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Getting patients to maintain weight loss remains one of the biggestobstacles in primary care. But researchers hope that new findings linkingweight loss to reduced incidents of urinary incontinence (UI)—inaddition to diabetes prevention—could serve as a powerful motivatingtool.
OBESITY AND DIABETES ARE UI RISK FACTORS
While the exact mechanism behind weight loss as an effective treatmentstrategy for UI remains unknown, researchers do know that obesity is anindependent risk factor for UI, says Kristene E. Whitmore, MD, professor ofurology and obstetrics/gynecology at Drexel University in Philadelphia."If there is weight loss, stress incontinence will improve,"Whitmore says.
Adding diabetes to the mix makes obese patients even more susceptible toUI. "Type 2 diabetes is a strong independent risk factor for urinaryincontinence in community-dwelling older women," concludes a studyreported in 2005 in the Journal of the American GeriatricsSociety.1
After adjusting for other factors, the investigators found women with type2 diabetes were almost twice as likely as women without diabetes to sufferfrom severe incontinence. Moreover, the risk of severe incontinence increasedup to threefold for subjects who had been diagnosed with type 2 diabetes forat least 5 years.
EVIDENCE LINKING WEIGHT LOSS TO UI RELIEF
Findings from two recent follow-up studies of the Diabetes PreventionProgram (DPP) offer particularly exciting information: first, weight lossimproves bladder control in women withpre-diabetes,2 andsecond, moderate exercise does not worsenUI.3
Launched in 1995, the DPP showed in landmark findings published in 2002that both intensive lifestyle intervention and metformin therapy lowered theincidence of diabetes, by 58% and 31%, respectively, in 3,234 women withimpaired glucosetolerance.4Intensive lifestyle intervention was defined as at least 150 minutes ofmoderate exercise, such as 30 minutes of brisk walking five times per week,and a minimum weight loss of 7% of body weight.
A study of women who participated in the DPP, published in the February2006 issue of Diabetes Care, found that patients who lost 7% of bodyweight through dietary change and increased physical activity had fewerepisodes of weekly incontinence compared with those in the metformin orplacebo groups.2Researchers note that weight loss was effective in reducing episodes of stressincontinence, but did not alleviate urge incontinence.
"A 200-lb woman who loses 10 to 15 lbs not only lowers the risk ofdeveloping type 2 diabetes but also improves bladder control," says leadauthor Jeanette S. Brown, MD, director of the Women's Health Clinical ResearchCenter at University of California, San Francisco. "If you're a woman atrisk for type 2 diabetes, preventing or delaying diabetes and improvingbladder control are powerful reasons to make these lifestylechanges."
Another DPP follow-up study, presented at the 2004 American UrologicalAssociation Annual Meeting in San Francisco, found intensive lifestyleintervention also protects subjects from developingUI.3 Subjects whohad maintained intensive lifestyle intervention of 150 minutes of moderateexercise a week and a 7% loss of body weight experienced a 31.3% prevalence ofstress urinary incontinence, compared with 39.4% among subjects on metformin.Prevalence of urinary urge incontinence was 23.9% among the lifestyleintervention subjects, compared with 28.5% among metformin subjects. Nobaseline UI data was recorded for comparison purposes.
That moderate exercise did not worsen incontinence came as a bonus finding."It's a really important piece of information," Brown says."One of the things we don't want to do is to say, `Stay home in bed, belethargic.' We have to think bigger and broader."
A third study providing mounting evidence of weight loss's role in reducingincontinence examined 48 overweight and obese female subjects (median baselineage of 52 years, weight 213.4 lb) over 3months.5 Atbaseline, all subjects experienced at least four urine leaks weekly. Theexperimental group was placed on a liquid-diet weight-reduction program. Bystudy's end, this group lost an average of 35.2 lb and experienced a 60%reduction in weekly UI episodes—both stress and urge incontinenceepisodes decreased. Participants maintained the improvements for 6 months.
Even subjects who lost only 5–10% of baseline weight reduced UIfrequency by 50%. "That's a very reasonable and attainable goal,"says primary investigator Leslee L. Subak, MD.
Subak notes that after the study, all subjects in the weight-reductiongroup completed extensive bladder testing that demonstrated positive changesin all urodynamic variables. "We don't know what's causing theeffect," Subak admits. "We don't know if you need to lose acertain amount of weight, or get your BMI down a certain amount."
SUFFERING IN SILENCE
Before weight loss as a treatment for UI can lead to clinical inroads, moreeducation and openness are needed during the medical visit.
In a 1995 survey designed to evaluate physicians' perceptions of UI,investigators sent a questionnaire to 1,500 family physicians and generalpractitioners.6 Thedoctors were asked if they routinely inquired about the prevalence ofincontinence among female patients age 25–64 years. Of the 270physicians who responded, 30% admitted that they did not routinely make thisinquiry. What's more, 85% of respondents underestimated the prevalence ofincontinence among this patientpopulation.
Just as many doctors don't ask, many patients don't tell. In a 2002 surveyof 1,039 women 
18 years of age conducted by Harris Interactive for theNational Association for Continence, only half of those who experienced UIsymptoms ever mentioned them to their doctor. Twenty-two percent ofrespondents said they stayed quiet because their doctor did not ask them, 17%were not aware that something could be done, and 34% assumed incontinence wasan inevitable part of the aging process.
"Urinary incontinence is a costly, socially isolating condition thatimpairs quality of life and takes a psychological toll on many women,"says Leroy Nyberg, MD, PhD, of the National Institute of Diabetes andDigestive and Kidney Disorders. Primary care physicians really need to askabout incontinence, Whitmore says, noting that the condition costs up to $26billion a year.
"A lot of this [recognition of the role of weight loss in UI] startedby patients saying, `I want to be dry for my wedding,'" Subak says."We had anecdotal evidence that weight loss might help. Now we know thatweight loss is the biggest single modifiable risk factor forincontinence." 
The Lowdown on UI
More than 13 million people in the U.S.—mostly middle-aged and olderwomen—have issues with loss of bladder control. In the National Healthand Nutrition Examination Survey 2001–2002 sample, one out of threewomen with diabetes or pre-diabetic glucose levels reported weekly or morefrequent episodes of urinary incontinence (UI).
Several types of incontinence plague women with diabetes:
Footnotes
The National Institute of Diabetes and Digestive and Kidney Diseases(NIDDK) funds research to improve the treatment and prevention of diabetes andurologic disorders, including
• The Urinary Incontinence Treatment Network,www.uitn.net.
• The Specialized Center of Research on Lower Urinary TractDysfunction in women, a multidisciplinary translational research center at theUniversity of California, San Francisco,www.ucsf.edu/scor.
• "Let's Talk About Bladder Control," a campaign to informwomen about treatments for incontinence,www.niddk.nih.govor 1-800-891-5388.
An additional resource for information on preventing and treating urinaryincontinence is the National Association for Continence,www.nafc.orgor 1-800-BLADDER (252-3337).
References
2. Brown JS, Wing R, Barrett-Conner E, et al.: Lifestyle interventionis associated with lower prevalence of urinary incontinence: The DiabetesPrevention Program. Diabetes Care 29: 385–390, 2006.
3. Brown JS, Barrett-Connor E, Nyberg LM, et al.: Incontinence inwomen with impaired glucose tolerance: Results of the Diabetes PreventionProgram (Abstract). J Urol 171:325–326, 2004.
4. Knowler WC, Barrett-Conner E, Fowler SE, et al.: Reduction in theincidence of type 2 diabetes with lifestyle intervention or metformin.N Engl J Med 346:393–403, 2002.
5. Subak LL, Whitcomb E, Shen H, et al.: Weight loss: A novel andeffective treatment for urinary incontinence. J Urol 174: 190–195, 2005.[Medline]
6. Flood CG, Drutz HP. Physicians' perception of urinary incontinenceas a health care problem in women. Int Urogynecol J 6: 89–94, 1995.
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