation and also how well patients sus-

tained improvements over time.

Changes in weight and sustainability

The numbers and proportions of patients achiev-

ing a weight loss of 2.5 kg or more at 6, 12 and 18

months are shown in Table 2.

Analysis of the 38 patients who had been in the

programme for one year showed that of the nine

who had achieved weight loss at 6 months, seven

sustained weight loss at 12 months. A further

three who had not achieved weight loss at

6 months achieved a weight loss at 12 months.

Analysis of the 22 patients, who had been in

the programme for 18 months showed that of the

five patients who achieved a weight loss at

6 months, three had sustained weight loss at both

12 and 18 months. A further two achieved weight

loss by 18 months.

Changes in HbA1c and sustainability

Blood samples were routinely collected on or

within a few weeks of the patients initial visit.

However, failure to follow up collection of blood

samples at 6, 12 and 18 months from patient

visits that were cancelled, rescheduled or not

attended resulted in incomplete data collection. It

was not possible to obtain the HbA1c data on

eight out of 50 (16%) of patients at 6 months,

11 of 38 (29%) patients at 12 months and on

seven of 22 (32%) patients at 18 months.

The numbers and proportions of patients who

achieved a change in HbA1c of 1% or more at 6,

12 and 18 months is shown in Table 3.

Analysis of HbA1c assays of 27 patients, who

had been in the programme for 1 year showed

that, of the five who had achieved a reduction in

Table 2. Patients achieving weight loss 5 2.5 kg at 6, 12 and 18 months (WL)

Programme length n WL at 6 months n HbA1c n WL at 18 months

Count (%) Count (%) Count (%)

6 months 12 4 (33.3)

12 months 16 4 (25.0) 16 5 (31.3)

18 months 22 5 (22.7) 22 6 (27.3) 22 7 (31.8)

Total No. 50 13 (26.0) 38 11 (28.9) 22 7 (31.8)

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HbA1c at 6 months, three sustained a reduction

in HbA1c at 12 months. A further two who had

not achieved a reduction in HbA1c at 6 months

achieved a reduction in HbA1c at 12 months.

Analysis of HbA1c assays of the 15 patients,

who had been in the programme for 18 months

showed that of the three patients who achieved a

reduction in HbA1c at 6 months, three had

sustained a reduction in HbA1c at 18 months.

Data was only available for one of these patients

at 12 and 18 months.

Sustainability of both weight loss and HbA1c

Three patients achieved both a reduction in

HbA1c of 1% or more and a reduction in weight

of 2.5 kg or more at 6 months.

One patient achieved a sustained weight loss

and a sustained reduction in HbA1c at 1 year.

This same patient had sustained weight loss and

a reduction in HbA1c at 18 months.

Table 4 shows the numbers and proportions

who achieved either or both a reduction in HbA1cand weight of 2.5 kg or more according to

whether they attended group sessions or not.

Whilst only 19 (38%) of patients attended group

sessions, a higher proportion of these reduced

their HbA1c by 1% or more than those who did

not attend group sessions (32% and 19%,

respectively). Likewise a higher proportion of

those attending group sessions reduced their

weight by 2.5 kg or more than those not attending

group sessions (37% and 19%, respectively).

Discussion

As all patients had been referred to the pro-

gramme due to failure to achieve satisfactory

outcomes in standard treatment protocols, any

positive outcome in this group was viewed as

success. Patients did not come to the programme

because they had decided to lose weight, or

improve their blood glucose control but because

they were referred to the programme by the

consultant. In some instances patients were

pleased to be offered a new source of help, but

most initial appointments were viewed with

suspicion. Many patients felt that any effort to

control their blood sugar or manage their weight

would be futile. At the point of evaluation the

pilot programme has been running for 18 months.

Despite initial scepticism, only two patients were

no longer attending the sessions demonstrating

that a good level of commitment to the programme

had been achieved. However, it must be noted that

due to the nature of diabetes care, annual clinic

visits are scheduled for patients so there is some

pressure to attend if only to assure the consultant

an effort was made to comply with advice!

Half of the patients involved in the programme

experienced either weight loss greater than 2.5 kg

in 6 months or a reduction in HbA1c of one

percentage against baseline measurements. For a

group that had not achieved success previously,

this seemed a slow but impressive start, particu-

larly since 72% of the group were over the age of

50 years and had very reduced or impaired

physical activity on initial interviews.

Table 4. Changes in weight, HbA1c at 6 months by attendance at group sessions

Criteria Attended group sessions Did not attend group

RR

n Count (%) n Count (%)

HbA1c drop 5 1% 19 6 (32) 31 6 (19) 1.63Weight loss 5 2.5 kg 19 7 (37) 31 6 (19) 1.9Both HbA1c drop 5 1%and Weight loss 5 2.5 kg 19 2 (11) 31 1 (3) 3.26

Table 3. Patients achieving a reduction in HbA1c by 1% or more at 6, 12 and 18 months (c Hb).

Programme length Na/n* cHb at 6 months n cHb n cHb at 18 months

Count (%) Count (%) Count (%)

6 months 11/12 3 (27)

12 months 15/16 5 (33) 13/16 5 (38)

18 months 16/22 4 (25) 14/22 2 (14) 15/22 5 (33)

Total Nos. 42/50 12 (28) 27/38 7 (26) 15/22 5 (33)

*Na=number of HbA1c assays available, n=number of patients in programme

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As one would expect with a patient group,

whose blood glucose values were significantly

higher than recommended, the first effect of

dietary intake reduction was to reduce blood

glucose rather than reduce weight. Only three

patients were able to fulfil both criteria of weight

loss and improvement in HbA1c. It often seemed to

both patients and staff alike that patients, whose

diabetes control was poor, required an almost

impossibly high level of co-ordination to achieve

both goals. Many patients had experienced fre-

quent episodes of hypoglycaemia as well as

hyperglycaemia prior to entry into the programme.

There was considerable reluctance on the part of

the patient to run any risk of hypoglycaemia and

there was often a lack of awareness of warning

signs prior to the onset of hypoglycaemia.

The small sample size made it unlikely that

statistically significant results would be found

even with large effects. The impact of the group

sessions, although not significant statistically,

was noticeable. Patients attending groups were

1.9 times more likely to experience weight loss

than those who did not attend group sessions.

Also, although not significant statistically,

those who attended group sessions were 1.6

times more likely to achieve an improvement in

HbA1c values.

The proportion of patients who achieved the

modest weight loss goal was small. However,

those who achieved weight loss were likely to

sustain their weight loss up to 12 and 18 months.

It is also of note than success in weight loss for

some patients was achieved with greater length

of contact, achieving goals in 12 months rather

than 6 months.

Patient commitment to the programme is

evident, as after 18 months only two patients

are no longer participating in the programme.

Continued patient participation is hopefully a

step towards responsibility for self-care and thus

the behaviour changes required for continued

and sustained weight loss.

Conclusions

Study results indicate that for a sector of this

population, group sessions are an acceptable

method of maintaining contact and, thus perhaps,

promoting adherence and assisting in sustaining

weight loss. Study numbers are too small at this

time to provide any conclusive answers. The

programme will need to be re-evaluated when

patient numbers are greater.

Pre-programme tests of self-care behaviours, as

well as dietary records should be incorporated

into the programme. HbA1c assays should be

scheduled at regular intervals. The present

practice left gaps in available data.

The programmes focus on making lifestyle

changes achieved a measure of success in weight

loss and/or improved glycaemic control despite

working with patients resistant to intervention.

Although it is a slow method of achieving weight

loss, there appears to be good potential for not

only sustained weight loss but also further

weight loss for this patient group. As diabetes

is a lifelong condition, a programme that sup-

ports and encourages appropriate self-care beha-

viours in a continuous model appears to offer

potential for long-term weight management and

thus improved health outcomes for patients

with diabetes.

Acknowledgements

The Department of the Health for the grant which

made it possible to carry out an evaluation of

The Sugar Buddies programme. Mark Myatt,

consultant epidemiologist for his invaluable help

and advice. The Sugar Buddy team Gill French,

diabetes specialist nurse and Dr Roger Blandford,

consultant for his tremendous support of the

programme; Diane, who always tracked down the

records, Judy for assistance with the typing, and

all the staff of the Diabetes Centre.

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