PREVENT-DM Comparative Effectiveness Trial of Lifestyle Intervention and Metformin

The optimal dose of metformin to control conversion to diabetes in patients with prediabetes: A meta-analysis

AIM

This study aims to investigate the optimal dose of metformin for controlling the transition to diabetes in patients diagnosed with prediabetes.

METHODS

We systematically searched randomized controlled trials (RCTs) in CNKI, Wanfang, VIP, SinoMed, Scopus, PubMed, Embase, Cochrane Library, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) from inception to February 2024. Meta-analysis was conducted using RevMan 5.4 software.

RESULTS

We included 25 randomized controlled trials comprising 2437 patients. The results of the meta-analysis revealed that compared to dose groups of 500 mg/d, 850 mg/d, 1000 mg/d, 1500 mg/d, 1700 mg/d, and 2000 mg/d, a dosage of 750 mg/d of metformin significantly reduced the incidence of diabetes in patients (risk ratio [RR] = 0.21, 95 % confidence interval [CI]: 0.11, 0.41; p < 0.00001), lowered Postprandial Blood Glucose (PBG) (mean difference[MD] = -2.60, 95 % CI: -4.34, -0.86; p = 0.003), and promoted the normalization of blood glucose levels (RR = 2.13, 95 % CI: 1.68, 2.71; p < 0.00001). Regarding safety evaluation, no significant differences were identified among the various dose groups. In contrast, the cohort receiving a daily dosage of 750 mg demonstrated the most pronounced decrease in the incidence of adverse reactions.

CONCLUSION

Based on the efficacy and safety evaluation results, our findings suggest that a daily dosage of 750 mg of metformin may represent the optimal dose for controlling the progression from pre-diabetes to diabetes.

REGISTRATION

PROSPERO registration ID: CRD42024538322.

Efficacy of lifestyle weight loss interventions on regression to normoglycemia and progression to type 2 diabetes in individuals with prediabetes: a systematic review and pairwise and dose-response meta-analyses

BACKGROUND

Current recommendations for weight loss in individuals with prediabetes come from individual trials and are derived from older data.

OBJECTIVES

To elucidate the dose-dependent impacts of weight loss on participants with prediabetes to determine the optimal magnitude of weight loss required for the implementation of the most effective diabetes prevention program.

METHODS

We searched PubMed, Scopus, CENTRAL, CINAHL, and gray literature sources to September 2023 for randomized trials ≥6 mo that evaluated the efficacy of a lifestyle weight loss intervention on participants with prediabetes. We conducted random-effects pairwise meta-analyses to calculate relative and absolute effects. We performed a 1-stage weighted mixed-effects meta-analysis to elucidate the dose-response curves.

RESULTS

Forty-four randomized trials with 14,742 participants with prediabetes [intervention duration range: 6-72 mo (median: 24 mo), mean weight loss range: 1%-9%] were included. Lifestyle weight loss interventions increased regression to normoglycemia by 11/100 participants (95% confidence interval [CI]: 8 more, 17 more; risk ratio: 1.51; 95% CI: 1.27, 1.80; n = 20 trials, grading of recommendations assessment, development, and evaluation = moderate], and reduced progression to type 2 diabetes by 8/100 participants (95% CI: 11 fewer, 6 fewer; risk ratio: 0.59; 95% CI: 0.51, 0.67; n = 37, grading of recommendations assessment, development, and evaluation = moderate). There were no significant or credible differences between subgroups categorized by the type and duration of intervention. Dose-response meta-analyses indicated that the risk of regression to normoglycemia increased, and the risk of progression to type 2 diabetes declined in a linear pattern within the range of weight loss from 1% to 9%.

CONCLUSIONS

Over a median duration of 24 mo, with weight loss ranging from 1% to 9%, the relationship between weight loss and the progression to type 2 diabetes, as well as the regression to normoglycemia, follows a linear pattern. Any form of lifestyle weight loss intervention, including diet, exercise, or a combination of both, can have beneficial impacts on participants with prediabetes. This trial was registered at PROSPERO as CRD42023465322.

The impact of metformin on weight and metabolic parameters in patients with obesity: A systematic review and meta-analysis of randomized controlled trials

There are conflicting data on the weight-reducing potential of metformin (MTF) in nondiabetic patients with obesity. The purpose of this systematic review and meta-analysis was to evaluate the effect of MTF on weight and cardiometabolic parameters in adults with overweight/obesity with or without nonalcoholic fatty liver disease (NAFLD) (CRD42018085512). We included randomized controlled trials (RCTs) in adults without diabetes mellitus, with mean body mass index (BMI) ≥ 25 kg/m2, with or without NAFLD, comparing MTF to placebo/control, lifestyle modification (LSM) or a US Food and Drug Administration-approved anti-obesity drug, reporting on weight or metabolic parameters, and extending over at least 3 months. We conducted a systematic search in MEDLINE, EMBASE, PubMed and the Cochrane Library without time limitation (until March 2022). We screened and selected eligible articles, abstracted relevant data, and assessed the risk of bias. All steps were in duplicate and independently. We conducted a random-effects model meta-analysis using Review Manager version 5.3, with prespecified subgroup analyses in case of heterogeneity. We identified 2650 citations and included 49 trials (55 publications). Compared to placebo, MTF was associated with a significant reduction in BMI (mean difference [MD] -0.56 [-0.74, -0.37] kg/m2; p < 0.0001), at doses ranging from 500 to 2550 mg/day, and with a significant percentage change in BMI of -2.53% (-2.90, -2.17) at the dose 1700 mg/day. There was no interaction by baseline BMI, MTF dose or duration, nor presence or absence of NAFLD. There was no significant difference between MTF and LSM. Orlistat was more effective than MTF (at doses of 1000-1700 mg/day) in terms of weight loss, with an MD in BMI of -3.17 (-5.88; -0.47) kg/m2, favouring the former. Compared to placebo/control, MTF improved insulin parameters, while no effect was detected when compared to LSM. A few small trials showed heterogenous effects on liver parameters in patients with NAFLD treated with MTF compared to placebo/control. There was a large variability in the expression of outcome measures and RCTs were of low quality. In conclusion, MTF was associated with a modest weight reduction in obese nondiabetic patients. Further high-quality and better powered studies are needed to examine the impact of MTF in patients with insulin resistance and NAFLD.

Metabolic disorders in prediabetes: From mechanisms to therapeutic management

Diabetes, one of the world's top ten diseases, is known for its high mortality and complication rates and low cure rate. Prediabetes precedes the onset of diabetes, during which effective treatment can reduce diabetes risk. Prediabetes risk factors include high-calorie and high-fat diets, sedentary lifestyles, and stress. Consequences may include considerable damage to vital organs, including the retina, liver, and kidneys. Interventions for treating prediabetes include a healthy lifestyle diet and pharmacological treatments. However, while these options are effective in the short term, they may fail due to the difficulty of long-term implementation. Medications may also be used to treat prediabetes. This review examines prediabetic treatments, particularly metformin, glucagon-like peptide-1 receptor agonists, sodium glucose cotransporter 2 inhibitors, vitamin D, and herbal medicines. Given the remarkable impact of prediabetes on the progression of diabetes mellitus, it is crucial to intervene promptly and effectively to regulate prediabetes. However, the current body of research on prediabetes is limited, and there is considerable confusion surrounding clinically relevant medications. This paper aims to provide a comprehensive summary of the pathogenesis of pre-diabetes mellitus and its associated therapeutic drugs. The ultimate goal is to facilitate the clinical utilization of medications and achieve efficient and timely control of diabetes mellitus.

Educational Model and Prevention on Prediabetes: A Systematic Review

BACKGROUND

Prediabetes is a reversible condition before the onset of Type 2 Diabetes Mellitus. Untreated condition of prediabetes will develop into diabetes and its complications. The prevalence of prediabetes has been emerging worldwide and has a considerable socioeconomic impact. The current study reviews the roles of early detection, educational models, life modification, and prophylaxis of individuals with prediabetes in preventing the progression of prediabetes into Type 2 Diabetes Mellitus and complications in the future.

METHODS

This study included published articles from several electronic databases. The obtained articles were limited to March 2023. Articles that were not open access and not in Indonesian or English were excluded. The protocol for this study used the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020.

RESULTS

Of 39627 articles, 39601 were excluded due to duplication and did not meet the eligibility criteria. At the final, there were 26 articles that were eligible for systematic review.

CONCLUSION

Prevention of the development of prediabetes into diabetes is essential. A comprehensive understanding and training on intensive lifestyle modification protocols from local and national experts in diabetes prevention through digital-based education models and linguistically and culturally approach can be considered. Intensive lifestyle modification and pharmacological approaches may improve the outcome. Regular monitoring of glycemic control is also important for early diagnosis of diabetes, especially in patients with special conditions.

Comparison of the Efficacy of Metformin and Lifestyle Modification for the Primary Prevention of Type 2 Diabetes: A Meta-Analysis of Randomized Controlled Trials

This meta-analysis aimed to compare the effectiveness of metformin versus lifestyle interventions in preventing diabetes in individuals with prediabetes. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and conducted a comprehensive search of databases (PubMed, Cochrane Library, EMBASE) up to September 1, 2023. Five eligible studies were included. The results showed that there was no significant difference in the risk of developing diabetes between the metformin and lifestyle intervention groups (RR: 1.14, 95% CI: 0.77-1.68). Similarly, when comparing metformin with lifestyle intervention, the risk of diabetes was slightly higher in the metformin group, but this difference was not statistically significant (RR: 1.31, 95% CI: 0.93-1.86). When comparing metformin with lifestyle intervention to lifestyle intervention alone, no significant difference was observed in the incidence of diabetes (RR: 0.88, 95% CI: 0.74-1.04). In conclusion, our analysis found that the incidence of type 2 diabetes was slightly higher in patients receiving metformin alone compared to lifestyle intervention, but this difference did not reach statistical significance. Further trials are necessary to better evaluate these interventions for preventing type 2 diabetes in high-risk individuals.

Comparing the effectiveness of metformin with lifestyle modification for the primary prevention of type II diabetes: a systematic review and meta-analysis

BACKGROUND

Concerning ascending trend in the prevalence of chronic type II diabetes, prevention and the development of an effective approach after the recognition of at-risk individuals is crucial. This study aims to investigate comparing the influence of lifestyle modification and metformin interventions in the prevention of type II diabetes developments.

METHOD

The search was conducted using PubMed, Google Scholar, Scopus and Web of Science databases. The inclusion criteria include randomized controlled trials (RCT) which studied both lifestyle modification and metformin interventions in the population above 18 years old without a history of any type of diabetes. After excluding studies with intervention time of fewer than 6 months, a systematic review and meta-analysis were performed to evaluate relative risk (RR) with a confidence interval (CI) of 95% of type II diabetes development.

RESULTS

Data from 5 studies were included in the meta-analysis. The population also consists of individuals with a mean age of 50 years old with BMI and FBS of 35.5 and 104.7 mg/dl respectively. Participants range of prevention years was between 2-3 years with a mean of 2.8 years. Lifestyle modification decreases the probability of the incidence of type II diabetes by 25.3% (RR: 0.747, 95% CI, 0.6-0.92) compared to the metformin intervention (p-value = 0.007). Our results indicate that long-term lifestyle modifications can prevent diabetes type II and decrease diabetes mellitus incidence down to one-quarter in comparison to metformin.

CONCLUSION

Lifestyle modification can be more efficacious than metformin in diminishing the incidence of type II diabetes. Therefore, lifestyle modification can be a therapeutic strategy for controlling type II diabetes incidence, especially in high-risk individuals.

Transcultural Lifestyle Medicine in Type 2 Diabetes Care: Narrative Review of the Literature

Disparities in type 2 diabetes (T2D) care is a global problem across diverse cultures. The Dysglycemia-Based Chronic Disease (DBCD) model promotes early and sustainable interventions along the insulin resistance (stage 1), prediabetes (stage 2), T2D (stage 3), and complications (stage 4) spectrum. In this model, lifestyle medicine is the cornerstone of preventive care to reduce DBCD progression and the socioeconomic/biological burden of disease. A comprehensive literature review, spanning 2000 to 2021, was performed and 55 studies were included examining the effects of lifestyle medicine and their cultural adaptions with different prevention modalities. In stage 1, primordial prevention targets modifiable primary drivers (behavior and environment), unhealthy lifestyles, abnormal adiposity, and insulin resistance with educational and motivational health promotion activities at individual, group, community, and population-based scales. Primary, secondary, and tertiary prevention targets individuals with mild hyperglycemia, severe hyperglycemia, and complications, respectively, using programs that incorporate structured lifestyle interventions. Culturally adapted lifestyle change in primary and secondary prevention improved quality of life and biomarkers, but with a limited impact of tertiary prevention on cardiovascular events. In conclusion, lifestyle medicine with cultural adaptations is an integral part of preventive care in patients with T2D. However, considerable research gaps exist, especially for tertiary prevention.

A systematic review of inequalities in the uptake of, adherence to, and effectiveness of behavioral weight management interventions in adults

The extent to which behavioral weight management interventions affect health inequalities is uncertain, as is whether trials of these interventions directly consider inequalities. We conducted a systematic review, synthesizing evidence on how different aspects of inequality impact uptake, adherence, and effectiveness in trials of behavioral weight management interventions. We included (cluster-) randomized controlled trials of primary care-applicable behavioral weight management interventions in adults with overweight or obesity published prior to March 2020. Data about trial uptake, intervention adherence, attrition, and weight change by PROGRESS-Plus criteria (place of residence, race/ethnicity, occupation, gender, religion, education, socioeconomic status, social capital, plus other discriminating factors) were extracted. Data were synthesized narratively and summarized in harvest plots. We identified 91 behavioral weight loss interventions and 12 behavioral weight loss maintenance interventions. Fifty-six of the 103 trials considered inequalities in relation to at least one of intervention or trial uptake (n = 15), intervention adherence (n = 15), trial attrition (n = 32), or weight outcome (n = 34). Most trials found no inequalities gradient. If a gradient was observed for trial uptake, intervention adherence, and trial attrition, those considered "more advantaged" did best. Alternative methods of data synthesis that enable data to be pooled and increase statistical power may enhance understanding of inequalities in behavioral weight management interventions.

Effects of Diet, Lifestyle, Chrononutrition and Alternative Dietary Interventions on Postprandial Glycemia and Insulin Resistance

As years progress, we are found more often in a postprandial than a postabsorptive state. Chrononutrition is an integral part of metabolism, pancreatic function, and hormone secretion. Eating most calories and carbohydrates at lunch time and early afternoon, avoiding late evening dinner, and keeping consistent number of daily meals and relative times of eating occasions seem to play a pivotal role for postprandial glycemia and insulin sensitivity. Sequence of meals and nutrients also play a significant role, as foods of low density such as vegetables, salads, or soups consumed first, followed by protein and then by starchy foods lead to ameliorated glycemic and insulin responses. There are several dietary schemes available, such as intermittent fasting regimes, which may improve glycemic and insulin responses. Weight loss is important for the treatment of insulin resistance, and it can be achieved by many approaches, such as low-fat, low-carbohydrate, Mediterranean-style diets, etc. Lifestyle interventions with small weight loss (7-10%), 150 min of weekly moderate intensity exercise and behavioral therapy approach can be highly effective in preventing and treating type 2 diabetes. Similarly, decreasing carbohydrates in meals also improves significantly glycemic and insulin responses, but the extent of this reduction should be individualized, patient-centered, and monitored. Alternative foods or ingredients, such as vinegar, yogurt, whey protein, peanuts and tree nuts should also be considered in ameliorating postprandial hyperglycemia and insulin resistance. This review aims to describe the available evidence about the effects of diet, chrononutrition, alternative dietary interventions and exercise on postprandial glycemia and insulin resistance.

Implementation of Diabetes Prevention in Health Care Organizations: Best Practice Recommendations

Approximately 1 in 3 American adults has prediabetes, a condition characterized by blood glucose levels that are above normal, not in the type 2 diabetes ranges, and that increases the risk of developing type 2 diabetes. Evidence-based treatments can be used to prevent or delay type 2 diabetes in adults with prediabetes. The American Medical Association (AMA) has collaborated with health care organizations across the country to build sustainable diabetes prevention strategies. In 2017, the AMA formed the Diabetes Prevention Best Practices Workgroup (DPBP) with representatives from 6 health care organizations actively implementing diabetes prevention. Each organization had a unique strategy, but all included the National Diabetes Prevention Program lifestyle change program as a core evidence-based intervention. DPBP established the goal of disseminating best practices to guide other health care organizations in implementing diabetes prevention and identifying and managing patients with prediabetes. Workgroup members recognized similarities in some of their basic steps and considerations and synthesized their practices to develop best practice recommendations for 3 strategy maturity phases. Recommendations for each maturity phase are classified into 6 categories: (1) organizational support; (2) workforce and funding; (3) promotion and dissemination; (4) clinical integration and support; (5) evaluation and outcomes; (6) and program. As the burden of chronic disease grows, prevention must be prioritized and integrated into health care. These maturity phases and best practice recommendations can be used by any health care organization committed to diabetes prevention. Further research is suggested to assess the impact and adoption of diabetes prevention best practices.

Engineered mesoporous silica reduces long-term blood glucose, HbA1c, and improves metabolic parameters in prediabetics

Aim: To investigate the effect of oral consumption of engineered mesoporous silica particles, SiPore15^®, on long-term blood glucose levels and other metabolic parameters in individuals with prediabetes and newly diagnosed Type 2 diabetes. Method: An open-label, single-arm, multicenter trial was conducted in which SiPore15 was consumed three times daily for 12 weeks. Hemoglobin A1c (HbA1c, primary end point) and an array of metabolic parameters were measured at baseline and throughout the trial. Result: SiPore15 treatment significantly reduced HbA1c by a clinically meaningful degree and improved several disease-associated parameters with minimal side effects. Conclusion: The results from this study demonstrate the potential use of SiPore15 as a treatment for prediabetes that may also delay or prevent the onset of Type 2 diabetes.

Kudzu Resistant Starch: An Effective Regulator of Type 2 Diabetes Mellitus

Kudzu is a traditional medicinal dietary supplement, and recent research has shown its significant benefits in the prevention/treatment of type 2 diabetes mellitus (T2DM). Starch is one of the main substances in Kudzu that contribute decisively to the treatment of T2DM. However, the underlying mechanism of the hypoglycemic activity is not clear. In this study, the effect of Kudzu resistant starch supplementation on the insulin resistance, gut physical barrier, and gut microbiota was investigated in T2DM mice. The result showed that Kudzu resistant starch could significantly decrease the value of fasting blood glucose and the levels of total cholesterol, total triglyceride, and high-density lipoprotein, as well as low-density lipoprotein, in the blood of T2DM mice. The insulin signaling sensitivity in liver tissue was analyzed; the result indicated that intake of different doses of Kudzu resistant starch can help restore the expression of IRS-1, p-PI3K, p-Akt, and Glut4 and thus enhance the efficiency of insulin synthesis. Furthermore, the intestinal microorganism changes before and after ingestion of Kudzu resistant starch were also analyzed; the result revealed that supplementation of KRS helps to alleviate and improve the dysbiosis of the gut microbiota caused by T2DM. These results validated that Kudzu resistant starch could improve the glucose sensitivity of T2DM mice by modulating IRS-1/PI3K/AKT/Glut4 signaling transduction. Kudzu resistant starch can be used as a promising prebiotic, and it also has beneficial effects on the gut microbiota structure of T2DM mice.

Metformin for diabetes prevention: update of the evidence base

We have conducted a narrative review based on a structured search strategy, focusing on the effects of metformin on the progression of non-diabetic hyperglycemia to clinical type 2 diabetes mellitus. The principal trials that demonstrated a significantly lower incidence of diabetes in at-risk populations randomized to metformin (mostly with impaired glucose tolerance [IGT]) were published mainly from 1999 to 2012. Metformin reduced the 3-year risk of diabetes by -31% in the randomized phase of the Diabetes Prevention Program (DPP), vs. -58% for intensive lifestyle intervention (ILI). Metformin was most effective in younger, heavier subjects. Diminishing but still significant reductions in diabetes risk for subjects originally randomized to these groups were present in the trial's epidemiological follow-up, the DPP Outcomes Study (DPPOS) at 10 years (-18 and -34%, respectively), 15 years (-18 and -27%), and 22 years (-18 and -25%). Long-term weight loss was also seen in both groups, with better maintenance under metformin. Subgroup analyses from the DPP/DPPOS have shed important light on the actions of metformin, including a greater effect in women with prior gestational diabetes, and a reduction in coronary artery calcium in men that might suggest a cardioprotective effect. Improvements in long-term clinical outcomes with metformin in people with non-diabetic hyperglycemia ("prediabetes") have yet to be demonstrated, but cardiovascular and microvascular benefits were seen for those in the DPPOS who did not vs. did develop diabetes. Multiple health economic analyses suggest that either metformin or ILI is cost-effective in a community setting. Long-term diabetes prevention with metformin is feasible and is supported in influential guidelines for selected groups of subjects. Future research will demonstrate whether intervention with metformin in people with non-diabetic hyperglycemia will improve long-term clinical outcomes.

Prevention of Type 2 Diabetes

The global diabetes burden is staggering, and prevention efforts are needed to reduce the impact on individuals and populations. There is strong evidence from efficacy trials showing that lifestyle interventions promoting increased physical activity, improvements in diet, and/or weight loss significantly reduce diabetes incidence and improve cardiometabolic risk factors. Implementation research assessing the feasibility, effectiveness, and cost-effectiveness of delivering these proven programs at the community level has shown success, but more research is needed to overcome barriers to implementation in different settings globally. New avenues of research should be considered to combat this public health issue.

Perspectives on Kidney Disease Education and Recommendations for Improvement Among Latinx Patients Receiving Emergency-Only Hemodialysis

IMPORTANCE

In most states, undocumented Latinx immigrants with kidney failure receive dialysis in acute care settings on an emergency-only basis. How much kidney disease education Latinx immigrants receive and how to improve kidney disease education and outreach among Latinx populations are unknown.

OBJECTIVE

To understand the kidney disease educational gaps of Latinx individuals who need but lack access to scheduled outpatient dialysis.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study used semistructured interviews in a Texas hospital system from March 2020 to January 2021 with 15 individuals who received emergency-only dialysis when they were first diagnosed with kidney failure. Demographic information was collected, and a thematic analysis was performed using the constant comparative method on interviews after they were audio-recorded, translated, and transcribed verbatim. Data analysis was performed from April 2020 to February 2021.

MAIN OUTCOMES AND MEASURES

Subthemes and themes from semistructured interviews.

RESULTS

All 15 persons interviewed (9 male individuals [60%]; mean [SD] age, 51 [17] years) identified as Hispanic, 11 (73%) were born in Mexico, and none reported knowing about their kidney disease more than 6 months before starting dialysis. The themes identified were (1) lack of kidney disease awareness, (2) education provided was incomplete and poor quality, (3) lack of culturally concordant communication and care, (4) elements that Latinx patients receiving emergency-only dialysis want in their education, (5) facilitators of patient activation and coping, and (6) Latinx patient recommendations to improve community outreach.

CONCLUSIONS AND RELEVANCE

Latinx adults receiving emergency-only dialysis are usually unaware of their kidney disease until shortly before or after they start dialysis, and the education they receive is poor quality and often not culturally tailored. Participants made feasible recommendations on how to improve education and outreach among Latinx communities.

Evaluation of a Community Health Worker Social Prescribing Program Among UK Patients With Type 2 Diabetes

IMPORTANCE

Despite lacking robust evidence of effectiveness, health care systems in developed countries are funding holistic community health worker (CHW) social prescribing programs that address social needs and health behaviors as adjuncts to clinical care.

OBJECTIVE

To determine whether a UK National Health Service (NHS) CHW social prescribing program was associated with improved hemoglobin A1c (HbA1c) levels among patients with type 2 diabetes.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study with difference-in-differences analysis was conducted among 8086 patients (4752 in the referral program, 3334 in the control group) in 24 NHS primary care practices in a city in North East England. Patients aged 40 to 74 years with a diagnosis of type 2 diabetes were observed for 8 years, from 2011 through 2019. The statistical analysis was conducted between June 1, 2019, and January 31, 2021.

INTERVENTIONS

A social prescribing program, launched in April 2015, enabling primary care staff to refer patients to CHW support to identify condition management and social needs goals and access voluntary and community sector support to address these goals. Intervention referral was only available in primary care practices in the city's west. The control group included patients in the city's east where referral was unavailable.

MAIN OUTCOMES AND MEASURES

HbA1c level, a marker of glycemic control.

RESULTS

A total of 8086 patients were included in the analysis (mean [SD] age, 57.8 [8.78] years; 3477 women [43%]; 6631 White patients [82%]). Mean (SD) baseline HbA1c levels were 7.56% (1.47%) in the referral program group and 7.44% (1.43%) in the control group. Following introduction of the social prescribing referral program, the referral group experienced an HbA1c reduction of -0.10 percentage points (95% CI, -0.17 to -0.03 percentage points) compared with the control group. The association increased over time: after 3 years the estimated association was -0.14 percentage points (95% CI, -0.24 to -0.03 percentage points). The association was stronger for White patients compared with non-White patients (-0.15 percentage points [95% CI, -0.26 to -0.04 percentage points] after 3 years), those with fewer additional comorbidities (-0.16 percentage points [95% CI, -0.29 to -0.04 percentage points] after 3 years), and those living in the most socioeconomically deprived areas (-0.19 percentage points [95% CI, -0.32 to -0.07 percentage points] after 3 years).

CONCLUSIONS AND RELEVANCE

In this study of UK adults with type 2 diabetes, a social prescribing program with referral to CHWs targeting patients' social needs and health behaviors was associated with improved HbA1c levels, suggesting that holistic CHW interventions may help to reduce the public health burden of type 2 diabetes.

Screening for Prediabetes and Type 2 Diabetes: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Type 2 diabetes is common and is a leading cause of morbidity and disability.

OBJECTIVE

To review the evidence on screening for prediabetes and diabetes to inform the US Preventive Services Task Force (USPSTF).

DATA SOURCES

PubMed/MEDLINE, Cochrane Library, and trial registries through September 2019; references; and experts; literature surveillance through May 21, 2021.

STUDY SELECTION

English-language controlled studies evaluating screening or interventions for prediabetes or diabetes that was screen detected or recently diagnosed.

DATA EXTRACTION AND SYNTHESIS

Dual review of abstracts, full-text articles, and study quality; qualitative synthesis of findings; meta-analyses conducted when at least 3 similar studies were available.

MAIN OUTCOMES AND MEASURES

Mortality, cardiovascular morbidity, diabetes-related morbidity, development of diabetes, quality of life, and harms.

RESULTS

The review included 89 publications (N = 68 882). Two randomized clinical trials (RCTs) (25 120 participants) found no significant difference between screening and control groups for all-cause or cause-specific mortality at 10 years. For harms (eg, anxiety or worry), the trials reported no significant differences between screening and control groups. For recently diagnosed (not screen-detected) diabetes, 5 RCTs (5138 participants) were included. In the UK Prospective Diabetes Study, health outcomes were improved with intensive glucose control with sulfonylureas or insulin. For example, for all-cause mortality the relative risk (RR) was 0.87 (95% CI, 0.79 to 0.96) over 20 years (10-year posttrial assessment). For overweight persons, intensive glucose control with metformin improved health outcomes at the 10-year follow-up (eg, all-cause mortality: RR, 0.64 [95% CI, 0.45 to 0.91]), and benefits were maintained longer term. Lifestyle interventions (most involving >360 minutes) for obese or overweight persons with prediabetes were associated with reductions in the incidence of diabetes (23 RCTs; pooled RR, 0.78 [95% CI, 0.69 to 0.88]). Lifestyle interventions were also associated with improved intermediate outcomes, such as reduced weight, body mass index, systolic blood pressure, and diastolic blood pressure (pooled weighted mean difference, -1.7 mm Hg [95% CI, -2.6 to -0.8] and -1.2 mm Hg [95% CI, -2.0 to -0.4], respectively). Metformin was associated with a significant reduction in diabetes incidence (pooled RR, 0.73 [95% CI, 0.64 to 0.83]) and reduction in weight and body mass index.

CONCLUSIONS AND RELEVANCE

Trials of screening for diabetes found no significant mortality benefit but had insufficient data to assess other health outcomes; evidence on harms of screening was limited. For persons with recently diagnosed (not screen-detected) diabetes, interventions improved health outcomes; for obese or overweight persons with prediabetes, interventions were associated with reduced incidence of diabetes and improvement in other intermediate outcomes.

Screening for Prediabetes and Type 2 Diabetes: US Preventive Services Task Force Recommendation Statement

IMPORTANCE

An estimated 13% of all US adults (18 years or older) have diabetes, and 34.5% meet criteria for prediabetes. The prevalences of prediabetes and diabetes are higher in older adults. Estimates of the risk of progression from prediabetes to diabetes vary widely, perhaps because of differences in the definition of prediabetes or the heterogeneity of prediabetes. Diabetes is the leading cause of kidney failure and new cases of blindness among adults in the US. It is also associated with increased risks of cardiovascular disease, nonalcoholic fatty liver disease, and nonalcoholic steatohepatitis and was estimated to be the seventh leading cause of death in the US in 2017. Screening asymptomatic adults for prediabetes and type 2 diabetes may allow earlier detection, diagnosis, and treatment, with the ultimate goal of improving health outcomes.

OBJECTIVE

To update its 2015 recommendation, the USPSTF commissioned a systematic review to evaluate screening for prediabetes and type 2 diabetes in asymptomatic, nonpregnant adults and preventive interventions for those with prediabetes.

POPULATION

Nonpregnant adults aged 35 to 70 years seen in primary care settings who have overweight or obesity (defined as a body mass index ≥25 and ≥30, respectively) and no symptoms of diabetes.

EVIDENCE ASSESSMENT

The USPSTF concludes with moderate certainty that screening for prediabetes and type 2 diabetes and offering or referring patients with prediabetes to effective preventive interventions has a moderate net benefit.

CONCLUSIONS AND RECOMMENDATION

The USPSTF recommends screening for prediabetes and type 2 diabetes in adults aged 35 to 70 years who have overweight or obesity. Clinicians should offer or refer patients with prediabetes to effective preventive interventions. (B recommendation).

All of That Causes Me Stress: An Exploration of the Sources of Stress Experienced by Latinxs Living with Prediabetes

Latinxs immigrants in the United States experience sources of stress (i.e., stressors) that can limit their ability to engage in healthy behaviors. Stress has been linked to increased type 2 diabetes (T2D) risk in Latinxs living with prediabetes, a group disproportionately affected by T2D. The purpose of this qualitative study is to describe and contextualize the variety of stressors experienced by Latinxs immigrants diagnosed with prediabetes. Semi-structured, in-depth interviews were conducted from March to September 2018 with 20 Latinx immigrants living with prediabetes in North Carolina. We used qualitative content analysis including systematic coding and comparative matrices. The most prominent stressors were those related to health status and healthcare access, finances, interpersonal relationships with family, and loneliness. Participants also identified stressors related to documentation status and discrimination. The stressors Latinx immigrants with prediabetes experience vary, therefore studies and interventions need to specify which sources of stress they are addressing. Multilevel interventions that ameliorate the effects of stressors may facilitate preventive health behaviors among Latinxs with prediabetes.

Nigella sativa as a promising intervention for metabolic and inflammatory disorders in obese prediabetic subjects: A comparative study of Nigella sativa versus both lifestyle modification and metformin

AIM

This study aimed at evaluating the effect of Nigella sativa (NS) on anthropometric, metabolic and inflammatory parameters and examining its related molecular mechanisms in obese prediabetic individuals as compared to both lifestyle modification (LM) and Metformin (Met).

METHODS

This study included 117 obese prediabetic subjects who were randomized into LM group which followed controlled diet and exercise regimen, metformin group received metformin 500 mg tablets twice daily and NS group received NS oil soft gelatin capsules 450 mg twice daily. Anthropometric (weight, BMI), glycemic, lipid, inflammatory parameters and genetic expressions of Sirtuin-1 (SIRT1) and p53 genes were assessed before and six months after interventions.

RESULTS

Post-intervention pairwise comparison revealed that, NS was statistically similar to metformin in improving anthropometric, glycemic parameters and SIRT1 gene expression. There was non-significant difference between LM and NS regarding their effects on anthropometric and most of glycemic parameters. Lifestyle modification group showed significantly higher HOMA-B and SIRT1 expression than NS and metformin. Nigella sativa improved lipid panel and significantly reduced TNF-α level and Castelli risk index-I as compared to other interventions.

CONCLUSION

Nigella sativa uniquely improved lipid panel and significantly suppressed inflammation. Therefore, Nigella sativa may represent a promising intervention for obese prediabetic subjects. Clinicaltrial.gov ID: NCT03925714.

Diabetes Complications in Racial and Ethnic Minority Populations in the USA

PURPOSE OF REVIEW

Racial and ethnic minority populations have a higher burden of diabetes-related complications. There have been many epidemiologic studies to better define these racial/ethnic disparities in diabetes outcomes with additional studies offering interventions to mitigate them. This narrative review highlights the epidemiologic trends in diabetes complications specific to racial and ethnic minorities and underscores differences in microvascular and macrovascular complications of diabetes, health care utilization, and diabetes prevention efforts and also reviews interventions aimed to reduce racial/ethnic disparities and their limitations.

RECENT FINDINGS

While we have seen in general an overall improvement in complication rates for all people with diabetes, the disparities between Black and Hispanic compared to non-Hispanic White people with diabetes seem to persist. There is a continued need to better understand the underlying causes of and strategies to mitigate race/ethnicity disparities in diabetes complications in the USA.

Effect of a Culturally Adapted Behavioral Intervention for Latino Adults on Weight Loss Over 2 Years: A Randomized Clinical Trial

Importance

Identifying effective weight loss interventions for Latino adults at risk of diabetes is of critical public health importance.

Objective

To determine whether a culturally adapted behavioral intervention for Latino adults was more effective than usual care for weight loss over 24 months.

Design, Setting, and Participants

In this randomized clinical trial, Latino adults with a body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 24 or greater and a high risk for type 2 diabetes were recruited in primary care practices in the San Francisco, California, area, randomized to receive the Vida Sana intervention or usual care, and followed up for 24 months. The study was conducted from November 2015 to May 2019, and data were analyzed from July 2019 to Septmeber 2020.

Interventions

The treatment group received Vida Sana, a culturally adapted lifestyle intervention that included a family-based orientation session and 22 group sessions over 12 months. Participants were encouraged to use a wearable activity tracker and mobile applications to track their physical activity and dietary intake. Participants received monthly email messages for an additional 12 months. The control group received usual care.

Main Outcomes and Measures

The primary outcome was weight loss at 24 months. Secondary outcomes included weight loss at 12 months and achieving at least 5% weight loss at 12 and 24 months. Associations of baseline characteristics and intervention adherence with weight loss outcomes were also examined.

Results

Among 191 participants (mean [SD] age, 50.2 [12.2] years; 118 [61.8%] women; 107 participants [57.2%] of Mexican origin; mean [SD] baseline BMI, 32.4 [5.7]) randomized, 92 participants were randomized to the intervention and 99 participants were randomized to usual care. Of these, 185 participants (96.9%) completed 24-month follow-up. Mean (SD) weight loss did not differ significantly by group at 24 months (intervention: -1.1 [5.7] kg; control: -1.1 [7.1] kg; P = .93). However, mean (SD) weight loss was significantly greater in the intervention group (-2.6 [6.0] kg) than the control group (-0.3 [4.2] kg) at 12 months (mean difference, -2.1 [95% CI, -3.6 to -0.7] kg; P = .005). Intervention participants were more likely to achieve at least 5% weight loss than control participants at 12 months (22 participants [25.9%] vs 9 participants [9.2%]; P = .003), and participants who achieved at least 5% weight loss attended more intervention sessions than those who did not (mean [SD], 16.6 [7.6] sessions vs 12.4 [7.5] sessions; P = .03).

Conclusions and Relevance

These findings suggest that among Latino adults with high diabetes risk, a culturally adapted behavioral lifestyle intervention was effective for weight loss over 12 months but not 24 months.

Trial Registration

ClinicalTrials.gov Identifier: NCT02459691.

Design of a cluster-randomized trial of the effectiveness and cost-effectiveness of metformin on prevention of type 2 diabetes among prediabetic Mexican adults (the PRuDENTE initiative of Mexico City)

INTRODUCTION

Type 2 diabetes (T2D) is a global epidemic, and nations are struggling to implement effective healthcare strategies to reduce the burden. While efficacy studies demonstrate that metformin can reduce incident T2D by half among younger, obese adults with prediabetes, its real-world effectiveness are understudied, and its use for T2D prevention in primary care is low. We describe the design of a pragmatic trial to evaluate the incremental effectiveness of metformin, as an adjunct to a simple lifestyle counseling.

METHODS

The "Prevención de la Diabetes con Ejercicio, Nutrición y Tratamiento" [Diabetes Prevention with Exercise, Nutrition and Treatment; PRuDENTE, (Spanish acronym)] is a cluster-randomized trial in Mexico City's public primary healthcare system. The study randomly assigns 51 clinics to deliver one of two interventions for 36 months: 1) lifestyle only; 2) lifestyle plus metformin, to 3060 patients ages 30-65 with impaired fasting glucose and obesity. The primary endpoint is incident T2D (fasting glucose ≥126 mg/dL, or HbA1c ≥6.5%). We will also measure a range of implementation-related process outcomes at the clinic-, clinician- and patient-levels to inform interpretations of effectiveness and enable efforts to refine, adapt, adopt and disseminate the model. We will also estimate the cost-effectiveness of metformin as an adjunct to lifestyle counseling in Mexico.

DISCUSSION

Findings from this pragmatic trial will generate new translational knowledge in Mexico and beyond, both with respect to metformin's real-world effectiveness among an 'at-risk' population, and uncovering facilitators and barriers to the reach, adoption and implementation of metformin preventive therapy in public primary care settings.

TRIAL REGISTRATION

This trial is registered at Clinicaltrials.gov (NCT03194009).

Effects of metformin in obesity treatment in different populations: a meta-analysis

OBJECTIVE

Some studies have shown that metformin can reduce body weight. However, metformin has not been officially approved as a medicine for weight loss because its effect on different populations remains inconsistent. This meta-analysis aimed to summarize the weight loss effect of metformin quantitatively.

METHOD

The randomized controlled and high-quality case-control trials of metformin monotherapy in obesity treatment were eligible. Baseline body mass index (BMI) was chosen as a self-control to compare the changes in BMI of different populations before and after treatment. All changes were calculated as differences between the final and initial BMI values (with negative values indicating a decrease). Results were presented as weighted mean difference (WMD) with a 95% confidence interval (CI 95%). Subgroup analysis was performed based on baseline BMI, age, daily dose, and duration of medication.

RESULTS

A total of 21 trials (n = 1004) were included, and the meta-analysis of metformin treatment in different populations showed that metformin has a modest reduction in the BMI of included participants (WMD -0.98; 95% CI, -1.25 to -0.72), and the reduction of BMI was most significant in the simple obesity population (WMD -1.31; 95% CI, -2.07 to -0.54). The subgroup analysis showed that metformin treatment significantly reduced BMI in obesity patients with a BMI >35kg/m2 (WMD -1.12; 95% CI, -1.84 to -0.39) compared with before treatment. BMI in the high dose group decreased by 1.01 units (WMD-1.01; 95% CI, -1.29 to -0.73) and BMI did not continue to decrease significantly after treatment of more than 6 months.

CONCLUSION

Patients treated with metformin experienced about a one-unit reduction in BMI at the end of treatment. But whether this decreased value produced enough weight loss (5% of baseline body weight) to qualify as a "weight loss drug" as current guidelines require, requires larger specific randomized control trials.

Nutrition and Lifestyle Behavior Peer Support Program for Adults with Metabolic Syndrome: Outcomes and Lessons Learned from a Feasibility Trial

BACKGROUND

While peer support interventions have shown to benefit adults with certain chronic conditions, there is limited evidence on its feasibility and effectiveness among people with metabolic syndrome (MetS). This paper describes the outcomes of a pre-post feasibility trial of "PEeR SUpport program for ADults with mEtabolic syndrome" (PERSUADE), an evidence-based and community-specific nutrition and lifestyle behavior peer support program for Malaysian adults with MetS.

METHODS

We recruited 48 peers (median age: 46 (IQR = 11) years old) into four peer groups, who underwent 3 months of PERSUADE, followed by 3 months of follow-up period. Statistical analyses were conducted at post-intervention and post-follow-up to assess the changes in nutrition intake, anthropometry, and metabolic parameters.

RESULTS

Although there were significant overall increases in total carbohydrate intake and glycemic load (both p < 0.001), we noted significant reductions in the intakes of total energy and fat (both p < 0.001). Physical activity (total METS/week) also showed a significant improvement (p < 0.001). Overall, significant but marginal improvements in anthropometric and vital metabolic parameters were also observed.

CONCLUSIONS

The feasibility trial supported the adoption of PERSUADE, though there is a need to assess the long-term impact of the peer support program in local community settings.

Obtaining evidence base for the development of Feel4Diabetes intervention to prevent type 2 diabetes - a narrative literature review

BACKGROUND

Feel4Diabetes was a school and community based intervention aiming to promote healthy lifestyle and tackle obesity for the prevention of type 2 diabetes among families in 6 European countries. We conducted this literature review in order to guide the development of evidence-based implementation of the Feel4Diabetes intervention. We focused on type 2 diabetes prevention strategies, including all the phases from risk identification to implementation and maintenance. Special focus was given to prevention among vulnerable groups and people under 45 years.

METHODS

Scientific and grey literature published between January 2000 and January 2015 was searched for relevant studies using electronic databases. To present the literature review findings in a systematic way, we used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. A complementary literature search from February 2015 to December 2018 was also conducted.

RESULTS

The initial review included 27 studies with a follow-up ≥12 months and 9 studies with a follow-up ≥6 months and with a participant mean age < 45 years. We found out that interventions should be targeted at people at risk to improve recruiting and intervention effectiveness. Screening questionnaires (primarily Finnish Diabetes Risk Score FINDRISC) and blood glucose measurement can both be used for screening; the method does not appear to affect intervention effectiveness. Screening and recruitment is time-consuming, especially when targeting lower socioeconomic status and age under 45 years. The intervention intensity is more important for effectiveness than the mode of delivery. Moderate changes in several lifestyle habits lead to good intervention results. A minimum of 3-year follow-up seemed to be required to show a reduction in diabetes risk in high-risk individuals. In participants < 45 years, the achieved results in outcomes were less pronounced. The complementary review included 12 studies, with similar results regarding intervention targets and delivery modes, as well as clinical significance.

CONCLUSION

This narrative review highlighted several important aspects that subsequently guided the development of the Feel4Diabetes high-risk intervention. Research on diabetes prevention interventions targeted at younger adults or vulnerable population groups is still relatively scarce. Feel4Diabetes is a good example of a project aiming to fill this research gap.

TRIAL REGISTRATION

clinicaltrials.gov NCT02393872, registered 20th March 2015.

Effect of a family and interdisciplinary intervention to prevent T2D: randomized clinical trial

Background

Lifestyle changes can reduce the risk of T2D; however, no study has evaluated the effect of a lifestyle intervention involving patients´ family. The aim of this study was to compare the impact of an interdisciplinary family (FI) Vs individual intervention (II) on glucose metabolism, insulin resistance (IR), pancreatic β-cell function and cardiovascular risk markers in patients with prediabetes, as well as to measure the impact on their families’ metabolic risk.

Methods

Randomized Clinical Trial (RCT) to compare the impact of FI and II on IR and pancreatic β-cell function in subjects with prediabetes. There were 122 subjects with prediabetes (and 101 family members) randomized to FI or II. Data were collected in 2015–2016 and analyzed in 2017–2018. FI group had the support of their family members, who also received personalized diet and exercise recommendations; patients and their family members attended monthly a lifestyle enhancement program. II group received personalized diet and exercise recommendations. The follow-up was for 12 months. Glucose, IR, pancreatic β-cell function and secondary outcomes (body composition and lipid profile) were assessed at baseline, 6 and 12 months.

Results

FI group improved area under the glucose curve (AUC) (from 18,597 ± 2611 to 17,237 ± 2792, p = 0.004) and the Matsuda index (from 3.5 ± 2.3 to 4.7 ± 3.5, p = 0.05) at 12 months. II group improved Disposition Index (from 1.5 ± 0.4 to 1.9 ± 0.73, p < .0001) at 12 months.

The improvements achieved in weight and lipids at 6 months, were lost in II group at 12 moths, whereas in FI persisted. Adherence up to 12 months was not different between the study groups (FI 56% Vs II 60%).

Conclusions

FI intervention was more effective by improving glucose AUC, insulin sensitivity and lipid profile, besides that, metabolic risk in family members of the FI group was maintained, while the risk of II group was increased.

Trial registration

This study was retrospectively registered at clinicaltrials.gov on December 15, 2015 (NTC026365646).

Ethnicity and Metabolic Syndrome: Implications for Assessment, Management and Prevention

The metabolic syndrome (MetS) is a constellation of cardiometabolic risk factors that identifies people at increased risk for type 2 diabetes and cardiovascular disease. While the global prevalence is 20%–25% of the adult population, the prevalence varies across different racial/ethnic populations. In this narrative review, evidence is reviewed regarding the assessment, management and prevention of MetS among people of different racial/ethnic groups. The most popular definition of MetS considers race/ethnicity for assessing waist circumference given differences in visceral adipose tissue and cardiometabolic risk. However, defining race/ethnicity may pose challenges in the clinical setting. Despite 80% of the world’s population being of non-European descent, the majority of research on management and prevention has focused on European-derived populations. In these studies, lifestyle management has proven an effective therapy for reversal of MetS, and randomised studies are underway in specific racial/ethnic groups. Given the large number of people at risk for MetS, prevention efforts need to focus at community and population levels. Community-based interventions have begun to show promise, and efforts to improve lifestyle behaviours through alterations in the built environment may be another avenue. However, careful consideration needs to be given to take into account the unique cultural context of the target race/ethnic group.

Metformin for prevention or delay of type 2 diabetes mellitus and its associated complications in persons at increased risk for the development of type 2 diabetes mellitus

BACKGROUND

The projected rise in the incidence of type 2 diabetes mellitus (T2DM) could develop into a substantial health problem worldwide. Whether metformin can prevent or delay T2DM and its complications in people with increased risk of developing T2DM is unknown.

OBJECTIVES

To assess the effects of metformin for the prevention or delay of T2DM and its associated complications in persons at increased risk for the T2DM.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Scopus, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform and the reference lists of systematic reviews, articles and health technology assessment reports. We asked investigators of the included trials for information about additional trials. The date of the last search of all databases was March 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with a duration of one year or more comparing metformin with any pharmacological glucose-lowering intervention, behaviour-changing intervention, placebo or standard care in people with impaired glucose tolerance, impaired fasting glucose, moderately elevated glycosylated haemoglobin A1c (HbA1c) or combinations of these.

DATA COLLECTION AND ANALYSIS

Two review authors read all abstracts and full-text articles and records, assessed risk of bias and extracted outcome data independently. We used a random-effects model to perform meta-analysis and calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs) for effect estimates. We assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included 20 RCTs randomising 6774 participants. One trial contributed 48% of all participants. The duration of intervention in the trials varied from one to five years. We judged none of the trials to be at low risk of bias in all 'Risk of bias' domains. Our main outcome measures were all-cause mortality, incidence of T2DM, serious adverse events (SAEs), cardiovascular mortality, non-fatal myocardial infarction or stroke, health-related quality of life and socioeconomic effects.The following comparisons mostly reported only a fraction of our main outcome set. Fifteen RCTs compared metformin with diet and exercise with or without placebo: all-cause mortality was 7/1353 versus 7/1480 (RR 1.11, 95% CI 0.41 to 3.01; P = 0.83; 2833 participants, 5 trials; very low-quality evidence); incidence of T2DM was 324/1751 versus 529/1881 participants (RR 0.50, 95% CI 0.38 to 0.65; P < 0.001; 3632 participants, 12 trials; moderate-quality evidence); the reporting of SAEs was insufficient and diverse and meta-analysis could not be performed (reported numbers were 4/118 versus 2/191; 309 participants; 4 trials; very low-quality evidence); cardiovascular mortality was 1/1073 versus 4/1082 (2416 participants; 2 trials; very low-quality evidence). One trial reported no clear difference in health-related quality of life after 3.2 years of follow-up (very low-quality evidence). Two trials estimated the direct medical costs (DMC) per participant for metformin varying from $220 to $1177 versus $61 to $184 in the comparator group (2416 participants; 2 trials; low-quality evidence). Eight RCTs compared metformin with intensive diet and exercise: all-cause mortality was 7/1278 versus 4/1272 (RR 1.61, 95% CI 0.50 to 5.23; P = 0.43; 2550 participants, 4 trials; very low-quality evidence); incidence of T2DM was 304/1455 versus 251/1505 (RR 0.80, 95% CI 0.47 to 1.37; P = 0.42; 2960 participants, 7 trials; moderate-quality evidence); the reporting of SAEs was sparse and meta-analysis could not be performed (one trial reported 1/44 in the metformin group versus 0/36 in the intensive exercise and diet group with SAEs). One trial reported that 1/1073 participants in the metformin group compared with 2/1079 participants in the comparator group died from cardiovascular causes. One trial reported that no participant died due to cardiovascular causes (very low-quality evidence). Two trials estimated the DMC per participant for metformin varying from $220 to $1177 versus $225 to $3628 in the comparator group (2400 participants; 2 trials; very low-quality evidence). Three RCTs compared metformin with acarbose: all-cause mortality was 1/44 versus 0/45 (89 participants; 1 trial; very low-quality evidence); incidence of T2DM was 12/147 versus 7/148 (RR 1.72, 95% CI 0.72 to 4.14; P = 0.22; 295 participants; 3 trials; low-quality evidence); SAEs were 1/51 versus 2/50 (101 participants; 1 trial; very low-quality evidence). Three RCTs compared metformin with thiazolidinediones: incidence of T2DM was 9/161 versus 9/159 (RR 0.99, 95% CI 0.41 to 2.40; P = 0.98; 320 participants; 3 trials; low-quality evidence). SAEs were 3/45 versus 0/41 (86 participants; 1 trial; very low-quality evidence). Three RCTs compared metformin plus intensive diet and exercise with identical intensive diet and exercise: all-cause mortality was 1/121 versus 1/120 participants (450 participants; 2 trials; very low-quality evidence); incidence of T2DM was 48/166 versus 53/166 (RR 0.55, 95% CI 0.10 to 2.92; P = 0.49; 332 participants; 2 trials; very low-quality evidence). One trial estimated the DMC of metformin plus intensive diet and exercise to be $270 per participant compared with $225 in the comparator group (94 participants; 1 trial; very-low quality evidence). One trial in 45 participants compared metformin with a sulphonylurea. The trial reported no patient-important outcomes. For all comparisons there were no data on non-fatal myocardial infarction, non-fatal stroke or microvascular complications. We identified 11 ongoing trials which potentially could provide data of interest for this review. These trials will add a total of 17,853 participants in future updates of this review.

AUTHORS' CONCLUSIONS

Metformin compared with placebo or diet and exercise reduced or delayed the risk of T2DM in people at increased risk for the development of T2DM (moderate-quality evidence). However, metformin compared to intensive diet and exercise did not reduce or delay the risk of T2DM (moderate-quality evidence). Likewise, the combination of metformin and intensive diet and exercise compared to intensive diet and exercise only neither showed an advantage or disadvantage regarding the development of T2DM (very low-quality evidence). Data on patient-important outcomes such as mortality, macrovascular and microvascular diabetic complications and health-related quality of life were sparse or missing.

Efficacy of Metformin Treatment with Respect to Weight Reduction in Children and Adults with Obesity: A Systematic Review

BACKGROUND

Obesity and its related complications are increasing health issues. Since generally only minor weight loss is obtained with lifestyle intervention, additional pharmacological therapies such as metformin are often used.

OBJECTIVE

We conducted a systematic review to provide an overview of the efficacy of ≥ 6 months of metformin treatment in children and adults with respect to weight, insulin resistance, and progression toward type 2 diabetes mellitus (T2DM).

METHODS

In September 2018, we searched PubMed, Embase, and the Cochrane Library for studies published in English using the keywords metformin, obesity/overweight, and weight loss. Prospective studies reporting weight/body mass index (BMI) as a primary or secondary outcome in patients with overweight/obesity with ≥ 6 months' metformin treatment were included. Included subjects were children and adults with overweight/obesity who received ≥ 6 months of metformin and/or lifestyle intervention, and/or placebo and/or lifestyle intervention, and/or standard care. Studies were independently screened by two reviewers. Data were extracted by one and verified by the other reviewer, and both reviewers assessed the risk of bias using the Cochrane risk-of-bias tool.

RESULTS

Our review includes 15 pediatric and 14 adult studies. In children, after 6 months, more than half the studies reported a greater reduction in BMI with metformin versus controls. Only six studies had an intervention of > 6 months, and these studies found no further improvement in BMI in the metformin users, though their BMI was lower than that of controls. Three studies showed a significant improvement in insulin sensitivity in the metformin versus the control group. Adults using metformin experienced and maintained small decreases in weight irrespective of duration of intervention. In 11 of 14 studies, a greater reduction in weight/BMI was observed with metformin than with placebo. Progression toward T2DM was significantly reduced in adults using metformin, ranging from 7 to 31%. The safety and tolerability of metformin, withdrawal of participants, and comparison with other drugs were not taken into account.

CONCLUSIONS

The effects of metformin on weight/BMI vary, with smaller reductions in children than in adults. This could be because of differences in adherence, daily dosage, and insulin status. Metformin significantly reduced the progression toward T2DM in adults. Therefore, metformin should be considered as a treatment for obesity and its related complications.

Endothelium-Derived Factors Influence Differentiation of Fat-Derived Stromal Cells Post-Exercise in Subjects with Prediabetes

Purpose: We investigated the effect of aerobic and resistance exercise on abdominal subcutaneous fat-derived stromal cells in middle-aged subjects with prediabetes, pre- and post-exercise to establish molecular mechanisms that drive the effect of exercise. Methods: Five subjects, aged between 40 and 60 years with a body mass index between 25 and 39.9 kg/m² and with prediabetes, were enrolled in a 12-week exercise intervention program. Biophysical parameters were assessed pre- and post-exercise. Stromal cells were obtained from subcutaneous abdominal fat and cultured for 2-3 weeks. The stromal cells were then analyzed for mRNA analysis pre- and post-exercise. This was followed up with in vitro experiments where commercially obtained human fat-derived mesenchymal stromal cells (MSCs) were exposed to adipogenic media, and conditioned media from human endothelial conditioned media (ECM) cells were added to note if ECM addition altered adipogenesis. Subsequently, MSC differentiation was monitored by reverse transcription-polymerase chain reaction (RT-PCR). Results: Post-exercise, subjects' cardiometabolic parameters improved. MSC obtained at post-exercise phase, from subcutaneous fat biopsies, on RT-PCR analysis, showed upregulation of antioxidant, mitochondrial, glucose transporter, and genes associated with osteogenesis compared with pre-exercise MSC mRNA. A concomitant increase in plasma osteocalcin levels was also noted post-exercise. In vitro, MSCs exposed to adipogenic differentiation media with the addition of ECM showed a significant reduction in expression of adipogenic marker genes and instead showed upregulation of genes associated with osteogenic differentiation. Conclusions: Exercise appears to prevent adipogenic differentiation of fat-derived stromal cells and promote osteogenic differentiation, in prediabetic middle-aged subjects. Interestingly, the addition of endothelium-derived factors to adipogenic media also appears to prevent adipogenic differentiation of commercially obtained fat-derived stromal cells and promotes osteogenic differentiation. Both in vivo and in vitro findings emphasize the paracrine effect of endothelium-derived factors on fat differentiation.

Obesity, Motility, Diet, and Intestinal Microbiota-Connecting the Dots

PURPOSE OF REVIEW

The goal of the present review is to explore the relationship between dietary changes and alterations in gut microbiota that contribute to disorders of gut motility and obesity.

RECENT FINDINGS

We review the microbiota changes that are seen in obesity, diarrhea, and constipation and look at potential mechanisms of how dysbiosis can predispose to these. We find that microbial metabolites, particularly short chain fatty acids, can lead to signaling changes in the host enterocytes. Microbial alteration leading to both motility disorders and obesity may be mediated by the release of hormones including glucagon-like peptides 1 and 2 (GLP-1, GLP-2) and polypeptide YY (PYY). These pathways provide avenues for microbiota-targeted interventions that can treat both disorders of motility and obesity. In summary, multiple mechanisms contribute to the interplay between the microbial dysbiosis, obesity, and dysmotility.

Digital Health-Supported Lifestyle Change Programs to Prevent Type 2 Diabetes

IN BRIEF Type 2 diabetes can be prevented or delayed in people with prediabetes through participation in an intensive lifestyle change program (LCP), particularly one based on the Diabetes Prevention Program research study. Digital health offers opportunities to extend the reach of such LCPs and possibly improve on these programs, which traditionally have been delivered in person. In this review, we describe the current state of evidence regarding digital health-supported LCPs and discuss gaps in research and opportunities for future efforts.

Review of Metformin Use for Type 2 Diabetes Prevention

CONTEXT

Prediabetes is prevalent and significantly increases lifetime risk of progression to type 2 diabetes. This review summarizes the evidence surrounding metformin use for type 2 diabetes prevention.

EVIDENCE ACQUISITION

Articles published between 1998 and 2017 examining metformin use for the primary indication of diabetes prevention available on MEDLINE.

EVIDENCE SYNTHESIS

Forty articles met inclusion criteria and were summarized into four general categories: (1) RCTs of metformin use for diabetes prevention (n=7 and n=2 follow-up analyses); (2) observational analyses examining metformin use in heterogeneous subgroups of patients with prediabetes (n=9 from the Diabetes Prevention Program, n=1 from the biguanides and the prevention of the risk of obesity [BIGPRO] trial); (3) observational analyses examining cost effectiveness of metformin use for diabetes prevention (n=11 from the Diabetes Prevention Program, n=1 from the Indian Diabetes Prevention Program); and (4) real-world assessments of metformin eligibility or use for diabetes prevention (n=9). Metformin was associated with reduced relative risk of incident diabetes, with the strongest evidence for use in those at highest risk (i.e., aged <60 years, BMI ≥35, and women with histories of gestational diabetes). Metformin was also deemed cost effective in 11 economic analyses. Recent studies highlighted low rates of metformin use for diabetes prevention in real-world settings.

CONCLUSIONS

Two decades of evidence support metformin use for diabetes prevention among higher-risk patients. However, metformin is not widely used in real-world practice, and enhancing the translation of this evidence to real-world practice has important implications for patients, providers, and payers.

Effects of lifestyle changes on adults with prediabetes: A systematic review and meta-analysis

AIMS

To assess the efficacy, safety, and cost-effectiveness of lifestyle intervention, compared with treatment as usual in people with prediabetes as defined by the American Diabetes Association. For older studies, we used the 1985 World Health Organization definition.

METHODS

We systematically searched multiple electronic databases and referenced lists of pertinent review articles from January 1980 through November 2015. We performed an update search in MEDLINE on April 26, 2017. Based on a priori established eligibility criteria, we dually reviewed the literature, extracted data, and rated the risk of bias of included studies with validated checklists. To assess the efficacy of lifestyle intervention to prevent or delay further progression to type 2 diabetes, we conducted a random-effects meta-analysis. We assessed the certainty of evidence using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.

RESULT

Pooled results of 16 randomized controlled trials showed that people with prediabetes who received lifestyle intervention had a lower rate of progression to type 2 diabetes after one (4% vs. 10%, RR 0.46 [CI 0.32, 0.66]) and three years of follow-up (14% vs. 23%, RR 0.64 [95% CI 0.53, 0.77]). The majority of the studies also showed a greater weight loss in lifestyle intervention participants, with a great variation between studies. Costs per quality-adjusted life-year were lower when the benefits of lifestyle intervention were analyzed over a lifelong time horizon compared to only the period of lifestyle intervention (three years) or to modeling over a ten-year period.

CONCLUSION

Lifestyle intervention is an efficacious, safe, and cost-effective measure to reduce the risk of progression to type 2 diabetes in people diagnosed with prediabetes. More research is necessary to compare the efficacy of various modes, frequencies, and intensities of lifestyle intervention across studies.

Behavioral and Pharmacotherapy Weight Loss Interventions to Prevent Obesity-Related Morbidity and Mortality in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Overweight and obesity have been associated with adverse health effects.

OBJECTIVE

To systematically review evidence on benefits and harms of behavioral and pharmacotherapy weight loss and weight loss maintenance interventions in adults to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, PubMed Publisher-Supplied Records, PsycINFO, and the Cochrane Central Register of Controlled Trials for studies published through June 6, 2017; ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials through August 2017; and ongoing surveillance in targeted publications through March 23, 2018. Studies from previous reviews were reevaluated for inclusion.

STUDY SELECTION

Randomized clinical trials (RCTs) focusing on weight loss or weight loss maintenance in adults.

DATA EXTRACTION AND SYNTHESIS

Data were abstracted by one reviewer and confirmed by another. Random-effects meta-analyses were conducted for weight loss outcomes in behavior-based interventions.

MAIN OUTCOMES AND MEASURES

Health outcomes, weight loss or weight loss maintenance, reduction in obesity-related conditions, and adverse events.

RESULTS

A total of 122 RCTs (N = 62 533) and 2 observational studies (N = 209 993) were identified. Compared with controls, participants in behavior-based interventions had greater mean weight loss at 12 to 18 months (-2.39 kg [95% CI, -2.86 to -1.93]; 67 studies [n = 22065]) and less weight regain (-1.59 kg [95% CI, -2.38 to -0.79]; 8 studies [n = 1408]). Studies of medication-based weight loss and maintenance interventions also reported greater weight loss or less weight regain in intervention compared with placebo groups at 12 to 18 months (range, -0.6 to -5.8 kg; no meta-analysis). Participants with prediabetes in weight loss interventions had a lower risk of developing diabetes compared with controls (relative risk, 0.67 [95% CI, 0.51 to 0.89]). There was no evidence of other benefits, but most health outcomes such as mortality, cardiovascular disease, and cancer were infrequently reported. Small improvements in quality of life in some medication trials were noted but were of unclear clinical significance. There was no evidence of harm such as cardiovascular disease from behavior-based interventions; higher rates of adverse events were associated with higher dropout rates in medication groups than in placebo groups.

CONCLUSIONS AND RELEVANCE

Behavior-based weight loss interventions with or without weight loss medications were associated with more weight loss and a lower risk of developing diabetes than control conditions. Weight loss medications, but not behavior-based interventions, were associated with higher rates of harms. Long-term weight and health outcomes data, as well as data on important subgroups, were limited.

[The Old-Age Heart]

The Old-Age Heart Abstract. Knowledge of cardiovascular changes in old age and their therapeutic options is important. Old age can lead to hypertrophy of the left ventricle, diastolic dysfunction, heart valve changes and pulmonary hypertension. Patients often develop arterial hypertension. Valvular changes are common in people over 100 years of age (aortic stenosis and mitral insufficiency). The risk of coronary heart disease is 35 % for men and 24 % for women. In old age, sinus node dysfunction and atrial fibrillation are common. 25 % of all strokes are cardiac embolisms in atrial fibrillation. Cardiac interventions in the elderly are increasingly frequent and include coronary catheter revascularization or valve interventions (percutaneous aortic valve replacement or MitraClip). Optimal therapy in old age includes not only cardiovascular interventions also include drugs and a lifestyle modification and mainly serves to improve the quality of life.

Association of changes in mental health with weight loss during intensive lifestyle intervention: does the timing matter?

Objective

This study examined changes in mental health symptoms and weight during weight loss treatment. It was hypothesized that worsening mental health would negatively impact weight loss.

Methods

Data were analyzed from a trial of 92 Hispanic women with overweight/obesity and prediabetes, who were randomized to receive intensive lifestyle intervention (ILI), metformin 1,700 mg daily, or standard care. Depression, anxiety and perceived stress were assessed at 0, 6 and 12 months. Six‐ and 12‐month weight change was compared among participants whose symptom scores worsened on any mental health measure (W) vs. improved or remained stable on all three (I/S).

Results

Among ILI participants, the 12‐month difference in weight loss between I/S and W groups was statistically significant: −5.1 kg (P = 0.001). From baseline to 6 months, ILI participants in I/S and W groups experienced comparable weight loss. However, from 6 to 12 months, W participants regained weight, whereas I/S participants experienced continued weight loss. In the metformin and standard care arms, there was no weight difference between I/S and W groups.

Conclusions

In ILI, 12‐month improvement or stability in mental health was significantly associated with weight loss. Weight trajectories between I/S and W groups diverged at 6 months.

Diabetes Risk Assessment in Latinas: Effectiveness of a Brief Diabetes Risk Questionnaire for Detecting Prediabetes in a Community-Based Sample

OBJECTIVE

Numerous validated questionnaires use self-reported data to quantify individuals' risk of having diabetes or developing it in the future. Evaluations of these tools have primarily used nationally representative data, limiting their application in clinical and community settings. This analysis tested the effectiveness of the American Diabetes Association (ADA) risk questionnaire for identifying prediabetes in a community-based sample of Latinas.

METHODS

Data were collected using the ADA risk questionnaire and assessing A1C. Among 204 participants without diabetes, we examined the association between individual characteristics and glycemic status. We then calculated the performance characteristics (sensitivity, specificity, positive predictive value [PPV], and negative predictive value [NPV]) of the ADA risk questionnaire for detecting prediabetes, using A1C results as the gold standard to define the outcome.

RESULTS

All participants were women of self-reported Hispanic/Latino ethnicity. Their mean ADA risk score was 5.6 ± 1.6. Latinas who had prediabetes were older, with significantly higher rates of hypertension and a higher ADA risk score than those without prediabetes. At a risk score ≥5-the threshold for high risk set by the ADA-the questionnaire had the following test performance characteristics: sensitivity 77.8%, specificity 41.7%, PPV 76.2%, and NPV 43.9%.

CONCLUSION

The ADA risk questionnaire demonstrates reasonable performance for identifying prediabetes in a community-based sample of Latinas. Our data may guide other groups' use of this tool in the same target population. Future research should examine the effectiveness of this questionnaire for recruiting diverse populations into diabetes prevention programs. In addition, unique diabetes risk assessment tools for specific target populations are needed and may outperform questionnaires developed using nationally representative data.

"I don't want to look sick skinny": Perceptions of Body Image and Weight Loss in Hispanics Living with HIV in South Texas

Objective

Obesity is rising in people with HIV (PLWH) and Hispanics. Both HIV and obesity are associated with cardiovascular disease morbidity and mortality. Our goal is to understand perceptions of body image and lifestyle in Hispanics with HIV to adapt interventions appropriately.

Methods

We conducted semi-structured interviews with 22 Hispanic PLWH and 6 providers. Purposive sampling selected patient participants across weights and genders. Interviews were coded and analyzed using grounded theory, comparing perspectives between patients with and without obesity, and patients and providers.

Results

Participants felt obesity and diabetes were "normal" in the community. Patients exhibited understanding of healthy diet and lifestyle but felt incapable of maintaining either. Traditionally Hispanic foods were blamed for local obesity prevalence. Five patients equated weight with health and weight loss with illness, and four expressed concerns that weight loss could lead to unintentional disclosure of HIV status. Participants with overweight or obesity expressed awareness of their weight and felt shamed by providers. Providers found weight loss interventions to be ineffective.

Conclusion

Interventions in this population must address identified barriers: overweight/obesity as a normative value, lack of self-efficacy, cultural beliefs surrounding food, fear of HIV-associated weight loss and stigma, and provider perspectives on intervention futility.

From Sea to Shining Sea and the Great Plains to Patagonia: A Review on Current Knowledge of Diabetes Mellitus in Hispanics/Latinos in the US and Latin America

The past two decades have witnessed many advances in the prevention, treatment, and control of diabetes mellitus (DM) and its complications. Increased screening has led to a greater recognition of type 2 diabetes mellitus (type 2 DM) and prediabetes; however, Hispanics/Latinos, the largest minority group in the US, have not fully benefited from these advances. The Hispanic/Latino population is highly diverse in ancestries, birth places, cultures, languages, and socioeconomic backgrounds, and it populates most of the Western Hemisphere. In the US, the prevalence of DM varies among Hispanic/Latino heritage groups, being higher among Mexicans, Puerto Ricans, and Dominicans, and lower among South Americans. The risk and prevalence of diabetes among Hispanics/Latinos are significantly higher than in non-Hispanic Whites, and nearly 40% of Hispanics/Latinos with diabetes have not been formally diagnosed. Despite these striking facts, the representation of Hispanics/Latinos in pharmacological and non-pharmacological clinical trials has been suboptimal, while the prevalence of diabetes in these populations continues to rise. This review will focus on the epidemiology, etiology and prevention of type 2 DM in populations of Latin American origin. We will set the stage by defining the terms Hispanic, Latino, and Latin American, explaining the challenges identifying Hispanics/Latinos in the scientific literature and databases, describing the epidemiology of diabetes-including type 2 DM and gestational diabetes mellitus (GDM)-and cardiovascular risk factors in Hispanics/Latinos in the US and Latin America, and discussing trends, and commonalities and differences across studies and populations, including methodology to ascertain diabetes. We will discuss studies on mechanisms of disease, and research on prevention of type 2 DM in Hispanics/Latinos, including women with GDM, youth and adults; and finalize with a discussion on lessons learned and opportunities to enhance research, and, consequently, clinical care oriented toward preventing type 2 DM in Hispanics/Latinos in the US and Latin America.

Transculturalizing Diabetes Prevention in Latin America

BACKGROUND

Type 2 diabetes (T2D) imposes a heavy burden in developing countries, requiring effective primary prevention policies. Randomized clinical trials have identified successful strategies in T2D prevention. However, translating these results to real-life scenarios and adapting to ethnocultural differences is a major challenge. Transculturalization allows incorporating cultural factors to diabetes prevention strategies to optimize implementation of clinical trials results. The purpose of this paper is to review the transcultural adaptations developed for T2D prevention in Latin America (LA).

METHODS

A comprehensive literature review spanning 1960-2016 was performed, using "Diabetes," "Latin America," "Prevention," "Screening," and "Tools" as key words.

RESULTS

Two major tasks are underway in LA: adaptation of screening tools for high-risk individuals, and implementation of diabetes prevention programs. The Finnish Diabetes Risk Score (FINDRISC) is the most widely used screening tool to detect new cases of T2D and people with prediabetes, and it has been adapted (LA-FINDRISC) to include the waist circumference cutoff values appropriate for LA population (≥94 cm for men and ≥90 cm for women). The validation of the LA-FINDRISC performance depends on the local characteristics. A LA-FINDRISC score >10 may be the best cutoff to identify individuals with impaired glucose regulation in population-based studies, but a higher score (>12-14) might be more appropriate in a clinical setting. A shorter version of the FINDRISC using only the 4 variables with highest impact has been developed and validated in Colombia (ColDRISC). The translation of the Diabetes Prevention Program study in a Latino population in Venezuela found a significant improvement in cardiometabolic risk factors. An adaptation of the Diabetes Prevention Study in the DEMOJUAN study in Barranquilla, Colombia, reduced 2-hour postload glucose.

CONCLUSION

Successful transculturalization strategies have been implemented in screening tools and prevention programs in LA.