Effects of a Diabetes Prevention Program on Type 2 Diabetes Risk Factors and Quality of Life Among Latino Youths With Prediabetes: A Randomized Clinical Trial

Association between total, regional and organ fat and type 2 diabetes risk factors among Latino youth: A longitudinal study

INTRODUCTION

To examine whether within-person changes in total, regional and organ fat were associated with within-person changes in type 2 diabetes (T2D)-related biomarkers following interventions.

METHODS

A secondary analysis from a randomised trial among Latino youth (30 males, 25 females) aged 12-16 years with obesity. The study sample combined participants randomised to either lifestyle intervention (N = 39) or usual care (N = 16). Total body composition was assessed by DEXA. Hepatic and pancreatic fat fractions were assessed using MRI. T2D risk factors included insulin sensitivity, beta-cell function and post-challenge glucose.

RESULTS

Significant changes in %body fat, lean mass, insulin sensitivity and 2-h glucose were observed. Changes in fat mass were associated with changes in insulin sensitivity (β = -0.45, p < 0.001), while changes in lean mass were associated with changes in 2-h glucose concentrations (β = -0.50, p = 0.02). No association between changes in total, regional, or organ fat and beta cell function were noted.

CONCLUSIONS

Our study revealed that within-person changes in fat mass and lean mass were associated with increased insulin sensitivity and reduced 2-h glucose concentrations, respectively, among high-risk Latino youth. The impact of reductions in regional and organ fat deposition on T2D risk factors warrants further examination.

Pathophysiology and Treatment of Prediabetes and Type 2 Diabetes in Youth

Youth-onset type 2 diabetes is a heterogeneous disease with increasing prevalence in relation to increased rates of obesity in children. It has genetic, epigenetic, social, and environmental determinants. Youth-onset type 2 diabetes is alarming given a rapidly progressive course compared with the course of adult-onset disease, early-onset vascular complications, and long-term exposure to hyperglycemia and associated complications. It is often preceded by prediabetes, a disease phase where defects in β-cell function relative to insulin sensitivity emerge. Herein, we review the current understanding of the pathophysiology of prediabetes and type 2 diabetes in youth. We describe the mechanisms underlying insulin resistance, the precipitous decline of β-cell function, and the role of other hormonal abnormalities in the pathogenesis of the disease. We discuss the critical importance of social determinants of health in the predisposition and progression of these conditions and present current management strategies and the advances in therapeutic approaches. These must adapt to meet the unique needs of the individual patient and family. Significant knowledge gaps remain that need to be addressed in future research.

Preconception HbA1c Levels in Adolescents and Young Adults and Adverse Birth Outcomes

Importance

Subclinical hyperglycemia before pregnancy may be associated with the likelihood of maternal morbidity but is understudied among young people.

Objective

To explore the association of preconception hemoglobin A1c (HbA1c) levels among adolescents and young adults with risk of gestational diabetes at first live birth.

Design, Setting, and Participants

This retrospective cohort study used linked 2009 to 2017 birth registry, hospital discharge, and New York City Department of Health A1C Registry data for birthing individuals aged 10 to 24 years with no history of diabetes and at least 1 preconception HbA1c test in New York, New York. Statistical analysis was performed from August to November 2022.

Exposure

Preconception HbA1c values categorized as no diabetes (HbA1c <5.7%) or prediabetes (HbA1c ≥5.7% to <6.5%).

Main Outcomes and Measures

The primary outcome was gestational diabetes at first birth. Secondary outcomes included hypertensive disorders of pregnancy, preterm birth, cesarean delivery, and macrosomia. Log binomial regression was used to estimate the relative risk (RR) of gestational diabetes at first birth by preconception HbA1c level, adjusting for prepregnancy characteristics. The optimal HbA1c threshold for gestational diabetes was examined using receiver operating curve regression.

Results

A total of 14 302 individuals (mean [SD] age, 22.10 [1.55] years) met study eligibility criteria. Of these, 5896 (41.0%) were Hispanic, 4149 (29.0%) were Black, 2583 (18.1%) were White, 1516 (10.6%) were Asian, and 185 (1.3%) had other or unknown race and ethnicity. Most (11 407 individuals [79.7%]) had normoglycemia before pregnancy, and 2895 individuals (20.2%) had prediabetes. Adjusting for prepregnancy characteristics, those with preconception prediabetes had more than twice the risk of gestational diabetes vs those with normoglycemia (adjusted RR [aRR], 2.21; 95% CI, 1.91-2.56). Preconception prediabetes was associated with small increases in the likelihood of a hypertensive disorder of pregnancy (aRR, 1.18; 95% CI, 1.03-1.35) and preterm delivery (aRR, 1.18; 95% CI, 1.02-1.37). The aRRs for cesarean delivery (aRR, 1.09; 95% CI, 0.99-1.20) and macrosomia (aRR, 1.13; 95% CI, 0.93-1.37) were increased but not statistically significant. The optimal HbA1c threshold to identify gestational diabetes among adolescents and young adults was 5.6%. The threshold did not vary by obesity status but was slightly lower among Hispanic individuals (HbA1c of 5.5%).

Conclusions and Relevance

In this study of adolescents and young adults with at least 1 preconception HbA1c test, prediabetes was associated with increased likelihood of maternal cardiometabolic morbidity at first birth. Efforts to optimize cardiometabolic health before pregnancy may avert excess maternal risk.

Construct validity of the 12-item Short Form Health Survey (SF-12) version 2 and the impact of lifestyle modifications on the health-related quality of life among Indian adults with prediabetes: results from the D-CLIP trial

PURPOSE

This study aimed to validate the factor structure of the 12-item Short-Form (SF-12) health-related quality of life (HRQOL) survey for Indian adults and assess the impact of lifestyle modification on the SF-12 of Indian adults with prediabetes.

METHODS

To validate the context-specific construct of the SF-12, two-factor confirmatory factor analysis (CFA) was performed using data from 1285 adults residing in Chennai, India, who screened for the Diabetes Community Lifestyle Improvement Program (D-CLIP). D-CLIP was a randomized controlled trial of 578 participants with prediabetes (283 treatment, 293 control), focusing on the effect of lifestyle modifications on the prevention of diabetes. Physical and mental component scores (PCS and MCS) were computed by using CFA standardized factor loadings. Multiple linear regression was subsequently conducted to estimate the effect of lifestyle modification on post-study changes of PCS and MCS among D-CLIP participants.

RESULTS

Cronbach's alpha and CFA fit indices demonstrated acceptable reliability and model fit of the SF-12 for Indian adults. The intervention group showed greater mean change in PCS after study participation compared to the controls (1.63 ± 0.82, p = 0.046); no significant difference was observed for MCS between two groups (1.00 ± 0.85, p = 0.242).

CONCLUSION

The study confirmed that the SF-12 is suitable for assessing the physical and mental health dimensions of HRQOL for Indian adults. Our findings suggest that the benefits of diabetes prevention lifestyle modification strategies may primarily enhance the physical well-being of adults with prediabetes. Further studies validating the SF-12 in a broader Asian Indian population are needed.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT01283308.

Family systems approaches in pediatric obesity management: a scoping review

Family-based obesity management interventions targeting child, adolescent and parental lifestyle behaviour modifications have shown promising results. Further intervening on the family system may lead to greater improvements in obesity management outcomes due to the broader focus on family patterns and dynamics that shape behaviours and health. This review aimed to summarize the scope of pediatric obesity management interventions informed by family systems theory (FST). Medline, Embase, CINAHL and PsycInfo were searched for articles where FST was used to inform pediatric obesity management interventions published from January 1980 to October 2023. After removal of duplicates, 6053 records were screened to determine eligibility. Data were extracted from 50 articles which met inclusion criteria; these described 27 unique FST-informed interventions. Most interventions targeted adolescents (44%), were delivered in outpatient hospital settings (37%), and were delivered in person (81%) using group session modalities (44%). Professionals most often involved were dieticians and nutritionists (48%). We identified 11 FST-related concepts that guided intervention components, including parenting skills, family communication, and social/family support. Among included studies, 33 reported intervention effects on at least one outcome, including body mass index (BMI) (n = 24), lifestyle behaviours (physical activity, diet, and sedentary behaviours) (n = 18), mental health (n = 12), FST-related outcomes (n = 10), and other outcomes (e.g., adiposity, cardiometabolic health) (n = 18). BMI generally improved following interventions, however studies relied on a variety of comparison groups to evaluate intervention effects. This scoping review synthesises the characteristics and breadth of existing FST-informed pediatric obesity management interventions and provides considerations for future practice and research.

Changes in proteomic cargo of circulating extracellular vesicles in response to lifestyle intervention in adolescents with hepatic steatosis

BACKGROUND

Recent studies suggest that proteomic cargo of extracellular vesicles (EVs) may play a role in metabolic improvements following lifestyle interventions. However, the relationship between changes in liver fat and circulating EV-derived protein cargo following intervention remains unexplored.

METHODS

The study cohort comprised 18 Latino adolescents with obesity and hepatic steatosis (12 males/6 females; average age 13.3 ± 1.2 y) who underwent a six-month lifestyle intervention. EV size distribution and concentration were determined by light scattering intensity; EV protein composition was characterized by liquid chromatography tandem-mass spectrometry.

RESULTS

Average hepatic fat fraction (HFF) decreased 23% by the end of the intervention (12.5% [5.5] to 9.6% [4.9]; P = 0.0077). Mean EV size was smaller post-intervention compared to baseline (120.2 ± 16.4 nm to 128.4 ± 16.5 nm; P = 0.031), although the difference in mean EV concentration (1.1E+09 ± 4.1E+08 particles/mL to 1.1E+09 ± 1.8E+08 particles/mL; P = 0.656)) remained unchanged. A total of 462 proteins were identified by proteomic analysis of plasma-derived EVs from participants pre- and post-intervention, with 113 proteins showing differential abundance (56 higher and 57 lower) between the two timepoints (adj-p <0.05). Pathway analysis revealed enrichment in complement cascade, initial triggering of complement, creation of C4 and C2 activators, and regulation of complement cascade. Hepatocyte-specific EV affinity purification identified 40 proteins with suggestive (p < 0.05) differential abundance between pre- and post-intervention samples.

CONCLUSIONS

Circulating EV-derived proteins, particularly those associated with the complement cascade, may contribute to improvements in liver fat in response to lifestyle intervention.

Prediabetes in children and adolescents: An updated review

Prediabetes, the precursor of type 2 diabetes mellitus, is an intermediate stage between normal glucose homeostasis and overt diabetes. This asymptomatic metabolic state is increasingly prevalent in pediatric population and is very difficult to detect without appropriate screening. Studies have shown that a certain proportion of children with prediabetes will develop diabetes in a few years. Even more alarming is the evidence that youth-onset diabetes has a more aggressive clinical course with progressive beta-cell decline and accelerated end-organ damage. Despite its importance, several aspects involving prediabetes in childhood are disputed or unknown. This review presents the latest insights into this challenging entity and outlines a simplified screening approach to aid clinical practice. In summary, childhood prediabetes is an important clinical condition indicating the need for proper screening and timely intervention.

A co-designed, community-based intensive health behavior intervention promotes participation and engagement in youth with risk factors for type 2 diabetes

Background

Obesity among youth (children and adolescents) is associated with increased risk for youth-onset type 2 diabetes. Lifestyle change can delay or prevent the development of type 2 diabetes, yet real-world implementation of health behavior recommendations is challenging. We previously engaged youth with risk factors for type 2 diabetes, their caregivers, and professionals in a human-centered design study to co-design a lifestyle change program. Here we report the outcomes for this 16-week co-designed lifestyle change program for youth at risk for T2D and their caregivers.

Research design and methods

This single-arm family-based cohort study included youth aged 7-18 years, with BMI ≥85th percentile (overweight or obese) and at least one additional risk factor for type 2 diabetes, and their caregivers. Clinical (BMI, HbA1c), self-reported physical activity, and quality of life outcomes were evaluated at baseline (B), post-intervention (M4), and 1 year (M12) following the intervention.

Results

Seventy-eight youth (mean age 12.4 ± 2.7y, 67% female, 37.8% white) and 65 caregivers were included in the data analysis. Youth baseline BMI z-scores (2.26 ± 0.47) and HbA1c (5.3 ± 0.3) were unchanged at follow up time points [BMI z-scores M4 (2.25 ± 0.52), M12 (2.16 ± 0.58), p-value 0.46], [HbA1c M4 (5.3 ± 0.3), M12 (5.2 ± 0.3), p-value (0.04)]. Youth reported increased physical activity at M4 (p = 0.004), but not at M12. Youth quality of life scores increased at M12 (p=0.01). Families who attended at least one session (n=41) attended an average of 9 out of 16 sessions, and 37 percent of families attended 13 or more sessions.

Conclusion

A co-designed, community-based lifestyle intervention promotes increased physical activity, improved quality of life, maintenance of BMI z-scores and HbA1c, and engagement in youth with risk factors for T2D.

Application of natural compounds in the treatment and prevention of prediabetes

Prediabetes is an intermediate stage in the development of type 2 diabetes mellitus characterized by impaired fasting glucose and/or impaired glucose tolerance. Prediabetes generally has no obvious clinical symptoms, and most patients are found in health examinations or due to other diseases. Reactive hypoglycemia may indicate the possibility of early diabetes. Without effective preventive measures, prediabetes can progress to diabetes leading to serious public health problems. Therefore, early diagnosis and intervention are important. Many animal experiments and clinical trials have proven that natural compounds substantially improve glucose metabolism disorder. The active ingredients are mainly alkaloids, polysaccharides, saponins, terpenoids, flavonoids and polyphenols. Their mechanism of action mainly involves improved insulin sensitivity and insulin resistance, inhibited activity of alpha-glucosidase, antioxidant activity, anti-inflammatory, regulation of gut microbiota and activating of peroxisome proliferator-activated receptor-γ. This paper reviews the mechanisms of action of natural compounds on prediabetes and the status of related research.

Effectiveness of Lifestyle Nutrition and Physical Activity Interventions for Childhood Obesity and Associated Comorbidities among Children from Minority Ethnic Groups: A Systematic Review and Meta-Analysis

Lifestyle physical activity (PA) and nutrition are known to be effective interventions in preventing and managing obesity-related comorbidities among adult populations but less so among children and adolescents. We examined the effectiveness of lifestyle interventions in children from minority ethnic populations in Western high-income countries (HICs). Our systematic review included 53 studies, involving 26,045 children from minority ethnic populations who followed lifestyle intervention programmes lasting between 8 weeks and 5 years with the aim of preventing and/or managing childhood obesity and associated comorbidities, including adiposity and cardiometabolic risks. The studies were heterogenous in terms of lifestyle intervention components (nutrition, PA, behavioural counselling) and settings (community vs. schools and after-school settings). Our meta-analysis included 31 eligible studies and showed no significant effects of lifestyle interventions when they focused on body mass index (BMI) outcomes (pooled BMI mean change = -0.09 (95% CI = -0.19, 0.01); p = 0.09). This was irrespective of the intervention programme duration (<6 months vs. ≥6 months), type (PA vs. nutrition/combined intervention) and weight status (overweight or obese vs. normal weight) as all showed nonsignificant effects in the sensitivity analysis. Nonetheless, 19 of the 53 studies reported reductions in BMI, BMI z-score and body fat percentage. However, the majority of lifestyle interventions adopting a quasi-design with combined primary and secondary obesity measures (11 out of 15 studies) were effective in reducing the obesity comorbidities of cardiometabolic risks, including metabolic syndrome, insulin sensitivity and blood pressure, in overweight and obese children. Preventing childhood obesity in high-risk ethnic minority groups is best achieved using combined PA and nutrition intervention approaches, which jointly target preventing obesity and its comorbidities, especially the outcomes of diabetes, hypertension and cardiovascular disease. Therefore, public health stakeholders should integrate cultural and lifestyle factors and contextualise obesity prevention strategies among minority ethnic groups in Western HICs.

Inflammatory Mediators and Type 2 Diabetes Risk Factors before and in Response to Lifestyle Intervention among Latino Adolescents with Obesity

Obesity is associated with chronic inflammation that may contribute to T2D among youth. We examined the association between inflammatory biomarkers and insulin sensitivity and β-cell function and response to lifestyle intervention among Latino youth with obesity. Latino youth (n = 64) were randomized to six months of lifestyle intervention (INT, n = 40) or usual care (UC, n = 24). INT included nutrition education and physical activity. UC involved meeting with a pediatric endocrinologist and registered dietitian to discuss healthy lifestyles. At baseline, multiple linear regression assessed fasting serum interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), monocyte chemoattractant protein-1 (MCP-1), high-molecular weight adiponectin (HMW Adpn), IL-10, IL-1 receptor antagonist (IL-1ra) as predictors of insulin sensitivity (whole-body insulin sensitivity index, WBISI) and β-cell function (oral disposition index, oDI). Changes in outcomes between groups were assessed using covariance pattern models. At baseline, MCP-1 (β ± SE, -0.12 ± 0.05, p = 0.027) and IL-1ra (-0.03 ± 0.01, p = 0.005) were negatively associated with WBISI. Treatment effects were not observed for inflammatory markers. WBISI was significantly increased among both INT (from 1.8 ± 0.2 to 2.6 ± 0.4, p = 0.005) and UC (from 1.6 ± 0.2 to 2.8 ± 0.5, p = 0.002) with no significant differences between the groups. Obesity-related inflammatory mediators were associated with T2D risk factors but were unaffected by lifestyle intervention among Latino youth.

Type 2 Diabetes Prevention Programs-From Proof-of-Concept Trials to National Intervention and Beyond

The prevention of type 2 diabetes (T2D) in high-risk people with lifestyle interventions has been demonstrated by several randomized controlled trials. The intervention effect has sustained up to 20 years in post-trial monitoring of T2D incidence. In 2000, Finland launched the national T2D prevention plan. For screening for high T2D risk, the non-laboratory Finnish Diabetes Risk Score was developed and widely used, also in other countries. The incidence of drug-treated T2D has decreased steadily since 2010. The US congress authorized public funding for a national diabetes prevention program (NDPP) in 2010. It was built around a 16-visit program that relies on referral from primary care and self-referral of persons with either prediabetes or by a diabetes risk test. The program uses a train-the-trainer program. In 2015 the program started the inclusion of online programs. There has been limited implementation of nationwide T2D prevention programs in other countries. Despite the convincing results from RCTs in China and India, no translation to the national level was introduced there. T2D prevention efforts in low-and middle-income countries are still limited, but results have been promising. Barriers to efficient interventions are greater in these countries than in high-income countries, where many barriers also exist. Health disparities by socioeconomic status exist for T2D and its risk factors and form a challenge for preventive interventions. It seems that a stronger commitment to T2D prevention is needed, such as the successful WHO Framework Convention on Tobacco Control, which legally binds the countries to act.

Pros and Cons of Current Diagnostic Tools for Risk-Based Screening of Prediabetes and Type 2 Diabetes in Children and Adolescents with Overweight or Obesity

It is still a matter of debate which is the most suitable diagnostic test for risk-based screening of prediabetes and type 2 diabetes (T2D) in children and adolescents with overweight or obesity. This review highlighted benefits and pitfalls of currently recommended screening tools (fasting plasma glucose [FPG], oral glucose tolerance test [OGTT], glycated hemoglobin A1c [HbA1c]). The greatest advantage of OGTT is the ability to detect people with impaired glucose tolerance, a subcategory at high risk of developing both T2D and cardiovascular disease. Important disadvantages are low reproducibility and inconvenience. FPG measurement is more practical, as it needs only one blood draw, although both OGTT and FPG require fasting. The reliability of HbA1c as a screening tool has been questioned, especially in children and adolescents, but its undeniable convenience can lead to increased adherence to screening. In contrast, it can be altered by several nonglycemic factors. Importantly, none of these tests have been validated in the pediatric population. Alternative tests have been recently proposed, including new OGTT-derived biomarkers and additional nonfasting glycemic markers. In conclusion, when choosing the most suitable test in clinical practice, advantages and disadvantages should be considered, as well as the possibility of performing different tests at once.