One-year effects of a group-based lifestyle intervention in adults with type 2 diabetes: A randomized encouragement trial

Global comparison of the effect of non-pharmacological interventions on glycemic control in patients with type 2 diabetes: A network meta-analysis from 107 randomized controlled trials

OBJECTIVE

To investigate the effectiveness of non-pharmacological interventions (NPIs) on glycemic control in patients with type 2 diabetes (T2D) and to provide guidance for clinical healthcare-giver.

DESIGN

Network meta-analysis (NMA).

SETTING AND PARTICIPANTS

Randomized controlled trials comparing the effect of NPIs with usual care, waitlist, or other NPIs on glycemic control in patients with T2D.

METHODS

This NMA was guided by frequentist framework. PubMed, Embase, the Cochrane Library Central Register of Controlled Trials, Cumulated Index to Nursing and Allied Health Literature, and Web of Science were searched from their inception until January 2023. The primary outcome was HbA1c and secondary outcomes were cardiovascular risk scores and related psychosocial scores. Mean differences and standardized mean differences were pooled using NMA. Study quality was assessed with the Confidence in Network Meta-analysis.

RESULTS

A total of 107 studies (10,496 participants) were included. The median sample size of the included studies was 64 (range, 10-563) and the median duration was 3 months (range, 1-24). Compared to usual care, all NPIs except acupuncture (MD: -0.28; 95 % CI: -1.02, 0.26) and psychological therapy (MD: -0.29; 95 % CI: -0.66, 0.08) showed significantly differences in improving glycemic control in patients with T2D. And according to the results of surface under the cumulative ranking analysis and Cluster ranking, meditation therapy was considered to the best choice when balancing the efficacy of glycemic control with self-efficacy and diabetes related problems, while nutrition therapy was considered to the best choice when balancing quality of life with risk of cardiovascular complications.

CONCLUSIONS

These findings validate the efficacy of NPIs for glycemic control in patients with T2D and suggest that healthcare-giver should consider both the efficacy of interventions and the psychosocial needs of patients when developing NPIs programs.

A nutritional web-based approach in obesity and diabetes before and during the COVID-19 lockdown

INTRODUCTION

Obesity and type 2 diabetes (T2D) are two closely related pandemic conditions. Novel technologies represent promising tools for their management, the use of which has been greatly encouraged during the COVID-19 pandemic. The aim of the present study is to compare a web-based nutritional intervention versus a traditional one, before and during the Italian 'lockdown' period due to the COVID-19 outbreak, in overweight and obese subjects affected by T2D or impaired glucose regulation (IGR).

METHODS

For the study, 36 subjects were randomly allocated into two arms: a traditional arm, providing face-to-face individual and group-based intervention; and a web arm, deploying the in-presence traditional approach with intervention provided through web technologies. The outcomes were the data resulting from the comparison between the subjects' anthropometric and clinical parameters as well as PREDIMED scores at baseline with those at 3 months (T3), 6 months (T6) and at lockdown.

RESULTS

In the web arm we detected a progressive reduction in weight and body mass index (BMI) from baseline to T6 and a minimal increase of both parameters during the lockdown. Improvement of these parameters compared with baseline was observed in controls during the lockdown. The PREDIMED score improved at T6 compared with baseline in both arms. Significant variations were observed considering weight (p < 0.001), BMI (p = 0.001) and PREDIMED scores (p = 0.023) over time.

DISCUSSION

The study showed the effectiveness and feasibility of a short-term nutritional web-based intervention in patients affected by T2D or IGR before and during the COVID 19 pandemic.Clinical Trial registration number: NCT04386200, ClinicalTrials.gov.

Results of a 2-year lifestyle intervention for type 2 diabetes: the Reach Ahead for Lifestyle and Health-Diabetes randomized controlled trial

OBJECTIVE

The Reach Ahead for Lifestyle and Health (REAL HEALTH)-Diabetes study assessed the comparative effectiveness of two Look AHEAD (Action for Health in Diabetes)-adapted lifestyle intervention (LI) arms targeting weight loss in type 2 diabetes compared with medical nutrition therapy (MNT) referral. At 1 year, LI had greater weight loss than MNT. This study reports outcomes at 24 (end of LI) and 36 months.

METHODS

Participants (N = 211) with type 2 diabetes and BMI > 25 kg/m2 were randomly assigned to in-person LI, telephone conference call LI, or MNT. The primary outcome was percentage weight change. Secondary outcomes included 5% and 10% weight loss, glycated hemoglobin (HbA1c), and patient-reported outcomes.

RESULTS

Participants were 61.7 (SD 10.2) years old; 55% were female; 77% were non-Hispanic White; and had mean (SD) weight of 98 (18.9) kg and mean (SD) HbA1c of 7.7% (1.2%). Mean (SD) weight change at 24 and 36 months was -4.4% (5.9%) and -4.4% (5.4%) in in-person LI, -4.0% (5.8%) and -5.3% (6.4%) in telephone LI, and -3.1% (5.2%) and -5.8% (7.1%) in MNT, with no statistically significant difference in weight or HbA1c at 24 and 36 months. Compared with MNT, LI arms had favorable changes in patient-reported outcomes related to learned dietary skills.

CONCLUSIONS

There were no differences in weight outcomes among LI participants compared with referral to MNT at the end of intervention or 1 year after its conclusion.

Effectiveness of Strategies for Nutritional Therapy for Patients with Type 2 Diabetes and/or Hypertension in Primary Care: A Systematic Review and Meta-Analysis

A central aspect to the management of type 2 Diabetes Mellitus (T2DM) and hypertension is promoting a healthy lifestyle, and nutritional therapy (NT) can support patients achieving glycemic control and blood pressure targets. This systematic review aimed to evaluate the effectiveness of NT in the management of patients with T2DM and/or hypertension in primary care. Primary outcomes were HbA1c, systolic blood pressure (SBP) and diastolic blood pressure (DBP). Thirty-nine studies were included, thirty on T2DM and nine on hypertension. With a moderate quality of evidence, educational/counseling programs and food replacement programs in primary care likely reduce HbA1c on patients with T2DM (mean difference (MD): −0.37, 95% CI: −0.57 to −0.17, 7437 patients, 27 studies; MD: −0.54, 95% CI: −0.75 to −0.32, 440 patients, 2 studies, respectively). Mediterranean diet for T2DM was accessed by one study, and no difference between the groups was found. Educational and counseling programs likely reduce DBP in patients with hypertension (MD: −1.79, 95% CI: −3.46, −0.12, 2840 patients, 9 studies, moderate quality of the evidence), but the effect in SBP was unclear due to risk of bias and imprecision. Nutritional therapy strategies (i.e., educational/counseling programs and food replacement programs) in primary care improved HbA1c in patients with T2DM and DBP in individuals with hypertension.

The effect of nonpharmaceutical weight-loss interventions in rural patients with diabetes: RE-POWER Diabetes

OBJECTIVE

In this secondary analysis of the Rural Engagement in Primary Care for Optimizing Weight Reduction (RE-POWER) randomized trial, the authors determined the effectiveness of weight-loss interventions in people with diabetes compared with those without diabetes living in rural areas.

METHODS

The RE-POWER study was a randomized trial designed to determine the effectiveness of nonpharmacological behavioral weight-loss interventions in rural participants with obesity, comparing the individual in-clinic visit model to in-person group sessions and phone group sessions over 24 months. In this secondary analysis, weight loss was compared in participants with and without diabetes. The effects of factors such as medications, insulin, and behavioral factors were compared.

RESULTS

Participants with diabetes were less likely to lose weight during the study compared with those without diabetes up to 18 months (4.12% vs. 5.31%; net difference = 1.46%; 95% CI: 0.63%-2.28%). Participants with diabetes on insulin lost less weight than patients with diabetes not on insulin at 6 months (4.52% vs. 6.88%; net difference = 2.35%; 95% CI: 0.55%-4.16%). The group with diabetes had significantly lower changes in blood pressure and lipid parameters versus the group without diabetes.

CONCLUSIONS

Patients with diabetes in rural areas were less likely to lose weight, and metabolic parameters were less responsive to weight loss, compared with patients without diabetes.

Effectiveness of a Non-pharmacological Intervention to Control Diabetes Mellitus in a Primary Care Setting in Kerala: A Cluster-Randomized Controlled Trial

Background: Despite being the first Indian state with a dedicated Non-Communicable Disease (NCD) program, glycemic control among a large proportion of patients is low in Kerala. This study tries to find evidence for a standardized non-pharmacological strategy delivered through Junior Public Health Nurses (JPHNs) in achieving and maintaining glycemic control among diabetic patients registered with NCD clinics of primary health care settings. Design: A cluster randomized controlled trial was conducted among adult patients with Diabetes Mellitus attending NCD clinics of primary care settings of South Kerala, India. JPHNs of the intervention group received additional module-based training while standard management continued in the control group. Sequence generation was done by random permuted blocks method and a cluster of 12 patients was selected from each of the 11 settings by computer-generated random numbers. Patients were followed up for 6 months with monthly monitoring of Fasting Blood Sugar (FBS), Post-Prandial Blood Sugar (PPBS), blood pressure, Body Mass Index (BMI), and health-related behaviors. Knowledge and skills/practice of JPHNs were also evaluated. Analysis of Covariance was done to study the final outcome adjusting for the baseline values and a model for glycemic control was predicted using multilevel modeling. Results: We analyzed 72 participants in the intervention group and 60 participants in the control group according to the intention-to-treat principle. The intervention was associated with a significant reduction in FBS (p < 0.001) and PPBS (p < 0.001) adjusting for the baseline values. The achievement of glycemic control was 1.5 (95% CI: 1.05-2.3) times better with intervention and they showed a better trend of maintenance of glycemic control (FBS, p = 0.003 and PPBS, p = 0.039). Adjusting for clustering and the baseline values, the intervention showed a significant effect on FBS (B = -3.1, SE = 0.57; p < 0.001) and PPBS (B = -0.81, SE = 0.3; p < 0.001) with time. Drug adherence score (p < 0.001), hours of physical activity (p < 0.001), BMI (p = 0.002), fruit intake (p = 0.004), and green leafy vegetable intake (p = 0.01) were the major predictors of FBS control. The practice/skills score of the JPHNs significantly improved with intervention (p < 0.001) adjusting for baseline values. Conclusion: A well-designed health worker intervention package incorporated into the existing health system can translate into attitude change and skill development in the health workers which can reflect in the improvement of glycemic control among the patients. Trial registration: [URL: http://www.ctri.nic.in], identifier [CTRI/2017/11/010622].

Effectiveness of Lifestyle Intervention for Type 2 Diabetes in Primary Care: the REAL HEALTH-Diabetes Randomized Clinical Trial

BACKGROUND

Intensive lifestyle interventions (LI) improve outcomes in obesity and type 2 diabetes but are not currently available in usual care.

OBJECTIVE

To compare the effectiveness and costs of two group LI programs, in-person LI and telephone conference call (telephone LI), to medical nutrition therapy (MNT) on weight loss in primary care patients with type 2 diabetes.

DESIGN

A randomized, assessor-blinded, practice-based clinical trial in three community health centers and one hospital-based practice affiliated with a single health system.

PARTICIPANTS

A total of 208 primary care patients with type 2 diabetes, HbA1c 6.5 to < 11.5, and BMI > 25 kg/m² (> 23 kg/m² in Asians).

INTERVENTIONS

Dietitian-delivered in-person or telephone group LI programs with medication management or MNT referral.

MAIN MEASURES

Primary outcome: mean percent weight change.

SECONDARY OUTCOMES

5% and 10% weight loss, change in HbA1c, and cost per kilogram lost.

KEY RESULTS

Participants' mean age was 62 (SD 10) years, 45% were male, and 77% were White, with BMI 35 (SD 5) kg/m² and HbA1c 7.7 (SD 1.2). Seventy were assigned to in-person LI, 72 to telephone LI, and 69 to MNT. The mean percent weight loss (95% CI) at 6 and 12 months was 5.6% (4.4-6.8%) and 4.6% (3.1-6.1%) for in-person LI, 4.6% (3.3-6.0%) and 4.8% (3.3-6.2%) for telephone LI, and 1.1% (0.2-2.0%) and 2.0% (0.9-3.0%) for MNT, with statistically significant differences between each LI arm and MNT (P < 0.001) but not between LI arms (P = 0.63). HbA1c improved in all participants. Compared with MNT, the incremental cost per kilogram lost was $789 for in-person LI and $1223 for telephone LI.

CONCLUSIONS

In-person LI or telephone group LI can achieve good weight loss outcomes in primary care type 2 diabetes patients at a reasonable cost.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02320253.

Effectiveness of non-pharmacological strategies in the management of type 2 diabetes in primary care: a protocol for a systematic review and network meta-analysis

INTRODUCTION

Despite the increasing number of drugs and various guidelines on the management of type 2 diabetes mellitus (T2DM), several patients continue with the disease uncontrolled. There are several non-pharmacological treatments available for managing T2DM, but various of them have never been compared directly to determine the best strategies.

OBJECTIVE

This study will evaluate the comparative effects of non-pharmacological strategies in the management of T2DM in primary care or community settings.

METHODS AND ANALYSIS

We will perform a systematic review and network meta-analysis (NMA), and will include randomised controlled trials if one of the following interventions were applied in adult patients with T2DM: nutritional therapy, physical activity, psychological interventions, social interventions, multidisciplinary lifestyle interventions, diabetes self-management education and support (DSMES), technology-enabled DSMES, interventions delivered only either by pharmacists or by nurses, self-blood glucose monitoring in non-insulin-treated T2DM, health coaching, benchmarking and usual care. The primary outcome will be glycaemic control (glycated haemoglobin (HbA1c) (%)), and the secondary outcomes will be weight loss, quality of life, patient satisfaction, frequency of cardiovascular events and deaths, number of patients in each group with HbA1c <7, adverse events and medication adherence. We have developed search strategies for Embase, Medline, Latin American and Caribbean Health Sciences Literature, Cochrane Central Register of Controlled Trials, Trip database, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature Australasian Medical Index and Chinese Biomedical Literature Database. Four reviewers will assess the studies for their eligibility and their risk of bias in pairs and independently. An NMA will be performed using a Bayesian hierarchical model, and the treatment hierarchy will be obtained using the surface under the cumulative ranking curve. To determine our confidence in an overall treatment ranking from the NMA, we will follow the Grading of Recommendations Assessment, Development and Evaluation approach.

ETHICS AND DISSEMINATION

As no primary data collection will be undertaken, no formal ethical assessment is required. We plan to present the results of this systematic review in a peer-reviewed scientific journal, conferences and the popular press.

PROSPERO REGISTRATION NUMBER

CRD42019127856.