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

The flavones apigenin and luteolin induce FOXO1 translocation but inhibit gluconeogenic and lipogenic gene expression in human cells

The flavones apigenin (4′,5,7,-trihydroxyflavone) and luteolin (3′,4′,5,7,-tetrahydroxyflavone) are plant secondary metabolites with antioxidant, antiinflammatory, and anticancer activities. We evaluated their impact on cell signaling pathways related to insulin-resistance and type 2 diabetes. Apigenin and luteolin were identified in our U-2 OS (human osteosarcoma) cell screening assay for micronutrients triggering rapid intracellular translocation of the forkhead box transcription factor O1 (FOXO1), an important mediator of insulin signal transduction. Insulin reversed the translocation of FOXO1 as shown by live cell imaging. The impact on the expression of target genes was evaluated in HepG2 (human hepatoma) cells. The mRNA-expression of the gluconeogenic enzymes phosphoenolpyruvate carboxykinase (PEPCK) and glucose-6-phosphatase (G6Pc), the lipogenic enzymes fatty-acid synthase (FASN) and acetyl-CoA-carboxylase (ACC) were down-regulated by both flavones with smaller effective dosages of apigenin than for luteolin. PKB/AKT-, PRAS40-, p70S6K-, and S6-phosphorylation was reduced by apigenin and luteolin but not that of the insulin-like growth factor receptor IGF-1R by apigenin indicating a direct inhibition of the PKB/AKT-signaling pathway distal to the IGF-1 receptor. N-acetyl-L-cysteine did not prevent FOXO1 nuclear translocation induced by apigenin and luteolin, suggesting that these flavones do not act via oxidative stress. The roles of FOXO1, FOXO3a, AKT, sirtuin1 (SIRT1), and nuclear factor (erythroid-derived2)-like2 (NRF2), investigated by siRNA knockdown, showed differential patterns of signal pathways involved and a role of NRF2 in the inhibition of gluconeogenic enzyme expression. We conclude that these flavones show an antidiabetic potential due to reduction of gluconeogenic and lipogenic capacity despite inhibition of the PKB/AKT pathway which justifies detailed investigation in vivo.

Effect of a participant-driven health education programme in primary care for people with hyperglycaemia detected by screening: 3-year results from the Ready to Act randomized controlled trial (nested within the ADDITION-Denmark study)

AIM

To assess whether a 12-week participant-driven health education programme offered to individuals with screening-detected hyperglycaemia in Danish primary care would lead to improvements in cardiovascular risk factors, health behaviour and patient-reported outcomes after 3 years.

METHODS

We conducted a randomized controlled trial in 509 patients with screening-detected hyperglycaemia (impaired fasting glucose, impaired glucose tolerance or type 2 diabetes) from 33 general practices in Denmark. Individuals were pre-randomized to receive (i) routine care (n = 187), or (ii) an invitation to participate in the Ready to Act health education programme (n = 322). The programme was delivered over 12 weeks in primary care and focused on motivation, action experience, informed decision-making and social involvement to promote health behaviour change. The primary outcome was 10-year modelled cardiovascular risk.

RESULTS

Of 322 individuals, 123 (38%) received the intervention and 436/509 individuals (86%) returned for follow-up assessment. There was no difference between the trial groups in modelled cardiovascular risk at 3 years (relative difference: 1.01; 95% CI: 0.84 to 1.23). Total cholesterol was lower (-0.24mmol/l, 95% CI: -0.45 to -0.03, P = 0.027), and patient activation was higher in the intervention than in the control group (5.3, 95% CI: 0.97 to 9.7). No other between-group differences were observed for any cardiovascular risk factor, health behaviour or patient-reported outcome variables. Subgroup analyses suggested that the intervention was more beneficial in those with impaired fasting glucose/impaired glucose tolerance than in those with type 2 diabetes.

CONCLUSION

For patients with screening-detected hyperglycaemia, a participant-driven health education programme was not associated with improvements in most clinical, behavioural and patient-reported outcomes after 3 years of follow-up.

Obesity and associated lifestyle in a large sample of multi-morbid German primary care attendees

Background

Obesity and the accompanying increased morbidity and mortality risk is highly prevalent among older adults. As obese elderly might benefit from intentional weight reduction, it is necessary to determine associated and potentially modifiable factors on senior obesity. This cross-sectional study focuses on multi-morbid patients which make up the majority in primary care. It reports on the prevalence of senior obesity and its associations with lifestyle behaviors.

Methods

A total of 3,189 non-demented, multi-morbid participants aged 65–85 years were recruited in primary care within the German MultiCare-study. Physical activity, smoking, alcohol consumption and quantity and quality of nutritional intake were classified as relevant lifestyle factors. Body Mass Index (BMI, general obesity) and waist circumference (WC, abdominal obesity) were used as outcome measures and regression analyses were conducted.

Results

About one third of all patients were classified as obese according to BMI. The prevalence of abdominal obesity was 73.5%. Adjusted for socio-demographic variables and objective and subjective disease burden, participants with low physical activity had a 1.6 kg/m² higher BMI as well as a higher WC (4.9 cm, p<0.001). Current smoking and high alcohol consumption were associated with a lower BMI and WC. In multivariate logistic regression, using elevated WC and BMI as categorical outcomes, the same pattern in lifestyle factors was observed. Only for WC, not current but former smoking was associated with a higher probability for elevated WC. Dietary intake in quantity and quality was not associated with BMI or WC in either model.

Conclusions

Further research is needed to clarify if the huge prevalence discrepancy between BMI and WC also reflects a difference in obesity-related morbidity and mortality. Yet, age-specific thresholds for the BMI are needed likewise. Encouraging and promoting physical activity in older adults might a starting point for weight reduction efforts.

Diabetes prevention in the real world: effectiveness of pragmatic lifestyle interventions for the prevention of type 2 diabetes and of the impact of adherence to guideline recommendations: a systematic review and meta-analysis

OBJECTIVE To summarize the evidence on effectiveness of translational diabetes prevention programs, based on promoting lifestyle change to prevent type 2 diabetes in real-world settings and to examine whether adherence to international guideline recommendations is associated with effectiveness. RESEARCH DESIGN AND METHODS Bibliographic databases were searched up to July 2012. Included studies had a follow-up of ≥12 months and outcomes comparing change in body composition, glycemic control, or progression to diabetes. Lifestyle interventions aimed to translate evidence from previous efficacy trials of diabetes prevention into real-world intervention programs. Data were combined using random-effects meta-analysis and meta-regression considering the relationship between intervention effectiveness and adherence to guidelines. RESULTS Twenty-five studies met the inclusion criteria. The primary meta-analysis included 22 studies (24 study groups) with outcome data for weight loss at 12 months. The pooled result of the direct pairwise meta-analysis shows that lifestyle interventions resulted in a mean weight loss of 2.12 kg (95% CI -2.61 to -1.63; I(2) = 91.4%). Adherence to guidelines was significantly associated with a greater weight loss (an increase of 0.3 kg per point increase on a 12-point guideline-adherence scale). CONCLUSIONS Evidence suggests that pragmatic diabetes prevention programs are effective. Effectiveness varies substantially between programs but can be improved by maximizing guideline adherence. However, more research is needed to establish optimal strategies for maximizing both cost-effectiveness and longer-term maintenance of weight loss and diabetes prevention effects.

Action research led to a feasible lifestyle intervention in general practice for people with prediabetes

AIM

To develop and pilot a feasible lifestyle intervention for people with prediabetes tailored for general practice. The study was designed to explore (i) what resources and competencies would be required and (ii) which intervention components should be included.

METHODS

In the first of two action research cycles various interventions were explored in general practice. The second cycle tested the intervention described by the end of the first cycle. In total, 64 patients, 8 GPs and 10 nurses participated.

RESULTS

An intervention comprising six consultations to be delivered during the first year after identified prediabetes was found feasible by the general practice staff in terms of resources. Practice nurses possessed the adequate competences to undertake the core part of the intervention. The intervention comprised fixed elements according to structure, time consumption and educational principles, and flexible elements according to educational material and focus points for behaviour change. Clinical relevant reductions in patients' BMI and HbA1c were found.

CONCLUSION

A prediabetes lifestyle intervention for Danish general practice with potential for diabetes prevention was developed based on action research. The transferability of the developed intervention to other general practices depends on the GPs priorities, availability of practice nurses to deliver the core part, and the remuneration system for general practice. The long-term feasibility in larger patient populations is unknown.

Therapeutic interventions to reduce the risk of progression from prediabetes to type 2 diabetes mellitus

Clinical trials have demonstrated that it is possible to prevent diabetes through lifestyle modification, pharmacological intervention, and surgery. This review aims to summarize the effectiveness of these various therapeutic interventions in reducing the risk of progression of prediabetes to diabetes, and address the challenges to implement a diabetes prevention program at a community level. Strategies focusing on intensive lifestyle changes are not only efficient but cost-effective and/or cost-saving. Indeed, lifestyle intervention in people at high risk for type 2 diabetes mellitus (T2DM) has been successful in achieving sustained behavioral changes and a reduction in diabetes incidence even after the counseling is stopped. Although prediabetes is associated with health and economic burdens, it has not been adequately addressed by interventions or regulatory agencies in terms of prevention or disease management. Lifestyle intervention strategies to prevent T2DM should be distinct for different populations around the globe and should emphasize sex, age, ethnicity, and cultural and geographical considerations to be feasible and to promote better compliance. The translation of diabetes prevention research at a population level, especially finding the most effective methods of preventing T2DM in various societies and cultural settings remains challenging, but must be accomplished to stop this worldwide epidemic.

Short and long-term lifestyle coaching approaches used to address diverse participant barriers to weight loss and physical activity adherence

Background

Individual barriers to weight loss and physical activity goals in the Diabetes Prevention Program, a randomized trial with 3.2 years average treatment duration, have not been previously reported. Evaluating barriers and the lifestyle coaching approaches used to improve adherence in a large, diverse participant cohort can inform dissemination efforts.

Methods

Lifestyle coaches documented barriers and approaches after each session (mean session attendance = 50.3 ± 21.8). Subjects were 1076 intensive lifestyle participants (mean age = 50.6 years; mean BMI = 33.9 kg/m²; 68% female, 48% non-Caucasian). Barriers and approaches used to improve adherence were ranked by the percentage of the cohort for whom they applied. Barrier groupings were also analyzed in relation to baseline demographic characteristics.

Results

Top weight loss barriers reported were problems with self-monitoring (58%); social cues (58%); holidays (54%); low activity (48%); and internal cues (thought/mood) (44%). Top activity barriers were holidays (51%); time management (50%); internal cues (30%); illness (29%), and motivation (26%). The percentage of the cohort having any type of barrier increased over the long-term intervention period. A majority of the weight loss barriers were significantly associated with younger age, greater obesity, and non-Caucasian race/ethnicity (p-values vary). Physical activity barriers, particularly thought and mood cues, social cues and time management, physical injury or illness and access/weather, were most significantly associated with being female and obese (p < 0.001 for all). Lifestyle coaches used problem-solving with most participants (≥75% short-term; > 90% long term) and regularly reviewed self-monitoring skills. More costly approaches were used infrequently during the first 16 sessions (≤10%) but increased over 3.2 years.

Conclusion

Behavioral problem solving approaches have short and long term dissemination potential for many kinds of participant barriers. Given minimal resources, increased attention to training lifestyle coaches in the consistent use of these approaches appears warranted.

'I saw what the future direction would be...': experiences of diabetes risk and physical activity after diabetes screening

OBJECTIVES

To improve understanding of how individuals at high risk of type 2 diabetes experience the risk of diabetes and how these experiences relate to the adoption of physical activity as a protective behaviour.

DESIGN

A qualitative study using semi-structured interview with individuals identified by screening as at high risk of type 2 diabetes.

METHODS

Fourteen individuals, aged 40-64, were interviewed twice, with a 2-year interval between. Participants' experiences of their risk of diabetes and physical activity were assessed. The transcribed interview data were analysed using inductive qualitative content analysis.

RESULTS

Two themes emerged from the data: a threatening risk perception and a rejected risk perception. The threatening risk perception occurred when the risk was unexpected by the participant, but became internalized through the screening procedure. The threatening perception also involved a commitment to increase physical activity to prevent diabetes. However, short-term anxiety and subsequently emerging hopelessness were also part of this perception. The rejected risk perception involved indifference and scepticism regarding the risk. Here, physical activity behaviour and cognitions appeared to remain unchanged. Rejection also involved difficulties in accepting one's high-risk identity. The rejecting group lacked motivation for increased physical activity, while the other group showed determination regarding increased physical activity, often leading to success.

CONCLUSION

Perceptions of the risk of diabetes emerged as threatening or as rejected. Participants' perceptions reflected varying and intertwining emotional, cognitive, and behavioural mechanisms for coping with the risk, all of which should be recognized in promoting physical activity among high-risk individuals. Statement of contribution What is already known on this subject? Diabetes screening has few adverse psychological effects on screened individuals. Diabetes can be prevented by increased physical activity and modest weight loss among high-risk individuals. The evidence on the effects of screening on protective behaviour is limited and inconsistent. What does this study add? High-risk individuals' threatening perception of risk appears encouraging increased physical activity. Individuals having problems in adjusting to high-risk identification may not be motivated to engage in physical activity for prevention. Failure to achieve the outcomes expected from lifestyle changes may lead people with threatening risk perception to a sense of hopelessness.

The treatment of type 2 diabetes

BACKGROUND

5% to 8% of adults have type 2 diabetes, a disease that is usually asymptomatic at first. The goals of management are timely diagnosis and the prevention of complications.

METHODS

Selective review of the literature, including guidelines from Germany and abroad.

RESULTS

High caloric intake and lack of exercise are the main contributing causes of type 2 diabetes and the principal targets of intervention. If lifestyle changes do not yield adequate improvement, then drug treatment should be initiated (or intensified) and managed on the basis of the HbA1c fraction. Guidelines recommend an HbA1c target range of 6.5% to 7.5%; the individual target value should be chosen in consideration of patient-specific factors and established in collaboration with the patient. Metformin is recommended for initial drug treatment. If metformin is contraindicated, poorly tolerated, or inadequately effective, many therapeutic alternatives and supplements are available. Clinical trials have shown that sulfonylureas and insulin are beneficial with respect to patient-relevant endpoints, but comparable data from clinical trials are not yet available for any other antidiabetic drug (except metformin). For individual patients, other drugs may have advantages such as a lower risk of hypoglycemia, less weight gain, oral administration, and/or applicability in the setting of renal insufficiency. The treatment is individually oriented, depending on the patient's age, disease stage, body weight, comorbidities, work situation, adherence, and personal priorities. Combining more than two antidiabetic drugs is not recommended.

CONCLUSION

Although there are many treatment options, individualized long-term treatment still presents a challenge in many cases.

Is There a Right Time to Know? The Right Not to Know and Genetic Testing in Children

The increasing implementation of next-generation sequencing technologies in the clinical context and the expanding commercial offer of genetic tests directly-toconsumers has increased the availability of previously inaccessible genetic information. A particular concern in both situations is how the volume of novel information will affect the processing of genetic and genomic information from minors. For minors, it is argued that in the provision of genetic testing, their "right not to know" should be respected as much as possible. Testing a minor early in life eliminates the possibility for the minor to make use of his or her "right not to know." The article discusses the theoretical underpinnings of the right not know, analyzes reasons why various direct-to-consumer companies process samples from minors, and discusses the right not to know in relation to common complex disorders in a pediatric population.

Risk factors contributing to type 2 diabetes and recent advances in the treatment and prevention

Type 2 diabetes is a serious and common chronic disease resulting from a complex inheritance-environment interaction along with other risk factors such as obesity and sedentary lifestyle. Type 2 diabetes and its complications constitute a major worldwide public health problem, affecting almost all populations in both developed and developing countries with high rates of diabetes-related morbidity and mortality. The prevalence of type 2 diabetes has been increasing exponentially, and a high prevalence rate has been observed in developing countries and in populations undergoing "westernization" or modernization. Multiple risk factors of diabetes, delayed diagnosis until micro- and macro-vascular complications arise, life-threatening complications, failure of the current therapies, and financial costs for the treatment of this disease, make it necessary to develop new efficient therapy strategies and appropriate prevention measures for the control of type 2 diabetes. Herein, we summarize our current understanding about the epidemiology of type 2 diabetes, the roles of genes, lifestyle and other factors contributing to rapid increase in the incidence of type 2 diabetes. The core aims are to bring forward the new therapy strategies and cost-effective intervention trials of type 2 diabetes.

Non-invasive risk scores for prediction of type 2 diabetes (EPIC-InterAct): a validation of existing models

BACKGROUND

The comparative performance of existing models for prediction of type 2 diabetes across populations has not been investigated. We validated existing non-laboratory-based models and assessed variability in predictive performance in European populations.

METHODS

We selected non-invasive prediction models for incident diabetes developed in populations of European ancestry and validated them using data from the EPIC-InterAct case-cohort sample (27,779 individuals from eight European countries, of whom 12,403 had incident diabetes). We assessed model discrimination and calibration for the first 10 years of follow-up. The models were first adjusted to the country-specific diabetes incidence. We did the main analyses for each country and for subgroups defined by sex, age (<60 years vs ≥60 years), BMI (<25 kg/m(2)vs ≥25 kg/m(2)), and waist circumference (men <102 cm vs ≥102 cm; women <88 cm vs ≥88 cm).

FINDINGS

We validated 12 prediction models. Discrimination was acceptable to good: C statistics ranged from 0·76 (95% CI 0·72-0·80) to 0·81 (0·77-0·84) overall, from 0·73 (0·70-0·76) to 0·79 (0·74-0·83) in men, and from 0·78 (0·74-0·82) to 0·81 (0·80-0·82) in women. We noted significant heterogeneity in discrimination (pheterogeneity<0·0001) in all but one model. Calibration was good for most models, and consistent across countries (pheterogeneity>0·05) except for three models. However, two models overestimated risk, DPoRT by 34% (95% CI 29-39%) and Cambridge by 40% (28-52%). Discrimination was always better in individuals younger than 60 years or with a low waist circumference than in those aged at least 60 years or with a large waist circumference. Patterns were inconsistent for BMI. All models overestimated risks for individuals with a BMI of <25 kg/m(2). Calibration patterns were inconsistent for age and waist-circumference subgroups.

INTERPRETATION

Existing diabetes prediction models can be used to identify individuals at high risk of type 2 diabetes in the general population. However, the performance of each model varies with country, age, sex, and adiposity.

FUNDING

The European Union.

Risk predictive modelling for diabetes and cardiovascular disease

Absolute risk models or clinical prediction models have been incorporated in guidelines, and are increasingly advocated as tools to assist risk stratification and guide prevention and treatments decisions relating to common health conditions such as cardiovascular disease (CVD) and diabetes mellitus. We have reviewed the historical development and principles of prediction research, including their statistical underpinning, as well as implications for routine practice, with a focus on predictive modelling for CVD and diabetes. Predictive modelling for CVD risk, which has developed over the last five decades, has been largely influenced by the Framingham Heart Study investigators, while it is only ∼20 years ago that similar efforts were started in the field of diabetes. Identification of predictive factors is an important preliminary step which provides the knowledge base on potential predictors to be tested for inclusion during the statistical derivation of the final model. The derived models must then be tested both on the development sample (internal validation) and on other populations in different settings (external validation). Updating procedures (e.g. recalibration) should be used to improve the performance of models that fail the tests of external validation. Ultimately, the effect of introducing validated models in routine practice on the process and outcomes of care as well as its cost-effectiveness should be tested in impact studies before wide dissemination of models beyond the research context. Several predictions models have been developed for CVD or diabetes, but very few have been externally validated or tested in impact studies, and their comparative performance has yet to be fully assessed. A shift of focus from developing new CVD or diabetes prediction models to validating the existing ones will improve their adoption in routine practice.

Type 2 diabetes patients' preferences and willingness to pay for lifestyle programs: a discrete choice experiment

BACKGROUND

Participation rates of lifestyle programs among type 2 diabetes mellitus (T2DM) patients are less than optimal around the globe. Whereas research shows notable delays in the development of the disease among lifestyle program participants. Very little is known about the relative importance of barriers for participation as well as the willingness of T2DM patients to pay for participation in such programs. The aim of this study was to identify the preferences of T2DM patients with regard to lifestyle programs and to calculate participants' willingness to pay (WTP) as well as to estimate the potential participation rates of lifestyle programs.

METHODS

A Discrete Choice Experiment (DCE) questionnaire assessing five different lifestyle program attributes was distributed among 1250 Dutch adults aged 35-65 years with T2DM, 391 questionnaires (31%) were returned and included in the analysis. The relative importance of the program attributes (i.e., meal plan, physical activity (PA) schedule, consultation structure, expected program outcome and out-of-pocket costs) was determined using panel-mixed logit models. Based on the retrieved attribute estimates, patients' WTP and potential participation rates were determined.

RESULTS

The out-of-pocket costs (β = -0.75, P < .001), consultation structure (β = -0.46, P < .001) and expected outcome (β =0.72, P < .001) were the most important factors for respondents when deciding whether to participate in a lifestyle program. Respondents were willing to pay €128 per year for individual instead of group consultation and €97 per year for 10 kilograms anticipated weight loss. Potential participation rates for different lifestyle-program scenarios ranged between 48.5% and 62.4%.

CONCLUSIONS

When deciding whether to participate in a lifestyle program, T2DM patients are mostly driven by low levels of out-of-pocket costs. Thereafter, they prefer individual consultation and high levels of anticipated outcomes with respect to weight loss.

Association of living alone with the presence of undiagnosed diabetes in Japanese men: the role of modifiable risk factors for diabetes: Toranomon Hospital Health Management Center Study 13 (TOPICS 13)

AIMS

To investigate whether living alone was associated with the presence of undiagnosed diabetes and whether this association could be attenuated by modifiable lifestyle habits.

METHODS

This cross-sectional study included 6400 Japanese men without a history of diagnosed diabetes. Individuals with currently undiagnosed diabetes were identified through fasting glucose concentration ≥7.0 mmol/l or HbA1c concentration ≥ 48 mmol⁄mol (≥ 6.5%). Effect modification was examined using body mass index, hypertension, history of dyslipidaemia, drinking habits, smoking habits, physical activity, vegetable intake, emotional stress and depressed mood.

RESULTS

Men who lived alone (n = 1098) had a significantly elevated odds ratio for having undiagnosed diabetes in an age-adjusted model (odds ratio 1.45, 95% CI 1.07, 1.96; P = 0.018). After adjustment for lifestyle factors, the association was slightly attenuated (odds ratio 1.40, 95% CI 1.02, 1.91; P = 0.036). After further adjustment for all factors mentioned above, living alone was still marginally significantly associated with the presence of undiagnosed diabetes (odds ratio 1.38, 95% CI 1.003, 1.90; P = 0.048). A significant association of living alone with the presence of undetected diabetes was particularly observed among men who were overweight, currently smoked and were physically inactive, or had any one of those three factors.

CONCLUSIONS

The association between undiagnosed diabetes and living alone can be partially influenced by modifiable lifestyle factors. Men who lived alone, especially those who did not engage in favourable lifestyle habits, were more likely to have undiagnosed diabetes. Such individuals have a higher probability of having undetected diabetic hyperglycaemia and would need to undergo glucose tests to identify the disease.

Insulin resistance and environmental pollutants: experimental evidence and future perspectives

BACKGROUND

The metabolic disruptor hypothesis postulates that environmental pollutants may be risk factors for metabolic diseases. Because insulin resistance is involved in most metabolic diseases and current health care prevention programs predominantly target insulin resistance or risk factors thereof, a critical analysis of the role of pollutants in insulin resistance might be important for future management of metabolic diseases.

OBJECTIVES

We aimed to critically review the available information linking pollutant exposure to insulin resistance and to open the discussion on future perspectives for metabolic disruptor identification and prioritization strategies.

METHODS

We searched PubMed and Web of Science for experimental studies reporting on linkages between environmental pollutants and insulin resistance and identified a total of 23 studies as the prime literature.

DISCUSSION

Recent studies specifically designed to investigate the effect of pollutants on insulin sensitivity show a potential causation of insulin resistance. Based on these studies, a summary of viable test systems and end points can be composed, allowing insight into what is missing and what is needed to create a standardized insulin resistance toxicity testing strategy.

CONCLUSIONS

It is clear that current research predominantly relies on top-down identification of insulin resistance-inducing metabolic disruptors and that the development of dedicated in vitro or ex vivo screens to allow animal sparing and time- and cost-effective bottom-up screening is a major future research need.

Risk equations for the development of worsened glucose status and type 2 diabetes mellitus in a Swedish intervention program

Background

Several studies investigated transitions and risk factors from impaired glucose tolerance (IGT) to type 2 diabetes mellitus (T2D). However, there is a lack of information on the probabilities to transit from normal glucose tolerance (NGT) to different pre-diabetic states and from these states to T2D. The objective of our study is to estimate these risk equations and to quantify the influence of single or combined risk factors on these transition probabilities.

Methods

Individuals who participated in the VIP program twice, having the first examination at ages 30, 40 or 50 years of age between 1990 and 1999 and the second examination 10 years later were included in the analysis. Participants were grouped into five groups: NGT, impaired fasting glucose (IFG), IGT, IFG&IGT or T2D. Fourteen potential risk factors for the development of a worse glucose state (pre-diabetes or T2D) were investigated: sex, age, education, perceived health, triglyceride, blood pressure, BMI, smoking, physical activity, snus, alcohol, nutrition and family history. Analysis was conducted in two steps. Firstly, factor analysis was used to find candidate variables; and secondly, logistic regression was employed to quantify the influence of the candidate variables. Bootstrap estimations validated the models.

Results

In total, 29 937 individuals were included in the analysis. Alcohol and perceived health were excluded due to the results of the factor analysis and the logistic regression respectively. Six risk equations indicating different impacts of different risk factors on the transition to a worse glucose state were estimated and validated. The impact of each risk factor depended on the starting or ending pre-diabetes state. High levels of triglyceride, hypertension and high BMI were the strongest risk factors to transit to a worsened glucose state.

Conclusions

The equations could be used to identify individuals with increased risk to develop any of the three pre-diabetic states or T2D and to adapt prevention strategies.

Diabetes mellitus in Jamaica: sex differences in burden, risk factors, awareness, treatment and control in a developing country

OBJECTIVE

The objective of this study was to provide valid estimates of the burden of and risk factors for diabetes mellitus by sex in Jamaica, a predominantly Black, middle-income and developing country.

METHODS

The Jamaica Health and Lifestyle Survey 2008 examined a nationally representative sample of 2848 Jamaicans aged 15-74. Parameter estimates and 95% confidence intervals [CI] were weighted for non-response as well as age and sex of the source population. Sex differences in risk factors and diabetes prevalence, awareness, treatment and control were estimated in multivariable models. Population-attributable fractions (PAFs) of obesity on diabetes mellitus were estimated in both sexes.

RESULTS

The prevalence of diabetes mellitus was 7.9% (95% CI: 6.7-9.1%), significantly higher in women than men 9.3% vs. 6.4% (P = 0.02) and increasing with age. Seventy-six percentage of persons with diabetes mellitus were aware of their status; urban women and rural men were less likely to be aware. Diabetes control (43% overall) was less common in higher-income men, but more common in higher-income women. Persons without health insurance were less likely to control their diabetes. The prevalence of diabetes risk factors was higher in women than men. Increased waist circumference (≥94 cm [men]/≥80 cm [women]), overweight/obesity (body mass index ≥ 25 kg/m(2)) and low physical activity/inactivity were associated with PAFs for diabetes mellitus of 27%, 37% and 15%, respectively, in men and 77%, 54% and 24%, respectively, in women.

CONCLUSIONS

Prevalence of diabetes mellitus and its risk factors is high in Jamaica, especially among women, and national programmes to stem the diabetes mellitus epidemic should take these sex differences into consideration.

A culturally adapted lifestyle intervention addressing a Middle Eastern immigrant population at risk of diabetes, the MEDIM (impact of Migration and Ethnicity on Diabetes In Malmö): study protocol for a randomized controlled trial

BACKGROUND

Studies have shown that lifestyle interventions are effective in preventing or delaying the onset of type 2 diabetes in high-risk patients. However, research on the effectiveness of lifestyle interventions in high-risk immigrant populations with different cultural and socioeconomic backgrounds is scarce. The aim was to design a culturally adapted lifestyle intervention for an immigrant population and to evaluate its effectiveness and cost-effectiveness.

METHODS/DESIGN

In this randomized controlled trial, 308 participants (born in Iraq, living in Malmö, Sweden and at high risk of type 2 diabetes) will be allocated to either a culturally adapted intervention or a control group. The intervention will consist of 10 group counseling sessions focusing on diet, physical activity and behavioral change over 6 months, and the offer of exercise sessions. Cultural adaptation includes gender-specific exercise sessions, and counseling by a health coach community member. The control group will receive the information about healthy lifestyle habits provided by the primary health care center. The primary outcome is change in fasting glucose level. Secondary outcomes are changes in body mass index, insulin sensitivity, physical activity, food habits and health-related quality of life. Measurements will be taken at baseline, after 3 and 6 months. Data will be analyzed by the intention-to-treat approach. The cost-effectiveness during the trial period and over the longer term will be assessed by simulation modeling from patient, health care and societal perspectives.

DISCUSSION

This study will provide a basis to measure the effectiveness of a lifestyle intervention designed for immigrants from the Middle East in terms of improvement in glucose metabolism, and will also assess its cost-effectiveness. Results from this trial may help health care providers and policy makers to adapt and implement lifestyle interventions suitable for this population group that can be conducted in the community.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01420198.

Neighborhood walkability and cardiometabolic risk factors in Australian adults: an observational study

BACKGROUND

Studies repeatedly highlight associations between the built environment and physical activity, particularly walking. Fewer studies have examined associations with cardiometabolic risk factors, with associations with obesity inconsistent and scarce evidence examining associations with other cardiometabolic risk factors. We aim to investigate the association between neighborhood walkability and the prevalence of obesity, hypertension, hypercholesterolaemia, and type-2 diabetes mellitus.

METHODS

Cross-sectional study of 5,970 adults in Western Australia. Walkability was measured objectively for a 1,600 m and 800 m neighborhood buffer. Logistic regression was used to assess associations overall and by sex, adjusting for socio-demographic factors. Mediation by physical activity and sedentary behavior was investigated.

RESULTS

Individuals living in high compared with less walkable areas were less likely to be obese (1,600 m OR: 0.84, 95% CI: 0.7 to 1; 800 m OR: 0.75, 95% CI: 0.62 to 0.9) and had lower odds of type-2 diabetes mellitus at the 800 m buffer (800 m OR: 0.69, 95% CI: 0.51 to 0.93). There was little evidence for an association between walkability and hypertension or hypercholesterolaemia. The only significant evidence of any difference in the associations in men and women was a stronger association with type-2 diabetes mellitus at the 800 m buffer in men. Associations with obesity and diabetes attenuated when additionally adjusting for physical activity and sedentary behavior but the overall association with obesity remained significant at the 800 m buffer (800 m OR: 0.78, 95% CI: 0.64 to 0.96).

CONCLUSIONS

A protective association between neighborhood walkability and obesity was observed. Neighborhood walkability may also be protective of type-2 diabetes mellitus, particularly in men. No association with hypertension or hypercholesterolaemia was found. This warrants further investigation. Findings contribute towards the accumulating evidence that city planning and policy related strategies aimed at creating supportive environments could play an important role in the prevention of chronic diseases.

Effect of concomitant administration of trospium chloride extended release on the steady-state pharmacokinetics of metformin in healthy adults

Background

Overactive bladder (OAB) is often associated with a number of co-morbid medical conditions, including diabetes mellitus. This may necessitate several concomitant treatments, thus creating the potential for drug–drug interactions (DDIs). Trospium is renally eliminated, not metabolized via cytochrome P450; therefore, cytochrome P450 DDIs are unlikely. However, coadministration with another renally eliminated drug (e.g., metformin) may theoretically result in a DDI.

Objective

The objective of this study was to evaluate the pharmacokinetics (plasma and urine) and safety/tolerability of the coadministration of trospium chloride extended release (XR) and metformin under steady-state conditions in healthy male and female subjects.

Methods

In a single-centre, randomized, open-label, two-group, two-period study in healthy males and females aged 18–45 years, 44 subjects received oral metformin 500 mg twice daily for 3.5 days during one period, and oral trospium chloride XR 60 mg once daily for 10 days, followed by trospium chloride XR 60 mg once daily for 4 days plus metformin 500 mg twice daily for 3.5 days during the other period. The two periods occurred in a crossover fashion, separated by a 3-day washout period.

Results

Trospium chloride XR coadministration did not alter metformin steady-state pharmacokinetics. Metformin coadministration reduced trospium steady-state maximum plasma concentration (by 34 %) and area under the concentration–time curve from 0–24 hours (by 29 %). Neither drug’s renal clearance was affected. No safety/tolerability issues of concern were observed with coadministration.

Conclusion

No dosage adjustment is necessary for metformin when coadministered with trospium chloride XR.

Assessment of daily food and nutrient intake in Japanese type 2 diabetes mellitus patients using dietary reference intakes

Medical nutrition therapy for the management of diabetes plays an important role in preventing diabetes complications and managing metabolic control. However, little is known about actual eating habits of individuals with type 2 diabetic mellitus (T2DM), especially in Japan. Therefore, we sought to (1) assess the dietary intake of individuals with T2DM, and (2) characterize their intake relative to national recommendations. This cross-sectional study involved 149 patients (77 males and 72 females) aged 40-79 years with T2DM recruited at a Kyoto hospital. Dietary intake was assessed using a validated self-administered diet history questionnaire. Under-consumption, adequacy, and over-consumption, of nutrients were compared to the age- and sex-based standards of the Japanese Dietary Reference Intakes. Among the results, most notable are (1) the inadequacy of diets in men with respect to intake of vitamins and minerals, likely owing to low intake of vegetables and fruits; (2) excess contributions of fat intake to total energy in both sexes; and (3) excess consumption of sweets and beverages relative to the national average. The prevalence of diabetes complications may be increasing because of a major gap between the typical dietary intake of individuals with T2DM and dietary recommendation.

A systematic review of IT for diabetes self-management: are we there yet?

BACKGROUND

Recent advances in information technology (IT) coupled with the increased ubiquitous nature of information technology (IT) present unique opportunities for improving diabetes self-management. The objective of this paper is to determine, in a systematic review, how IT has been used to improve self-management for adults with Type 1 and Type 2 diabetes.

METHODS

The review covers articles extracted from relevant databases using search terms related information technology and diabetes self-management published after 1970 until August 2012. Additional articles were extracted using the citation map in Web of Science. Articles representing original research describing the use of IT as an enabler for self-management tasks performed by the patient are included in the final analysis.

RESULTS

Overall, 74% of studies showed some form of added benefit, 13% articles showed no-significant value provided by IT, and 13% of articles did not clearly define the added benefit due to IT. Information technologies used included the Internet (47%), cellular phones (32%), telemedicine (12%), and decision support techniques (9%). Limitations and research gaps identified include usability, real-time feedback, integration with provider electronic medical record (EMR), as well as analytics and decision support capabilities.

CONCLUSION

There is a distinct need for more comprehensive interventions, in which several technologies are integrated in order to be able to manage chronic conditions such as diabetes. Such IT interventions should be theoretically founded and should rely on principles of user-centered and socio-technical design in its planning, design and implementation. Moreover, the effectiveness of self-management systems should be assessed along multiple dimensions: motivation for self-management, long-term adherence, cost, adoption, satisfaction and outcomes as a final result.

Behavior change in a lifestyle intervention for type 2 diabetes prevention in Dutch primary care: opportunities for intervention content

BACKGROUND

Despite the favorable effects of behavior change interventions on diabetes risk, lifestyle modification is a complicated process. In this study we therefore investigated opportunities for refining a lifestyle intervention for type 2 diabetes prevention, based on participant perceptions of behavior change progress.

METHODS

A 30 month intervention was performed in Dutch primary care among high-risk individuals (FINDRISC-score ≥ 13) and was compared to usual care. Participant perceptions of behavior change progress for losing weight, dietary modification, and increasing physical activity were assessed after18 months with questionnaires. Based on the response, participants were categorized as 'planners', 'initiators' or 'achievers' and frequencies were evaluated in both study groups. Furthermore, participants reported on barriers for lifestyle change.

RESULTS

In both groups, around 80% of all participants (intervention: N = 370; usual care: N = 322) planned change. Except for reducing fat intake (p = 0.08), the number of initiators was significantly higher in the intervention group than in usual care. The percentage of achievers was high for the dietary and exercise objectives (intervention: 81-95%; usual care: 83-93%), but was lower for losing weight (intervention: 67%; usual care: 62%). Important motivational barriers were 'I already meet the standards' and 'I'm satisfied with my current behavior'. Temptation to snack, product taste and lack of time were important volitional barriers.

CONCLUSIONS

The results suggest that the intervention supports participants to bridge the gap between motivation and action. Several opportunities for intervention refinement are however revealed, including more stringent criteria for participant inclusion, tools for (self)-monitoring of health, emphasis on the 'small-step-approach', and more attention for stimulus control.

TRIAL REGISTRATION

Netherlands Trial Register: NTR1082.

Gender-related personality traits, self-efficacy, and social support: How do they relate to women’s waist circumference change?

This study investigated whether gender-role related traits agency and communion contribute to successful health behavior change, in an interplay with domain-specific psychosocial factors, namely, agency, mediated by health-related self-efficacy, and communion, moderated by social support. Data from women ( N = 282) participating in the GOAL Lifestyle Implementation Trial were analyzed using structural equation modeling. Agency and increase in self-efficacy both independently predicted waist circumference reduction in the 1-year follow-up. Individuals high in communion succeeded in waist reduction only if they received social support. Initial self-efficacy increase predicted 3-year waist reduction. Gender-role orientation, together with social environment, influences behavior change intervention outcomes.

Skin autofluorescence based decision tree in detection of impaired glucose tolerance and diabetes

Aim

Diabetes (DM) and impaired glucose tolerance (IGT) detection are conventionally based on glycemic criteria. Skin autofluorescence (SAF) is a noninvasive proxy of tissue accumulation of advanced glycation endproducts (AGE) which are considered to be a carrier of glycometabolic memory. We compared SAF and a SAF-based decision tree (SAF-DM) with fasting plasma glucose (FPG) and HbA1c, and additionally with the Finnish Diabetes Risk Score (FINDRISC) questionnaire±FPG for detection of oral glucose tolerance test (OGTT)- or HbA1c-defined IGT and diabetes in intermediate risk persons.

Methods

Participants had ≥1 metabolic syndrome criteria. They underwent an OGTT, HbA1c, SAF and FINDRISC, in adition to SAF-DM which includes SAF, age, BMI, and conditional questions on DM family history, antihypertensives, renal or cardiovascular disease events (CVE).

Results

218 persons, age 56 yr, 128M/90F, 97 with previous CVE, participated. With OGTT 28 had DM, 46 IGT, 41 impaired fasting glucose, 103 normal glucose tolerance. SAF alone revealed 23 false positives (FP), 34 false negatives (FN) (sensitivity (S) 68%; specificity (SP) 86%). With SAF-DM, FP were reduced to 18, FN to 16 (5 with DM) (S 82%; SP 89%). HbA1c scored 48 FP, 18 FN (S 80%; SP 75%). Using HbA1c-defined DM-IGT/suspicion ≥6%/42 mmol/mol, SAF-DM scored 33 FP, 24 FN (4 DM) (S76%; SP72%), FPG 29 FP, 41 FN (S71%; SP80%). FINDRISC≥10 points as detection of HbA1c-based diabetes/suspicion scored 79 FP, 23 FN (S 69%; SP 45%).

Conclusion

SAF-DM is superior to FPG and non-inferior to HbA1c to detect diabetes/IGT in intermediate-risk persons. SAF-DM’s value for diabetes/IGT screening is further supported by its established performance in predicting diabetic complications.

The European perspective of diabetes prevention: the need for individualization of diabetes prevention

Over the last decade the situation for people with diabetes mellitus in Europe has changed significantly. The number of patients increases continuously, the age of diagnosis decreases and effective management grows to become a burden for European healthcare systems. In this situation numerous stakeholders try to develop concepts for innovative chronic care management as well as individualized and personalized diabetes management. A major focus is set to activities for early screening and prevention of the diabetes and associated diseases. The present article will give an overview about current achievements in European projects addressing the unmet needs in diabetes management and also to introduce undergoing projects in the field of diabetes prevention and care. Furthermore, the SweetSmart concept will be presented, which is the initiation of a strategy to individualize interventions for the prevention of diabetes and care management. In the current discussion about the management of health care resources it is important to have a strategic vision about a realistic future of innovative chronic care management.

Associations of objectively measured sedentary behaviour and physical activity with markers of cardiometabolic health

AIMS/HYPOTHESIS

The study aimed to examine the associations between objectively measured sedentary time, breaks in sedentary time, moderate-to-vigorous physical activity (MVPA) and total physical activity with markers of cardiometabolic health in a population with known risk factors for type 2 diabetes mellitus.

METHODS

This study reports data from two ongoing diabetes prevention programmes. Participants with known risk factors were recruited from primary care practices located within the East Midlands, UK, over the period 2010-2011. ActiGraph GT3X accelerometers (15 s epochs) were used to assess sedentary time (<25 counts per 15 s), MVPA (≥ 488 counts per 15 s) and total physical activity (total counts). A break was considered as any interruption in sedentary time (≥ 25 counts per 15 s). Linear regression examined the independent association of sedentary time, breaks in sedentary time, MVPA and total physical activity with markers of cardiometabolic health.

RESULTS

The sample comprised 878 participants; 153 from Project STAND (Sedentary Time And Diabetes) (age 32.9 ± 5.6 years, 28.8% male) and 725 from Walking Away from Diabetes (age 63.7 ± 7.8 years, 64.8% male). Following adjustment for various covariates, including MVPA and BMI, there were detrimental linear associations of sedentary time with 2 h plasma glucose (standardised beta coefficient) (β = 0.220, p < 0.001), triacylglycerol (β = 0.206, p = 0.001) and HDL-cholesterol (β = -0.123, p = 0.029). Breaks in sedentary time, total physical activity and MVPA were significantly inversely associated with measures of adiposity, but not with any other cardiometabolic variables after adjustment for sedentary time and BMI.

CONCLUSIONS/INTERPRETATION

In adults at high risk of type 2 diabetes mellitus, time spent sedentary is strongly and adversely associated with cardiometabolic health and may be a more important indicator of poor health than MVPA.

Taking small steps towards targets - perspectives for clinical practice in diabetes, cardiometabolic disorders and beyond

Big changes are hard. When trying to achieve guideline targets in diabetes and cardiometabolic disorders, patients can lack commitment or suffer despondency. It is much easier to make small changes in lifestyle or treatment, which are less noticeable and easier to manage long-term. Obesity is central to the cardiometabolic disorders, and even small weight losses of 2-5% can improve the cardiometabolic risk profile and substantially reduce the risk of developing type 2 diabetes. Likewise, small increases in physical activity, such as 15-30 min of brisk walking per day, can cut the risk of heart disease by 10%. Lifestyle or treatment changes that lead to small improvements in metabolic parameters also impact patient outcome - for example, a 5 mmHg decrease in blood pressure can translate into significant reductions in the rates of myocardial infarction and cardiovascular mortality. Benefits of small changes can also be seen in health economic outcome models. Implementing change at an individual versus a population level has different implications for overall benefit and patient motivation. Even very small steps taken in trying to reach guideline targets should represent a positive achievement for patients. Patient engagement is essential - only when patients commit themselves to change can benefits be maintained, and physicians should recognise their influence. Small changes in individual parameters can result in significant beneficial effects; however, a major impact can occur when small changes are made together in multiple parameters. More research is required to elucidate the full impact of small changes on patient outcome.

Random glucose is useful for individual prediction of type 2 diabetes: results of the Study of Health in Pomerania (SHIP)

AIM

Random glucose is widely used in routine clinical practice. We investigated whether this non-standardized glycemic measure is useful for individual diabetes prediction.

METHODS

The Study of Health in Pomerania (SHIP), a population-based cohort study in north-east Germany, included 3107 diabetes-free persons aged 31-81 years at baseline in 1997-2001. 2475 persons participated at 5-year follow-up and gave self-reports of incident diabetes. For the total sample and for subjects aged ≥50 years, statistical properties of prediction models with and without random glucose were compared.

RESULTS

A basic model (including age, sex, diabetes of parents, hypertension and waist circumference) and a comprehensive model (additionally including various lifestyle variables and blood parameters, but not HbA1c) performed statistically significantly better after adding random glucose (e.g., the area under the receiver-operating curve (AROC) increased from 0.824 to 0.856 after adding random glucose to the comprehensive model in the total sample). Likewise, adding random glucose to prediction models which included HbA1c led to significant improvements of predictive ability (e.g., for subjects ≥50 years, AROC increased from 0.824 to 0.849 after adding random glucose to the comprehensive model+HbA1c).

CONCLUSIONS

Random glucose is useful for individual diabetes prediction, and improves prediction models including HbA1c.

Behaviour change among people with impaired glucose tolerance: Comparison of telephone-based and face-to-face advice

Objectives

To develop, implement and compare two lifestyle services for people at risk of developing type 2 diabetes.

Methods

Two localities were selected to implement two different service delivery models, telephone-based and face-to-face, supporting people at risk of developing type 2 diabetes. Impact was assessed by comparing weight, fasting plasma glucose and oral glucose tolerance test (OGTT) results at baseline and six months later.

Results

Both services were associated with an improvement in OGTT 2-h plasma glucose and weight. In the telephone intervention, 47.3% of participants who completed the project achieved both normal fasting plasma glucose (≤6.0 mmol/l) and normal plasma glucose levels (≤7.7 mmol/l). Participants had a mean weight loss of 3.3 kg ( SD 4.3), equating to 3.4% of body weight ( p < 0.001). In the face-to-face intervention, 46.3% of participants achieved normal plasma glucose (≤7.7 mmol/l) and a mean weight loss of 2.9 kg ( SD 4.5), equating to 3.1% of bodyweight ( p < 0.001).

Conclusions

Local health providers can adapt existing service provision and tailor it to provide lifestyle programmes for people with impaired glucose tolerance. Both service delivery models offer effective diabetes prevention although each model may cater for different population needs and a choice of services might be the preferred option.

Gestational diabetes: prospective interview-study of the developing beliefs about health, illness and health care in migrant women

AIMS AND OBJECTIVES

To explore the development over time of beliefs about health, illness and health care in migrant women with gestational diabetes mellitus born in the Middle East and living in Sweden and to study the influence on self-care and care seeking.

BACKGROUND

With today's extensive global migration, contact with the new society/health care confronts the migrant's culture of origin with the culture of the host country. The question is whether immigrants' patterns of beliefs about health, illness and health-related behaviour change over time, as no previous studies have been found on this topic.

DESIGN

A qualitative prospective exploratory study.

METHODS

Semi-structured interviews, with 14 women (28-44 years), on three occasions: during pregnancy in gestational weeks 34-38 and three and 14 months after delivery.

RESULTS

  There was a U-shaped development of beliefs, from focusing on worries about the baby's health during pregnancy and trying to comply with advice from health professionals, particularly a healthy diet, through regression to dietary habits (more sugar, less fibre) and lifestyle held before being diagnosed with gestational diabetes mellitus three months after delivery, back to a healthy diet/lifestyle and worries 14 months after delivery but then focusing on their own risk, as mothers, of developing type 2 diabetes and being unable to care for the child. Over time, the number of persons perceiving gestational diabetes mellitus as a transient condition decreased. Respondents lacked information about gestational diabetes mellitus, diet and follow-ups.

CONCLUSION

Beliefs changed over time and influenced health-related behaviour. Beliefs about the seriousness of gestational diabetes mellitus among healthcare staff/care organisation influence the development of patients' beliefs and need to be considered in planning care.

RELEVANCE TO CLINICAL PRACTICE

Pregnancy should be used as an opportunity to provide complete information about gestational diabetes mellitus and future health risks. This should continue after delivery and wishes for regular follow-ups should be met.

Development of a screening score for undiagnosed diabetes and its application in estimating absolute risk of future type 2 diabetes in Japan: Toranomon Hospital Health Management Center Study 10 (TOPICS 10)

OBJECTIVE

The objective of the study was to develop a screening score for undiagnosed diabetes by eliciting information on noninvasive clinical markers and to assess its effectiveness for identifying the presence of diabetes and predicting future diabetes.

DESIGN, SETTING, AND PARTICIPANTS

A screening score was cross-sectionally developed for 33 335 Japanese individuals aged 18-88 years without known diabetes who underwent a health examination. We validated its utility and compared it with existing screening tools in an independent population (n = 7477). After initial assessment of the instrument, 7332 nondiabetic individuals were followed up for a mean 4.0 years.

RESULTS

Prevalence of undiagnosed diabetes (fasting plasma glucose ≥ 7.0 mmol/L or glycated hemoglobin ≥ 6.5%) was 2.9% (n = 965). Diabetes score included age, sex, family history of diabetes, current smoking habit, body mass index, and hypertension with an area under the receiver-operating characteristics curve of 0.771. Screening with 8 or more points yielded a sensitivity of 72.7% and a specificity of 68.1%. In the validation cohort, the area under the receiver-operating characteristics curve was 0.806. The developed score with 8 or more points had better positive predictive value (9.6%) and positive likelihood ratio (2.52) compared with existing tools (positive predictive value, from 6.9% to 9.4%; positive likelihood ratio, from 1.77 to 2.46) in which each tool's highest combination of sensitivity and specificity was observed. The 4-year cumulative risk of developing diabetes gradually escalated in association with higher screening scores at the initial examination.

CONCLUSIONS

Our algorithm could serve as a self-assessment tool for undiagnosed diabetic patients needing timely medical care and as a prognostic tool for individuals without present diabetes who must be closely followed up to prevent future diabetes.

Shifting from glucose diagnosis to the new HbA1c diagnosis reduces the capability of the Finnish Diabetes Risk Score (FINDRISC) to screen for glucose abnormalities within a real-life primary healthcare preventive strategy

BACKGROUND

To investigate differences in the performance of the Finnish Diabetes Risk Score (FINDRISC) as a screening tool for glucose abnormalities after shifting from glucose-based diagnostic criteria to the proposed new hemoglobin (Hb)A1c-based criteria.

METHODS

A cross-sectional primary-care study was conducted as the first part of an active real-life lifestyle intervention to prevent type 2 diabetes within a high-risk Spanish Mediterranean population. Individuals without diabetes aged 45-75 years (n = 3,120) were screened using the FINDRISC. Where feasible, a subsequent 2-hour oral glucose tolerance test and HbA1c test were also carried out (n = 1,712). The performance of the risk score was calculated by applying the area under the curve (AUC) for the receiver operating characteristic, using three sets of criteria (2-hour glucose, fasting glucose, HbA1c) and three diagnostic categories (normal, pre-diabetes, diabetes).

RESULTS

Defining diabetes by a single HbA1c measurement resulted in a significantly lower diabetes prevalence (3.6%) compared with diabetes defined by 2-hour plasma glucose (9.2%), but was not significantly lower than that obtained using fasting plasma glucose (3.1%). The FINDRISC at a cut-off of 14 had a reasonably high ability to predict diabetes using the diagnostic criteria of 2-hour or fasting glucose (AUC = 0.71) or all glucose abnormalities (AUC = 0.67 and 0.69, respectively). When HbA1c was used as the primary diagnostic criterion, the AUC for diabetes detection dropped to 0.67 (5.6% reduction in comparison with either 2-hour or fasting glucose) and fell to 0.55 for detection of all glucose abnormalities (17.9% and 20.3% reduction, respectively), with a relevant decrease in sensitivity of the risk score.

CONCLUSIONS

A shift from glucose-based diagnosis to HbA1c-based diagnosis substantially reduces the ability of the FINDRISC to screen for glucose abnormalities when applied in this real-life primary-care preventive strategy.

The Melbourne Diabetes Prevention Study (MDPS): study protocol for a randomized controlled trial

Background

Worldwide, type 2 diabetes (T2DM) prevalence has more than doubled over two decades. In Australia, diabetes is the second highest contributor to the burden of disease. Lifestyle modification programs comprising diet changes, weight loss and moderate physical activity, have been proven to reduce the incidence of T2DM in high risk individuals.

As part of the Council of Australia Governments, the State of Victoria committed to develop and support the diabetes prevention program ‘Life! Taking action on diabetes’ (Life!) which has direct lineage from effective clinical and implementation trials from Finland and Australia. The Melbourne Diabetes Prevention Study (MDPS) has been set up to evaluate the effectiveness and cost-effectiveness of a specific version of the Life! program.

Methods/design

We intend to recruit 796 participants for this open randomized clinical trial; 398 will be allocated to the intervention arm and 398 to the usual care arm. Several methods of recruitment will be used in order to maximize the number of participants. Individuals aged 50 to 75 years will be screened with a risk tool (AUSDRISK) to detect those at high risk of developing T2DM. Those with existing diabetes will be excluded. Intervention participants will undergo anthropometric and laboratory tests, and comprehensive surveys at baseline, following the fourth group session (approximately three months after the commencement of the intervention) and 12 months after commencement of the intervention, while control participants will undergo testing at baseline and 12 months only.

The intervention consists of an initial individual session followed by a series of five structured-group sessions. The first four group sessions will be carried out at two week intervals and the fifth session will occur eight months after the first group session. The intervention is based on the Health Action Process Approach (HAPA) model and sessions will empower and enable the participants to follow the five goals of the Life! program.

Discussion

This study will determine whether the effect of this intervention is larger than the effect of usual care in reducing central obesity and cardiovascular risk factors and thus the risk of developing diabetes and cardiovascular disease. Also it will evaluate how these two options compare economically.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12609000507280

Prevalence of undiagnosed abnormal glucose tolerance in adult patients cared for by general practitioners in Hungary. Results of a risk-stratified screening based on FINDRISC questionnaire

BACKGROUND

The prevalence of type 2 diabetes mellitus is rapidly increasing, worldwide and also in Hungary. Timely diagnosis and early treatment could be aided by targeted screening. Recognizing this, the Hungarian Diabetes Association initiated a risk-stratified screening with the involvement of primary care physicians.

MATERIAL/METHODS

In the first phase of screening, the FINDRISC questionnaire was completed, followed by an oral glucose tolerance test (OGTT) for those with a score of ≥12. Between September 1, 2010 and March 31, 2011, 70,432 non-diabetic adults, who visited their general practitioners for any reason, were involved in the screening. Of these, 68,476 questionnaires proved to be suitable for processing.

RESULTS

From the questionnaires, 28,077 (41.0%) had a score of ≥12. A valid OGTT was performed in 22,846 cases; of this group 3,217 subjects (14.1%) had elevated fasting glucose levels, 5,663 (24.8%) had impaired glucose tolerance, and 1,750 (7.6%) had manifest, previously undiagnosed, diabetes mellitus. Overall, from the valid OGTT group, 46.5% subjects had some degree of glucose intolerance.

CONCLUSIONS

Based on the FINDRISC questionnaire, the risk-stratified screening for diabetes mellitus proved to be simple and cost-effective method for the early detection of carbohydrate metabolism disorders. Using this method, the prevalence rate of previously undiagnosed abnormal glucose tolerance was high in adult patients cared for by general practitioners in Hungary.

Fasting substrate oxidation in relation to habitual dietary fat intake and insulin resistance in non-diabetic women: a case for metabolic flexibility?

Background

Metabolic flexibility described as “the capacity of the body to match fuel oxidation to fuel availability” has been implicated in insulin resistance. We examined fasting substrate oxidation in relation to dietary macronutrient intake, and markers of insulin resistance in otherwise healthy women, with and without a family history of diabetes mellitus (FH DM).

Methods

We measured body composition (dual x-ray absorptiometry), visceral and subcutaneous adipose tissue area (VAT, SAT, using Computerised Tomography), fasting [glucose], [insulin], [free fatty acids], [blood lipids], insulin resistance (HOMA-IR), resting energy expenditure (REE), respiratory exchange ratio(RER) and self-reported physical activity in a convenience sample of 180 women (18-45 yrs). A food frequency questionnaire was used to assess energy intake (EI) and calculate the RER: Food Quotient (FQ) ratio. Only those with EI:REE (1.05 -2.28) were included (N=140). Insulin resistance was defined HOMA-IR (>1.95).

Results

The Insulin Resistant (IR) group had higher energy, carbohydrate and protein intakes (p < 0.05) and lower PA levels than Insulin Sensitive (IS) group (P < 0.001), but there were no differences in RER or RER:FQ between groups. However, nearly 50% of the variance in HOMA-IR was explained by age, body fat %, VAT, RER:FQ and FH DM (adjusted R² = 0.50, p < 0.0001). Insulin-resistant women, and those with FH DM had a higher RER:FQ than their counterparts (p < 0.01), independent of body fat % or distribution.

Conclusion

In these apparently healthy, weight-stable women, insulin resistance and FH DM were associated with lower fat oxidation in relation to dietary fat intake, suggesting lower metabolic flexibility.

Effectiveness of community-wide and individual high-risk strategies to prevent diabetes: a modelling study

BACKGROUND

Diabetes has been described as one of the most important threats to the health of developed countries. Effective population strategies to prevent diabetes have not been determined but two broad strategies have been proposed: "high-risk" and "community-wide" strategies.

METHODS

We modelled the potential effectiveness of two strategies to prevent 10% of new cases of diabetes in Ontario, Canada over a 5-year period. The 5-year risk of developing physician-diagnosed diabetes was estimated for respondents to the Canadian Community Health Survey 2003 (CCHS 2.1, N = 26 232) using a validated and calibrated diabetes risk tool (Diabetes Population Risk Tool [DPoRT]). We estimated how many cases of diabetes could be prevented using two different strategies: a) a community-wide strategy that would uniformly reduce body mass index (BMI) in the entire population; and b) a high baseline risk strategy using either pharmacotherapy or lifestyle counselling to treat people who have an increased risk of developing diabetes.

RESULTS

In 2003, the 5-year risk of developing diabetes was 4.7% (383 600 new diagnosed cases of diabetes in 8 189 000 Ontarians aged 20+) and risk was moderately diffused (0.5%, 3.1% and 17.9% risk in the 1(st), 5(th) (median) and 10(th) deciles of risk). A 10% reduction in new cases of diabetes would have been achieved under any of the following scenarios: if BMI was 3.5% lower in the entire population; if lifestyle counselling covered 32.2% of high-risk people (371 900 of 1 155 000 people with 5 year diabetes risk greater than 10%); or, if pharmacotherapy covered 65.2% of high-risk people.

CONCLUSIONS

Prevention using pharmacotherapy alone requires unrealistically high coverage levels to achieve modest population reduction in new diabetes cases. On the other hand, in recent years few jurisdictions have been able to achieve a reduction in BMI at the population level, let alone a reduction of BMI of 3.5%.

Identifying risk and preventing progression to Type 2 diabetes in vulnerable and disadvantaged adults: a pragmatic review

AIM

To identify effective approaches to recognize diabetes risk and prevent progression to Type 2 diabetes in vulnerable groups, whose diabetes risk may be difficult to identify or manage.

METHODS

UK-based interventions that assess diabetes risk and/or target known risk factors were identified through four main sources: submissions to two calls for evidence by the National Institute for Health and Clinical Excellence; local practice examples collected via a targeted email questionnaire; selected electronic databases; and a focused search of relevant websites. No restriction was placed on the study type or evaluation methods used. Key themes and sub-themes on outcomes, as well as facilitators and barriers to successful delivery, are reported.

RESULTS

Twenty-four interventions met all inclusion criteria: 15 included a risk identification element and 14 included preventative activities. A range of risk identification tools were used to improve diagnosis of unmet diabetes-related health needs and raise awareness of diabetes risk factors. All preventative interventions focused on lifestyle change. No interventions monitored blood glucose as an outcome and only one reported improvements in baseline risk scores. Facilitators included tailored and flexible programme design, outreach delivery in familiar locations and effective inter-agency working. Barriers included literacy and language difficulties, transient participant populations, low prioritization of diabetes prevention and cost.

CONCLUSIONS

It is possible to engage successfully with high-risk adults in vulnerable groups to achieve positive health outcomes relevant to the prevention of diabetes. However, more robust evidence on longer-term outcomes is required to ensure that programmes are targeted and delivered appropriately.

Health information, behavior change, and decision support for patients with type 2 diabetes: development of a tailored, preference-sensitive health communication application

PURPOSE

Patient involvement in diabetes treatment such as shared decision-making and patient self-management has significant effects on clinical parameters. As a prerequisite for active involvement, patients need to be informed in an adequate and preference-sensitive way. Interactive Health Communication Applications (IHCAs) that combine web-based health information for patients with additional support offer the opportunity to reach great numbers of patients at low cost and provide them with high-quality information and support at the time, place, and learning speed they prefer. Still, web-based interventions often suffer from high attrition. Tailoring the intervention to patients' needs and preferences might reduce attrition and should thereby increase effectiveness. The purpose of this study was to develop a tailored IHCA offering evidence-based, preference-sensitive content and treatment decision support to patients with type 2 diabetes. The content was developed based on a needs assessment and two evidence-based treatment guidelines. The delivery format is a dialogue-based, tunneled design tailoring the content and tone of the dialogue to relevant patient characteristics (health literacy, attitudes toward self-care, and psychological barriers to insulin treatment). Both content and tailoring were revised by an interdisciplinary advisory committee.

CONCLUSION

The World Wide Web holds great potential for patient information and self-management interventions. With the development and evaluation of a tailored IHCA, we complement face-to-face consultations of patients with their health care practitioners and make them more efficient and satisfying for both sides. Effects of the application are currently being tested within a randomized controlled trial.

Mobile applications for diabetes self-management: status and potential

BACKGROUND

Advancements in smartphone technology coupled with the proliferation of data connectivity has resulted in increased interest and unprecedented growth in mobile applications for diabetes self-management. The objective of this article is to determine, in a systematic review, whether diabetes applications have been helping patients with type 1 or type 2 diabetes self-manage their condition and to identify issues necessary for large-scale adoption of such interventions.

METHODS

The review covers commercial applications available on the Apple App Store (as a representative of commercially available applications) and articles published in relevant databases covering a period from January 1995 to August 2012. The review included all applications supporting any diabetes self-management task where the patient is the primary actor.

RESULTS

Available applications support self-management tasks such as physical exercise, insulin dosage or medication, blood glucose testing, and diet. Other support tasks considered include decision support, notification/alert, tagging of input data, and integration with social media. The review points to the potential for mobile applications to have a positive impact on diabetes self-management. Analysis indicates that application usage is associated with improved attitudes favorable to diabetes self-management. Limitations of the applications include lack of personalized feedback; usability issues, particularly the ease of data entry; and integration with patients and electronic health records.

CONCLUSIONS

Research into the adoption and use of user-centered and sociotechnical design principles is needed to improve usability, perceived usefulness, and, ultimately, adoption of the technology. Proliferation and efficacy of interventions involving mobile applications will benefit from a holistic approach that takes into account patients' expectations and providers' needs.

Risk assessment of Pakistani individuals for diabetes (RAPID)

OBJECTIVE

To develop and evaluate a risk score to predict people at high risk of developing type 2 diabetes in Pakistan.

METHODOLOGY

Cross sectional data regarding primary prevention of diabetes in Pakistan. Diabetes risk score was developed by using simple parameters namely age, waist circumference, and family history of diabetes. Odds ratios of the model were used to assign a score value for each variable and the diabetes risk score was calculated as the sum of those scores.

RESULTS

We externally validated the score using two data from 1264 subjects and 856 subjects aged 25 years and above from two separate studies respectively. Validating this score using the first data from the second screening study gave an area under the receive operator characteristics curve [AROC] of 0.758. A cut point of 4 had a sensitivity of 47.0% and specificity of 88% and in the second data AROC is 0.7 with 44% sensitivity and 89% specificity.

CONCLUSIONS

A simple diabetes risk score, based on a set of variables can be used for the identification of high risk individuals for early intervention to delay or prevent type 2 diabetes in Pakistani population.

Feasibility of the FINDRISC questionnaire to identify individuals with impaired glucose tolerance in Swedish primary care. A cross-sectional population-based study

AIM

To evaluate the performance of the FINDRISC questionnaire as a tool to recruit individuals with impaired glucose tolerance for lifestyle intervention programmes.

METHODS

A cross-sectional population-based study in primary Health Care Centres in a middle-sized Swedish town. All 9734 individuals, aged 35-75 years, living within a defined area, were invited by mail to fill in and return the FINDRISC questionnaire. Participants with a risk score ≥ 15 (n = 525) were invited to perform an oral glucose tolerance test while those with known diabetes were excluded.

RESULTS

In total, 5452 questionnaires (58%) were returned and revealed a mean risk-score of 8.5 ± 4.5 (mean ± SD). We found that 525 participants had a risk-score ≥ 15 and 302 (58%) were further examined with an oral glucose tolerance testing (OGTT). Among them we detected 11% with previously undiagnosed Type 2 diabetes, 16% with impaired glucose tolerance and 29% with impaired fasting glucose. A FINDRISC score ≥ 15 was associated with a positive predictive value of 55% for impaired glucose metabolism (impaired fasting glucose + impaired glucose tolerance + Type 2 diabetes) and of 16% for impaired glucose tolerance, respectively. The positive predictive value for impaired glucose tolerance did not increase to more than 17% when choosing the cut-point 17, while there was a significant increase in the positive predictive value for impaired glucose metabolism (70%).

CONCLUSIONS

The FINDRISC questionnaire is a useful instrument for identification of individuals with impaired glucose metabolism but seems less effective for detection of individuals with impaired glucose tolerance. Strategies to find individuals with impaired glucose tolerance for implementation of lifestyle changes in primary care should therefore be developed further.