And we always give him the same answera€¦ Measure how many calories you eat, verses how many calories burned (expending more calories than you consume) then you can control your weight. This works out the Basal Metabolic Rate (BMR) - the number of calories your body needs to live if you laid in bed all day. Running Tips HQ: Whichever way you choose to track your calories it will involve weighing foods, so get a decent pair of digital kitchen scales. Healthy Food Choicesa€?Running to lose weight is not only about how much you eat but also what you eat.a€?Junk foods, sweets and cakes tend to be high calorie and low nutrient foods. Eating healthy food alternatives means more fuel for your running performance and, because your body is receiving a higher level of nutrients, you will become stronger and therefore less likely to get injuredA Win-win..! As we said at the beginning running burns plenty of calories (more than any other exercise), but you still need to account for these calories when working out your daily numbers. Running Tips HQ: As a beginner runner maybe start your weight loss strategy with our Couch to 5K.
Strength Training For RunnersThese strength training exercises can be done at home and without any equipment. Obesity is of major pathogenetic importance to type 2 diabetes, it contributes to poor glycemic control and increases the risk of cardiovascular disease.
After obtaining a‰?5% of weight loss with a VLCD, participants will be randomly assigned to CPI or usual care for 10 weeks.
When successful, we want to conduct an analysis of the cost effectiveness of the intervention as compared to usual care. We expect that a CPI after a VLCD will be effective in maintaining weight loss and improving cardiovascular risk and glycaemic control, while being cost-effective and improving quality of life in patients with type 2 diabetes. BackgroundDiabetes has become a worldwide epidemic: the estimated global prevalence was 2,8% in 2000 and is expected to rise up to 4,4% in 2030. Patients with psychiatric disorders or major psychological disturbances are excluded from the trial. BlindingGiven the nature of the intervention, it is impossible to blind the participants, CPI-therapist and researcher (KACB). In sessions 1a€“5 dysfunctional cognitions about eating, weight and shape are identified and challenged. Systolic and diastolic blood pressure (mmHg) are measured twice in upright position, while the patient had rested for at least 5 minutes with an Omron M4-I Intelli-sense device. Anxiety and depression are measured by the Hospital Anxiety and Depression Scale (HADS)[50, 51]. Somatic symptoms are measured by the VOEG-13 (a€?Vragenlijst Onderzoek Ervaren Gezondheida€™) [52], a Dutch 13-item questionnaire used to measure the health of a population, often used in social science research.
Fatigue is measured by the Checklist Individual Strength (CIS) [53], which quantifies subjective fatigue and related behavioral aspects. Eating disorders are measured by the Eating Disorder Examination-Questionnaire (EDE-Q) [56], a 36 item questionnaire that measures concerns about shape, weight and eating, restraint and binge eating. We developed a lifestyle questionnaire on diet history, smoking, drinking habits, drug use and hours sleep. Physical activity is measured using the SQUASH (Short Questionnaire to Assess Health Enhancing Physical Activity) [58]. Statistical analysesAll analyses will be conducted according to the intention-to-treat as well as the on-treatment principle. DiscussionTo our knowledge, this trial is the first randomized controlled trial to test the effects of an integrated multi-model cognitive group therapy in the battle against weight regain after a successful weight loss intervention (VLCD) in patients with type 2 diabetes.
Sounds simple, but frequently overlooked by us runners ;-)The good news is that running burns a shed load of calories and can play a major part in your weight loss plan. If using a calorie counter this is done automatically as you enter your daily exercise - if not, add the calories burned while running on to your daily allowance and include calories burned during other exercise, such as cycling and walkingFor example, if your daily allowance is 1500 and you burn 600 through running, you will be able to eat a total of 2100 calories for that day. Start today!Running to lose weight and calorie control are long term lifestyle choices with very worthwhile results a€“ So do it! We also look at the importance of strength training for runners and what benefits they have a€“ its all here! Psychosocial parameters are also studied, as secondary outcomes as well as determinants for weight loss.
In the year 2000 the excess global mortality attributable to diabetes was 5,2% making diabetes the fifth leading cause of death [1].
This arbitrary cut-off value was chosen because of its relatively large effect on the risk profile [3].
During week 10 of the diet, the intervention group starts with a total of 17 sessions of CPI. The follow-up will continue until 2015.Study populationPatients are recruited from the outpatient diabetes clinic of the Erasmus Medical Centre in Rotterdam by the medical team, based on the in- and exclusion criteria shown in Tablea€‰1.
Patients with eating disorders (bulimia nervosa and binge eating disorder) or depression are not excluded, since it is expected that these conditions are common among patients with type 2 diabetes and previous research has shown that cognitive behaviour therapy can have beneficial effects in these patient groups [28, 41a€“43]. Nevertheless, we will try to keep the intervention as separate as possible from the diabetes treatment, by giving participants strict instructions not to communicate about the intervention with their medical team. The items consist of somatic symptoms like headache, nervousness and lethargy and respondents indicate whether they have these symptoms or not. The CIS consists of 20 statements for which the respondent has to indicate on a 7-point scale to what extent the particular statement applies to him or her (1 = Yes, that is true; to 7 = No, that is not true). How the participants value the sessions is measured by the Session Rating Scale (SRS) [57]. The SQUASH collects days per week, average time per day, and effort for physical activities such as commuting activities, leisure time and sport activities, household activities, and activities at work or school. The TiC-P measures direct medical costs due to healthcare utilization during the past four weeks.
We consider participants on-treatment when they miss less then 8 sessions CPI.At baseline, comparability between the control- and intervention group will be assessed to test the success of the randomization. Weight regain is common in the obese population in general, but even more pronounced in the diabetes type 2 population, and with more devastating effects on their health outcomes. It may vary by a couple of pounds up or down but overall stays stable Now, of course, I have to think about maintaining this for the years ahead (the hard bit) Ia€™ll keep you posted! The increase in prevalence is associated with aging of the population, the increasing prevalence of obesity in combination with physical inactivity. Moreover, we need a relevant weight loss to investigate weight maintenance after weight reduction. In our hospital, a tertiary referral centre, we see both patients with only oral antidiabetic agents and patients treated with one or more insulin doses daily.
We will analyze the effect of these background variables on the outcome of the intervention.RandomizationGroups of 20 patients will start with a VLCD concomitantly.
Patients are given the possibility to discuss problems related to the study with an independent medical doctor.


Cognitive diaries are introduced and participants are encouraged to use these diaries at home to record personal critical situations and dysfunctional thoughts. Waist circumference (cm) is measured at the level midway between the lowest rib margin and the aliac crest. The statements refer to four fatigue aspects: (1) subjective fatigue (2) reduced motivation (3) reduced activity and (4) reduced concentration.
The SRS is an ultra brief alliance measure designed specifically for every session clinical use.
Total minutes of activity are calculated for each question by multiplying frequency (days per week) by duration (minutes per day). Also, it registers the indirect non-medical costs due to productivity loss during the past two weeks. As measures of central tendency for numerical data we will use the mean (in case of normal distribution) and median values (in case of non-normal distribution), with respectively the standard deviation and interquartile range as measures of dispersion.Mixed modelling, also known as random effect modelling, multilevel or hierarchical linear regression analyses will be applied for longitudinal analyses of the data. The strength of this study is the combined psychological intervention (CPI) of cognitive restructuring, problem solving treatment and proactive coping, which will provide powerful tools to the participants for maintaining behavioral change and improving health outcomes. However, current treatment programs for obese DM type 2 patients are not effective in the long term. After randomization, stratified to the achieved weight loss at 8 weeks, participants are assigned to one of the following conditions:1.
At 8 weeks (randomization after VLCD), only the primary outcome (weight) will be measured.Figure 1 shows the design of the study.
In general, our patients will have more complex disease and more comorbidity compared to the average diabetic patient referred to a GP. After 8 weeks of VLCD, the patients who lost a‰?5% of bodyweight are randomly assigned to either or the intervention group (usual care + CPI) or the control group (usual care) with an allocation ratio of 1:1. The CPI group sessions will take place in another part of the hospital, outside the diabetes clinic, to ensure that patients and medical team will not run into each other. Because binge eating cannot be measured reliably by the EDE-Q, we use a questionnaire composed by Werrij, et al.
The SRS consists of four 10-cm visual analogue scales (relationship scale, goals and topic scale, approach or method scale, overall evaluation scale), with instructions to place a hash mark on a line (continuum) with negative responses depicted on the left and positive responses indicated on the right.
Activity scores for separate questions are calculated by multiplying total minutes of activity by an intensity score (range 1a€“9). The scores on the three dimensions can be combined into one co called a€?utilitya€™ score, which represents the societal value of quality of life.
Since we expect that the treatment will be less effective when more then 8 sessions are missed, this non-compliant participants will be considered drop-outs.We have conducted a pilot study to improve our research protocol.
Also bear in mind these are average numbers and you may need to tweak them to get the correct rate of weight loss (especially at the start)Calorie Counters?Keeping a food diary helps to keep track of calorie intake.
In this RCT, we compare the effectiveness of a Combined Psychological Intervention (CPI) and usual care in maintaining the favourable effects on weight and risk profile during 2 years of follow-up after a Very Low Calorie Diet (VLCD).
An intensive pharmaceutical and behavioral therapy treatment has been estimated to reduce the risk of cardiovascular and micro vascular events by approximately 50% [2].Approximately 80% of the people with type 2 diabetes are overweight. The stratified randomization is computer controlled, carried out by a secretary and supervised by a statistician, who are both not involved in the trial. Furthermore, the validity of the dysfunctional thoughts is tested and alternative thoughts are generated.
Both waist- and hip circumference are measured by the nearest 0,5 cm, using a tape-measure. People with a score above this cut-off point are at an increased risk of long-term sickness absence. Based on a total possible score of 40, any score lower than 36 overall, or 9 on any scale, could be a source of concern and therefore prudent to invite the client to comment. The total activity score is calculated by taking the sum of the activity scores for the separate questions. It corrects for bias when absence of data is dependent on characteristics that are present in the models (missing at random, MAR) [62]. You can do this writing down the number of calories from packets and workig out the totals at the end of each day.
Losing weight is the cornerstone of prevention and treatment of type 2 diabetes: it decreases the resistance to insulin, improves glycaemic control and reduces hypertension and lipid abnormalities [3a€“5]. Patients interested in participating in the study will receive an information letter and a questionnaire to be filled in at home. The reason for a stratified randomization is to avoid an unsuccessful randomization with regard to weight loss during the VLCD.
When after 8 weeks of VLCD a loss of 5% or more of the initial bodyweight is reached, random allocation to the intervention- and control group will take place. Guided by examples of the group, the group is acting as a research team, investigating the validity of dysfunctional cognitions and creating alternative and more realistic thoughts. This societal value of quality of life is used as input for so called Quality Adjusted Life Years (QALY) analysis, as the societal perspective is the preferred perspective in health economics. In this pilot study, we found that the protocol was feasible and that no major changes had to be done.
Weight loss interventions thus may contribute to a reduction of cardiovascular risk and is shown to reduce mortality in patients with type 2 diabetes and obesity [6].Unfortunately, interventions aimed at weight reduction have only a limited effect in the long run because of regain of the initial weight loss.
Two weeks later they will visit the outpatient clinic for an intake interview with the researcher (KACB). It is not possible to correct afterwards in the analysis, as it is the primary outcome measurement.
Patients losing less then 5% of bodyweight in the first 8 weeks are excluded from the study and will receive usual care, including dietary advice.The use of a VLCD is an integrated part of the dietary treatment at our outpatient diabetes clinic. The EuroQol instrument contains also the EQ-VAS, a vertical visual analogue scale with the anchors best imaginable health (score of 100) and worst imaginable health (score of 0). The only change we made was in the lay-out of the questionnaires, making them better understandable to our participants. Normally, the patients are free to choose between the different types of weight reduction strategies.
Methods used for testing the validity of a persona€™s thoughts are the Socratic dialogue and behavioral experiments. First, for each outcome variable a saturated model will be postulated, with the primary or secondary outcomes as dependent variables.
You just type in the foods you eat, exercise for that day and everything else is done for you. A meta-analysis of weight loss interventions in adults with type 2 diabetes showed that multi-component interventions including Very Low Calorie Diets may hold promise for achieving weight loss [7, 8]. In the present study however, only one type of weight reduction therapy is used (VLCD).The product we use for this study is Glucerna SRA®, a product specifically developed for patients with diabetes and based on a combination of slow released carbohydrates, a low-fat, high monounsaturated fatty acid content and the addition of dietary fibre.


Behavioral experiments are set up during the session, carried out at home, and discussed in the next session.The underlying schemas (a€?core beliefsa€™) are explored during sessions 6a€“10.
The saturated models will include treatment group, time, quadratic time, logarithm of time and all treatment-time interactions as fixed effects.
You wona€™t have to worry about recalculating your BMR because, as you lose weight, it will adjust your allowance.
Various studies indicate that this product decreases the postprandial blood glucose levels, which may have a lowering effect on HbA1c. The validity of self schemas is tested in the same way as the other dysfunctional thoughts and recorded in the diary.Subsequently, 7 relapse prevention meetings are held to stabilize behaviour change, with increasing intervals until the end of the study (2 years).
The deviance statistic [63] using restricted maximum likelihood [64] will be applied to determine the covariance structure. This diabetes-specific diet product is also used as a meal replacement for achieving weight reduction in people with type 2 diabetes, with positive effects on weight control, glycaemic control and lipid profile [46a€“48]. Next, using Wald tests, the saturated models will be reduced by eliminating insignificant fixed effects. We have chosen to use a twice a day regimen of meal replacements, together with a small dinner, providing 750 kcal, 67 g carbohydrates, 54 g protein and 32 g fat (of which 16 g monounsaturated fatty acids (MUFA)) a day and RDA recommendations in micronutrients. In addition, techniques of Problem Solving Therapy are used to help participants coping with everyday problems they encounter while implementing their lifestyle changes. The significance of the difference between the saturated models and the parsimonious final models will be determined with the deviance statistics using ordinary likelihood. We believe that enabling the participants to have dinner with their family during the VLCD will improve compliance.We have developed a protocol for the use of a VLCD in patients with type 2 diabetes, where we describe the different aspects of the treatment. Based on individually set goals, experienced problems are identified and possible solutions will be put forward in a group brainstorm session. Oral anti-diabetic agents (except Metformin) and short-acting insulin analogues are discontinued, while the dosage of long-acting insulin analogues and biphasic mixtures is halved, to avoid severe hypoglycaemia. The participant will choose the most appropriate solution and creates and carries out an implementation plan. In this plan, the participant formulates the solution as a SMART (Specific, Measurable, Attainable, Realistic, Timely) goal and considers which steps should be taken to achieve this goal. During the VLCD and gradual transition to a normal diet, medication is adjusted by means of glucose self-control and frequent contact with diabetes nurses and dieticians.
Subsequently, the participants will be encouraged to identify barriers that may arise while trying to achieve their goals. Under guidance of the psychologist, activities will be defined which can be undertaken to prevent the occurrence or diminish the effect of these potentially threats (Proactive Coping).In following relapse prevention sessions, the implementation plan is evaluated and new (sub) problems are chosen to tackle. The authors indicated that the success was based on the strong motivation of the patients to prevent a need for insulin and a slow reintroduction of normal diet. Usual care consists of a 3-monthly visit to the physician and diabetes nurse, including medical examinations. For this purpose, a variety of psychological interventions have been implemented in weight reduction programmes.
Patients are free to make additional appointments with their dietician in- or outside the hospital and they can choose to follow whatever diet they would like during the follow-up period. Behaviour therapy and cognitive behaviour therapy (CBT) are potential psychological interventions facilitating better maintenance of weight loss [20]. Both the number of visits to a dietician and the dieting methods, products and duration of the diet are noted during the follow-up period of 2 years.
CBT is used to describe a wide range of techniques to change thinking patterns and behaviours. Dieticians in our hospital are all trained in motivational interviewing to motivate the patients in changing their lifestyle.
All members of the diabetic team encourage the patients to get enough exercise, but we do not refer to an exercise programme.
In the current study, we propose to combine them into an integrated weight maintenance programme.Cognitive behaviour therapyWithin cognitive psychology, humans are regarded as information processing systems, where knowledge is organized in so-called schemas.
Patients in need of psychological help (ie psychological disorder, clinical depression, major eating disorder) are referred to a clinical psychologist in- or outside the hospital. Cognitive schemas are activated by incoming information, leading to cognitions (thoughts), emotions and subsequently to behaviour. According to the founding father of the cognitive therapy, Aaron Beck, emotional disorders such as depression and anxiety disorders result from dysfunctional schemas.
Nonetheless, the number of visits to a psychologist as well as to other caregivers will be noted during this trial.
Cognitive therapy focuses on changing dysfunctional schemas and cognitions, using behavioral experiments and challenges [21].
In eating disorders, the cognitive model was first used to treat bulimia nervosa by adjusting overvaluation of weight and shape based on low self-esteem [22, 23].
Two psychologists (HB and AVTS) are involved in this study, so we can investigate the a€?therapist-effecta€™.The first 10 weekly sessions consist of cognitive behaviour therapy, partly based on the method developed by Werrij and colleagues from the University of Maastricht [27]. Moreover, it was found that a longer duration of the intervention and more frequent clinical contact was associated with an increased effect.
The problem-solving model for obesity treatment was first described by Perri, Nezu and Viegener in 1992 [34] and proposes that active problem solving efforts by a health care provider can help the obese person encounter everyday problems in their weight management.
Moreover, a recent study showed that people with better problem-solving skills lost more weight and were more compliant to therapy [36].Proactive copingProactive coping (PC), directed at an upcoming instead of an ongoing stressor, is a new focus in positive psychology research. PC consists of efforts undertaken in advance of a potentially stressful event to prevent it or modify its form before it occurs. The theory described by Aspinwall and Taylor consists of five stages: PC starts with the a€?accumulation of resourcesa€™ such as time, money, planning or organizational skills and social support, so that one is prepared as much as possible to deal with future threats. The next stage consists of a€?initial coping effortsa€™: activities undertaken to prevent or minimize a recognized or suspected stressor. Finally, the a€?use of feedbacka€™ involves the evaluation of the stressful event itself and the effects of onea€™s preliminary efforts [37].Schwarzer and Taubert described PC as a way of aspiring a positive future by accumulating resources and realistic goal setting [38]. A recent publication has shown that the pursuit of goals was related to improved wellbeing, while preventing a negative future was not [39].A study of the effects of PC on the self-care behaviours of newly diagnosed DM patients revealed that the treatment was highly appreciated and even after 9 months improvements in eating and exercising habits were seen. In addition, the intervention was effective in reducing both weight and blood pressure after 9 months, but had no effect on HbA1c or lipid profile [40].In the current randomized study, we compare the effect of a Combined Psychological Intervention (CPI) with usual care on weight maintenance after a Very Low Calorie Diet.



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