Lifestyle interventions to reduce diabetes and cardiovascular disease risk among children

A Systematic Review of Behavioral Interventions on Children at Risk for Diabetes

INTRODUCTION

In adults, behavioral-based interventions support prevention of Type 2 diabetes; less is known in children. The aim of this systematic review was to examine the impact of behavioral-based interventions on cardiometabolic outcomes among children at risk for diabetes.

METHODS

PubMed, CINAHL Plus with Full Text, PsycINFO, and Web of Science were searched between September 2011 and September 2021. RCTs in children aged 6-12 years at risk for Type 2 diabetes that implemented a behavioral-based intervention and included ≥1 cardiometabolic outcome were eligible. If reported, dietary quality data were extracted. Risk of bias was assessed using the revised Cochrane risk-of-bias tool.

RESULTS

Of the 2,386 records identified, 4 met the inclusion criteria. Study length ranged from 10 weeks to 24 months, with sample sizes ranging from 53 to 113 participants. Among the 4 studies, there were 5 behavioral-based arms. All studies included weight status outcomes, with 3 finding significant between-group differences. Four studies assessed fasting glucose, and 3 assessed HbA1c; none found significant changes between groups. Of the 4 studies reporting blood pressure outcomes, 1 found a significant between-group difference for systolic blood pressure. Three studies assessed cholesterol and found no changes. No studies reported measures of dietary quality. All studies had some concerns about risk of bias.

DISCUSSION

Behavioral-based interventions improved weight status and supported the maintenance of cardiometabolic parameters. Stronger consideration of the most important risk factors in children along with intermediate outcomes (e.g., diet quality) may help to elucidate the relationship between behavioral-based interventions and cardiometabolic outcomes.

Hyperglycemia in pregnancy and developmental outcomes in children at 18–60 months of age: the PANDORA Wave 1 study

This study aimed to explore the association between hyperglycemia in pregnancy (type 2 diabetes (T2D) and gestational diabetes mellitus (GDM)) and child developmental risk in Europid and Aboriginal women.

PANDORA is a longitudinal birth cohort recruited from a hyperglycemia in pregnancy register, and from normoglycemic women in antenatal clinics. The Wave 1 substudy included 308 children who completed developmental and behavioral screening between age 18 and 60 months. Developmental risk was assessed using the Ages and Stages Questionnaire (ASQ) or equivalent modified ASQ for use with Aboriginal children. Emotional and behavioral risk was assessed using the Strengths and Difficulties Questionnaire. Multivariable logistic regression was used to assess the association between developmental scores and explanatory variables, including maternal T2D in pregnancy or GDM.

After adjustment for ethnicity, maternal and child variables, and socioeconomic measures, maternal hyperglycemia was associated with increased developmental “concern” (defined as score ≥1 SD below mean) in the fine motor (T2D odds ratio (OR) 5.30, 95% CI 1.77–15.80; GDM OR 3.96, 95% CI 1.55–10.11) and problem-solving (T2D OR 2.71, 95% CI 1.05–6.98; GDM OR 2.54, 95% CI 1.17–5.54) domains, as well as increased “risk” (score ≥2 SD below mean) in at least one domain (T2D OR 5.33, 95% CI 1.85–15.39; GDM OR 4.86, 95% CI 1.95–12.10). Higher maternal education was associated with reduced concern in the problem-solving domain (OR 0.27, 95% CI 0.11–0.69) after adjustment for maternal hyperglycemia.

Maternal hyperglycemia is associated with increased developmental concern and may be a potential target for intervention so as to optimize developmental trajectories.

Promoting healthy lifestyle behaviours in youth: Findings from a novel intervention for children at risk of cardiovascular disease

Objectives

Obesity is the most prevalent risk factor for cardiovascular disease (CVD) in children. We developed a 2-year lifestyle intervention for youth at risk of CVD. We assessed changes in body mass index z-scores (zBMI) and key cardiometabolic risk factors, physical fitness, and capacity among those who completed the program.

Methods

The CIRCUIT program is a multidisciplinary lifestyle intervention for children aged 4 to 18 years at risk of CVD, based on a personalized plan to improve cardiometabolic outcomes by increasing physical activity and reducing sedentary behaviours. Both at baseline and 2-year follow-up, we measured zBMI, blood pressure z-scores (zBP), adiposity (%body and %trunk fat), fasting blood glucose and lipid profile, aerobic (VO2max) and anaerobic (5×5 m shuttle run test) fitness, and physical capacity indicators. Differences between baseline and follow-up were examined using paired t-tests (for age-sex standardized outcomes) and multivariable mixed effect models, adjusted for age and sex (for other outcomes).

Results

Among the 106 participants (53 males) who completed the 2-year program, mean age at baseline was 10.9 years (SD=3.2). After 2 years, zBMI and diastolic zBP decreased by 0.30SD (95% CI: −0.44; −0.16) and 0.43SD (95% CI: −0.65; −0.23), respectively. Participants improved %body and %trunk fat, lipid profile, aerobic and anaerobic fitness levels, and physical capacity (p<0.02). No changes in systolic zBP nor in fasting plasma glucose were observed.

Conclusion

Our findings showed improved zBMI, cardiometabolic outcomes, physical fitness, and capacity among children at risk of CVD, suggesting that CIRCUIT is a promising intervention.

The lockdown effects on a pediatric obese population in the COVID-19 era

Background

The social consequences of COVID-19 pandemic are universally known. In particular, the pediatric population is dealing with a radical lifestyle change. For some risk categories, such as overweight or obese children, the impact of home confinement has been greater than for others. The increased sedentary life, the wrong diet and social distancing have stopped the chance of losing weight.

The aims of this study were to analyse the impact of COVID-19 lockdown on the behavior changes in a obese pediatric population and to explore the correlation between the new lifestyle and the level of parental instruction.

Methods

Data show features of 40 obese and overweight pediatric patients of our Clinic in Messina (Italy). We evaluated weight, height, BMI and other biochemical parameters: total cholesterol, HDL, LDL, triglyceride, transaminases, glycemia and insulinemia. After the lockdown, we contacted all patients in order to get some information about diet, physical activity and sedentary lifestyle changes in correlation to the level of their parents’ instruction. Additionally, we also evaluated 20 children twice from a clinical and laboratory perspective.

Results

The study showed an increase of daily meals during COVID-19 lockdown (3.2 ± 0.4 vs 5 ± 1, P < 0.001). In particular, children whose parents have primary school diploma ate a greater significant number of meals during the lockdown, compared to those who have parents with secondary school diploma (P = 0.0019). In addition, the 95% of patients did low physical activity during the lockdown and the 97.5% spent more time in sedentary activity. Even if BMI’s values don’t show significant differences, they have increased after the lockdown. We didn’t find any correlation between biochemical parameters before and after the lockdown.

Conclusion

The lockdown has had bad consequences on good style of life’s maintenance in overweight and obese children. The absence of a significant correlation between the worsening of biochemical parameters and the lockdown doesn’t allow to exclude any long-term consequences. It’s safe to assume that, if the hours spent in sedentary activity and the number of meals don’t diminish, there will probably repercussion on the biochemical parameters.

Changes in lifestyle behaviours during the COVID-19 confinement in Spanish children: A longitudinal analysis from the MUGI project

BACKGROUND

Home confinement during the COVID-19 pandemic could have affected lifestyle behaviours of children, however evidence about it is emerging and yet scarce.

OBJECTIVES

To examine the effects of the COVID-19 confinement on lifestyle behaviours in Spanish children, and to assess the influence of social vulnerabilities on changes in lifestyle behaviours.

METHODS

Physical activity (PA), screen time, sleep time, adherence to the Mediterranean diet (KIDMED) and sociodemographic information were longitudinally assessed before (N = 291, 12.1 ± 2.4 years, 47.8% girls) and during the COVID-19 confinement (N = 113, 12.0 ± 2.6 years, 48.7% girls) by online questionnaires.

RESULTS

During the COVID-19 confinement, PA (-91 ± 55 min/d, P < .001) and screen time (±2.6 h/d, P < .001) worsened, whereas the KIDMED score improved (0.5 ± 2.2 points, P < .02). The decrease of PA was higher in children with mother of non-Spanish origin (-1.8 ± 0.2 vs -1.5 ± 0.1 h/d, P < .04) or with non-university studies (-1.7 ± 0.1 vs -1.3 ± 0.1 h/d, P < .005) in comparison to their counterparts.

CONCLUSION

This study evidence the negative impact of the COVID-19 confinement on PA levels and sedentary behaviours of Spanish children. These findings should be taken into account to design and implement public health strategies for preserving children´s health during and after the pandemic, particularly, in children with social vulnerabilities.

Development of an Interactive Lifestyle Programme for Adolescents at Risk of Developing Type 2 Diabetes: PRE-STARt

Background: Type 2 diabetes (T2D) is increasing in young people. Reporting on the processes used when developing prevention interventions is needed. We present the development of a family-based interactive lifestyle intervention for adolescents with risk factors for T2D in the future. Method: A multidisciplinary team in the UK site led the intervention development process with sites in Portugal, Greece, Germany and Spain. Potential programme topics and underpinning theory were gathered from literature and stakeholders. A theoretical framework based on self-efficacy theory and the COM-B (capability, opportunity, motivation, behaviour) model was developed. Sessions and supporting resources were developed and refined via two iterative cycles of session and resource piloting, feedback, reflection and refinement. Decision on delivery and content were made by stakeholders (young people, teachers, parents, paediatricians) and all sites. Materials were translated to local languages. Site-specific adaptations to the language, content and supporting resources were made. Results: The “PRE-STARt” programme is eight 90-min interactive sessions with supporting curriculum and resources. Iterative development work provided valuable feedback on programme content and delivery. Conclusion: Reporting on the intervention development process, which includes stakeholder input, could yield a flexible approach for use in this emerging ‘at risk’ groups and their families.

Association between physical activity and diabetic complications among Bangladeshi type 2 diabetic patients

BACKGROUND

The aim of the study was to assess the association of physical activity (PA) with the presence of diabetes related complications among Bangladeshi type 2 diabetic subjects.

METHODS

This cross-sectional study was conducted in the Out Patient Department (OPD) of BIRDEM, Bangladesh. A group of 977 subjects were randomly selected and followed up. Diabetes was diagnosed following the WHO study group criteria. The level of PA was categorized into inactive/low (<150 min/week) and moderate-to-vigorous (≥150 min/week). The WHO recommended Asian criteria was used to identify general obesity. Retinopathy was detected by fundal photography, CKD by serum creatinine and hypertension was diagnosed clinically. Univariate and multivariate analyses were used to assess the associations of PA with diabetes related complications.

RESULTS

Out of the 977 subjects investigated, 468 were male and 509 were female (mean ± SD of age, 56 ± 8 years). In the study subjects, 74% were either inactive or in low PA and of them 65.1% were overweight/obese. Analysis showed that inactive/low PA was associated with all the three diabetes related complications (p < 0.001)-hypertension, retinopathy, and nephropathy. Multivariate analysis showed that inactive/low level of PA was strongly associated with complications like retinopathy (p < 0.001) and hypertension (p = 0.01) in the female patients. It was also found to be highly associated with retinopathy (p < 0.001) among the male patients.

CONCLUSION

A large number of urban Bangladeshi population are involved only in low PA or remain inactive themselves, which is leading to obesity and it seems to have a strong association with diabetes related complications in this population.

Associations of physical activity and fruit and vegetable intake with well-being and depressive symptoms among obese schoolchildren in Wuhan, China: a cross-sectional study

BACKGROUND

The prevalence of childhood obesity is increasing and psychological disorder is a common comorbidity of obesity. We investigated the associations of physical activity (PA) and fruit and vegetable (FV) intake with well-being and depressive symptoms among obese schoolchildren.

METHODS

Participants included 188 obese children aged 9.8 ± 0.7 years living in Wuhan, China. Self-administered questionnaires were used to collect the children's PA and FV intake information. PA was considered to be high if the child participated in sport and/or vigorous free play at least 3 days per week with 60 min per day, while sufficient FV intake was defined as consuming FV 5 times per day. Children's well-being and depressive symptoms were assessed by standard questionnaires. Multiple logistic regression was performed to determine the odds ratios (ORs) and 95% confidence intervals (CIs) of the relationships of PA and FV intake with well-being and depressive symptoms.

RESULTS

High PA and sufficient FV intake were independently associated with significantly decreased risks for depressive symptoms (for PA, OR: 0.39, 95% CI: 0.16-0.92; for FV, OR: 0.21, 95% CI: 0.08-0.55) and poor well-being (for PA, OR: 0.35, 95% CI: 0.16-0.74), respectively. Furthermore, interactive inverse associations were observed between combined high PA and sufficient FV intake with poor well-being and depressive symptoms. Compared to their counterparts, children with high PA and sufficient FV intake had significantly reduced risk for poor well-being (OR: 0.16, 95%CI: 0.05-0.55) and depressive symptoms (OR: 0.12, 95% CI: 0.03-0.48).

CONCLUSIONS

High PA and sufficient FV intake are inversely associated with the risks of poor well-being and depressive symptoms among obese Chinese schoolchildren.

Longitudinal associations of lifestyle factors and weight status with insulin resistance (HOMA-IR) in preadolescent children: the large prospective cohort study IDEFICS

Background

This study investigates prospective associations of anthropometrical and lifestyle indices with insulin resistance (IR) in European children from the IDEFICS cohort. Insulin resistance (IR) is a growing concern in childhood obesity and a central aspect of the metabolic syndrome (MS). It most likely represents the link between obesity and type 2 diabetes.

Methods

This longitudinal study included 3348 preadolescent children aged 3 to 10.9 years from 8 European countries who were observed from 2007/2008 to 2009/2010. The main outcome measure in the present analysis is HOMA-IR (homeostasis model assessment as a common proxy indicator to quantify IR) at follow-up and in its longitudinal development. Anthropometrical measures and lifestyle indices, including objectively determined physical activity, were considered, among others factors, as determinants of IR. Prospective associations between IR at follow-up and anthropometrical and lifestyle indices were estimated by logistic regression models.

Results

Country-specific prevalence rates of IR in the IDEFICS cohort of European children showed a positive trend with weight category. Prospective multivariate analyses showed the strongest positive associations of IR with BMI z-score (OR = 2.6 for unit change from the mean, 95 % CI 2.1–3.1) and z-score of waist circumference (OR = 2.2 for unit change from the mean, 95 % CI 1.9–2.6), which were analysed in separate models, but also for sex (OR = 2.2 for girls vs. boys, 95 % CI 1.5–3.1 up to OR 2.5, 95 % CI 1.8–3.6 depending on the model), audio-visual media time (OR = 1.2 for an additional hour per day, 95 % CI 1.0–1.4 in both models) and an inverse association of objectively determined physical activity (OR = 0.5 for 3^rd compared to 1^st quartile, 95 % CI 0.3–0.9 in both models). A longitudinal reduction of HOMA-IR was accompanied with a parallel decline in BMI.

Conclusions

This study is, to our knowledge, the first prospective study on IR in a preadolescent children’s population. It supports the common hypothesis that overweight and obesity are the main determinants of IR. Our data also indicate that physical inactivity and a sedentary lifestyle are likewise associated with the development of IR, independent of weight status. The promotion of physical activity should thus be considered as an equal option to dietary intervention for the treatment of IR in the paediatric practice.

In vitro Screening and Evaluation of 37 Traditional Chinese Medicines for Their Potential to Activate Peroxisome Proliferator-Activated Receptors-γ

BACKGROUND

Peroxisome proliferator-activated receptors (PPAR)-γ is widely used as an attractive target for the treatment of type 2 diabetes mellitus. Thiazolidinediones, the agonists of PPARγ, has been popularly utilized as insulin sensitizers in the therapy of type 2 diabetes whereas numerous severe side-effects may also occur concomitantly.

OBJECTIVE

The PPARγ activation activity of different polar extracts, including petroleum ether, ethyl acetate, n-butanol, residual of ethanol, the precipitate part of water and the supernatant of water extracts, from 37 traditional Chinese medicines were systematically evaluated.

MATERIALS AND METHODS

HeLa cells were transiently co-transfected with the re-constructed plasmids of GAL4-PPARγ-ligand binding domain and pGL4.35. The activation of PPARγ by different polarity extracts were evaluated based on the PPARγ transactivation assay and rosiglitazone was used as positive control.

RESULTS

Seven medicines (root bark of Lycium barbarum, Anoectochilus sroxburghii, the rhizome of Phragmites australis, Pterocephalus hookeri, Polygonatum sibiricum, fruit of Gleditsia sinensis, and Epimedium brevicornu) were able to significantly activate PPARγ.

CONCLUSION

As seven medicines were able to activate PPARγ, the anti-diabetic activity of them is likely to be mediated by this nuclear receptor.

SUMMARY

Lots of the tested medicinal products had activation effects on activating PPARγEthyl acetate extracts of root bark of L.barbarum, rhizome of P.saustralis and fruit of G.siasinensis showed good PPARγ activation effect similar or higher than that of positive control, 0.5 μg/mL rosiglitazonePetroleum ether extracts of A.roxburghii, P. hookeri, P. sibiricum, E.brevicornu also can significantly activate PPARγ, the effects of them were higher than t0.5 μg/mL rosiglitazoneSchisandra chinensis (Turcz.) Baill., the fruit Cornus officinalis Siebold and Zucc., Alisma plantago-aquatica L. and the root of Trichosanthes Kirilowii Maxim., traditional anti-diabetic mediciness in China, had no effects on the activation of PPARγ. Abbreviations used: PPARγ: Peroxisome Proliferator-activated Receptors-γ, TCMs: Traditional Chinese medicines, TZDs: Thiazolidinediones, LBD: Ligand binding domain, DMSO: Dimethyl sulfoxide, FBS: Fetal bovine serum, DMEM: Dulbecco's modified Eagle's medium.

A Home-Visiting Diabetes Prevention and Management Program for American Indian Youth: The Together on Diabetes Trial

PURPOSE

The purpose of this study was to test the feasibility of a family-based, home-visiting diabetes prevention/management intervention for American Indian (AI) youth with or at risk for type 2 diabetes.

METHODS

The Together on Diabetes program, developed through community-based participatory research, enrolled 255 AI youth (aged 10-19 years) with or at risk for type 2 diabetes and 223 support persons. Delivered by local AI paraprofessionals in 4 rural AI communities, the program included home-based lifestyle education and psychosocial support, facilitated referrals, and community-based healthy living activities. Changes in AI youth participants' knowledge, behavior, psychosocial status, and physiological measurements were assessed over 12 months.

RESULTS

Over one-half (56.1%) of youth were boys. The median age was 13.2 years. At baseline, 68.0% of youth reported no physical activity in the past 3 days; median percentages of kilocalories from fat (36.18%) and sweets (13.67%) were higher than US Department of Agriculture recommendations. Nearly 40% of participants reported food insecurity in the past month; 17.1% screened positive for depression. Support persons were predominantly family members, few reported having home Internet access (38.6%), and the majority reported being long distances (>30 minutes) from food stores. Whereas support persons were primarily responsible (≥69%) for obtaining medical care for the youth, the youth had a greater role in behavioral outcomes, indicating joint diabetes prevention/management responsibility.

CONCLUSIONS

Baseline results confirmed the need for family-based youth diabetes prevention interventions in rural AI communities and indicated that enrolling at-risk youth and family members is feasible and acceptable.