Efficacy of interventions that include diet, aerobic and resistance training components for type 2 diabetes prevention: a systematic review with meta-analysis

Association of plant-based dietary patterns with the risk of type 2 diabetes mellitus using cross-sectional results from RaNCD cohort

The prevalence of type 2 diabetes mellitus (T2DM) is increasing in middle- and low-income countries, and this disease is a burden on public health systems. Notably, dietary components are crucial regulatory factors in T2DM. Plant-based dietary patterns and certain food groups, such as whole grains, legumes, nuts, vegetables, and fruits, are inversely correlated with diabetes incidence. We conducted the present study to determine the association between adherence to a plant-based diet and the risk of diabetes among adults. We conducted a cross-sectional, population-based RaNCD cohort study involving 3401 men and 3699 women. The plant-based diet index (PDI) was developed using a 118-item food frequency questionnaire (FFQ). Logistic regression models were used to evaluate the association between the PDI score and the risk of T2DM. A total of 7100 participants with a mean age of 45.96 ± 7.78 years were analysed. The mean PDI scores in the first, second, and third tertiles (T) were 47.13 ± 3.41, 54.44 ± 1.69, and 61.57 ± 3.24, respectively. A lower PDI was significantly correlated with a greater incidence of T2DM (T1 = 7.50%, T2 = 4.85%, T3 = 4.63%; P value < 0.001). Higher PDI scores were associated with significantly increased intakes of fibre, vegetables, fruits, olives, olive oil, legumes, soy products, tea/coffee, whole grains, nuts, vitamin E, vitamin C, and omega-6 fatty acids (P value < 0.001). After adjusting for confounding variables, the odds of having T2DM were significantly lower (by 30%) at T3 of the PDI than at T1 (OR = 0.70; 95% CI = 0.51, 0.96; P value < 0.001). Our data suggest that adhering to plant-based diets comprising whole grains, fruits, vegetables, nuts, legumes, vegetable oils, and tea/coffee can be recommended today to reduce the risk of T2DM.

Effects of combined aerobic exercise and diet on cardiometabolic health in patients with obesity and type 2 diabetes: a systematic review and meta-analysis

BACKGROUND

Lifestyle modifications involving diet and exercise are recommended for patients diagnosed with obesity and type 2 diabetes mellitus (T2DM). The purpose of this review was to systematically evaluate the effects of combined aerobic exercise and diet (AEDT) on various cardiometabolic health-related indicators among individuals with obesity and T2DM.

METHODOLOGY

A comprehensive search of the PubMed/Medline, Web of Science, Scopus, Science Direct, Cochrane, and Google Scholar databases was conducted for this meta-analysis. The Cochrane risk of bias tool was used to evaluate eligible studies, and the GRADE tool was used to rate the certainty of evidence. A random-effects model for continuous variables was used, and the results were presented as mean differences or standardised mean differences with 95% confidence intervals.

RESULTS

A total of 16,129 studies were retrieved; 20 studies were included, and data were extracted from 1,192 participants. The findings revealed significant improvements in body mass index, body weight, waist circumference, systolic blood pressure, diastolic blood pressure, total cholesterol, triglycerides, fasting blood glucose, fasting plasma insulin, glycated hemoglobin, leptin, interleukin-6, C-reactive protein, and adiponectin (p < 0.05) compared to the standard treatment (ST) group. No significant differences were observed between the AEDT and ST groups in fat mass, hip circumference, waist-to-hip ratio, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and tumor necrosis factor-alpha. The present findings are based on low- to moderate-quality evidence.

CONCLUSIONS

AEDT may be a critical behavior for holistic cardiometabolic health-related benefits as a contemporary anti-obesity medication due to its significant positive impact on patients with obesity and T2DM. Nevertheless, further robust evidence is necessary to determine whether AEDT is an effective intervention for lowering cardiovascular and metabolic risk factors among individuals with obesity and T2DM.

American Association of Clinical Endocrinology Consensus Statement: Comprehensive Type 2 Diabetes Management Algorithm - 2023 Update

OBJECTIVE

This consensus statement provides (1) visual guidance in concise graphic algorithms to assist with clinical decision-making of health care professionals in the management of persons with type 2 diabetes mellitus to improve patient care and (2) a summary of details to support the visual guidance found in each algorithm.

METHODS

The American Association of Clinical Endocrinology (AACE) selected a task force of medical experts who updated the 2020 AACE Comprehensive Type 2 Diabetes Management Algorithm based on the 2022 AACE Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan and consensus of task force authors.

RESULTS

This algorithm for management of persons with type 2 diabetes includes 11 distinct sections: (1) Principles for the Management of Type 2 Diabetes; (2) Complications-Centric Model for the Care of Persons with Overweight/Obesity; (3) Prediabetes Algorithm; (4) Atherosclerotic Cardiovascular Disease Risk Reduction Algorithm: Dyslipidemia; (5) Atherosclerotic Cardiovascular Disease Risk Reduction Algorithm: Hypertension; (6) Complications-Centric Algorithm for Glycemic Control; (7) Glucose-Centric Algorithm for Glycemic Control; (8) Algorithm for Adding/Intensifying Insulin; (9) Profiles of Antihyperglycemic Medications; (10) Profiles of Weight-Loss Medications (new); and (11) Vaccine Recommendations for Persons with Diabetes Mellitus (new), which summarizes recommendations from the Advisory Committee on Immunization Practices of the U.S. Centers for Disease Control and Prevention.

CONCLUSIONS

Aligning with the 2022 AACE diabetes guideline update, this 2023 diabetes algorithm update emphasizes lifestyle modification and treatment of overweight/obesity as key pillars in the management of prediabetes and diabetes mellitus and highlights the importance of appropriate management of atherosclerotic risk factors of dyslipidemia and hypertension. One notable new theme is an emphasis on a complication-centric approach, beyond glucose levels, to frame decisions regarding first-line pharmacologic choices for the treatment of persons with diabetes. The algorithm also includes access/cost of medications as factors related to health equity to consider in clinical decision-making.

Effect of In-Person Delivered Behavioural Interventions in People with Multimorbidity: Systematic Review and Meta-analysis

BACKGROUND

To investigate the effect of in-person delivered behavioural interventions in people with multimorbidity and which behaviour change techniques (BCTs), targeting lifestyle behaviours, are associated with better outcomes.

METHODS

Systematic review of randomised controlled trials. We searched MEDLINE, EMBASE, CENTRAL, and CINAHL and screened reference list of reviews including people with multimorbidity, registries, and citation tracking of included studies. Meta-analyses using random-effects model to assess the effect of behavioural interventions and meta-regression analyses and effectiveness ratios to investigate the impact of mediators on effect estimates. Cochrane 'Risk of Bias Tool' 2.0 and the GRADE assessment to evaluate the overall quality of evidence.

RESULTS

Fourteen studies involving 1,378 people. Behavioural interventions had little to no effect on physical activity (standardised mean difference 0.38, 95% CI -0.12-0.87) and the effect on weight loss was uncertain (BMI mean difference -0.17, 95% CI -1.1-0.83) at the end-treatment follow-up. Small improvements were seen in health-related quality of life (SMD 0.29, 95% CI 0.17-0.42) and physical function (SMD 0.42, 95% CI 0.12-0.73), and moderate improvements were seen for depression symptoms (SMD -0.70, 95% CI -0.97-0.42). Studies using the BCTs 'action planning' and 'social support (practical)' reported greater physical activity and weight loss.

CONCLUSIONS

Behavioural interventions targeting lifestyle behaviours may improve health-related quality of life and physical function, and reduce depression, whereas little to no effect was achieved on physical activity and weight loss in people with multimorbidity. However, the evidence for physical activity and weight loss were of low quality and the end-treatment benefits diminished over time.

Development of a tailored intervention targeting sedentary behavior and physical activity in people with stroke and diabetes: A qualitative study using a co-creation framework

Purpose

Type 2 diabetes and sedentary behavior pose serious health risks in stroke survivors. Using a co-creation framework, this study aimed to develop an intervention in collaboration with stroke survivors with type 2 diabetes, relatives, and cross-sectoral health care professionals to reduce sedentary behavior and increase physical activity.

Materials and methods

This qualitative explorative study used a co-creation framework consisting of a workshop and focus group interviews with stroke survivors with type 2 diabetes (n = 3), relative (n = 1), and health care professionals (n = 10) to develop the intervention. A content analysis was used to analyze data.

Results

The developed "Everyday Life is Rehabilitation" (ELiR) intervention consisted of a tailored 12-week home-based behavior change intervention with two consultations of action planning, goal setting, motivational interviewing, and fatigue management including education on sedentary behavior, physical activity, and fatigue. The intervention has a minimalistic setup using a double-page paper "Everyday Life is Rehabilitation" (ELiR) instrument making it implementable and tangible.

Conclusions

In this study, a theoretical framework was used to develop a tailored 12-week home-based behavior change intervention. Strategies to reduce sedentary behavior and increase physical activity through activities of daily living along with fatigue management in stroke survivors with type 2 diabetes were identified.

Evaluation under real-life conditions of a lifestyle intervention for diabetes prevention developed by the municipal health services of Madrid, Spain

The Diet, Physical Activity and Health (Alimentación, Actividad física y Salud, ALAS) program is an intervention implemented by the municipal health services of Madrid with the objective of reducing weight and preventing diabetes in high-risk population by improving diet and physical activity. The ALAS program combines individual visits with a 10-session group workshop that takes place over a 6-month period. This study evaluated the effectiveness of the ALAS intervention implemented under real-life conditions between 2016 and 2019. The intervention was evaluated with a pre- and post-intervention study with follow-up performed 6 and 12 months from the start of the program. The analyzed outcomes were a 5-10% reduction in the initial weight, body mass index (BMI), waist circumference and a change in glycemic status in prediabetic participants. Statistical models were adjusted by sociodemographic variables. The participants were recruited from municipal community health centers or referred by municipal occupational health services. Between 2016 and 2019, 1629 people participated in the program. At 6 months, 85% of the participants had lost weight; 43% had lost 5% or more of their initial weight, and 12% had lost 10% or more. Regarding BMI, 22.3% of participants who were initially obese were no longer obese, and 15.2% of the overweight participants achieved normal weight. A total of 35.1% of the prediabetic participants reverted to normoglycemic status. The intervention was found to be more effective for men, for those who completed the intervention and those who accessed the program through the occupational health route. Among the participants who accessed the intervention via the community, the intervention was more effective in those with a high educational level. The evaluation demonstrated the effectiveness of the ALAS program for reducing weight and the risk of developing Type 2 diabetes when applied under real-life conditions. The effectiveness of the intervention differed according to gender, access route and educational level of the participants.

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update

OBJECTIVE

The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.

METHODS

The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RESULTS

This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.

CONCLUSIONS

This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.

Associations of specific types of physical activities with 10-year risk of cardiovascular disease among adults: Data from the national health and nutrition examination survey 1999–2006

Background

Physical activity plays a key role in the prevention of cardiovascular disease (CVD). However, previous studies focused predominantly on the associations of the total amount of physical activity with CVD. There were few evidences on the associations of specific sport disciplines with CVD. Furthermore, little was known on the interactions between the different types of sports on CVD risk. Therefore, this study aimed to examine the independent associations of specific types of physical activities with the 10-year risk of CVD, and further evaluate the interactions between specific types of physical activities on the 10-year risk of CVD in US adults.

Methods

This study used the data of the National Health and Nutrition Examination Survey (NHANES) 1999-2006. Participants aged ≥ 30 years and with free of CVD were eligible. The physical activity questionnaire is used to collect general information on leisure-time activities in the past 30 days, including the frequency, duration, and intensity of participation in each activity. The exposures of interest included cycling, swimming, aerobics, running, American Football, basketball, and racquet sports. The Framingham risk score algorithm was used to assess 10-year CVD risk based on age, high density lipoprotein, total cholesterol, systolic blood pressure, smoking status, and diabetes. A higher total score reflects a greater risk of CVD.

Results

This study included 10829 participants. Compared to no participation, participation in cycling (β = −0.890, 95% CI:−1.278,−0.502, P < 0.001), running (β = −1.466, 95% CI:−1.837,−1.095, P < 0.001), American Football (β = −2.934, 95% CI:−3.750,−2.119, P < 0.001), basketball (β = −1.968, 95% CI:−2.645,−1.291, P < 0.001), and aerobics (β = −0.980, 95% CI:−1.352,−0.608, P < 0.001) was associated with a lower CVD risk. Furthermore, cycling was antagonistic with basketball and racquet sports in the associations with CVD risk. An antagonistic action between swimming and aerobics was also observed. Nevertheless, running was synergistic with cycling, aerobics, and racquet sports in the associations with CVD risk.

Conclusions

There were inverse associations of specific types of physical activities with CVD risk. Furthermore, there might be synergistic and antagonistic associations of multiple types of physical activities with CVD risk.

Plant Extracts as Add-On Therapeutics in Homeopathy: An Open-Label, Randomized Trial Using Mother Tinctures in Prediabetes

Objectives: Prediabetes is a major public health concern. Different plant extracts are used in homeopathy as mother tinctures (MTs) for the treatment of prediabetes as an adjunct to individualized homeopathic medicines (IHMs); however, their effectiveness remains under-researched. Design: Open-label, randomized (1:1), active-controlled, pragmatic, exploratory trial. Setting: Mahesh Bhattacharyya Homoeopathic Medical College and Hospital, Howrah, West Bengal, India. Subjects: Eighty-nine patients with prediabetes. Interventions: Group 1 (n = 45; IHMs plus any one of the following MTs: Cephalandra indica, Gymnema sylvestre, and Syzygium jambolanum; experimental/verum) versus Group 2 (n = 44; IHMs only; control). Outcome measures: Blood parameters, including-the fasting blood sugar (FBS) level, blood sugar level 2 h after ingestion of 75 g of glucose (oral glucose tolerance test [OGTT] result), and glycosylated hemoglobin percentage (HbA1c%), and symptoms, including the Diabetes Symptom Checklist-Revised (DSC-R) score; all of them were measured at baseline and after 3 and 6 months. Results: Although recruitment of 140 patients was initially planned, the target sample size could not be achieved because of coronavirus disease pandemic-related restrictions. Only 89 patients could be enrolled, and the trial had to be terminated prematurely owing to the time constraints of the project. The data of 82 patients (Group 1, n = 40; Group 2, n = 42) were analyzed using a modified intention-to-treat approach. Improvements in all outcomes were greater in Group 1 than in Group 2, but without a significant difference: FBS level (F_{1, 80} = 4.095, p = 0.046), OGTT result (F_{1, 80} = 2.399, p = 0.125), HbA1c% (F_{1, 80} = 1.612, p = 0.208), and DSC-R score (F_{1, 80} = 0.023, p = 0.880). Conclusions: A promising but nonsignificant trend favored the combination of MTs and IHMs compared with IHMs alone among the patients with prediabetes, especially in FBS. Therefore, further studies are required. Clinical Trial Registration number: CTRI/2018/08/015319; secondary identifier (UTN): U1111-1218-6016.

Modelling geographical heterogeneity of diabetes prevalence and socio-economic and built environment determinants in Saudi City - Jeddah

Type-2 diabetes is a growing lifestyle disease mainly due to increasing physical inactivity but also associated with various other variables. In Saudi Arabia, around 58.5% of the population is deemed to be physically inactive. Against this background, this study attempts explore the spatial heterogeneity of Type-2 diabetes prevalence in Jeddah and to estimate various socio-economic and built environment variables contributing to the prevalence of this disease based on modelling by ordinary least squares (OLS), weighted regression (GWR) and multi-scale geographically weighted (MGWR). Our OLS results suggest that income, population density, commercial land use and Saudi population characteristics are statistically significant for Type-2 diabetes prevalence. However, by the GWR model, income, commercial land use and Saudi population characteristics were significantly positive while population density was significantly negative in this model for 70.6%, 9.1%, 26.6% and 58.7%, respectively, out of 109 districts investigated; by the MGWR model, the corresponding results were 100%, 22%, 100% and 100% of the districts. With the given data, the corrected Akaike information criterion (AICc), the adjusted R2, the log-likelihood and the residual sum of squares (RSS) indices demonstrated that the MGWR model outperformed the GWR and OLS models explaining 29% more variance than the OLS model, and 10.2% more than the GWR model. These results support the development of evidence-based policies for the spatial allocation of health associated resources for the control of Type-2 diabetes in Jeddah and other cities in the Arabian Gulf.

Muscle-strengthening activities are associated with lower risk and mortality in major non-communicable diseases: a systematic review and meta-analysis of cohort studies

OBJECTIVE

To quantify the associations between muscle-strengthening activities and the risk of non-communicable diseases and mortality in adults independent of aerobic activities.

DESIGN

Systematic review and meta-analysis of prospective cohort studies.

DATA SOURCES

MEDLINE and Embase were searched from inception to June 2021 and the reference lists of all related articles were reviewed.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Prospective cohort studies that examined the association between muscle-strengthening activities and health outcomes in adults aged ≥18 years without severe health conditions.

RESULTS

Sixteen studies met the eligibility criteria. Muscle-strengthening activities were associated with a 10-17% lower risk of all-cause mortality, cardiovascular disease (CVD), total cancer, diabetes and lung cancer. No association was found between muscle-strengthening activities and the risk of some site-specific cancers (colon, kidney, bladder and pancreatic cancers). J-shaped associations with the maximum risk reduction (approximately 10-20%) at approximately 30-60 min/week of muscle-strengthening activities were found for all-cause mortality, CVD and total cancer, whereas an L-shaped association showing a large risk reduction at up to 60 min/week of muscle-strengthening activities was observed for diabetes. Combined muscle-strengthening and aerobic activities (versus none) were associated with a lower risk of all-cause, CVD and total cancer mortality.

CONCLUSION

Muscle-strengthening activities were inversely associated with the risk of all-cause mortality and major non-communicable diseases including CVD, total cancer, diabetes and lung cancer; however, the influence of a higher volume of muscle-strengthening activities on all-cause mortality, CVD and total cancer is unclear when considering the observed J-shaped associations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020219808.

Muscle-strengthening activities and risk of cardiovascular disease, type 2 diabetes, cancer and mortality: A review of prospective cohort studies

The benefits of aerobic moderate-to-vigorous physical activity (MVPA) on major non-communicable diseases (NCDs) are well established. However, much less is known whether muscle-strengthening activities (i.e., resistance/weight/strength training) confer similar benefits. Herein, we conducted a narrative literature review and summarized the existing evidence from large prospective cohort studies on muscle strengthening activities and risk of major chronic diseases and mortality in adults generally free of major NCDs at baseline. Current epidemiologic evidence suggests that engagement in muscle-strengthening activities over 1-2 sessions (or approximately 60-150 min) per week was associated with reduced risk of cardiovascular disease (seven studies; approximately 20%-25% reduction), type 2 diabetes (four studies; approximately 30% reduction), cancer mortality (four studies; approximately 15%-20% reduction) as well as all-cause mortality (six studies; approximately 20%-25% reduction). For diabetes, the risk appears to lower further with even higher levels of muscle-strengthening activities, but some studies for cardiovascular and all-cause mortality suggest a reversal whereby higher levels (≥2.5 h/week) have less benefit, or are even harmful, relative to lower levels of activity. The likely mechanisms contributing to a benefit include improvement in body composition, lipid profile, insulin resistance and inflammation. The evidence supports engaging in 1-2 sessions (up to 2.5 h) per week, preferably performed complementary to the recommended levels of aerobic MVPA. Although data are limited, caution is suggested for training exceeding 2.5 h per week. Further studies are required to better understand the influence of frequency, duration and intensity of muscle-strengthening activities on major NCDs and mortality in diverse populations.

Cardiovascular disease risk communication in NHS Health Checks using QRISK®2 and JBS3 risk calculators: the RICO qualitative and quantitative study

BACKGROUND

The NHS Health Check is a national cardiovascular disease prevention programme. There is a lack of evidence on how health checks are conducted, how cardiovascular disease risk is communicated to foster risk-reducing intentions or behaviour, and the impact on communication of using different cardiovascular disease risk calculators.

OBJECTIVES

RIsk COmmunication in Health Check (RICO) study aimed to explore practitioner and patient understanding of cardiovascular disease risk, the associated advice or treatment offered by the practitioner, and the response of the patients in health checks supported by either the QRISK^®2 or the JBS3 lifetime risk calculator.

DESIGN

This was a qualitative study with quantitative process evaluation.

SETTING

Twelve general practices in the West Midlands of England, stratified on deprivation of the local area (bottom 50% vs. top 50%), and with matched pairs randomly allocated to use QRISK2 or JBS3 during health checks.

PARTICIPANTS

A total of 173 patients eligible for NHS Health Check and 15 practitioners.

INTERVENTIONS

The health check was delivered using either the QRISK2 10-year risk calculator (usual practice) or the JBS3 lifetime risk calculator, with heart age, event-free survival age and risk score manipulation (intervention).

RESULTS

Video-recorded health checks were analysed quantitatively (n = 173; JBS3, n = 100; QRISK2, n = 73) and qualitatively (n = 128; n = 64 per group), and video-stimulated recall interviews were undertaken with 40 patients and 15 practitioners, with 10 in-depth case studies. The duration of the health check varied (6.8-38 minutes), but most health checks were short (60% lasting < 20 minutes), with little cardiovascular disease risk discussion (average < 2 minutes). The use of JBS3 was associated with more cardiovascular disease risk discussion and fewer practitioner-dominated consultations than the use of QRISK2. Heart age and visual representations of risk, as used in JBS3, appeared to be better understood by patients than 10-year risk (QRISK2) and, as a result, the use of JBS3 was more likely to lead to discussion of risk factors and their management. Event-free survival age was not well understood by practitioners or patients. However, a lack of effective cardiovascular disease risk discussion in both groups increased the likelihood of a maladaptive coping response (i.e. no risk-reducing behaviour change). In both groups, practitioners often missed opportunities to check patient understanding and to tailor information on cardiovascular disease risk and its management during health checks, confirming apparent practitioner verbal dominance.

LIMITATIONS

The main limitations were under-recruitment in some general practices and the resulting imbalance between groups.

CONCLUSIONS

Communication of cardiovascular disease risk during health checks was brief, particularly when using QRISK2. Patient understanding of and responses to cardiovascular disease risk information were limited. Practitioners need to better engage patients in discussion of and action-planning for their cardiovascular disease risk to reduce misunderstandings. The use of heart age, visual representation of risk and risk score manipulation was generally seen to be a useful way of doing this. Future work could focus on more fundamental issues of practitioner training and time allocation within health check consultations.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN10443908.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 50. See the NIHR Journals Library website for further project information.

Iranian National Clinical Practice Guideline for Exercise in Patients with Diabetes

CONTEXT

Growing evidence highlights the importance of physical activity as a critical element for the prevention and control of diabetes. However, there is no clinical practice guideline focusing on the different aspects of exercise in patients with diabetes, especially for the Iranian population.

OBJECTIVE

We aimed to prepare and adopt a clinical practice guideline to provide well-defined, simple, and concise responses to certain questions related to physical activity and exercise in all patients with diabetes, including type 1, 2, and gestational diabetes mellitus (GDM).

EVIDENCE ACQUISITION

A multidisciplinary team of experts in various fields (sports medicine specialists, endocrinologists, and cardiologists) developed the guideline. This group did the task in four stages: (1) identifying and refining the subject area using 17 clinical questions; (2) appraising evidence through a systematic review of the literature; (3) extracting recommendations from evidence and grading them as A, B, C, or D based on the quality, quantity, and consistency of existing evidence; and (4) subjecting the guideline to external review and finally selecting the recommendations with high scores of appropriateness and agreement. The final version was evaluated and approved by the National Deputy for Curative Affairs - Ministry of Health and Medical Education and has also been endorsed by the Iran Endocrine Society (IES) and Iranian Association of Sports and Exercise Medicine (IASEM).

RESULTS

The guideline consists of 52 recommendations addressing 17 important questions concerning different aspects of exercise prescription in Iranian patients with diabetes.

CONCLUSIONS

The guideline provides evidence-based information that may help physicians to prescribe exercise for Iranian patients with diabetes safely and effectively.

Interactions of Carbohydrate Intake and Physical Activity with Regulatory Genes Affecting Glycaemia: A Food4Me Study Analysis

INTRODUCTION

Carbohydrate intake and physical activity are related to glucose homeostasis, both being influenced by individual genetic makeup. However, the interactions between these 2 factors, as affected by genetics, on glycaemia have been scarcely reported.

OBJECTIVE

We focused on analysing the interplay between carbohydrate intake and physical activity levels on blood glucose, taking into account a genetic risk score (GRS), based on SNPs related to glucose/energy metabolism.

METHODS

A total of 1,271 individuals from the Food4Me cohort, who completed the nutritional intervention, were evaluated at baseline. We collected dietary information by using an online-validated food frequency questionnaire, a questionnaire on physical activity, blood biochemistry by analysis of dried blood spots, and by analysis of selected SNPs. Fifteen out of 31 SNPs, with recognized participation in carbohydrate/energy metabolism, were included in the component analyses. The GRS included risk alleles involved in the control of glycaemia or energy-yielding processes.

RESULTS

Data concerning anthropometric, clinical, metabolic, dietary intake, physical activity, and genetics related to blood glucose levels showed expected trends in European individuals of comparable sex and age, being categorized by lifestyle, BMI, and energy/carbohydrate intakes, in this Food4Me population. Blood glucose was inversely associated with physical activity level (β = -0.041, p = 0.013) and positively correlated with the GRS values (β = 0.015, p = 0.047). Interestingly, an interaction affecting glycaemia, concerning physical activity level with carbohydrate intake, was found (β = -0.060, p = 0.033), which also significantly depended on the genetic background (GRS).

CONCLUSIONS

The relationships of carbohydrate intake and physical activity are important in understanding glucose homeostasis, where a role for the genetic background should be ascribed.

Association between domain-specific physical activity and diabetes in Korean adults

This study aimed to investigate the association between domain-specific physical activity (PA) and diabetes in Korean adults. We analyzed 26,653 men and women (aged > 18 years) from the Korea National Health and Nutrition Examination Survey (2014–2018). PA was measured using a validated Global PA Questionnaire. Multivariable logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) after adjustment for various confounders. Transport PA accounted for the majority of total PA (46%, men; 58%, women), followed by leisure-time PA (30%; 22%) and work PA (24%; 20%). In men, ORs (95% CI) of diabetes comparing ≥ 600 metabolic task of equivalent (MET)-min/week vs. no activity were 0.82 (0.71–0.95) for leisure-time PA, 0.85 (0.75–0.96) for transport PA, and 0.88 (0.78–0.99) for leisure-time + transport PA. In women, ORs (95% CI) of diabetes comparing the same groups were 0.73 (0.60–0.89) for leisure-time PA, 0.97 (0.85–1.10) for transport PA, and 0.88 (0.78–1.00) for leisure-time + transport PA. However, work PA showed no association with diabetes. In conclusion, leisure-time PA was inversely associated with diabetes in both men and women, while transport PA was inversely associated only in men. But work PA was not associated with diabetes in Korean adults.

Effectiveness of a Multicomponent Intervention in Primary Care That Addresses Patients with Diabetes Mellitus with Two or More Unhealthy Habits, Such as Diet, Physical Activity or Smoking: Multicenter Randomized Cluster Trial (EIRA Study)

Introduction: We evaluated the effectiveness of an individual, group and community intervention to improve the glycemic control of patients with diabetes mellitus aged 45-75 years with two or three unhealthy life habits. As secondary endpoints, we evaluated the inverventions' effectiveness on adhering to Mediterranean diet, physical activity, sedentary lifestyle, smoking and quality of life. Method: A randomized clinical cluster (health centers) trial with two parallel groups in Spain from January 2016 to December 2019 was used. Patients with diabetes mellitus aged 45-75 years with two unhealthy life habits or more (smoking, not adhering to Mediterranean diet or little physical activity) participated. Centers were randomly assigned. The sample size was estimated to be 420 people for the main outcome variable. Educational intervention was done to improve adherence to Mediterranean diet, physical activity and smoking cessation by individual, group and community interventions for 12 months. Controls received the usual health care. The outcome variables were: HbA1c (main), the Mediterranean diet adherence score (MEDAS), the international diet quality index (DQI-I), the international physical activity questionnaire (IPAQ), sedentary lifestyle, smoking ≥1 cigarette/day and the EuroQuol questionnaire (EVA-EuroQol5D5L). Results: In total, 13 control centers (n = 356) and 12 intervention centers (n = 338) were included with similar baseline conditions. An analysis for intention-to-treat was done by applying multilevel mixed models fitted by basal values and the health center: the HbA1c adjusted mean difference = -0.09 (95% CI: -0.29-0.10), the DQI-I adjusted mean difference = 0.25 (95% CI: -0.32-0.82), the MEDAS adjusted mean difference = 0.45 (95% CI: 0.01-0.89), moderate/high physical activity OR = 1.09 (95% CI: 0.64-1.86), not living a sedentary lifestyle OR = 0.97 (95% CI: 0.55-1.73), no smoking OR = 0.61 (95% CI: 0.54-1.06), EVA adjusted mean difference = -1.26 (95% CI: -4.98-2.45). Conclusions: No statistically significant changes were found for either glycemic control or physical activity, sedentary lifestyle, smoking and quality of life. The multicomponent individual, group and community interventions only showed a statistically significant improvement in adhering to Mediterranean diet. Such innovative interventions need further research to demonstrate their effectiveness in patients with poor glycemic control.

The Modified Healthy Ageing Index Is Associated with Mortality and Disability: The Rugao Longevity and Ageing Study

INTRODUCTION

The Healthy Ageing Index (HAI) has been shown not only to have wider applicability and predictive ability but also to adequately predict mortality in Western populations. There is still a lack of studies validating the applicability of the HAI in China.

OBJECTIVE

To evaluate the applicability of the HAI and validate whether the HAI is suitable for monitoring ageing in the elderly population in China.

METHODS

Data were obtained from the Rugao Longevity and Ageing Study. The modified HAI was constructed based on systolic blood pressure, chronic pulmonary diseases, cognitive function, fasting glucose, and kidney function. It was calculated in 1719 individuals aged 70-84 years at baseline. The adverse outcomes were mortality and disability. Demographic, physiologic, and clinical data were collected. Cox proportional hazards and logistic regression models were used to analyze the relationship between the modified HAI and adverse outcomes.

RESULTS

A total of 1,719 older adults were analyzed in our study. A total of 793 (46.13%) males were recruited. The mean age was 75.69 ± 3.93 years. At the 5-year follow-up, there were 266 deaths and 275 individuals with disabilities. In the multivariable models, the modified HAI was associated with mortality (hazard ratio = 1.11, 95% confidence interval [CI]: 1.03-1.20) and disability (odds ratio = 1.11, 95% CI: 1.05-1.18). In the sensitivity analyses, similar associations remained after imputing missing data using multiple imputation and excluding participants with major cardiovascular disease at baseline.

CONCLUSION

The modified HAI was a robust and independent predictor of adverse outcomes. It is a valid and feasible tool for monitoring ageing in older adults.

Effect of Calorie Restriction and Exercise on Type 2 Diabetes

Type-2 diabetes (T2D) is a chronic condition, generally regarded as an irreversible, that is among the top 10 causes of death globally. The hallmark of T2D is hyperglycemia, which results from disturbances in insulin sensitivity, insulin secretion, β-cell dysfunction and insulin resistance. Several clinical and lifestyle factors are involved in the progression of T2D, such as obesity and physical inactivity. A high-calorie diet is the main contributor to the development of obesity, which results in T2D, as obesity or increased intra-abdominal adipose tissue is related to insulin resistance. Technological advances have contributed to individuals having a more sedentary lifestyle, leading to obesity and T2D. T2D can be treated with lifestyle interventions, such as diet and exercise. Herein, we highlight the positive impact of a very low-calorie diet (VLCD) and lifestyle modalities in the treatment and prevention of T2D. An inclusion of VLCD 400-800 kcal/day for 8 weeks and ≥ 150 minutes exercise 5 times a week as lifestyle interventions can decrease glucose levels to normal, reduce HbA1c and improve insulin resistance and sensitivity. Therefore, a potential mechanism in maintaining glucose homeostasis and remission of T2D by VLCD and exercise reduces body weight.

Cancer prevention through weight control-where are we in 2020?

Growing data from epidemiological studies highlight the association between excess body fat and cancer incidence, but good indicative evidence demonstrates that intentional weight loss, as well as increasing physical activity, offers much promise as a cost-effective approach for reducing the cancer burden. However, clear gaps remain in our understanding of how changes in body fat or levels of physical activity are mechanistically linked to cancer, and the magnitude of their impact on cancer risk. It is important to investigate the causal link between programmes that successfully achieve short-term modest weight loss followed by weight-loss maintenance and cancer incidence. The longer-term impact of weight loss and duration of overweight and obesity on risk reduction also need to be fully considered in trial design. These gaps in knowledge need to be urgently addressed to expedite the development and implementation of future cancer-control strategies. Comprehensive approaches to trial design, Mendelian randomisation studies and data-linkage opportunities offer real possibilities to tackle current research gaps. In this paper, we set out the case for why non-pharmacological weight-management trials are urgently needed to support cancer-risk reduction and help control the growing global burden of cancer.

International Exercise Recommendations in Older Adults (ICFSR): Expert Consensus Guidelines

The human ageing process is universal, ubiquitous and inevitable. Every physiological function is being continuously diminished. There is a range between two distinct phenotypes of ageing, shaped by patterns of living - experiences and behaviours, and in particular by the presence or absence of physical activity (PA) and structured exercise (i.e., a sedentary lifestyle). Ageing and a sedentary lifestyle are associated with declines in muscle function and cardiorespiratory fitness, resulting in an impaired capacity to perform daily activities and maintain independent functioning. However, in the presence of adequate exercise/PA these changes in muscular and aerobic capacity with age are substantially attenuated. Additionally, both structured exercise and overall PA play important roles as preventive strategies for many chronic diseases, including cardiovascular disease, stroke, diabetes, osteoporosis, and obesity; improvement of mobility, mental health, and quality of life; and reduction in mortality, among other benefits. Notably, exercise intervention programmes improve the hallmarks of frailty (low body mass, strength, mobility, PA level, energy) and cognition, thus optimising functional capacity during ageing. In these pathological conditions exercise is used as a therapeutic agent and follows the precepts of identifying the cause of a disease and then using an agent in an evidence-based dose to eliminate or moderate the disease. Prescription of PA/structured exercise should therefore be based on the intended outcome (e.g., primary prevention, improvement in fitness or functional status or disease treatment), and individualised, adjusted and controlled like any other medical treatment. In addition, in line with other therapeutic agents, exercise shows a dose-response effect and can be individualised using different modalities, volumes and/or intensities as appropriate to the health state or medical condition. Importantly, exercise therapy is often directed at several physiological systems simultaneously, rather than targeted to a single outcome as is generally the case with pharmacological approaches to disease management. There are diseases for which exercise is an alternative to pharmacological treatment (such as depression), thus contributing to the goal of deprescribing of potentially inappropriate medications (PIMS). There are other conditions where no effective drug therapy is currently available (such as sarcopenia or dementia), where it may serve a primary role in prevention and treatment. Therefore, this consensus statement provides an evidence-based rationale for using exercise and PA for health promotion and disease prevention and treatment in older adults. Exercise prescription is discussed in terms of the specific modalities and doses that have been studied in randomised controlled trials for their effectiveness in attenuating physiological changes of ageing, disease prevention, and/or improvement of older adults with chronic disease and disability. Recommendations are proposed to bridge gaps in the current literature and to optimise the use of exercise/PA both as a preventative medicine and as a therapeutic agent.

Associations of muscle-strengthening and aerobic exercise with self-reported components of sleep health among a nationally representative sample of 47,564 US adults

OBJECTIVES

Evidence demonstrates that physical activity is favorably associated with indicators of sleep health. However, population-based studies rarely examine the relationship between different physical activity modalities (ie, aerobic exercise vs muscle-strengthening exercise) with components of sleep health.

METHODS

Cross-sectional analyses were conducted on the US 2017 Behavioral Risk Factor Surveillance System. Validated items assessed self-reported moderate-to-vigorous-intensity aerobic physical activity (MVPA), muscle-strengthening exercise (MSE), sleep duration, difficulties and disorders. Poisson regression assessed prevalence ratios (PR) of 5 components of detrimental sleep health (short sleep; long sleep; poor quality sleep; observed snoring; and observed breathing stoppage) separately for adults 18-64 years and ≥65 years, across 4 categories of physical activity guideline adherence (met neither [reference]; MSE only; MVPA only; met both).

RESULTS

The sample comprised 47,564 adults (mean age: 48.4 years; ±1.4; 51.6% female). Among those 18-64 years, with the exception of short sleep (4-6 hours), for all other detrimental sleep health components, the lowest PRs were observed among those meeting both MVPA-MSE guidelines. Among those aged ≥65 years, for all 5 detrimental sleep health components, compared to the other physical activity categories, the lowest PRs were observed among those meeting both MVPA-MSE guidelines. All associations remained after adjusting for potential confounders (sex, education, income, smoking, alcohol, depression, hypertension, diabetes).

CONCLUSION

A physical activity routine that includes both MVPA and MSE is likely to be beneficial for better sleep health. Longitudinal studies are needed to establish the temporal relationships between MVPA/MSE guideline adherence and sleep health.

Association of metabolic phenotypes, grip strength and diabetes risk: The 15-year follow-up of The North West Adelaide Health Study, Australia

BACKGROUND

The association of diabetes risk in the long-term, metabolic phenotypes (MP) and muscle strength is unclear. We aimed to investigate the association between strictly defined MP, grip strength (GS) and diabetes.

MATERIAL AND METHODS

MP were defined according to BMI and presence of any individual metabolic abnormality for ≥18 years, in participants of the North West Adelaide Health Study (Australia) free of diabetes at baseline. The association of MP and dominant hand GS with incident diabetes over 15-years follow-up and the moderation effect of GS on the association between diabetes and MP were investigated by logistic regression models.

RESULTS

Of 3039 participants followed over 13.3 years (SD 2.6), 236 (7.8%) developed diabetes. Compared to the metabolically healthy (MH) normal weight phenotype, the metabolically unhealthy (MU) overweight (OR 6.15, 95%CI 2.43-15.59) and obese (OR 12.32, 95%CI 4.97-30.52) phenotypes were associated with a high risk of diabetes, but not the MU normal weight (OR 1.73, 95%CI 0.57-5.25), MH overweight (OR 1.15, 95%CI 0.31-4.31) or MH obese phenotypes (OR 0.77, 0.07-8.89). GS was inversely associated with diabetes (OR 0.97, 95% CI 0.95-0.99) and attenuated the risk associated with MU overweight (beta = -0.296, p = 0.039) and MU normal weight (beta = -0.773; p for interaction = 0.009).

CONCLUSION

Strictly defined MP (rather than based on metabolic syndrome criteria) and GS, a proxy of muscle strength, might be useful for stratifying the risk of diabetes in the long-term. Improving muscle strength might be an important strategy to reduce diabetes risk.

The metabolic syndrome - What is it and how should it be managed?

A cluster of metabolic factors have been merged into an entity named the metabolic syndrome. Although the characteristics of this syndrome have varied over time the presently used definition was established in 2009. The presence of three abnormal findings out of five components qualifies a person for the metabolic syndrome: elevated waist circumference, elevated triglycerides, reduced high-density lipoprotein cholesterol, elevated blood pressure and elevated fasting plasma glucose. Cut points have been defined for all components apart from waist circumference, for which national or regional values are used. The metabolic syndrome predicts cardiovascular disease and type 2 diabetes. This associated risk does not exceed its components whereof elevated blood pressure is the most frequent. A successful management should, however, address all factors involved. The management is always based on healthy lifestyle choices but has not infrequently to be supported by pharmacological treatment, especially blood pressure lowering drugs. The metabolic syndrome is a useful example of the importance of multiple targets for preventive interventions. To be successful management has to be individualized not the least when it comes to pharmacological therapy. Frail elderly people should not be over-treated. Knowledge transfer of how risk factors act should be accompanied by continuous trust building and motivation. In complex situations with a mix of biological risk factors, adverse social conditions and unhealthy lifestyle, everything cannot be changed at once. It is better to aim for small steps that are lasting than large, unsustainable steps with relapses to unhealthy behaviours. A person with the metabolic syndrome will always be afflicted by its components, which is the reason that management has to be sustained over a very long time. This review summarizes the knowledge on the metabolic syndrome and its management according to present state of the art.

Using a group medical visit model to promote healthy behaviour change with an underserved population

BACKGROUND

Models of care are needed to address physical activity, nutrition promotion and weight loss in primary care settings, especially with underserved populations who are disproportionately affected by chronic illness. Group medical visits (GMVs) are one approach that can help overcome some of the barriers to behaviour change in underserved populations, including the amount of time required to care for these patients due to socio-economic stressors and psychosocial complexities (1). GMVs have been shown to improve care in coronary artery disease and diabetes, but more evidence is needed in underserved settings.

OBJECTIVE

This project sought to evaluate a GMV incorporating a physical activity component in an underserved patient population, measuring biometric and motivation outcome measures.

METHODS

This project used a pre-post intervention study design through patient surveys at baseline and 12 weeks. We included validated motivational measures along with self-reported demographic information. A GMV intervention promoting physical activity and nutrition to promote weight loss was delivered by an interdisciplinary primary care team and community partners in a Federally Qualified Health Center in Rochester, NY. The intervention consisted of six, 2-hour sessions that occurred every other week at the clinic site.

RESULTS

Participants lost a significant amount of weight and maintained the weight loss at 6 months. In addition, there was a significant improvement in motivation measures.

CONCLUSION

This study provides preliminary evidence that our GMV model can improve weight loss and autonomous motivation in an underserved population. This project has potential for scalability and sustainability.

Efficacy of a Multi-component m-Health Weight-loss Intervention in Overweight and Obese Adults: A Randomised Controlled Trial

BACKGROUND

This study compared the efficacy of two multi-component m-health interventions with a wait-list control group on body weight (primary outcome), and secondary outcomes of cardiovascular risk factors, lifestyle behaviours, and mental health.

METHODS

Three-arm randomised controlled trial (Enhanced: physical activity, diet, sleep, Traditional: physical activity, diet, Control) with assessments conducted at baseline, 6 and 12 months. Participants (n = 116) were overweight or obese adults aged 19-65 (M = 44.5 [SD = 10.5]). The 6-month intervention was delivered via a smartphone app providing educational materials, goal-setting, self-monitoring and feedback, and also included one face-to-face dietary consultation, a Fitbit and scales. The trial was prospectively registered and conducted between May 2017 and September 2018. Group differences on primary and secondary outcomes were examined between the Pooled Intervention groups (Pooled Intervention = Enhanced and Traditional) and Control groups, and then between Enhanced and Traditional groups.

RESULTS

Nineteen participants (16.4%) formally withdrew from the trial. Compared with the Control group, average body weight of the Pooled Intervention group did not differ at 6 (between-group difference = -0.92, (95% CI -3.33, 1.48)) or 12 months (0.00, (95% CI -2.62, 2.62)). Compared with the Control group, the Pooled Intervention group significantly increased resistance training (OR = 7.83, (95% CI 1.08, 56.63)) and reduced energy intake at 6 months (-1037.03, (-2028.84, -45.22)), and improved insomnia symptoms at 12 months (-2.59, (-4.79, -0.39)). Compared with the Traditional group, the Enhanced group had increased waist circumferences (2.69, (0.20, 5.18)) and sedentary time at 6 months (105.66, (30.83, 180.48)), and improved bed time variability at 12 months (-1.08, (-1.86, -0.29)). No other significant differences were observed between groups.

CONCLUSIONS

Relative to Controls, the Pooled Intervention groups did not differ on body weight but improved resistance training, and reduced energy intake and insomnia symptom severity. No additional weight loss was apparent when targeting improvements in physical activity, diet and sleep in combination compared with physical activity and diet.

The Effect of Aerobic and Resistance Training and Combined Exercise Modalities on Subcutaneous Abdominal Fat: A Systematic Review and Meta-analysis of Randomized Clinical Trials

Subcutaneous abdominal adipose tissue (SAT), is the largest fat depot and major provider of free fatty acids to the liver. Abdominal fat is indirectly (via increased levels of low-grade inflammation) correlated with many of the adverse health effects of obesity. Although exercise is one of the most prominent components of obesity management, its effects on SAT are still unclear. The aim of this study was to investigate the independent effects of aerobic training (AT) and resistance training (RT) modalities and combined exercise modalities on SAT in adults. PubMed, SCOPUS, and Google Scholar were searched to find relevant publications up to November 2018. The effect sizes were represented as weighted mean difference (WMD) and 95% CIs. Between-study heterogeneity was examined using the I2 test. Overall, 43 identified trials that enrolled 3552 subjects (2684 women) were included. After removal of outliers, combining effect sizes indicated a significant effect of AT (WMD: -13.05 cm2; 95% CI: -18.52, -7.57; P < 0.001), RT (WMD: -5.39 cm2; 95% CI: -9.66, -1.12; P = 0.01), and combined exercise training (CExT; WMD: -28.82 cm2; 95% CI: -30.83, -26.81; P < 0.001) on SAT relative to control groups. Pooled effect sizes demonstrated a significant effect of AT on SAT compared with a CExT group (WMD: 11.07 cm2; 95% CI: 1.81, 20.33; P = 0.01). However, when comparing the AT and RT groups, no significant difference was seen in SAT (WMD: -0.73 cm2; 95% CI: -4.50, 3.04; P = 0.70). Meta-analysis of relevant trials indicated that AT, RT, and CExT lead to SAT reduction. Aerobic exercise was shown to produce greater efficacy in decreasing SAT.

Effects of Exercise Combined with a Healthy Diet or Calanus finmarchicus Oil Supplementation on Body Composition and Metabolic Markers-A Pilot Study

Aging is accompanied by a progressive decline in muscle mass and an increase in fat mass, which are detrimental changes associated with the development of health conditions such as type-2 diabetes mellitus or chronic low-grade inflammation. Although both exercise as well as nutritional interventions are known to be beneficial in counteracting those age-related changes, data to which extent untrained elderly people may benefit is still sparse. Therefore, a randomized, controlled, 12-week interventional trial was conducted in which 134 healthy untrained participants (96 women and 38 men, age 59.4 ± 5.6 years, body mass index (BMI) 28.4 ± 5.8 kg/m²) were allocated to one of four study groups: (1) control group with no intervention (CON); (2) 2×/week aerobic and resistance training only (EX); (3) exercise routine combined with dietary counseling in accordance with the guidelines of the German Nutrition Society (EXDC); (4) exercise routine combined with intake of 2 g/day oil from Calanus finmarchicus (EXCO). Body composition (bioelectrical impedance analysis), as well as markers of glucose metabolism and blood lipids, were analyzed at the beginning and the end of the study. The highest decreases in body fat were observed within the EXCO group (−1.70 ± 2.45 kg, p < 0.001), and the EXDC (−1.41 ± 2.13 kg, p = 0.008) group. Markers of glucose metabolism and blood lipids remained unchanged in all groups. Taken together results of this pilot study suggest that a combination of moderate exercise and intake of oil from Calanus finmarchicus or a healthy diet may promote fat loss in elderly untrained overweight participants.

A Wearable Technology Delivering a Web-Based Diabetes Prevention Program to People at High Risk of Type 2 Diabetes: Randomized Controlled Trial

BACKGROUND

Intensive lifestyle interventions are effective in reducing the risk of type 2 diabetes, but the implementation of learnings from landmark studies is expensive and time consuming. The availability of digital lifestyle interventions is increasing, but evidence of their effectiveness is limited.

OBJECTIVE

This randomized controlled trial (RCT) aimed to test the feasibility of a web-based diabetes prevention program (DPP) with step-dependent feedback messages versus a standard web-based DPP in people with prediabetes.

METHODS

We employed a two-arm, parallel, single-blind RCT for people at high risk of developing diabetes. Patients with a hemoglobin A_1c (HbA_1c) level of 39-47 mmol/mol were recruited from 21 general practices in London. The intervention integrated a smartphone app delivering a web-based DPP course with SMS texts incorporating motivational interviewing techniques and step-dependent feedback messages delivered via a wearable device over 12 months. The control group received the wearable technology and access to the web-based DDP but not the SMS texts. As this was a feasibility study, the primary aim was to estimate potential sample size at different stages of the study, including the size of the target study population and the proportion of participants who consented, were randomized, and completed follow-up. We also measured the main outcomes for a full-scale RCT, namely, change in weight and physical activity at 6- and 12-month follow-ups, and secondary outcomes, including changes in the HbA_1c level, blood pressure, waist circumference, waist-to-hip ratio, and lipid levels.

RESULTS

We enrolled 200 participants: 98 were randomized to the intervention and 102 were randomized to the control group. The follow-up rate was higher in the control group (87/102, 85.3%) than in the intervention group (69/98, 70%) at 12 months. There was no treatment effect on weight at 6 months (mean difference 0.15; 95% CI -0.93 to 1.23) or 12 months (mean difference 0.07 kg; 95% CI -1.29 to 1.44) or for physical activity levels at 6 months (mean difference -382.90 steps; 95% CI -860.65 to 94.85) or 12 months (mean difference 92.64 steps; 95% CI -380.92 to 566.20). We did not observe a treatment effect on the secondary outcomes measured at the 6-month or 12-month follow-up. For the intervention group, the mean weight was 92.33 (SD 15.67) kg at baseline, 91.34 (SD 16.04) kg at 6 months, and 89.41 (SD 14.93) kg at 12 months. For the control group, the mean weight was 92.59 (SD 17.43) kg at baseline, 91.71 (SD 16.48) kg at 6 months, and 91.10 (SD 15.82) kg at 12 months. In the intervention group, the mean physical activity was 7308.40 (SD 4911.93) steps at baseline, 5008.76 (SD 2733.22) steps at 6 months, and 4814.66 (SD 3419.65) steps at 12 months. In the control group, the mean physical activity was 7599.28 (SD 3881.04) steps at baseline, 6148.83 (SD 3433.77) steps at 6 months, and 5006.30 (SD 3681.1) steps at 12 months.

CONCLUSIONS

This study demonstrates that it is feasible to successfully recruit and retain patients in an RCT of a web-based DPP.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02919397; http://clinicaltrials.gov/ct2/show/NCT02919397.

Community-based interventions for prevention of Type 2 diabetes in low- and middle-income countries: a systematic review

Type 2 diabetes is an increasing burden in low- and middle-income countries (LMICs). Knowledge of effective prevention programs in LMICs is thus important. The aim of this review was to establish an overview of studies evaluating the effectiveness of community-based interventions for prevention of Type 2 diabetes in LMICs. A literature review with searches in the databases using MEDLINE in Ovid (Ovid MEDLINE® In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily, Ovid MEDLINE and Version (R); Embase; PsycINFO; Global Health; and Google Scholar) between 1 January 2000 and 31 December 2015 was conducted. Only 10 studies that met our selection criteria were included; 3 were randomized controlled trials, 2 non-randomized controlled trials and 5 were pre-and post-intervention studies. About 9 of 10 studies reported significant reduction in both the glycated hemoglobin (HbA1c) and fasting blood glucose (FBG) levels as a result of the intervention. A majority of the studies included multicomponent interventions such as education and behavioral encompassing both individual and group work, and included health education, nutrition education, nutrition counseling, exercise and promoting physical activity, psychosocial approaches and lifestyle modification. The interventions were delivered by community health workers, volunteers, social workers, community nutritionists and community nurses. Comparisons between studies, however, was not possible due to substantial heterogeneity in study design. This review contributes to the current literature on community-based interventions for prevention of Type 2 diabetes in LMICs, acknowledging the community-based approach can be effective in prevention and control of Type 2 diabetes. Due to the heterogeneity across study designs, outcomes and in terms of variation and duration of interventions, only limited conclusions can be drawn about the effectiveness of interventions. More evidence from randomized controlled trials on culturally tailored, community-based interventions is needed to compare findings and test implementation in practice.

Exercise Training, Intermittent Fasting and Alkaline Supplementation as an Effective Strategy for Body Weight Loss: A 12-Week Placebo-Controlled Double-Blind Intervention with Overweight Subjects

BACKGROUND

Intermittent fasting (IF) combined with exercise has been suggested to enhance weight loss. However, both procedures might negatively influence acid-base status. The aim of this study was to determine the combined effects of IF, exercise training and alkaline supplementation in overweight subjects on body composition and running performance.

METHODS

80 overweight subjects of age 45.5 ± 7.8 years were assigned to IF or non-intermittent fasting (nIF). Furthermore, subjects were randomly assigned to take either an alkaline supplement (IF-v, nIF-v) or a placebo (IF-p, nIF-p) twice a day. All subjects performed a personalized endurance exercise program (3-4 times/week for 12 weeks). Body weight, body composition, running performance and acid-base parameters were determined before (pre) and after the 12-week program (post).

RESULTS

68 participants completed the study. There was a significant effect on body weight loss, body fat loss, visceral fat loss and running performance enhancement in all groups (p < 0.01) for pre and post measurements. Body weight decreased in all groups (IF-p: -5.80 ± 0.77 kg and nIF-p: -3.40 ± 0.58 kg; IF-v: -8.28 ± 0.75 kg and nIF-v: -5.59 ± 0.87 kg). In both dietary strategies, weight loss was significantly further enhanced by alkaline supplementation. The increase in running velocity was significantly higher in IF combined with alkaline supplementation (IF-v 1.73 ± 0.23 km/h and IF-p 0.97 ± 0.20 km/h). In addition, alkaline supplementation increased plasma HCO₃^- concentration and urinary pH.

CONCLUSION

Exercise training in combination with IF and alkaline supplementation is an effective strategy to reduce body weight and improve running performance in a 12-week intervention.

Inulin-type fructans supplementation improves glycemic control for the prediabetes and type 2 diabetes populations: results from a GRADE-assessed systematic review and dose-response meta-analysis of 33 randomized controlled trials

Background

Currently, many clinical trials have shown that inulin-type fructans (ITF) supplementation is associated with glycemic control; nevertheless, the results are inconclusive. The aim of this meta-analysis of randomized controlled trials was to assess the effects of ITF supplementation on glycemic control.

Methods

PubMed, EMBASE and the Cochrane Library were searched for eligible articles up to March 6, 2019. A random-effects model was used to analyze the pooled results, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was applied to assess the quality of evidence. The dose–response model was used to recommend the daily dose and duration for ITF supplementation.

Results

Thirty-three trials involving 1346 participants were included. Overall, ITF supplementation could significantly reduce concentrations of fasting blood glucose (FBG), glycosylated hemoglobin (HbA1c), fasting insulin (FINS) and homeostasis model assessment-insulin resistance (HOMA-IR). In the prediabetes and type 2 diabetes (T2DM) population, a more significant reduction in FBG [weighted mean difference (WMD): − 0.60 mmol/l; 95% CI − 0.71, − 0.48 mmol/l; high rate], HbA1c (WMD: − 0.58%; 95% CI − 0.83, − 0.32%; high rate), FINS (WMD: − 1.75 µU/ml; 95% CI − 2.87, − 0.63 µU/ml; low rate), and HOMA-IR (WMD: − 0.69; 95% CI − 1.10, − 0.28; low rate) were observed, and ITF supplementation with a daily dose of 10 g for a duration of 6 weeks and longer was recommended. Moreover, subgroup analyses suggested that the effects of glycemic control were significantly influenced by the sex of the subjects and the type and the method of intake of ITF.

Conclusions

Our analyses confirmed that these four main glycemic indicators were significantly reduced by ITF supplementation, particularly in the prediabetes and T2DM population. Evidence supports that reasonable administration of ITF supplementation may have potential clinical value as an adjuvant therapy for prediabetes and T2DM management.

Trial registration The trial was registered at PROSPERO as CRD42018115875 on November 23, 2018.

Effectiveness of Exercise Intervention in Reducing Body Weight and Glycosylated Hemoglobin Levels in Patients with Type 2 Diabetes Mellitus in Korea: A Systematic Review and Meta-Analysis

BACKGROUND

This study aimed to assess the effectiveness of exercise intervention in reducing body weight and glycosylated hemoglobin (HbA1c) level in patients with type 2 diabetes mellitus (T2DM) in Korea.

METHODS

Cochrane, PubMed, Embase, KoreaMed, KMbase, NDSL, KCI, RISS, and DBpia databases were used to search randomized controlled trials and controlled clinical trials that compared exercise with non-exercise intervention among patients with non-insulin-treated T2DM in Korea. The effectiveness of exercise intervention was estimated by the mean difference in body weight changes and HbA1c level. Weighted mean difference (WMD) with its corresponding 95% confidence interval (CI) was used as the effect size. The pooled mean differences of outcomes were calculated using a random-effects model.

RESULTS

We identified 7,692 studies through literature search and selected 23 articles (723 participants). Compared with the control group, exercise intervention (17 studies) was associated with a significant decline in HbA1c level (WMD, -0.58%; 95% CI, -0.89 to -0.27; I²=73%). Although no significant effectiveness on body weight was observed, eight aerobic training studies showed a significant reduction in body weight (WMD, -2.25 kg; 95% CI, -4.36 to -0.13; I²=17%) in the subgroup analysis.

CONCLUSION

Exercise significantly improves glycemic control; however, it does not significantly reduce body weight. Aerobic training can be beneficial for patients with non-insulin-treated T2DM in Korea.

Evaluation of the digital diabetes prevention programme pilot: uncontrolled mixed-methods study protocol

INTRODUCTION

The prevalence of type 2 diabetes is rising steeply. National Health Service England (NHSE) is exploring the potential of a digital diabetes prevention programme (DDPP) and has commissioned a pilot with embedded evaluation.

METHODS AND ANALYSIS

This study aims to determine whether, and if so, how, should NHSE implement a national DDPP, using a mixed-methods pretest and post-test design, underpinned by two theoretical frameworks: the Coventry, Aberdeen and London - Refined (CALO-RE) taxonomy of behavioural change techniques for the digital interventions and the Consolidated Framework for Implementation Research (CFIR) for implementation processes. In eight pilot areas across England, adults with non-diabetic hyperglycaemia (NDH) (glycated haemoglobin (HbA1c) 42-47 mmol/mol or fasting plasma glucose 5.5-6.9 mmol/L) and adults without NDH who are overweight (body mass index (BMI) >25 kg/m²) or obese (BMI >30 kg/m²) will be referred to one of five digitally delivered diabetes prevention interventions. The primary outcomes are reduction in HbA1c and weight (for people with NDH) and reduction in weight (for people who are overweight or obese) at 12 months. Secondary outcomes include use of the intervention, satisfaction, physical activity, patient activation and resources needed for successful implementation. Quantitative data will be collected at baseline, 6 months and 12 months by the digital intervention providers. Qualitative data will be collected through semistructured interviews with commissioners, providers, healthcare professionals and patients. Quantitative data will be analysed descriptively and using generalised linear models to determine whether changes in outcomes are associated with demographic and intervention factors. Qualitative data will be analysed using framework analysis, with data pertaining to implementation mapped onto the CFIR.

ETHICS AND DISSEMINATION

The study has received ethical approval from the Public Health England Ethics and Research Governance Group (reference R&D 324). Dissemination will include a report to NHSE to inform future policy and publication in peer-reviewed journals.

Association of abdominal muscle composition with prediabetes and diabetes: The CARDIA study

AIM

To evaluate the relationship of abdominal muscle lean tissue and adipose tissue volumes with prediabetes and diabetes.

RESEARCH DESIGN AND METHODS

We measured abdominal muscle composition in 3170 participants in the Coronary Artery Risk Development in Young Adults (CARDIA) study who underwent computed tomography (CT) at Year 25 of follow-up (ages, 43-55 years). Multinomial regression analysis was used to evaluate the associations of CT-measured intermuscular adipose tissue (IMAT), lean muscle tissue (lean) and visceral adipose tissue (VAT) volumes with diabetes at any point during the CARDIA study, newly detected prediabetes, prior history of prediabetes, and normal glucose tolerance. Models were adjusted for potential confounding factors: age, sex, race, height, smoking status, hypertension, hyperlipidaemia, cardiorespiratory fitness and study centre.

RESULTS

Higher IMAT, lean and VAT volumes were all separately associated with a higher prevalence of prediabetes and diabetes. Inclusion of VAT volume in models with both IMAT volume and lean volume attenuated the association of IMAT with both prediabetes and diabetes, but higher lean volume retained its association with prediabetes and diabetes. Individuals in the highest IMAT quartile, coupled with VAT in its lower three quartiles, had a higher prevalence of diabetes, but not of prediabetes, than those with both IMAT and VAT in their respective lower three quartiles. Adjusting for cardiorespiratory fitness did not substantially change the findings.

CONCLUSION

Higher IMAT volume was associated with a higher prevalence of diabetes even after adjustment for VAT volume. However, further study is warranted to understand the complicated relationship between abdominal muscle and adipose tissues.

A qualitative study of cardiovascular disease risk communication in NHS Health Check using different risk calculators: protocol for the RIsk COmmunication in NHS Health Check (RICO) study

BACKGROUND

NHS Health Check is a national cardiovascular disease (CVD) risk assessment programme for 40-74 year olds in England, in which practitioners should assess and communicate CVD risk, supported by appropriate risk-management advice and goal-setting. This requires effective communication, to equip patients with knowledge and intention to act. Currently, the QRISK®2 10-year CVD risk score is most common way in which CVD risk is estimated. Newer tools, such as JBS3, allow manipulation of risk factors and can demonstrate the impact of positive actions. However, the use, and relative value, of these tools within CVD risk communication is unknown. We will explore practitioner and patient CVD risk perceptions when using QRISK®2 or JBS3, the associated advice or treatment offered by the practitioner, and patients' responses.

METHODS

RIsk COmmunication in NHS Health Check (RICO) is a qualitative study with quantitative process evaluation. Twelve general practices in the West Midlands of England will be randomised to one of two groups: usual practice, in which practitioners use QRISK®2 to assess and communicate CVD risk; intervention, in which practitioners use JBS3. Twenty Health Checks per practice will be video-recorded (n = 240, 120 per group), with patients stratified by age, gender and ethnicity. Post-Health Check, video-stimulated recall (VSR) interviews will be conducted with 48 patients (n = 24 per group) and all practitioners (n = 12-18), using video excerpts to enhance participant recall/reflection. Patient medical record reviews will detect health-protective actions in the first 12-weeks following a Health Check (e.g., lifestyle referrals, statin prescription). Risk communication, patient response and intentions for health-protective behaviours in each group will be explored through thematic analysis of video-recorded Health Checks (using Protection Motivation Theory as a framework) and VSR interviews. Process evaluation will include between-group comparisons of quantitatively coded Health Check content and post-Health Check patient outcomes. Finally, 10 patients with the most positive intentions or behaviours will be selected for case study analysis (using all data sources).

DISCUSSION

This study will produce novel insights about the utility of QRISK®2 and JBS3 to promote patient and practitioner understanding and perception of CVD risk and associated implications for patient intentions with respect to health-protective behaviours (and underlying mechanisms). Recommendations for practice will be developed.

TRIAL REGISTRATION

ISRCTN ISRCTN10443908 . Registered 7th February 2017.

Diets along with interval training regimes improves inflammatory & anti-inflammatory condition in obesity with type 2 diabetes subjects

Background

Different physical activities and diets change the regulation of inflammations in both type 2 diabetes (T2D) patients and obese individuals, but the effect of both (Physical activity and diet) on pro/anti-inflammations has remained unknown. We investigated pro/anti-inflammations control, cardiovascular function, and total physiological parameters before and after 24 weeks of low volume high intensity interval training (HIIT) on a cycle ergometer along with four dietary regimes in obesity with T2D patients.

Methods

33 non-active obesity T2D patients (BMI ≥ 30) midges (47 yrs. ± 5) were volunteered to participate and randomly divided into three experimental(n = 11) [(1) LCD = low Carbohydrate Diet, (2) LFD = Low Fat Diet and (3) HFD = High Fat Diet)] and one control (n = 9) [ND = normal diet] groups. The whole groups performed underwent 8-week dietary regimes and then performed 3 days/weeks (3 set 10 × 60 s) HIIT on a cycle ergometer for 12 weeks, which followed by a 4-week diet period again. Also, prior to and after 8 weeks diet-12 weeks High Intensity Interval Training (HIIT) and 4 weeks diet 2-h oral glucose tolerance test (OGTT), resting blood pressure, incremental maximal oxygen uptake (VO2peak) cycle ergometer test and blood sample was collected from the subjects in order to measure pro/anti-inflammatory cytokines (IL-6, TNF-α, leptin, resistin, adiponectin, and FGF21).

Results

After 24 weeks of intervention, the results indicated that the highest improvement in the percentage of changes in glucose happened in LCD (-34.76), insulin in ND (+16.43), cholesterol in LCD (-33.35), LDL in LFD (-9.14), HDL in LCD (+41.81), TG in LCD (-40.71), weight in LCD (-12.49) and HOMA-IR in HFD (-6.82). The results also indicated that after 24 weeks of HIIT and diet interventions, highest benefit percentage change IL-6, resistin and leptin occurred in LCD (-32.10, -28.29 and - 53.92, respectively), TNF-α, FGF21 and adiponectin in LFD (-48.06, +55.30 and + 42.32, respectively). However, these changes were observed in other groups.

Conclusions

These results demonstrated that HIIT along with low carbohydrate regimes improves overall cardiovascular parameters and reduce pro-inflammatory markers and increase anti-inflammatory markers in type 2 diabetic patients. Additionally, as with HIIT along with low carbohydrate, HIIT coupled with low fat would improve inflammation markers, though these effects were less significant. These findings suggest that HIIT along with low carbohydrate is a beneficial exercise and dietary strategy in T2D patients.

Examining the efficacy of a multicomponent m-Health physical activity, diet and sleep intervention for weight loss in overweight and obese adults: randomised controlled trial protocol

INTRODUCTION

Traditional behavioural weight loss trials targeting improvements in physical activity and diet are modestly effective. It has been suggested that sleep may have a role in weight loss and maintenance. Improving sleep health in combination with physical activity and dietary behaviours may be one strategy to enhance traditional behavioural weight loss trials. Yet the efficacy of a weight loss intervention concurrently targeting improvements in physical activity, dietary and sleep behaviours remains to be tested.

METHODS AND ANALYSIS

The primary aim of this three-arm randomised controlled trial is to examine the efficacy of a multicomponent m-Health behaviour change weight loss intervention relative to a waitlist control group. The secondary aims are to compare the relative efficacy of a physical activity, dietary behaviour and sleep intervention (enhanced intervention), compared with a physical activity and dietary behaviour only intervention (traditional intervention), on the primary outcome of weight loss and secondary outcomes of waist circumference, glycated haemoglobin, physical activity, diet quality and intake, sleep health, eating behaviours, depression, anxiety and stress and quality of life. Assessments will be conducted at baseline, 6 months (primary endpoint) and 12 months (follow-up). The multicomponent m-Health intervention will be delivered using a smartphone/tablet 'app', supplemented with email and SMS and individualised in-person dietary counselling. Participants will receive a Fitbit, body weight scales to facilitate self-monitoring, and use the app to access educational material, set goals, self-monitor and receive feedback about behaviours. Generalised linear models using an analysis of covariance (baseline adjusted) approach will be used to identify between-group differences in primary and secondary outcomes, following an intention-to-treat principle.

ETHICS AND DISSEMINATION

The Human Research Ethics Committee of The University of Newcastle Australia provided approval: H-2017-0039. Findings will be disseminated via publication in peer-reviewed journals, conference presentations, community presentations and student theses.

TRIAL REGISTRATION NUMBER

ACTRN12617000735358; UTN1111-1219-2050.

Effectiveness of interventions aimed at improving dietary behaviours among people at higher risk of or with chronic non-communicable diseases: an overview of systematic reviews

Programmes that promote dietary behaviour change for the prevention of chronic disease must include components that are rooted in best practice and associated with effectiveness. The purpose of this overview of systematic reviews was to examine the characteristics and dietary behaviour change outcomes of nutrition interventions among populations with or at risk of non-communicable chronic diseases. Systematic reviews of randomised controlled trials (RCTs) testing dietary behaviour change interventions published between January 2006 and November 2015 were identified via searches in Cochrane Library, PubMed, EMBASE and PsycINFO. Quality of reviews were appraised using AMSTAR. Dietary behaviour change and intervention details were extracted and systematically summarised. Fifteen articles met the inclusion criteria. Dietary behaviour changes in response to nutrition interventions were significant in over half of interventions. Reducing dietary fat and increasing fruits and vegetables were the most common behaviour changes. The characteristics of nutrition interventions and their relationship to effectiveness for dietary behaviour change among chronic disease or at-risk populations were reported inconsistently. However, associative evidence exists to support more frequent contacts and the use of specific behaviour change techniques. No clear relationships were found between effectiveness and intervention setting, mode of delivery or intervention provider, although some population-specific relationships were identified. Interventions that promote long-term maintenance of dietary behaviour changes are lacking in the literature. This comprehensive umbrella review identifies specific characteristics of interventions that are associated with effectiveness in interventions that promote dietary behaviour change among different at-risk populations. In order to maximise outcomes, public health, health promotion and healthcare organisations should consider these results in order to inform the development and improvement of nutrition programmes.

Feeding in adults with type II diabetes mellitus in three public hospitals in Cundinamarca, Colombia

Introduction: Type II diabetes mellitus (DMII) is one of the main causes of morbidity and mortality both worldwide and in Colombia. It mainly affects men and women over 45 years of age. Inadequate control of this disease can generate greater health complications making it one of the most costly diseases in the country. Treatment includes activities other than glycemic control and requires constant monitoring by medical personnel and educational processes directed at the patient and his or her family. Objective: To characterize the feeding of patients with DMII in three public hospitals of Cundinamarca. Materials and methods: We conducted a cross-sectional descriptive study of 212 patients that analyzed sociodemographic characteristics, frequency of consumption and feeding practices. Results: Most of the population was over 45 years old and had a low educational level. In total, 52% had a dietary plan, but only 8.9% received nutritional guidance from a nutritionist. The consumption of carbohydrates predominated, with low consumption of proteins, vitamins, minerals, and fiber. The consumption of sugars was lower in patients with a dietary plan (p <0.05). Conclusions: Most of the patients did not have an adequate nutrition; moreover, there was low adherence to dietary treatment, weakness in nutritional counseling and barriers to food access. These results can contribute to improving policies for the prevention and control of DMII and strategies based on the sociocultural context of the patients.

Diabetes Intervention Accentuating Diet and Enhancing Metabolism (DIADEM-I): a randomised controlled trial to examine the impact of an intensive lifestyle intervention consisting of a low-energy diet and physical activity on body weight and metabolism in early type 2 diabetes mellitus: study protocol for a randomized controlled trial

Background

Type 2 diabetes mellitus (T2DM) and obesity are syndemic and will have a significant impact on affected individuals and healthcare services worldwide. Evidence shows that T2DM remission can be achieved with significant weight loss in those who are younger with early diabetes and requiring fewer medications for glycaemic control. DIADEM-I aims to examine the impact of an intensive lifestyle intervention (ILI) using a low-energy diet (LED) meal replacement approach combined with physical activity in younger individuals with early T2DM.

Methods

The planned study is an ongoing, non-blinded, pragmatic, randomised controlled, parallel-group trial examining the impact of an LED-based ILI on body weight and diabetes remission in younger (18–50 years) T2DM individuals with early diabetes (≤ 3-year duration). The ILI will be compared to usual medical care (UMC). The primary outcome will be weight loss at 12 months. Other key outcomes of interest include diabetes remission, glycaemic control, diabetes complications, cardiovascular health, physical activity, mental health, and quality of life. It is planned for the study to include 138 subjects for assessment of the primary outcome. Safety will be assessed throughout.

Discussion

If DIADEM-I demonstrates a clinically significant effect for younger individuals with early T2DM, it will inform clinical guidelines and services of the future for management of T2DM.

Trial registration

ISRCTN: ISRCTN20754766 (date assigned: 7 June 2017); ClinicalTrials.gov, ID: NCT03225339 Registered on 26 June 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2660-1) contains supplementary material, which is available to authorized users.

Usefulness of a Short Dietary Propensity Questionnaire in Japan

Aim: There is a growing need for nutritional education for prevention and non-pharmacological treatment of risk factors for cardiovascular diseases (CVD). We compared the results of a short dietary propensity questionnaire (SDPQ) with those from the food frequency and quantity survey (FF Quantity), which had been previously quantitatively assessed by comparison with the 24-hr dietary recall (24hr-DR), to examine the usefulness of the SDPQ. The SDPQ was designed to assess dietary propensities of 12 food/nutrients relevant to CVD risk factors.

Methods: We conducted a dietary survey using the SDPQ on Japanese men and women. After 2–3 weeks, we conducted the FF Quantity survey with the same participants. For each of the 12 food/nutrient categories, the relationships between quintiles of results from the SDPQ and FF Quantity were examined. Results from 79 participants who completed both surveys were used.

Results: Spearman's correlation coefficients (r) were significant for all food/nutrient categories. Good correlations were found with alcohol (r = 0.792), starchy foods (r = 0.566), and milk and dairy products (r = 0.687), for which good correlations between the FF Quantity and 24hr-DR had been observed previously. Moderate correlations were found for vegetables (r = 0.386) and high-salt foods (r = 0.505), although the FF Quantity survey poorly correlated with the 24hr-DR.

Conclusion: The SDPQ may be useful for assessment of dietary propensities for alcohol, starchy foods, and milk and dairy products in Japan.

HOMBRE: A randomized controlled trial to compare two approaches to weight loss for overweight and obese Latino men (Hombres con Opciones para Mejorar el Bienestar y bajar el Riesgo de Enfermedades crónicas; men with choices to improve well-being and decrease chronic disease risk)

Latino men bear a disproportionate burden of obesity, diabetes, and cardiovascular disease.However, limited behavioral lifestyle intervention research has focused on Latino men. This trial compares two approaches to weight loss for overweight and obese Latino men: 1) HOMBRE is a culturally adapted intervention that provides individual choice of either self-directed online videos, coach-facilitated in-person groups, and coach-facilitated online groups; and 2) a minimal intensity intervention that uses online videos with a coach available, if solicited by the participant.Latino men with a Body Mass Index (BMI) of ≥27 kg/m2 and one or more cardiometabolic risk factors (n = 424) will be randomly assigned to receive one of the two approaches.The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework guides the planned evaluations.The primary aim is to determine the effectiveness of the HOMBRE intervention (the "E" in RE-AIM) on clinically significant weight loss (≥5% of baseline weight) at 18 months. We hypothesize that a significantly higher proportion of HOMBRE participants will maintain ≥5% of weight loss compared with those in the minimal intensity intervention.Secondary aims are to determine the effectiveness of HOMBRE on cardiometabolic risk factors (e.g., blood pressure, waist circumference), health behaviors (e.g., diet and physical activity), and psychosocial well-being (e.g., quality of life and depressive symptoms) and to evaluate the other attributes of RE-AIM. These findings have real word applicability with value to clinicians, patients, and other decision makers considering effective diabetes prevention programs for Latino men in primary care.

Psychological factors of healthful diet promotion among diabetics: an application of health action process approach

Background and aim

Worldwide, type 2 diabetes mellitus (T2DM) prevalence has increased. Non-healthful diet is one of the main reasons to T2DM growth. This study aims to determine the efficacy of the health action process approach (HAPA) in explaining healthful diet (HD) in T2DM patients.

Methods

This cross-sectional study was conducted based on HAPA in Isfahan, Iran between July and December 2015. Participants were recruited by convenience sampling method. HAPA inventory was administered to 203 Isfahan diabetics. Intentions, outcome expectancies, risk perception, action self-efficacy, action and coping planning, maintenance and recovery self-efficacy, and dietary style were the constructs measured. Structural equation modeling (SEM) in AMOS 21 was used to test the hypothesis.

Results

The results based on the common fit indices revealed that the HAPA fitted the data acceptably well among the T2DM patients and within dietary behavior (p<0.001), RMSEA=0.082, CFI=0.903, NFI=0.899). Action self-efficacy was the best predictor of intention (β=2.49, p<0.001). Result revealed action and coping planning (β=5.36, p=0.027) and recovery self-efficacy (β=5.67, p=0.021) significantly predicted behavior.

Conclusions

Our findings provide preliminary support for the practical usage of the HAPA model for predicting HD intention and behavior among T2DM patients. Randomized controlled trials should be performed in the future in order to involve causality.

Predictors of adherence to exercise interventions during and after cancer treatment: A systematic review

Objective

Exercise interventions benefit cancer patients. However, only low numbers of patients adhere to these interventions. This review aimed to identify predictors of exercise intervention adherence in patients with cancer, during and after multimodality cancer treatment.

Methods

A literature search was performed using electronic databases (PubMed, Embase, and Cochrane) to identify relevant papers published before February 1, 2017. Papers reporting randomized controlled trials, conducted in adult cancer patients who participated in an exercise intervention during and/or after multimodality cancer treatment, and providing outcome of factors predicting exercise adherence were included. Papers were assessed for methodological quality by using the Physiotherapy Evidence Database scale.

Results

The search identified 720 potentially relevant papers, of which 15 fulfilled the eligibility criteria. In these 15 studies, 2279 patients were included and 1383 of these patients were randomized to an exercise intervention. During cancer treatment, the factors predicting exercise adherence were as follows: location of the rehabilitation center, extensive exercise history, high motivation for exercise, and fewer exercise limitations. After cancer treatment, factors that predicted adherence were as follows: less extensive surgery, low alcohol consumption, high previous exercise adherence, family support, feedback by trainers, and knowledge and skills of exercise. Methodological quality of the included papers was rated “high”.

Conclusions

The most prominent predictors of adherence to exercise interventions were location of the rehabilitation center, extensive exercise history, high motivation for exercise, and fewer exercise limitations. To increase the number of cancer patients who will benefit, these results should be considered into the development and implementation of future exercise interventions.

Reducing the Risk of Type 2 Diabetes in Nonselected Outpatients With Schizophrenia: A 30-Month Program

BACKGROUND

Type 2 diabetes is 2- to 3-fold more common in patients with schizophrenia than in the general population. A lifestyle with a focus on diet, exercise, and medication is required to prevent complications from type 2 diabetes, but patients with schizophrenia frequently have trouble maintaining such a lifestyle because of factors related to their illness, such as cognitive disturbances, negative and positive symptoms, and side effects of psychotropic medications.

OBJECTIVE

To measure and reduce risk factors for type 2 diabetes in patients with schizophrenia and examine characteristics associated with positive outcomes.

METHODS

This study, which was conducted in clinics treating both newly diagnosed and long-term (LT) patients with schizophrenia, evaluated the effects of a 30-month naturalistic intervention on improvement in the physical health of patients treated for schizophrenia and reduction in their risk factors for type 2 diabetes. The clinical intervention incorporated individual guidance, group sessions, and treatment as usual.

RESULTS

Patients newly diagnosed with schizophrenia were found to have high consumption of soft drinks and low physical activity at their index evaluation. At follow-up, the physical profile of these patients had worsened, with increased weight, waist circumferences, visceral adiposity index (P=0.030), and glycosylated hemoglobin (HbA1c; P=0.010). Average HbA1c values increased in newly diagnosed male patients by 0.24 mmol/l (P=0.007). At follow-up, LT patients improved with regard to their consumption of soft drinks (P=0.001) and fast food (P=0.009). The LT patients also reduced their weight and waist circumferences and became more physically active. No changes in HbA1c values were found in the LT patients during the intervention period.

CONCLUSION

The study found that positive outcomes were associated with female sex and a longer duration of illness. Negative outcomes with worsening of risk factors were associated with being newly diagnosed with schizophrenia and male sex. It was possible to produce improvements in some risk factors through individual health-oriented lifestyle interventions, especially in LT patients.

Diet, physical activity or both for prevention or delay of type 2 diabetes mellitus and its associated complications in people at increased risk of developing type 2 diabetes mellitus

BACKGROUND

The projected rise in the incidence of type 2 diabetes mellitus (T2DM) could develop into a substantial health problem worldwide. Whether diet, physical activity or both can prevent or delay T2DM and its associated complications in at-risk people is unknown.

OBJECTIVES

To assess the effects of diet, physical activity or both on the prevention or delay of T2DM and its associated complications in people at increased risk of developing T2DM.

SEARCH METHODS

This is an update of the Cochrane Review published in 2008. We searched the CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, ICTRP Search Portal and reference lists of systematic reviews, articles and health technology assessment reports. The date of the last search of all databases was January 2017. We continuously used a MEDLINE email alert service to identify newly published studies using the same search strategy as described for MEDLINE up to September 2017.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with a duration of two years or more.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology for data collection and analysis. We assessed the overall quality of the evidence using GRADE.

MAIN RESULTS

We included 12 RCTs randomising 5238 people. One trial contributed 41% of all participants. The duration of the interventions varied from two to six years. We judged none of the included trials at low risk of bias for all 'Risk of bias' domains.Eleven trials compared diet plus physical activity with standard or no treatment. Nine RCTs included participants with impaired glucose tolerance (IGT), one RCT included participants with IGT, impaired fasting blood glucose (IFG) or both, and one RCT included people with fasting glucose levels between 5.3 to 6.9 mmol/L. A total of 12 deaths occurred in 2049 participants in the diet plus physical activity groups compared with 10 in 2050 participants in the comparator groups (RR 1.12, 95% CI 0.50 to 2.50; 95% prediction interval 0.44 to 2.88; 4099 participants, 10 trials; very low-quality evidence). The definition of T2DM incidence varied among the included trials. Altogether 315 of 2122 diet plus physical activity participants (14.8%) developed T2DM compared with 614 of 2389 comparator participants (25.7%) (RR 0.57, 95% CI 0.50 to 0.64; 95% prediction interval 0.50 to 0.65; 4511 participants, 11 trials; moderate-quality evidence). Two trials reported serious adverse events. In one trial no adverse events occurred. In the other trial one of 51 diet plus physical activity participants compared with none of 51 comparator participants experienced a serious adverse event (low-quality evidence). Cardiovascular mortality was rarely reported (four of 1626 diet plus physical activity participants and four of 1637 comparator participants (the RR ranged between 0.94 and 3.16; 3263 participants, 7 trials; very low-quality evidence). Only one trial reported that no non-fatal myocardial infarction or non-fatal stroke had occurred (low-quality evidence). Two trials reported that none of the participants had experienced hypoglycaemia. One trial investigated health-related quality of life in 2144 participants and noted that a minimal important difference between intervention groups was not reached (very low-quality evidence). Three trials evaluated costs of the interventions in 2755 participants. The largest trial of these reported an analysis of costs from the health system perspective and society perspective reflecting USD 31,500 and USD 51,600 per quality-adjusted life year (QALY) with diet plus physical activity, respectively (low-quality evidence). There were no data on blindness or end-stage renal disease.One trial compared a diet-only intervention with a physical-activity intervention or standard treatment. The participants had IGT. Three of 130 participants in the diet group compared with none of the 141 participants in the physical activity group died (very low-quality evidence). None of the participants died because of cardiovascular disease (very low-quality evidence). Altogether 57 of 130 diet participants (43.8%) compared with 58 of 141 physical activity participants (41.1%) group developed T2DM (very low-quality evidence). No adverse events were recorded (very low-quality evidence). There were no data on non-fatal myocardial infarction, non-fatal stroke, blindness, end-stage renal disease, health-related quality of life or socioeconomic effects.Two trials compared physical activity with standard treatment in 397 participants. One trial included participants with IGT, the other trial included participants with IGT, IFG or both. One trial reported that none of the 141 physical activity participants compared with three of 133 control participants died. The other trial reported that three of 84 physical activity participants and one of 39 control participants died (very low-quality evidence). In one trial T2DM developed in 58 of 141 physical activity participants (41.1%) compared with 90 of 133 control participants (67.7%). In the other trial 10 of 84 physical activity participants (11.9%) compared with seven of 39 control participants (18%) developed T2DM (very low-quality evidence). Serious adverse events were rarely reported (one trial noted no events, one trial described events in three of 66 physical activity participants compared with one of 39 control participants - very low-quality evidence). Only one trial reported on cardiovascular mortality (none of 274 participants died - very low-quality evidence). Non-fatal myocardial infarction or stroke were rarely observed in the one trial randomising 123 participants (very low-quality evidence). One trial reported that none of the participants in the trial experienced hypoglycaemia. One trial investigating health-related quality of life in 123 participants showed no substantial differences between intervention groups (very low-quality evidence). There were no data on blindness or socioeconomic effects.

AUTHORS' CONCLUSIONS

There is no firm evidence that diet alone or physical activity alone compared to standard treatment influences the risk of T2DM and especially its associated complications in people at increased risk of developing T2DM. However, diet plus physical activity reduces or delays the incidence of T2DM in people with IGT. Data are lacking for the effect of diet plus physical activity for people with intermediate hyperglycaemia defined by other glycaemic variables. Most RCTs did not investigate patient-important outcomes.

What is the most effective exercise protocol to improve cardiovascular fitness in overweight and obese subjects?

BACKGROUND

Increased peak oxygen consumption (VO_2peak) can reduce cardiovascular risks associated with obesity. Our aim was to analyze the effect of a weight loss program on cardiovascular fitness in overweight (W) and obese (O) subjects.

METHODS

One hundred and sixty-seven subjects (77 males and 90 females), aged 18-50 years, performed a modified Bruce protocol before (pre) and after (post) a weight loss program of 24 weeks. This program combined physical training (strength, S; endurance, E; combined strength + endurance, SE; or physical activity recommendation, PA) 3 times per week, with a 25%-30% caloric restriction diet.

RESULTS

VO_2peak improved in overweight and obese males (pre and post values in L/min, respectively; W = 3.2 ± 0.6 vs. 3.7 ± 0.5, p < 0.001; O = 3.6 ± 0.6 vs. 3.8 ± 0.6, p = 0.013) as well as in overweight females (2.0 ± 0.3 vs. 2.3 ± 0.4, p < 0.001). VO_2peak in the first ventilatory threshold (VT₁) increased for all 4 interventions in males (p < 0.05), except for S in the obese group (1.6 ± 0.2 vs. 1.7 ± 0.3, p = 0.141). In females, it increased in E (0.9 ± 0.2 vs. 1.4 ± 0.3, p < 0.001), SE (0.9 ± 0.2 vs. 1.2 ± 0.4, p = 0.003), and PA (0.9 ± 0.1 vs. 1.2 ± 0.2, p = 0.006) in overweight groups. Time-to-exhaustion improved in all subjects except for females in PA group (15.7 ± 0.3 min vs. 15.9 ± 0.3 min, p = 0.495).

CONCLUSION

Our results suggest that all methods, including the recommendation of physical activity, can improve cardiovascular fitness in overweight subjects and obese males.

Effect of a vitamin and mineral supplementation on glycemic status: Results from a community-based program

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Vitamin D and a multivitamin supplement in a natural experiment is described.

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Both vitamin D and the multivitamin were associated with a greater chance of regression to normoglycemia.

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Higher vitamin D levels were associated with better outcomes.

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This simple, inexpensive intervention may have implications for prevention of diabetes.

Aims

Diet is a major risk factor for type 2 diabetes mellitus. As cofactors necessary for enzyme function of all metabolic pathways, vitamins and minerals have the potential to improve glucose metabolism. We investigated the effects of a nutrient intervention program on glycemic status.

Methods

We used a form of natural experiment to compare Pure North program participants (n = 1018) that received vitamin D alone (Vital 1) or vitamin D in combination with other nutrients (Vital 2) during two different time periods. Changes in 25-hydroxyvitamin D [25(OH)D], high-sensitivity C reactive protein (hs-CRP), glycated hemoglobin (HbA1c) and glycemic status were characterized over one and two years.

Results

Serum 25(OH)D concentrations increased significantly in both Vital 1 (to 111  ±  49 nmol/L) and Vital 2 (to 119  ±  52 nmol/L) over one year. HbA1c and hs-CRP were significantly reduced over time in Vital 2. Higher 25(OH)D levels after one year were associated with larger decreases in HbA1c and hs-CRP in Vital 2. At one year, 8% of Vital 2 and 16% of Vital 1 participants progressed from normoglycemia to prediabetes/diabetes, whereas 44% of Vital 2 and 8% of Vital prediabetes/diabetes subjects regressed to normoglycemia.

Conclusions

Vitamin D combined with other nutrients was associated with a reduced risk of progression to diabetes and with an increased rate of reversion to normoglycemia in high risk participants. The results suggest that nutrient supplementation regimes may provide a safe, economical and effective means for lowering diabetes risk. Further examination of this potential via randomized controlled trials is warranted.

A protocol for the development and piloting of quality measures to support the Healthier You: The NHS Diabetes Prevention Programme

Background

The increasing prevalence of type 2 diabetes in the UK creates an additional, potentially preventable burden on health care and service providers. The Healthier You: NHS Diabetes Prevention Programme aims to reduce the incidence of type 2 diabetes through the identification of people at risk and the provision of intensive lifestyle change support. The provision of this care can be monitored through quality measurement at both the general practice and specialist service level.

Aim

To develop quality measures through piloting to assess the validity, credibility, acceptability, reliability, and feasibility of any proposed measures.

Design & setting

The non-experimental mixed design piloting study consists of consensus testing and exploratory research with GPs, commissioners, and patients from Herefordshire, England.

Method

A mixed-method approach will be used to develop and validate measures for diabetes prevention care and evaluate their performance over a 6-month pilot period consisting of consensus testing using a modified RAND approach with GPs and commissioners; four focus groups with 8-10 participants discussing experiences of non-diabetic hyperglycaemia (NDH), perceived ability to access care and prevent diabetes, and views on potential quality measures; and piloting final measures with at least five general practices for baseline and 6-month data.

Results

The findings will inform the implementation of the diabetes prevention quality measures on a national scale while addressing any issue with validity, credibility, feasibility, and cost-effectiveness.

Conclusion

Healthcare professionals and patients have the opportunity to evaluate the reliability, acceptability, and validity of measures.