Four-year change in cardiorespiratory fitness and influence on glycemic control in adults with type 2 diabetes in a randomized trial: the Look AHEAD Trial

Weight loss and lifestyle intervention for cardiorespiratory fitness in obstructive sleep apnea: The INTERAPNEA trial

INTRODUCTION

Although recent trials have shown benefits of weight loss and lifestyle interventions on obstructive sleep apnea (OSA) severity and comorbidities, the effect of these interventions on cardiorespiratory fitness (CRF) remains unknown. This study aimed to investigate the effects of an interdisciplinary weight loss and lifestyle intervention on CRF and self-reported physical fitness in adults with OSA.

METHODS

Eighty-nine men aged 18-65 years with moderate-to-severe OSA and a body mass index ≥25 kg/m2 were randomly assigned to a usual-care group or an 8-week interdisciplinary weight loss and lifestyle intervention. CRF was assessed through the 2-km walking test, and the International Fitness Scale (IFIS) was used to assess self-reported physical fitness.

RESULTS

As compared with usual-care, the intervention group had greater improvements at intervention endpoint in objective CRF (6% reduction in 2-km walking test total time, mean between-group difference, -1.7 min; 95% confidence interval, -2.3 to -1.1), and self-reported overall physical fitness (18% increase in IFIS total score, mean between-group difference, 2.3; 95% CI 1.2 to 3.3). At 6 months after intervention, the intervention group also had greater improvements in both 2-km walking test total time (10% reduction) and IFIS total score (22% increase), with mean between-group differences of -2.5 (CI 95%, -3.1 to -1.8) and 3.0 (CI 95%, 1.8 to 4.1), respectively.

CONCLUSIONS

An 8-week interdisciplinary weight loss and lifestyle intervention resulted in significant and sustainable improvements in CRF and self-reported physical fitness in men with overweight/obesity and moderate-to-severe OSA.

STUDY REGISTRATION

ClinicalTrials.gov registration (NCT03851653).

Associations that Cardiorespiratory Fitness and Body Mass Index Loss Have with Deficit Accumulation Frailty

INTRODUCTION/PURPOSE

Lower cardiorespiratory fitness and obesity may accelerate aging processes. The degree to which changes in fitness and body mass index (BMI) may alter the rate of aging may be important for planning treatment. We assessed cross-sectional and longitudinal associations that cardiorespiratory fitness and BMI had with a deficit accumulation frailty index (FI).

METHODS

Fitness, based on standardized graded exercise tests, and weight to calculate BMI at baseline and year 4 were collected from 3944 participants aged 45-76 yr in the Action for Health in Diabetes (Look AHEAD) randomized controlled clinical trial. A validated 38-item deficit accumulation FI was used as a marker of aging. Associations between baseline and changes in fitness and BMI with changes in FI were assessed using linear models.

RESULTS

Both baseline and 4-yr changes in fitness and BMI were independently associated with 4-yr changes in frailty (all P < 0.001). Mean (95% confidence interval) changes in FI ranged from -0.019 (-0.024, -0.013) for participants in the group with the greatest fitness increase and BMI loss to 0.029 (0.024, 0.034) for participants in the group with the greatest fitness loss and BMI gain. Associations of 4-yr changes in fitness and BMI with FI changes were similar across subgroups based on age, sex, baseline BMI, diabetes duration, and cardiovascular disease history. Increased fitness across 4 yr was associated with less FI accumulation independent of baseline fitness.

CONCLUSIONS

Adults with type 2 diabetes and overweight or obesity may slow aging processes captured by an FI by increasing their cardiorespiratory fitness and losing weight.

Nutritional Aspects to Cardiovascular Diseases and Type 2 Diabetes Mellitus

PURPOSE OF REVIEW

In this narrative review, we discuss the current evidence related to the role of dietary interventions to prevent and treat type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD). We also propose alternative therapeutic strategies other than weight loss in this population, namely, improvements in cardiorespiratory fitness and its determinants.

RECENT FINDINGS

While weight loss has been consistently associated with the prevention of T2DM and improvements in glycemic control in those with established diseases, its role in preventing and treating CVD is less clear. In fact, in this setting, improvements in diet quality have provided greater benefits, suggesting that this might represent an alternative, or an even more effective strategy than energy-restriction. Improvements in diet quality, with and without caloric restriction have been shown to improve CVD risk and to prevent the development of T2DM in individuals at risk; however, with regard to glycemic control in patients with T2DM, any dietary intervention resulting in significant weight loss may produce clinically meaningful benefits. Finally, dietary interventions with and without energy restriction that can improve cardiorespiratory fitness, even in absence of weight loss in patients with obesity, should be encouraged.

Accumulated Short Bouts of Walking in Older Adults With Type 2 Diabetes: Effects on Glycosylated Hemoglobin (HbA1c) and Homeostasis Model Assessment of Insulin Resistance (HOMA-IR)

The current study examined the effects of accumulated short bouts of walking on glycosylated hemoglobin (HbA1c) and homeostasis model assessment of insulin resistance (HOMA-IR) of older adults with type 2 diabetes. Differences in variables between models of accumulated bouts of walking and 10,000 steps were also investigated. Sedentary participants (N = 38) were randomized into one of three groups: accumulated 10-minute bouts of walking at 100 steps/min (10/100MW), accumulated 10,000 steps (10KS), or control. HbA1c, HOMA-IR, blood lipids, and cardiorespiratory fitness (VO2max) were assessed before and after the intervention. VO2max, HbA1c, and HOMA-IR in the 10/100MW and 10KS groups showed significant and comparable improvements postintervention compared to preintervention (p < 0.05). Furthermore, the change in average daily step count was significantly associated with the change in HbA1c of the two walking groups (r = -0.61 for 10KS and r = -0.63 for 10/100MW; p < 0.05). Accumulated short bouts of walking at 100 steps/min and 10,000 steps daily improved HbA1c and HOMA-IR of older adults with type 2 diabetes. [Research in Gerontological Nursing, 16(5), 250-258.].

Longitudinal cardio-respiratory fitness prediction through wearables in free-living environments

Cardiorespiratory fitness is an established predictor of metabolic disease and mortality. Fitness is directly measured as maximal oxygen consumption (VO2max), or indirectly assessed using heart rate responses to standard exercise tests. However, such testing is costly and burdensome because it requires specialized equipment such as treadmills and oxygen masks, limiting its utility. Modern wearables capture dynamic real-world data which could improve fitness prediction. In this work, we design algorithms and models that convert raw wearable sensor data into cardiorespiratory fitness estimates. We validate these estimates' ability to capture fitness profiles in free-living conditions using the Fenland Study (N=11,059), along with its longitudinal cohort (N = 2675), and a third external cohort using the UK Biobank Validation Study (N = 181) who underwent maximal VO2max testing, the gold standard measurement of fitness. Our results show that the combination of wearables and other biomarkers as inputs to neural networks yields a strong correlation to ground truth in a holdout sample (r = 0.82, 95CI 0.80-0.83), outperforming other approaches and models and detects fitness change over time (e.g., after 7 years). We also show how the model's latent space can be used for fitness-aware patient subtyping paving the way to scalable interventions and personalized trial recruitment. These results demonstrate the value of wearables for fitness estimation that today can be measured only with laboratory tests.

Cardiorespiratory Fitness, BMI, Mortality, and Cardiovascular Disease in Adults with Overweight/Obesity and Type 2 Diabetes

INTRODUCTION

We estimated the effects of cardiorespiratory fitness (CRF) and body mass index (BMI) at baseline on mortality and cardiovascular disease events in people with type 2 diabetes who participated in the Look AHEAD randomized clinical trial.

METHODS

Look AHEAD compared effects of an intensive lifestyle intervention with diabetes support and education on cardiovascular disease events in 5145 adults age 45-76 yr with overweight/obesity and type 2 diabetes. In 4773 participants, we performed a secondary analysis of the association of baseline CRF during maximal treadmill test (expressed as metabolic equivalents (METs)) on mortality and cardiovascular disease events during a mean follow-up of 9.2 yr.

RESULTS

The mean (SD) CRF was 7.2 (2.0) METs. Adjusted for age, sex, race/ethnicity, BMI, intervention group, and β-blocker use, all-cause mortality rate was 30% lower per SD greater METs (hazard ratio (HR) = 0.70 (95% confidence interval, 0.60 to 0.81); rate difference (RD), -2.71 deaths/1000 person-years (95% confidence interval, -3.79 to -1.63)). Similarly, an SD greater METs predicted lower cardiovascular disease mortality (HR, 0.45; RD, -1.65 cases/1000 person-years) and a composite cardiovascular outcome (HR, 0.72; RD, -6.38). Effects of METs were homogeneous on the HR scale for most baseline variables and outcomes but heterogeneous for many on the RD scale, with greater RD in subgroups at greater risk of the outcomes. For example, all-cause mortality was lower by 7.6 deaths/1000 person-years per SD greater METs in those with a history of cardiovascular disease at baseline but lower by only 1.6 in those without such history. BMI adjusted for CRF had little or no effect on these outcomes.

CONCLUSIONS

Greater CRF is associated with reduced risks of mortality and cardiovascular disease events.

Impact of weight loss with diet or diet plus physical activity on cardiac magnetic resonance imaging and cardiovascular disease risk factors: Heart Health Study randomized trial

OBJECTIVE

The primary aim of this study was to examine the change in left ventricular mass (LVM) in adults with overweight or obesity in response to a behavioral weight-loss intervention, with variable physical activity (PA) prescriptions.

METHODS

A total of 383 adults were randomized to a 12-month intervention of diet modification (DIET), DIET plus 150 min/wk of PA (DIET+MODPA), or DIET plus prescription of 250 min/wk of PA (DIET+HIGHPA). LVM was measured with cardiac magnetic resonance imaging.

RESULTS

Twelve-month weight loss was -10.2% (95% CI: -11.7% to -8.8%) in the DIET group, -11.0% (95% CI: -12.4% to -9.5%) in the DIET+MODPA group, and -10.3% (95% CI: -11.8% to -8.9%) in the DIET+HIGHPA group. LVM decreased at 12 months in the DIET group (-2.9 g [95% CI: -5.2 to -0.7]; p = 0.0114), with no change observed in the DIET+MODPA group (-0.8 g [95% CI: -3.0 to 1.5]; p = 0.4979) or the DIET+HIGHPA group (-1.1 g [95% CI: -3.3 to 1.1]; p = 0.3299).

CONCLUSIONS

Weight loss through dietary modification resulted in reduced LVM, whereas, when combined with at least 150 min/wk of prescribed moderate-to-vigorous PA, LVM was preserved. These may both be favorable adaptations to weight loss and PA in adults with overweight or obesity that warrant further investigation to understand the clinical implications of these changes on cardiovascular disease risk.

Association Between Change in Accelerometer-Measured and Self-Reported Physical Activity and Cardiovascular Disease in the Look AHEAD Trial

OBJECTIVE

To conduct post hoc secondary analysis examining the association between change in physical activity. Measured with self-report and accelerometry, from baseline to 1 and 4 years and cardiovascular disease (CVD) outcomes in the Look AHEAD Trial.

RESEARCH DESIGN AND METHODS

Participants were adults with overweight/obesity and type 2 diabetes with physical activity. Data at baseline and year 1 or 4 (n = 1,978). Participants were randomized to diabetes support and education or intensive lifestyle intervention. Measures included accelerometry-measured moderate-to-vigorous physical activity (MVPA), self-reported physical activity, and composite (morbidity and mortality) CVD outcomes.

RESULTS

In pooled analyses of all participants, using Cox proportional hazards models, each 100 MET-min/week increase in accelerometry-measured MVPA from baseline to 4 years was associated with decreased risk of the subsequent primary composite outcome of CVD. Results were consistent for changes in total MVPA (hazard ratio 0.97 [95% CI 0.95, 0.99]) and MVPA accumulated in ≥10-min bouts (hazard ratio 0.95 [95% CI 0.91, 0.98]), with a similar pattern for secondary CVD outcomes. Change in accelerometry-measured MVPA at 1 year and self-reported change in physical activity at 1 and 4 years were not associated with CVD outcomes.

CONCLUSIONS

Increased accelerometry-measured MVPA from baseline to year 4 is associated with decreased risk of CVD outcomes. This suggests the need for long-term engagement in MVPA to reduce the risk of CVD in adults with overweight/obesity and type 2 diabetes.

Comprehensive Management of Cardiovascular Risk Factors for Adults With Type 2 Diabetes: A Scientific Statement From the American Heart Association

Cardiovascular disease remains the leading cause of death in patients with diabetes. Cardiovascular disease in diabetes is multifactorial, and control of the cardiovascular risk factors leads to substantial reductions in cardiovascular events. The 2015 American Heart Association and American Diabetes Association scientific statement, "Update on Prevention of Cardiovascular Disease in Adults With Type 2 Diabetes Mellitus in Light of Recent Evidence," highlighted the importance of modifying various risk factors responsible for cardiovascular disease in diabetes. At the time, there was limited evidence to suggest that glucose-lowering medications reduce the risk of cardiovascular events. At present, several large randomized controlled trials with newer antihyperglycemic agents have been completed, demonstrating cardiovascular safety and reduction in cardiovascular outcomes, including cardiovascular death, myocardial infarction, stroke, and heart failure. This AHA scientific statement update focuses on (1) the evidence and clinical utility of newer antihyperglycemic agents in improving glycemic control and reducing cardiovascular events in diabetes; (2) the impact of blood pressure control on cardiovascular events in diabetes; and (3) the role of newer lipid-lowering therapies in comprehensive cardiovascular risk management in adults with diabetes. This scientific statement addresses the continued importance of lifestyle interventions, pharmacological therapy, and surgical interventions to curb the epidemic of obesity and metabolic syndrome, important precursors of prediabetes, diabetes, and comorbid cardiovascular disease. Last, this scientific statement explores the critical importance of the social determinants of health and health equity in the continuum of care in diabetes and cardiovascular disease.

The Moderating Effects of Genetic Variations on Changes in Physical Activity Level and Cardiorespiratory Fitness in Response to a Life-Style Intervention: A Randomized Controlled Trial

OBJECTIVE

Prior studies identified single nucleotide polymorphisms (SNPs) associated with physical activity (PA) level in a natural environment and intervention study: rs978656-DNAPTP6, rs10887741-PAPSS2, rs7279064-C18orf2, and rs6265-BDNF. Using the four SNPs' polygenic score (PGS), we examined whether PGS moderates a life-style intervention's effect on changes in PA level and cardiorespiratory fitness (CRF).

METHODS

This is a secondary analysis of Look AHEAD, a multicenter randomized controlled trial designed to test the health benefits of a life-style intervention among 2675 participants with overweight/obesity and type 2 diabetes (ages, 45-76 years). Using linear mixed-effects models, level of PA (Paffenbarger PA questionnaire) and treadmill-assessed CRF were each regressed on four SNPs' PGS, study time (baseline, year 1, and year 4), intervention arm, and interactions between the three. Models adjusted for age, sex, body mass index, ancestry principal components (population stratification), and study sites, with Bonferroni corrections for multiple testing (α < .005). Effect modification by age was examined.

RESULTS

PGS was not predictive of change in CRF or PA level in response to intervention. In analyses without PGS by intervention by time, the relationships between PGS and PA phenotypes were modified by age (p interaction = .048 for CRF and .058 for PA), such that a 1-unit increase in PGS was associated with 24 kcal · wk-1 more in moderate-intensity PA and 0.004 MET higher CRF only among older groups (age >55 years for CRF, >60 years for PA level).

CONCLUSIONS

The effects of the intervention on PA and CRF were not moderated by the four SNPs. Future studies with extended SNP list should confirm the findings on effect modification by age.

Abnormal Exercise Test or CVD History on Weight Loss or Fitness: the Look AHEAD Trial

PURPOSE

Obesity and type 2 diabetes are associated with an increased risk of cardiovascular disease (CVD) and the combination of weight loss and increased physical exercise are commonly recommended to reduce CVD. This study examined whether people with obesity and type 2 diabetes with an abnormal graded exercise tolerance test (GXT) or a history of CVD would have less success in achieving weight loss and improved fitness, compared to adults without these conditions.

METHODS

The Look AHEAD Study examined whether an intensive lifestyle intervention (ILI) compared with diabetes support and education (DSE) reduced cardiovascular events in adults with overweight/obesity and type 2 diabetes. Participants underwent a baseline maximal GXT and provided medical history data. Weight loss and fitness change were examined in 5011 participants over four years in those with or without an abnormal baseline GXT and/or history of CVD.

RESULTS

After four years, weight loss in both ILI and DSE were significantly greater in those without a prior history of CVD than in those with a CVD history (6.69% vs 5.98%, p=0.02, in ILI and 0.73 vs -.07% (weight gain), p=0.01, in DSE). Likewise, those without a prior history of CVD experienced greater improvements in fitness in both ILI and DSE relative to those with a history of CVD. Having an abnormal GXT at baseline did not affect weight loss or fitness.

CONCLUSIONS

A history of CVD at baseline modestly lessened weight loss and fitness changes at 4 years, whereas having any abnormality on the baseline GXT did not affect these outcomes. Thus, weight loss and improved fitness are achievable in adults with a history of CVD or ECG abnormalities.

Effectiveness of strategies for nutritional therapy for patients with type 2 diabetes and/or hypertension in primary care: protocol of a systematic review of randomised controlled trials

INTRODUCTION

Despite the increasing number of drugs available and various guidelines on the management of type 2 diabetes mellitus (T2DM) and hypertension, an expressive number of patients continue with these diseases uncontrolled. Nutrition therapy (NT) plays a fundamental role in the prevention and management of these comorbidities, as well as in the prevention of complications related to them. The objective of this review is to evaluate the effectiveness of NT strategies in the management of patients with T2DM and/or hypertension in primary care. The selected strategies did not substitute pharmaceutical treatment but instead focused on preventing a sedentary lifestyle and stimulating healthy nutrition.

METHODS AND ANALYSIS

We will perform a systematic review according to Cochrane methodology of randomised controlled trials, wherein patients with T2DM and/or hypertension were allocated into one of the two groups: NT strategy, which may be of dietary quality or energy restriction, and conventional treatment. The primary outcomes will be glycaemic and blood pressure (BP) control, measured by final glycosylated hemoglobin (HbA1c) (%) and BP (mm Hg), respectively. Four general and adaptive search strategies have been created for the Embase, Medline, Latin American and Caribbean Health Sciences Literature (LILACS) and Cochrane Central Register of Controlled Trials (CENTRAL) electronic databases. Two reviewers will independently select eligible studies, assess the risk of bias and extract data from the included studies. Similar outcomes measured in at least two trials will be plotted in the meta-analysis using Review Manager V.5.3. The quality of evidence of the effect estimate of the intervention will be generated according to the Grading of Recommendations Assessment, Development, and Evaluation Working Group.

ETHICS AND DISSEMINATION

As no primary data collection will be undertaken, formal ethical assessment is not required. We plan to present the results of this systematic review in a peer-reviewed scientific journal, conferences and the popular press.

PROSPERO REGISTRATION NUMBER

Our systematic review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 20 December 2018 (Registration number CRD42018118117).

Obesity, risk of diabetes and role of physical activity, exercise training and cardiorespiratory fitness

The epidemic of obesity contributes to the burden of type 2 diabetes mellitus (T2DM) in the United States and worldwide. Importantly, obesity is not only preventable but can be treated, particularly with lifestyle modifications to forestall T2DM in those with excess adiposity. The mechanisms linking obesity to T2DM are numerous and involve adipose tissue remodeling as a result of unhealthy behaviors, including unhealthy diet, reduced physical activity (PA) and exercise training (ET), and increased sedentary behaviors. Taken together, these factors markedly reduce cardiorespiratory fitness (CRF), one of the strongest predictors for cardiovascular outcomes and all-cause mortality in the general population, but also in those with T2DM. In this review we describe the mechanisms leading to adipose tissue remodeling resulting in obesity, as well as the mechanisms linking excess adiposity to insulin resistance and, in turn, T2DM. We then present the therapeutic strategies that can be implemented in obesity to prevent T2DM, with a brief discussion on weight loss, and greater emphasis on PA and ET. We finally present the evidence to support the beneficial effects of such strategies in patients with established T2DM and discuss the importance of achieving improvements in CRF in this population to potentially improve clinical outcomes.

Physical Function Following a Long-Term Lifestyle Intervention Among Middle Aged and Older Adults With Type 2 Diabetes: The Look AHEAD Study

Background

Lifestyle interventions have been shown to improve physical function over the short term; however, whether these benefits are sustainable is unknown. The long-term effects of an intensive lifestyle intervention (ILI) on physical function were assessed using a randomized post-test design in the Look AHEAD trial.

Methods

Overweight and obese (body mass index ≥ 25 kg/m2) middle-aged and older adults (aged 45-76 years at enrollment) with type 2 diabetes enrolled in Look AHEAD, a trial evaluating an ILI designed to achieve weight loss through caloric restriction and increased physical activity compared to diabetes support and education (DSE), underwent standardized assessments of performance-based physical function including a 4- and 400-m walk, lower extremity physical performance (expanded Short Physical Performance Battery, SPPBexp), and grip strength approximately 11 years postrandomization and 1.5 years after the intervention was stopped (n = 3,783).

Results

Individuals randomized to ILI had lower odds of slow gait speed (<0.8 m/s) compared to those randomized to DSE (adjusted OR [95% CI]: 0.84 [0.71 to 0.99]). Individuals randomized to ILI also had faster gait speed over 4- and 400-m (adjusted mean difference [95% CI]: 0.019 [0.007 to 0.031] m/s, p = .002, and 0.023 [0.012 to 0.034] m/sec, p < .0001, respectively) and higher SPPBexp scores (0.037 [0.011 to 0.063], p = .005) compared to those randomized to DSE. The intervention effect was slightly larger for SPPBexp scores among older versus younger participants (0.081 [0.038 to 0.124] vs 0.013 [-0.021 to 0.047], p = .01).

Conclusions

An intensive lifestyle intervention has modest but significant long-term benefits on physical function in overweight and obese middle-aged and older adults with type 2 diabetes.

ClinicalTrials.gov Identifier

NCT00017953.

Non-exercise activity thermogenesis (NEAT): a component of total daily energy expenditure

[Purpose]

The purpose of this review is to promote awareness of non-exercise activity thermogenesis (NEAT) as a new strategy to increase energy expenditure, and to manage obesity.

[Methods]

The content of this review is based on a literature search of PubMed and the Google Scholar search engine, using the search terms obesity, energy expenditure, non-exercise activity thermogenesis (NEAT), and sitting disease.

[Results]

Daily energy expenditure is of great interest because most obese individuals have no exercise activity-related thermogenesis (EAT); thus their physical activity-related energy expenditure (PEE) is comprised almost entirely of NEAT. Consequently, NEAT represents the main variable component of daily total energy expenditure (TEE); this varies considerably, both within among individuals. These somewhat unplanned and unstructured low level physical activities are associated with energy expenditure in excess of the resting metabolic rate (RMR). They may therefore have the potential to stimulate greater energy expenditure over time with a higher rate of adherence.

[Conclusion]

In conclusion, NEAT is a highly variable component of daily TEE and a low level of NEAT is associated with obesity. NEAT enhances lifestyle, and variations in individual and environmental factors can significantly affect daily energy expenditure. Therefore, well designed longitudinal studies that focus on personal behavioral approaches and re-engineered environments to increase NEAT should be conducted in the future.

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.

Impact of Intensive Lifestyle Intervention on Disability-Free Life Expectancy: The Look AHEAD Study

OBJECTIVE

The impact of weight loss intervention on disability-free life expectancy in adults with diabetes is unknown. We examined the impact of a long-term weight loss intervention on years spent with and without physical disability.

RESEARCH DESIGN AND METHODS

Overweight or obese adults with type 2 diabetes age 45-76 years (n = 5,145) were randomly assigned to a 10-year intensive lifestyle intervention (ILI) or diabetes support and education (DSE). Physical function was assessed annually for 12 years using the 36-Item Short Form Health Survey. Annual incidence of physical disability, mortality, and disability remission were incorporated into a Markov model to quantify years of life spent active and physically disabled.

RESULTS

Physical disability incidence was lower in the ILI group (6.0% per year) than in the DSE group (6.8% per year) (incidence rate ratio 0.88 [95% CI 0.81-0.96]), whereas rates of disability remission and mortality did not differ between groups. ILI participants had a significant delay in moderate or severe disability onset and an increase in number of nondisabled years (P < 0.05) compared with DSE participants. For a 60-year-old, this effect translates to 0.9 more disability-free years (12.0 years [95% CI 11.5-12.4] vs. 11.1 years [95% CI 10.6-11.7]) but no difference in total years of life. In stratified analyses, ILI increased disability-free years of life in women and participants without cardiovascular disease (CVD) but not in men or participants with CVD.

CONCLUSIONS

Long-term lifestyle interventions among overweight or obese adults with type 2 diabetes may reduce long-term disability, leading to an effect on disability-free life expectancy but not on total life expectancy.

Impact of lifestyle behavior change on glycemic control in youth with type 2 diabetes

BACKGROUND

Little is known about the feasibility and impact of lifestyle intervention, determined by change in diet and cardiovascular fitness (CRF), on glycemic control in youth who are overweight with type 2 diabetes. This was examined in the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY) clinical trial cohort from across 15 US centers.

SUBJECTS

TODAY enrolled 699 youth aged 10 to 17 years with type 2 diabetes <2 years and body mass index ≥85th percentile at baseline.

METHODS

Dietary data were collected by an interviewer-administered food frequency questionnaire; CRF was assessed using a submaximal cycle ergometer test. Change from baseline in these variables was analyzed using generalized linear mixed models for both continuous and categorical measures. Models were adjusted for age, baseline HbA1c, treatment group, and medication adherence. Data were collected at baseline, 6, and 24 months. Trial registration ClinicalTrials.gov NCT00081328.

RESULTS

At 6 months, ~25% of females and ~33% of males improved CRF. In males, this was related to a decreased HbA1c (P = .001) and a lower percent experiencing glycemic failure (HbA1c ≥8%; P = .007). Females who decreased their saturated fat intake and/or increased their fiber intake had lower HbA1c at month 24 (P = .01 and P = .007, respectively). Males who increased their sweetened beverage intake at 6-month follow-up were at a 1.6-fold higher risk of experiencing glycemic failure (P = .04).

CONCLUSIONS

Few youth improved fitness and/or diet over time, although those who did showed a beneficial impact on glycemic outcomes. Although lifestyle behaviors are difficult to change in youth with type 2 diabetes, interventions are needed that are feasible (in scope, complexity, and demands), sustainable, and clinically meaningful.

Diabetes-related weight change in a Canadian First Nation cohort

The Canadian First Nations population is disproportionately burdened by diabetes and diabetes complications. Body weight management is purported to be important in the prevention and management of diabetes. In this study, we sought to describe weight change in a First Nation cohort according to diabetes status and management. Study data were from two diabetes screening studies in Sandy Bay First Nation in Manitoba, Canada, collected in 2002/2003 (baseline) and 2011/2012 (follow-up). The cohort was composed of respondents to both screening studies (n=171). Fasting blood samples, anthropometric, health and demographic data were collected. At baseline, 24.8% (n=41) of the cohort members had diabetes. At follow-up, an additional 20.6% (n=34) developed diabetes. Among all participants with diabetes (long-term and incident cases), 66.6% lost weight between the two study periods. Among only participants with long-term diabetes (>8 years), 31.7% lost >10 kg. HbA1c at baseline, positive change in HbA1c over time, and use of metformin were significantly associated with weight loss ≥5%, independent of age, sex, and BMI at baseline. Further research is needed to better understand if and how diabetes-related weight loss contributes to morbidity and mortality in this First Nation population.

Role of Physical Activity and Exercise in Treating Patients with Overweight and Obesity

BACKGROUND

Overweight and obesity are significant public health concerns that are linked to numerous negative health consequences. Physical activity is an important lifestyle behavior that contributes to body weight regulation.

CONTENT

Physical activity is inversely associated with weight gain and the incidence of obesity. Physical activity also contributes to additional weight loss when coupled with dietary modification, and it can result in modest weight loss when not coupled with dietary modification. Moreover, physical activity is associated with improved long-term weight loss and prevention of weight gain following initial weight loss. Current evidence supports that physical activity should be moderate to vigorous in intensity to influence body weight regulation. There is also a growing body of evidence that physical activity can be accumulated throughout the day in shorter periods of time rather than being performed during a structured and longer period, and that physical activity performed in this manner can be important for body weight regulation.

SUMMARY

The literature supports the inclusion of physical activity as an important lifestyle behavior for regulating body weight. There are multiple intervention approaches that may be effective for enhancing physical activity engagement within the context of weight control.

Long-term impact of intensive lifestyle intervention on cognitive function assessed with the National Institutes of Health Toolbox: The Look AHEAD study

Introduction

This study sought to determine whether 10 years of assignment to intensive lifestyle intervention (ILI) relative to diabetes support and education leads to better cognition. We examine intervention effects overall and among clinical subgroups, and report correlations between computer-administered and interviewer-administered cognitive batteries.

Methods

The Action for Health in Diabetes (Look AHEAD) was a 16-site randomized controlled trial with overweight/obese individuals (aged 45-76) who had type 2 diabetes. The NIH Toolbox Cognition Battery tests developed to measure cognition across the lifespan were used to evaluate cognition. Results were compared with standard paper-and-pencil tests. The Toolbox and paper-and-pencil tests were administered an average of 10.9 years after randomization to 1002 participants.

Results

Toolbox measures significantly correlated with interviewer-administered measures, with the strongest correlations between the Toolbox Fluid Cognition Composite and Trails B (r = -0.64, P < .0001) and Digit Symbol Coding (r = 0.63, P < .0001), and between the Toolbox Dimensional Change Card Sort (r = 0.55, P < .0001) and the Digit Symbol Coding test. Overall, ILI and diabetes support and education groups had similar adjusted mean cognitive outcomes (P > .05 for all). Subgroup analyses identified different intervention effects within baseline body mass index groups for Picture Sequence Memory (P = .01), within baseline cardiovascular disease groups for Picture Vocabulary (P = .01) and Fluid Cognition Composite (P = .02) measures, and within baseline age groups for Picture Vocabulary (P = .02).

Discussion

Correlations between Toolbox and interviewer-administered outcomes provide a measure of internal validity. Findings suggest no overall effect of the intervention on cognition and that an ILI resulting in weight loss may have negative implications for cognition in individuals aged ≥60, with previous history of cardiovascular disease, and those with body mass index ≥40.

The Look AHEAD Trial: Translating Lessons Learned Into Clinical Practice and Further Study

IN BRIEF Although the Look AHEAD (Action for Health in Diabetes) trial, which spanned more than 8 years, did not find significant differences in cardiovascular morbidity and mortality between study groups, it did demonstrate significant differences in weight loss and maintenance. Using lessons learned from the Look AHEAD protocol, clinicians can help people with type 2 diabetes lose weight, improve glucose management, increase physical activity, alter eating patterns, and support long-term positive health outcomes. It remains important, however, to avoid assigning a higher priority to weight loss goals than to improvements in glucose management, long-term health outcomes, and quality of life.

Outcomes of a community-based lifestyle programme for adults with diabetes or pre-diabetes

INTRODUCTION Diabetes, a long-term condition increasing in prevalence, requires ongoing healthcare management. Exercise alongside lifestyle education and support is effective for diabetes management. AIM To investigate clinical outcomes and acceptability of a community-based lifestyle programme for adults with diabetes/prediabetes at programme completion and 3-month follow-up. METHODS The 12-week community programme included twice-weekly sessions of self-management education and exercise, supervised by a physiotherapist, physiotherapy students and a nurse. Clinical outcomes assessed were cardiorespiratory fitness, waist circumference, exercise behaviour and self-efficacy. A standardised evaluation form was used to assess programme acceptability. RESULTS Clinically significant improvements were found from baseline (n = 36) to programme completion (n = 25) and 3-months follow-up (n = 20) for the six minute walk test (87 m (95%CI 65-109; p ≤ 0.01), 60 m (95%CI 21-100; p ≤ 0.01)), waist circumference (-3 cm (95%CI -6 to -1), -3 cm (95%CI -6 to 1)), exercise behaviour (aerobic exercise 53 min/week (95%CI 26 to 81; p ≤ 0.01), 71 min/week (95%CI 25 to 118; p ≤ 0.01)) and self-efficacy (0.7 (95%CI -0.2 to 1.6), 0.8 (95%CI 0.04 to 1.5)). Good programme acceptability was demonstrated by themes suggesting a culturally supportive, motivating, friendly, informative atmosphere within the programme. The attrition rate was 30% but there were no adverse medical events related to the programme. DISCUSSION The programme was safe and culturally acceptable and outcomes demonstrated clinical benefit to participants. The attrition rate was largely due to medical reasons unrelated to the programme. This model of a community-based lifestyle programme has the potential to be reproduced in other regions and in adults with similar long-term conditions. KEYWORDS Diabetes Mellitus Type II; Prediabetic state; Co-morbidity; Exercise; Self-management.

Clinical Update: Cardiovascular Disease in Diabetes Mellitus: Atherosclerotic Cardiovascular Disease and Heart Failure in Type 2 Diabetes Mellitus - Mechanisms, Management, and Clinical Considerations

Cardiovascular disease remains the principal cause of death and disability among patients with diabetes mellitus. Diabetes mellitus exacerbates mechanisms underlying atherosclerosis and heart failure. Unfortunately, these mechanisms are not adequately modulated by therapeutic strategies focusing solely on optimal glycemic control with currently available drugs or approaches. In the setting of multifactorial risk reduction with statins and other lipid-lowering agents, antihypertensive therapies, and antihyperglycemic treatment strategies, cardiovascular complication rates are falling, yet remain higher for patients with diabetes mellitus than for those without. This review considers the mechanisms, history, controversies, new pharmacological agents, and recent evidence for current guidelines for cardiovascular management in the patient with diabetes mellitus to support evidence-based care in the patient with diabetes mellitus and heart disease outside of the acute care setting.

Management of obesity

A modern approach to obesity acknowledges the multifactorial determinants of weight gain and the health benefits to be derived from weight loss. Foundational to any weight loss effort is lifestyle change, diet, and increased physical activity. The approach should be a high quality diet to which patients will adhere accompanied by an exercise prescription describing frequency, intensity, type, and time with a minimum of 150 min moderate weekly activity. For patients who struggle with weight loss and who would receive health benefit from weight loss, management of medications that are contributing to weight gain and use of approved medications for chronic weight management along with lifestyle changes are appropriate. Medications approved in the USA or European Union are orlistat, naltrexone/bupropion, and liraglutide; in the USA, lorcaserin and phentermine/topiramate are also available. Surgical management (gastric banding, sleeve gastrectomy, and Roux-en Y gastric bypass) can produce remarkable health improvement and reduce mortality for patients with severe obesity.

Comparative Effectiveness Research: A Roadmap for Physical Activity and Lifestyle

PURPOSE

Comparative effectiveness research (CER) is designed to support informed decision making at both the individual, population, and policy levels. The American College of Sports Medicine and partners convened a conference with the focus of building an agenda for CER within the context of physical activity and nonpharmacological lifestyle approaches in the prevention and treatment of chronic disease. This report summarizes the conference content and consensus recommendations that culminated in a CER roadmap for physical activity and lifestyle approaches to reducing the risk of chronic disease.

METHODS

This conference focused on presentations and discussion around the following topic areas: 1) defining CER, 2) identifying the current funding climate to support CER, 3) summarizing methods for conducting CER, and 4) identifying CER opportunities for physical activity.

RESULTS

This conference resulted in consensus recommendations to adopt a CER roadmap for physical activity and lifestyle approaches to reducing the risk of chronic disease. In general, this roadmap provides a systematic framework by which CER for physical activity can move from a planning phase to a phase of engagement in CER related to lifestyle factors with particular emphasis on physical activity to a societal change phase that results in changes in policy, practice, and health.

CONCLUSIONS

It is recommended that physical activity researchers and health care providers use the roadmap developed from this conference as a method to systematically engage in and apply CER to the promotion of physical activity as a key lifestyle behavior that can be effective at making an impact on a variety of health-related outcomes.

Time-based physical activity interventions for weight loss: a randomized trial

PURPOSE

This study aims to examine whether enhancing standard behavioral weight loss interventions (standard behavioral weight loss program (SBWP)) with additional strategies at the initiation of intervention (ADOPT) or providing the additional strategies at predetermined times over the intervention period (MAINTAIN) enhances 18-month weight loss.

METHODS

This was a clinical trial of participants (N = 195; mean ± SEM: age, 43.2 ± 8.6 yr; body mass index, 33.0 ± 3.4 kg·m) randomized to SBWP, ADOPT, or MAINTAIN. All participants were prescribed an energy-restricted diet and physical activity, with group intervention sessions delivered over 18 months. ADOPT participants received additional phone contact (months 1-3), supervised exercise (months 1-6), and behavior campaigns (months 4-9). MAINTAIN participants received additional phone contact (months 4-6), supervised exercise (months 7-12), and behavior campaigns (months 13-18).

RESULTS

There was a significant group-time interaction for weight loss (P = 0.0032). SBWP participants lost 9.3 ± 0.9, 7.8 ± 1.1, and 5.9 ± 1.2 kg at 6, 12, and 18 months, respectively. ADOPT participants lost 8.9 ± 0.9, 7.6 ± 1.2, and 5.8 ± 1.2 kg, whereas MAINTAIN participants lost 9.7 ± 0.9, 11.0 ± 1.2, and 9.0 ± 1.2 kg at 6, 12, and 18 months, respectively. The group-time interactions for SBWP versus MAINTAIN (P = 0.0033) and for ADOPT versus MAINTAIN (P = 0.0075) were significant. There was a significant group-time interaction for change in fitness (P = 0.0060). The group-time interaction for MAINTAIN versus ADOPT (P = 0.0018) was significant, with a trend for MAINTAIN versus SBWP (P = 0.0525).

CONCLUSIONS

MAINTAIN improves 18-month weight loss compared with SBWP and ADOPT, with statistical trends indicating that MAINTAIN results in greater improvements in fitness. These results suggest that time-based strategies emphasizing physical activity confer greater benefits when delivered later and over the full course of intervention. This provides valuable information for the implementation of time-based strategies for improving long-term weight loss and fitness in overweight and obese adults.

An Updated Review of Interventions that Include Promotion of Physical Activity for Adult Men

The marked disparity in life expectancy between men and women suggests men are a vulnerable group requiring targeted health promotion programs. As such, there is an increasing need for health promotion strategies that effectively engage men with their health and/or illness management. Programs that promote physical activity could significantly improve the health of men. Although George et al. (Sports Med 42(3):281, 30) reviewed physical activity programs involving adult males published between 1990 and 2010, developments in men's health have prompted the emergence of new sex- and gender-specific approaches targeting men. The purpose of this review was to: (1) extend and update the review undertaken by George et al. (Sports Med 42(3):281, 30) concerning the effectiveness of physical activity programs in males, and (2) evaluate the integration of gender-specific influences in the content, design, and delivery of men's health promotion programs. A search of MEDLINE, CINAHL, ScienceDirect, Web of Science, PsycINFO, the Cochrane Library, and the SPORTDiscus databases for articles published between January 2010 and August 2014 was conducted. In total, 35 studies, involving evaluations of 31 programs, were identified. Findings revealed that a variety of techniques and modes of delivery could effectively promote physical activity among men. Though the majority of programs were offered exclusively to men, 12 programs explicitly integrated gender-related influences in male-specific programs in ways that recognized men's interests and preferences. Innovations in male-only programs that focus on masculine ideals and gender influences to engage men in increasing their physical activity hold potential for informing strategies to promote other areas of men's health.

The Effect of Changes in Cardiorespiratory Fitness and Weight on Obstructive Sleep Apnea Severity in Overweight Adults with Type 2 Diabetes

STUDY OBJECTIVES

To examine the effect of changes in cardiorespiratory fitness on obstructive sleep apnea (OSA) severity prior to and following adjustment for changes in weight over the course of a 4-y weight loss intervention.

METHODS

As secondary analyses of a randomized controlled trial, 263 overweight/obese adults with type 2 diabetes and OSA participated in an intensive lifestyle intervention or education control condition. Measures of OSA severity, cardiorespiratory fitness, and body weight were obtained at baseline, year 1, and year 4. Change in the apnea-hypopnea index (AHI) served as the primary outcome. The percentage change in fitness (submaximal metabolic equivalents [METs]) and change in weight (kg) were the primary independent variables. Primary analyses collapsed intervention conditions with statistical adjustment for treatment group and baseline METs, weight, and AHI among other relevant covariates.

RESULTS

At baseline, greater METs were associated with lower AHI (B [SE] = -1.48 [0.71], P = 0.038), but this relationship no longer existed (B [SE] = -0.24 [0.73], P = 0.75) after adjustment for weight (B [SE] = 0.31 [0.07], P < 0.0001). Fitness significantly increased at year 1 (+16.53 ± 28.71% relative to baseline), but returned to near-baseline levels by year 4 (+1.81 ± 24.48%). In mixed-model analyses of AHI change over time without consideration of weight change, increased fitness at year 1 (B [SE] = -0.15 [0.04], P < 0.0001), but not at year 4 (B [SE] = 0.04 [0.05], P = 0.48), was associated with AHI reduction. However, with weight change in the model, greater weight loss was associated with AHI reduction at years 1 and 4 (B [SE] = 0.81 [0.16] and 0.60 [0.16], both P < 0.0001), rendering the association between fitness and AHI change at year 1 nonsignificant (B [SE] = -0.04 [0.04], P = 0.31).

CONCLUSIONS

Among overweight/obese adults with type 2 diabetes, fitness change did not influence OSA severity change when weight change was taken into account.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identification number NCT00194259.

Diet-Related Knowledge and Physical Activity in a Large Cohort of Insulin-Treated Type 2 Diabetes Patients: PROGENS ARENA Study

There is no doubt that behavioral intervention is crucial for type 2 diabetes mellitus (T2DM) prevention and management. We aimed to estimate dietary habits and diet-oriented knowledge as well as the level of physical activity in 2500 insulin-treated Polish type 2 diabetes mellitus (T2DM) patients (55.4% women). The mean age of the study participants was 64.9 ± 9.3 years, mean BMI was 31.4 kg/m² ± 4.5, mean diabetes duration was 12.4 ± 6.9 years, and mean baseline HbA1c was 8.5%  ± 1.2. At the study onset, all the patients completed a questionnaire concerning health-oriented behavior. Results showed a significant lack of diet-related knowledge. For example, only 37.5% recognized that buckwheat contains carbohydrates; the percentage of correct answers in questions about fruit drinks and pasta was 56.4% and 61.2%, respectively. As for the physical activity, only 57.4% of examined T2DM patients declared any form of deliberate physical activity. To conclude, the cohort of poorly controlled insulin-treated T2DM patients studied by us is characterized by insufficient diet-related knowledge and by a very low level of physical activity. Further studies on other populations of insulin-treated T2DM patients are required to confirm these findings.

Improving diabetes outcomes through lifestyle change--A randomized controlled trial

OBJECTIVE

To compare a diabetes group lifestyle intervention (GLI) with dietitian referral for medical nutrition therapy (RD) for weight loss in the usual care setting.

METHODS

Randomized clinical trial was conducted with 57 primary care patients with type 2 diabetes and body mass index (BMI) >25 kg/m(2) who received either a dietitian-led 19-week GLI adapted from the Look AHEAD study or RD. Outcome measures include 6-month and 1-year weight loss, changes in medications, glycemic control, cardiac risk factors, and cost analysis.

RESULTS

Patients were mean age 61, 59% male, and 32% non-white, and they weighed 97 kg with mean HbA1c 8.2%. At 6 months, 46% of GLI vs. 21% of RD lost ≥5% body weight (P = 0.04), with mean weight loss 6.6 (SD 7.0) kg with GLI and 2.1 (3.5) kg in RD (P = 0.004). HbA1c improved by 0.70 (1.13) vs. 0.39 (1.51) in GLI vs. RD (P = 0.4), respectively, and 82% vs. 38% stopped or reduced diabetes medications (P < 0.001). Weight loss remained significantly greater in GLI compared to RD at 1 year. GLI program cost was $578 per participant.

CONCLUSIONS

An affordable GLI achieved significantly more weight loss and medication reduction than RD in primary care patients with type 2 diabetes.

Improving Adiponectin Levels in Individuals With Diabetes and Obesity: Insights From Look AHEAD

OBJECTIVE

This study investigated whether fitness changes resulting from lifestyle interventions for weight loss may independently contribute to the improvement of low adiponectin levels in obese individuals with diabetes.

RESEARCH DESIGN AND METHODS

Look AHEAD (Action for Health in Diabetes) randomized overweight/obese individuals with type 2 diabetes to intensive lifestyle intervention (ILI) for weight loss or to diabetes support and education (DSE). Total and high-molecular weight adiponectin (adiponectins), weight, and cardiorespiratory fitness (submaximal exercise stress test) were measured in 1,397 participants at baseline and at 1 year, when ILI was most intense. Regression analyses examined the associations of 1-year weight and fitness changes with change in adiponectins.

RESULTS

ILI resulted in greater improvements in weight, fitness, and adiponectins at 1 year compared with DSE (P < 0.0001). Weight loss and improved fitness were each associated with changes in adiponectins in men and women (P < 0.001 for all), after adjusting for baseline adiponectins, demographics, clinical variables, and treatment arm. Weight loss contributed an additional 4-5% to the variance of change in adiponectins than did increased fitness in men; in women, the contributions of improved fitness (1% greater) and of weight loss were similar. When weight and fitness changes were both accounted for, weight loss in men and increased fitness in women retained their strong associations (P < 0.0001) with adiponectin change.

CONCLUSIONS

Improvements in fitness and weight with ILI were favorably but distinctly associated with changes in adiponectin levels in overweight/obese men and women with diabetes. Future studies need to investigate whether sex-specific biological determinants contribute to the observed associations.

Metabolic Effects of Exercise Training Among Fitness-Nonresponsive Patients With Type 2 Diabetes: The HART-D Study

OBJECTIVE

To evaluate the impact of exercise training (ET) on metabolic parameters among participants with type 2 diabetes mellitus (T2DM) who do not improve their cardiorespiratory fitness (CRF) with training.

RESEARCH DESIGN AND METHODS

We studied participants with T2DM participating in the Health Benefits of Aerobic and Resistance Training in Individuals With Type 2 Diabetes (HART-D) trial who were randomized to a control group or one of three supervised ET groups for 9 months. Fitness response to ET was defined as a change in measured peak absolute oxygen uptake (ΔVO(2peak), in liters per minute) from baseline to follow-up. ET participants were classified based on ΔVO(2peak) into fitness responders (ΔVO(2peak) ≥5%) and nonresponders (ΔVO(2peak) <5%), and changes in metabolic profiles were compared across control, fitness responder, and fitness nonresponder groups.

RESULTS

A total of 202 participants (mean age 57.1 ± 7.9 years, 63% women) were included. Among the exercise groups (n = 161), there was substantial heterogeneity in ΔVO(2peak); 57% had some improvement in CRF (ΔVO(2peak) >0), with only 36.6% having a ≥5% increase in VO(2peak). Both fitness responders and nonresponders (respectively) had significant improvements in hemoglobin A1c and measures of adiposity (ΔHbA(1c): -0.26% [95% CI -0.5 to -0.01] and -0.26% [-0.45 to -0.08]; Δwaist circumference: -2.6 cm [-3.7 to -1.5] and -1.8 cm [-2.6 to -1.0]; Δbody fat: -1.07% [-1.5 to -0.62] and -0.75% [-1.09 to -0.41]). No significant differences were observed in the degree of change of these metabolic parameters between fitness responders and nonresponders. Control group participants had no significant changes in any of these metabolic parameters.

CONCLUSIONS

ET is associated with significant improvements in metabolic parameters irrespective of improvement in cardiorespiratory fitness.

Assessing and targeting key lifestyle cardiovascular risk factors at the workplace: Effect on hemoglobin A1c levels

PURPOSE

Despite the key role played by lifestyle habits in the epidemic of type 2 diabetes (T2D), nutritional quality and physical activity are not systematically considered in clinical practice. The project was conducted to verify whether assessing/targeting lifestyle habits could reduce hemoglobin A1c (HbA1c) levels of employees.

METHODS

The intervention consisted of a 3-month competition among teams of five employees to favor peer-based support in the adoption of healthier lifestyle habits (Eat better, Move more, and Quit smoking) (n = 900). A comprehensive cardiometabolic/cardiorespiratory health assessment was conducted before and after the contest (nutrition/physical activity questionnaires, blood pressure, anthropometric measurements, lipid profile, HbA1c, fitness). HbA1c levels were used to identify individuals with prediabetes (5.7%-6.4%) or T2D (≥6.5%).

RESULTS

At baseline, 51% of the employees had increased HbA1c levels (≥5.7%). The HbA1c levels were associated with waist circumference, independently of body mass index. Subjects with prediabetes showed a higher waist circumference as well as a more deteriorated cardiometabolic profile compared to workers with normal HbA1c levels. After the intervention, employees with elevated HbA1c significantly reduced their HbA1c levels.

CONCLUSION

Results suggest that assessing/targeting key lifestyle correlates of the cardiometabolic profile represents a relevant approach to target abdominal obesity and fitness with a significant impact on HbA1c levels.

A long-term intensive lifestyle intervention and physical function: the look AHEAD Movement and Memory Study

OBJECTIVE

To assess the long-term effects of an intensive lifestyle intervention on physical function using a randomized post-test design in the Look AHEAD trial.

METHODS

Overweight and obese (BMI ≥ 25 kg m(-2)) middle-aged and older adults (aged 45-76 years at enrollment) with type 2 diabetes (n = 964) at four clinics in Look AHEAD, a trial evaluating an intensive lifestyle intervention (ILI) designed to achieve weight loss through caloric restriction and increased physical activity compared to diabetes support and education (DSE), underwent standardized assessments of performance-based physical function including an expanded short physical performance battery (SPPBexp ), 20-m and 400-m walk, and grip and knee extensor strength 8 years post-randomization, during the trial's weight maintenance phase.

RESULTS

Eight years post-randomization, individuals randomized to ILI had better SPPBexp scores [adjusted mean (SE) difference: 0.055 (0.022), P = 0.01] and faster 20-m and 400-m walk speeds [0.032 (0.012) m s(-1) , P = 0.01, and 0.025 (0.011) m s(-1) , P = 0.02, respectively] compared to those randomized to DSE. Achieved weight loss greatly attenuated the group differences in physical function, and the intervention effect was no longer significant.

CONCLUSIONS

An intensive lifestyle intervention has long-term benefits for mobility function in overweight and obese middle-aged and older individuals with type 2 diabetes.

The Look AHEAD Trial: A Review and Discussion Of Its Outcomes

The LookAhead trial was a randomized controlled trial comparing an Intensive Lifestyle Intervention (ILI) to a Diabetes Support and Education (DSE) in overweight and obese type 2 diabetes patients to track the development of cardiovascular disease over time. The triaI intervention was stopped for futility after a median follow-up of 9.6 years. While there was a differential effect on weight loss and fitness between the two groups, there was no effect on cardiovascular outcomes. Cardiovascular events were less than half the projected rate per year in the DSE group: thus there was a very low over-all rate of events in both groups. There were many other health benefits of ILI, including improved biomarkers of glucose and lipid control, less sleep apnea, lower liver fat, less depression, improved insulin sensitivity, less urinary incontinence, less kidney disease, reduced need of diabetes medications, maintenance of physical mobility, improved quality of life and lower costs.

Long-term impact of behavioral weight loss intervention on cognitive function

BACKGROUND

It is unknown whether intentional weight loss provides long-term benefits for cognitive function.

METHODS

An ancillary study to a randomized controlled clinical trial was conducted in overweight and obese individuals (N = 978), aged 45-76 years at enrollment, with type 2 diabetes. An intensive behavioral intervention designed to promote and maintain weight loss through caloric restriction and increased physical activity was compared with diabetes support and education. Standardized assessments of cognitive function were collected an average of 8.1 years after trial enrollment.

RESULTS

Participants assigned to intensive lifestyle intervention lost a mean (SE) 11.1% (0.4%) and 7.2% (0.5%) of weight at Years 1 and 8, respectively, compared with 1.0% (0.2%) and 3.3% (0.5%) in the control group (p < .001). Covariate-adjusted mean composite cognitive function test scores were similar for the two groups (p = .69), and no significant differences were found for any individual cognitive test. There was some evidence of a differential effect (nominal interaction p = .008) for a prespecified comparison: Intensive lifestyle intervention was associated with a relative mean benefit for composite cognitive function of 0.276 (95% confidence interval: 0.033, 0.520) SDs among individuals with body mass index less than 30 kg/m(2) at baseline compared with a relative mean deficit of 0.086 (-0.021, 0.194) SDs among individuals with body mass more than or equal to 30 kg/m(2).

CONCLUSIONS

Eight years of intensive lifestyle intervention did not alter cognitive function in obese adults with type 2 diabetes; however, there was evidence for benefit among overweight but not obese individuals. Changes in cognition were not assessed in this cross-sectional study.

Impact of social determinants of health on outcomes for type 2 diabetes: a systematic review

Social determinants of health include the social and economic conditions that influence health status. Research into the impact of social determinants on individuals with type 2 diabetes has largely focused on the prevention of or risk of developing diabetes. No review exists summarizing the impact of social determinants of health outcomes in patients with type 2 diabetes. This systematic review examined whether social determinants of health have an impact on health outcomes in type 2 diabetes. Medline was searched for articles that (a) were published in English (b) targeted adults, ages 18 + years, (c) had a study population which was diagnosed with type 2 diabetes, (d) the study was done in the United States, and (e) the study measured at least one of the outcome measures-glycemic control, cholesterol (LDL), blood pressure, quality of life or cost. Using a reproducible strategy, 2,110 articles were identified, and 61 were reviewed based on inclusion criteria. Twelve were categorized as Economic Stability and Education, 17 were categorized as Social and Community Context, 28 were categorized as Health and Health Care, and three were categorized as Neighborhood and Built Environment. Based on the studies reviewed, social determinants have an impact on glycemic control, LDL, and blood pressure to varying degrees. The impact on cost and quality of life was not often measured, but when quality of life was investigated, it did show significance. More research is needed to better characterize the direct impact of social determinants of health on health outcomes in diabetes.

Exercise is Medicine - The Importance of Physical Activity, Exercise Training, Cardiorespiratory Fitness and Obesity in the Prevention and Treatment of Type 2 Diabetes

Type 2 diabetes has reached epidemic proportions worldwide and is associated with increased risk of cardiovascular diseases and premature mortality. Diet and physical activity (PA)-based lifestyle interventions have been shown to prevent progression to type 2 diabetes in patients at high risk. Regular PA substantially reduces the risk of type 2 diabetes and a high level of PA is associated with a substantial reduction in type 2 diabetes risk. In addition, there is strong evidence suggesting a steep inverse relationship between both PA and cardiorespiratory fitness (CRF) and mortality in patients with type 2 diabetes. Of particular concern is the dramatic, steep increase in mortality among patients with low CRF. An important point is that obese individuals who are at least moderately fit have a lower mortality risk than those who are normal weight but unfit. A large body of evidence demonstrates that exercise improves glycaemic control in type 2 diabetes; the greatest improvements are achieved with combined aerobic and resistance training. A primary goal of public health strategies is to promote PA and move patients out of the least fit, highrisk cohort by increasing PA among the least active. Any plan to deal with the global epidemic of type 2 diabetes must give major attention to low PA and how this can be reversed in the general population.

The results of Look AHEAD do not row against the implementation of lifestyle changes in patients with type 2 diabetes

The Look AHEAD trial, evaluating the effects of weight loss on cardiovascular (CV) morbidity and mortality in overweight/obese people with type 2 diabetes (T2D), was interrupted after a median 9.5-year follow-up because the incidence of CV events was not different between the Intensive Lifestyle Intervention (ILI) and the control groups, and unlikely to statistically change thereafter. This made health providers and patients wondering about clinical value of diet and physical exercise in diabetic patients. Many factors may have made difficult to ascertain benefits of lifestyle intervention, besides the lower than predicted CV event rates. Among others, LDL-cholesterol was lowered more, with a higher use of statins, in the control group. Anyhow, ILI significantly improved numerous health conditions, including quality of life, CV risk factors and blood glucose control, with more diabetes remissions and less use of insulin. The intervention aimed at weight loss by reducing fat calories, and using meal replacements and, eventually, orlistat, likely underemphasizing dietary composition. There is suggestive evidence, in fact, that qualitative changes in dietary composition aiming at higher consumption of foods rich in fiber and with a high vegetable/animal fat ratio favorably influence CV risk in T2D patients. In conclusion, the Look AHEAD showed substantial health benefits of lifestyle modifications. Prevention of CV events may need higher attention to dietary composition, contributing to stricter control of CV risk factors. As a better health-related quality of life in people with diabetes is an important driver of our clinical decisions, efforts on early implementation of behavioral changes through a multifactorial approach are strongly justified.

Exenatide extended-release; clinical trials, patient preference, and economic considerations

Type 2 diabetes remains an escalating problem worldwide, despite a range of treatments being available. The revelation that insulin secretion is under the control of a gut hormone, glucagon-like peptide 1, has led to a new paradigm in the management of type 2 diabetes, ie, use of medicines that directly stimulate or prolong the actions of endogenous glucagon-like peptide 1 at its receptors. Exenatide is an agonist at the glucagon-like peptide 1 receptor, and was initially developed as a subcutaneous medication twice daily (ExBID). Clinical trials with ExBID established a role for exenatide in the treatment of type 2 diabetes. Subsequently, exenatide once weekly (ExQW) was shown to have advantages over ExBID, and there is now more emphasis on the development of ExQW. ExQW alone reduces glycosylated hemoglobin (HbA(1c)) and body weight, and is well tolerated. ExQW has been compared with sitagliptin, pioglitazone, and metformin, and been shown to have a greater ability to reduce HbA(1c) than these other medicines. The only preparation of insulin with which ExQW has been compared is insulin glargine, and ExQW had some favorable properties in this comparison, notably causing weight loss compared with the weight gain on insulin glargine. ExQW has been compared with another glucagon-like peptide 1 receptor agonist, liraglutide, and was noninferior to liraglutide in reducing HbA(1c). The small amount of evidence available shows that subjects with type 2 diabetes prefer ExQW to ExBID, and that adherence is high in the clinical trial setting. Health care and economic modeling suggests that ExQW will reduce diabetic complications and be cost-effective, compared with other medications, in long-term use. Little is known about whether subjects with type 2 diabetes prefer ExQW to other medicines, and whether adherence is good with ExQW in practice. These important topics require further study.