Lifestyle strategies for weight control: experience from the Finnish Diabetes Prevention Study

The gestational diabetes future diabetes prevention study (GODDESS): A partially randomised feasibility controlled trial

OBJECTIVES

To assess the feasibility of an ante- and post-natal lifestyle intervention for women with gestational diabetes mellitus (GDM) to reduce type 2 diabetes risk.

DESIGN

A partially randomised patient preference feasibility trial.

SETTING

Diabetes antenatal clinics in two inner-London hospitals, UK.

PARTICIPANTS

Pregnant women ≥18 years with a GDM diagnosis and pre-pregnancy body mass index of ≥25kg/m2.

INTERVENTION

Participants in the intervention group were offered four motivational interview-based sessions (two antenatally and two postnatally, at 3 and 6 months postpartum), a WhatsApp support group, a FitBit and electronic self-help resources.

OUTCOME MEASURES

Recruitment; retention; intervention dose received; data completion; adaptions; proportion achieving ≥5% weight loss; weight change, blood glucose; blood pressure; diet, physical activity, breastfeeding and depression. Clinical outcomes were measured at baseline and 6 months postpartum.

RESULTS

50 participants were recruited from 155 eligible women (32% recruitment rate). Thirty-four were recruited to the intervention group (23 following randomisation (RI-group) and 11 based on preference (PI-group)); and 16 to the control group (13 randomised (RC-group) and 3 preference (PC-group)). Attrition was 44% (n = 22/50). Forty-six percent (n = 6) of the intervention group (25% (n = 2) of the RI-group and 80% (n = 4) of the PI-group) achieved ≥5% weight loss compared to 8% (n = 1) in the control group (95% confidence interval (CI) -0.69 to 0.07). Mean weight change was -2.1kg±9.0 in the intervention group (0kg±5.4 in the RI-group and -5.4kg±13.0 in the PI-group) compared to +4.4kg±4.9 in the control group (RC +4.4kg ±5.3 and PC +4.7kg ±3.1, 95% CI -12.4 to 0.2).

CONCLUSIONS

Recruitment was feasible, but strategies to improve retention are needed. The findings suggest the intervention can support women with GDM to lose weight. The observed weight loss was primarily in women who preferred the intervention. Therefore, future trials may need to adopt a preference design and consider factors associated with preference.

TRIAL REGISTRATION

Trial registration: ISRCTN52675820 https://www.isrctn.com/ISRCTN52675820?q=ISRCTN52675820&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10&searchType=basic-search.

Factors Related to the Weight Control Practices of Korean Adults

Background

Maintenance of proper weight can help protect against chronic diseases. This study investigated the weight control practices of Korean adults and associated factors.

Methods

Secondary data from a nationwide cross-sectional survey of the fifth Korea National Health and Nutrition Examination Survey from 2016 to 2018 were analyzed. Subjects were aged 21 to 80 years (n=14,661). The influences of socio-demographic characteristics, health status, health behaviors, and perception of body image on weight control efforts were identified.

Results

Women (odds ratio [OR], 1.191; 95% confidence interval [CI], 1.723-2.210), city dwellers (OR, 1.229; 95% CI, 1.097-1.377), those who had a middle school or higher level of education (OR, from 1.281 to 1.525), individuals who perceived themselves to be healthy or in fairly health (OR, from 1.103 to 1.257), those with high blood pressure (OR, 1.244; 95% CI, 1.104-1.401), normal or obese body mass index (BMI; OR from 2.579 to 4.430), non-smokers (OR, 1.373; 95% CI, 1.192-1.582), and those who drank alcohol (OR, 1.174; 95% CI, 1.057-1.305) made more weight loss efforts than other individuals. Regardless of actual BMI, if someone perceived themselves to be obese or normal weight (OR, from 4.324 to 10.884), they made more effort to reduce their weight than those individuals who perceived themselves to be underweight.

Conclusion

Weight control is a positive behavior for people with high BMI. However, those individuals with a normal weight who believe they are obese may require further education. It is also necessary to monitor and address the lack of weight control efforts in rural residents and that there is a need for weight control counseling and support for people with high blood pressure and diabetes. Various related causes should be considered and community-wide efforts be made to support people who need weight control.

Association between Lung Function and New-Onset Diabetes Mellitus in Healthy Individuals after a 6-Year Follow-up

BACKGROUND

We analyzed hemoglobin A1c (HbA1c) levels and various lung function test results in healthy individuals after a 6-year follow-up period to explore the influence of lung function changes on glycemic control.

METHODS

Subjects whose HbA1c levels did not qualify as diabetes mellitus (DM) and who had at least two consecutive lung function tests were selected among the people who visited a health promotion center. Lung function parameters, including forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), FEV/FVC ratio, and forced expiratory flow 25% to 75% (FEF25%-75%), were divided into four groups based on their baseline quantiles. To evaluate future DM onset risk in relation to lung function changes, the correlation between baseline HbA1c levels and changes in lung function parameters after a 6-year follow-up period was analyzed.

RESULTS

Overall, 17,568 individuals were included; 0.9% of the subjects were diagnosed with DM. The individuals included in the quartile with FEV1/FVC ratio values of 78% to 82% had lower risk of DM than those in the quartile with FEV1/FVC ratio values of ≥86% after adjusting for age, sex, and body mass index (P=0.04). Baseline percent predicted FEV1, FVC, FEV1/FVC ratio, and FEF25%-75%, and differences in the FEV1/FVC ratio or FEF25%-75%, showed negative linear correlations with baseline HbA1c levels.

CONCLUSION

Healthy subjects with FEV1/FVC ratio values between 78% and 82% had 40% lower risk for future DM. Smaller differences and lower baseline FEV1/FVC ratio or FEF25%-75% values were associated with higher baseline HbA1c levels. These findings suggest that airflow limitation affects systemic glucose control and that the FEV1/FVC ratio could be one of the factors predicting future DM risk in healthy individuals.

Obesity prevention and the role of hospital and community-based health services: a scoping review

BACKGROUND

Control of obesity is an important priority to reduce the burden of chronic disease. Clinical guidelines focus on the role of primary healthcare in obesity prevention. The purpose of this scoping review is to examine what the published literature indicates about the role of hospital and community based health services in adult obesity prevention in order to map the evidence and identify gaps in existing research.

METHODS

Databases were searched for articles published in English between 2006 and 2016 and screened against inclusion and exclusion criteria. Further papers were highlighted through a manual search of the reference lists. Included papers evaluated interventions aimed at preventing overweight and obesity in adults that were implemented within and/or by hospital and community health services; were an empirical description of obesity prevention within a health setting or reported health staff perceptions of obesity and obesity prevention.

RESULTS

The evidence supports screening for obesity of all healthcare patients, combined with referral to appropriate intervention services but indicates that health professionals do not typically adopt this practice. As well as practical issues such as time and resourcing, implementation is impacted by health professionals' views about the causes of obesity and doubts about the benefits of the health sector intervening once someone is already obese. As well as lacking confidence or knowledge about how to integrate prevention into clinical care, health professional judgements about who might benefit from prevention and negative views about effectiveness of prevention hinder the implementation of practice guidelines. This is compounded by an often prevailing view that preventing obesity is a matter of personal responsibility and choice.

CONCLUSIONS

This review highlights that whilst a population health approach is important to address the complexity of obesity, it is important that the remit of health services is extended beyond medical treatment to incorporate obesity prevention through screening and referral. Further research into the role of health services in obesity prevention should take a systems approach to examine how health service structures, policy and practice interrelationships, and service delivery boundaries, processes and perspectives impact on changing models of care.

Global status of diabetes prevention and prospects for action: A consensus statement

Primary prevention of type 2 diabetes (T2D) should be achievable through the implementation of early and sustainable measures. Several randomized control studies that found success in preventing the progression to T2D in high-risk populations have identified early and intensive intervention based on an individualized prevention model as the key factor for participant benefit. The global prevalence of both overweight and obesity has now been widely recognized as the major epidemic of the 21st century. Obesity is a major risk factor for the progression from normal glucose tolerance to prediabetes and then to T2D. However, not all obese individuals will develop prediabetes or progress to diabetes. Intensive, multicomponent behavioural interventions for overweight and obese adults can lead to weight loss. Diabetes medications, including metformin, GLP-1 agonists, glitazones, and acarbose, can be considered for selected high-risk patients with prediabetes when lifestyle-based programmes are proven unsuccessful. Nutrition education is the cornerstone of a healthy lifestyle. Also, physical activity is an integral part of the prediabetes management plan and one of the main pillars in the prevention of diabetes. Mobile phones, used extensively worldwide, can facilitate communication between health professionals and the general population, and have been shown to be helpful in the prevention of T2D. Universal screening is needed. Noninvasive risk scores should be used in all countries, but they should be locally validated in all ethnic populations focusing on cultural differences around the world. Lifestyle interventions reduce the progression to prediabetes and diabetes. Nevertheless, many questions still need to be answered.

WITHDRAWN: Dietary advice for the prevention of type 2 diabetes mellitus in adults

Review status was set to withdrawn. The review is out of date and does not meet current Cochrane standards. It will be superseded by a new expanding Cochrane review on 'Diet, physical activity or both for the prevention or delay of type 2 diabetes mellitus and its associated complications in persons at increased risk'.

The editorial group responsible for this previously published document have withdrawn it from publication.

A systematic review of the cost-effectiveness of non-surgical obesity interventions in men

BACKGROUND

Increasing obesity related health conditions have a substantial burden on population health and healthcare spending. Obesity may have a sex-specific impact on disease development, men and women may respond differently to interventions, and there may be sex-specific differences to the cost-effectiveness of interventions to address obesity. There is no clear indication of cost-effective treatments for men.

METHODS

This systematic review summarises the literature reporting the cost-effectiveness of non-surgical weight-management interventions for men. Studies were quality assessed against a checklist for appraising decision modelling studies.

RESULTS

Although none of the included studies explicitly set out to determine the cost-effectiveness of treatment for men, seven studies reported results for subgroups of men. Interventions were grouped into lifestyle interventions (five studies) and Orlistat (two studies). The retrieved studies showed promising evidence of cost-effectiveness, especially when interventions were targeted at high-risk groups, such as those with impaired glucose tolerance. There appears to be some sex-specific elements to cost-effectiveness, however, there were no clear trends or indications of what may be contributing to this.

CONCLUSION

The economic evidence was highly uncertain, and limited by variable methodological quality of the included studies. It was therefore not possible to draw strong conclusions on cost-effectiveness. Future studies are required to demonstrate the cost-effectiveness of interventions specifically targeted towards weight loss for men.

Challenges of diabetes prevention in the real world: results and lessons from the Melbourne Diabetes Prevention Study

OBJECTIVE

To assess effectiveness and implementability of the public health programme Life! Taking action on diabetes in Australian people at risk of developing type 2 diabetes.

RESEARCH DESIGN AND METHODS

Melbourne Diabetes Prevention Study (MDPS) was a unique study assessing effectiveness of Life! that used a randomized controlled trial design. Intervention participants with AUSDRISK score ≥15 received 1 individual and 5 structured 90 min group sessions. Controls received usual care. Outcome measures were obtained for all participants at baseline and 12 months and, additionally, for intervention participants at 3 months. Per protocol set (PPS) and intention to treat (ITT) analyses were performed.

RESULTS

PPS analyses were considered more informative from our study. In PPS analyses, intervention participants significantly improved in weight (-1.13 kg, p=0.016), waist circumference (-1.35 cm, p=0.044), systolic (-5.2 mm Hg, p=0.028) and diastolic blood pressure (-3.2 mm Hg, p=0.030) compared with controls. Based on observed weight change, estimated risk of developing diabetes reduced by 9.6% in the intervention and increased by 3.3% in control participants. Absolute 5-year cardiovascular disease (CVD) risk reduced significantly for intervention participants by 0.97 percentage points from 9.35% (10.4% relative risk reduction). In control participants, the risk increased by 0.11 percentage points (1.3% relative risk increase). The net effect for the change in CVD risk was -1.08 percentage points of absolute risk (p=0.013).

CONCLUSIONS

MDPS effectively reduced the risk of diabetes and CVD, but the intervention effect on weight and waist reduction was modest due to the challenges in recruiting high-risk individuals and the abbreviated intervention.

Genetic predisposition to obesity and lifestyle factors--the combined analyses of twenty-six known BMI- and fourteen known waist:hip ratio (WHR)-associated variants in the Finnish Diabetes Prevention Study

Recent genome-wide association studies have identified multiple loci associated with BMI or the waist:hip ratio (WHR). However, evidence on gene-lifestyle interactions is still scarce, and investigation of the effects of well-documented dietary and other lifestyle data is warranted to assess whether genetic risk can be modified by lifestyle. We assessed whether previously established BMI and WHR genetic variants associate with obesity and weight change in the Finnish Diabetes Prevention Study, and whether the associations are modified by dietary factors or physical activity. Individuals (n 459) completed a 3 d food record and were genotyped for twenty-six BMI- and fourteen WHR-related variants. The effects of the variants individually and in combination were investigated in relation to obesity and to 1- and 3-year weight change by calculating genetic risk scores (GRS). The GRS were separately calculated for BMI and the WHR by summing the increasing alleles weighted by their published effect sizes. At baseline, the GRS were not associated with total intakes of energy, macronutrients or fibre. The mean 1- and 3-year weight changes were not affected by the BMI or WHR GRS. During the 3-year follow-up, a trend for higher BMI by the GRS was detected especially in those who reported a diet low in fibre (P for interaction=0·065). Based on the present findings, it appears unlikely that obesity-predisposing variants substantially modify the effect of lifestyle modification on the success of weight reduction in the long term. In addition, these findings suggest that the association between the BMI-related genetic variants and obesity could be modulated by the diet.

Patient-reported experiences with first-time naturopathic care for type 2 diabetes

Differences in the effectiveness of diverse healthcare providers to promote health behavior change and successful diabetes self-care have received little attention. Because training in naturopathic medicine (NM) emphasizes a patient-centered approach, health promotion, and routine use of clinical counseling on wellness and prevention, naturopathic physicians (NDs) may be particularly well-prepared for promoting behavior change. However, patients' experiences with NM have not been well studied. This study provides the first report of the perceptions of persons with type 2 diabetes of their first experiences with naturopathic care for their diabetes. Following their participation in a one-year prospective cohort study of adjunctive naturopathic care for diabetes, twenty-two patients were interviewed about their experiences working with a naturopathic physician. Using a content analysis approach, nine dominant themes were identified. Three themes characterized the nature of the ND-patient interaction: 1) patient-centered, 2) holistic health rather than diabetes focused, and 3) collaborative. Five themes characterized the content of the clinical encounter: 1) individualized and detailed health promotion, 2) counseling that promoted self-efficacy, 3) pragmatic and practical self-care recommendations, 4) novel treatment options that fostered hopefulness, and 5) patient education that addressed both diabetes self-care and general health. A ninth theme was cross-cutting: the contrast between ND care and conventional medical care. Results indicate that the routine clinical approach used by NDs is consistent with behavior change theory and clinical strategies found most effective in promoting self-efficacy and improving clinical outcomes.

Maternal obesity, lipotoxicity and cardiovascular diseases in offspring

Maternal obesity has risen dramatically over the past 20 years, by nearly 42% in African-Americans and 29% in Caucasians. Maternal obesity is afflicted with many maternal obstetric complications in the offspring including high blood pressure, obesity, gestational diabetes and increased perinatal morbidity. Maternal nutritional environment plays a rather important role in the programming of the health set-points in the offspring such as glucose and insulin metabolism, energy balance and predisposition to metabolic disorders. In particular, maternal obesity is associated with elevated prevalence of cardiovascular diseases in the offspring. Evidence from human and experimental studies including rodents and nonhuman primates has indicated that maternal obesity or overnutrition programs offspring for an increased risk of adult obesity. Maternal obesity or fat diet exposure predisposes the onset and development of obesity, insulin resistance, cardiac hypertrophy and myocardial contractile anomalies in the offspring. A number of mechanisms including elevated hormones (leptin, insulin), nutrients (fatty acids, triglycerides and glucose) and inflammatory cytokines have been postulated to play a key role in maternal obesity-induced postnatal cardiovascular sequelae. In addition, lipotoxicity (accumulation of lipid metabolites) resulting from maternal obesity is capable of activating a number of stress signaling cascades including pro-inflammatory cytokines and oxidative stress to exacerbate maternal obesity-induced cardiovascular complications later on in adult life. This mini-review summarizes the recent knowledge with regard to the role of lipotoxicity in maternal obesity-induced change in cardiovascular function in the offspring. This article is part of a Special Issue entitled "Focus on Cardiac Metabolism".

Risk factors for type 2 diabetes among female Pakistani immigrants: the InvaDiab-DEPLAN study on Pakistani immigrant women living in Oslo, Norway

The risk for type 2 diabetes (T2D) in Pakistani immigrants is high. The aim of this study was to provide an update of the risk of T2D and the metabolic syndrome (MetS) in female Pakistani immigrants living in Oslo, Norway. Female Pakistani immigrants (n = 198, age 25-63) were interviewed, and data related to T2D, including anthropometric measurements, blood data, heart rate, and level of physical activity, were determined. Ninety-eight percentage had body mass index (BMI > 23 kg m(-2)) and 39% were obese (BMI ≥ 30). Impaired glucose tolerance (IGT) was found in 37%, MetS in 41%, and T2D in 13%, using fasting glucose. By score evaluation, approximately 90% had risk of T2D. The participants had low energy expenditure, despite acceptable number of steps walked during a day. The risk of T2D is very high in female Pakistani immigrants in Oslo.

Behavioral strategies in diabetes prevention programs: a systematic review of randomized controlled trials

The worldwide epidemic of type 2 diabetes (T2D) emphasizes the need for guidelines regarding community implementation of lifestyle modification prevention programs. An understanding of effective behavioral strategies is needed if evidence translation is to be realized. The aim of this paper is to systematically review the behavioral change strategies for lifestyle T2D prevention programs.

METHODS

randomized controlled trials (RCTs) of lifestyle interventions for the prevention of T2D were reviewed with a systematic literature search. Data relating to the behavioral strategies and trial outcomes were extracted.

RESULTS

overall, lifestyle interventions were successful in reducing the incidence of T2D. The behavioral strategies utilized in these interventions were drawn from a variety of theoretical backgrounds. All RCTs utilized intensive modes of delivery and were associated with low dropout rates of 5.5-13.4%.

CONCLUSIONS

the available evidence shows that a robust behavioral change strategy is an essential part of an effective lifestyle modification program, as the absence of intensive individualized advice or "information only" more closely resembles the control group interventions used in these RCTs.

Delivering the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cost effectiveness analysis

OBJECTIVES

To assess the long term clinical and cost effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) intervention compared with usual care in people with newly diagnosed type 2 diabetes.

DESIGN

We undertook a cost-utility analysis that used data from a 12 month, multicentre, cluster randomised controlled trial and, using the Sheffield type 2 diabetes model, modelled long term outcomes in terms of use of therapies, incidence of complications, mortality, and associated effect on costs and health related quality of life. A further cost-utility analysis was also conducted using current "real world" costs of delivering the intervention estimated for a hypothetical primary care trust.

SETTING

Primary care trusts in the United Kingdom.

PARTICIPANTS

Patients with newly diagnosed type 2 diabetes.

INTERVENTION

A six hour structured group education programme delivered in the community by two professional healthcare educators.

MAIN OUTCOME MEASURES

Incremental costs and quality adjusted life years (QALYs) gained.

RESULTS

On the basis of the data in the trial, the estimated mean incremental lifetime cost per person receiving the DESMOND intervention is pound209 (95% confidence interval - pound704 to pound1137; euro251, -euro844 to euro1363; $326, -$1098 to $1773), the incremental gain in QALYs per person is 0.0392 (-0.0813 to 0.1786), and the mean incremental cost per QALY is pound5387. Using "real world" intervention costs, the lifetime incremental cost of the DESMOND intervention is pound82 (- pound831 to pound1010) and the mean incremental cost per QALY gained is pound2092. A probabilistic sensitivity analysis indicated that the likelihood that the DESMOND programme is cost effective at a threshold of pound20 000 per QALY is 66% using trial based intervention costs and 70% using "real world" costs. Results from a one way sensitivity analysis suggest that the DESMOND intervention is cost effective even under more modest assumptions that include the effects of the intervention being lost after one year.

CONCLUSION

Our results suggest that the DESMOND intervention is likely to be cost effective compared with usual care, especially with respect to the real world cost of the intervention to primary care trusts, with reductions in weight and smoking being the main benefits delivered.

Glomerulonephritis and managing the risks of chronic renal disease

The rising global burden of chronic renal disease, the high cost of providing renal replacement therapies, and renal disease also being a risk factor for cardiovascular disease is increasing focus on renal disease prevention. This article focuses on the aspects of renal disease (specifically poststreptococcal glomerulonephritis [PSGN] and chronic kidney disease [CKD]) in Indigenous populations in Australia, New Zealand, Canada, and the United States that diverge from those typically seen in the general population of those countries. The spectrum of renal and many other diseases seen in Indigenous people in developed countries is similar to that seen in developing countries. Diseases like PSGN that have largely disappeared in developed countries still occur frequently in Indigenous people. CKD during the childhood years is due to congenital anomalies of the kidney and urinary tract in up to 70% of cases and occurs later in polycystic kidney disease and childhood-onset diabetes. Several risk factors for CKD in adulthood are already present in childhood.

Dietary advice for the prevention of type 2 diabetes mellitus in adults

BACKGROUND

Prevention of type 2 diabetes in adults is a far better option than treatment, to alleviate pressure on health care providers and resources. However, there is no current review of the evidence regarding the efficacy of a diet-only intervention for prevention.

OBJECTIVES

To assess the effects of type and frequency of dietary advice for the prevention of type 2 diabetes mellitus.

SEARCH STRATEGY

We carried out a comprehensive search of The Cochrane Library, MEDLINE, EMBASE, CINAHL, AMED, bibliographies and contacted relevant experts.

SELECTION CRITERIA

All randomised controlled trials, of twelve months or longer, in which dietary advice for the prevention of type 2 diabetes was the only intervention in adults.

DATA COLLECTION AND ANALYSIS

The lead investigator performed all data extraction and quality scoring with duplication being carried out by one of the other four investigators independently with discrepancies resolved by discussion and consensus. Authors were contacted for missing data. Change data are presented.

MAIN RESULTS

Two trials which randomised 358 people to dietary treatment and control groups were identified. Longest duration of follow-up was six years. In the 6-year Da Qing IGT & Diabetes study, the incidence of type 2 diabetes in the control group was 67.7% (95% confidence interval (CI) 59.8% to 75.2%) which was reduced to 43.8% (95% CI 35.5% to 54.7%) in the diet group. Overall, the dietary intervention group had a 33% reduction in the incidence of diabetes after six years (P < 0.03). The Oslo Diet & Exercise Study (ODES) found significant (P<0.05) reductions in insulin resistance, fasting insulin (pmol/L), fasting C-peptide (pmol/L), fasting proinsulin (pmol/L), fasting blood glucose (mmol/L), BMI (kg/m(2)), mBP (mmHg) and fasting triglycerides (mmol/L), and a significant increase in fasting HDL cholesterol (mmol/L) and PAI-1 (U/ml) after 12 months of dietary intervention. Data on mortality, morbidity, health-related quality of life, adverse effects, costs were not reported in either study.

AUTHORS' CONCLUSIONS

There are no high quality data on the efficacy of dietary intervention for the prevention of type 2 diabetes. More well-designed, long-term studies, providing well-reported, high-quality data are required before proper conclusions can be made into the best dietary advice for the prevention of diabetes mellitus in adults.

Effects of high-fat diet exposure during fetal life on type 2 diabetes development in the progeny

Nutrition during fetal life is a critical factor contributing to diabetes development in adulthood. The aim of our study was to verify: 1) whether a high-fat (HF) diet in young adult mice induces alterations in beta-cell mass, proliferation, neogenesis, and apoptosis, as well as insulin sensitivity and secretion; 2) whether these alterations may be reversible after HF diet suspension; 3) the effects in a first (F1) and second generation (F2) of mice without direct exposure to a HF diet after birth. Type 2 diabetes developed in adult mice on a HF diet, in F1 mice that were HF diet-exposed during fetal or neonatal life, and in F2 mice whose mothers were HF diet-exposed during their fetal life. beta-cell mass, replication, and neogenesis were high in HF diet-exposed mice and decreased after diet suspension. beta-cell mass and replication remained high in F1 mice and decreased in F2 mice whose mothers were exposed to a HF diet. beta-cell neogenesis was present in adult mice on a HF diet and in F1 mice that were HF diet-exposed during fetal and/or neonatal life. We conclude that a HF diet during fetal life, particularly if combined with the same insult during the suckling period, can induce the type 2 diabetes phenotype, which can be directly transmitted to the progeny even in the absence of additional dietary insults.

Uncertainty in decision-making: value of additional information in the cost-effectiveness of lifestyle intervention in overweight and obese people

OBJECTIVES

To quantify the uncertainty in the cost-effectiveness of lifestyle intervention versus standard care in overweight and obese people in Switzerland and to determine if further research is necessary based on current information. There has been an increasing interest in using value of information analysis in medical decision-making to quantify the uncertainty in decision-making, and to identify the need for further research.

METHODS

Value of information analysis was applied on a probabilistic cost-effectiveness model to evaluate the uncertainty by calculating the patient expected value of perfect information (EVPI), population EVPI, and partial EVPI. The costs were expressed in Swiss Francs (CHF), price year 2006.

RESULTS

Overall, the EVPI was higher in overweight than in obese people. The maximum population EVPI was CHF 6.8 million in overweight people and CHF 3.2 million in moderate obese people, representing the upper limit on costs associated with decision uncertainty. The partial EVPI estimated a higher uncertainty in the model parameters such as utilities, body mass index, cardiovascular risk factors, and systolic blood pressure in overweight and moderate obese subjects.

CONCLUSIONS

The EVPI analysis indicates that there is some uncertainty regarding the choice between lifestyle intervention and standard care. The parameter EVPI suggests that if further research is commissioned, this should focus on the effectiveness of lifestyle intervention on cardiovascular risk factors and utilities.

How should the clinician most effectively prevent type 2 diabetes in the obese person at high risk?

The dramatic increase in newly diagnosed cases of type 2 diabetes (T2D) has developed into a major public health concern worldwide. Conversely, several clinical studies have demonstrated that preventive efforts can significantly reduce the risk of developing diabetes. There is a clear consensus that action is needed to develop targeted community-based prevention programs and strategies for T2D. Currently, numerous prevention management concepts that can be implemented into clinical practice exist in various countries. Finland is the pioneer country in implementing community-wide diabetes prevention programs. Nevertheless, population-based nationwide strategies are still lacking in virtually all countries. We report on intervention strategies to prevent T2D in people with increased diabetes risk, as well as strategies on how to implement diabetes prevention programs into the real world of public health or clinical care. The implementation of managed prevention concepts will realistically help to improve the ability to prevent T2D in the public health framework.

[Gene-environment interactions in the pathogenesis and prevention of type 2 diabetes mellitus]

Type 2 diabetes mellitus is a chronic progressive disease characterized by impaired insulin secretion of the beta cell and impaired insulin sensitivity of different tissues. The incidence of type 2 diabetes mellitus is increasing worldwide, and the disease has reached epidemic proportions. Lifestyle intervention programs are able to delay or possibly prevent the manifestation of type 2 diabetes mellitus. This review summarizes the genetic and environmental factors which influence the risk for type 2 diabetes and their interactions, and determine the success of prevention programs.

Prenatal exposure to a low-protein diet programs disordered regulation of lipid metabolism in the aging rat

The nutritional environment encountered during fetal life is strongly implicated as a determinant of lifelong metabolic capacity and risk of disease. Pregnant rats were fed a control or low-protein (LP) diet, targeted to early (LPE), mid-(LPM), or late (LPL) pregnancy, or throughout gestation (LPA). The offspring were studied at 1, 9, and 18 mo of age. All LP-exposed groups had similar plasma triglyceride, cholesterol, glucose, and insulin concentrations to those of controls at 1 and 9 mo of age, but by 18 mo there was evidence of LP-programmed hypertriglyceridemia and insulin resistance. All LP-exposed groups exhibited histological evidence of hepatic steatosis and were found to have two- to threefold more hepatic triglyceride than control animals. These phenotypic changes were accompanied by age-related changes in mRNA and protein expression of the transcription factors SREBP-1c, ChREBP, PPARgamma, and PPARalpha and their respective downstream target genes ACC1, FAS, L-PK, and MCAD. At 9 mo of age, the LP groups exhibited suppression of the SREBP-1c-related lipogenic pathway but between 9 and 18 mo underwent a switch to increased lipogenic capacity with a lower expression of PPARgamma and MCAD, consistent with reduced lipid oxidation. The findings indicate that prenatal protein restriction programs development of a metabolic syndrome-like phenotype that develops only with senescence. The data implicate altered expression of SREBP-1c and ChREBP as key mediators of the programmed phenotype, but the basis of the switch in metabolic status that occurred between 9 and 18 mo of age is, as yet, unidentified.

Efficacy of lifestyle behavior change programs in diabetes

Evidence that a comprehensive lifestyle behavior change program targeting eating and physical activity, and ultimately weight loss, can alter the course of diabetes progression is growing. This report summarizes data from major clinical trials primarily, describes key features of behavior change programs, and comments on existing challenges regarding the adequacy, sustainability, and feasibility of behavior change programs for weight loss and diabetes prevention.

Exercise, pregnancy, and insulin sensitivity – what is new?

Pregnancy is characterized by a marked physiological insulin resistance. Overweight and obesity or lack of physical activity can aggravate this reduced insulin sensitivity further. Increased insulin resistance has been associated with serious pregnancy complications, such as gestational diabetes mellitus (GDM) and pre-eclampsia. Recent studies clearly indicate that physical activity before and during pregnancy can reduce the risk of GDM and pre-eclampsia.

Effect of genotype on success of lifestyle intervention in subjects at risk for type 2 diabetes

Lifestyle intervention programs including increased physical activity and healthy nutrition have been proven to delay the onset of type 2 diabetes. This is achieved mainly by reducing body weight and improving insulin sensitivity. However, response to lifestyle or dietary interventions does differ between individuals, and the genetic or environmental factors that may account for these differences are not yet precisely characterized. Identification of these factors would be desirable in order to provide an individually tailored preventive strategy for patients at risk of developing diabetes. This review summarizes the so far known genetic variations, which determine responders and nonresponders to a lifestyle intervention. In addition, general methodological approaches to study gene-lifestyle interactions are described.

A worksite diabetes prevention program: two-year impact on employee health

The purpose of this study was to determine the 2-year impact of a worksite-based diabetes prevention program. Thirty-seven pre-diabetic and previously undiagnosed diabetic employees participating in a 12-month worksite diabetes prevention program were included. Weight, body mass index, waist circumference, oral glucose tolerance testing, fasting insulin, blood lipids, and aerobic fitness had improved significantly after 6 months. Much of this improvement continued through 12 months. One year following the intervention, oral glucose tolerance and aerobic fitness had improved significantly. Of the 22 employees remaining in the study through 24 months, more than half had normal results on glucose tolerance testing. Worksite diabetes prevention programs may reduce blood glucose below pre-diabetic and diabetic levels. Improvements in diabetes risk factors persisted for at least 2 years in most of these employees.

High-fibre, low-fat diet predicts long-term weight loss and decreased type 2 diabetes risk: the Finnish Diabetes Prevention Study

AIMS/HYPOTHESIS

The aim of this study was to investigate the association of dietary macronutrient composition and energy density with the change in body weight and waist circumference and diabetes incidence in the Finnish Diabetes Prevention Study.

SUBJECTS AND METHODS

Overweight, middle-aged men (n=172) and women (n=350) with impaired glucose tolerance were randomised to receive either 'standard care' (control) or intensive dietary and exercise counselling. Baseline and annual examinations included assessment of dietary intake with 3-day food records and diabetes status by repeated 75-g OGTTs. For these analyses the treatment groups were combined and only subjects with follow-up data (n=500) were included.

RESULTS

Individuals with low fat (<median) and high fibre (>median) intakes lost more weight compared with those consuming a high-fat (>median), low-fibre (<median) diet (3.1 vs 0.7 kg after 3 years). In separate models, hazard ratios for diabetes incidence during a mean follow-up of 4.1 years were (highest compared with lowest quartile) 0.38 (95% CI 0.19-0.77) for fibre intake, 2.14 (95% CI 1.16-3.92) for fat intake, and 1.73 (95% CI 0.89-3.38) for saturated-fat intake, after adjustment for sex, intervention assignment, weight and weight change, physical activity, baseline 2-h plasma glucose and intake of the nutrient being investigated. Compared with the low-fat/high-fibre category, hazard ratios were 1.98 (95% CI 0.98-4.02), 2.68 (95% CI 1.40-5.10), and 1.89 (95% CI 1.09-3.30) for low-fat/low-fibre, high-fat/high-fibre, and high-fat/low-fibre, respectively.

CONCLUSIONS/INTERPRETATION

Dietary fat and fibre intake are significant predictors of sustained weight reduction and progression to type 2 diabetes in high-risk subjects, even after adjustment for other risk factors.