Does the effect of lifestyle intervention for individuals with diabetes vary by food insecurity status? A preplanned subgroup analysis of the REAL HEALTH randomized clinical trial

A Systematic Review of Interventions for Obesity Among Adults With Food Insecurity

OBJECTIVE

Food insecurity is associated with reduced dietary quality and excess weight gain. However, interventions that are effective for obesity among individuals with food insecurity are unclear. The purpose of this systematic review was to synthesize studies in which authors examined interventions for obesity among adults with food insecurity.

METHODS

PubMed, PsycINFO, CINAHL, and EMBASE were searched from inception to October 2022. Studies were included if their authors reported on nonpharmacological and nonsurgical interventions that focused on adults with food insecurity and overweight/obesity and reported weight loss.

RESULTS

A total of 1360 titles were reviewed during the electronic search, and only 5 studies met inclusion criteria. There were 2 primary types of interventions that have been tested: first, behavioral weight loss counseling with or without tailoring for individuals with food insecurity and, second, subsidies for food. Findings of the benefits of one type of intervention over another are mixed.

CONCLUSIONS

This systematic review highlights that the current evidence for interventions that address food insecurity and obesity is mixed and limited in scope. There is a need for rigorous controlled trials to examine the effectiveness and cost-effectiveness of interventions for weight management among individuals with food insecurity and obesity while considering sustainability.

Racial/ethnic and socioeconomic disparities in achievement of treatment goals within a clinical trial: a secondary analysis of the ACCORD trial

AIMS/HYPOTHESIS

Clinical trial participation should theoretically reduce barriers to care by ensuring medication and healthcare access. We aimed to evaluate disparities in achieving diabetes treatment targets by race/ethnicity and educational attainment within the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial (ClinicalTrials.gov NCT00000620).

METHODS

The ACCORD trial included three interventions of varying participant burden: glycaemic (high burden), blood pressure (medium burden) and triglyceride-lowering (low burden). We examined adjusted odds ratios (aORs) for achievement of glycaemic targets, blood pressure targets and a ≥25% reduction in triglyceride levels (a proxy for adherence to fenofibrate therapy) in the first year, and for hypoglycaemia requiring medical assistance at any time, by treatment arm, race/ethnicity and educational attainment using multivariable models adjusted for demographics and clinical characteristics. We explored whether disparities in glycaemic goal achievement were mediated by hypoglycaemia, medication use, change in BMI or number of study visits attended.

RESULTS

Compared with White participants, participants who identified as Black, Hispanic and Other race/ethnicity were less likely to achieve glycaemic targets (aOR [95% CI]) 0.63 [0.55,0.71], 0.73 [0.61, 0.88], 0.82 [0.71, 0.96], respectively); Black participants but not Hispanic and Other race/ethnicity participants were less likely to achieve blood pressure targets (aOR [95% CI] 0.77 [0.65, 0.90], 1.01 [0.78, 1.32], 1.01 [0.81, 1.26], respectively); and Black, Hispanic and Other race/ethnicity participants were equally or more likely to achieve triglyceride reduction (aOR [95% CI] 1.77 [1.38, 2.28], 1.34 [0.98, 1.84], 1.43 [1.10, 1.85], respectively). Differences in goal achievement by educational attainment were generally not significant after adjusting for baseline characteristics. Rates of hypoglycaemia requiring medical assistance were highest among Black individuals and those with lower educational attainment. Associations between race/ethnicity and glycaemic control were partially mediated by differences in insulin dosing and oral medication use.

CONCLUSIONS/INTERPRETATION

Racially/ethnically minoritised participants in the ACCORD trial were less likely to achieve high-burden (glycaemic) treatment goals but were generally similarly likely to achieve goals of less intensive interventions. Differences in glycaemic treatment goal achievement were partially mediated by differences in medication use but not mediated by hypoglycaemia, change in BMI or study visit attendance.

Psychological and Behavioral Predictors of Weight Loss in the Reach Ahead for Lifestyle and Health-Diabetes Lifestyle Intervention Cohort

BACKGROUND

Understanding the effect lifestyle intervention (LI) has on important psychological and behavioral variables that are associated with weight loss can help inform LI design, content, and delivery.

OBJECTIVE

The aim was to determine the modifiable psychological and behavioral factors that are associated with percent weight loss (%WL) and their relative importance in predicting %WL at 12, 24, and 36 months in the REAL HEALTH-Diabetes randomized controlled trial LI.

DESIGN

This is a secondary analysis of LI arms of the REAL HEALTH-Diabetes randomized controlled trial LI cohort over a 24-month intervention period and 12-month follow-up period. Patient-reported outcomes were measured using validated questionnaires that were either self-administered or administered by a research coordinator.

PARTICIPANTS/SETTING

Adults with type 2 diabetes and overweight/obesity (N = 142) from community health centers, primary care, and local endocrinology practices affiliated with Massachusetts General Hospital in Boston, MA, between 2015 and 2020, were randomized to LI and were included in the analysis.

INTERVENTION

The LI was a lower intensity adaptation of Look Action for Health in Diabetes's (HEALTH) evidence-based LI delivered either in-person or via telephone. Registered dietitians delivered 19 group sessions during the first 6 months followed by 18 monthly sessions.

MAIN OUTCOME MEASURES

The association of psychological (diabetes-related distress, depression, autonomous motivation, diet and exercise self-efficacy, and social support for healthy behaviors) and behavioral (fat-related diet and dietary self-regulation) variables with %WL.

STATISTICAL ANALYSIS

Baseline and 6-month change scores in psychological and behavioral variables were modeled as predictors of %WL at 12, 24, and 36 months using linear regression. Random forests were used to compare the relative importance of changes in the variables in predicting %WL.

RESULTS

Six-month improvement in autonomous motivation, exercise self-efficacy, diet self-efficacy, and dietary self-regulation were associated with %WL at 12 and 24 months, but not at 36 months. Improvement in fat-related diet behavior and depressive symptoms were the only variables associated with %WL at all three timepoints. Autonomous motivation, dietary self-regulation, and low-fat diet behaviors were the three most important predictors of %WL during the 2-year LI.

CONCLUSIONS

The REAL HEALTH-Diabetes randomized controlled trial LI resulted in 6-month improvements in modifiable psychological and behavioral factors that were associated with %WL. LI programs for weight loss should focus on skills and strategies to promote autonomous motivation, flexible dietary self-regulation, and habituation of low-fat eating habits during the intervention period.

Racial/ethnic and socioeconomic disparities in weight outcomes, cardiovascular events, and mortality in the look AHEAD trial

BACKGROUND

Intensive lifestyle interventions (ILI) for type 2 diabetes (T2D) improve health outcomes, but participants from different races/ethnicities or socioeconomic status may not benefit equally.

METHODS

Within the Look AHEAD trial, we examined achievement of the 7% weight loss goal, as well as secondary weight, cardiovascular, and mortality outcomes, by race/ethnicity and educational attainment (EA).

RESULTS

Among 4,640 participants (31 % Black or Hispanic, 13 % with less than a high school degree), Black and Hispanic participants were less likely than White participants to achieve 7 % weight loss in both the ILI (45.8 % v. 60.7 %, p < 0.001 and 53.0 % v. 60.7 %, p = 0.01, respectively) and diabetes support and education (DSE) arms. Contrastingly, participants with less than a high school degree were more likely in the ILI but less likely in the DSE arm to achieve this goal, with a significant arm by EA interaction. Hispanic participants and those with lowest EA also experienced decreased mortality in the ILI versus the DSE arm.

CONCLUSIONS

All Look AHEAD participant subgroups achieved greater weight loss from ILI; however, Black and Hispanic participants lost less weight than White participants in both arms, while those with lowest EA benefited disproportionately from the ILI compared to participants with higher EA.

Home Food Environment Changes and Dietary Intake during an Adolescent Behavioral Weight Loss Intervention Differ by Food Security Status

Behavioral weight loss (BWL) for pediatric obesity includes guidance on improving the home food environment and dietary quality; yet food insecurity presents barriers to making these changes. This study examined if home food environment, dietary quality, energy intake, and body weight changes during adolescent obesity treatment differed by food security status, and if changes in the home food environment were associated with changes in dietary quality and energy intake by food security status. Adolescents (n = 82; 13.7 ± 1.2 years) with obesity participated in a 4-month BWL treatment. Food insecurity, home food environment (Home Food Inventory [HFI]), dietary quality (Healthy Eating Index [HEI]), energy intake, and body mass index (BMI) were assessed at baseline and post-treatment. A reduced obesogenic home food environment and improved dietary quality were observed for food secure (ps < 0.01), but not insecure households (ps > 0.05) (mean difference, HFI: −6.6 ± 6.4 vs. −2.4 ± 7.4; HEI: 5.1 ± 14.4 vs. 2.7 ± 17.7). Energy intake and BMI decreased for adolescents in food secure and insecure households (ps < 0.03) (mean difference; energy intake: −287 ± 417 vs. −309 ± 434 kcal/day; BMI: −1.0 ± 1.4 vs. −0.7 ± 1.4). BWL yielded similar reductions in energy intake and body weight yet did not offer the same benefits for improved dietary quality and the home food environment for adolescents with food insecurity.