Effects of a culturally adapted lifestyle intervention on cardio-metabolic outcomes: a randomized controlled trial in Iraqi immigrants to Sweden at high risk for Type 2 diabetes

A controlled weight loss intervention study among women of Somali background in Norway

Background

Women of Somali background in Norway have a high prevalence of overweight and obesity, compared with women in the general Norwegian population. For lifestyle interventions to be applicable for immigrants to Norway, it is important to culturally tailor interventions in collaboration with relevant communities. The primary outcome was a difference in weight change between the intervention and control groups.

Methods

In this interventional study, Somali women living in one borough of Oslo Municipality in Norway with body mass index (BMI) ≥27.0 kg.m-2 received a co-created, culturally tailored 12-month weight loss intervention consisting of 24 interactive sessions during the first three months, and monthly sessions for the next nine months, compared to a control group. Both groups were measured at baseline and 12 months.

Results

A total of 169 participants were recruited, and 101 participants completed the follow-up. After multiple imputation, the mean difference in weight change adjusted for baseline weight, age, education, employment, marital status, number of children in the household and length of Norwegian residency was -1.6 kg (95 % CI -3.57, 0.43, p = 0.12) in the intervention compared to the control group.

Conclusion

This culturally tailored intervention study demonstrated a modest non-significant effect on weight change after 12 months, possibly due to the short intervention duration and COVID-19. Further studies of a longer duration and considering the provision of childcare are needed to understand whether this approach can be transferred to other immigrant groups and genders.Trial registration: The study was registered at clinicaltrials.gov NCT04578067, 2020-09-29.

Nutrition and Physical Activity Interventions Provided by Nutrition and Exercise Practitioners for the General Population: An Evidence-Based Practice Guideline From the Academy of Nutrition and Dietetics and American Council on Exercise

A nutritious diet and adequate physical activity vitally contribute to disease prevention, but most adults do not meet population-based dietary and physical activity recommendations. Qualified nutrition and exercise practitioners can address challenges to adopting healthy lifestyle behaviors by providing consistent, individualized, and evidence-based education and programming within their professional scopes of practice to improve client outcomes. The objective of this evidence-based practice guideline is to inform practice decisions for nutrition and exercise practitioners providing nutrition and physical activity interventions for adults who are healthy or have cardiometabolic risk factors, but no diagnosed disease. Evidence from a systematic review was translated to practice recommendations using an evidence-to-decision framework by an interdisciplinary team of nutrition and exercise practitioners and researchers. This evidence-based practice guideline does not provide specific dietary or physical activity recommendations but rather informs nutrition and exercise practitioners how they may utilize existing guidelines for the general population to individualize programming for a range of clients. This evidence-based practice guideline provides widely applicable recommendation statements and a detailed framework to help practitioners implement the recommendations into practice. Common barriers and facilitators encountered when delivering nutrition and physical activity interventions, such as adherence to professional scopes of practice; methods to support behavior change; and methods to support inclusion, diversity, equity, and access, are discussed. Nutrition and exercise practitioners can consistently provide individualized, practical, and evidence-based interventions by seeking to understand their clients' needs, circumstances, and values and by co-creating interventions with the client and their allied health team.

The effect of a randomised controlled lifestyle intervention on weight loss and plasma proneurotensin

AIMS

Proneurotensin (Pro-NT) is a strong predictor of cardiometabolic disease including type 2 diabetes and obesity, however, the effect of lifestyle change on Pro-NT has not been investigated in this context. Middle Eastern (ME) immigrants represent the largest and fastest growing minority population in Europe and are a high-risk population for obesity and type 2 diabetes. In this randomised controlled lifestyle intervention (RCT) addressing ME immigrants to Sweden where weight-loss was previously studied as the main outcome, as a secondary analysis we aimed to study change in Pro-NT during follow-up and if baseline Pro-NT predicted weight loss.

METHODS

Immigrants from the Middle East at high risk for type 2 diabetes were invited to participate in this RCT adapted lifestyle intervention of four months' duration. The intervention group (N = 48) received a culturally adapted lifestyle intervention comprising seven group sessions and a cooking class addressing healthier diet and increased physical activity. The control group (N = 44) received treatment as usual with information to improve lifestyle habits on their own. Data assessed using mixed effects regression.

OUTCOMES

Primary outcome; change in Pro-NT. Secondary outcome; change in BMI in relation to baseline plasma concentration of Pro-NT.

RESULTS

During the four months follow up, weight was significantly reduced in the intervention (-2.5 kg) compared to the control group (0.8 kg) (β -0.12, 95% CI -0.24 to -0.01, P = 0.028). Pro-NT increased to a significantly greater extent in the intervention compared to the control group during follow up (28.2 vs. 3.5 pmol/L) (β 11.4; 4.8 to 18.02, P < 0.001). Change over time in BMI was associated with baseline Pro-NT (β 0.02; 0.01 to 0.04, P = 0.041).

CONCLUSION

In consistence with data from surgical weight loss, this RCT paradoxically shows increased levels of Pro-NT during a multifactorial lifestyle intervention resulting in weight loss. Long term studies of Pro-NT following weight loss are needed.

TRIAL REGISTRATION

This study is a secondary analysis of the RCT trial registered at www.

CLINICALTRIALS

gov .

REGISTRATION NUMBER

NCT01420198. Date of registration 19/08/2011. The performance and results of this trial conform to the CONSORT 2010 guidelines.

Postprandial triglyceride levels rather than fat distribution may reflect early signs of disturbed fat metabolism in Iraqi immigrants

PURPOSE

Previous studies have shown that at a similar body mass index, Middle Eastern immigrants are more insulin resistant and at higher risk for type 2 diabetes (T2D) than native Europeans. Insulin resistance is strongly associated with disturbed fat metabolism and cardiovascular disease (CVD). However, fat metabolism is poorly investigated comparing Middle Eastern and European ethnicities.

METHODS

This observational study included 26 Iraqi and 16 Swedish-born men without T2D or clinical risk factors for CVD. An oral fat tolerance test (OFTT) was performed, where plasma triglycerides (p-TG) were measured for 6 h. mRNA expression and adipocyte size were measured in subcutaneous adipose tissue biopsies collected prior to OFTT, and magnetic resonance imaging was conducted to assess body fat distribution.

RESULTS

The median p-TG accumulation was higher and the clearance slower among Iraqis than Swedes. None of the groups reached their fasting p-TG (Iraqis 1.55 mmol/l; Swedes 0.95 mmol/l) after 6 h (Iraqis p-TG 3.10 mmol/l; Swedes p-TG 1.50 mmol/l). Adipocyte size, mRNA expression, and fat accumulation in the liver, muscle and abdomen were similar in both groups.

CONCLUSION

Postprandial p-TG levels rather than fat distribution may reflect early signs of disturbed fat metabolism in Iraqi immigrants without CVD risk factors.

Effects of a 10-Week Physical Activity Intervention on Asylum Seekers’ Physiological Health

Introduction: The rise in armed conflicts has contributed to an increase in the number of asylum seekers. Prolonged asylum processes may negatively affect asylum seekers’ health and lead to inactivity. Studies show that physical activity interventions are associated with improvements in health outcomes. However, there are a limited number of studies investigating the associations of physical activity on asylum seekers’ health. Methods: Participants (263 males and 204 females), mostly from Syria, were assessed before and after a 10-week intervention for VO₂ max, body mass index (BMI), skeletal muscle mass (SMM), body fat, and visceral fat. Linear mixed models were used to test differences within groups, and a linear regression model analysis was performed to test whether physiological variables predicted adherence. Results: Participants’ VO₂ max increased: males by 2.96 mL/min/kg and females 2.57 mL/min/kg. Increased SMM percentages were seen in both genders: females by 0.38% and males 0.23%. Visceral fat area decreased: males by 0.73 cm² and females 5.44 cm². Conclusions: Participants showed significant increases in VO2 max and SMM and decreased visceral fat. This study provides an insight into asylum seekers’ health and serves as a starting point to new interventions in which physical activity is used as a tool to promote and improve vulnerable populations’ health.

Impact of Nutrition and Physical Activity Interventions Provided by Nutrition and Exercise Practitioners for the Adult General Population: A Systematic Review and Meta-Analysis

Healthy dietary intake and physical activity reduce the risk of non-communicable diseases. This systematic review and meta-analysis aimed to examine the effect of interventions including both nutrition and physical activity provided by nutrition and exercise practitioners for adults in the general population (those without diagnosed disease). The MEDLINE, CINAHL, Cochrane Central, Cochrane Database of Systematic Reviews and SportDiscus databases were searched for randomized controlled trials (RCTs) published from 2010 until April 2021. Outcomes included physical activity, fruit and vegetable intake, waist circumference, percent weight loss, quality of life (QoL) and adverse events. Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods were used to synthesize and grade evidence. Meta-analyses were stratified according to participant health status. The database search identified 11,205 articles, and 31 RCTs were included. Interventions increased physical activity amount [standardized mean difference (SMD) (95% CI): 0.25 (0.08, 0.43)] (low certainty evidence); increased vegetable intake [SMD (95% CI): 0.14 (0.05, 0.23)] (moderate certainty evidence); reduced waist circumference [MD (95% CI): −2.16 cm (−2.96, −1.36)] (high certainty evidence); and increased likelihood of achieving 5% weight loss for adults with overweight and obesity [relative risk (95% CI): 2.37 (1.76, 3.19)] (high certainty evidence). Very low and low certainty evidence described little-to-no effect on QoL or adverse events. Nutrition and exercise practitioners play key roles in facilitating positive lifestyle behaviors to reduce cardiometabolic disease risk in adults.

Immigrants' perspectives on healthy life and healthy lifestyle counseling: a focus group study

BACKGROUND

Immigrants have a higher risk of developing chronic diseases than the general population, but there is a lack of knowledge about appropriate counseling models to promote their health. This study aimed to explore Asian and Russian immigrants' perspectives in Finland on healthy lifestyle and healthy lifestyle counseling to improve the quality of the counseling in primary health care services to prevent type 2 diabetes and other chronic diseases.

METHODS

We conducted a qualitative study using semi-structured questions for eight focus groups. The participants were 46 adult immigrants (21 Asian and 25 Russian) living legally in Finland. Interviews were transcribed verbatim, coded, and analyzed using deductive content analysis.

RESULTS

We identified three themes regarding healthy lifestyle: (1) limited knowledge on different dimensions of healthy lifestyle, (2) understanding the impact of culture and community on healthy living, and (3) changing the lifestyle to live healthier after immigration. Moreover, we found three themes regarding healthy lifestyle counseling: (1) shortcomings in health care for providing healthy lifestyle counseling, such as lack of educational materials and miscommunication, (2) influential individual factors for using healthy lifestyle counseling, such as stress, and (3) positive outcomes of healthy lifestyle counseling.

CONCLUSION

Developing a culturally tailored healthy lifestyle counseling program for the enhancement of immigrants' knowledge regarding healthy lifestyle with consideration of cultural and linguistic aspects is recommended for preventing chronic diseases among immigrants.

Type 2 diabetes burden among migrants in Europe: unravelling the causal pathways

European populations are ethnically and culturally diverse due to international migration. Evidence indicates large ethnic inequalities in the prevalence of type 2 diabetes. This review discusses the burden of type 2 diabetes and its related complications, and the potential explanatory mechanisms among migrants in Europe. The current available data suggest that the rate of type 2 diabetes is higher in all migrant groups and that they develop this disease at an earlier age than the host European populations. The level of diabetes awareness among migrant populations is high, but glycaemic control remains suboptimal compared with Europeans. The culturally adapted lifestyle modification intervention trials to prevent type 2 diabetes mainly focus on South Asian adults in Europe. Diabetes-related microvascular and macrovascular complications remain a major burden among migrant populations in Europe. Earlier studies found higher mortality rates among migrants, but recent studies seem to suggest a shifting trend in favour of first-generation migrants. However, the extent of the burden of type 2 diabetes varies across migrant groups and European countries. Despite the higher burden of type 2 diabetes among migrants, the key underlying factors are not well understood mainly due to limited investment in basic science research and development of prospective cohort studies. We hypothesise that the underlying risk factors for the high burden of type 2 diabetes and its related complications in migrants are multifaceted and include pre-migration factors, post-migration factors and genetic predispositions. Given the multi-ethnic nature of the current European population, there is a clear need for investment in research among migrant populations to gain insight into factors driving the high burden of type 2 diabetes and related complications to facilitate prevention and treatment efforts in Europe.

Adult-onset diabetes in Middle Eastern immigrants to Sweden: Novel subgroups and diabetic complications-The All New Diabetes in Scania cohort diabetic complications and ethnicity

BACKGROUND

Middle Eastern immigrants to Europe represent a high risk population for type 2 diabetes. We compared prevalence of novel subgroups and assessed risk of diabetic macro- and microvascular complications between diabetes patients of Middle Eastern and European origin.

METHODS

This study included newly diagnosed diabetes patients born in Sweden (N = 10641) or Iraq (N = 286), previously included in the All New Diabetes in Scania cohort. The study was conducted between January 2008 and August 2016. Patients were followed to April 2017. Incidence rates in diabetic macro- and microvascular complications were assessed using cox-regression adjusting for the confounding effect of age at onset, sex, anthropometrics, glomerular filtration rate (eGFR) and HbA1c.

FINDINGS

In Iraqi immigrants versus native Swedes, severe insulin-deficient diabetes was almost twice as common (27.9 vs. 16.2% p < 0.001) but severe insulin-resistant diabetes was less prevalent. Patients born in Iraq had higher risk of coronary events (hazard ratio [HR] 1.84, 95% CI 1.06-3.12) but considerably lower risk of chronic kidney disease (CKD) than Swedes (HR 0.19; 0.05-0.76). The lower risk in Iraqi immigrants was partially attributed to better eGFR. Genetic risk scores (GRS) showed more genetic variants associated with poor insulin secretion but lower risk of insulin resistance in the Iraqi than native Swedish group.

INTERPRETATION

People with diabetes, born in the Middle East present with a more insulin-deficient phenotype and genotype than native Swedes. They have a higher risk of coronary events but lower risk of CKD. Ethnic differences should be considered in the preventive work towards diabetes and its complications.

Feasibility and acceptability of a culturally tailored physical activity intervention for Arab-Australian women

BACKGROUND

Despite being one of the largest migrant groups in Australia, few physical activity interventions exist for Arab-Australians. The primary aim of this study was to test the feasibility and acceptability of a 12-week culturally tailored physical activity intervention for Arab-Australian women.

METHODS

This study used a single-group pretest-posttest design, and was informed by extensive formative research and consultation involving the Arab-Australian community. Participants were insufficiently active Arab-Australian women aged 35-64 with no current illness or injury that would limit physical activity participation. The intervention comprised 6 face-to-face physical activity and education sessions over 12 weeks. The intervention was conducted at 2 separate intervention sites in Western Sydney, Australia. Feasibility outcomes included recruitment, session attendance, and retention. The acceptability of the intervention was assessed through a process evaluation questionnaire completed post-intervention. Accelerometers and the short-form International Physical Activity Questionnaire were used to measure physical activity at baseline and post-intervention. Descriptive statistics were used for feasibility and acceptability outcomes, and changes in physical activity were examined using Wilcoxon signed-rank tests.

RESULTS

Of the 53 women who were contacted or expressed interest, 22 were eligible and enrolled in the study. Participants were primarily recruited through direct contact by Arab-Australian community workers and by word-of-mouth. Average session attendance was 63% and the retention rate post-intervention was 68%. The culturally-related intervention components, such as the appropriateness of content, and women-only setting, were rated highly favourably (4.33 to 4.87/5). General intervention elements, such as the face-to-face delivery, knowledge and approachability of facilitators, and session structure, were also rated favourably (4.33 to 4.93/5), and the lowest scored item was the intervention session frequency (3.2/5). There were no statistically significant changes in physical activity post-intervention.

CONCLUSIONS

The findings from this study highlighted factors related to recruitment and delivery that need to be considered when developing physical activity interventions for Arab-Australian women. Further research is required using a larger sample and a randomised controlled trial design to examine the longer-term impact on physical activity, and to also examine ways of increasing intervention engagement and retention among Arab-Australian women.

TRIAL REGISTRATION

ANZCTR, ACTRN12618001392257. Registered 20 August 2018, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375636 .

Physical activity participation among Arab immigrants and refugees in Western societies: A scoping review

Insufficient physical activity (PA) is the fourth prime risk factor for numerous non-communicable diseases. Arab immigrants and refugees (AIR) are at elevated risk for low or no participation in PA due to socio-cultural and ecological factors. This scoping review examined PA prevalence, knowledge, attitudes as well as barriers vs. facilitators to PA engagement across life domains among AIR in Western countries. A systematic search strategy was implemented across five automated databases (PubMed, Embase, Medline, Sociology Database and Transportation Research Board) to locate pertinent English language papers. Seventy-five articles were included in this study, and stakeholder consultation was conducted to validate the findings. The US and Europe are substantially ahead of Canada, Australia, and New Zealand in AIR-PA research. Despite showing positive attitudes and sound knowledge of PA recommendations, AIR exhibited a low PA engagement prevalence, revealing a knowledge-compliance gap. The prevalence of sufficient PA was lowest in the US (11-22%), whereas Europe showed the highest figures (26-45%). Personal barriers to PA participation involved mainstream language illiteracy and limited exercise skills, whereas improved PA literacy was a significant facilitator. Family responsibility and cultural restrictions were common psychosocial/cultural barriers, whereas social support and culturally-sensitive resources were powerful facilitators. Poorly maintained pedestrian/cyclist infrastructure was a leading environmental barrier amongst AIR in North America, but not Europe. Longitudinal and community-engaged AIR-PA research is needed, and intersectoral collaboration is required to inform tailored interventions and inclusive policies, fostering AIR and other vulnerable populations' exercise participation and improving their health and well-being.

Adherence to Low-Fat, Vegan Diets in Individuals With Type 2 Diabetes: A Review

Low-fat, vegan diets seem to be particularly effective for glycemic control and may significantly lower hemoglobin A1c levels in individuals with type 2 diabetes. However, health care providers report low levels of practice and argue that this diet is hard to follow. This controversy on the acceptability of low-fat vegan diets appears to be a significant barrier to its broader clinical implementation. This review investigated dropout and adherence rates in intervention studies using a low-fat vegan diet in individuals with type 2 diabetes. In contrast to the common belief that this diet is poorly accepted, this review suggests different findings. Dietary adherence appears to be good with approximately 50% of individuals meeting the criteria for high adherence in most studies. Adherence to a low-fat vegan diet was higher than adherence to conventional diets in several studies. Group support and regular supervision improve adherence. Moreover, relatively low dropout rates were found—indirectly indicating good acceptance and high patient interest in this particular dietary modification. Although this review has several important limitations, it appears inappropriate to associate low-fat, vegan diets with poor adherence in individuals with type 2 diabetes. With good and regular support, adherence rates are more than solid and physicians should advocate for this diet more frequently.

Effects of a randomized, culturally adapted, lifestyle intervention on mental health among Middle-Eastern immigrants

BACKGROUND

Middle-Eastern immigrants in Sweden are at increased risk for type 2 diabetes (T2D) and poor mental health. Physical activity not only prevents/delays onset of T2D but also shows favorable effects on mental health. However, the effects of a culturally adapted lifestyle intervention on mental health among Middle-Eastern immigrants have not been explored before. We aimed to study the effects of a randomized controlled, culturally adapted lifestyle intervention on anxiety and depression levels in diabetes-prone Iraqi immigrants.

METHODS

Participants (n = 96) were randomized to intervention group, IG (n = 50) or control group, CG (n = 46). The IG received seven group sessions addressing lifestyle change and the CG received treatment as usual. Montgomery-Åsberg Depression Rating Scale (MADRS-S) and Hospital Anxiety and Depression Scale (HADS) assessed mental health at start, mid (2 months) and end of the study (4 months). Proportional odds ratio (OR) model was used to study the effect of the intervention.

RESULTS

The odds of scoring lower on MADRS-S and HADS depression scale at visit 3 vs. baseline were higher in the IG compared to the CG (MADRS-S OR 5.9, 95% CI: 1.6-22.5; HADS OR 4.4, 95% CI: 0.9-20.3). The findings persisted after adjustment for age, sex, body mass index, time since migration, sedentary lifestyle and language spoken at home. Group differences were non-significant at visit 2 vs. baseline.

CONCLUSION

A culturally adapted lifestyle intervention addressing T2D prevention in Middle-Eastern immigrants has favorable effects on mental health. The effect was more pronounced at the 4 months than at 2 months follow-up, indicating beneficial effect of longer study duration.

TRIAL REGISTRATION

www.clinicaltrials.gov NCT01420198.

Cardiovascular risk assessment in South and Middle-East Asians living in the Western countries

Nearly a quarter of the world population lives in the South Asian region (India, Pakistan, Bangladesh, Sri Lanka, Nepal, Bhutan, and the Maldives). Due to rapid demographic and epidemiological transition in these countries, the burden of non-communicable diseases is growing, which is a serious public health concern. Particularly, the prevalence of pre-diabetes, diabetes and atherosclerotic cardiovascular disease (CVD) is increasing. South Asians living in the West have also substantially higher risk of CVD and mortality compared with white Europeans and Americans. Further, as a result of global displacement over the past three decades, Middle-Eastern immigrants now represent the largest group of non-European immigrants in Northern Europe. This vulnerable population has been less studied. Hence, the aim of the present review was to address cardiovascular risk assessment in South Asians (primarily people from India, Pakistan and Bangladesh), and Middle-East Asians living in Western countries compared with whites (Caucasians) and present results from some major intervention studies. A systematic search was conducted in PubMed to identify major cardiovascular health studies of South Asian and Middle-Eastern populations living in the West, relevant for this review. Results indicated an increased risk of CVD. In conclusion, both South Asian and Middle-Eastern populations living in the West carry significantly higher risk of diabetes and CVD compared with native white Europeans. Lifestyle interventions have been shown to have beneficial effects in terms of reduction in the risk of diabetes by increasing insulin sensitivity, weight loss as well as better glycemic and lipid control.

The effectiveness of living well multicultural-lifestyle management program among ethnic populations in Queensland, Australia

ISSUE

Some migrant groups have higher risks of deaths and chronic diseases due to barriers associated with socioeconomic disadvantage, social isolation, racism, language, poor access to health services and low levels of health literacy. However, few culturally tailored interventions have targeted ethnic groups in Australia. This study evaluated the effectiveness of the Living Well Multicultural-Lifestyle Management Program (LWM-LMP) in Queensland, Australia.

METHODS

The LWM-LMP was originally co-designed with the targeted communities. Participants aged ≥18 years were eligible to participate without a fee. The evaluation was a quasi-experimental design without a control group, with data collected at baseline, the end of the programme and after-programme follow-up at week 14. The programme lasted 8 weeks with one group-based session of 120 minutes delivered each week in local community venues. Each session also included time to undertake physical activity (PA). Eating and PA behaviours were self-reported. Weight, height, waist circumference and blood pressure were measured using standard protocols.

RESULTS

Participants were more likely to consume ≥2 servings of fruit/day, five servings of vegetable/day, low-fat milk, processed meat, fast food, hot chips/fries, salty snacks, sweet snacks, sweet beverages less than once per week and meet the PA recommendation of ≥150 minutes/wk (P < .001) at week 8. Weight, BMI, waist circumference, waist-to-height ratio and blood pressure were also improved at week 8. Many of the changes were sustained at week 14.

CONCLUSIONS

The LWM-LMP was effective in improving participants' lifestyle behaviours and cardiometabolic indicators.

SO WHAT

Engaging targeted communities in designing interventions focussed on healthy personal behaviours helps with delivery and implementation. Behavioural interventions should be culturally tailored to increase their effectiveness.

Perceptions, experiences and barriers to lifestyle modifications in first-generation Middle Eastern immigrants to Sweden: a qualitative study

OBJECTIVE

The prevalence of type 2 diabetes (T2D) among Iraqi immigrants to Sweden is high and partly related to sedentary physical activity and calorie dense food. The aim of the present study was to explore perceptions, experiences and barriers concerning lifestyle modifications (LSM) in Iraqi immigrants to Sweden at risk for T2D.

DESIGN

A qualitative thematic analysis was conducted on data collected from gender-specific focus group interviews which took place during a culturally adapted randomised controlled intervention study addressing motivation to lifestyle change, self-empowerment, behavioural modifications and sociocultural barriers to LSM. Seven focus groups were held, with an interval of 1-4 weeks between January and May of 2015; each session lasted approximately 1.5 hours.

SETTING

The city of Malmö, Sweden.

PARTICIPANTS

Out of 27 women and 23 men assigned to the intervention group, 19 women and 14 men who attended at least one focus group session were included in the study.

RESULTS

Participants expressed awareness of the content of healthy lifestyle practices. They also expressed numerous social and cultural barriers to LSM connected to irregular meals, overeating, food and drinking preferences and family expectations. Overeating was described as a consequence of social and cultural norms and expectations and of poor mental well-being. Facilitators for reaching successful LSM were connected to family involvement and support.

CONCLUSION

Our study reports that facilitators for LSM are connected to presence of family support. Preventive actions addressing family involvement may benefit Middle Eastern immigrants at high risk for T2D to consider healthier lifestyles practices. Identification of sociocultural barriers and facilitators for LSM are crucial for successful health promotion in minority populations at risk for T2D.

TRIAL REGISTRATION

Trial registration number: NCT01420198 for the MEDIM-study; Pre-results.

Experiences of Kurdish immigrants with the management of type 2 diabetes: a qualitative study from Norway

Objective: To explore the experiences of immigrant Kurdish patients in Oslo, Norway, related to the management of type 2 diabetes mellitus (T2DM). Design: A qualitative study with focus group interviews. Setting: Participants were recruited at meeting places in Oslo through Kurdish networks. Subjects: Eighteen Kurdish immigrants (9 females and 9 males) living in Oslo, aged 40 to 64 years, diagnosed with T2DM participated in a total of five focus groups. Participants had to be proficient in the Norwegian language to be eligible. Main outcome measures: Immigrant Kurdish patients' experiences with being diagnosed with T2DM, their disease management, and need for medical information. Results: Participants stressed that living with T2DM was emotionally challenging, mainly because they were afraid of possible complications of the disease. They claimed to adhere satisfactorily to their medicines and blood glucose measurements. The majority of participants shared that they had made changes to their diet, even though it was difficult. To the contrary, physical activity received only minimal attention. The participants' main source of information was general practitioners and the majority of them were satisfied with the information that they had received about their disease and its management. Conclusion: Kurdish T2DM patients in the present study from Norway reported that they adhered to the medical treatment, even if they were stressed about living with the disease. However, they were more occupied with changing their diet than to be physically active. Therefore, healthcare personnel should try to be aware of lifestyle challenges among their patients. KEY POINTS Eighteen Kurdish patients in Oslo with Type 2 diabetes claimed to be adherent to medication treatment and blood glucose measurement. The participants shared that they had made changes to their diet, even though it was hard. There was generally little attention given to the need for physical activity in their daily lives. The participants were in need of more information and support in making healthy lifestyle changes.

The Impact of a Cultural Lifestyle Intervention on Metabolic Parameters After Gestational Diabetes Mellitus A Randomized Controlled Trial

OBJECTIVES

The prevalence of type 2 diabetes in Israel is increasing in all ethnic groups but most markedly in the Bedouin population. We aimed to assess the effects of a lifestyle change intervention on risk markers for type 2 diabetes after gestational diabetes mellitus (GDM).

METHODS

One hundred eighty Jewish and Bedouin post-GDM women were randomly assigned to a lifestyle intervention group (IG) or a control group (CG) starting 3-4 months after delivery. The IG participated in healthy lifestyle sessions led by a dietician and a sports instructor for 24 months after delivery. The IG participants had three individual 45-min counseling sessions and four 90-min group meetings (10 women each). The dietary and exercise recommendations were culturally adapted. The primary outcome of the study was HOMA-IR. We monitored clinical and chemical biomarkers 1 and 2 years after delivery.

RESULTS

After 1 and 2 years of intervention, the metabolic measures improved substantially. The intervention reduced the insulin, glucose and HOMA-IR levels in the IG compared with those in the CG (p < 0.001).

CONCLUSIONS

This novel culturally tailored lifestyle intervention program significantly improved the metabolic and morphometric indices measured 1 and 2 years after delivery. These results highlight and underscore the importance of effective lifestyle change education following GDM.

Preventing Type 2 Diabetes with Home Cooking: Current Evidence and Future Potential

PURPOSE OF REVIEW

Various dietary regimes have proven effective in preventing diabetes, yet its prevalence is growing. This review's goals are to examine the relationship between home cooking and diabetes and to present the literature on home cooking education programs as a novel strategy to improve adherence to healthy nutrition, thus decreasing the risk of diabetes.

RECENT FINDINGS

Consumption of home-cooked food is linked to healthier nutrition and decreased risk of diabetes. Further, home cooking interventions have a short-term positive impact on nutritional intake of both children and adults, and on diabetes prevention. Well-designed randomized controlled studies are needed to rigorously evaluate the long-term impact of home cooking interventions on cooking behavior, dietary intake, diabetes, and healthcare costs. Culinary education is an emerging field that aims to change nutrition education paradigms. Clinicians can empower patients to adopt home cooking by role modeling home cooking themselves, including home cooking content in their medical encounters, and through comprehensive lifestyle medicine interventions.

A Co-Designed, Culturally-Tailored mHealth Tool to Support Healthy Lifestyles in Māori and Pasifika Communities in New Zealand: Protocol for a Cluster Randomized Controlled Trial

Background

New Zealand urgently requires scalable, effective, behavior change programs to support healthy lifestyles that are tailored to the needs and lived contexts of Māori and Pasifika communities.

Objective

The primary objective of this study is to determine the effects of a co-designed, culturally tailored, lifestyle support mHealth tool (the OL@-OR@ mobile phone app and website) on key risk factors and behaviors associated with an increased risk of noncommunicable disease (diet, physical activity, smoking, and alcohol consumption) compared with a control condition.

Methods

A 12-week, community-based, two-arm, cluster-randomized controlled trial will be conducted across New Zealand from January to December 2018. Participants (target N=1280; 64 clusters: 32 Māori, 32 Pasifika; 32 clusters per arm; 20 participants per cluster) will be individuals aged ≥18 years who identify with either Māori or Pasifika ethnicity, live in New Zealand, are interested in improving their health and wellbeing or making lifestyle changes, and have regular access to a mobile phone, tablet, laptop, or computer and to the internet. Clusters will be identified by community coordinators and randomly assigned (1:1 ratio) to either the full OL@-OR@ tool or a control version of the app (data collection only plus a weekly notification), stratified by geographic location (Auckland or Waikato) for Pasifika clusters and by region (rural, urban, or provincial) for Māori clusters. All participants will provide self-reported data at baseline and at 4- and 12-weeks postrandomization. The primary outcome is adherence to healthy lifestyle behaviors measured using a self-reported composite health behavior score at 12 weeks that assesses smoking behavior, fruit and vegetable intake, alcohol intake, and physical activity. Secondary outcomes include self-reported body weight, holistic health and wellbeing status, medication use, and recorded engagement with the OL@-OR@ tool.

Results

Trial recruitment opened in January 2018 and will close in July 2018. Trial findings are expected to be available early in 2019.

Conclusions

Currently, there are no scalable, evidence-based tools to support Māori or Pasifika individuals who want to improve their eating habits, lose weight, or be more active. This wait-list controlled, cluster-randomized trial will assess the effectiveness of a co-designed, culturally tailored mHealth tool in supporting healthy lifestyles.

Trial Registration

Australia New Zealand Clinical Trials Register ACTRN12617001484336; http://www.ANZCTR.org.au/ACTRN12617001484336.aspx (Archived by WebCite at http://www.webcitation.org/71DX9BsJb)

Registered Report Identifier

RR1-10.2196/10789

Physical Activity in a Randomized Culturally Adapted Lifestyle Intervention

INTRODUCTION

Middle Eastern immigrants exhibit high levels of physical inactivity and are at an increased risk for Type 2 diabetes. The primary aim of this study was to examine the changes in objectively assessed physical activity levels following a culturally adapted lifestyle intervention program. The secondary aim was to examine the association between objectively assessed physical activity and insulin sensitivity.

STUDY DESIGN

RCT conducted over 4 months in 2015.

PARTICIPANTS

Iraqi immigrants residing in Malmö, Sweden, exhibiting one or more risk factors for Type 2 diabetes.

INTERVENTION

The intervention group (n=50) was offered a culturally adapted lifestyle intervention comprising seven group sessions including a cooking class. The control group (n=46) received usual care.

MAIN OUTCOME MEASURES

Raw accelerometry data were processed by validated procedures and daily mean physical activity intensity, vector magnitude high-pass filtered (VM-HPF), was inferred. Further inferences into the number of hours/day spent in sedentary (VM-HPF <48 milli-Gs [mGs] where G=9.8 m/sec²) and light- (48- <163 mGs); moderate- (163- <420 mGs); and vigorous-intensity (≥420 mGs) activities were also calculated (year of analysis was 2016-2017).

RESULTS

No difference was observed between the two groups in terms of change over time in VM-HPF. There was a significant increase in the number of hours/day spent in light intensity physical activity in the intervention group compared with the control group (β=0.023, 95% CI=0.001, 0.045, p=0.037). The intervention group also increased the time spent in sedentary activities, with the highest VM-HPF (36- <48 mGs) within the sedentary behavior (B=0.022, 95% CI=0.002, 0.042, p=0.03). Higher VM-HPF was significantly associated with a higher insulin sensitivity index (β=0.014, 95% CI=0.0004, 0.025, p=0.007).

CONCLUSIONS

The findings favor the culturally adapted intervention approach for addressing low physical activity levels among Middle Eastern immigrants. Replacing sedentary time with light-intensity activities could be an achievable goal and will have potential beneficial effects for diabetes prevention among this sedentary group of immigrants.

TRIAL REGISTRATION

This study was registered at www.clinicaltrials.gov NCT01420198.

Valuing a Lifestyle Intervention for Middle Eastern Immigrants at Risk of Diabetes

Willingness-to-pay (WTP) techniques are increasingly being used in the healthcare sector for assessing the value of interventions. The objective of this study was to estimate WTP and its predictors in a randomized controlled trial of a lifestyle intervention exclusively targeting Middle Eastern immigrants living in Malmö, Sweden, who are at high risk of type 2 diabetes. We used the contingent valuation method to evaluate WTP. The questionnaire was designed following the payment-scale approach, and administered at the end of the trial, giving an ex-post perspective. We performed logistic regression and linear regression techniques to identify the factors associated with zero WTP value and positive WTP values. The intervention group had significantly higher average WTP than the control group (216 SEK vs. 127 SEK; p = 0.035; 1 U.S.$ = 8.52 SEK, 2015 price year) per month. The regression models demonstrated that being in the intervention group, acculturation, and self-employment were significant factors associated with positive WTP values. Male participants and lower-educated participants had a significantly higher likelihood of zero WTP. In this era of increased migration, our findings can help policy makers to take informed decisions to implement lifestyle interventions for immigrant populations.

A Feasible and Efficacious Mobile-Phone Based Lifestyle Intervention for Filipino Americans with Type 2 Diabetes: Randomized Controlled Trial

Background

Filipino Americans have a high prevalence of obesity, type 2 diabetes (T2D), and cardiovascular disease compared with other Asian American subgroups and non-Hispanic whites. Mobile health (mHealth) weight loss interventions can reduce chronic disease risks, but these are untested in Filipino Americans with T2D.

Objective

The objective of this study was to assess feasibility and potential efficacy of a pilot, randomized controlled trial (RCT) of a culturally adapted mHealth weight loss lifestyle intervention (Pilipino Americans Go4Health [PilAm Go4Health]) for overweight Filipino Americans with T2D.

Methods

This was a 2-arm pilot RCT of the 3-month PilAm Go4Health intervention (phase 1) with an active waitlist control and 3-month follow-up (phase 2). The waitlist control received the PilAm Go4Health in phase 2, whereas the intervention group transitioned to the 3-month follow-up. PilAm Go4Health incorporated a Fitbit accelerometer, mobile app with diary for health behavior tracking (steps, food/calories, and weight), and social media (Facebook) for virtual social support, including 7 in-person monthly meetings. Filipino American adults ≥18 years with T2D were recruited from Northern California. Feasibility was measured by rates of recruitment, engagement, and retention. Multilevel regression analyses assessed within and between group differences for the secondary outcome of percent weight change and other outcomes of weight (kg), body mass index (BMI), waist circumference, fasting plasma glucose, HbA1c, and steps.

Results

A total of 45 Filipino American adults were enrolled and randomized. Mean age was 58 (SD 10) years, 62% (28/45) were women, and mean BMI was 30.1 (SD 4.6). Participant retention and study completion were 100%, with both the intervention and waitlist group achieving near-perfect attendance at all 7 intervention office visits. Groups receiving the PilAm Go4Health in phase 1 (intervention group) and phase 2 (waitlist group) had significantly greater weight loss, −2.6% (−3.9 to −1.4) and −3.3% (−1.8 to −4.8), respectively, compared with the nonintervention group, resulting in a moderate to small effect sizes (d=0.53 and 0.37, respectively). In phase 1, 18% (4/22) of the intervention group achieved a 5% weight loss, whereas 82% (18/22) maintained or lost 2% to 5% of their weight and continued to maintain this weight loss in the 3-month follow-up. Other health outcomes, including waist circumference, BMI, and step counts, improved when each arm received the PilAm Go4Health, but the fasting glucose and HbA1c outcomes were mixed.

Conclusions

The PilAm Go4Health was feasible and demonstrated potential efficacy in reducing diabetes risks in overweight Filipino Americans with T2D. This study supports the use of mHealth and other promising intervention strategies to reduce obesity and diabetes risks in Filipino Americans. Further testing in a full-scale RCT is warranted. These findings may support intervention translation to reduce diabetes risks in other at-risk diverse populations.

Trial Registration

Clinicaltrials.gov NCT02290184; https://clinicaltrials.gov/ct2/show/NCT02290184 (Archived by WebCite at http://www.webcitation.org/6vDfrvIPp)

Self-rated health and social capital in Iraqi immigrants to Sweden: The MEDIM population-based study

OBJECTIVES

Poor self-rated health is an estimator of quality of life and a predictor of mortality seldom studied in immigrant populations. This work aimed to study self-rated health in relation to social capital, socioeconomic status, lifestyle and comorbidity in immigrants from Iraq - one of the largest non-European immigrant group in Sweden today - and to compare it with the self-rated health of native Swedes.

DESIGN

The study was a cross-sectional population-based study conducted from 2010 to 2012 among citizens of Malmö, Sweden, aged 30-65 years and born in Iraq or Sweden. All participants underwent a health examination and answered questionnaires on self-rated health, social capital, comorbidity, lifestyle and socioeconomic status.

RESULTS

In total, 1348 Iraqis and 677 Swedes participated. Poor self-rated health was identified in 43.9% of Iraqis and 21.9% of native Swedes ( p<0.001), with the highest prevalence (55.5%) among Iraqi women. Low social capital was highly prevalent in the immigrants. Female gender showed higher odds of poor self-rated health in Iraqis than in Swedes (OR 1.8, 95% CI 1.4-2.5, p_interaction=0.024), independent of other risk factors connected to social capital, socioeconomic status, lifestyle or comorbidity.

CONCLUSIONS

Although public health initiatives promoting social capital, socioeconomic status and comorbidity in immigrants are crucial, the excess risk of poor self-rated health in Iraqi women is not fully attributed to known risk factors for self-rated health, but remains to be further explored.

Changes in dietary intake following a culturally adapted lifestyle intervention among Iraqi immigrants to Sweden at high risk of type 2 diabetes: a randomised trial

Objective

To investigate the effectiveness of a culturally adapted lifestyle intervention for changing dietary intake, particularly energy, fat and fibre intakes, in the intervention group (IG) compared with the control group (CG).

Design

Randomised controlled trial.

Setting

IG (n 50) and CG (n 46). The IG was offered seven group sessions, including one cooking class, over a period of 4 months. The participants filled out 4 d food diaries at the start, mid and end of the study.

Subjects

Iraqi-born residents of Malmö, Sweden, at increased risk for developing diabetes.

Results

At baseline, participants’ fat intake was high (40 % of total energy intake (E%)). The predefined study goals of obtaining <30 E% from fat and ≥15 g fibre/4184 kJ (1000 kcal) were met by very few individuals. In the IG v. the CG, the proportion of individuals obtaining <40 E% from fat (48·4 v. 34·6 %, P=0·65), <10 E% from saturated fat (32·3 v. 11·5 %, P=0·14) and ≥10 g fibre/4184 kJ (45·2 v. 26·9 %, P=0·46) appeared to be higher at the last visit, although the differences were statistically non-significant. A trend towards decreased mean daily intakes of total energy (P=0·03), carbohydrate (P=0·06), sucrose (P=0·02) and fat (P=0·02) was observed within the IG. Differences in changes over time between the groups did not reach statistical significance.

Conclusions

Although no significant differences were observed in the two groups, our data indicate that this culturally adapted programme has the potential to modify dietary intake in Middle Eastern immigrants. The high fat intake in this group should be addressed.