How much might achievement of diabetes prevention behaviour goals reduce the incidence of diabetes if implemented at the population level?

A simulation study of the economic and health impact of a diabetes prevention programme in Ireland

AIMS

Type 2 diabetes is a major public health issue that has a large effect on society including its health and social services. The aims of this paper are to generate a projection of the number of cases and explore the potential impact of a preventive intervention targeted at people with pre-diabetes on disease prevalence, complications, mortality and cost.

METHODS

A Markov simulation model of diabetes and pre-diabetes in Ireland, for the period 1991 to 2036, was generated based on international epidemiological data. The simulation was calibrated with the available Irish data on the prevalence of pre-diabetes, diabetes and diabetic complications. The economic and health impact of a hypothetical nationwide preventive intervention programme, which reduces the incidence by a factor consistent with the international literature, was estimated under three scenarios of alternative effectiveness and uptake.

RESULTS

The estimated number of people over 40 years of age with type 2 diabetes in Ireland is projected to increase from 216,000 in 2020 to 414,000 in 2036. A prevention programme, based on the NHS Diabetes Prevention Programme, is estimated to result in a reduction of between 2000 (0.5%) and 19,000 (4.6%) in the number of prevalent cases of diabetes in 2036 resulting in substantial health and quality of life benefits.

CONCLUSIONS

A wide range of initiatives with uncertain outcomes will be required to reduce the impact of obesity and type 2 diabetes. A diabetes prevention programme seems likely to be worth pursuing as one element of this set of initiatives.

Large Cohort Data Based Cost-Effective Disease Prevention Design Strategy: Strong Heart Study

Background and Objective:

A multitude of large cohort studies have collected data on incidence and covariates/risk factors of various chronic diseases. However, approaches for utilization of these large data and translation of the valuable results to inform and guide clinical disease prevention practice are not well developed. In this paper, we proposed, based on large cohort study data, a novel conceptual cost-effective disease prevention design strategy for a target group when it is not affordable to include everyone in the target group for intervention.

Methods and Results:

Data from American Indian participants (n = 3516; 2056 women) aged 45 – 74 years in the Strong Heart Study, the diabetes risk prediction model from the study, a utility function, and regression models were used. A conceptual cost-effective disease prevention design strategy based on large cohort data was initiated. The application of the proposed strategy for diabetes prevention was illustrated.

Discussion:

The strategy may provide reasonable solutions to address cost-effective prevention design issues. These issues include complex associations of a disease with its significant risk factors, cost-effectively selecting individuals at high risk of developing disease to undergo intervention, individual differences in health conditions, choosing intervention risk factors and setting their appropriate, attainable, gradual and adaptive goal levels for different subgroups, and assessing effectiveness of the prevention program.

Conclusions:

The strategy and methods shown in the illustrative example can also be analogously adopted and applied to other diseases preventions. The proposed strategy provides a way to translate and apply epidemiological study results to clinical disease prevention practice.

Large Cohort Data Based Group or Community Disease Prevention Design Strategy: Strong Heart Study

BACKGROUND AND OBJECTIVE

A multitude of large cohort studies have data on incidence rates and predictors of various chronic diseases. However, approaches for utilization of these costly collected data and translation of these valuable results to inform and guide clinical disease prevention practice are not well developed. In this paper we proposed a novel conceptual group/community disease prevention design strategy based on large cohort study data.

METHODS AND RESULTS

The data from participants (n = 3516; 2056 women) aged 45 to 74 years and the diabetes risk prediction model from Strong Heart Study were used. The Strong Heart Study is a population-based cohort study of cardiovascular disease and its risk factors in American Indians. A conceptual group/community disease prevention design strategy based on large cohort data was initiated. The application of the proposed strategy for group diabetes prevention was illustrated.

DISCUSSION

The strategy may provide reasonable solutions to the prevention design issues. These issues include complex associations of a disease with its combined and correlated risk factors, individual differences, choosing intervention risk factors and setting their appropriate, attainable, gradual and adaptive goal levels for different subgroups, and assessing effectiveness of the prevention program.

CONCLUSIONS

The strategy and methods shown in the illustration example can be analogously adopted and applied for other diseases preventions. The proposed strategy for a target group/community in a population provides a way to translate and apply epidemiological study results to clinical disease prevention practice.

[Prediabetes, definition and treatment]

Prediabetes corresponds to high levels of glycaemia on an empty stomach and/or lower tolerance to glucose. It is necessary to detect and treat it in order to prevent type 2 diabetes and its long-term morbidity-mortality. Several clinical trials, based notably on modifying the patient's lifestyle, have shown that prevention is possible. Bariatric surgery could constitute a favoured treatment option in prediabetic obese patients.

Diabetes Prevention in Australia: 10 Years Results and Experience

Clinical trials have demonstrated the efficacy of lifestyle modification for the prevention of type 2 diabetes mellitus but it was achieved at higher cost than can be sustained in routine health services. The first clinical trial to report was the Finnish Diabetes Prevention Study. This paper describes how Australia worked with Finnish colleagues to adapt the findings of that study to achieve a statewide diabetes prevention program. Small evaluative, effectiveness trials have been conducted in a number of countries to see if the results of the clinical trials can be replicated in routine health services. The Australian evaluative trial, Greater Green Triangle Diabetes Prevention Program is described in detail to demonstrate the ingredients for success in moving a program from one country to another. Few countries have managed to scale up from evaluative trials to statewide or national programs. The Australian experience is described in detail including lessons learned about what reduced the effectiveness, particularly the need for policy makers in government, people from the implementing organisation and researchers to work together from the start of the evaluative trial and throughout the first 5 years of a national program.

Change in lifestyle behaviors and diabetes risk: evidence from a population-based cohort study with 10 year follow-up

Background

Promoting positive changes in lifestyle behavior in the whole population may be a feasible and effective approach to reducing type 2 diabetes burden, but the impact of population shifts of modifiable risk factors remains unclear. Currently most of the evidence on modifiable lifestyle behavior and type 2 diabetes risk on a population level comes from studies of between-individual differences. The objective of the study was to investigate the association and potential impact on disease burden for within-individual change in lifestyle behavior and diabetes risk.

Methods

Population-based prospective cohort study of 35,680 participants aged 30–50 at baseline in 1990–2003 in Västerbotten County, Sweden (follow-up until 2013). Five self-reported modifiable lifestyle behaviors (tobacco use, physical activity, alcohol intake, dietary fiber intake and dietary fat intake) were measured at baseline and 10 year follow-up. Lifestyle behaviors were studied separately, and combined in a score. Incident diabetes was detected by oral glucose tolerance tests. Multivariate logistic regression models and population attributable fractions (PAF) were used to analyze the association between change in lifestyle behavior between baseline and 10 year follow-up, and risk of incident diabetes.

Results

Incident diabetes was detected in 1,184 (3.3%) participants at 10 year follow-up. There was a reduced diabetes risk associated with increase in dietary fiber intake, odds ratio (OR) 0.79 (95% confidence interval (CI) 0.66, 0.96) for increase of at least one unit standard deviation (3.0 g/1,000 kcal) of the baseline distribution, PAF 16.0% (95% CI 4.2, 26.4%). Increase in the lifestyle behavior score was associated with reduced diabetes risk, OR 0.92 (95% CI 0.85, 0.99) per unit increase of the score.

Conclusions

These results support a causal link between lifestyle behavior and type 2 diabetes incidence. A small shift in lifestyle behaviors, in particular intake of dietary fiber, has the potential to reduce diabetes burden in the population and might be a suitable target for public health intervention.

Electronic supplementary material

The online version of this article (doi:10.1186/s12966-017-0489-8) contains supplementary material, which is available to authorized users.

Evidence-Based Guideline of the German Nutrition Society: Fat Intake and Prevention of Selected Nutrition-Related Diseases

As nutrition-related chronic diseases have become more and more frequent, the importance of dietary prevention has also increased. Dietary fat plays a major role in human nutrition, and modification of fat and/or fatty acid intake could have a preventive potential. The aim of the guideline of the German Nutrition Society (DGE) was to systematically evaluate the evidence for the prevention of the widespread diseases obesity, type 2 diabetes mellitus, dyslipoproteinaemia, hypertension, metabolic syndrome, coronary heart disease (CHD), stroke, and cancer through the intake of fat or fatty acids. The main results can be summarized as follows: it was concluded with convincing evidence that a reduced intake of total and saturated fat as well as a larger intake of polyunsaturated fatty acids (PUFA) at the expense of saturated fatty acids (SFA) reduces the concentration of total and low-density lipoprotein cholesterol in plasma. Furthermore, there is convincing evidence that a high intake of trans fatty acids increases risk of dyslipoproteinaemia and that a high intake of long-chain polyunsaturated n-3 fatty acids reduces the triglyceride concentration in plasma. A high fat intake increases the risk of obesity with probable evidence when total energy intake is not controlled for (ad libitum diet). When energy intake is controlled for, there is probable evidence for no association between fat intake and risk of obesity. A larger intake of PUFA at the expense of SFA reduces risk of CHD with probable evidence. Furthermore, there is probable evidence that a high intake of long-chain polyunsaturated n-3 fatty acids reduces risk of hypertension and CHD. With probable evidence, a high trans fatty acid intake increases risk of CHD. The practical consequences for current dietary recommendations are described at the end of this article.

Healthy behaviours and 10-year incidence of diabetes: a population cohort study

OBJECTIVE

To examine the association between meeting behavioural goals and diabetes incidence over 10 years in a large, representative Swedish population.

METHODS

Population-based prospective cohort study of 32,120 individuals aged 35 to 55 years participating in a health promotion intervention in Västerbotten County, Sweden (1990 to 2013). Participants underwent an oral glucose tolerance test, clinical measures, and completed diet and activity questionnaires. Poisson regression quantified the association between achieving six behavioural goals at baseline - body mass index (BMI) <25 kg/m(2), moderate physical activity, non-smoker, fat intake <30% of energy, fibre intake ≥15 g/4184 kJ and alcohol intake ≤20 g/day - and diabetes incidence over 10 years.

RESULTS

Median interquartile range (IQR) follow-up time was 9.9 (0.3) years; 2211 individuals (7%) developed diabetes. Only 4.4% of participants met all 6 goals (n=1245) and compared to these individuals, participants meeting 0/1 goals had a 3.74 times higher diabetes incidence (95% confidence interval (CI)=2.50 to 5.59), adjusting for sex, age, calendar period, education, family history of diabetes, history of myocardial infarction and long-term illness. If everyone achieved at least four behavioural goals, 14.1% (95% CI: 11.7 to 16.5%) of incident diabetes cases might be avoided.

CONCLUSION

Interventions promoting the achievement of behavioural goals in the general population could significantly reduce diabetes incidence.

Quantifying the risk of type 2 diabetes in East London using the QDScore: a cross-sectional analysis

BACKGROUND

Risk scores calculated from electronic patient records can be used to predict the risk of adults developing diabetes in the future.

AIM

To use a risk-prediction model on GPs' electronic health records in three inner-city boroughs, and to map the risk of diabetes by locality for commissioners, to guide possible interventions for targeting groups at high risk.

DESIGN AND SETTING

Cross-sectional analysis of electronic general practice records from three deprived and ethnically diverse inner-city boroughs in London.

METHOD

A cross-sectional analysis of 519 288 electronic primary care records was performed for all people without diabetes aged 25-79 years. A validated risk score, the QDScore, was used to predict 10-year risk of developing type 2 diabetes. Descriptive statistics were generated, including subanalysis by deprivation and ethnicity. The proportion of people at high risk (≥20% risk) per general practice was geospatially mapped.

RESULTS

Data were obtained from 135 out of 145 general practices (91.3%); 1 in 10 people in this population were at high risk (≥20%) of developing type 2 diabetes within 10 years. Of those with known cardiovascular disease or hypertension, approximately 50% were at high risk. Male sex, increasing age, South Asian ethnicity, deprivation, obesity, and other comorbidities increased the risk. Geospatial mapping revealed hotspots of high risk.

CONCLUSION

Individual risk scores calculated from electronic records can be aggregated to produce population risk profiles to inform commissioning and public health planning. Specific localities were identified (the 'East London diabetes belt'), where preventive efforts should be targeted. This method could be used for other diseases and risk states, to inform targeted commissioning and preventive research.

Expansion of electronic health record-based screening, prevention, and management of diabetes in New York City

To address the increasing burden of diabetes in New York City, we designed 2 electronic health records (EHRs)-facilitated diabetes management systems to be implemented in 6 primary care practices on the West Side of Manhattan, a standard system and an enhanced system. The standard system includes screening for diabetes. The enhanced system includes screening and ensures close patient follow-up; it applies principles of the chronic care model, including community–clinic linkages, to the management of patients newly diagnosed with diabetes and prediabetes through screening. We will stagger implementation of the enhanced system across the 6 clinics allowing comparison, through a quasi-experimental design (pre–post difference with a control group), of patients treated in the enhanced system with similar patients treated in the standard system. The findings could inform health system practices at multiple levels and influence the integration of community resources into routine diabetes care.

Predictors of lifestyle intervention outcome and dropout: the SLIM study

BACKGROUND/OBJECTIVES

To evaluate the effect of a 4.1-year (range 3-6 years) lifestyle intervention according to general public health recommendations on glucose tolerance and dropout in a Dutch population with impaired glucose tolerance (IGT).

SUBJECTS/METHODS

In the Study on Lifestyle intervention and Impaired glucose tolerance Maastricht, 147 Caucasian IGT subjects were randomized to an intervention group (INT: n=74; 38 male, 36 female) and control group (CON: n=73; 37 male, 36 female). Annually, subjects underwent measurements of body weight, anthropometry, glucose tolerance (oral glucose tolerance test), insulin resistance (homeostasis model assessment-insulin resistance), maximal aerobic capacity (VO(2) max), blood lipids and blood pressure. INT received individual advice regarding a healthy diet and physical activity.

RESULTS

INT decreased their saturated fat intake, increased their carbohydrate intake (P<0.05) and VO(2) max (P=0.04) compared with CON. Body weight did not change significantly (P=0.20) between the groups. After an initial decrease, 2-h glucose levels overall increased in INT (+0.11 mmol/l), but significantly less than CON (+1.18 mmol/l; P=0.04). Diabetes incidence was lower in INT versus CON (30 versus 56%, P=0.04). Change in body weight was associated with change in 2-h glucose levels (β=0.399 mmol/l per kg, P=0.02). Dropouts had a lower aerobic fitness and socioeconomic status, and a higher body mass index (BMI) and 2-h glucose compared with non-dropouts.

CONCLUSIONS

Prolonged feasible changes in diet and physical activity prevent deterioration of glucose tolerance and reduce diabetes risk. Low socioeconomic status, low aerobic fitness and high BMI and 2-h glucose are indicative of dropout to the program.

Provider practices in prediabetes intervention and diabetes prevention: application of evidence-based research in the medical office setting

A cross-sectional study was performed to determine if evidence-based research in prediabetes management is utilized in the medical office setting in an effort to reduce the incidence of type 2 diabetes, and to determine whether any particular demographic variables including body mass index (BMI) and provider type (physician and nonphysician) predict referrals for prediabetes management (P = .05). Electronic medical records (n = 82 317) were examined for International Classification of Diseases (ICD) codes and keywords disclosing a diagnosis of prediabetes. The records of individuals with diagnosed prediabetes were subsequently examined for keywords and ICD codes for lifestyle intervention. Logistic regression was utilized to determine whether any particular demographic factors significantly predicted whether medical providers will provide recommendations or referrals for lifestyle management of prediabetes. Age, BMI, and race were found to be significant predictors for recommendations/referrals, although overall rates of recommendation or referral were poor. Provider education and enhancements in organizational policy related to referral procedures and continuity of care from the clinical setting to the community health setting are crucial in promoting early interventions in prediabetes to offset the current projections for an increase in diabetes incidence.

Reduction of diabetes risk in routine clinical practice: are physical activity and nutrition interventions feasible and are the outcomes from reference trials replicable? A systematic review and meta-analysis

Background

The clinical effectiveness of intensive lifestyle interventions in preventing or delaying diabetes in people at high risk has been established from randomised trials of structured, intensive interventions conducted in several countries over the past two decades. The challenge is to translate them into routine clinical settings. The objective of this review is to determine whether lifestyle interventions delivered to high-risk adult patients in routine clinical care settings are feasible and effective in achieving reductions in risk factors for diabetes.

Methods

Data sources: MEDLINE (PubMed), EMBASE, CINAHL, The Cochrane Library, Google Scholar, and grey literature were searched for English-language articles published from January 1990 to August 2009. The reference lists of all articles collected were checked to ensure that no relevant suitable studies were missed. Study selection: We included RCTs, before/after evaluations, cohort studies with or without a control group and interrupted time series analyses of lifestyle interventions with the stated aim of diabetes risk reduction or diabetes prevention, conducted in routine clinical settings and delivered by healthcare providers such as family physicians, practice nurses, allied health personnel, or other healthcare staff associated with a health service. Outcomes of interest were weight loss, reduction in waist circumference, improvement of impaired fasting glucose or oral glucose tolerance test (OGTT) results, improvements in fat and fibre intakes, increased level of engagement in physical activity and reduction in diabetes incidence.

Results

Twelve from 41 potentially relevant studies were included in the review. Four studies were suitable for meta-analysis. A significant positive effect of the interventions on weight was reported by all study types. The meta-analysis showed that lifestyle interventions achieved weight and waist circumference reductions after one year. However, no clear effects on biochemical or clinical parameters were observed, possibly due to short follow-up periods or lack of power of the studies meta-analysed. Changes in dietary parameters or physical activity were generally not reported. Most studies assessing feasibility were supportive of implementation of lifestyle interventions in routine clinical care.

Conclusion

Lifestyle interventions for patients at high risk of diabetes, delivered by a variety of healthcare providers in routine clinical settings, are feasible but appear to be of limited clinical benefit one year after intervention. Despite convincing evidence from structured intensive trials, this systematic review showed that translation into routine practice has less effect on diabetes risk reduction.

Screening for type 2 diabetes: an update of the evidence

A growing body of evidence on diabetes screening has been published during the last 10 years. Type 2 diabetes meets many but not all of the criteria for screening. Concerns about potential harms of screening have largely been resolved. Screening identifies a high-risk population with the potential to gain from widely available interventions. However, in spite of the findings of modelling studies, the size of the benefit of earlier initiation of treatment and the overall cost-effectiveness remains uncertain, in contrast to other screening programmes (such as for abdominal aortic aneurysms) that are yet to be fully implemented. There is also uncertainty about optimal specifications and implementation of a screening programme, and further work to complete concerning development and delivery of individual- and population-level preventive strategies. While there is growing evidence of the net benefit of earlier detection of individuals with prevalent but undiagnosed diabetes, there remains limited justification for a policy of universal population-based screening for type 2 diabetes at the present time. Data from ongoing studies should inform the key assumptions in existing modelling studies and further reduce uncertainty.

Individual saturated fatty acids are associated with different components of insulin resistance and glucose metabolism: the GOCADAN study

OBJECTIVES

Type 2 diabetes and the consumption of saturated fatty acids (FAs) are on the rise among Alaska Inuits. This analysis, based on a cross-sectional study, explores the possible associations of saturated FA content in red blood cells (RBCs) and parameters of glucose metabolism in a sample of Alaska Natives.

STUDY DESIGN AND METHODS

The sample included 343 women and 282 men aged 35-74. Statistical analyses explored the associations of selected RBC (myristic, palmitic and stearic acids) FAs with fasting glucose (plasma), fasting insulin (plasma), 2h glucose (2-hour glucose tolerance test), 2h insulin and homeostasis model assessment (HOMA) index. The models included sex and glucose metabolism status as fixed factors and age, body mass index (BMI), waist circumference, physical activity (METS) and FA content in RBCs as covariates. Measures of insulin, glucose and HOMA index were used as dependent variables.

RESULTS

Myristic acid was positively associated with fasting insulin (β=0.47, p<0.001), 2h insulin (β=0.53, p=0.02) and HOMA index (β=0.455, p<0.001). Palmitic acid was associated with 2h glucose (β=2.3×10(-2), p<0.001) and 2h insulin (β=5.6×10(-2), p=0.002) and stearic acid was associated with fasting glucose (β=4.8×10(-3), p=0.006).

CONCLUSIONS

These results strongly support the hypothesis that saturated fatty acids are associated with insulin resistance and glucose intolerance and that saturated fatty acids are significant risk factors for type 2 diabetes.

Reduction in incidence of type 2 diabetes by lifestyle intervention in a middle eastern community

BACKGROUND

Very few studies have used community-based interventions for primary prevention of Type 2 diabetes, and the direct effect of such interventions on diabetes incidence is relatively unknown.

PURPOSE

This study aims to assess the effect of lifestyle modification on risk factors for noncommunicable diseases (NCDs) and the development of Type 2 diabetes at the community level.

DESIGN

A cluster-controlled trial was conducted.

SETTING/PARTICIPANTS

In all, 3098 and 5114 individuals in intervention and control groups, respectively (mean age=43 years), recruited from District 13 of Tehran, Iran, participated in the baseline examination in 1999-2001. Among these individuals, a total of 1754 and 2993 individuals in the intervention and control groups, respectively (58%), completed a follow-up examination in 2002-2005.

INTERVENTION

The study intervention involved improvement in diet, increase in the level of physical activity, and reduction in cigarette smoking through educational interviews, lectures, and publications.

MAIN OUTCOME MEASURES

Incident Type 2 diabetes was measured by fasting plasma glucose (FPG) and 2-hour plasma glucose (2hPG) and change in NCD risk factors.

RESULTS

The mean follow-up time was 3.6 years. The incidence of diabetes in the control and intervention groups was 12.2 and 8.2 per 1000 person-years, respectively, with a relative risk reduction of 65% (95% CI=30%, 83%, p<0.003). The adjusted difference in mean change of risk factors between the intervention and control groups was significant for weight (-0.5 kg in men); BMI (-0.18 kg/m(2) in men); waist circumference (-1.0 cm in women); systolic and diastolic blood pressure (-1.1 and -0.6 mmHg, respectively, in women); FPG (-2.1 and -2.3 mg/dL in men and women); 2hPG (-4.6 mg/dL in women); total cholesterol (-2.8 mg/dL in women); triglycerides (-7.6 and -5.2 mg/dL in men and women); and high-density lipoprotein cholesterol (1.1 mg/dL in women; all p<0.05).

CONCLUSIONS

Lifestyle intervention resulted in a significant decrease in the incidence of Type 2 diabetes and better control of NCD risk factors in a population-based setting. ISRCTN TRIAL REGISTRATION #: ISRCTN52588395.

International Diabetes Federation: An update of the evidence concerning the prevention of type 2 diabetes

This article aims to provide an updated summary of diabetes prevention efforts by reviewing relevant literature published between 2007 and 2009. These include results from the long-term follow-up of diabetes prevention trials and the roll-out of community-based interventions in "real world" settings. Some countries have begun to implement population-based strategies for chronic disease prevention, but investment in developing and evaluating population-level interventions remains inadequate. By focussing on the "small change" approach and involving a number of different agencies, it may be possible to shift the population distribution of risk factors for diabetes and cardiovascular disease in a favourable direction. The cost-effectiveness of primary prevention strategies for type 2 diabetes has not been universally demonstrated. Some of the uncertainties relating to screening for diabetes have now been resolved but longer-term data on hard cardiovascular outcomes are still needed. In summary, individual countries should aim to develop and evaluate cost-effective, setting-specific diabetes risk identification and prevention strategies based on available resources. These should be linked to initiatives aimed at reducing the burden of cardiovascular disease, and complemented with population-based strategies focusing on the control and reduction of behavioural and cardiovascular risk factors by targeting their key determinants.

Nonpharmacologic therapy and exercise in the prevention of type 2 diabetes

OBJECTIVE

To review the current knowledge about nonpharmacologic approaches in the prevention and early treatment of type 2 diabetes.

RESEARCH DESIGN AND METHODS

This study reviewed the research reports dealing with nonpharmacologic interventions aimed at preventing type 2 diabetes with early lifestyle interventions.

RESULTS

The results from the randomized controlled trials all show that people with impaired glucose tolerance who received enhanced lifestyle advice had significantly lower (on average approximately 50% reduced) incidence of type 2 diabetes compared with those allocated to receive "usual care." Individuals who were able to correct their lifestyle habits as recommended for usual healthy life patterns were mostly protected against type 2 diabetes. Thus, compelling evidence exists that most of the cases of type 2 diabetes can be prevented or at least the onset of the disease can be significantly delayed.

CONCLUSIONS

Randomized controlled trials have unequivocally demonstrated that lifestyle management is highly efficient in the prevention and also in the early management of type 2 diabetes. This evidence of lifestyle modification in diabetes prevention is stronger than for most other multifactorial diseases.

Generational status and duration of residence predict diabetes prevalence among Latinos: the California Men's Health Study

BACKGROUND

Diabetes disproportionately affects Latinos. However, examining Latinos as one group obscures important intra-group differences. This study examined how generational status, duration of US residence, and language preference are associated with diabetes prevalence and to what extent these explain the higher prevalence among Latinos.

METHODS

We determined nativity, duration of US residence, language preference, and diabetes prevalence among 11 817 Latino, 6109 black, and 52 184 white participants in the California Men's Health Study. We combined generational status and residence duration into a single migration status variable with levels: > or = third generation; second generation; and immigrant living in the US for > 25, 16-25, 11-15, or < or = 10 years. Language preference was defined as language in which the participant took the survey. Logistic regression models were specified to assess the associations of dependent variables with prevalent diabetes.

RESULTS

Diabetes prevalence was 22%, 23%, and 11% among Latinos, blacks, and whites, respectively. In age-adjusted models, we observed a gradient of risk of diabetes by migration status among Latinos. Further adjustment for socioeconomic status, obesity and health behaviors only partially attenuated this gradient. Language preference was a weak predictor of prevalent diabetes in some models and not significant in others. In multivariate models, we found that odds of diabetes were higher among US-born Latinos than US-born blacks.

CONCLUSION

Generational status and residence duration were associated with diabetes prevalence among middle-aged Latino men in California. As the Latino population grows, the burden of diabetes-associated disease is likely to increase and demands public health attention.

Do lifestyle interventions work in developing countries? Findings from the Isfahan Healthy Heart Program in the Islamic Republic of Iran

OBJECTIVE

To assess the effects of a comprehensive, integrated community-based lifestyle intervention on diet, physical activity and smoking in two Iranian communities.

METHODS

Within the framework of the Isfahan Healthy Heart Program, a community trial was conducted in two intervention counties (Isfahan and Najaf-Abad) and a control area (Arak). Lifestyle interventions targeted the urban and rural populations in the intervention counties but were not implemented in Arak. In each community, a random sample of adults was selected yearly by multi-stage cluster sampling. Food consumption, physical exercise and smoking behaviours were quantified and scored as 1 (low-risk) or 0 (other) at baseline (year 2000) and annually for 4 years in the intervention areas and for 3 years in the control area. The scores for all behaviours were then added to derive an overall lifestyle score.

FINDINGS

After 4 years, changes from baseline in mean dietary score differed significantly between the intervention and control areas (+2.1 points versus -1.2 points, respectively; P < 0.01), as did the change in the percentage of individuals following a healthy diet (+14.9% versus -2.0%, respectively; P < 0.001). Daily smoking had decreased by 0.9% in the intervention areas and by 2.6% in the control area at the end of the third year, but the difference was not significant. Analysis by gender revealed a significant decreasing trend in smoking among men (P < 0.05) but not among women. Energy expenditure for total daily physical activities showed a decreasing trend in all areas, but the mean drop from baseline was significantly smaller in the intervention areas than in the control area (-68 metabolic equivalent task (MET) minutes per week versus -114 MET minutes per week, respectively; P < 0.05). Leisure time devoted to physical activities showed an increasing trend in all areas. A significantly different change from baseline was found between the intervention areas and the control area in mean lifestyle score, even after controlling for age, sex and baseline values.

CONCLUSION

The results suggest that community-based lifestyle intervention programmes can be effective in a developing country setting.

Conference on "Multidisciplinary approaches to nutritional problems". Symposium on "Diabetes and health". Nutrition interventions for the prevention of type 2 diabetes

Diabetes mellitus is escalating globally and it is predicted that 200 million individuals worldwide will have diabetes by 2010 and 300 million by 2025. However, there is compelling evidence from many studies that for subjects with impaired fasting glucose or impaired glucose tolerance the presentation of type 2 diabetes can be delayed by lifestyle modification. The aim of the present review is to present a summary of lifestyle modification interventions that have included a dietary component in their overall diabetes prevention programme. Medline, allied health literature and diabetes journals were searched for peer-reviewed literature using the terms 'diet*' and 'diabetes' and 'intervention'. Inclusion criteria were: peer-reviewed studies from 1975 to 2008; a sample of at least fifty subjects; a healthy eating and/or physical activity component; prevention of diabetes as a primary goal. Generally, the participants were in a high-risk category for the development of diabetes. Outcomes were evaluated at two points in time (pre- and post-intervention) in terms of knowledge, behaviour change and clinical improvement, which included weight, blood pressure, BMI, body fat, waist circumference, waist:hip ratio and physiological and/or biochemical measures. Findings indicate that the most successful interventions combine individual dietary counselling with an activity component. Further factors predicting success are weight loss achieved, duration and intensity of the intervention and dietary compliance.

Aerobic physical activity and resistance training: an application of the theory of planned behavior among adults with type 2 diabetes in a random, national sample of Canadians

Background

Aerobic physical activity (PA) and resistance training are paramount in the treatment and management of type 2 diabetes (T2D), but few studies have examined the determinants of both types of exercise in the same sample.

Objective

The primary purpose was to investigate the utility of the Theory of Planned Behavior (TPB) in explaining aerobic PA and resistance training in a population sample of T2D adults.

Methods

A total of 244 individuals were recruited through a random national sample which was created by generating a random list of household phone numbers. The list was proportionate to the actual number of household telephone numbers for each Canadian province (with the exception of Quebec). These individuals completed self-report TPB constructs of attitude, subjective norm, perceived behavioral control and intention, and a 3-month follow-up that assessed aerobic PA and resistance training.

Results

TPB explained 10% and 8% of the variance respectively for aerobic PA and resistance training; and accounted for 39% and 45% of the variance respectively for aerobic PA and resistance training intentions.

Conclusion

These results may guide the development of appropriate PA interventions for aerobic PA and resistance training based on the TPB.

Physical activity and diabetes: opportunities for prevention through policy

Over the past decade, the prevalence of type 2 diabetes mellitus has reached epidemic levels in the United States and other developed countries. With a concomitant rise in obesity levels in the United States and advances in the treatment of diabetes and its complications, the prevalence of diabetes is expected to continue to rise through the year 2050. Despite strong evidence that regular physical activity can prevent or delay the onset of diabetes, too many Americans are not meeting the recommended levels of regular physical activity. Although most physical activity interventions to date have been focused on characteristics of the individual, more-recent studies have considered how changing characteristics of the social and physical environment in which people live may ultimately have a greater impact on increasing population levels of physical activity. Policy interventions are a way to make sustainable changes in the physical environment of a community and thus provide support for other intrapersonal and interpersonal behavioral change interventions. Policy changes also can affect the social norms that shape behavior. The purposes of this perspective article are: (1) to describe the rationale for population approaches to primary prevention of type 2 diabetes, (2) to discuss how policy interventions can increase physical activity levels within populations, and (3) to provide recommendations for the role of physical therapists in interventions that can increase the level of physical activity in communities. Public health approaches to curb the diabetes epidemic are urgently needed. Policy interventions to increase population levels of physical activity show promise for diabetes prevention. Physical therapists are uniquely suited to influence primary prevention efforts for diabetes.

What's law got to do with it part 1: A framework for obesity prevention

This article provides a conceptual framework for thinking about the role of law in responding to population weight gain in Australia. Part 1 focuses on two core questions. Firstly, in pursuing the aim of weight reduction at the population level, what should law be trying to influence? The challenge here is to identify a model of the determinants of obesity that is adequate for legal purposes and that illustrates the entry points where law could best be used as an instrument of public health policy. Secondly, what kinds of strategies and tools can law offer to obesity prevention? The challenge here is to identify a model of law that captures the variety of contributions law is capable of making, at different levels of government, and across different legal systems.In Part 1 of the article, I argue that although law can intervene at a number of levels, the most important opportunities lie in seeking to influence the social, economic and environmental influences that shape patterns of eating and nutrition across the population as a whole. Only policies that impact broadly across the population can be expected to influence the weight distribution curve that has shifted relentlessly to the right in recent decades. Part 2 of the article builds on this analysis by offering a critical review of selected legal strategies for healthier nutrition and obesity prevention.

International Diabetes Federation: a consensus on Type 2 diabetes prevention

AIMS

Early intervention and avoidance or delay of progression to Type 2 diabetes is of enormous benefit to patients in terms of increasing life expectancy and quality of life, and potentially in economic terms for society and health-care payers. To address the growing impact of Type 2 diabetes the International Diabetes Federation (IDF) Taskforce on Prevention and Epidemiology convened a consensus workshop in 2006. The primary goal of the workshop and this document was the prevention of Type 2 diabetes in both the developed and developing world. A second aim was to reduce the risk of cardiovascular disease in people who are identified as being at a higher risk of Type 2 diabetes. The IDF plan for prevention of Type 2 diabetes is based on controlling modifiable risk factors and can be divided into two target groups: People at high risk of developing Type 2 diabetes. The entire population.

CONCLUSIONS

In planning national measures for the prevention of Type 2 diabetes, both groups should be targeted simultaneously with lifestyle modification the primary goal through a stepwise approach. In addition, it is important that all activities are tailored to the specific local situation. Further information on the prevention of diabetes can be found on the IDF website: http://www.idf.org/prevention.

Lifestyle interventions are cost-effective in people with different levels of diabetes risk: results from a modeling study

OBJECTIVE

In the current study we explore the long-term health benefits and cost-effectiveness of both a community-based lifestyle program for the general population (community intervention) and an intensive lifestyle intervention for obese adults, implemented in a health care setting (health care intervention).

RESEARCH DESIGN AND METHODS

Short-term intervention effects on BMI and physical activity were estimated from the international literature. The National Institute for Public Health and the Environment Chronic Diseases Model was used to project lifetime health effects and effects on health care costs for minimum and maximum estimates of short-term intervention effects. Cost-effectiveness was evaluated from a health care perspective and included intervention costs and related and unrelated medical costs. Effects and costs were discounted at 1.5 and 4.0% annually.

RESULTS

One new case of diabetes per 20 years was prevented for every 7-30 participants in the health care intervention and for every 300-1,500 adults in the community intervention. Intervention costs needed to prevent one new case of diabetes (per 20 years) were lower for the community intervention (2,000-9,000 euros) than for the health care intervention (5,000-21,000 euros). The cost-effectiveness ratios were 3,100-3,900 euros per quality-adjusted life-year (QALY) for the community intervention and 3,900-5,500 euros per QALY for the health care intervention.

CONCLUSIONS

Health care interventions for high-risk groups and community-based lifestyle interventions targeted to the general population (low risk) are both cost-effective ways of curbing the growing burden of diabetes.