A European evidence-based guideline for the prevention of type 2 diabetes

Combined effect of metformin and gallic acid on inflammation, antioxidant status, endoplasmic reticulum (ER) stress and glucose metabolism in fructose-fed streptozotocin-induced diabetic rats

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Metformin, gallic acid and a combination of both improved glucose metabolism and antioxidant status in diabetic rats.

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Metformin, gallic acid and a combination of both lowered levels of IL-6 and TNF-α in liver and pancreas of diabetic rats.

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Metformin, gallic acid and a combination of both decreased the expression of ATF4 in liver and pancreas of diabetic rats.

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Metformin/GA combination appeared more effective than metformin only and gallic acid only.

Over time, diabetes patients usually need combination therapy involving two or more agents, including phytonutrients to attain therapeutic targets. The purpose of this research is to elucidate the combined effect of metformin and gallic acid (GA) on glucose metabolism, inflammation as well as oxidative and endoplasmic reticulum (ER) stresses in fructose-fed diabetic rats. Thirty-five rats of Wistar strain were arbitrarily distributed into five groups, each containing seven animals as follows: normal control, diabetic control, groups administered 100 mg/kg bw metformin only, 50 mg/kg bw gallic acid only and a combination of both. Experimental animals were made diabetic by single injection of 40 mg/kg streptozotocin (intraperitoneally) subsequent to 14 days administration of 10 % fructose prior. Treatment of rats continued for 21 days following diabetes confirmation. Glucose and insulin levels as well as lipid profile were evaluated in the serum, while activities of catalase and superoxide dismutase were estimated in both liver and pancreas. In addition, levels of malondialdehyde, interleukin-6 and tumor necrosis factor-alpha, as well as expression of activating transcription factor-4 were evaluated in liver and pancreas of diabetic rats. Activities of glucose-6-phosphatase and glucokinase were also determined in liver of diabetic animals. Metformin only, GA only and combination of metformin and GA significantly improved antioxidant status and glucose homeostasis while inflammation and endoplasmic reticulum stress were significantly ameliorated in diabetic rats. Metformin/GA combination appeared to improve glucose metabolism by increasing insulin level and ameliorating the dysregulated activities of glucose metabolizing enzymes and ER stress better than either metformin only or GA only. It could be concluded that coadministration of metformin/GA produced a combined effect in ameliorating diabetes in Wistar rats and could be considered in treatment of diabetes.

Quality-of-Life Determinants in People with Diabetes Mellitus in Europe

This study aims to analyze self-perceived health and lifestyles in the European Union Member States Iceland, Norway, and the United Kingdom, examining associations with diabetes prevalence; and to identify the demographic, economic and health variables associated with diabetes in this population. We performed a cross-sectional study of 312,172 people aged 15 years and over (150,656 men and 161,516 women), using data collected from the European Health Interview Survey (EHIS). The EHIS includes questions on the health status and health determinants of the adult population, as well as health care use and accessibility. To estimate the magnitudes of the associations with diabetes prevalence, we fitted multivariate logistic models. The EHIS data revealed a prevalence of diabetes in Europe of 6.5% (n = 17,029). Diabetes was associated with being physically inactive (OR 1.14; 95% CI 1.02–1.28), obese (OR 2.75; 95% CI 2.60–2.90), male (OR 1.46; 95% CI 1.40–1.53) and 65–74 years old (OR 3.47; 95% CI 3.09–3.89); and having long-standing health problems (OR 7.39; 95% CI, 6.85–7.97). These results were consistent in the bivariate and multivariate analyses, with an area under the receiver operating characteristic curve of 0.87 (95% CI 0.87–0.88). In a large European health survey, diabetes was clearly associated with a poorer perceived quality of life, physical inactivity, obesity, and other comorbidities, as well as non-modifiable factors such as older age and male sex.

Prevalence and risk factors of undiagnosed diabetes mellitus among gastroenterological patients: a HbA1c-based single center experience

BACKGROUND

Diabetes mellitus is a major risk factor for microvascular disease, leading to chronic kidney injury or cardiovascular disease, but there is a tremendous proportion of patients worldwide who suffer from undiagnosed diabetes. Until now, little is known about the prevalence of undiagnosed diabetes in gastroenterology inpatients.

OBJECTIVE

To improve detection of undiagnosed diabetes, a routine screening procedure for gastroenterology inpatients, based on hemoglobin A1c (HbA1c) and fasting plasma glucose (FPG) measurement, was established.

METHODS

We conducted a retrospective analysis of the implemented diabetes screening. Diabetes mellitus was diagnosed according to the guideline of the German Diabetes Association in patients with an HbA1c of ≥6.5% anld/or fasting plasma glucose (FPG) ≥126 mg/dL. Univariate and multivariate analyses were performed to identify independent risk factors for undiagnosed diabetes.

RESULTS

Within a 3-month period, 606 patients were eligible for a diabetes screening. Pre-existing diabetes was documented in 120 patients (19.8 %), undiagnosed diabetes was found in 24 (3.9%), and 162 patients (26.7%) met the definition for prediabetes. Steroid medication use, age, and liver cirrhosis due to primary sclerosing cholangitis (PSC) were identified as risk factors for undiagnosed diabetes.

CONCLUSION

The prevalence of undiagnosed diabetes in gastroenterology inpatients is markedly elevated in comparison to the general population, and a substantial number of inpatients are in a prediabetic status, underlining the need for diabetes screening. In addition to previously described risk factors of patient age and steroid medication use, we identified PSC-related liver cirrhosis (but not liver cirrhosis due to another etiology) as an independent risk factor for undiagnosed diabetes.

Migrant Middle Eastern women with gestational diabetes seven years after delivery - positive long-term development of beliefs about health and illness shown in follow-up interviews

AIM

No previous studies have been found focusing on the long-term development of beliefs about health, illness and healthcare in migrant women with gestational diabetes mellitus (GDM). The aim of this study was to explore this and the influence on health-related behaviour (i.e. self-care and care seeking) in migrant women from the Middle East living in Sweden seven years after delivery.

BACKGROUND

GDM is increasing, particularly in migrant women. The risk of adverse outcomes of GDM for health can be improved by interventions reducing blood glucose and lifestyle modifications which medicalise the woman's pregnancy due to intensive follow-up and demanding self-care. The reactions might have an enduring impact on the women's long-term psychological and physical health and adoption of preventive health behaviours.

METHOD

Qualitative exploratory study. Semi-structured follow-up interviews 7 years after delivery with women previously interviewed in gestational weeks 34-38 and 3 and 14 months after delivery. Data analysed with qualitative content analysis.

FINDINGS

Health meant freedom from illness, feeling well and living long to be able to care for the children. The present situation was described either positively, changing to a healthier lifestyle, or negatively, with worries about being affected by type 2 diabetes. Beliefs changed among the majority of women, leading to a healthier lifestyle, and they looked positively back at the time when diagnosed and their reactions to it. With few exceptions, they were confident of being aware of future health risks and felt responsible for their own and their children's health/lifestyle. None except those diagnosed with type 2 diabetes had been in contact with healthcare since the last follow-up a year after delivery. Yet, they still would like and need a healthcare model delivering more information, particularly on developing a healthy lifestyle for children, and with regular check-ups also after the first year after delivery.

Management of prediabetes from the perspective of Spanish physicians and community pharmacists: Detecta2 study

INTRODUCTION

Prediabetes is a high-risk state for diabetes. The study aims to describe routine clinical practice and the views of physicians and pharmacists on prediabetes management.

MATERIALS AND METHODS

An observational, descriptive, cross-sectional study was conducted using a structured questionnaire.

RESULTS

A total of 410 physicians and 393 pharmacists completed the questionnaire. Self-adherence to clinical practice guidelines (CPGs) was reported by 51.5% and 23.2% of physicians and pharmacists, respectively. Less than 60% of participants defined prediabetes according to main CPG. Regarding the use of screening strategies to detect prediabetes (physicians: 96%; pharmacists: 42.1%), reports indicate the opportunistic strategy is widely employed (≥75%) whereas systematic screening is unusual (<20%). Changes in lifestyle were deemed essential by almost all participants (≥95%), but in clinical practice only 58.3% of healthcare centers and 28.0% of pharmacies were found to provide awareness-raising/instruction. The role of pharmacists in the prevention of prediabetes/diabetes was judged useful by most participants.

CONCLUSIONS

Use of CPG, systematic prediabetes screening strategies, and specific strategies for patient education are scarce. The support of community pharmacists in prediabetes management was well valued. Therefore, it is crucial that the lines of action followed by both physicians and pharmacists align with each other and with the CPG.

A randomized trial to decrease risk for diabetes among Cambodian Americans with depression: Intervention development, baseline characteristics and process outcomes

Background:

Depression and antidepressant medications are associated with increased risk for type 2 diabetes. It is not known if diabetes can be prevented in the setting of depression. Cambodian Americans have high rates of both depression and diabetes. This paper reports intervention development, experimental design, baseline characteristics, and process outcomes of diabetes prevention interventions for Cambodian Americans with depression, “Diabetes Risk Reduction through Eat, Walk, Sleep and Medication Therapy Management” (DREAM).

Methods:

Participants were aged 35–75, Khmer speaking, at high risk for developing diabetes, and met criteria for likely depression by either a) antidepressant medication and/or b) elevated depressive symptoms at two time-points during a study eligibility period. Treatment arms were: 1) community health educator (CHE) delivered lifestyle intervention called Eat, Walk, Sleep (EWS), 2) EWS plus pharmacist/CHE-delivered medication therapy management (EWS + MTM), and, 3) social services (SS; control).

Results:

188 participants were randomized. Treatment fidelity was high (98% checklist adherence) and on a scale from 0 to 3, participants reported high EWS treatment satisfaction (M = 2.9, SD = 0.2), group cohesion (M = 2.9, SD = 0.3), and therapeutic alliance to CHEs (M = 2.9, SD = 0.2) and to pharmacists (2.9, SD = 0.3). Attendance was challenging but highly successful; in EWS, 99% attended ≥ one session and 86% completed ≥ 24 sessions, M = 27.3 (SD = 3.7) sessions. Of those randomized to EWS + MTM, 98% attended at least one MTM session and 77%) completed ≥ 4 sessions. Retention was high, 95% at 12-month and 96% at 15-month assessments.

Conclusions:

The interventions were successfully implemented. Lessons learned and suggestions for future trials are offered.

ClinicalTrials.gov identifier: NCT02502929

Acute and long-term effects of saxagliptin on post-prandial glycemic response in obese patients with impaired glucose tolerance

BACKGROUND AND AIMS

Dipeptidyl-peptidase inhibitors might be useful in type 2 diabetes prevention. ACCES (ACute and Chronic Effects of Saxagliptin) was a randomized, placebo-controlled, double-blind, controlled phase 2, pilot study aiming to examine in obese patients with impaired glucose tolerance (IGT) the acute effects and the effects after 12 weeks of treatment by saxagliptin on glucose levels at fasting and postprandially after a standard breakfast, and on glucose tolerance.

METHODS AND RESULTS

We included 24 obese patients with IGT. Patients were randomized to receive saxagliptin 5 mg or placebo in the morning. The treatment was taken on Visit 1 before breakfast, then continued for 12 weeks. Biochemical measurements were performed before, one, two and three hours after a standard breakfast including 75 g of carbohydrates, during Visit 1 and Visit 2 (12 weeks). Glucose variability (GV) was evaluated at Visit 1 from 24-h continuous glucose monitoring including the breakfast. A second OGTT was performed at Visit 3 (3-5 days after Visit 2). Compared with placebo-treated patients, saxagliptin-treated patients had lower 1 h and 2 h post-meal plasma glucose levels at Visit 1 and similar changes at Visit 2 (p < 0.01 to p < 0.004), with lower GV indexes after breakfast at Visit 1. At Visit 3, all patients but one in saxagliptin group and only 4 patients in placebo group turned to normal glucose tolerance. Lower glucose response to breakfast at Visit 1 was predictive of recovery of glucose tolerance.

CONCLUSION

Saxagliptin has metabolically beneficial effects in glucose-intolerant obese patients by significantly lowering postprandial blood glucose levels.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01521312: https://clinicaltrials.gov/ct2/show/NCT01521312.

Gonadal hormonal factors before menopause and incident type 2 diabetes in women: A 22-year follow-up of 83 799 women from the E3N cohort study

BACKGROUND

In many populations the incidence of type 2 diabetes is higher in men than in women. This may be explained by exposure to female gonadal hormones, but so far, there is no consensus on their role over the life course in type 2 diabetes etiology.

METHODS

Data are from 83 799 French women from the E3N (Etude Épidémiologique de Femmes de la Mutuelle Générale de l'Education Nationale) cohort study, followed for 22 years. Multivariable Cox models including classical risk factors were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) between gonadal hormonal factors and incident type 2 diabetes.

RESULTS

Older age at menarche, more menstrual cycles, older age at menopause, longer duration of exposure to gonadal hormones and breastfeeding were inversely associated with incident type 2 diabetes cases (n = 4806). While a longer duration of menstrual cycles (HR = 1.23 [95% CI: 1.07-1.41] comparing ≥32 vs ≤24 days) and use of contraceptive pills (HR = 1.33 [1.25-1.42]) were associated with a greater risk of type 2 diabetes.

CONCLUSIONS

In women, a longer exposure to endogenous gonadal hormones with a later menopause as well as breastfeeding were associated with a lower risk of developing type 2 diabetes, independently of classical diabetes risk factors. In contrast, the use of contraceptive agents was associated with incident diabetes, but the influence of each type of contraception and of exposure duration remain to be investigated.

A Genetic Risk Score Improves the Prediction of Type 2 Diabetes Mellitus in Mexican Youths but Has Lower Predictive Utility Compared With Non-Genetic Factors

Background

Type 2 diabetes (T2D) is a multifactorial disease caused by a complex interplay between environmental risk factors and genetic predisposition. To date, a total of 10 single nucleotide polymorphism (SNPs) have been associated with pediatric-onset T2D in Mexicans, with a small individual effect size. A genetic risk score (GRS) that combines these SNPs could serve as a predictor of the risk for pediatric-onset T2D.

Objective

To assess the clinical utility of a GRS that combines 10 SNPs to improve risk prediction of pediatric-onset T2D in Mexicans.

Methods

This case-control study included 97 individuals with pediatric-onset T2D and 84 controls below 18 years old without T2D. Information regarding family history of T2D, demographics, perinatal risk factors, anthropometric measurements, biochemical variables, lifestyle, and fitness scores were then obtained. Moreover, 10 single nucleotide polymorphisms (SNPs) previously associated with pediatric-onset T2D in Mexicans were genotyped. The GRS was calculated by summing the 10 risk alleles. Pediatric-onset T2D risk variance was assessed using multivariable logistic regression models and the area under the receiver operating characteristic curve (AUC).

Results

The body mass index Z-score (Z-BMI) [odds ratio (OR) = 1.7; p = 0.009] and maternal history of T2D (OR = 7.1; p < 0.001) were found to be independently associated with pediatric-onset T2D. No association with other clinical risk factors was observed. The GRS also showed a significant association with pediatric-onset T2D (OR = 1.3 per risk allele; p = 0.006). The GRS, clinical risk factors, and GRS plus clinical risk factors had an AUC of 0.66 (95% CI 0.56-0.75), 0.72 (95% CI 0.62-0.81), and 0.78 (95% CI 0.70-0.87), respectively (p < 0.01).

Conclusion

The GRS based on 10 SNPs was associated with pediatric-onset T2D in Mexicans and improved its prediction with modest significance. However, clinical factors, such the Z-BMI and family history of T2D, continue to have the highest predictive utility in this population.

Risk Prediction of the Diabetes Missing Million: Identifying Individuals at High Risk of Diabetes and Related Complications

Early diagnosis and effective management of type 2 diabetes (T2D) are crucial in reducing the risk of developing life-changing complications such as heart failure, stroke, kidney disease, blindness and amputation, which are also associated with significant costs for healthcare providers. However, as T2D symptoms often develop slowly it is not uncommon for people to live with T2D for years without being aware of their condition-commonly known as the undiagnosed missing million. By the time a diagnosis is received, many individuals will have already developed serious complications. While the existence of undiagnosed diabetes has long been recognised, wide-reaching awareness among the general public, clinicians and policymakers is lacking, and there is uncertainty in how best to identify high-risk individuals. In this article we have used consensus expert opinion alongside the available evidence, to provide support for the diabetes healthcare community regarding risk prediction of the missing million. Its purpose is to provide awareness of the risk factors for identifying individuals at high, moderate and low risk of T2D and T2D-related complications. The awareness of risk predictors, particularly in primary care, is important, so that appropriate steps can be taken to reduce the clinical and economic burden of T2D and its complications.

The external validity and performance of the no-laboratory American Diabetes Association screening tool for identifying undiagnosed type 2 diabetes among the Iranian population

AIMS

The aim of this study is to assess the American Diabetes Association (ADA) risk score as a self-assessment screening tool for undiagnosed type 2 diabetes (T2DM) in Iran.

METHODS

In a national survey of risk factors for non-communicable diseases, we included 3458 Iranian adults. The discrimination and validity were assessed using the area under the curve (AUC), sensitivity, specificity, Youden's index, positive and negative predictive values (PPV and NPV). The frequency of high-risk Iranian population who need a glucose test and those who need intervention were also estimated.

RESULTS

The AUC was 73.7% and the suggested ADA score of ≥5 yielded a sensitivity of 51.6%, specificity 82.4%, NPV 98.3%, and PPV 7.9%. This threshold results in classifying 18.6% of the Iranians, equals to 8.5 million, as high-risk and 1.5% of the population, about 700,000, would need intervention. However, our study suggested score ≥4 that identified 34% of the population as high-risk and 2% of the population would need intervention.

CONCLUSION

Our findings support the ADA suggested threshold for identifying high-risk individuals for undiagnosed T2DM; however, a lower threshold is also recommended for higher sensitivity. The ADA screening tool could help the public health system for low-cost screening.

Intake of dietary fats and fatty acids and the incidence of type 2 diabetes: A systematic review and dose-response meta-analysis of prospective observational studies

BACKGROUND

The role of fat quantity and quality in type 2 diabetes (T2D) prevention is controversial. Thus, this systematic review and meta-analysis aimed to investigate the associations between intake of dietary fat and fatty acids and T2D, and to evaluate the certainty of evidence.

METHODS AND FINDINGS

We systematically searched PubMed and Web of Science through 28 October 2019 for prospective observational studies in adults on the associations between intake of dietary fat and fatty acids and T2D incidence. The systematic literature search and data extraction were conducted independently by 2 researchers. We conducted linear and nonlinear random effects dose-response meta-analyses, calculated summary relative risks (SRRs) with their corresponding 95% confidence intervals (95% CIs), and assessed the certainty of evidence. In total, 15,070 publications were identified in the literature search after the removal of duplicates. Out of the 180 articles screened in full text, 23 studies (19 cohorts) met our inclusion criteria, with 11 studies (6 cohorts) conducted in the US, 7 studies (7 cohorts) in Europe, 4 studies (5 cohorts) in Asia, and 1 study (1 cohort) in Australia. We mainly observed no or weak linear associations between dietary fats and fatty acids and T2D incidence. In nonlinear dose-response meta-analyses, the protective association for vegetable fat and T2D was steeper at lower levels up to 13 g/d (SRR [95% CI]: 0.81 [0.76; 0.88], pnonlinearity = 0.012, n = 5 studies) than at higher levels. Saturated fatty acids showed an apparent protective association above intakes around 17 g/d with T2D (SRR [95% CI]: 0.95 [0.90; 1.00], pnonlinearity = 0.028, n = 11). There was a nonsignificant association of a decrease in T2D incidence for polyunsaturated fatty acid intakes up to 5 g/d (SRR [95% CI]: 0.96 [0.91; 1.01], pnonlinearity = 0.023, n = 8), and for alpha-linolenic acid consumption up to 560 mg/d (SRR [95% CI]: 0.95 [0.90; 1.00], pnonlinearity = 0.014, n = 11), after which the curve rose slightly, remaining close to no association. The association for long-chain omega-3 fatty acids and T2D was approximately linear for intakes up to 270 mg/d (SRR [95% CI]: 1.10 [1.06; 1.15], pnonlinearity < 0.001, n = 16), with a flattening curve thereafter. Certainty of evidence was very low to moderate. Limitations of the study are the high unexplained inconsistency between studies, the measurement of intake of dietary fats and fatty acids via self-report on a food group level, which is likely to lead to measurement errors, and the possible influence of unmeasured confounders on the findings.

CONCLUSIONS

There was no association between total fat intake and the incidence of T2D. However, for specific fats and fatty acids, dose-response curves provided insights for significant associations with T2D. In particular, a high intake of vegetable fat was inversely associated with T2D incidence. Thus, a diet including vegetable fat rather than animal fat might be beneficial regarding T2D prevention.

A 2 year physical activity and dietary intervention attenuates the increase in insulin resistance in a general population of children: the PANIC study

AIMS/HYPOTHESIS

We studied for the first time the long-term effects of a combined physical activity and dietary intervention on insulin resistance and fasting plasma glucose in a general population of predominantly normal-weight children.

METHODS

We carried out a 2 year non-randomised controlled trial in a population sample of 504 children aged 6-9 years at baseline. The children were allocated to a combined physical activity and dietary intervention group (306 children at baseline, 261 children at 2-year follow-up) or a control group (198 children, 177 children) without blinding. We measured fasting insulin and fasting glucose, calculated HOMA-IR, assessed physical activity and sedentary time by combined heart rate and body movement monitoring, assessed dietary factors by a 4 day food record, used the Finnish Children Healthy Eating Index (FCHEI) as a measure of overall diet quality, and measured body fat percentage (BF%) and lean body mass by dual-energy x-ray absorptiometry. The intervention effects on insulin, glucose and HOMA-IR were analysed using the intention-to-treat principle and linear mixed-effects models after adjustment for sex, age at baseline, and pubertal status at baseline and 2 year follow-up. The measures of physical activity, sedentary time, diet and body composition at baseline and 2 year follow-up were entered one-by-one as covariates into the models to study whether changes in these variables might partly explain the observed intervention effects.

RESULTS

Compared with the control group, fasting insulin increased 4.65 pmol/l less (absolute change +8.96 vs +13.61 pmol/l) and HOMA-IR increased 0.18 units less (+0.31 vs +0.49 units) over 2 years in the combined physical activity and dietary intervention group. The intervention effects on fasting insulin (regression coefficient β for intervention effect -0.33 [95% CI -0.62, -0.04], p = 0.026) and HOMA-IR (β for intervention effect -0.084 [95% CI -0.156, -0.012], p = 0.023) were statistically significant after adjustment for sex, age at baseline, and pubertal status at baseline and 2 year follow-up. The intervention had no effect on fasting glucose, BF% or lean body mass. Changes in total physical activity energy expenditure, light physical activity, moderate-to-vigorous physical activity, total sedentary time, the reported consumption of high-fat (≥60%) vegetable oil-based spreads, and FCHEI, but not a change in BF% or lean body mass, partly explained the intervention effects on fasting insulin and HOMA-IR.

CONCLUSIONS/INTERPRETATION

The combined physical activity and dietary intervention attenuated the increase in insulin resistance over 2 years in a general population of predominantly normal-weight children. This beneficial effect was partly mediated by changes in physical activity, sedentary time and diet but not changes in body composition.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01803776 Graphical abstract.

Patient preferences for preventive health checks in Danish general practice: a discrete choice experiment among patients at high risk of noncommunicable diseases

BACKGROUND

Preventive health checks targeted at the at-risk population can be a way of preventing noncommunicable diseases. However, evidence on patient preferences for preventive health checks is limited, especially among patients with a high risk of noncommunicable diseases.

OBJECTIVE

To examine patient preferences for preventive health checks in Danish general practice, targeting persons at high risk of a noncommunicable disease.

METHODS

The method used in this study was a discrete choice experiment (DCE) with five attributes: assess, advice, agree, assist and arrange. The attributes were inspired by the 5A model for behaviour change counselling but was altered for the purpose of this study to grasp the entirety of the general practice-based intervention. Moreover, the attribute levels were defined to resemble daily clinical practice. The experimental design of the DCE was an efficient Bayesian main effects design and the results were analysed using a random utility theory framework.

RESULTS

A total of 148 patients completed the DCE. Patients at high risk of a noncommunicable disease have positive preferences for: giving brief explanations about own lifestyle, practicing shared decision-making with the general practitioner (GP), follow-up counselling with the GP after the preventive health check and scheduling a new appointment right after the preventive health check.

CONCLUSIONS

The results provide Danish GPs with evidence on their patients' preferences towards preventive health checks which will enable the GPs to tailor these consultations. Moreover, the results suggest that pre-appointment measures, such as a health profile, may mediate a preference for more action-oriented attributes.

TRIAL REGISTRATION

Registered at Clinical Trial Gov (Unique Protocol ID: TOFpilot2016, https://clinicaltrials.gov/ct2/show/NCT02797392?term=TOFpilot2016&rank=1). Prospectively registered on the 29th of April 2016.

Preferences of people with type 2 diabetes for telemedical lifestyle programmes in Germany: protocol of a discrete choice experiment

INTRODUCTION

Telemedical lifestyle programmes for people with type 2 diabetes mellitus (T2DM) provide an opportunity to develop a healthier lifestyle and consequently to improve health outcomes. When implementing new programmes into standard care, considering patients' preferences may increase the success of the participants. This study aims to examine the preferences of people with T2DM with respect to telemedical lifestyle programmes, to analyse whether these preferences predict programme success and to explore the changes that may occur during a telemedical lifestyle intervention.

METHODS AND ANALYSIS

We outline the protocol of the development and assessment of a discrete choice experiment (DCE) to examine patient preferences in a telemedical lifestyle programme with regard to the functions of the online portal, communication, responsibilities, group activities and time requirements. To develop the design of the DCE, we conducted pilot work involving healthcare experts and in particular people with T2DM using cognitive pretesting. The final DCE is being implemented within a randomised controlled trial for investigating whether participation in a telemedical lifestyle intervention programme sustainably improves the HbA1c values in 850 members of a large German statutory health insurance with T2DM. Preferences are being assessed before and after participants complete the programme. The DCE data will be analysed using regression and latent class analyses.

ETHICS AND DISSEMINATION

The DCE study has been approved by the ethics committee of the medical faculty of the Heinrich Heine University Duesseldorf, registration number 2018-242-ProspDEuA, registered on 6 December 2018. The TeLIPro trial is registered at the US National Library of Medicine, registration number NCT03675919, registered on 15 September 2018. We aim to disseminate our results in peer-reviewed journals, at national and international conferences and among interested patient groups and the public.

Effectiveness of a family-, school- and community-based intervention on physical activity and its correlates in Belgian families with an increased risk for type 2 diabetes mellitus: the Feel4Diabetes-study

Background

The study aimed to investigate the effectiveness of the European Feel4Diabetes intervention, promoting a healthy lifestyle, on physical activity and its correlates among families at risk for type 2 diabetes mellitus (based on the Finnish Diabetes Risk Score) in Belgium.

Methods

The Feel4Diabetes intervention involved three components: family, school and community component, with the family component consisting of 6 counseling sessions for families at risk. Main outcomes were objectively measured physical activity levels and its subjectively measured correlates. The final sample consisted of 454 parents (mean age 39.4 years; 72.0% women) and 444 children (mean age 8.0 years; 50.1% girls). Multilevel repeated measures analyses were performed to assess intervention effectiveness after 1 year.

Results

In parents, there was no significant intervention effect. In children, there were only significant negative effects for moderate to vigorous physical activity (p = 0.05; η_p² = 0.008) and steps (p = 0.03; η_p² = 0.006%) on weekdays, with physical activity decreasing (more) in the intervention group.

Conclusions

The F4D-intervention lacks effectiveness on high-risk families’ physical activity and its correlates in Belgium. This could partially be explained by low attendance rates and a large drop-out. To reach vulnerable populations, future interventions should invest in more appropriate recruitment (e.g. more face-to-face contact) and more bottom-up development of the intervention (i.e. co-creation of the intervention with the target group).

Trial registration

The Feel4Diabetes-study was prospectively registered at clinicaltrials.gov as NCT02393872 on 20 March 2015.

A systematic review of recruitment strategies and behaviour change techniques in group-based diabetes prevention programmes focusing on uptake and retention

BACKGROUND

Many countries worldwide have developed diabetes prevention programmes (DPPs) that involve lifestyle modification. Research has shown that uptake and retention of DPPs are important and by exploring recruitment strategies and behaviour change techniques (BCTs) used, factors that are most effective in promoting uptake and retention can be identified.

OBJECTIVES

This review aims to identify recruitment strategies of group-based DPPs that are associated with high uptake and common BCTs associated with high retention.

METHODS

Papers were identified with a systematic literature search. Programmes that were predominantly group-based and involved lifestyle modification and in which uptake and/or retention could be determined, were included. Intervention details were extracted, recruitment strategies and BCTs identified, and response, uptake and retention rates were calculated.

RESULTS

A range of recruitment strategies were used making it difficult to discern associations with uptake rates. For BCTs, all programmes used a credible source, 81% used instruction on how to perform a behaviour and 71% used goal setting (behaviour). BCTs more commonly found in high retention programmes included problem-solving, demonstrating the behaviour, using behavioural practice and reducing negative emotions.

CONCLUSIONS

Recommendations include that DPPs incorporate BCTs like problem-solving and demonstrating the behaviour to maximise retention.

Midlife susceptibility to the effects of poor diet on diabetes risk

OBJECTIVE

Type 2 diabetes mellitus (T2D) prevalence continues to increase, and age of incidence continues to decrease. More information is needed to target interventions to the ages where they can be most effective. The objective of this study was to explore the degree to which the association between diet and T2D incidence changes through adulthood.

METHODS

Participants were a large number (N = 2818) of community living adults in Canberra and Queanbeyan, Australia across three cohorts; young (20-24 followed to 32-36), mid-life (40-44 followed to 52-56) and late-life (60-64 followed to 72-76). Self-report dietary pattern scores at baseline and diabetes incidence across 12 years follow-up were measured, alongside confounders of caloric intake, sex, smoking status, years of education, hypertension, BMI and physical activity.

RESULTS

Cox proportional hazards indicated that neither Western nor Prudent dietary pattern scores were significantly associated with T2D incidence when confounders were included in the model. Unadjusted estimates suggested a positive association between Western dietary pattern scores and subsequent diabetes incidence (HR = 1.40, 95% CI [1.18, 1.64]). Compared with the mid-life cohort, a higher Western dietary pattern score posed a lower risk for incident T2D in the young cohort (unadjusted HR = 0.46, 95% CI [0.22, 0.96]), who also had significantly lower BMI and higher physical activity. No such significant effects were found for the late-life cohort.

CONCLUSIONS

Our findings indicate that mid-life may be a period of heightened vulnerability to the effects of an unhealthy diet on diabetes risk, but this effect is attenuated when risk factors related to diet, such as adiposity, are taken into account.

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.

Lifestyle and Progression to Type 2 Diabetes in a Cohort of Workers with Prediabetes

Background: People with prediabetes have an increased risk of developing type 2 diabetes (T2D). Few studies have evaluated the influence of lifestyle factors on the risk of progression to diabetes and reversion to normoglycemia. The aim of this study was to determine the incidence of T2D in a large cohort of workers with prediabetes, and to evaluate the influence of sociodemographic, clinical, metabolic, and lifestyle factors that affect the persistence of prediabetes and the progression to T2D. Methods: A cohort study of 27,844 adult workers (aged 20 to 65 years) from Spain who had prediabetes based on an occupational medical examination from 2012 to 2013. Prediabetes was defined as fasting plasma glucose (FPG) between 100 and 125 mg/dL. At the baseline evaluation, sociodemographic, anthropometric, metabolic, and lifestyle data were collected. At the 5-year follow-up, incident T2D was defined as an FPG of at least 126 mg/dL or initiation of an antidiabetic medication. Results: Among 235,995 initially screened workers, the prevalence of T2D was 14.19% (95% confidence interval (CI) 14.05 to 14.33) and the prevalence of prediabetes was 11.85% (95% CI 11.71 to 11.99). Follow-up data were available for 23,293 individuals with prediabetes. Among them, 36.08% (95% CI 35.46 to 36.70) returned to normoglycemia, 40.92% (95% CI 40.29 to 41.55) had persistent prediabetes, and 23.00% (95% CI 22.46 to 23.54) progressed to T2D. The risk for persistence of prediabetes and for progression to T2D increased with age, body mass index (BMI), triglyceride level, and less than 150 min/week of physical activity. An HbA1c level of 6% or greater was the strongest individual predictor of progression to T2D. Conclusions: Physical activity, diet, smoking, and BMI are modifiable factors that are associated with the persistence of prediabetes and the progression to T2D. The workplace is a feasible setting for the early detection of prediabetes and the promotion of lifestyles that can prevent progression to T2D.

Diabetes in adults with intellectual disability: prevalence and associated demographic, lifestyle, independence and health factors

BACKGROUND

As people with intellectual disabilities (ID) are now living longer, they are more at risk of developing non-communicable diseases, including type 2 diabetes mellitus. However, understanding of factors associated with diabetes for targeted management and prevention strategies is limited. This study aimed to investigate prevalence of diabetes in adults (aged ≥18 years) with ID and its relationship with demographic, lifestyle, independence and health factors.

METHOD

This was a cross-sectional analysis of interview data from 1091 adults with ID from the Leicestershire Learning Disability Register from 1 January 2010 to 31 December 2016. Logistic regression models were used to identify factors associated with diabetes in the study population.

RESULTS

The study population did not have healthy lifestyles: just under half reported having lower physical activity levels than people without ID of a similar age; one-quarter consumed fizzy drinks daily; and 20% consumed five or more fruit and/or vegetables per day. Prevalence of carer/self-reported diabetes was 7.3% (95% confidence interval 5.9-9.0). After adjustment, diabetes was positively associated with South Asian ethnicity (P = 0.03) and older age groups (P < 0.001). Diabetes was less common in people living with family members (P = 0.02). We did not find a relationship between any of the lifestyle, independence and health factors investigated.

CONCLUSIONS

A significant proportion of people with ID are living with diabetes. Diabetes management and prevention strategies should be tailored to individuals' complex needs and include consideration of lifestyle choices. Such strategies may want to focus on adults of South Asian ethnicity and people living in residential homes where prevalence appears to be higher.

Genetic Risk, a Healthy Lifestyle, and Type 2 Diabetes: the Dongfeng-Tongji Cohort Study

OBJECTIVE

The objective of this study is to examine whether healthy lifestyle could reduce diabetes risk among individuals with different genetic profiles.

DESIGN

A prospective cohort study with a median follow-up of 4.6 years from the Dongfeng-Tongji cohort was performed.

PARTICIPANTS

A total of 19 005 individuals without diabetes at baseline participated in the study.

MAIN VARIABLE MEASURE

A healthy lifestyle was determined based on 6 factors: nonsmoker, nondrinker, healthy diet, body mass index of 18.5 to 23.9 kg/m2, waist circumference less than 85 cm for men and less than 80 cm for women, and higher level of physical activity. Associations of combined lifestyle factors and incident diabetes were estimated using Cox proportional hazard regression. A polygenic risk score of 88 single-nucleotide polymorphisms previously associated with diabetes was constructed to test for association with diabetes risk among 7344 individuals, using logistic regression.

RESULTS

A total of 1555 incident diabetes were ascertained. Per SD increment of simple and weighted genetic risk score was associated with a 1.39- and 1.34-fold higher diabetes risk, respectively. Compared with poor lifestyle, intermediate and ideal lifestyle were reduced to a 23% and 46% risk of incident diabetes, respectively. Association of lifestyle with diabetes risk was independent of genetic risk. Even among individuals with high genetic risk, intermediate and ideal lifestyle were separately associated with a 29% and 49% lower risk of diabetes.

CONCLUSION

Genetic and combined lifestyle factors were independently associated with diabetes risk. A healthy lifestyle could lower diabetes risk across different genetic risk categories, emphasizing the benefit of entire populations adhering to a healthy lifestyle.

Physical activity and lipidomics in a population at high risk of type 2 diabetes mellitus

The aim was to investigate how measurements of the lipidome differ according to the level and intensity of physical activity in a population at high risk of type 2 diabetes (T2DM). A targeted metabolomics platform provided quantitative molecular data on lipid species. Linear regression examined the associations between plasma lipid concentrations, particle size and time spent in objectively measured physical activity intensity domains, in increments of 500 counts per minute (cpm) (up to >4500 cpm (~>5.6METs)). Results are presented as % difference in the concentration (lower/higher) or particle size (smaller/larger) per 10 min of activity within each intensity. Five hundred and nine participants were included. Time spent in the lowest physical activity intensity domain (<500 cpm) was unfavourably associated with VLDL (2%), HDL (-2%) and Apolipoprotein A-1 particle concentrations (-2%) and HDL diameter (-2%). Conversely, time spent in intensities ≥1000 cpm were favourably associated with HDL subclass concentrations; with stronger associations seen at moderate intensities (2000-3999 cpm (~4.5METs)). For Apolipoprotein-B concentration and VLDL particle concentration and size, a negative association was consistently observed at the highest physical activity intensity only. If these associations are causal, HDL subclasses appear sensitive to light-intensities whereas only the high category of physical activity intensity was consistently associated with VLDL subclasses.

Extrahepatic Manifestations of Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease and encompasses a spectrum of pathology from simple steatosis to inflammation and significant fibrosis that leads to cirrhosis. NAFLD and its comorbid conditions extend well beyond the liver. It is a multisystemic clinical disease entity with extrahepatic manifestations such as cardiovascular disease, type 2 diabetes, chronic kidney disease, hypothyroidism, polycystic ovarian syndrome, and psoriasis. Indeed, the most common causes of mortality in subjects with NAFLD are cardiovascular disease, followed by malignancies and then liver-related complications as a distant third. This review focuses on several of the key extrahepatic manifestations of NAFLD and areas for future investigation. Clinicians should learn to screen and initiate treatment for these extrahepatic manifestations in a prompt and timely fashion before they progress to end-organ damage.

Engaging Users in the Behavior Change Process With Digitalized Motivational Interviewing and Gamification: Development and Feasibility Testing of the Precious App

Background

Most adults do not engage in sufficient physical activity to maintain good health. Smartphone apps are increasingly used to support physical activity but typically focus on tracking behaviors with no support for the complex process of behavior change. Tracking features do not engage all users, and apps could better reach their targets by engaging users in reflecting their reasons, capabilities, and opportunities to change. Motivational interviewing supports this active engagement in self-reflection and self-regulation by fostering psychological needs proposed by the self-determination theory (ie, autonomy, competence, and relatedness). However, it is unknown whether digitalized motivational interviewing in a smartphone app engages users in this process.

Objective

This study aimed to describe the theory- and evidence-based development of the Precious app and to examine how digitalized motivational interviewing using a smartphone app engages users in the behavior change process. Specifically, we aimed to determine if use of the Precious app elicits change talk in participants and how they perceive autonomy support in the app.

Methods

A multidisciplinary team built the Precious app to support engagement in the behavior change process. The Precious app targets reflective processes with motivational interviewing and spontaneous processes with gamified tools, and builds on the principles of self-determination theory and control theory by using 7 relational techniques and 12 behavior change techniques. The feasibility of the app was tested among 12 adults, who were asked to interact with the prototype and think aloud. Semistructured interviews allowed participants to extend their statements. Participants’ interactions with the app were video recorded, transcribed, and analyzed with deductive thematic analysis to identify the theoretical themes related to autonomy support and change talk.

Results

Participants valued the autonomy supportive features in the Precious app (eg, freedom to pursue personally relevant goals and receive tailored feedback). We identified the following five themes based on the theory-based theme autonomy support: valuing the chance to choose, concern about lack of autonomy, expecting controlling features, autonomous goals, and autonomy supportive feedback. The motivational interviewing features actively engaged participants in reflecting their outcome goals and reasons for activity, producing several types of change talk and very little sustain talk. The types of change talk identified were desire, need, reasons, ability, commitment, and taking steps toward change.

Conclusions

The Precious app takes a unique approach to engage users in the behavior change process by targeting both reflective and spontaneous processes. It allows motivational interviewing in a mobile form, supports psychological needs with relational techniques, and targets intrinsic motivation with gamified elements. The motivational interviewing approach shows promise, but the impact of its interactive features and tailored feedback needs to be studied over time. The Precious app is undergoing testing in a series of n-of-1 randomized controlled trials.

Prevalence of pre-diabetes and undiagnosed diabetes in the Mollerussa prospective observational cohort study in a semi-rural area of Catalonia

OBJECTIVES

To assess the prevalence of undiagnosed diabetes and pre-diabetes in the healthy population in the Mollerussa cohort. As a secondary objective, to identify the variables associated with these conditions and to describe the changes in glycaemic status after 1 year of follow-up in subjects with pre-diabetes.

DESIGN

Prospective observational cohort study.

SETTING

General population from a semi-rural area.

PARTICIPANTS

The study included 583 participants without a diagnosis of diabetes recruited between March 2011 and July 2014.

RESULTS

The prevalence of undiagnosed diabetes was 20, 3.4% (95% CI 2.6 to 4.2) and that of pre-diabetes was 229, 39.3% (37.3 to 41.3). Among those with pre-diabetes, 18.3% had isolated impaired fasting plasma glucose (FPG) (FPG: 100 to <126 mg/dL), 58.1% had isolated impaired glycated haemoglobin (HbA1c) (HbA1c 5.7 to <6.5) and 23.6% fulfilled both criteria. Follow-up data were available for 166 subjects; 41.6%(37.8 to 45.4) returned to normoglycaemia, 57.6% (57.8 to 61.4) persisted in pre-diabetes and 0.6% (0 to 1.2) progressed to diabetes. Individuals with pre-diabetes had worse cardiometabolic risk profiles and sociodemographic features than normoglycaemic subjects. In the logistic regression model, variables significantly associated with pre-diabetes were older age (OR; 95% CI) (1.033; 1.011 to 1.056), higher physical activity (0.546; 0.360 to 0.827), body mass index (1.121; 1.029 to 1.222) and a family history of diabetes (1.543; 1.025 to 2.323). The variables significantly associated with glycaemic normalisation were older age (0.948; 0.916 to 0.982) and body mass index (0.779; 0.651 to 0.931).

CONCLUSIONS

Among adults in our region, the estimated prevalence of undiagnosed diabetes was 3.4% and that of pre-diabetes was 39.3%. After a 1-year follow-up, a small proportion of subjects (0.6%) with pre-diabetes progressed to diabetes, while a high proportion (41.6%) returned to normoglycaemia. Individuals with pre-diabetes who returned to normoglycaemia were younger and had a lower body mass index.

Eating Competence Is Associated with Lower Prevalence of Obesity and Better Insulin Sensitivity in Finnish Adults with Increased Risk for Type 2 Diabetes: The StopDia Study

A healthy diet prevents type 2 diabetes but is often difficult to adhere to. This cross-sectional study aimed to investigate whether eating competence is associated with diet or risk factors and prevalence of type 2 diabetes in individuals screened for type 2 diabetes risk. Eating competence is an indicator of food acceptance, positive attitudes, internal regulation and contextual skills related to food and eating. In total, 3147 Finnish adults aged 18-74 at an increased risk for type 2 diabetes identified via online risk screening participated in the baseline examinations of the Stop Diabetes (StopDia) study. The participants filled out the digital questionnaire on food intake, physical activity and sleep, and the Satter Eating Competence Inventory 2.0^TM (ecSI 2.0^TM). In addition, anthropometric and laboratory measurements were performed at primary healthcare centres. Eating competent individuals (37%, classified by ecSI 2.0^TM) had a better quality of diet (p < 0.05 for all). Additionally, eating competence was associated with a lower prevalence of previously undiagnosed type 2 diabetes, abdominal obesity, metabolic syndrome and hypertriglyceridaemia, and with better insulin sensitivity (p < 0.05 for all). However, these associations, except for metabolic syndrome, were at least partly mediated by body mass index. Eating competence is associated with a healthy diet and could, thus, in the long term, support the prevention of type 2 diabetes.

The community-based prevention of diabetes (ComPoD) study: a randomised, waiting list controlled trial of a voluntary sector-led diabetes prevention programme

Objective

This two-site randomised trial compared the effectiveness of a voluntary sector-led, community-based diabetes prevention programme to a waiting-list control group at 6 months, and included an observational follow-up of the intervention arm to 12 months.

Methods

Adults aged 18–75 years at increased risk of developing type 2 diabetes due to elevated blood glucose and being overweight were recruited from primary care practices at two UK sites, with data collected in participants’ homes or community venues. Participants were randomised using an online central allocation service. The intervention, comprising the prototype “Living Well, Taking Control” (LWTC) programme, involved four weekly two-hour group sessions held in local community venues to promote changes in diet and physical activity, plus planned follow-up contacts at two, three, six, nine and 12 months alongside 5 hours of additional activities/classes. Waiting list controls received usual care for 6 months before accessing the programme. The primary outcome was weight loss at 6 months. Secondary outcomes included glycated haemoglobin (HbA1c), blood pressure, physical activity, diet, health status and well-being. Only researchers conducting analyses were blinded.

Results

The target sample of 314 participants (157 each arm) was largely representative of local populations, including 44% men, 26% from ethnic minorities and 33% living in deprived areas. Primary outcome data were available for 285 (91%) participants (141 intervention, 144 control). Between baseline and 6 months, intervention participants on average lost more weight than controls (− 1.7 kg, 95% CI − 2.59 to − 0.85). Higher attendance was associated with greater weight loss (− 3.0 kg, 95% CI − 4.5 to − 1.5). The prototype LWTC programme more than doubled the proportion of participants losing > 5% of their body weight (21% intervention vs. 8% control, OR 2.83, 95% CI 1.36 to 5.90) and improved self-reported dietary behaviour and health status. There were no impacts on HbA1c, blood pressure, physical activity and well-being at 6 months and, amongst intervention participants, few further changes from six to 12-months (e.g. average weight re-gain 0.36 kg, 95% CI − 0.20 to 0.91). There were no serious adverse events but four exercise-related injuries were reported in the intervention arm.

Conclusions

This voluntary sector-led diabetes prevention programme reached a broad spectrum of the population and had modest effects on weight-related outcomes, but limited impacts on other diabetes risk factors.

Trial registration

Trial registration number: ISRCTN70221670, 5 September 2014

Funder (National Institute for Health Research School for Public Health Research) project reference number: SPHR-EXE-PES-COM.

Economic impact of disease prevention in a morbidity-based financing system: does prevention pay off for a statutory health insurance fund in Germany?

Preventable chronic diseases account for the greatest burden in the German health system and statutory health insurance (SHI) funds play a crucial role in implementing and financing prevention strategies. On the contrary, the morbidity-based scheme to distribute financial resources from the Central Reallocation Pool among the different sickness funds may counteract efforts of effective prevention from an economic perspective. We assessed financial impacts of prevention from a sickness funds perspective in a retrospective controlled study. Claims data of 6,247,275 persons were analyzed and outcomes between two propensity-matched groups (n = 852,048) of prevention users and non-users were compared in a 4-year follow-up. Using a difference-in-differences approach, we analyzed healthcare expenditures, the development of morbidity, financial transfers from the Central Reallocation Pool, and contribution margins. The group of prevention users develops less morbidity (incidences and disease aggravations) compared to the control group. Healthcare expenditures increase in both groups within 4 years, whereas the increase is lower for prevention users compared to non-users (€568.04 vs. €640.60, p < 0.0001). Taking morbidity-based financial transfers into account, the decrease in contribution margins is stronger for prevention users (- €188.44 vs. - €138.73, p < 0.0001). This study demonstrates an economic disincentive from a sickness funds' perspective. In the semi-competitive SHI market, sickness funds will be discouraged from effective prevention strategies if investments are not worth it financially. Their efforts and knowledge are, however, crucial for joint action to foster prevention over cure in the health system.

Influence of Educational Level on Psychosocial Correlates and Perceived Environmental Correlates of Physical Activity in Adults at Risk for Type 2 Diabetes: The Feel4Diabetes-Study

BACKGROUND

This study aimed to investigate whether the relationship between psychosocial and perceived environmental factors and physical activity (PA) in adults at risk for type 2 diabetes is influenced by educational level.

METHODS

Based on the Finnish Diabetes Risk Score questionnaire, this study selected 164 adults (Mage: 38 (5.34) y, 13.4% men) at type 2 diabetes risk from 11 low socioeconomic neighborhoods in Flanders (Belgium). Participants filled out questionnaires on psychosocial and perceived environmental factors and wore an ActiGraph accelerometer for 5 consecutive days. Statistical analyses were performed using analysis of covariance in SPSS.

RESULTS

Educational level significantly influenced the association between perception of body weight and light PA (P = .01) and total PA (P = .03) on weekend days. Educational level did not influence the associations between other psychosocial and perceived environmental factors (ie, perceived social influence; environmental, time and attitudinal barriers, perceived self-efficacy; knowledge and fatalism) and PA.

CONCLUSIONS

Educational level did not influence the relationship between most psychosocial and perceived environmental factors and PA in this sample of adults at type 2 diabetes risk. This suggests that addressing different psychosocial and perceived environmental correlates in lower and higher educated participants might not be necessary. However, more research in this specific population is needed.

Perceptions, experiences and barriers to lifestyle modifications in first-generation Middle Eastern immigrants to Sweden: a qualitative study

OBJECTIVE

The prevalence of type 2 diabetes (T2D) among Iraqi immigrants to Sweden is high and partly related to sedentary physical activity and calorie dense food. The aim of the present study was to explore perceptions, experiences and barriers concerning lifestyle modifications (LSM) in Iraqi immigrants to Sweden at risk for T2D.

DESIGN

A qualitative thematic analysis was conducted on data collected from gender-specific focus group interviews which took place during a culturally adapted randomised controlled intervention study addressing motivation to lifestyle change, self-empowerment, behavioural modifications and sociocultural barriers to LSM. Seven focus groups were held, with an interval of 1-4 weeks between January and May of 2015; each session lasted approximately 1.5 hours.

SETTING

The city of Malmö, Sweden.

PARTICIPANTS

Out of 27 women and 23 men assigned to the intervention group, 19 women and 14 men who attended at least one focus group session were included in the study.

RESULTS

Participants expressed awareness of the content of healthy lifestyle practices. They also expressed numerous social and cultural barriers to LSM connected to irregular meals, overeating, food and drinking preferences and family expectations. Overeating was described as a consequence of social and cultural norms and expectations and of poor mental well-being. Facilitators for reaching successful LSM were connected to family involvement and support.

CONCLUSION

Our study reports that facilitators for LSM are connected to presence of family support. Preventive actions addressing family involvement may benefit Middle Eastern immigrants at high risk for T2D to consider healthier lifestyles practices. Identification of sociocultural barriers and facilitators for LSM are crucial for successful health promotion in minority populations at risk for T2D.

TRIAL REGISTRATION

Trial registration number: NCT01420198 for the MEDIM-study; Pre-results.

Which clinical and biochemical predictors should be used to screen for diabetes in patients with serious mental illness receiving antipsychotic medication? A large observational study

OBJECTIVE

We aimed to investigate which clinical and metabolic tests offer optimal accuracy and acceptability to help diagnose diabetes among a large sample of people with serious mental illness in receipt of antipsychotic medication.

METHODS

A prospective observational study design of biochemical and clinical factors was used. Biochemical measures were fasting glucose, insulin and lipids, oral glucose tolerance testing (OGTT), hemoglobin A1c, and insulin resistance assessed with the homeostatic model (HOMA-IR) were determined in a consecutive cohort of 798 adult psychiatric inpatients receiving antipsychotics. Clinical variables were gender, age, global assessment of functioning (GAF), mental health clinicians' global impression (CGI), duration of severe mental illness, height, weight, BMI and waist/hip ratio. In addition, we calculated the risk using combined clinical predictors using the Leicester Practice Risk Score (LPRS) and the Topics Diabetes Risk Score (TDRS). Diabetes was defined by older criteria (impaired fasting glucose (IFG) or OGTT) as well as2010 criteria (IFG or OGTT or Glycated haemoglobin (HBA1c)) at conventional cut-offs.

RESULTS

Using the older criteria, 7.8% had diabetes (men: 6.3%; women: 10.3%). Using the new criteria, 10.2% had diabetes (men: 8.2%, women: 13.2%), representing a 30.7% increase (p = 0.02) in the prevalence of diabetes. Regarding biochemical predictors, conventional OGTT, IFG, and HbA1c thresholds used to identify newly defined diabetes missed 25%, 50% and 75% of people with diabetes, respectively. The conventional HBA1c cut-point of ≥6.5% (48 mmol/mol) missed 7 of 10 newly defined cases of diabetes while a cut-point of ≥5.7% improved sensitivity from 44.4% to up to 85%. Specific algorithm approaches offered reasonable accuracy. Unfortunately no single clinical factor was able to accurately rule-in a diagnosis of diabetes. Three clinical factors were able to rule-out diabetes with good accuracy namely: BMI, waist/hip ratio and height. A BMI < 30 had a 92% negative predictive value in ruling-out diabetes. Of those not diabetic, 20% had a BMI ≥ 30. However, for complete diagnosis a specific biochemical protocol is still necessary.

CONCLUSIONS

Patients with SMI maintained on antipsychotic medication cannot be reliably screened for diabetes using clinical variables alone. Accurate assessment requires a two-step algorithm consisting of HBA1c ≥5.7% followed by both FG and OGTT which does not require all patients to have OGTT and FG.

Flavonoids and Their Anti-Diabetic Effects: Cellular Mechanisms and Effects to Improve Blood Sugar Levels

Diabetes mellitus (DM) is a prevailing global health metabolic disorder, with an alarming incidence rate and a huge burden on health care providers. DM is characterized by the elevation of blood glucose due either to a defect in insulin synthesis, secretion, binding to receptor, or an increase of insulin resistance. The internal and external factors such as obesity, urbanizations, and genetic mutations could increase the risk of developing DM. Flavonoids are phenolic compounds existing as secondary metabolites in fruits and vegetables as well as fungi. Their structure consists of 15 carbon skeletons and two aromatic rings (A and B) connected by three carbon chains. Flavonoids are furtherly classified into 6 subclasses: flavonols, flavones, flavanones, isoflavones, flavanols, and anthocyanidins. Naturally occurring flavonoids possess anti-diabetic effects. As in vitro and animal model's studies demonstrate, they have the ability to prevent diabetes and its complications. The aim of this review is to summarize the current knowledge addressing the antidiabetic effects of dietary flavonoids and their underlying molecular mechanisms on selected pathways: Glucose transporter, hepatic enzymes, tyrosine kinase inhibitor, AMPK, PPAR, and NF-κB. Flavonoids improve the pathogenesis of diabetes and its complications through the regulation of glucose metabolism, hepatic enzymes activities, and a lipid profile. Most studies illustrate a positive role of specific dietary flavonoids on diabetes, but the mechanisms of action and the side effects need more clarification. Overall, more research is needed to provide a better understanding of the mechanisms of diabetes treatment using flavonoids.

Effectiveness of a type 2 diabetes prevention program combining FINDRISC scoring and telephone-based coaching in the French population of bakery/pastry employees

Background/objectives

Preventive actions targeting the risk of type 2 diabetes mellitus (T2D) and deployed from the workplace are scarce. This study aimed to measure this T2D risk in a large sample of the bakery/pastry employees in France and to assess the effectiveness of a telephone coaching program in participants with the highest risk.

Subjects/methods

A screening survey using the FINDRISC score was conducted by phone among the employees. Those with a moderate risk (score ≥ 12 and <15; body mass index ≥ 25 kg/m²) or high/very high risk (score ≥ 15) were invited to participate in a 6-month coaching program including 6 monthly interviews together with a final evaluation interview three months later. The effects and impact were evaluated using 8 questions on dietary knowledge/behavior as well as the GPAQ (physical activity) and SF-12 (quality of life) questionnaires.

Results

There were 19,951 employees eligible for screening (age: 38.0 ± 13.5 years, men 49.6%, mean FINDRISC score 5.9 ± 4.4). A high/very high score was found in 4% of individuals. Overall, 1,348 (among 2,018) eligible employees agreed to participate in the coaching program, 630 of whom participated in all interviews. Of the latter, dietary knowledge/behavior (+1.60) and quality of life (+1.83) improved (P < 0.0001), with a favorable trend for physical activity (+0.06, P = 0.0756). Dietary knowledge/behavior continued to improve in the 581 completers (+0.17, P = 0.0001).

Conclusions

This two-step prevention program associating T2D risk estimation and a 6-month telephone coaching was deployed in the French craft bakery/pastry sector with significant adhesion. Such program appears beneficial for enhancing knowledge and mobilizing skills associated with T2D prevention.

Dietary factors and diabetes-related health outcomes in patients with type 2 diabetes: protocol for a systematic review and meta-analysis of prospective observational studies

INTRODUCTION

Type 2 diabetes (T2D) is a major health concern associated with several comorbidities such as diabetic chronic kidney disease, neuropathy and cardiovascular diseases. Many of these complications may be preventable by an adequate lifestyle, including a favourable dietary behaviour, additionally to pharmacological management. In general, dietary guidelines for patients with diabetes recommend a hypocaloric diet to achieve a normal weight, but there is a lack of detailed instructions on specific nutrients and foods to prevent diabetes-related outcomes. Therefore, the aim of this systematic review and meta-analysis is to summarise the available evidence on the association between dietary factors and health-related outcomes in patients with T2D.

METHODS AND ANALYSIS

A systematic literature search will be conducted in PubMed and Web of Science in May 2019 to identify prospective observational studies investigating dietary factors in association with major complications in patients with T2D. We will include studies investigating dietary patterns, food groups, foods, macronutrients and micronutrients as well as secondary plant compounds. As diabetes-related outcomes, we will include macrovascular (cardiovascular and cerebrovascular diseases) and microvascular outcomes (nephropathy, neuropathy and retinopathy), as well as cancer, quality of life, depression, cognitive disorders and mortality. We will conduct dose-response meta-analyses using random effects models. We will investigate heterogeneity across studies and publication bias. To assess the risk of bias and quality of the included studies, we will use the Cochrane risk of bias tool ROBINS-I and the quality of evidence will be assessed using Grades of Recommendation, Assessment, Development, and Evaluation.

ETHICS AND DISSEMINATION

As the systematic review is based on published studies, ethical considerations are not required. The systematic review and meta-analysis will be published in a peer-reviewed Journal.

PROSPERO REGISTRATION NUMBER

CRD42018110669.

Role of diet in type 2 diabetes incidence: umbrella review of meta-analyses of prospective observational studies

OBJECTIVE

To summarise the evidence of associations between dietary factors and incidence of type 2 diabetes and to evaluate the strength and validity of these associations.

DESIGN

Umbrella review of systematic reviews with meta-analyses of prospective observational studies.

DATA SOURCES

PubMed, Web of Science, and Embase, searched up to August 2018.

ELIGIBILITY CRITERIA

Systematic reviews with meta-analyses reporting summary risk estimates for the associations between incidence of type 2 diabetes and dietary behaviours or diet quality indices, food groups, foods, beverages, alcoholic beverages, macronutrients, and micronutrients.

RESULTS

53 publications were included, with 153 adjusted summary hazard ratios on dietary behaviours or diet quality indices (n=12), food groups and foods (n=56), beverages (n=10), alcoholic beverages (n=12), macronutrients (n=32), and micronutrients (n=31), regarding incidence of type 2 diabetes. Methodological quality was high for 75% (n=115) of meta-analyses, moderate for 23% (n=35), and low for 2% (n=3). Quality of evidence was rated high for an inverse association for type 2 diabetes incidence with increased intake of whole grains (for an increment of 30 g/day, adjusted summary hazard ratio 0.87 (95% confidence interval 0.82 to 0.93)) and cereal fibre (for an increment of 10 g/day, 0.75 (0.65 to 0.86)), as well as for moderate intake of total alcohol (for an intake of 12-24 g/day v no consumption, 0.75 (0.67 to 0.83)). Quality of evidence was also high for the association for increased incidence of type 2 diabetes with higher intake of red meat (for an increment of 100 g/day, 1.17 (1.08 to 1.26)), processed meat (for an increment of 50 g/day, 1.37 (1.22 to 1.54)), bacon (per two slices/day, 2.07 (1.40 to 3.05)), and sugar sweetened beverages (for an increase of one serving/day, 1.26 (1.11 to 1.43)).

CONCLUSIONS

Overall, the association between dietary factors and type 2 diabetes has been extensively studied, but few of the associations were graded as high quality of evidence. Further factors are likely to be important in type 2 diabetes prevention; thus, more well conducted research, with more detailed assessment of diet, is needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018088106.

Metabolic syndrome and pre-eclampsia

OBJECTIVE

To evaluate the association between different pre-eclampsia (PE) phenotypes and the development of metabolic syndrome postpartum, in order to identify the subgroup of formerly pre-eclamptic women with a worse cardiovascular risk profile requiring tailored postpartum follow-up.

METHODS

This was a cohort study of 1102 formerly pre-eclamptic women in whom cardiovascular and cardiometabolic evaluation was performed at least 3 months postpartum. Women were divided into four subgroups based on PE resulting in delivery before 34 weeks (early-onset (EO)) or at or after 34 weeks (late onset (LO)) of gestation and whether they delivered a small-for-gestational-age (SGA) neonate. Metabolic syndrome was diagnosed as the presence of hyperinsulinemia along with two or more of: body mass index ≥ 30 kg/m² ; dyslipidemia; hypertension; and microalbuminuria or proteinuria. Data were compared between groups using ANOVA after Bonferroni correction. Odds ratios (OR) were calculated using logistic regression to determine the association between metabolic syndrome and the four subgroups. We constructed receiver-operating characteristics curves and computed the area under the curve (AUC) to quantify the ability of different obstetric variables to distinguish between women who developed metabolic syndrome and those who did not.

RESULTS

The prevalence of metabolic syndrome was higher in women with EO-PE and SGA (25.8%) than in those with EO-PE without SGA (14.7%) (OR 2.01 (95% CI, 1.34-3.03)) and approximately five-fold higher than in women with LO-PE with SGA (5.6%) (OR 5.85 (95% CI, 2.60-13.10)). In women with LO-PE, the prevalence of metabolic syndrome did not differ significantly between women with and those without SGA. Multivariate analysis revealed that a history of SGA, a history of EO-PE and systolic blood pressure at the time of screening are the best predictors of developing metabolic syndrome postpartum. The AUC of the model combining these three variables was 74.6% (95% CI, 70.7-78.5%). The probability of the presence of metabolic syndrome was calculated as: P = 1/(1 + e^-LP ), where LP is linear predictor = -8.693 + (0.312 × SGA (yes = 1)) + (0.507 × EO-PE (yes = 1)) + (0.053 × systolic blood pressure).

CONCLUSIONS

The incidence of metabolic syndrome postpartum was associated more strongly with EO-PE in combination with SGA as compared with LO-PE or EO-PE without SGA. Both time of onset of PE and fetal growth affect the risk of metabolic syndrome after a pre-eclamptic pregnancy. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Determining minimum set of features for diabetes mobile apps

Purpose

Interest in mobile health applications (apps) for diabetes self-care is growing. Mobile health is a promising new treatment modality for diabetes, though few smartphone apps have been designed based on a proper study and prioritization. The aim of this study was to determine a minimum set of features for diabetes mobile apps.

Methods

This study was conducted in three steps: 1.A review of the literature to collect all available features, 2. Assessing the validity of suggested features by Content Validity Index (CVI) and Content Validity Ratio (CVR), 3. Examining the importance of features by Friedman test.

Results

We retrieved all features of available mobile apps for type 2 diabetes, which are suggested and discussed in literature and compiled as a single list comprising of 33 features. Then, a survey of expert's opinion produced a set of 23 final minimum features which includes all types of tracking, mealtime tagging, food database, diet management, educational materials, healthy coping, reducing risks, problem solving, Email, color coding, alerts, reminder, target range setting, trend chart view, logbook view, numerical indicators view, customizable theme, preset notes, and custom notes. According to the mean rank which indicates the priority of each feature, the most important one was blood glucose tracking (with 16.71 mean rank) and the least important feature was the numerical indicators like such as standard deviation or average (with 6.50 mean rank).

Conclusions

The present study is the first step towards the development of our mobile apps for people with type II diabetes, and highest the essential features that are required for an optimal self-care comprehensively.

[Quality of Life and Satisfaction During the Diabetes Prevention Program GLICEMIA: a Cluster-Randomized, Controlled Trial]

OBJECTIVES

We aimed to assess the health-related quality of life as well as participant satisfaction during the pharmacy-based diabetes prevention program GLICEMIA.

METHODS

GLICEMIA comprises 3 individual counseling sessions and 5 group-based lectures addressing a lifestyle modification. In a cluster-randomized controlled trial, GLICEMIA was compared with reduced standard information in the control group. After 12 months, the groups were compared regarding the diabetes risk score FINDRISC, health-related quality of life with the 12-item Short Form health survey (SF-12) and participant satisfaction.

RESULTS

In total, the data of 1,087 participants were analyzed. During GLICEMIA, 38.9% reduced their FINDRISC whereas 20.9% reached this goal in the control group. Moreover, the physical quality of life improved significantly in the intervention group compared with the control group (adjusted effect size: 2.39 points, 95% CI 1.43-3.34). Participants of GLICEMIA who reduced their diabetes risk had enhanced mental and physical quality of life after one year. This was not observed in the control group. The overall benefit and satisfaction were rated very high in the intervention group.

CONCLUSION

Participation in GLICEMIA results in a significant reduction of the diabetes risk according to the FINDRISC, as well as an improved physical and mental quality of life. The high satisfaction of the participants reflects the overall benefit. Nationwide implementation of the program is recommended.

1-Hour Post-OGTT Glucose Improves the Early Prediction of Type 2 Diabetes by Clinical and Metabolic Markers

CONTEXT

Early prediction of dysglycemia is crucial to prevent progression to type 2 diabetes. The 1-hour postload plasma glucose (PG) is reported to be a better predictor of dysglycemia than fasting plasma glucose (FPG), 2-hour PG, or glycated hemoglobin (HbA1c).

OBJECTIVE

To evaluate the predictive performance of clinical markers, metabolites, HbA1c, and PG and serum insulin (INS) levels during a 75-g oral glucose tolerance test (OGTT).

DESIGN AND SETTING

We measured PG and INS levels at 0, 30, 60, and 120 minutes during an OGTT in 543 participants in the Botnia Prospective Study, 146 of whom progressed to type 2 diabetes within a 10-year follow-up period. Using combinations of variables, we evaluated 1527 predictive models for progression to type 2 diabetes.

RESULTS

The 1-hour PG outperformed every individual marker except 30-minute PG or mannose, whose predictive performances were lower but not significantly worse. HbA1c was inferior to 1-hour PG according to DeLong test P value but not false discovery rate. Combining the metabolic markers with PG measurements and HbA1c significantly improved the predictive models, and mannose was found to be a robust metabolic marker.

CONCLUSIONS

The 1-hour PG, alone or in combination with metabolic markers, is a robust predictor for determining the future risk of type 2 diabetes, outperforms the 2-hour PG, and is cheaper to measure than metabolites. Metabolites add to the predictive value of PG and HbA1c measurements. Shortening the standard 75-g OGTT to 1 hour improves its predictive value and clinical usability.

Evaluating the utility of self-reported questionnaire data to screen for dysglycemia in young adults: Findings from the US National Health and Nutrition Examination Survey

Dysglycemia, including prediabetes and type 2 diabetes, is dangerous and widespread. Yet, the condition is transiently reversible and sequelae preventable, prompting the use of prediction algorithms to quickly assess dysglycemia status through self-reported data. However, as current algorithms have largely been developed in older populations, their application to younger adults is uncertain considering associations between risk factors and dysglycemia vary by age. We sought to identify sex-specific predictors of current dysglycemia among young adults and evaluate their ability to screen for prediabetes and undiagnosed diabetes. We analyzed 2005-2014 data from the National Health and Nutrition Examination Survey for 3251 participants aged 20-39, who completed an oral glucose tolerance test (OGTT), had not been diagnosed with diabetes, and, for females, were not pregnant. Sex-specific stepwise logistic models were fit with predictors identified from univariate analyses. Risk scores were developed using adjusted odds ratios and model performance was assessed using area under the curve (AUC) measures. The OGTT identified 906 (27.9%) and 78 (2.4%) participants with prediabetes or undiagnosed diabetes, respectively. Predictors of dysglycemia status for males were BMI, age, race, and first-degree family history of diabetes, and, in addition to those, education, delivered baby weight, waist circumference, and vigorous physical activity for females. Our male- and female-specific models demonstrated improved validity to assess dysglycemia presence among young adults relative to the widely-used American Diabetes Association test (AUC = 0.69 vs. 0.61; 0.92 vs. 0.71, respectively). Thus, age-specific scoring algorithms employing questionnaire data show promise and are effective in identifying dysglycemia among young adults.

Dietary fat and risk of type 2 diabetes

PURPOSE OF REVIEW

Nutrition recommendations emphasize that not only dietary fat quantity but also fat quality plays a role in the prevention of type 2 diabetes (T2D). The aim of this review is to summarize the evidence for dietary fat and risk of T2D, to highlight recent findings and point out future research directions.

RECENT FINDINGS

Total fat intake was not associated with risk of T2D, whereas the findings on fatty acids (FAs) and risk of T2D were controversial. Recent findings suggested that FAs from the same classes (e.g. omega-6 FAs) but different sources might be differently associated with the risk of T2D, with indication for an association with lower risk of T2D for plant-based and higher risk/no association for animal-based FAs. In addition, differences between populations from different geographic areas might exist, but no interaction effects for fat intake and genetic predisposition were observed regarding T2D risk. The simultaneous investigation of different fats and dietary patterns can provide important and meaningful insights into these associations.

SUMMARY

The evidence for the association between dietary fat intake and risk of T2D is not conclusive yet. To strengthen the evidence, the complexity of the different associations of dietary fats should be considered in well conducted future studies.

Evaluation of a Community-Based Diabetes Prevention Program in Thailand: A Cluster Randomized Controlled Trial

OBJECTIVES

Lifestyle interventions have been shown to effectively reduce the incidence of diabetes, but evidence from middle-income countries is scarce. We evaluated the effectiveness of a lifestyle program to prevent diabetes in primary-care settings in Thailand.

METHODS

A matched-pair cluster randomized controlled trial was conducted in 68 primary care units in 8 provinces. The primary care units were randomly assigned to intervention or control arms. Individuals aged 30 to 65 years with impaired oral glucose tolerance were recruited and followed up for 2 years. The intervention included periodic group-based activities on healthy lifestyle behaviors; the control group received a one-time education program. The primary outcome was the incidence rate of type 2 diabetes at 24 months after the intervention.

RESULTS

A total of 1903 individuals participated (873 in the control group and 1030 in the intervention group). At baseline, participants' characteristics did not differ between groups. After 24 months, the incidence rates (per 100 person-year) of diabetes was 12.1% (95% CI 10.7% to 13.8%) in the intervention group, and 16.6% (95% CI 14.6 to 18.8%) in the control group ( P < .001). Overall, the adjusted hazard ratio for diabetes incidence was 0.72 (95% CI 0.60 to 0.86). A mean body weight reduction of 1.5 kg was observed in the intervention group, whereas, an increase of 0.4 kg was observed in the control group ( P < .001).

CONCLUSION

A community-based lifestyle modification through participatory group activities can prevent or delay the incidence of diabetes among Thai populations with impaired glucose tolerance.

Validity of the FINDRISC as a prediction tool for diabetes in a contemporary Norwegian population: a 10-year follow-up of the HUNT study

OBJECTIVE

The Finnish Diabetes Risk Score (FINDRISC) is a recommended tool for type 2 diabetes prediction. There is a lack of studies examining the performance of the current 0-26 point FINDRISC scale. We examined the validity of FINDRISC in a contemporary Norwegian risk environment.

RESEARCH DESIGN AND METHODS

We followed 47 804 participants without known diabetes and aged ≥20 years in the HUNT3 survey (2006-2008) by linkage to information on glucose-lowering drug dispensing in the Norwegian Prescription Database (2004-2016). We estimated the C-statistic, sensitivity and specificity of FINDRISC as predictor of incident diabetes, as indicated by incident use of glucose-lowering drugs. We estimated the 10-year cumulative diabetes incidence by categories of FINDRISC.

RESULTS

The C-statistic (95% CI) of FINDRISC in predicting future diabetes was 0.77 (0.76 to 0.78). FINDRISC ≥15 (the conventional cut-off value) had a sensitivity of 38% and a specificity of 90%. The 10-year cumulative diabetes incidence (95% CI) was 4.0% (3.8% to 4.2%) in the entire study population, 13.5% (12.5% to 14.5%) for people with FINDRISC ≥15 and 2.8% (2.6% to 3.0%) for people with FINDRISC <15. Thus, FINDRISC ≥15 had a positive predictive value of 13.5% and a negative predictive value of 97.2% for diabetes within the next 10 years. To approach a similar sensitivity as in the study in which FINDRISC was developed, we would have to lower the cut-off value for elevated FINDRISC to ≥11. This would yield a sensitivity of 73%, specificity of 67%, positive predictive value of 7.7% and negative predictive value of 98.5%.

CONCLUSIONS

The validity of FINDRISC and the risk of diabetes among people with FINDRISC ≥15 is substantially lower in the contemporary Norwegian population than assumed in official guidelines. To identify ~3/4 of those developing diabetes within the next 10 years, we would have to lower the threshold for elevated FINDRISC to ≥11, which would label ~1/3 of the entire adult population as having an elevated FINDRISC necessitating a glycemia assessment.

Detecting persons at risk for diabetes mellitus type 2 using FINDRISC: results from a community pharmacy-based study

Background

This cross-sectional study has been developed within the framework of the Italian project 'We love your heart' ('Ci sta a cuore il tuo cuore') and reports the results of the initial type 2 diabetes mellitus (T2DM) risk assessment carried out in a big network of community pharmacies in Italy and Spain.

Methods

In total 4002 pharmacists from 854pharmacies were specifically trained to collect data and perform the evaluation of the probability of developing T2DM among pharmacy customers. The risk of developing T2DM within 10 years was evaluated using the FINDRISC.

Results

Overall, 7234 (22.1%) subjects were at low risk to develop the disease, whereas 43.3% were at slightly elevated risk (scores 7-11), 19.3% were at moderate (scores 12-14), 13.9% were at high (scores 15-20), and 1.4% were at very high risk (scores > 20). Spanish participants showed higher levels of risk than Italian (16.7 vs. 14.7%) taking the cut-off FINDRISC ≥ 15.

Conclusion

This study shows that considerable percentage of persons is likely to develop diabetes in the next 10 years. Analyses of the risk factors indicate that men were more susceptible to develop this disease, as well as the Spanish participants respect to Italian.

Heterogeneity of gestational diabetes (GDM) and challenges in developing a GDM risk score

AIMS

Gestational diabetes (GDM) affects a growing number of women and identification of individuals at risk, e.g., with risk prediction models, would be important. However, the performance of GDM risk scores has not been optimal. Here, we assess the impact of GDM heterogeneity on the performance of two top-rated GDM risk scores.

METHODS

This is a substudy of the RADIEL trial-a lifestyle intervention study including women at high GDM risk. We assessed the GDM risk score by Teede and that developed by Van Leeuwen in our high-risk cohort of 510 women. To investigate the heterogeneity of GDM, we further divided the women according to GDM history, BMI, and parity. With the goal of identifying novel predictors of GDM, we further analyzed 319 women with normal glucose tolerance in the first trimester.

RESULTS

Both risk scores underestimated GDM incidence in our high-risk cohort. Among women with a BMI ≥ 30 kg/m² and/or previous GDM, 49.4% developed GDM and 37.4% received the diagnosis already in the first trimester. Van Leeuwen score estimated a 19% probability of GDM and Teede succeeded in risk identification in 61%. The lowest performance of the risk scores was seen among the non-obese women. Fasting plasma glucose, HbA_1c, and family history of diabetes were predictors of GDM in the total study population. Analysis of subgroups did not provide any further information.

CONCLUSIONS

Our findings suggest that the marked heterogeneity of GDM challenges the development of risk scores for detection of GDM.

Quantified patient preferences for lifestyle intervention programs for diabetes prevention-a protocol for a systematic review

BACKGROUND

The 20-70% participation of diabetes patients in lifestyle interventions (LSI) worldwide seems to be rather sub-optimal, in spite of all intents of such interventions to delay further progress of the disease. Positive effects through LSI are expected in particular for patients who suffer less from diabetes-related limitations or other chronic diseases. Seeing that diabetes prevalence and with it mortality are increasing, LSI have become an inherent part of diabetes treatment standards. Various qualitative studies have been carried out to identify participation barriers for LSI. However, these have not resulted in more detailed knowledge about the relative importance of factors with an inhibiting impact on participation. Since it cannot be assumed that all of the influencing factors have equivalent values, it is necessary to investigate their individual importance with regard to a positive or negative decision about participating. There are no systematic reviews on patient preferences for LSI programs in diabetes prevention. As a result, the main objectives of this systematic review are to (i) identify existing patient preference elicitation studies related to LSI for diabetic patients, (ii) summarize the methods applied and findings, and (iii) appraise the reporting and methodological quality of such studies.

METHODS

We will perform systematic literature searches to identify suitable studies from 14 electronic databases. Retrieved study records will be included based on predefined eligibility criteria as defined in this protocol. We will run abstract and full-text screenings and then extract data from all selected studies by filling in a predefined data extraction spreadsheet. We will undertake a descriptive, narrative synthesis of findings to address the study objectives, since no pooling for quantified preferences is for methodological reasons implementable. We will pay special attention to aspects of methodological quality of preference elicitation by applying established evaluation criteria of the ISPOR and some own developed criteria for different elicitation techniques. All critical stages within the screening, data extraction, and synthesis processes will be conducted by two pairs of authors. This protocol adheres to PRISMA and PRISMA-P standards.

DISCUSSION

The proposed systematic review will provide an overview of the methods used and current practice in the elicitation and quantification of patients' preferences for diabetes prevention lifestyle interventions. Furthermore, the methodological quality of the identified studies will be appraised as well.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018086988.

Metformin and Type 2 Diabetes Prevention

IN BRIEF Metformin, an established therapy for the treatment of type 2 diabetes, has demonstrated safety and effectiveness in the prevention or delay of type 2 diabetes in people at high risk. The Diabetes Prevention Program randomized clinical trial demonstrated that intensive lifestyle intervention and metformin therapy reduced progression to diabetes by 58 and 31%, respectively, compared to placebo in people at risk of type 2 diabetes. Although lifestyle intervention was beneficial in all groups, metformin had a selectively greater effect in those who were more obese, had a higher fasting glucose, had a history of gestational diabetes, or were younger. Long-term effects included an 18% diabetes reduction with metformin compared to placebo over 15 years, a reduction in microvascular complications among those who did not progress to diabetes (without difference among treatment arms), and suggestion by coronary calcium assessment of a possible impact on atherosclerosis in men. Although long-term follow-up to assess later-stage outcomes is underway, current efforts to address gaps in evidence and translation remain of significant public health interest.

Exercise Increases Adiponectin and Reduces Leptin Levels in Prediabetic and Diabetic Individuals: Systematic Review and Meta-Analysis of Randomized Controlled Trials

It is speculated that lifestyle interventions known to improve diabetic metabolic state may exert their effects via adipokines. The aim of this systematic review and meta-analysis was to evaluate the chronic effects of physical exercise on adiponectin and leptin levels in adult prediabetic and diabetic individuals. PubMed, Embase, Scopus, The Cochrane Library, clinicaltrials.gov, and WHO Clinical Trials Registry were searched for randomized controlled trials. Pooled effects of interventions were assessed as mean difference (MD) with random effects model. Sensitivity analysis was conducted to test data robustness and subgroup analysis for study heterogeneity. Twenty-two trials with 2996 individuals were included in the meta-analysis. Physical exercise increased levels of adiponectin (MD: 0.42 µg/mL; 95% confidence interval (CI), 0.23, 0.60, p < 0.00001, n = 19 trials) and reduced leptin levels (MD: −1.89 ng/mL; 95% CI, −2.64, −1.14, p < 0.00001, n = 14 trials). These results were robust and remained significant after sensitivity analysis. Study heterogeneity was generally high. As for physical exercise modalities, aerobic exercise, but not other modalities, increased adiponectin and reduced leptin levels. In conclusion, physical exercise and, specifically, aerobic exercise, leads to higher adiponectin and lower leptin levels in prediabetic and diabetic adults. However, cautious interpretation of current findings is warranted.