Weight Loss to Treat Urinary Incontinence in Overweight and Obese Women New England Journal of Medic

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Weight Loss to Treat Urinary Incontinence in
Overweight and Obese WomenNew England Journal of
Medicine January 29, 2009

• CarolDeane Benedict, MD

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Background

• Observational studies suggest obesity is a strong
  risk factor for urinary incontinence.
• Previous study found weight loss of more than 5
  had reduction of a t least 50 in frequency of
  incontinence (P0.03)
• Reductions in urinary incontinence have been
  observed in morbidly obese women who have
  dramatic weight loss after bariatric surgery

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Background

• Profound adverse effects on quality of life
• Increased risk of falls, fractures and nursing
  home admissions
• More than 20 billion in estimated annual direct
  health care costs.

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Who???

• 338 Women recruited from Providence, Rhode Island
  and Birmingham, Alabama
• Women at least 30yo
• BMI 25 to 30
• Reported 10 or more urinary-incontinence episodes
  in a 7-day diary of voiding
• Could monitor food intake and physical activity
  for 1 week.
• Be able to walk unassisted for two blocks without
  stopping
• Agree not to initiate new treatment for
  incontinence or weight reduction for duration of
  study.

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Study Design

• Participants completed questionnaires concerning
  their demographic characteristics, medical and
  behavioral history, and history of incontinence.

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Exclusion

• Use of medical therapy for incontinence.
• Weight loss within the previous month.
• Current urinary tract infection or four or more
  UTIs in previous year.
• History of incontinence of neurologic or
  functional origin.
• Previous surgery for incontinence or urethral
  surgery.
• Major medical or genitourinary tract conditions
• Pregnancy or parturition in the previous 6 months
• Type 1 or type 2 Diabetes mellitus, requiring
  medical therapy that increased the risk of
  hypoglycemia
• Uncontrolled hypertension

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Study Design

• Participants randomly assigned at a 21 ratio to
  the treatment and control group.
• Treatment Group An intensive 6 month behavior
  weight-loss program
• Control Group A structured four session
  education program

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Results
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Study Design

• Participants were weighed to the nearest 0.5kg on
  a calibrated digital scale while wearing street
  clothes and without shoes
• Height was measured at baseline.

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Study Design

• For secondary outcome results 24 hour
  involuntary urine lost at baseline and 6 months
  were determined by a pad test standardized by the
  international Continence Society.
• Preweighed urinary-incontinence pads were used
  for 24hrs and returned , amount of urine lost was
  measured by weighing the pads.

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Study Design

• Participants were trained to complete a 7-day
  diary of voiding.
• Interviewers reviewed the diaries with the
  participants to answer questions and reconcile
  inconsistencies.

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The Diary

• Recorded time of each void and each incontinence
  episode.
• Each episode identified as stress incontinence
  (involuntary loss of urine with coughing,
  sneezing, straining, or exercise), urge
  incontinence (loss of urine associated with a
  strong need or urge to void)

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Classification

• Stress-only incontinence
• Stress-predominant (two thirds of the total
  number of episodes were urge episodes)
• Urge-only incontinence
• Urge-predominant incontinence
• Mixed Incontinence (two types reported, but no
  type constituted tow thirds of the total number
  of episodes)

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Study Design

• All participants were given a self-help
  behavioral-treatment booklet with instructions
  for improving bladder control.
• Basic information about incontinence
• How to locate pelvic-floor muscles and perform
  daily exercises with them.
• How to use pelvic-floor muscles to avoid stress
  incontinence
• How to control urinary urgency
• Instructions on completing voiding diaries

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Control Group

• Four education sessions at month 1, 2, 3, and 4
• 1 hour group sessions
• 10-15 women in each session
• General information was presented about weight
  loss, physical activity, and healthful eating
  habits, according to a structured protocol.

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Weight Loss Group

• Designed to produce an average loss of 7 to 9 of
  initial body weight within the first 6 months of
  the program.
• Met weekly for 6 months in groups of 10-15 for 1
  hour sessions led by experts in nutrition,
  exercise, and behavioral change and were based on
  a structured protocol.
• Given a standard reduced-calorie diet (1200 to
  1500kcal per day), goal of no more than 30 of
  calories from fat.
• Encouraged to gradually increase physical
  activity until active for at least 200minutes
  each week.
• Behavioral skills emphasized self-monitoring,
  stimulus control, and problem-solving

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Outcomes

• Primary Outcome Percentage change in number of
  incontinence episodes reported in the 7 day
  voiding diary at 6 months after randomization.

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Outcomes

• Secondary Outcome
• Percentage change in number of episodes of urge
  and stress incontinence,
• Proportion of women in whom the frequency of
  incontinence decreased by at least 50, 70, or
  100
• Change in a validated measure of participant
  satisfaction with incontinence treatment.
• Decrease in weight of 24hr urinary-incontinence
  pads.

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6 Month Follow Up Assessment

• 318 women (94) provided weight data (97.8 of
  weight-loss group and 86.6 of control group,
  plt0.001)
• 304 women (89.9) completed 7-day voiding diary
  (94.7 of those in weight-loss group and 80.4 of
  those in the control group, Plt0.001)

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Results6 Months Weight Loss

• Weight loss group mean loss of 8 of body weight
  from baseline, mean loss of 7.8 Kg (95
  confidence interval).
• Control group mean loss 1.6, mean loss 1.5 Kg
  (95 CI)

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Results6 months Urinary Incontinence

• Weight Loss Group mean decrease in total
  incontinence episodes per week of 47.4 (95 CI)
• Control Group 28.1 (95 CI)

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Discussion

• A greater number of women in weight loss group
  reported a clinically meaningful reduction of at
  least 70 in total weekly number of episodes of
  any incontinence, stress incontinence, and urge
  incontinence.
• Both stress incontinence and urge incontinence
  were reduced more in weight loss group than in
  the control group, but the difference between the
  groups was only significant fro stress
  incontinence.

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Discussion

• Both stress incontinence and urge incontinence
  were reduced more in weight loss group than in
  the control group, but the difference between the
  groups was only significant fro stress
  incontinence.
• Hypothesized that obesity may contribute to UI
  because of increase in intraabdominal pressure
  due to the central adiposity, which in turn
  increases bladder pressure and urethral mobility.
• Results could also be result of change in dietary
  intake and physical activity

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Discussion

• Control group had 28 decrease in incontinence
  episodes.
• Some decrease in urinary incontinence may due to
  heighted awareness of bladder habits among
  participants due to completing voiding diaries
  and questionnaires and exposure to the booklet
  describing behavioral approaches to the control
  of incontinence.

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Discussion

• Lack of parallel difference between treatment
  groups in 24hr pad weight.
• Consistent with other trials reporting lack of
  correlation between changes in pad weight and
  diary-recorded frequency of incontinence, subject
  measure of severity, and incontinence-specific
  quality of life.
• This may be due to that these techniques measure
  different domains of incontinence.

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Strengths

• Randomized
• Weight loss intervention design on two previous
  studies Diabetes Prevention Program and Look
  Ahead Trial.
• Looked at both subjective and objective aspects
  of urinary incontinence.
• Subdivided out types on urinary incontinence and
  looked at individually
• Not many people loss to follow up.
• Took into account women who had dropped out into
  statistical analysis. Assumed no change from
  baseline on average among dropouts

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Weaknesses

• Finding may not be able to be generalized as well
  due to that participants in this study were
  selected for their potential to adhere to the
  behavioral weight loss intervention and patients
  with certain medical conditions were excluded.
• Mostly white women
• Participants were not blinded to treatment
  assignment. Possible effect on reporting of
  symptoms.
• Results due to reporting in diary, relying on
  patient adherence.

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Conclusions

• 6 month behavior intervention targeting weight
  loss reduced the frequency of self-reported
  urinary-incontinence episodes among overweight
  and obese women compared with a control group

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Refrences

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