Effect of a Behavioral Intervention Strategy on Sustained Change in Physical Activity and Sedentary Behavior in Patients With Type 2 Diabetes: The IDES_2 Randomized Clinical Trial

Therapeutic education as a tool to improve patient-reported and clinical outcomes after renal transplantation: results of the EPHEGREN multicenter retrospective cohort study

Patients are not always aware of the inconveniences associated with renal transplantation, which they compare with a « rebirth », and from which they expect complete recovery. Therapeutic education is proposed to prepare patients for their life after transplantation. This study evaluated the impact of pretransplant therapeutic education on patient-reported outcomes and rejection-free survival over the first year. We collected data from 383 renal transplant patients followed-up in seven centers. Patients who benefited from therapeutic education before transplantation (N = 182) were compared with patients who did not (N = 139) for quality-of-life, adherence and adverse events using the Pearson's chi-square test, one-way ANOVA or t-test. The association between therapeutic education and time to acute rejection was investigated using Cox models. The patients who benefited from therapeutic education reported adverse events less frequently (e.g., tremor: 9% vs. 32.4%, P = 0.01) and better quality-of-life (MCS-QOL: 50.7 ± 8.1 vs. 47.7 ± 9.5, P = 0.02; PCS-QOL: 49.1 ± 7.1 vs. 46.0 ± 9.2, P = 0.013). No difference was found on adherence. Rejection-free survival was slightly better in the therapeutic education group (HR = 0.44, 95% CI = [0.19-1.01]). This multicenter retrospective cohort study suggests that integrating therapeutic education to care pathways entails clinical benefit, in terms of quality-of-life, self-reported adverse events and rejection-free survival. Randomized clinical trials are necessary to confirm this.

Effects of a three-armed randomised controlled trial using self-monitoring of daily steps with and without counselling in prediabetes and type 2 diabetes-the Sophia Step Study

BACKGROUND

This aimed to evaluate the effects of self-monitoring of daily steps with or without counselling support on HbA1c, other cardiometabolic risk factors and objectively measured physical activity (PA) during a 2-year intervention in a population with prediabetes or type 2 diabetes.

METHODS

The Sophia Step Study was a three-armed parallel randomised controlled trial. Participants with prediabetes or type 2 diabetes were recruited in a primary care setting. Allocation (1:1:1) was made to a multi-component intervention (self-monitoring of steps with counselling support), a single-component intervention (self-monitoring of steps without counselling support) or standard care. Data were collected for primary outcome HbA1c at baseline and month 6, 12, 18 and 24. Physical activity was assessed as an intermediate outcome by accelerometer (ActiGraph GT1M) for 1 week at baseline and the 6-, 12-, 18- and 24-month follow-up visits. The intervention effects were evaluated by a robust linear mixed model.

RESULTS

In total, 188 subjects (64, 59, 65 in each group) were included. The mean (SD) age was 64 (7.7) years, BMI was 30.0 (4.4) kg/m2 and HbA1c was 50 (11) mmol/mol, 21% had prediabetes and 40% were female. The dropout rate was 11% at 24 months. Effect size (CI) for the primary outcome (HbA1c) ranged from -1.3 (-4.8 to 2.2) to 1.1 (-2.4 to 4.6) mmol/mol for the multi-component vs control group and from 0.3 (-3.3 to 3.9) to 3.1 (-0.5 to 6.7) mmol/mol for the single-component vs control group. Effect size (CI) for moderate-to-vigorous physical activity ranged from 8.0 (0.4 to 15.7) to 11.1 (3.3 to 19.0) min/day for the multi-component vs control group and from 7.6 (-0.4 to 15.6) to 9.4 (1.4 to 17.4) min/day for the single-component group vs control group.

CONCLUSION

This 2-year intervention, including self-monitoring of steps with or without counselling, prevented a decrease in PA but did not provide evidence for improved metabolic control and cardiometabolic risk factors in a population with prediabetes or type 2 diabetes.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02374788 . Registered 2 March 2015-Retrospectively registered.

Heritability Estimation and Environmental Risk Assessment for Type 2 Diabetes Mellitus in a Rural Region in Henan, China: Family-Based and Case-Control Studies

Objective: The prevalence of type 2 diabetes mellitus (T2DM) varies greatly in different regions and populations. This study aims to assess the heritability and environmental risk factors of T2DM among rural Chinese adults.

Methods: Thousand five hundred thirty three participants from 499 extended families, which included 24 nuclear families, were recruited in the family-based study to assess the heritable risk of T2DM. Heritability of T2DM was estimated by the Falconer method. Using conditional logistic regression model, couple case-control study involving 127 couples were applied to assess the environmental risk factors of T2DM.

Results: Compared with the Henan Rural Cohort, T2DM was significantly clustered in the nuclear families (OR: 8.389, 95% CI: 5.537–12.711, P < 0.001) and heritability was 0.74. No association between the heredity of T2DM and sex was observed between the extended families and the Henan Rural Cohort. Besides, results from the couple case-control study showed that physical activity (OR: 0.482, 95% CI: 0.261–0.893, P = 0.020) and fat intake (OR: 3.036, 95% CI: 1.070–8.610, P = 0.037) was associated with T2DM, and the proportion of offspring engaged in medium and high physical activity was higher than that of mothers in mother-offspring pairs.

Conclusion: People with a family history of T2DM may have a higher risk of developing T2DM, however, there was no difference in genetic risk between males and females. Adherence to active physical activity and low fat intake can reduce the risk of T2DM.

Sedentary behaviour is an independent predictor of diabetic foot ulcer development: An 8-year prospective study

AIMS

To prospectively explore the association between sedentary time (SED-time) and the development of diabetic foot ulcer (DFU) in people with diabetic peripheral neuropathy (DPN).

METHODS

175 DPN individuals who attended the annual evaluation for the SAMBA Study (2012-2019) were included. Main outcome measure was the first diagnosis of DFU. SED-time was measured by the PAS 2.1 questionnaire. Nerve function was evaluated by nerve conduction studies. Vascular function was assessed by Ankle-brachial index (ABI) and pedal pulses. Foot deformity and skin dryness were examined by visual inspection.

RESULTS

62 participants (35.5%) developed a DFU during the study. SED-time was significantly higher in people who developed DFUs (12.8 ± 3.0 vs 9.4 ± 3.1 h/day). Logistic regression showed that among several nervous (motor amplitude, OR 0.33, 95% CI, 0.18-0.60; sensory amplitude, 0.85, 0.77-0.94) and vascular parameters (ABI, 0.23, 0.1-0.61; pedal pulses, 2.81, 0.12-0.63) and foot characteristics (deformity, 2.63, 1.30-5.32; skin dryness, 2.04, 0.95-4.37), SED-time was one of the strongest variables contributing to the development of DFUs (2.95, 1.45-6.44).

CONCLUSIONS

SED-time is an independent predictor of the risk of DFU in people with DPN. The monitoring of SED-time with strategies aimed at reducing it should be included in the standard care of diabetic patients.

Exercise as a drug for glucose management and prevention in type 2 diabetes mellitus

Physical inactivity and sedentary behavior are risk factors for type 2 diabetes mellitus (T2DM). Therefore, physical exercise (PE) together with medical treatment might be considered as a key strategy to counteract T2DM. Glycemic control is a central objective in the prevention and management of T2DM, and PE might be able to substantially affect the processes that determine it. Just like a drug, exercise can be dosed based on the characteristics of the individual to increase its benefits and reduce side effects. In this brief review, the mechanisms underlying the effects of PE on glucose metabolism in muscle are illustrated, and the effects of modulation of the parameters characterizing this atypical "drug" on glucose homeostasis are described.

Promoting physical activity in a multi-ethnic population at high risk of diabetes: the 48-month PROPELS randomised controlled trial

BACKGROUND

Physical activity is associated with a reduced risk of type 2 diabetes and cardiovascular disease but limited evidence exists for the sustained promotion of increased physical activity within diabetes prevention trials. The aim of the study was to investigate the long-term effectiveness of the Walking Away programme, an established group-based behavioural physical activity intervention with pedometer use, when delivered alone or with a supporting mHealth intervention.

METHODS

Those at risk of diabetes (nondiabetic hyperglycaemia) were recruited from primary care, 2013-2015, and randomised to (1) Control (information leaflet); (2) Walking Away (WA), a structured group education session followed by annual group-based support; or (3) Walking Away Plus (WAP), comprising WA annual group-based support and an mHealth intervention delivering tailored text messages supported by telephone calls. Follow-up was conducted at 12 and 48 months. The primary outcome was accelerometer measured ambulatory activity (steps/day). Change in primary outcome was analysed using analysis of covariance with adjustment for baseline, randomisation and stratification variables.

RESULTS

One thousand three hundred sixty-six individuals were randomised (median age = 61 years, ambulatory activity = 6638 steps/day, women = 49%, ethnic minorities = 28%). Accelerometer data were available for 1017 (74%) individuals at 12 months and 993 (73%) at 48 months. At 12 months, WAP increased their ambulatory activity by 547 (97.5% CI 211, 882) steps/day compared to control and were 1.61 (97.5% CI 1.05, 2.45) times more likely to achieve 150 min/week of moderate-to-vigorous physical activity. Differences were not maintained at 48 months. WA was no different to control at 12 or 48 months. Secondary anthropometric and health outcomes were largely unaltered in both intervention groups apart from small reductions in body weight in WA (~ 1 kg) at 12- and 48-month follow-up.

CONCLUSIONS

Combining a pragmatic group-based intervention with text messaging and telephone support resulted in modest changes to physical activity at 12 months, but changes were not maintained at 48 months.

TRIAL REGISTRATION

ISRCTN 83465245 (registered on 14 June 2012).

Evaluation of a Post-Operative Rehabilitation Program in Patients Undergoing Laparoscopic Colorectal Cancer Surgery: A Pilot Study

This pilot study explores the effects of a post-operative physical exercise program on the quality of life (QoL) and functional and nutritional parameters of patients that underwent laparoscopic colorectal cancer surgery, compared to usual care alone. The intervention group (IG) attended a 2-month-long supervised and combined exercise–training program during the post-operative period. Both IG and control group (CG) participated in the QoL, functional, and nutritional assessments before exercise training (T0), 2 months after the beginning of the exercise (end of treatment) (T1), and 2 (T2) and 4 (T3) months from the end of treatment. Eleven patients with colorectal cancer that underwent laparoscopic surgery were enrolled (six intervention; five control). The IG showed significant improvements compared to the CG in “Physical functioning” (PF2) (p = 0.030), “Cognitive functioning” (CF) (p = 0.018), and “Fatigue” (FA) (p = 0.017) of the European Organization for Research and Treatment of Cancer Quality of Life-C30 Questionnaire (EORTC QLQ-C30) at T1; in SMWT (p = 0.022) at T1; in PF2 (p = 0.018) and FA (p = 0.045) of EORTC QLQ-C30 at T2, in phase angle (PhA) of bioelectrical impedance analysis (p = 0.022) at T3. This pilot study shows that a post-operative, combined, and supervised physical exercise program may have positive effects in improving the QoL, functional capacity, and nutritional status in patients that undergo laparoscopic colorectal cancer surgery.

Multicomponent intervention provided by GPs to reduce cardiovascular risk factors: evaluation in an Italian large sample

BACKGROUND

The cardiovascular risk increases in a multiplicative way when patients present more risk factors simultaneously. Moreover, the General Practitioners (GPs) play a crucial role in risk factors prevention and reduction. This work aimed to evaluate a multicomponent intervention in the Primary Care Department in an Italian Local Health Unit.

METHODS

A pre-post study was conducted in Northern Italy (2018). Patients were eligible if: aged between 30 and 60 years, not chronic patients, not affected by hypertension or hypercholesterolaemia. The GPs assessed body mass index, hypertension, abdominal obesity, low-density lipoprotein (LDL) values, glycaemic values, smoking and exercise habit (T0). A counselling by GPs to at-risk patients and a multicomponent health education intervention were performed. Reassessment occurred after at least 3 months (T1). Main analyses were chi-squared tests for gender differences, McNemar or marginal homogeneity tests for changes in paired data (P < 0.05 as significant).

RESULTS

Participants were 5828 at T0 (54.0% females) and 4953 at T1 (53.4% females). At T0, 99.1% presented at least one risk factor. Significant changes in paired data were reported for each risk factor. The greatest improvement frequencies occurred in glycaemia values (51.0%) and hypertension (45.6%), the lowest in abdominal obesity (3.7%). Some differences were recorded between genders, e.g. females reported higher improvement frequencies in hypertension (P = 0.001) and abdominal obesity (P < 0.001), whereas males in physical activity (P = 0.011) and LDL values (P = 0.032).

CONCLUSION

The results showed significant changes for each risk factor, both for men and women. GPs and multicomponent educational interventions could play a key role in reducing cardiovascular risk factors.

Maintaining changes in physical activity among type 2 diabetics - A systematic review of rehabilitation interventions

The prevalence of type 2 diabetes mellitus (T2DM) is increasing worldwide, and physical activity (PA) is a suitable way of preventing and managing the disease. However, improving long-term levels of PA in people with T2DM is a challenge and the best approach to rehabilitation in this regard is unknown. With the aim of outlining the existing knowledge regarding the maintenance of active lifestyles among people with T2DM after rehabilitation programs and gaining knowledge about options and challenges for their long-term engagement in PA, a systematic review of original research articles assessing PA after rehabilitation programs was conducted. Two thousand two hundred and forty-one articles were identified through PubMed or secondary sources and subjected to various inclusion criteria. Only articles published between the 1st of January 2000 and the 30th of June 2020 were considered. Additionally, the minimum time frame from intervention start to last PA assessment was 6 months and only articles based on interventions performed in Europe were included. The review was based on eighteen randomized controlled trials, four randomized trials without control, and four case studies. The 26 articles described 30 interventions that were categorized as personalized counseling, generalized teaching, supervised exercise, or a combination of personalized and generalized interventions. Statistical and narrative syntheses revealed no clear pattern regarding the effectiveness in eliciting maintained changes in PA. However, across categories, individual involvement, goal setting, social support, and the formation of habits are argued to be important components in sustaining PA and relieving challenges associated with the transition out of rehabilitation programs.

Nonleisure-Time Physical Activity Guidance Following Minor Ischemic Stroke: A Randomized Clinical Trial

The purpose of this single-masked randomized clinical trial was to examine whether nonleisure-time physical activity guidance (NLTPAG) improves physical activity levels in patients after minor ischemic stroke. Patients who had been hospitalized for minor ischemic stroke in an acute care hospital (National Health Institute Stroke Scale ≤ 5) were randomized to either an NLTPAG group (n = 17) or a leisure-time physical activity guidance group (n = 16). NLTPAG focused on reducing sedentary behavior and increasing the frequency of walking for shopping and household activities to improve physical activity levels in daily life. Physical activity levels significantly improved only in participants in the NLTPAG group (initial assessment: metabolic equivalents of task = 12.6; final assessment: metabolic equivalents of task = 14.8; p = .035, r = .51). These results suggest that NLTPAG may be effective for improving physical activity levels in patients after minor ischemic stroke.

Walking for subjects with type 2 diabetes: a systematic review and joint AMD/SID/SISMES evidence-based practical guideline

Aims

Regular exercise is considered a cornerstone in the management of type 2 diabetes mellitus (T2DM). It improves glucose control and cardiovascular risk factors, contributes to weight loss, and also improves general well-being, likely playing a role in the prevention of chronic complications of diabetes. However, compliance to exercise recommendations is generally inadequate in subjects with T2DM. Walking is the most ancestral form of physical activity in humans, easily applicable in daily life. It may represent, in many patients, a first simple step towards lifestyle changes. Nevertheless, while most diabetic patients do not engage in any weekly walking, exercise guidelines do not generally detail how to improve its use. The aims of this document are to conduct a systematic review of available literature on walking as a therapeutic tool for people with T2DM, and to provide practical, evidence-based clinical recommendations regarding its utilization in these subjects.

Data synthesis

Analysis of available RCTs proved that regular walking training, especially when supervised, improves glucose control in subjects with T2DM, with favorable effects also on cardiorespiratory fitness, body weight, and blood pressure. Moreover, some recent studies have shown that even short bouts of walking, used for breaking prolonged sitting, can ameliorate glucose profiles in diabetic patients with sedentary behavior.

Conclusions

There is sufficient evidence to recognize that walking is a useful therapeutic tool for people with T2DM. This document discusses theoretical and practical issues for improving its use.

The Effect of High-Intensity Power Training on Habitual, Intervention and Total Physical Activity Levels in Older Adults with Type 2 Diabetes: Secondary Outcomes of the GREAT2DO Randomized Controlled Trial

BACKGROUND

We examined the effect of power training on habitual, intervention and total physical activity (PA) levels in older adults with type 2 diabetes and their relationship to metabolic control.

MATERIALS AND METHODS

103 adults with type 2 diabetes were randomized to receive supervised power training or sham exercise three times/week for 12 months. Habitual, intervention, and total PA, as well as insulin resistance (HOMA2-IR) and glycosylated hemoglobin (HbA1c), were measured.

RESULTS

Participants were aged 67.9 ± 5.5 yrs, with well-controlled diabetes (HbA1c = 7.1%) and higher than average habitual PA levels compared to healthy peers. Habitual PA did not change significantly over 12 months (p = 0.74), and there was no effect of group assignment on change over time in habitual PA over 0-6 (p = 0.16) or 0-6-12 months (p = 0.51). By contrast, intervention PA, leg press tonnage and total PA increased over both 6- and 12-month timepoints (p = 0.0001), and these changes were significantly greater in the power training compared to the sham exercise group across timepoints (p = 0.0001). However, there were no associations between changes in any PA measures over time and changes in metabolic profile.

CONCLUSION

Structured high-intensity power training may be an effective strategy to enhance overall PA in this high-risk cohort.

Effects of sedentary behaviour interventions on biomarkers of cardiometabolic risk in adults: systematic review with meta-analyses

CONTEXT/PURPOSE

Observational and acute laboratory intervention research has shown that excessive sedentary time is associated adversely with cardiometabolic biomarkers. This systematic review with meta-analyses synthesises results from free living interventions targeting reductions in sedentary behaviour alone or combined with increases in physical activity.

METHODS

Six electronic databases were searched up to August 2019 for sedentary behaviour interventions in adults lasting for ≥7 days publishing cardiometabolic biomarker outcomes covering body anthropometry, blood pressure, glucose and lipid metabolism, and inflammation (54 studies). The pooled effectiveness of intervention net of control on 15 biomarker outcomes was evaluated using random effects meta-analyses in the studies with control groups not providing other relevant interventions (33 studies; 6-25 interventions analysed).

RESULTS

Interventions between 2 weeks and <6 months in non-clinical populations from North America, Europe and Australia comprised much of the evidence base. Pooled effects revealed small, significant (p<0.05) beneficial effects on weight (≈ -0.6 kg), waist circumference (≈ -0.7 cm), percentage body fat (≈ -0.3 %), systolic blood pressure (≈ -1.1 mm Hg), insulin (≈ -1.4 pM) and high-density lipoprotein cholesterol (≈ 0.04 mM). Pooled effects on the other biomarkers (p>0.05) were also small, and beneficial in direction except for fat-free mass (≈ 0.0 kg). Heterogeneity ranged widely (I2=0.0-72.9).

CONCLUSIONS

Our review of interventions targeting sedentary behaviour reductions alone, or combined with increases in physical activity, found evidence of effectiveness for improving some cardiometabolic risk biomarkers to a small degree. There was insufficient evidence to evaluate inflammation or vascular function. Key limitations to the underlying evidence base include a paucity of high-quality studies, interventions lasting for ≥12 months, sensitive biomarkers and clinical study populations (eg, type 2 diabetes).

PROSPERO TRIAL REGISTRATION NUMBER

CRD42016041742.

Patterns of Sitting, Standing, and Stepping After Lower Limb Amputation

OBJECTIVE

The objectives of this study were to describe sitting, standing, and stepping patterns for people with lower limb amputation (LLA) and to compare sitting, standing, and stepping between people with dysvascular LLA and people with traumatic LLA.

METHODS

Participants with dysvascular or traumatic LLA were included if their most recent LLA was at least 1 year earlier, they were ambulating independently with a prosthesis, and they were between 45 and 88 years old. Sitting, standing, and stepping were measured using accelerometry. Daily sitting, standing, and stepping times were expressed as percentages of waking time. Time spent in bouts of specified durations of sitting (<30, 30-60, 60-90, and >90 minutes), standing (0-1, 1-5, and >5 minutes), and stepping (0-1, 1-5, and >5 minutes) was also calculated.

RESULTS

Participants (N = 32; mean age = 62.6 [SD = 7.8] years; 84% men; 53% with dysvascular LLA) spent most of the day sitting (median = 77% [quartile 1 {Q1}-quartile 3 {Q3} = 67%-84%]), followed by standing (median = 16% [Q1-Q3 = 12%-27%]) and stepping (median = 6% [Q1-Q3 = 4%-9%]). One-quarter (median = 25% [Q1-Q3 = 16%-38%]) of sitting was accumulated in bouts of >90 minutes, and most standing and stepping was accrued in bouts of <1 minute (standing: median = 42% [Q1-Q3 = 34%-54%]; stepping: median = 98% [Q1-Q3 = 95%-99%]). Between-etiology differences included proportion of time sitting (traumatic: median = 70% [Q1-Q3 = 59%-78%]; dysvascular: median = 79% [Q1-Q3 = 73%-86%]) and standing (traumatic: median = 23% [Q1-Q3 = 16%-32%]; dysvascular: median = 15% [Q1-Q3 = 11%-20%]).

CONCLUSION

Participants had high daily volumes of long durations of sitting. Further, these individuals accumulated most physical activity in bouts of <1 minute.

IMPACT

High levels of sedentary behavior and physical inactivity patterns may place people with LLA at greater mortality risk relative to the general population. Interventions to minimize sedentary behaviors and increase physical activity are potential strategies for improving poor outcomes of physical therapy after LLA.

Exercise training (ET) in adult and elderly patients receiving anti-lymphoma treatments is feasible and may improve the provision of care

Lymphoma treatments can produce adverse effects leading to a reduced quality-of-life (QoL). Besides, in patients ≥65years, it can promote an accelerated geriatric decay. We conducted a prospective study on supervised Exercise-Training (ET), in consecutive, patients aged 18-80years, during anti-lymphoma treatments.16/30 (53%), median-age = 65.5y, participated to the ET sessions, this was the Interventional Group (IG); 14/30 (47%), median-age = 63y, were the Reference Group (RG). Both groups participated to the fitness and the QoL assessments, at baseline (T0), 3-months (T1) and 6-months (T2) after the start of chemotherapy. The adherence to the ET program was 50% (95% CI:36-64%). The IG showed substantial improvements compared to the CG in cardiorespiratory fitness (Cooper test) at both T1 and T2 and in all the functional domain of the QoL questionnaire (QLQ-C30) at T2. This study showed ET, during chemotherapy, is feasible and safe, even in patients ≥65 years. Furthermore, it may improve the provision of care.

Walking for subjects with type 2 diabetes: A systematic review and joint AMD/SID/SISMES evidence-based practical guideline

AIMS

Regular exercise is considered a cornerstone in the management of type 2 diabetes mellitus (T2DM). It improves glucose control and cardiovascular risk factors, contributes to weight loss, and also improves general well-being, likely playing a role in the prevention of chronic complications of diabetes. However, compliance to exercise recommendations is generally inadequate in subjects with T2DM. Walking is the most ancestral form of physical activity in humans, easily applicable in daily life. It may represent, in many patients, a first simple step towards lifestyle changes. Nevertheless, while most diabetic patients do not engage in any weekly walking, exercise guidelines do not generally detail how to improve its use. The aims of this document are to conduct a systematic review of available literature on walking as a therapeutic tool for people with T2DM, and to provide practical, evidence-based clinical recommendations regarding its utilization in these subjects.

DATA SYNTHESIS

Analysis of available RCTs proved that regular walking training, especially when supervised, improves glucose control in subjects with T2DM, with favorable effects also on cardiorespiratory fitness, body weight and blood pressure. Moreover, some recent studies have shown that even short bouts of walking, used for breaking prolonged sitting, can ameliorate glucose profiles in diabetic patients with sedentary behavior.

CONCLUSIONS

There is sufficient evidence to recognize that walking is a useful therapeutic tool for people with T2DM. This document discusses theoretical and practical issues for improving its use. This article is co-published in the journals Sport Sciences for Health and Nutrition, Metabolism and Cardiovascular Diseases.

A Critical Review of Exercise Training in Hemodialysis Patients: Personalized Activity Prescriptions Are Needed

Exercise training appears to have modest or inconsistent benefits in hemodialysis patients. This may be due to the low volume and intensity of exercise often prescribed. To address this, research is needed to evaluate the efficacy of individualized exercise prescriptions as a component of a comprehensive lifestyle intervention strategy that gives patients more autonomy to choose preferred types of physical activity.

Beneficial Effects of Physical Activity in Diabetic Patients

One of the main goals of diabetic therapy is to achieve the best metabolic control to prevent the development and progression of potential complications. A multidisciplinary approach characterized by the combination of diet, physical activity (PA) and drug therapy with oral and injectable (non-insulin) pharmacological agents, is desirable to optimize metabolic control. The aim of this review is to explain the contribution of PA and its beneficial effects on patients affected by type 1 (T1D) and type 2 diabetes (T2D). We provide an overview of evidence on the effects of PA for the main two types of diabetes mellitus (DM) to identify the right level of PA to be recommended. We discuss the physiological and clinical role of PA in people with DM. It can be concluded that the objective of antidiabetic therapy should be the achievement and optimization of metabolic control through a multidisciplinary approach involving non-pharmacological therapy such as diet and PA, which has a crucial role.

A data-driven examination of which patients follow trial protocol

Protocol adherence in behavioral intervention clinical trials is critical to trial success. There is increasing interest in understanding which patients are more likely to adhere to trial protocols. The objective of this study was to demonstrate the use of a data-driven approach to explore patient characteristics associated with the lowest and highest rates of adherence in three trials assessing interventions targeting behaviors related to lifestyle and risk for cardiovascular disease. Each trial included a common set of baseline variables. Model-based recursive partitioning (MoB) was applied in each trial to identify participant characteristics of subgroups characterized by these baseline variables with differences in protocol adherence. Bootstrap resampling was conducted to provide optimism-corrected c-statistics of the final solutions. In the three trials, rates of protocol adherence varied from 56.9% to 87.5%. Evaluation of heterogeneity of protocol adherence via MoB in each trial resulted in trees with 2–4 subgroups based on splits of 1–3 variables. In two of the three trials, the first split was based on pain in the past week, and those reporting lower pain were less likely to be adherent. In one of these trials, the second and third splits were based on education and employment, where those with lower education levels and who were employed were less likely to be adherent. In the third trial, the two splits were based on smoking status and then marriage status, where smokers who were married were least likely to be adherent. Optimism-corrected c-statistics ranged from 0.54 to 0.63. Model-based recursive partitioning can be a useful approach to explore heterogeneity in protocol adherence in behavioral intervention trials. An important next step would be to assess whether patterns hold in other similar studies and samples. Identifying subgroups who are less likely to be adherent to an intervention can help inform modifications to the intervention to help tailor the intervention to these subgroups and increase future uptake and impact.

Trial registration

ClinicalTrials.gov identifiers: NCT01828567, NCT02360293, and NCT01838226.

Effects of a Supervised Nordic Walking Program on Obese Adults with and without Type 2 Diabetes: The C.U.R.I.A.Mo. Centre Experience

Exercise is a convenient non-medical intervention, commonly recommended in metabolic syndrome and type 2 diabetes (DM2) managements. Aerobic exercise and aerobic circuit training have been shown to be able to reduce the risk of developing DM2-related complications. Growing literature proves the usefulness of Nordic walking as exercise therapy in different disease populations, therefore it has a conceivable use in DM2 management. Aims of this study were to analyze and report the effects of two different supervised exercises (gym-based exercise and Nordic walking) on anthropometric profile, blood pressure values, blood chemistry and fitness variables in obese individuals with and without DM2. In this study, 108 obese adults (aged 45-65 years), with or without DM2, were recruited and allocated into one of four subgroups: (1) Gym-based exercise program (n = 49) or (2) Nordic walking program (n = 37) for obese adults; (3) Gym-based exercise program (n = 10) or (4) Nordic walking program (n = 12) for obese adults with DM2. In all exercise subgroups, statistically significant improvements in body weight, body mass index, fat mass index, muscular flexibility and maximal oxygen uptake (VO2 max) were observed. Moreover, a higher percentage of adherence to the gym-based program compared to Nordic walking was recorded. Our findings showed that, notwithstanding the lower adherence, a supervised Nordic walk is effective as a conventional gym-based program to improve body weight control, body composition parameters, muscular flexibility and VO2 max levels in obese adults with and without type 2 diabetes.

Interventions outside the workplace for reducing sedentary behaviour in adults under 60 years of age

BACKGROUND

Adults spend a majority of their time outside the workplace being sedentary. Large amounts of sedentary behaviour increase the risk of type 2 diabetes, cardiovascular disease, and both all-cause and cardiovascular disease mortality.

OBJECTIVES

Primary • To assess effects on sedentary time of non-occupational interventions for reducing sedentary behaviour in adults under 60 years of age Secondary • To describe other health effects and adverse events or unintended consequences of these interventions • To determine whether specific components of interventions are associated with changes in sedentary behaviour • To identify if there are any differential effects of interventions based on health inequalities (e.g. age, sex, income, employment) SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, Cochrane Database of Systematic Reviews, CINAHL, PsycINFO, SportDiscus, and ClinicalTrials.gov on 14 April 2020. We checked references of included studies, conducted forward citation searching, and contacted authors in the field to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster RCTs of interventions outside the workplace for community-dwelling adults aged 18 to 59 years. We included studies only when the intervention had a specific aim or component to change sedentary behaviour.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles/abstracts and full-text articles for study eligibility. Two review authors independently extracted data and assessed risk of bias. We contacted trial authors for additional information or data when required. We examined the following primary outcomes: device-measured sedentary time, self-report sitting time, self-report TV viewing time, and breaks in sedentary time.

MAIN RESULTS

We included 13 trials involving 1770 participants, all undertaken in high-income countries. Ten were RCTs and three were cluster RCTs. The mean age of study participants ranged from 20 to 41 years. A majority of participants were female. All interventions were delivered at the individual level. Intervention components included personal monitoring devices, information or education, counselling, and prompts to reduce sedentary behaviour. We judged no study to be at low risk of bias across all domains. Seven studies were at high risk of bias for blinding of outcome assessment due to use of self-report outcomes measures. Primary outcomes Interventions outside the workplace probably show little or no difference in device-measured sedentary time in the short term (mean difference (MD) -8.36 min/d, 95% confidence interval (CI) -27.12 to 10.40; 4 studies; I² = 0%; moderate-certainty evidence). We are uncertain whether interventions reduce device-measured sedentary time in the medium term (MD -51.37 min/d, 95% CI -126.34 to 23.59; 3 studies; I² = 84%; very low-certainty evidence) We are uncertain whether interventions outside the workplace reduce self-report sitting time in the short term (MD -64.12 min/d, 95% CI -260.91 to 132.67; I² = 86%; very low-certainty evidence). Interventions outside the workplace may show little or no difference in self-report TV viewing time in the medium term (MD -12.45 min/d, 95% CI -50.40 to 25.49; 2 studies; I² = 86%; low-certainty evidence) or in the long term (MD 0.30 min/d, 95% CI -0.63 to 1.23; 2 studies; I² = 0%; low-certainty evidence). It was not possible to pool the five studies that reported breaks in sedentary time given the variation in definitions used. Secondary outcomes Interventions outside the workplace probably have little or no difference on body mass index in the medium term (MD -0.25 kg/m², 95% CI -0.48 to -0.01; 3 studies; I² = 0%; moderate-certainty evidence). Interventions may have little or no difference in waist circumference in the medium term (MD -2.04 cm, 95% CI -9.06 to 4.98; 2 studies; I² = 65%; low-certainty evidence). Interventions probably have little or no difference on glucose in the short term (MD -0.18 mmol/L, 95% CI -0.30 to -0.06; 2 studies; I² = 0%; moderate-certainty evidence) and medium term (MD -0.08 mmol/L, 95% CI -0.21 to 0.05; 2 studies, I² = 0%; moderate-certainty evidence) Interventions outside the workplace may have little or no difference in device-measured MVPA in the short term (MD 1.99 min/d, 95% CI -4.27 to 8.25; 4 studies; I² = 23%; low-certainty evidence). We are uncertain whether interventions improve device-measured MVPA in the medium term (MD 6.59 min/d, 95% CI -7.35 to 20.53; 3 studies; I² = 70%; very low-certainty evidence). We are uncertain whether interventions outside the workplace improve self-reported light-intensity PA in the short-term (MD 156.32 min/d, 95% CI 34.34 to 278.31; 2 studies; I² = 79%; very low-certainty evidence). Interventions may have little or no difference on step count in the short-term (MD 226.90 steps/day, 95% CI -519.78 to 973.59; 3 studies; I² = 0%; low-certainty evidence) No data on adverse events or symptoms were reported in the included studies.

AUTHORS' CONCLUSIONS

Interventions outside the workplace to reduce sedentary behaviour probably lead to little or no difference in device-measured sedentary time in the short term, and we are uncertain if they reduce device-measured sedentary time in the medium term. We are uncertain whether interventions outside the workplace reduce self-reported sitting time in the short term. Interventions outside the workplace may result in little or no difference in self-report TV viewing time in the medium or long term. The certainty of evidence is moderate to very low, mainly due to concerns about risk of bias, inconsistent findings, and imprecise results. Future studies should be of longer duration; should recruit participants from varying age, socioeconomic, or ethnic groups; and should gather quality of life, cost-effectiveness, and adverse event data. We strongly recommend that standard methods of data preparation and analysis are adopted to allow comparison of the effects of interventions to reduce sedentary behaviour.

A position statement on screening and management of prediabetes in adults in primary care in Australia

Prediabetes has a high prevalence, with early detection essential to facilitate optimal management to prevent the development of conditions such as type 2 diabetes and cardiovascular disease. Prediabetes can include impaired fasting glucose, impaired glucose tolerance and elevated HbA1c. This position statement outlines the approaches to screening and management of prediabetes in primary care. There is good evidence to implement intensive, structured lifestyle interventions for individuals with impaired glucose tolerance. The evidence for those with impaired fasting glucose or elevated HbA1c is less clear, but individuals should still be provided with generalised healthy lifestyle strategies. A multidisciplinary approach is recommended to implement healthy lifestyle changes through education, nutrition and physical activity. Individuals should aim to lose weight (5-10% of body mass) using realistic and sustainable dietary approaches supported by an accredited practising dietitian, where possible. Physical activity and exercise should be used to facilitate weight maintenance and reduce blood glucose. Moderate-vigorous intensity aerobic exercise and resistance training should be prescribed by an accredited exercise physiologist, where possible. When indicated, pharmacotherapy, metabolic surgery and psychosocial care should be considered, in order to enhance the outcomes associated with lifestyle change. Individuals with prediabetes should generally be evaluated annually for their diabetes status.

The effectiveness and complexity of interventions targeting sedentary behaviour across the lifespan: a systematic review and meta-analysis

BACKGROUND

Evidence suggests that sedentary behaviour (SB) is associated with poor health outcomes. SB at any age may have significant consequences for health and well-being and interventions targeting SB are accumulating. Therefore, the need to review the effects of multicomponent, complex interventions that incorporate effective strategies to reduce SB are essential.

METHODS

A systematic review and meta-analysis were conducted investigating the impact of interventions targeting SB across the lifespan. Six databases were searched and two review authors independently screened studies for eligibility, completed data extraction and assessed the risk of bias and complexity of each of the included studies.

RESULTS

A total of 77 adult studies (n=62, RCTs) and 84 studies (n=62, RCTs) in children were included. The findings demonstrated that interventions in adults when compared to active controls resulted in non-significant reductions in SB, although when compared to inactive controls significant reductions were found in both the short (MD -56.86; 95%CI -74.10, -39.63; n=4632; I2 83%) and medium-to-long term (MD -20.14; 95%CI -34.13, -6.16; n=4537; I2 65%). The findings demonstrated that interventions in children when compared to active controls may lead to relevant reductions in daily sedentary time in the short-term (MD -59.90; 95%CI -102.16, -17.65; n=267; I2 86%), while interventions in children when compared to inactive controls may lead to relevant reductions in the short-term (MD -25.86; 95%CI -40.77, -10.96; n=9480; I2 98%) and medium-to-long term (MD -14.02; 95%CI -19.49, -8.55; n=41,138; I2 98%). The assessment of complexity suggested that interventions may need to be suitably complex to address the challenges of a complex behaviour such as SB, but demonstrated that a higher complexity score is not necessarily associated with better outcomes in terms of sustained long-term changes.

CONCLUSIONS

Interventions targeting reductions in SB have been shown to be successful, especially environmental interventions in both children and adults. More needs to be known about how best to optimise intervention effects. Future intervention studies should apply more rigorous methods to improve research quality, considering larger sample sizes, randomised controlled designs and valid and reliable measures of SB.

Dose-Response Effects of Exercise on Glucose-Lowering Medications for Type 2 Diabetes: A Secondary Analysis of a Randomized Clinical Trial

OBJECTIVE

To investigate whether a dose-response relationship exists between volume of exercise and discontinuation of glucose-lowering medication treatment in patients with type 2 diabetes.

PATIENTS AND METHODS

Secondary analyses of a randomized controlled exercise-based lifestyle intervention trial (April 29, 2015 to August 17, 2016). Patients with non-insulin-dependent type 2 diabetes were randomly assigned to an intensive lifestyle intervention (U-TURN) or standard-care group. Both groups received lifestyle advice and objective target-driven medical regulation. Additionally, the U-TURN group received supervised exercise and individualized dietary counseling. Of the 98 randomly assigned participants, 92 were included in the analysis (U-TURN, n=61, standard care, n=31). Participants in the U-TURN group were stratified into tertiles based on accumulated volumes of exercise completed during the 1-year intervention.

RESULTS

Median exercise levels of 178 (interquartile range [IQR], 121-213; lower tertile), 296 (IQR, 261-310; intermediate tertile), and 380 minutes per week (IQR, 355-446; upper tertile) were associated with higher odds of discontinuing treatment with glucose-lowering medication, with corresponding odds ratios of 12.1 (95% CI, 1.2-119; number needed to treat: 4), 30.2 (95% CI, 2.9-318.5; 3), and 34.4 (95% CI, 4.1-290.1; 2), respectively, when comparing with standard care. Cardiovascular risk factors such as glycated hemoglobin A_1c levels, fitness, 2-hour glucose levels, and triglyceride levels were improved significantly in the intermediate and upper tertiles, but not the lower tertile, compared with the standard-care group.

CONCLUSION

Exercise volume is associated with discontinuation of glucose-lowering medication treatment in a dose-dependent manner, as are important cardiovascular risk factors in well-treated participants with type 2 diabetes and disease duration less than 10 years. Further studies are needed to support these findings.

STUDY REGISTRATION

ClinicalTrials.gov registration (NCT02417012).

Sarcopenic Obesity in Heart Failure With Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) is a public health epidemic that is projected to double over the next two decades. Despite the high prevalence of HFpEF, there are currently no FDA approved therapies for health-related outcomes in this clinical syndrome making it one the greatest unmet needs in cardiovascular medicine. Aging and obesity are hallmarks of HFpEF and therefore there is a high incidence of sarcopenic obesity (SO) associated with this syndrome. The presence of SO in HFpEF patients is noteworthy as it is associated with co-morbidities, worsened cardiovascular health, hospitalizations, quality of life, and mortality. Furthermore, SO plays a central role in exercise intolerance, the most commonly reported clinical symptom of this condition. The aim of this review is to provide insights into the current knowledge pertaining to the contributing pathophysiological mechanisms and clinical outcomes associated with HFpEF-related SO. Current and prospective therapies to address SO in HFpEF, including lifestyle and pharmaceutical approaches, are discussed. The urgent need for future research aimed at better understanding the multifaceted physiological contributions to SO in HFpEF and implementing interventional strategies to specifically target SO is highlighted.

Ethnicity and Metabolic Syndrome: Implications for Assessment, Management and Prevention

The metabolic syndrome (MetS) is a constellation of cardiometabolic risk factors that identifies people at increased risk for type 2 diabetes and cardiovascular disease. While the global prevalence is 20%–25% of the adult population, the prevalence varies across different racial/ethnic populations. In this narrative review, evidence is reviewed regarding the assessment, management and prevention of MetS among people of different racial/ethnic groups. The most popular definition of MetS considers race/ethnicity for assessing waist circumference given differences in visceral adipose tissue and cardiometabolic risk. However, defining race/ethnicity may pose challenges in the clinical setting. Despite 80% of the world’s population being of non-European descent, the majority of research on management and prevention has focused on European-derived populations. In these studies, lifestyle management has proven an effective therapy for reversal of MetS, and randomised studies are underway in specific racial/ethnic groups. Given the large number of people at risk for MetS, prevention efforts need to focus at community and population levels. Community-based interventions have begun to show promise, and efforts to improve lifestyle behaviours through alterations in the built environment may be another avenue. However, careful consideration needs to be given to take into account the unique cultural context of the target race/ethnic group.

Naturopathy as a Model of Prevention-Oriented, Patient-Centered Primary Care: A Disruptive Innovation in Health Care

Background and Objective: The concept of a "disruptive innovation," recently extended to health care, refers to an emerging technology that represents a new market force combined with a new value system, that eventually displaces some, or all, of the current leading "stakeholders, products and strategic alliances." Naturopathy is a distinct system of traditional and complementary medicine recognized by the World Health Organization (WHO), emerging as a model of primary care. The objective here is to describe Naturopathy in the context of the criteria for a disruptive innovation. Methods: An evidence synthesis was conducted to evaluate Naturopathy as a potentially disruptive technology according to the defining criteria established by leading economists and health technology experts: (1) The innovation must cure disease; (2) must transform the way medicine is practiced; or (3) have an impact that could be disruptive or sustaining, depending on how it is integrated into the current healthcare marketplace. Results: The fact that Naturopathy de-emphasizes prescription drug and surgical interventions in favor of nonpharmacological health promotion and self-care could disrupt the present economic model that fuels health care costs. The patient-centered orientation of Naturopathy, combined with an emphasis on preventive behaviors and popular complementary and integrative health services like natural products, mind and body therapies, and other therapies not widely represented in current primary care models increase the likelihood for disruption. Conclusions: Because of its patient-centered approach and emphasis on prevention, naturopathy may disrupt or remain a durable presence in healthcare delivery depending on policymaker decisions.

Obesity, risk of diabetes and role of physical activity, exercise training and cardiorespiratory fitness

The epidemic of obesity contributes to the burden of type 2 diabetes mellitus (T2DM) in the United States and worldwide. Importantly, obesity is not only preventable but can be treated, particularly with lifestyle modifications to forestall T2DM in those with excess adiposity. The mechanisms linking obesity to T2DM are numerous and involve adipose tissue remodeling as a result of unhealthy behaviors, including unhealthy diet, reduced physical activity (PA) and exercise training (ET), and increased sedentary behaviors. Taken together, these factors markedly reduce cardiorespiratory fitness (CRF), one of the strongest predictors for cardiovascular outcomes and all-cause mortality in the general population, but also in those with T2DM. In this review we describe the mechanisms leading to adipose tissue remodeling resulting in obesity, as well as the mechanisms linking excess adiposity to insulin resistance and, in turn, T2DM. We then present the therapeutic strategies that can be implemented in obesity to prevent T2DM, with a brief discussion on weight loss, and greater emphasis on PA and ET. We finally present the evidence to support the beneficial effects of such strategies in patients with established T2DM and discuss the importance of achieving improvements in CRF in this population to potentially improve clinical outcomes.

Educational program to promote the self-care of people with diabetes mellitus

Objective: to evaluate the effect of an intervention program on the capacity and action for the self-care of people with diabetes mellitus.Method: this is an intervention study with the implementation of a problem-solving educational program in diabetes in a private health service. Capacity and action scales were applied for the self-care, in the initial moment and after the  intervention with analysis of the outcome by the metabolic control. Differences were identified by the Student t test and the comparison of the scales variability calculated by Cronbach's alpha, with a 95 % confidence interval.Results: participated in the study 23 people, with significant improvement in the values of glycated hemoglobin, glycemic and diastolic blood pressure variability after the educationalprogram. The educational strategy in diabetes provided improvement in both capacity and action for self-care,respectively (p ≤ 0.0 %), Cronbach’s alpha initial 0.895 and final 0.938 Conclusion: education programs using participatory methodologies are essential to enable the person with diabetes to manage and monitor the disease.