Effects of a lifestyle program in subjects with Impaired Fasting Glucose, a pragmatic cluster-randomized controlled trial

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.

Dose-dependent effects of insoluble fibre on glucose metabolism: a stratified post hoc analysis of the Optimal Fibre Trial (OptiFiT)

AIMS

As the first long-term RCT on insoluble cereal fibre, the optimal fibre trial demonstrated glycometabolic benefits, confirming cohort studies. The combined study intervention of lifestyle recommendations and supplementation with insoluble oat hulls fibre allows to clarify, which amount of fibre is required for a beneficial effect.

METHODS

One hundred and eighty participants with impaired glucose tolerance underwent the one-year PREDIAS lifestyle programme and received a blinded, randomized fibre or placebo supplement for two years. We conducted a regression analyses and cut-off-based tertile comparisons in subjects with full data on dietary compliance (food records and accounted supplement; n = 120) after one year, investigating effects on fasting blood parameters, oral glucose tolerance test and anthropometry.

RESULTS

We found a nonlinear inverse relation between fibre intake and change in postprandial 2-h glucose levels, showing a metabolic benefit beyond 14 g and a plateau beyond 25 g of total insoluble fibre per day. 2-h glucose levels improved significantly stronger in both upper tertiles (-0.9 [-1.6;-0.2] mmol/l, p = 0.047, and -0.6 [-1.6;0.3] mmol/l, p = 0.010) compared to the lowest tertile (0.1 [-1.2;1.1] mmol/l), also when adjusted for changes in bodyweight. Subjects with the highest fibre intake showed superior effects on fasting and postprandial insulin resistance, hepatic insulin clearance, leucocyte count and fatty liver index.

CONCLUSIONS

Extending the knowledge on the benefits of insoluble oat hulls fibre, our post hoc analysis demonstrates a dose effect for glycaemia and associated metabolic markers. Further research is needed in order to replicate our findings in larger trials.

Effects of a Proactive Interdisciplinary Self-Management Program on Patient Self-Efficacy and Participation During Practice Nurse Consultations: A Randomized Controlled Trial in Type 2 Diabetes

Background

Nowadays, patients with chronic conditions such as type 2 diabetes mellitus (T2DM) need and want to be more active participants in their health care. This study aimed to investigate the effects of the Proactive Interdisciplinary Self-Management (PRISMA) training program on participation during consultations with practice nurses and self-efficacy of patients with T2DM in general practice.

Methods

Within a randomized controlled trial, patients were followed for 6 months. They received either PRISMA in addition to usual care or usual care only. Self-efficacy was assessed using the 5-item Perceived Efficacy in Patient-Physician Interactions (PEPPI-5) scale. Consultations were video-recorded and analyzed using the Roter interaction analysis system. Multilevel analysis was carried out.

Results

No differences in the PEPPI-5 were found between the intervention (n = 101) and control groups (n = 102) (U = 1,737.5, z = -0.2, P = 0.8). In addition, the groups did not differ in patient participation. However, patients who attended the PRISMA program expressed more counselling utterances (B = 0.22; standard error (SE) = 0.09).

Conclusions

PRISMA did not result in higher self-efficacy or patient participation during the consultation with practice nurses at 6 months. Possibly, two training sessions are insufficient and a more powerful intervention might be needed. However, the study showed indications that patients counselled themselves more frequently during the consultation. Practice nurses could stimulate patients who are already engaged in self-counselling by further specifying their goals of behavior change.

A simple to implement and low-cost supervised walking programme in highly motivated individuals with or at risk for type 2 diabetes: An observational study with a pre-post design

This observational study with a pre-post design, conducted in two Dutch primary healthcare centres, aimed to evaluate the effect of a supervised walking programme in highly motivated individuals with or at risk for type 2 diabetes mellitus (T2DM). Those able and willing to walk at least 6 km, were invited for a 28-week walking programme (February to August 2017), in which participants walked in groups, once weekly under supervision of volunteer healthcare professionals. Changes in bodyweight, BMI, waist circumference, HbA1c, blood pressure, well-being, health status and patient activation were analysed using paired t-tests and the Wilcoxon signed-rank test. Fifty-six people were included (30 T2DM; 26 at risk), of whom 60.7% were female. Mean age was 60.6 years, median BMI 30.8 kg/m² and mean systolic blood pressure 146.9 mm Hg. Participants with T2DM had median HbA1c of 50.0 mmol/mol. Post-challenge, BMI had decreased to 29.7 kg/m², and waist circumference decreased 3.4 cm (95% CI 2.1-4.8), both p < 0.01. Systolic and diastolic blood pressure decreased significantly (mean difference 6.5 mm Hg (95% CI 1.6-11.3, p = 0.01) and 3.5 mm Hg (95% CI 1.0-6.0, p < 0.01), respectively). Participants with HbA1c >53 mmol/mol at baseline (n = 8), had median decrease in HbA1c of 6.5 mmol/mol (p = 0.03). Well-being, but not health status and patient activation, improved significantly. In conclusion, in highly motivated individuals with or at risk for T2DM, this simple to implement and low-cost, but intensive, volunteer-based supervised walking programme is favourable, and therefore, can be seen as an option for clinical programs to implement to support highly motivated patients.

Effects of lifestyle changes on adults with prediabetes: A systematic review and meta-analysis

AIMS

To assess the efficacy, safety, and cost-effectiveness of lifestyle intervention, compared with treatment as usual in people with prediabetes as defined by the American Diabetes Association. For older studies, we used the 1985 World Health Organization definition.

METHODS

We systematically searched multiple electronic databases and referenced lists of pertinent review articles from January 1980 through November 2015. We performed an update search in MEDLINE on April 26, 2017. Based on a priori established eligibility criteria, we dually reviewed the literature, extracted data, and rated the risk of bias of included studies with validated checklists. To assess the efficacy of lifestyle intervention to prevent or delay further progression to type 2 diabetes, we conducted a random-effects meta-analysis. We assessed the certainty of evidence using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.

RESULT

Pooled results of 16 randomized controlled trials showed that people with prediabetes who received lifestyle intervention had a lower rate of progression to type 2 diabetes after one (4% vs. 10%, RR 0.46 [CI 0.32, 0.66]) and three years of follow-up (14% vs. 23%, RR 0.64 [95% CI 0.53, 0.77]). The majority of the studies also showed a greater weight loss in lifestyle intervention participants, with a great variation between studies. Costs per quality-adjusted life-year were lower when the benefits of lifestyle intervention were analyzed over a lifelong time horizon compared to only the period of lifestyle intervention (three years) or to modeling over a ten-year period.

CONCLUSION

Lifestyle intervention is an efficacious, safe, and cost-effective measure to reduce the risk of progression to type 2 diabetes in people diagnosed with prediabetes. More research is necessary to compare the efficacy of various modes, frequencies, and intensities of lifestyle intervention across studies.

Engaging primary care professionals in collaborative processes for optimising type 2 diabetes prevention practice: the PREDIAPS cluster randomised type II hybrid implementation trial

BACKGROUND

There is a lack of evidence concerning the effectiveness of different strategies to engage healthcare professionals in collaborative processes that seek to optimise clinical practice. The PREDIAPS project aims to assess the effect of different primary health care (PHC) providers' engagement procedures in the creation and execution of a facilitated interprofessional collaborative process to optimise the integration of the recommended clinical practice for the prevention of type-2 diabetes (T2D) in routine PHC.

METHODS

This will be a randomised cluster type II hybrid implementation trial. Nine PHC centres from the Basque Health Service (Osakidetza) will be allocated to two different procedures to engage family doctors and nurses and create an interprofessional collaborative practice to optimise the integration of a T2D primary prevention programme. All centres and PHC professionals will receive training on current guidelines in primary prevention of T2D and effective interventions to promote healthy lifestyles. Headed by a local leader and an external facilitator, centres will conduct a collaborative structured process to model and adapt the intervention and its implementation to the specific context of professionals and centres. One of the groups will apply this strategy globally, promoting the cooperation of all health professionals from the beginning. The other will perform it sequentially, centred first on nurses, who will then seek the pragmatic cooperation of doctors. All patients without diabetes aged ≥ 30 years old who attend collaborating centres at least once during the study period and found to be at high risk of developing T2D will be eligible for programme inclusion. The main outcome measures focus on changes observed in indicators of T2D prevention clinical practice at centre level after 12 and 24 months, associated with the application of one or other engagement procedure. Secondary outcomes will compare their clinical effectiveness in changing eligible exposed patients' main lifestyle behaviours and risk factors (physical activity and diet, weight, etc.) after 12 months.

DISCUSSION

The PREDIAPS project will generate scientific knowledge on procedures for engaging PHC professional to facilitate feasible and effective adoption of proven interventions for the prevention of T2D in routine clinical practice through the application of implementation strategies.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT03254979 . Registered 16 August 2017.

Effective translation of a type-2 diabetes primary prevention programme into routine primary care: The PreDE cluster randomised clinical trial

AIMS

We assessed the effectiveness of a Type 2 diabetes mellitus (T2D) prevention programme in routine primary health care (PHC) in high-risk patients.

METHODS

Phase IV cluster clinical trial involving 14 PHC centres in the Basque Health Service were randomised to the DE-PLAN educational healthy lifestyle promotion programme or standard care. All non-diabetic 45- to 70-year-old PHC attendees considered at high risk of T2D (FINDRISC ≥ 14 points) were eligible. The primary outcome was the 24-month cumulative incidence of T2D confirmed by oral glucose tolerance testing. Secondary outcomes were self-reported physical activity and dietary changes at 12 months in a subsample.

RESULTS

Of the 4170 patients screened, 2128 (51%) were considered high risk, but 355 (33%) and 459 (43.6%) refused to participate in the control and intervention groups, respectively. Of all eligible non-diabetic patients, 634 and 454 were included in the control and intervention arms, 545 (85.9%) and 411 (90.5%) completed the follow-up. Intention-to-treat cumulative incidences of T2D were 12.1% (77/634) in the control group and 8.4% (38/454) in intervention group, with an absolute difference of 3.8% (95% CI: 0.18%-7.4%, p = 0.045) and a relative risk reduction of 32% (0.68; 95% CI: 0.47-0.99, p = 0.048) in favour of the intervention. Intervention patients were 1.83-fold more likely to meet recommended physical activity levels at 12 months (95% CI: 1.06-3.17, p = 0.03).

CONCLUSIONS

The DE-PLAN programme was effective in reducing T2D incidence in PHC high-risk patients. Research on implementation strategies to improve its feasible and sustainable adoption, reach and public health impact is warranted.

The effectiveness of a primary care nursing-led dietary intervention for prediabetes: a mixed methods pilot study

Background

Primary care nurse-led prediabetes interventions are seldom reported. We examined the implementation and feasibility of a 6-month multilevel primary care nurse-led prediabetes lifestyle intervention compared with current practice in patients with prediabetes, with weight and glycated haemoglobin (HbA1c) as outcomes.

Methods

This study used a convergent mixed methods design involving a 6-month pragmatic non-randomised pilot study with a qualitative process evaluation, and was conducted in two neighbouring provincial cities in New Zealand, with indigenous Māori populations comprising 18.2% and 23.0%, respectively. Participants were non-pregnant adults aged ≤ 70 years with newly diagnosed prediabetes (HbA1c 41-49 mmol/mol), body mass index (BMI) ≥ 25 kg/m² and not prescribed Metformin. A structured dietary intervention tool delivered by primary care nurses with visits at baseline, 2–3 weeks, 3 months and 6 months was implemented in four intervention practices. Four control practices continued to provide usual care. Primary quantitative outcome measures were weight and HbA1c. Linear and quantile regression models were used to compare each outcome between the two groups at follow-up. Qualitative data included: observations of nurse training sessions and steering group meetings; document review; semi-structured interviews with a purposive sample of key informants (n = 17) and intervention patients (n = 20). Thematic analysis was used.

Results

One hundred fifty-seven patients with prediabetes enrolled (85 intervention, 72 control), 47.8% female and 31.2% Māori. Co-morbidities were common, particularly hypertension (49.7%), dyslipidaemia (40.1%) and gout (15.9%). Baseline and 6 month measures were available for 91% control and 79% intervention participants. After adjustment, the intervention group lost a mean 1.3 kg more than the control group (p < 0.001). Mean HbA1c, BMI and waist circumference decreased in the intervention group and increased in the control group, but differences were not statistically significant. Implementation fidelity was high, and it was feasible to implement the intervention in busy general practice settings. The intervention was highly acceptable to both patients and key stakeholders, especially primary care nurses.

Conclusions

Study findings confirm the feasibility and acceptability of primary care nurses providing structured dietary advice to patients with prediabetes in busy general practice settings. The small but potentially beneficial mean weight loss among the intervention group supports further investigation.

Trial Registration

ANZCTR ACTRN12615000806561. Registered 3 August 2015 (Retrospectively registered).

Electronic supplementary material

The online version of this article (10.1186/s12875-017-0671-8) contains supplementary material, which is available to authorized users.

Diabetes prevention in the real world: Insights from the JDPP and J-DOIT1

Type 2 diabetes (T2D) is associated with increased risks of morbidity and mortality. Diabetes prevention is an urgent issue in Japan. The Finnish Diabetes Prevention Study and US Diabetes Prevention Program revealed that intensive lifestyle intervention can prevent or delay the development of T2D in high-risk populations. Translational research varies in hospitals, primary care, communities, the workplace, and other settings. Translational research is feasible but less effective. There have been no long-term follow-ups. The outcome of the studies was mainly weight changes. The Japan Diabetes Prevention Program (JDPP) is a trial to test the efficacy of a lifestyle intervention program, which carried out in a primary healthcare setting using existing resources. The Japan Diabetes Outcome Trial-1 (J-DOIT1) is a nationwide telephone-delivered lifestyle intervention in a real-world setting. This review will focus on the effectiveness of a diabetes prevention program (recruitment, target population, method of intervention, and evaluation) in the real world and insights from the JDPP and J-DOIT1.

Randomized Trials of Nurse-Delivered Interventions in Weight Management Research: A Systematic Review

The purpose of this systematic review was to determine whether nurse-delivered weight management interventions improve weight outcomes across the life span. We conducted a comprehensive search of the PubMed, CINAHL, and PsycINFO electronic databases. We graded the trials using an adapted Jadad approach for methodological quality. The search identified a total of 1,159 citations; 23 articles from 20 studies were eligible for this review. Sixty-five percent of the studies reported significant findings related to body mass index (BMI) or weight reduction. Studies that were particularly successful at helping participants reduce weight and/or BMI involved nurses engaged in health promotion activities, operating within multidisciplinary teams and/or providing consultations, physical activity education, and coaching over the phone. Of the studies that involved long-term follow-up assessments, three out of nine studies showed a significant loss in weight or BMI between the intervention and control groups at follow-up times ranging from 12 months to 2 years.