Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes-2020

Clinical practice recommendations for management of Diabetes Mellitus in Arab region: An expert consensus statement from Arab Diabetes Forum (ADF)

Prevalence of diabetes in Arab region has significantly increased, resulting in a significant economic burden on healthcare systems. This surge can be attributed to obesity, rapid urbanization, changing dietary habits, and sedentary lifestyles. The Arab Diabetes Forum (ADF) has established localized recommendations to tackle the region's rising diabetes prevalence. The recommendations, which incorporate worldwide best practices, seek to enhance the quality of treatment for people with diabetes by raising knowledge and adherence among healthcare providers. The guidelines include comprehensive recommendations for screening, diagnosing, and treating type 1 and type 2 diabetes in children and adults for better overall health results.

Effect of psychological intervention on glycemic control in middle-aged and elderly patients with type 2 diabetes mellitus: A systematic review and meta-analysis

AIM

There is an ongoing debate regarding the influence of psychological interventions on glycemic control in middle-aged and elderly patients diagnosed with type 2 diabetes. To establish evidence-based medical support for the therapeutic application of these interventions, this meta-analysis seeks to assess the impact of psychological interventions on glycemic control in middle-aged and elderly individuals with type 2 diabetes.

METHODS

This study systematically searched six electronic databases for randomized controlled studies of psychological interventions applied to middle-aged and elderly patients with type 2 diabetes, and the search time frames were all from the time of database creation to the search period from the establishment to March 2023. Two evaluators independently screened the literature evaluated the included studies' risk of bias, and carried out a meta-analysis using the RevMan5.4 program.

RESULTS

A total of 7 studies with 728 participants complied with the eligibility criteria. Meta-analysis showed that glycated glucagon was reduced in the psychological intervention group compared to the control group (MD = -0.26, 95 %CI:-0.51,-0.01,p = 0.01) with a statistically significant difference (p < 0.05). and their sensitivity analyses all showed stable and credible results.

CONCLUSIONS

This review concludes that psychological interventions, when applied to middle-aged and elderly individuals with type 2 diabetes, proved to be more effective in reducing HbA1c levels compared to standard care. Nevertheless, further evidence-based research is essential to elucidate the specific types of psychological interventions that contribute to improved glycemic control outcomes in middle-aged and older adults with type 2 diabetes.

Personal and Social-Built Environmental Factors of Glucose Variability Among Multiethnic Groups of Adults With Type 2 Diabetes: Research Protocol Using Ecological Momentary Assessment, Continuous Glucose Monitoring, and Actigraphy

Glucose variability (GV)-the degree of fluctuation in glucose levels over a certain period of time-is emerging as an important parameter of dynamic glycemic control. Repeated glycemic oscillations have been reported to be the link to diabetes complications. This prospective observational study aims to: (1) identify multilevel risk factors (personal and social-built environmental factors) associated with high GV; (2) identify "within-person predictors" of high GV leveraging the intra-person data to inform future personalized diabetes interventions; and (3) examine which lifestyle factors either mediate or moderate the relationship between emotional well-being and GV among diverse adults with type 2 diabetes (T2D). We will recruit 200 adults with T2D from the community. All participants will complete baseline surveys assessing demographics, lifestyle, social-built environmental, and clinical factors. Real-time dynamic glucose levels will be measured using continuous glucose monitoring (CGM). Sleep, physical activity, diet/eating, and emotional well-being will be measured with an actigraphy device and a real-time self-report tool (ecological momentary assessment [EMA]) across 14 days. Two 24-h dietary recall data will be collected by online video calls. Generalized linear models, multilevel models, and structural equation models will be developed to achieve the study aims. The findings from the study will identify high-risk groups of high GV who would benefit from CGM to improve diabetes outcomes and inform the future development of personalized just-in-time interventions targeting lifestyle behaviors with an increased understanding of GV and by supporting healthcare providers' clinical decisions.

Internet of things-based approach for glycemic control in people with type 2 diabetes: A randomized controlled trial

AIMS

The utilization of long-term effect of internet of things (IoT) on glycemic control is controversial. This trial aimed to examine the effect of an IoT-based approach for type 2 diabetes.

MATERIALS AND METHODS

This randomized controlled trial enrolled 1,159 adults aged 20-74 years with type 2 diabetes with a HbA1c of 6.0-8.9% (42-74 mmol/mol), who were using a smartphone on a daily basis were randomly assigned to either the IoT-based approach group (ITG) or the control group (CTG). The ITG were supervised to utilize an IoT automated system that demonstrates a summary of lifelogging data (weight, blood pressure, and physical activities) and provides feedback messages that promote behavioral changes in both diet and exercise. The primary end point was a HbA1c change over 52 weeks.

RESULTS

Among the patients, 581 were assigned to the ITG and 578 were in the CTG. The changes in HbA1c from baseline to the final measurement at 52 weeks [mean (standard deviation)] were -0.000 (0.6225)% in ITG and - 0.006 (0.6449)% in CTG, respectively (P = 0.8766). In the per protocol set, including ITG using the IoT system almost daily and CTG, excluding those using the application almost daily, the difference in HbA1c from baseline to 52 weeks were -0.098 (0.579)% and 0.027 (0.571)%, respectively (P = 0.0201). We observed no significant difference in the adverse event profile between the groups.

CONCLUSIONS

The IoT-based approach did not reduce HbA1c in patients with type 2 diabetes. IoT-based intervention using data on the daily glycemic control and HbA1c level may be required to improve glycemic control.

Blood glucose control among type 2 diabetic farmers in Chinese resettlement areas: a mixed methods study

BACKGROUND

Due to China's rapid urbanization, many farmers have relocated to urban resettlement regions. There is limited research on the glycemic control of Type 2 diabetes mellitus (T2DM) farmers in these areas. This study examined their blood glucose control and its determinants.

METHODS

This study took place from March 2021 to January 2022 in a resettlement community in Yiwu, Zhejiang Province, China. In the first phase, a quantitative survey of 181 T2DM farmers was conducted using a questionnaire to gather demographic data, blood glucose control status, disease cognition levels, and treatment compliance. Inclusion criteria were migrant workers with ≥ 3 months of residence and local household registration and T2DM patients who met the diagnostic criteria of the Chinese guidelines. In the second phase, qualitative research involved face-to-face, semi-structured interviews with 15 patients with varying blood glucose control levels to analyze their experiences.

RESULTS

The blood glucose control rate in this particular group was 27.62%, and the average disease cognition score was 2.5 ± 0.75. Many patients (67.96%) had inadequate treatment compliance, specifically in monitoring compliance (4.45 ± 1.92) and regular review compliance (3.58 ± 1.74).

CONCLUSION

There is a need for tailored programs to improve glycemic control among resettled farmers. Enhancing disease awareness and treatment compliance through targeted education and support is crucial. Further studies are needed to evaluate different treatment regimens' impact on glycemic control.

CLINICAL TRIAL NUMBER

Not applicable.

Poor self-care practices and contributing factors among adults with type 2 diabetes in Adama, Ethiopia

Diabetes mellitus (DM) is a prominent global health challenge, characterized by a rising prevalence and substantial morbidity and mortality, especially evident in developing nations. Although DM can be managed with self-care practices despite its complexity and chronic nature, the persistence of poor self-care exacerbates the disease burden. There is a dearth of evidence on the level of poor self-care practices and contributing factors among patients with DM in the study area. Thus, this study assessed the proportion of poor self-care practices and contributing factors among adults with type 2 DM in Adama, Ethiopia. An institution-based cross-sectional study was conducted among 404 patients. Self-care practice was assessed by the summary of diabetes self-care activities questionnaires. Binary logistic regression was used to identify factors associated with poor self-care practices. An adjusted odds ratio with a 95% confidence interval was used to assess the strength of associations. The statistical significance was declared for a p-value < 0.05. The proportion of poor self-care practices was 54% [95% CI 49.1, 58.6]. Being divorced (AOR = 3.5; 95% CI 1.0, 12.2), having a lower level of knowledge (AOR = 1.70; 95% CI 1.0, 2.8), being on insulin (AOR = 6.3; 95% CI 1.9, 20.6), taking oral medication (AOR = 8.6; 95% CI 3.0, 24.5), being unaware of fasting blood sugar (AOR = 2.9; 95% CI 1.6, 5.2), not a member of a diabetic association (AOR = 3.6; 95% CI 1.7, 7.5), a lack of social support (AOR = 2.9; 95% CI 1.7, 4.9), and having a poor perceived benefit of self-care practices (AOR = 1.84; 95% CI 1.0, 3.2) were associated with poor self-care practices. Overall, this finding demonstrated that a significant percentage of participants (54%) had poor self-care practices. Being divorced, having a low level of knowledge about diabetes and fasting blood sugar, lacking social support, relying on oral medication, perceiving limited benefits from self-care practices, and not being a member of diabetic associations were identified as independent factors of poor self-care.

Improving mental health in chronic care in general practice: study protocol for a cluster-randomised controlled trial of the Healthy Mind intervention

BACKGROUND

Mental health issues are common among patients with chronic physical conditions, affecting approximately one in five patients. Poor mental health is associated with worse disease outcomes and increased mortality. Problem-solving therapy (PST) may be a suitable treatment for targeting poor mental health in these patients. This study protocol describes a randomised controlled trial of the Healthy Mind intervention, a general practice-based intervention offering PST to patients with type 2 diabetes and/or ischaemic heart disease and poor mental well-being.

METHODS

A stepped-wedge cluster-randomised controlled trial with 1-year follow-up will be conducted in Danish general practice. At the annual chronic care consultation, patients with type 2 diabetes and/or chronic ischaemic heart disease will be screened for poor mental well-being. Patients in the control group will be offered usual care while patients in the intervention group will be offered treatment with PST provided by general practitioners (GPs) or general practice staff, such as nurses, who will undergo a 2-day PST course before transitioning from the control to the intervention group. The primary outcome is change in depressive symptoms after 6 and 12 months. Secondary outcomes include change in mental well-being, anxiety, and diabetes distress (patients with type 2 diabetes) after 6 and 12 months as well as change in total cholesterol levels, low-density lipoprotein (LDL) levels, and blood glucose levels (patients with diabetes) after 12 months. Process outcomes include measures of implementation and mechanisms of impact. We aim to include a total of 188 patients, corresponding to approximately 14 average-sized general practices.

DISCUSSION

The Healthy Mind trial investigates the impact of PST treatment for patients with chronic disease and poor mental well-being in general practice. This will be the first randomised controlled trial determining the effect of PST treatment for patients with chronic diseases in general practice. The results of this study will provide relevant insights to aid GPs, and general practice staff manage patients with poor mental well-being.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05611112. Registered on October 28, 2022.

Managing mental health in chronic care in general practice: a feasibility study of the Healthy Mind intervention

BACKGROUND AND OBJECTIVE

Mental health issues are common among patients with chronic physical conditions. This study aims to evaluate the feasibility of the Healthy Mind intervention, a general practice-based programme that provides problem-solving therapy (PST) to patients with poor mental well-being and type 2 diabetes (T2D) and/or ischaemic heart disease (IHD).

DESIGN AND SETTING

A one-arm feasibility study was conducted in three general practices in the Central Denmark Region.

INTERVENTION

Eight healthcare providers from the included general practices underwent a two-day course to acquire PST skills. Screening for poor mental health was carried out at the annual chronic care consultation for T2D or IHD, and PST sessions were offered to patients on indication of poor mental health. Nine patients received PST.

METHODS

Semi-structured interviews with eight healthcare providers and six patients were conducted. Data were analysed deductively focusing on appropriateness, acceptability and fidelity of the intervention.

RESULTS

The intervention was considered appropriate for the patient group and the general practice setting. The providers acknowledged PST as a valuable tool for managing psychological issues in general practice, and the patients perceived PST as an effective and tangible treatment. Since practice nurses' schedules were generally better suited for longer consultations, they were often the preferred intervention providers. The intervention was largely delivered as intended. However, the GPs generally expected patients to prefer a more directive approach, which sometimes challenged their role as facilitator and guide.

CONCLUSION

The Healthy Mind intervention was found to be feasible, and the results support proceeding to a full-scale evaluation trial.

Manipulation of Sonic Hedgehog Signaling Pathway in Maintenance, Differentiation, and Endocrine Activity of Insulin-Producing Cells: A Systematic Review

Background

Some studies have evaluated the manipulation of the sonic hedgehog (Shh) signaling pathway to generate more efficient insulin-producing cells (IPCs). In a systematic review, we evaluated in vitro and in vivo studies on the effect of inhibition or activation of the Shh pathway on the production, differentiation, maintenance, and endocrine activity of IPCs.

Methods

A systematic review was conducted using all available experimental studies published between January 2000 and November 2022. The review aimed at determining the effect of Shh manipulation on the differentiation of stem cells (SCs) into IPCs. Keywords and phrases using medical subject headings were extracted, and a complete search was performed in Web of Science, Embase, ProQuest, PubMed, Scopus, and Cochrane Library databases. The inclusion criteria were manipulation of Shh in SCs, SCs differentiation into IPCs, and endocrine activity of mature IPCs. Articles with incomplete data and duplications were excluded.

Results

A total of 208 articles were initially identified, out of which 11 articles were included in the study. The effect of Shh inhibition in the definitive endoderm stage to produce functional IPCs were confirmed. Some studies showed the importance of Shh re-activation at late-stage differentiation for the generation of efficient IPCs. It is proposed that baseline concentrations of Shh in mature pancreatic β-cells affect insulin secretion and endocrine activities of the cells. However, Shh overexpression in pancreatic β-cells ultimately leads to improper endocrine function and inadequate glucose-sensing insulin secretion.

Conclusion

Accurate manipulation of the Shh signaling pathway can be an effective approach in the production and maintenance of functional IPCs.

Defining "low-carb" in the scientific literature: A scoping review of clinical studies

There remains a lack of scientific consensus on what level of carbohydrate intake constitutes low-carbohydrate diets. We conducted a scoping review to understand how low-carbohydrate diets were defined in the peer-reviewed literature. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement scoping review extension. Three electronic databases were searched for clinical studies in English. We identified 508 articles (317 randomized controlled, 99 cross-over, 33 before-and-after, 12 non-randomized, and 47 other clinical trials). Most examined effects of low-carbohydrate diets in healthy adults (62.4%), 40 to 59 years old (55.5%), with obesity or overweight (66.1%). The majority reported effects on weight or body composition (29.9%), diabetes (18.7%), or cardiovascular risk factors (12.9%) as primary outcomes. Most articles (56.9%) reported percent of energy from carbohydrates, and of those, 60.3% defined low-carbohydrate diets as being ≤30% of energy from carbohydrates. Some articles (22.9%) reported grams of carbohydrates per day, and of those, most defined low-carbohydrate diets as being under ∼100 grams of carbohydrates per day. Systematic reviews and dose-response meta-regressions utilizing patient-level data on carbohydrate intake, status markers (e.g., RQ/ketones), and health outcomes would be useful in informing consensus around a standardized definition.

Exploring the progress of artificial intelligence in managing type 2 diabetes mellitus: a comprehensive review of present innovations and anticipated challenges ahead

A significant worldwide health issue, Type 2 Diabetes Mellitus (T2DM) calls for creative solutions. This in-depth review examines the growing severity of T2DM and the requirement for individualized management approaches. It explores the use of artificial intelligence (AI) in the treatment of diabetes, highlighting its potential for diagnosis, customized treatment plans, and patient self-management. The paper highlights the roles played by AI applications such as expert systems, machine learning algorithms, and deep learning approaches in the identification of retinopathy, the interpretation of clinical guidelines, and prediction models. Examined are difficulties with individualized diabetes treatment, including complex technological issues and patient involvement. The review highlights the revolutionary potential of AI in the management of diabetes and calls for a balanced strategy in which AI supports clinical knowledge. It is crucial to pay attention to ethical issues, data privacy, and joint research initiatives.

Significant reduction in diabetes distress and improvements in psychosocial outcomes: A pilot test of an intervention to reduce diabetes distress in adults with type 1 diabetes and moderate-to-severe diabetes distress (REDUCE)

AIM

To pilot-test an intervention, co-designed with people with type 1 diabetes (T1DM) and diabetes specialist nurses, to reduce diabetes distress (DD) in adults with T1DM and moderate-to-severe DD.

METHODS

A group-based programme to reduce DD in people with T1DM and moderate-to-severe DD (REDUCE) was pilot-tested in four groups with five bi-weekly two and a half-hour meetings facilitated by two trained diabetes specialist nurses. Data collection included baseline and post-intervention questionnaires measuring DD and psychosocial outcomes and semi-structured interviews with participants post-intervention (n = 18). Data were analysed using descriptive statistics and systematic text condensation.

RESULTS

Twenty-five adults with T1DM participated in the study. The median age and diabetes duration of participants were 50 (IQR: 32;57.5) years and 26 (IQR: 18;45) years, respectively. Seventeen (68%) were women. The pilot study showed a significant reduction in DD (measured by Type 1 Diabetes Distress Scale) between baseline and post-intervention from 2.6 ± 0.7 to 1.9 ± 0.6 (mean ± SD) (p < 0.001). The largest reductions were seen on the subscales: powerlessness 1.2 ± 1.1, eating distress 0.9 ± 1.2 and fear of hypoglycaemia 0.8 ± 1.0 (mean ± SD). Significant improvements were also seen for quality of life, diabetes empowerment and emotion regulation. Qualitative data showed that REDUCE supported participants in verbalizing emotions and seeing worries in a more constructive perspective. Acknowledgement of negative diabetes experiences eased negative self-judgments. Sharing experiences among peers increased relatedness and reduced loneliness.

CONCLUSION

Participation in REDUCE was associated with significant reduction in DD and significant increase in quality of life. Larger scale studies are planned to determine sustained effectiveness of REDUCE.

The effect of lifestyle interventions on depressive symptom severity in individuals with type-2 diabetes: A meta-analysis of randomized controlled trials

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a severe metabolic condition which is commonly comorbid with depression. Lifestyle factors are involved in the pathophysiology of both conditions; however, the role of lifestyle interventions remains unclear.

OBJECTIVE

The objective of this study is to systematically review the literature on randomized controlled trials evaluating the effect of lifestyle interventions on depressive scores in patients with T2DM.

METHODS

A systematic search was conducted in computerized databases before October 2022. A random-effects model was used to investigate the effect of lifestyle interventions on depression scores and meta-regression was conducted to assess the influence of age and disease onset.

RESULTS

Six trials met the eligibility criteria for inclusion. A statistically significant reduction in depression scores was found for groups receiving lifestyle interventions compared to controls (SMD = -0.49 [95%CI -0.89 to -0.08]; p = 0.0269]). Interventions increased in efficacy with the age of the participants but no significant correlation was found with years since disease onset. Participants in a control group receiving a less intense lifestyle intervention demonstrated improved depression scores when compared to those who received standard care or no intervention at all. Trial design and outcome measurement tools were heterogeneous between studies and limited data on antidepressant use was available which may introduce bias into the results.

CONCLUSION

Lifestyle interventions were effective at improving depressive symptom severity in patients with T2DM.

Challenges and perspectives of tobacco cessation in special groups of patients and populations

During the first 2 years of the coronavirus disease 2019 pandemic, health systems worldwide were put under extreme pressure, and healthcare professionals had to manage unprecedented health crises as well as provide healthcare services to an increased number of patients. Therefore, public health policies with respect to smoking and education of the general population regarding the harmful effects of active and second-hand smoking may not have received adequate attention during this period. More specifically, certain subpopulations suffering from chronic diseases may not have received adequate information about the effects of smoking on the course and outcome of their disease; high-level, evidence-based pharmaceutical therapies; and the potential for follow-up. However, adequate education and awareness regarding short- and long-term health benefits from smoking cessation for the general population as well as special subgroups remains of utmost importance. Healthcare professionals should understand that it is only through high-quality evidence and results from independent studies that they will be able to provide their expertise and scientific knowledge concerning newer tobacco products and their effects on human health.

Effects of COVID-19 pandemic lockdown on the metabolic control of type 2 diabetes mellitus in patients

Objective

The effects of the COVID-19 pandemic on the control of diabetes mellitus in patients are largely unknown. In this study we aimed to analyze the impact of the pandemic and the ensuing lockdown on the management of type 2 diabetes mellitus.

Subjects and methods

A total of 7,321patients with type 2 diabetes mellitus (4,501 from the pre-pandemic period, 2,820 from the post-pandemic period) were studied retrospectively.

Results

The admission of patients with diabetes melitus (DM) decreased significantly during the pandemic (4,501 pre-pandemic vs. 2,820 post-pandemic; p < 0.001). The mean age of patients was statistically lower (51.5 ± 14.0 vs. 49.7 ± 14.5 years; p < 0.001), and the mean glycated hemoglobin (A1c) level was significantly higher (7.9% ± 2.4% vs. 7.3% ± 1.7%; p < 0.001) in the post-pandemic period than in the pre-pandemic. The female/male ratio was similar in both periods (59.9%/40.1% for pre-pandemic, 58.6%/41.4% for post-pandemic; p = 0.304). As calculated by month the pre-pandemic rate of women was higher only in January (53.1% vs. 60.6%, p = 0.02). Mean A1c levels were higher in the postpandemic period than in the same month of the previous year, excluding July and October (p = 0.001 for November, p < 0.001 for others). Postpandemic patients admitted to the outpatient clinic were significantly younger than prepandemic visits for July (p = 0.001), August (p < 0.001) and December (p < 0.001).

Conclusion

The lockdown had detrimental effects on blood sugar management in patients with DM. Hence, diet and exercise programs should be adapted to home conditions, and social and psychological support should be provided to patients with DM.

Development and Validation of Protocol Based on Brazilian Dietary Guidelines for Adults with Diabetes Mellitus Who Attended Primary Health Care

BACKGROUND

To date, there is no protocol providing dietary guidelines to assist health care professionals in counseling Brazilian individuals with Diabetes Mellitus (DM) assisted in primary health care (PHC) according to the Dietary Guidelines for the Brazilian Population (DGBP). Therefore, this study aimed to develop and validate a protocol based on the DGBP for health care, non-nutritionist professionals in counseling adults with DM in PHC.

METHODS

We systematized the recommendations published in the DGBP, the Diabetes Brazilian Society guidelines, and the scientific literature regarding food and nutrition needs of adults with DM. The clarity and relevance were validated by an expert panel (n = 19) and the understanding and applicability were validated by PHC professionals (n = 12). The degree of agreement of the experts was assessed using a Content Validity Index (CVI). Items receiving CVI > 0.8 were considered appropriate.

RESULTS

The protocol consisted of six dietary recommendations that encouraged the daily consumption of beans, vegetables, and fruits, advised the avoidance of sugar-sweetened beverages and ultra-processed foods, stimulated eating in appropriate environments, and gave additional guidance addressed to the particularities of DM. The protocol clarity, relevance, and applicability were successfully validated.

CONCLUSION

The protocol supports health care, non-nutritionist professionals in the guidance of dietary recommendations and promoting adequate and healthy eating habits for adults with DM in PHC.

Time, Technology, Social Support, and Cardiovascular Health of Emerging Adults With Type 1 Diabetes

BACKGROUND

Emerging adults with Type 1 diabetes (T1DM) face an increased risk of cardiovascular disease; however, there are both barriers and facilitators to achieving ideal cardiovascular health in this stage of their lives.

OBJECTIVES

The aim of this study was to qualitatively explore the barriers and facilitators of achieving ideal levels of cardiovascular health in a sample of emerging adults with T1DM ages 18-26 years.

METHODS

A sequential mixed-methods design was used to explore achievement of ideal cardiovascular health using the seven factors defined by the American Heart Association (smoking status, body mass index, physical activity, healthy diet, total cholesterol, blood pressure, and hemoglobin A1C [substituted for fasting blood glucose]). We assessed the frequency of achieving ideal levels of each cardiovascular health factor. Using Pender's health promotion model as a framework, qualitative interviews explored the barriers and facilitators of achieving ideal levels of each factor of cardiovascular health.

RESULTS

The sample was mostly female. Their age range was 18-26 years, with a diabetes duration between 1 and 20 years. The three factors that had the lowest achievement were a healthy diet, physical activity at recommended levels, and hemoglobin A1C of <7%. Participants described lack of time as a barrier to eating healthy, being physically active, and maintaining in-range blood glucose levels. Facilitators included the use of technology in helping to achieve in-range blood glucose and social support from family, friends, and healthcare providers in maintaining several healthy habits.

DISCUSSION

These qualitative data provide insight into how emerging adults attempt to manage their T1DM and cardiovascular health. Healthcare providers have an important role in supporting these patients in establishing ideal cardiovascular health at an early age.

Low-Carbohydrate Diet Scores and Mortality Among Adults With Incident Type 2 Diabetes

OBJECTIVE

The current study aims to prospectively examine the association between postdiagnosis low-carbohydrate diet (LCD) patterns and mortality among individuals with type 2 diabetes (T2D).

RESEARCH DESIGN AND METHODS

Among participants with incident diabetes identified in the Nurses' Health Study and Health Professionals Follow-up Study, an overall total LCD score (TLCDS) was calculated based on the percentage of energy as total carbohydrates. In addition, vegetable (VLCDS), animal (ALCDS), healthy (HLCDS), and unhealthy (ULCDS) LCDS were further derived that emphasized different sources and quality of macronutrients. Multivariable-adjusted Cox models were used to assess the association between the LCDS and mortality.

RESULTS

Among 10,101 incident T2D cases contributing 139,407 person-years during follow-up, we documented 4,595 deaths of which 1,389 cases were attributed to cardiovascular disease (CVD) and 881 to cancer. The pooled multivariable-adjusted hazard ratios (HRs, 95% CIs) of total mortality per 10-point increment of postdiagnosis LCDS were 0.87 (0.82, 0.92) for TLCDS, 0.76 (0.71, 0.82) for VLCDS, and 0.78 (0.73, 0.84) for HLCDS. Both VLCDS and HLCDS were also associated with significantly lower CVD and cancer mortality. Each 10-point increase of TLCDS, VLCDS, and HLCDS from prediagnosis to postdiagnosis period was associated with 12% (7%, 17%), 25% (19%, 30%), and 25% (19%, 30%) lower total mortality, respectively. No significant associations were observed for ALCDS and ULCDS.

CONCLUSIONS

Among people with T2D, greater adherence to LCD patterns that emphasize high-quality sources of macronutrients was significantly associated with lower total, cardiovascular, and cancer mortality.

Consumption of sugar sweetened beverages, artificially sweetened beverages and fruit juices and risk of type 2 diabetes, hypertension, cardiovascular disease, and mortality: A meta-analysis

Introduction

Sugar-sweetened beverage (SSB) intake is associated with an increased risk of cardiometabolic diseases. However, evidence regarding associations of artificially sweetened beverages (ASBs) and fruit juices with cardiometabolic diseases is mixed. In this study, we aimed to investigate the association between the SSB, ASB and fruit juice consumption with the incidence of cardiometabolic conditions and mortality.

Methods

Relevant prospective studies were identified by searching PubMed, Web of Science, Embase, and Cochrane Library until December 2022 without language restrictions. The pooled relative risk (RR) and 95% confidence intervals (CIs) were estimated for the association of SSBs, ASBs, and fruit juices with the risk of type 2 diabetes (T2D), cardiovascular disease (CVD), and mortality by using random-effect models.

Results

A total of 72 articles were included in this meta-analysis study. Significantly positive associations were observed between the consumption of individual beverages and T2D risk (RR: 1.27; 95% CI: 1.17, 1.38 for SSBs; RR: 1.32; 95% CI: 1.11, 1.56 for ASBs; and RR:0.98; 95% CI: 0.93, 1.03 for fruit juices). Moreover, our findings showed that intakes of SSBs and ASBs were significantly associated with risk of hypertension, stroke, and all-cause mortality (RR ranging from 1.08 to 1.54; all p &lt; 0.05). A dose-response meta-analysis showed monotonic associations between SSB intake and hypertension, T2D, coronary heart disease (CHD), stroke and mortality, and the linear association was only significant between ASB consumption and hypertension risk. Higher SSB and ASB consumptions were associated with a greater risk of developing cardiometabolic diseases and mortality. Fruit juice intake was associated with a higher risk of T2D.

Conclusion

Therefore, our findings suggest that neither ASBs nor fruit juices could be considered as healthier beverages alternative to SSBs for achieving improved health.

Systematic Review Registration: [PROSPERO], identifier [No. CRD42022307003].

A survey study of adults with chronic conditions: Examining the correlation between patient activation and health locus of control

OBJECTIVES

This study aimed to examine (1) the association between patient activation (PA), health locus of control (HLOC), sociodemographic and clinical factors, and (2) the effect of HLOC dimensions, sociodemographic and clinical factors on PA.

METHODS

Three hundred U.S. adults, with at least one chronic condition (CC) were recruited through Amazon Mechanical Turk and completed an online survey which included sociodemographic questions, the Patient Activation Measure^® - 10, and the Multidimensional Locus of Control (MHLC) - Form B. Statistical analyses, including descriptive, correlation, and multiple linear regression, were conducted using IBM SPSS v25.

RESULTS

Of the 300 participants, more than half were male (66.3%), White (70.7%), with at least a college degree (76.0%), and employed full-time (79.0%). The average PA score was 68.8 ± 14.5. Multiple linear regression indicated that participants who reported they were Black, retired, with a greater number of CCs, and with higher scores in Chance MHLC had higher PA, while participants with higher scores in Internal MHLC, were unemployed and reported to have been affected by COVID-19-related worry or fear to manage their CC, had lower PA.

DISCUSSION

HLOC dimensions should be addressed concurrently with PA for patients with CCs, thus adding to a more patient-centered clinical approach.

Diabetes-Related Quality of Life: Learning From Individuals Making Lifestyle Changes to Improve Type 2 Diabetes Control

PURPOSE

The purpose of this study was to explore how treatment adherence and lifestyle changes required for glycemic control in type 2 diabetes (T2D) are related to quality of life (QoL) among predominantly ethnic minority and socioeconomically disadvantaged adults engaged in making changes to improve T2D self-management.

METHODS

Adults with T2D in New York City were recruited for the parent study based on recent A1C (≥7.5%) and randomly assigned to 1 of 2 arms, receiving educational materials and additional self-management support calls, respectively. Substudy participants were recruited from both arms after study completion. Participants (N = 50; 62% Spanish speaking) were interviewed by phone using a semistructured guide and were asked to define QoL and share ways that T2D, treatment, self-management, and study participation influenced their QoL. Interviews were analyzed using thematic analysis.

RESULTS

QoL was described as a multidimensional health-related construct with detracting and enhancing factors related to T2D. Detracting factors included financial strain, symptom progression and burden, perceived necessity to change cultural and lifestyle traditions, and dietary and medical limitations. Enhancing factors included social support, diabetes education, health behavior change, sociocultural connection.

CONCLUSION

QoL for diverse and socioeconomically disadvantaged adults with T2D is multifaceted and includes aspects of health, independence, social support, culture, and lifestyle, which may not be captured by existing QoL measures. Findings may inform the development of a novel QoL measure for T2D.

Perspectives on Promoting Physical Activity Using eHealth in Primary Care by Health Care Professionals and Individuals With Prediabetes and Type 2 Diabetes: Qualitative Study

BACKGROUND

The trend of an exponential increase in prediabetes and type 2 diabetes (T2D) is projected to continue rising worldwide. Physical activity could help prevent T2D and the progression and complications of the disease. Therefore, we need to create opportunities for individuals to acquire the necessary knowledge and skills to self-manage their chronic condition through physical activity. eHealth is a potential resource that could facilitate self-management and thus improve population health. However, there is limited research on users' perception of eHealth in promoting physical activity in primary care settings.

OBJECTIVE

This study aims to explore the perspectives of health care professionals and individuals with prediabetes and T2D on eHealth to promote physical activity in primary care.

METHODS

A qualitative approach was applied using focus group discussions among individuals with prediabetes or T2D (14 participants in four groups) and health care professionals (10 participants in two groups). The discussions were audio-recorded and transcribed verbatim. Qualitative content analysis was used inductively to code the data.

RESULTS

Three main categories emerged: utility, adoption process, and accountability. The utility of eHealth was described as a motivational, entertaining, and stimulating tool. Registration of daily medical measurements and lifestyle parameters in a cohesive digital platform was recognized as a potential resource for strengthening self-management skills. The adoption process includes eHealth to increase the accessibility of care and personalize the support of physical activity. However, participants stated that digital technology might only suit some and could increase health care providers' administrative burden. Accountability refers to the knowledge and skills to optimize eHealth and ensure data integrity and security.

CONCLUSIONS

People with prediabetes and T2D and health care professionals positively viewed an integration of eHealth technology in primary care to promote physical activity. A cohesive platform using personal metrics, goal-setting, and social support to promote physical activity was suggested. This study identified eHealth illiteracy, inequality, privacy, confidentiality, and an increased workload on health care professionals as factors of concern when integrating eHealth into primary care. Continuous development of eHealth competence was reported as necessary to optimize the implementation of eHealth technology in primary care.

Meta-analysis of the intervention effects of taekwondo on metabolic syndrome indicators

Objective: To quantify the effect of taekwondo as an intervention on the indicators of metabolic syndrome and identify an intervention plan with the optimal effects. Methods: Combining the Cnki.net, Wanfang, PubMed, Web of Science, Embase, KISS, RISS, and DBPIA databases, this paper retrieved relevant references in Chinese, English, and Korean, applied Review Manager 5.4 software to evaluate the methodological quality of the included references according to the Cochrane manual, and utilized Comprehensive Meta-Analysis version 3.7 to perform statistical analyses. Result: A total of 45 references and 1079 related subjects were included in the analysis. The results of the meta-analysis showed that taekwondo has a beneficial effect on all indicators of metabolic syndrome (Hedges' g [effect size] = -0.615, -0.672, -0.497, -0.785, -0.591, and 0.435; p < 0.05). Subgroup analysis revealed the superior intervention effect of taekwondo on metabolic syndrome in women compared to men, middle-aged and elderly compared to other age groups, and abnormal metabolic syndrome indicators compared to normal values. Moreover, the best results were obtained for longer intervention durations-12 weeks-three times per week, for 40-50 min per session. In addition, the combination of intervention types (poomsae, kick, and taekwondo gymnastics) showed optimal effects. The exercise intensity should consider the characteristics of the intervention object and be generally set to medium or high intensity. Conclusion: Taekwondo can effectively improve metabolic syndrome, as evidenced by decreased body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), fasting blood glucose (FBG), and triglyceride (TG) levels and increased high-density lipoprotein cholesterol (HDL-C) level. Taekwondo had the greatest effect on quinquagenarian women with abnormal levels of metabolic syndrome indicators. To maximize the intervention effect of taekwondo on metabolic syndrome, an exercise prescription of high-intensity poomsae, kick, and taekwondo gymnastics performed in 40-50 min sessions, three times weekly for 12 weeks is recommended.

Long-Term Tailor-Made Exercise Intervention Reduces the Risk of Developing Cardiovascular Diseases and All-Cause Mortality in Patients with Diabetic Kidney Disease

This study aimed to determine the effect of long-term exercise on the risk of developing cardiovascular diseases (CVD) and all-cause mortality in patients with diabetic kidney disease (DKD). A single-center, prospective intervention study using propensity score matching was performed over 24 months. The intervention group (n = 67) received six months of individual exercise instruction from a physical therapist, who performed aerobic and muscle-strengthening exercises under unsupervised conditions. New events were defined as the composite endpoint of stroke or CVD requiring hospitalization, initiation of hemodialysis or peritoneal dialysis, or all-cause mortality. The cumulative survival rate without new events at 24 months was significantly higher in the intervention group (0.881, p = 0.016) than in the control group (n = 67, 0.715). Two-way analysis of variance revealed a significant effect of the group factor on high density lipoprotein-cholesterol (HDL-C) which was higher in the intervention group than in the control group (p = 0.004); eGFRcr showed a significant effect of the time factor, which was lower at 24 months than before intervention (p = 0.043). No interactions were observed for all items. In conclusion, aerobic exercises combined with upper and lower limb muscle strengthening for six months reduce the risk of developing CVD and all-cause mortality in patients with DKD.

Health-related quality of life of Kuwaiti adults living with diabetes

Diabetes is known to compromise patients' health-related quality of life (HRQoL). It is important to understand the HRQoL of Kuwaiti nationals living with diabetes and identify factors that negatively affect it. This study included 1,182 Kuwaiti nationals with diabetes, aged 18-80 years. Patients' demographic and HRQoL information was collected using the EuroQol EQ-5D-5L instrument. Mean values for each EQ-5D subscale were worst for mobility (1.9) and pain/discomfort (1.8). Most patients reported having no problems in self-care (84.4%). Older adults were most likely to report severe problems with mobility (p < 0.001). Females were more likely to report severe problems with anxiety and depression than males (p < 0.006). The EQ visual analog scale (EQ VAS), which reports perceived overall health on a 0-100 scale, showed a mean of 74.7 (±19.6). Patients with comorbidities and/or complications perceived their health to be worse, with VAS scores significantly lower (p < 0.001). Other factors that negatively affected VAS scores were being female, obesity, insulin usage, and lower levels of education. In conclusion, patients with diabetes who have comorbidities and/or complications perceived their health to be worse. Further research is required to evaluate if current diabetes management interventions help improve patients' HRQoL.

Health Extension for Diabetes: Impact of a Community-Based Diabetes Self-Management Support Program on Older Adults' Activation

OBJECTIVE

The goals of this study were to determine whether completion of a community-based diabetes self-management support (DSMS) program delivered through a university Cooperative Extension network increased Patient Activation Measure (PAM) scores and to examine predictors of improvement in PAM score in individuals participating in the DSMS.

METHODS

The Health Extension for Diabetes (HED) is a 4-month program delivered via a paraprofessional extension agent in partnership with an established diabetes self-management education and support program. The study population included 148 adults (median age 69 years; interquartile range 60-74 years) with diabetes recruited from local community organizations. Data for the analysis were collected before and after participation in the intervention as part of a longitudinal study, using the PAM and Self-Efficacy for Diabetes instruments. Descriptive statistics were gathered, and hypothesis tests and simple and multivariable regression analyses were conducted.

RESULTS

The mean PAM score increased by 6.58 points, with a 5-point change considered clinically significant. From pre- to post-intervention, PAM scores significantly decreased for 23 participants, decreased for 6, did not change for 14, increased for 21, and significantly increased for 84. Higher pre-intervention PAM scores, younger age, greater educational attainment, and higher baseline self-efficacy scores were associated with increased post-intervention PAM scores when not controlling for potential covariates. Age was no longer associated with higher PAM scores after controlling for covariates.

CONCLUSION

Community-based DSMS interventions can be effective in generating positive change in individuals' activation. HED provides a feasible and accessible DSMS option that addresses key diabetes self-management components while effectively improving individuals' activation. It is recommended that people living with diabetes attend a DSMS program such as HED to increase their ability to effectively self-manage various components of their chronic condition.

Using Reminder Letters to Improve Adherence to Routine Hemoglobin A1C Testing in Adults with Diabetes

The American Diabetes Association (ADA) recommends hemoglobin A1C (A1C) goals of < 7% for most non-pregnant adults and < 8% for adult patients with extensive or life-limiting comorbidities. A1C testing is indicated every 3-months for patients not meeting goals to assess glycemic control, adjust medications, suggest lifestyle changes, and offer counseling. However, many patients do not adhere to routine testing. A clinic-wide quality improvement (QI) pilot project was implemented using mailed reminder letters to improve patient adherence to routine A1C testing in patients with hemoglobin A1C . 8%. Sixty-eight patients were identified for this letter intervention. Of these, 14 patients (20%) were historically adherent to 3-month interval testing, 31 patients (46%) were historically non-adherent, and 23 (34%) had historical A1C test intervals of less than 3-months because of provider orders. The primary outcome was improvement in A1C testing adherence rates of those who were previously non-adherent. There was a 58% increase overall and a 103% increase in testing rates among women. Statistical significance was not observed at the P = .05 level. However, improvement in adherence rates among women reached the P = .10 significance level. Mailed reminder letters may be useful in improving adherence to routine A1C testing in patients with diabetes. Further study of this intervention in larger groups is needed to provide timely data for the management of diabetes care.

Associations of combined healthy lifestyles with cancer morbidity and mortality among individuals with diabetes: results from five cohort studies in the USA, the UK and China

AIMS/HYPOTHESIS

Cancer has contributed to an increasing proportion of diabetes-related deaths, while lifestyle management is the cornerstone of both diabetes care and cancer prevention. We aimed to evaluate the associations of combined healthy lifestyles with total and site-specific cancer risks among individuals with diabetes.

METHODS

We included 92,239 individuals with diabetes but without cancer at baseline from five population-based cohorts in the USA (National Health and Nutrition Examination Survey and National Institutes of Health [NIH]-AARP Diet and Health Study), the UK (UK Biobank study) and China (Dongfeng-Tongji cohort and Kailuan study). Healthy lifestyle scores (range 0-5) were constructed based on current nonsmoking, low-to-moderate alcohol drinking, adequate physical activity, healthy diet and optimal bodyweight. Cox regressions were used to calculate HRs for cancer morbidity and mortality, adjusting for sociodemographic, medical and diabetes-related factors.

RESULTS

During 376,354 person-years of follow-up from UK Biobank and the two Chinese cohorts, 3229 incident cancer cases were documented, and 6682 cancer deaths were documented during 1,089,987 person-years of follow-up in the five cohorts. The pooled multivariable-adjusted HRs (95% CIs) comparing participants with 4-5 vs 0-1 healthy lifestyle factors were 0.73 (0.61, 0.88) for incident cancer and 0.55 (0.46, 0.67) for cancer mortality, and ranged between 0.41 and 0.63 for oesophagus, lung, liver, colorectum, breast and kidney cancers. Findings remained consistent across different cohorts and subgroups.

CONCLUSIONS/INTERPRETATION

This international cohort study found that adherence to combined healthy lifestyles was associated with lower risks of total cancer morbidity and mortality as well as several subtypes (oesophagus, lung, liver, colorectum, breast and kidney cancers) among individuals with diabetes.

Type 1 diabetes knowledge assessment: The KAT-1 validation study

OBJECTIVE

This study sought to examine the reliability and validity of a novel pediatric type 1 diabetes knowledge assessment (KAT-1) designed for children, adolescents, young adults and their parents/guardians. The instrument was designed to be integrated into the clinic workflow to obtain objective data electronically.

RESEARCH DESIGN AND METHODS

KAT-1 was developed by a multidisciplinary team and includes 11 independent topical subscales. Forty children/caregivers participated in a pilot study; their feedback was used to improve item clarity and readability. Subsequently, a validation study was performed in 200 participants (100 children/adolescents/young adults with type 1 diabetes ages 11-21 years and 100 parents/guardians of children with type 1 diabetes ages 1-15 years) to examine correlations between the KAT-1 scores and Revised Diabetes Knowledge Test (DKT2) scores and HbA1c. An item analysis was conducted to determine internal consistency and reliability; topical subscales were evaluated using Cronbach's alpha.

RESULTS

Total KAT-1 scores were positively correlated with DKT2 scores r = 0.674, p < 0.001, and negatively correlated with HbA1c, r = -0.3, p < 0.001. All KAT-1 subscales were positively and significantly correlated with one another and with total KAT-1 score. Internal consistency of total KAT-1 score was strong (Cronbach's α = 0.938, mean score 84.6, SD = 16.1) and 9 of 11 independent topical subscales demonstrated strong internal consistency. Completion time for subscales was <5 min.

CONCLUSIONS

KAT-1 is a valid instrument to assess type 1 diabetes knowledge. The instrument's short topical subscales can be used to objectively assess specific knowledge and individualize diabetes education. KAT-1 has been integrated into our electronic health record (EPIC) and is available online at no cost.

Executive summary of the consensus statement of: Clinical recommendations for sport practice in people with diabetes (RECORD Guide). Update 2021. Diabetes Mellitus Area of the Spanish Society of Endocrinology and Nutrition (SEEN)

OBJECTIVE

To guide professionals involved in the care of people with diabetes mellitus who practice sport.

PARTICIPANTS

Members of the Diabetes Mellitus Working Group of the Spanish Society of Endocrinology and Nutrition.

METHODS

A group of experts in each area covered by the statement carried out a bibliographic review of the available evidence for each topic, based on which recommendations were subsequently agreed upon within the Diabetes Mellitus Working Group.

CONCLUSIONS

The statement provides practical recommendations for the management of diabetes mellitus during sports practice.

[The effect of family caregiver empowerment interventions on family caregiver capabilities in self-management of type 2 diabetes mellitus in Indonesia]

OBJECTIVE

Empowering family caregivers is one of the strategies to increase the family caregiver's capability in T2DM self-management. The adequate capability of family caregivers in T2DM self-management can improve T2DM management, impacting people's health status with T2DM. This study aimed to examine the effect of family caregiver empowerment intervention on the family caregiver's T2DM self-management capability.

METHODS

This study is an experimental study with a randomized control group pre-test post-test design. The sample size is 60 respondents by simple random sampling, which is divided into two groups randomly. The treatment group (n=30) received 10-session intervention in 10 weeks (six education and training sessions and four mentoring sessions), and the control group (n=30) received standard care. Data were collected using a questionnaire, twice, before and after the intervention (12 weeks after the last intervention session) and analysed descriptively and statistically (One way-ANOVA test, dependent t-test, and independent t-test).

RESULTS

The empowerment intervention significantly increased the family caregiver's T2DM self-management capability, including diet management (t=4.070; p<.001), physical activity management (t=9.493; p<.001), medication management (t=4.021; p<.001), self-monitoring blood glucose levels (t=2.789; p<.001), and foot care skills (t=6.835; p<.001).

CONCLUSION

Family caregiver empowerment interventions can improve the capability of family caregivers in self-management of T2DM, including increasing the capability to manage diet, physical activity, medication, self-monitoring blood glucose levels, and foot care. Nurses can empower family members as family caregivers to improve self-management of T2DM.

Precision medicine in type 1 diabetes

First envisioned by early diabetes clinicians, a person-centred approach to care was an aspirational goal that aimed to match insulin therapy to each individual's unique requirements. In the 100 years since the discovery of insulin, this goal has evolved to include personalised approaches to type 1 diabetes diagnosis, treatment, prevention and prediction. These advances have been facilitated by the recognition of type 1 diabetes as an autoimmune disease and by advances in our understanding of diabetes pathophysiology, genetics and natural history, which have occurred in parallel with advancements in insulin delivery, glucose monitoring and tools for self-management. In this review, we discuss how these personalised approaches have improved diabetes care and how improved understanding of pathogenesis and human biology might inform precision medicine in the future.

The Effects of a Lifestyle Intervention Supported by the InterWalk Smartphone App on Increasing Physical Activity Among Persons With Type 2 Diabetes: Parallel-Group, Randomized Trial

Background

Effective and sustainable implementation of physical activity (PA) in type 2 diabetes (T2D) health care has in general not been successful. Efficacious and contemporary approaches to support PA adherence and adoption are required.

Objective

The primary objective of this study was to investigate the effectiveness of including an app-based (InterWalk) approach in municipality-based rehabilitation to increase moderate-and-vigorous PA (MVPA) across 52 weeks compared with standard care among individuals with T2D.

Methods

The study was designed as a parallel-group, randomized trial with 52 weeks’ intervention and subsequent follow-up for effectiveness (52 weeks from baseline). Participants were recruited between January 2015 and December 2016 and randomly allocated (2:1) into 12 weeks of (1) standard care + InterWalk app–based interval walking training (IWT; IWT group; n=140), or (2) standard care + the standard exercise program (StC group; n=74). Following 12 weeks, the IWT group was encouraged to maintain InterWalk app–based IWT (3 times per week for 30-60 minutes) and the StC group was encouraged to maintain exercise without structured support. Moreover, half of the IWT group (IWTsupport group, n=54) received additional motivational support following the 12-week program until 52-week follow-up. The primary outcome was change in objectively measured MVPA time (minutes/day) from baseline to 52-week follow-up. Key secondary outcomes included changes in self-rated physical and mental health–related quality of life (HRQoL), physical fitness, weight, and waist circumference.

Results

Participants had a mean age of 59.6 (SD 10.6) years and 128/214 (59.8%) were men. No changes in MVPA time were observed from baseline to 52-week follow-up in the StC and IWT groups (least squares means [95% CI] 0.6 [–4.6 to 5.8] and –0.2 [–3.8 to 3.3], respectively) and no differences were observed between the groups (mean difference [95% CI] –0.8 [–8.1 to 6.4] minutes/day; P=.82). Physical HRQoL increased by a mean of 4.3 (95% CI 1.8 to 6.9) 12-item Short-Form Health Survey (SF-12) points more in the IWT group compared with the StC group (Benjamini-Hochberg adjusted P=.007) and waist circumference apparently decreased a mean of –2.3 (95% CI –4.1 to –0.4) cm more in the IWT group compared with the StC group but with a Benjamini-Hochberg adjusted P=.06. No between-group differences were observed among the remaining key secondary outcomes.

Conclusions

Among individuals with T2D referred to municipality-based lifestyle programs, randomization to InterWalk app–based IWT did not increase objectively measured MVPA time over 52 weeks compared with standard health care, although apparent benefits were observed for physical HRQoL.

Trial Registration

ClinicalTrials.gov NCT02341690; https://clinicaltrials.gov/ct2/show/NCT02341690

Differences in Free-Living Patterns of Sedentary Behaviour between Office Employees with Diabetes and Office Employees without Diabetes: A Principal Component Analysis for Clinical Practice

AIMS

To identify principal components of free-living patterns of sedentary behaviour in office employees with type 2 diabetes (T2D) compared to normal glucose metabolism (NGM) office employees, using principal component analysis (PCA).

METHODS

213 office employees (n = 81 with T2D; n = 132 with NGM) wore an activPAL inclinometer 24 h a day for 7 consecutive days. Comparions of sedentary behaviour patterns between adults with T2D and NGM determined the dimensions that best characterise the sedentary behaviour patterns of office employees with T2D at work, outside work and at weekends.

RESULTS

The multivariate PCA technique identified two components that explained 60% of the variability present in the data of sedentary behaviour patterns in the population with diabetes. This was characterised by a fewer number of daily breaks and breaks in time intervals of less than 20 min both at work, outside work and at weekends. On average, adults with T2D took fewer 31 breaks/day than adults without diabetes.

CONCLUSION

Effective interventions from clinical practice to tackle prolonged sedentary behaviour in office employees with T2D should focus on increasing the number of daily sedentary breaks.

Stigma evaluation for diabetes and other chronic non-communicable disease patients: Development, validation and clinical use of stigma scale - The Kanden Institute Stigma Scale

AIMS/INTRODUCTION

The aim of this study was to develop a scale to evaluate disease stigma in patients with lifestyle-related chronic non-communicable diseases (LCNCDs), which we named the Kanden Institute Stigma Scale (KISS), and to consider its possible clinical application for patients with diabetes.

MATERIALS AND METHODS

An initial 90 questions were drafted and categorized into six subscales according to the manifestations of stigma. The final version of the KISS was developed as a 24-item questionnaire comprising four items for each subscale.

RESULTS

A total of 539 outpatients including 452 patients with diabetes and 87 patients without diabetes were recruited. Construct validity was confirmed by assessing the correlation with previously established measures. Confirmatory factor analysis showed the KISS to have good model fitness (adjusted goodness-of-fit index = 0.856). Test-retest reproducibility analysis showed that the intraclass coefficient of the first and a second KISS was 0.843 (P < 0.001), indicating excellent reproducibility. The KISS showed higher scores for patients with diabetes than for patients without diabetes (12.23 ± 0.49 vs 5.76 ± 0.73, P < 0.05). The KISS score was significantly higher in type 1 and type 2 diabetes patients taking insulin therapy than in type 2 diabetes patients not taking insulin (P < 0.05).

CONCLUSION

The KISS is a validated and reliable questionnaire for assessment of stigma among patients with diabetes as well as other lifestyle-related chronic non-communicable diseases, and might contribute to identifying and rectifying diabetes stigma, as well promoting awareness among health care professionals of this very consequential health problem.

Investigating the experiences of low-carbohydrate diets for people living with Type 2 Diabetes: A thematic analysis

Low-Carbohydrate Diets (LCDs) are becoming increasingly popular to manage Type 2 diabetes mellitus (T2DM). However, there is a need to identify people with T2DM’s understanding of LCDs, their reasons for engaging in such a diet, how they sustain it and any challenges they face. This study aimed to assess the experience of adhering to a LCD within a sample of individuals with T2DM. Ten participants with T2DM were recruited using a self-selecting sampling method from an online diabetes community that promotes LCDs. Participants completed one-to-one digitally recorded semi-structured interviews, which were later transcribed verbatim and data subjected to Thematic Analysis. Five core themes and twelve subthemes were developed during the analysis: (1) Lack of professional guidance; (2) Fear of complications & long-term medication use; (3) Dietary control as motivation; (4) Positive health outcomes; and (5) Social support. The findings are discussed with reference to a psychological model of behaviour, COM-B. Participants reported gaining knowledge and skills to increase their Capability to engage in LCDs, Motivation to manage diabetes outcomes influenced adherence. However, challenges were reported with the Opportunity to engage in behaviour, mainly influenced by social support. Health professionals and significant others may benefit from resources to help build knowledge and understanding and assist with maintaining a LCD long-term.

Effectiveness of an integrated primary care intervention in improving psychosocial outcomes among Latino adults with diabetes: the LUNA-D study

OBJECTIVE

To compare the effectiveness of usual care (UC) versus a culturally tailored integrated care model in improving mental health symptoms for Latino patients with Type 2 diabetes mellitus (T2DM).

METHODS

We conducted a two-arm randomized controlled trial from 2015 to 2019 at a federally qualified health center. Participants were 456 adults ages 23-80 years who had a previous diagnosis of T2DM and were not currently using insulin. Participants were randomly assigned to Integrated Care Intervention (ICI; including behavioral/mental healthcare, medical visits, health education and care coordination) or UC; standard of care including referrals for health education and behavioral/mental health care where appropriate. Intention-to-treat, multilevel models were used to compare group × time changes in depression and anxiety symptoms (PHQ-8; GAD-7) and perceived stress (PSS-10) across 6 months.

RESULTS

Participant mean age was 55.7 years, 36.3% were male, and 63.7% were primarily Spanish speaking. Baseline sociodemographic factors and mental health symptoms across study arms were balanced. Significant group × time interaction effects were observed for anxiety and depression symptoms (p < .05). Within the ICI and UC groups, mean depression symptom changes were -0.93 and -0.39 (p < .01); anxiety symptom changes were -0.97 (p < .01) and -0.11 (p = .35); and perceived stress changes were -1.56 and -1.27 (p < .01), respectively.

CONCLUSIONS

Although both ICI and UC showed decreases over time, the ICI group evidenced larger, statistically significant changes in both depression and anxiety. Adapted integrated models of behavioral and chronic disease management appear to be effective and could be considered for usual care practices.

CLINICALTRIALS.GOV IDENTIFIER

NCT03983499.

Relation of Change or Substitution of Low- and No-Calorie Sweetened Beverages With Cardiometabolic Outcomes: A Systematic Review and Meta-analysis of Prospective Cohort Studies

BACKGROUND

Adverse associations of low- and no-calorie sweetened beverages (LNCSB) with cardiometabolic outcomes in observational studies may be explained by reverse causality and residual confounding.

PURPOSE

To address these limitations we used change analyses of repeated measures of intake and substitution analyses to synthesize the association of LNCSB with cardiometabolic outcomes.

DATA SOURCES

MEDLINE, Embase, and the Cochrane Library were searched up to 10 June 2021 for prospective cohort studies with ≥1 year of follow-up duration in adults.

STUDY SELECTION

Outcomes included changes in clinical measures of adiposity, risk of overweight/obesity, metabolic syndrome, type 2 diabetes (T2D), cardiovascular disease, and total mortality.

DATA EXTRACTION

Two independent reviewers extracted data, assessed study quality, and assessed certainty of evidence using GRADE. Data were pooled with a random-effects model and expressed as mean difference (MD) or risk ratio (RR) and 95% CI.

DATA SYNTHESIS

A total of 14 cohorts (416,830 participants) met the eligibility criteria. Increase in LNCSB intake was associated with lower weight (5 cohorts, 130,020 participants; MD -0.008 kg/year [95% CI -0.014, -0.002]). Substitution of LNCSB for sugar-sweetened beverages (SSB) was associated with lower weight (three cohorts, 165,579 participants; MD, -0.12 [-0.14, -0.10,] kg/y) and lower incidence of obesity (OB) (one cohort, 15,765 participants; RR 0.88 [95% CI 0.88, 0.89]), coronary heart disease (six cohorts, 233,676 participants; 0.89 [0.81, 0.98]), cardiovascular disease mortality (one cohort, 118,363 participants; 0.95 [0.90, 0.99]), and total mortality (one cohort, 118,363 participants; 0.96 [0.94, 0.98]) with no adverse associations across other outcomes. Substitution of water for SSB showed lower weight (three cohorts, 165,579 participants; MD -0.10 kg/year [-0.13, -0.06]), lower waist circumference (one cohort, 173 participants; -2.71 cm/year [-4.27, -1.15]) and percent body fat (one cohort, 173 participants; -1.51% per year [-2.61, -0.42]), and lower incidence of OB (one cohort, 15,765 participants; RR 0.85 [0.75, 0.97]) and T2D (three cohorts, 281,855 participants; 0.96 [0.94, 0.98]). Substitution of LNCSB for water showed no adverse associations.

LIMITATIONS

The evidence was low to very low certainty owing to downgrades for imprecision, indirectness, and/or inconsistency.

CONCLUSIONS

LNCSB were not associated with cardiometabolic harm in analyses that model the exposure as change or substitutions. The available evidence provides some indication that LNCSB in their intended substitution for SSB may be associated with cardiometabolic benefit, comparable with the standard of care, water.

Dose-Dependent Effect of Supervised Aerobic Exercise on HbA1c in Patients with Type 2 Diabetes: A Meta-analysis of Randomized Controlled Trials

BACKGROUND

Previous meta-analyses indicated that aerobic exercise can improve glycemic control. However, the optimum dose of exercise is still being discussed.

OBJECTIVE

The aim of this study was to examine the dose-dependent effect of supervised aerobic training (SAT) on glycated hemoglobin (HbA_1c).

METHODS

We searched PubMed, Scopus, and Web of Science to May 2021 for randomized trials with an intervention period of 12 weeks or longer evaluating the effect of SAT on HbA_1c in adults with type 2 diabetes mellitus. Secondary outcomes included quality of life, change in hypoglycemic medications, and adverse events. A random-effects dose-response meta-analysis was conducted.

RESULTS

The analysis of 26 trials with 1253 participants indicated that each 30-min/week SAT reduced HbA_1c by - 0.22 percentage point (95% CI - 0.29 to - 0.15; GRADE = strong). Levels of HbA_1c decreased proportionally with the increase in the duration of moderate to vigorous-intensity SAT to 100 min/week (mean difference_{100 min/week}: - 0.96 percentage point, 95% CI - 1.25 to - 0.67), with flattening of the curve at higher duration. Aerobic exercise decreased antidiabetic medications by 13 per 100 patients (risk difference 0.13, 95% CI 0.02-0.23; 7 trials, n = 375; GRADE = moderate), and increased hypoglycemic reactions by 10 per 100 patients (risk difference: 0.10, 95% CI 0.03-0.17; 4 trials, n = 263; GRADE = low) and adverse events by 4 per 100 patients (risk difference: 0.04, 95% CI - 0.02 to 0.11; 2 trials, n = 236; GRADE = low). Limited evidence is available for quality of life.

CONCLUSIONS

Every 30 min/week of moderate to vigorous aerobic exercise can exert a significant effect on HbA_1c, with the highest effect observed from 100 min/week and above. However, exercise durations above 100 min/week seem ineffective for further reductions.

PROTOCOL REGISTRATION

PROSPERO (CRD42021257251).

Flexible inclusion of dialogue about psychosocial aspects of life with type 1 diabetes in routine consultations: A study of a questionnaire-based dialogue tool to promote person-centred support

AIMS

To explore (1) experiences among people with type 1 diabetes and diabetologists of using a questionnaire-based dialogue tool in routine consultations to identify and address psychosocial challenges and (2) experiences of person-centredness in this group compared with a group who did not use the tool.

METHODS

In all, 42 people with type 1 diabetes (mean age 54 years, mean diabetes duration 31 years and 60% women) were interviewed and completed an evaluation questionnaire following a routine consultation with the use of a dialogue tool including PAID-5, WHO-5 and open-ended questions. A comparison group of 42 people with type 1 diabetes attending routine consultations without the use of dialogue tools completed evaluation questionnaires. All consultations were audio recorded. Diabetologists were interviewed after completing all test consultations. Interviews were analysed using thematic text condensation. Evaluation questionnaires were analysed using descriptive statistics, chi square tests and Student's two-sided t-tests.

RESULTS

Most participants found questions in the dialogue tool relevant to discuss with the diabetologist, and two-thirds were satisfied with the time spent on that. Experiences of people with type 1 diabetes and diabetologists were related to three pathways: (1) the tool supported valuable conversations with the diabetologist, (2) conversations with the diabetologist were unchanged and (3) the tool derailed conversations. All participants reported high levels of person centredness; however, significantly more in the comparison group reported that the diabetologist made them feel at ease (80 vs. 55%) and discussed and planned specific changes with them (93 vs. 67%).

CONCLUSION

A questionnaire-based dialogue tool in consultations can support the discussion of psychosocial issues of people with type 1 diabetes. However, flexible and tailored use of the dialogue tool is crucial as consultations may otherwise be derailed.

Severity of depressive but not anxiety symptoms impacts glucose metabolism among patients with type 2 diabetes in primary care

Background

Data from primary care regarding the prevalence of symptoms of depression and anxiety, and their effect on glycemic control among people with diabetes is lacking in Hungary. The recently introduced Patient Health Record (PHR) requires family doctors to screen for depressive symptoms.

Objectives

We aimed to investigate the prevalence of depressive and anxiety symptoms among patients with type 2 diabetes in the general practice, and the relationship between these affective disorders and glycated hemoglobin (HbA1c) level.

Methods

We included 338 consecutive patients with type 2 diabetes from six primary care practices in this cross-sectional study. A self-administered questionnaire (patient history, anthropometric, socioeconomic, laboratory parameters), the Beck Depression Inventory (BDI) and the Hamilton Anxiety Scale (HAM-A) were used.

Results

The mean age of the sample was 64.0 ± 11.5 (years ± SD), 61% of participants were female. The prevalence of depressive symptoms was 21%, mainly moderate/severe symptoms (13%). Anxiety symptoms were more common (35%). We found significant univariate association between the depressive symptoms and HbA1c (p = 0.001), suicide attempt (p < 0.001), anxiety (p < 0.001), micro- and macrovascular complication (p = 0.028 and p < 0.001), education (p = 0.001) and place of residence (p = 0.002). In multivariate analysis, however, only BDI score had significant (p = 0.03191) association with glycemic control.

Conclusion

Among primary care patients with type 2 diabetes, the prevalence of depressive symptoms was less frequent than anxiety symptoms. More severe depressive symptoms were associated with worse glycemic control.

Determinants of healthful eating and physical activity among adolescents and young adults with type 1 diabetes in Qatar: A qualitative study

BACKGROUND

In Qatar, as in the rest of the world, the sharp rise in the prevalence of type 1 diabetes (T1D) is a leading cause for concern, in terms associated with morbidity, mortality, and increasing health costs. Besides adhering to medication, the outcome of diabetes management is also dependent on patient adherence to the variable self-care behaviors including healthful eating (HE) and physical activity (PA). Yet, dietary intake and PA in adolescents and young adults (AYAs) with T1D are known to fall short of recommended guidelines. The aim of this study was to develop an in-depth understanding of the behavioral determinants of HE and PA adherence among Arab AYAs within the age range of 17-24 years with T1D attending Hamad General Hospital.

METHODS

Semi-structured, face-to-face individual interviews were conducted with 20 participants. Interviews were based on an integrative health behavior change model, the I-Change model (ICM). All interviews were audio-recorded, transcribed verbatim, and analyzed using the framework method.

RESULTS

More participants reported non-adherence than adherence. Several motivational determinants of adherence to HE and PA were identified. The majority of participants were cognizant of their own behaviors towards HE and PA. Yet, some did not link low adherence to HE and PA with increased risks of health problems resulting from T1D. Facilitators to adherence were identified as being convinced of the advantages of HE and PA, having support and high self-efficacy, a high level of intention, and a good health care system.

CONCLUSION

The suboptimal adherence in AYAs to HE and PA needs more attention. Supportive actions are needed to encourage adherence to a healthy lifestyle to achieve benefits in terms of glycemic control and overall health outcomes, with a special focus on adolescents. Interventions are needed to foster motivation by addressing the relevant determinants in order to promote adherence to these two behaviors in AYAs with T1D.

Diabetes Control in a Student-Run Free Clinic During the COVID-19 Pandemic

Student run free health clinics (SRFCs) provide medical care to vulnerable populations in communities throughout the United States. The COVID-19 pandemic had a significant impact on the delivery of healthcare services and demanded a rapid adjustment in care delivery methods in both resource-rich and resource-poor settings. The aim of this study is to evaluate the impact of the pandemic on the management of chronic disease, specifically diabetes. Patients with diabetes who received care continuously throughout the pre-pandemic (face-to-face) and pandemic (telehealth) study periods at MedZou Community Health Center, a SRFC located in central Missouri, were evaluated. This sample of patients (n = 29) was evaluated on six quality measures including annual eye exams, blood pressure, hemoglobin A1c, chronic kidney disease monitoring, flu vaccination, and statin therapy. Overall diabetes care, as measured by the number of quality measures met per patient, decreased by 0.37 after the onset of the pandemic. The median COVID-era ranks were not statistically significantly different than the pre-pandemic ranks (z = 1.65, P = 0.099). Fewer patients received an influenza vaccination the year following the onset of the pandemic (10.3%) compared to the year before the pandemic (37.9%; difference in proportions 0.276, 95% CI 0.079, 0.473; p = 0.005). No other individual measures of diabetes care statistically differed significantly in the year after the pandemic began. Twenty-six (90%) patients received diabetes care using telehealth after the onset of the pandemic. Diabetes care using telehealth in a SRFC may be an acceptable alternative model when face-to-face visits are not feasible. Observed decreases in diabetes-related clinical quality measure performance warrant further study.

The Transcultural Diabetes Nutrition Algorithm: A Middle Eastern Version

Diabetes prevalence is on the rise in the Middle East. In countries of the Gulf region-Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates-prevalence rates are among the highest in the world. Further, Egypt now ranks as one of the top 10 countries in the world for high number of people with diabetes. Medical nutrition therapy is key to optimal management of diabetes. Patient adherence to nutritional guidance depends on advice that is tailored to regional foods and cultural practices. In 2012, international experts created a transcultural Diabetes Nutrition Algorithm (tDNA) for broad applicability. The objective of this current project was to adapt the algorithm and supportive materials to the Middle East region. A Task Force of regional and global experts in the fields of diabetes, obesity, and metabolic disorders met to achieve consensus on Middle East-specific adaptations to the tDNA. Recommendations, position statements, figures, and tables are presented here, representing conclusions of the tDNA-Middle Eastern (tDNA-ME) Task Force. Educational materials can be used to help healthcare professionals optimize nutritional care for patients with type 2 diabetes. The tDNA-ME version provides evidence-based guidance on how to meet patients' nutritional needs while following customs of people living in the Middle Eastern region.

Trends in dietary macronutrient composition and diet quality among US adults with diagnosed and undiagnosed elevated glycemic status: a serial cross-sectional study

BACKGROUND

Knowledge of glycemic status may affect dietary intake for subjects with diabetes and prediabetes.

OBJECTIVES

We aimed to determine whether trends of macronutrient intake and dietary quality differed by diagnosis of glycemic status among US adults with diabetes and prediabetes.

METHODS

Data from NHANES 1999-2016 were analyzed. Diagnosed cases were established by self-report, and undiagnosed cases were defined by laboratory criteria (glycated hemoglobin ≥ 5.7%, fasting plasma glucose ≥ 100 mg/dL, or 2-h oral-glucose-tolerance test ≥ 140 mg/dL). A difference-in-differences model was used to compare the temporal trends between the 2 groups.

RESULTS

There were 7502 diagnosed and 12,974 undiagnosed cases with elevated glycemic status included in the study. During 1999-2016, the intake of low-quality carbohydrates was lower, whereas intakes of high-quality carbohydrates, animal protein, plant protein, and unsaturated fat and the Healthy Eating Index 2015 (HEI-2015) score were higher, among the diagnosed cases than among the undiagnosed cases (P < 0.001 for all). However, in the trend analyses from 1999 to 2016, the increase in intake of high-quality carbohydrates was smaller among the diagnosed cases than among the undiagnosed cases (difference: -1.16%; 95% CI: -1.82%, -0.50%; P = 0.001). Moreover, the decrease in low-quality carbohydrate intake was smaller (difference: 0.79%; 95% CI: 0.01%, 1.57%; P = 0.05) and the increase in saturated fat intake was larger (difference: 0.44%; 95% CI: 0.08%, 0.79%; P = 0.02) among the diagnosed cases than among the undiagnosed cases. A significant difference of temporal trends in the HEI-2015 score between the diagnosed and undiagnosed cases was also observed, in favor of the undiagnosed cases (difference: -2.56; 95% CI: -3.71, -1.41; P < 0.001).

CONCLUSIONS

Although dietary habits among adults with diagnosed diabetes and prediabetes were better than those among the undiagnosed cases, these advantages have been diminishing during the past 2 decades.

Perceived Changes in Emotions, Worries and Everyday Behaviors in Children and Adolescents Aged 5-18 Years with Type 1 Diabetes during the COVID-19 Pandemic

The COVID-19 pandemic and the consequent restrictive measures may be related to increased stress and anxiety and to changes in daily behaviors. Children with type 1 diabetes (T1D) are a vulnerable group due to their difficulties in achieving glycemic control and to their medical and psychological comorbidities. The purpose of the current study was to the investigate the changes on emotional and behavioral parameters in children with T1D due to the Coronavirus crisis. A total of 152 children and adolescents, aged 5−18, were studied: 114 (62 boys) with T1D and 38 (19 boys) healthy volunteers (HV) (controls). The study was performed at the Diabetes Center, Aghia Sofia Children’s Hospital, during the first national lockdown in Greece. The CRISIS questionnaire was completed by parents/caregivers. The data were collected in May 2020 and referred to two time-points: three months prior (before the pandemic), and the past two weeks. During the lockdown, it was observed significant aggravation in the “Emotion/Worries (EW)” symptoms in both groups (logEW-before vs. logEW-during the crisis, T1D: 2.66 ± 0.23 vs. 3.00 ± 0.21, p < 0.001 and HV: 2.62 ± 0.16 vs. 2.83 ± 0.18, p < 0.001). Deterioration of “ΕW” was recorded for 93.0% of those with T1D and 92.1% of the HV. “EW” during the lockdown were affected by: previous psychological condition, COVID-related concerns, and “Life Changes due to the COVID-19 crisis in the past two weeks (LC)”. Deterioration was observed in the “daily behaviors” and “use of digital media” for all of the children. The crisis and the associated restrictions negatively affected both the lifestyle parameters and the behavioral and emotional variables of the children with T1D.

Lower carbohydrate diets for adults with type 2 diabetes

In May 2021, the Scientific Advisory Committee on Nutrition (SACN) published a risk assessment on lower carbohydrate diets for adults with type 2 diabetes (T2D)⁽⁾. The purpose of the report was to review the evidence on 'low'-carbohydrate diets compared with the current UK government advice on carbohydrate intake for adults with T2D. However, since there is no agreed and widely utilised definition of a 'low'-carbohydrate diet, comparisons in the report were between lower and higher carbohydrate diets. SACN's remit is to assess the risks and benefits of nutrients, dietary patterns, food or food components for health by evaluating scientific evidence and to make dietary recommendations for the UK based on its assessment⁽⁾. SACN has a public health focus and only considers evidence in healthy populations unless specifically requested to do otherwise. Since the Committee does not usually make recommendations relating to clinical conditions, a joint working group (WG) was established in 2017 to consider this issue. The WG comprised members of SACN and members nominated by Diabetes UK, the British Dietetic Association, Royal College of Physicians and Royal College of General Practitioners. Representatives from NHS England and NHS Health Improvement, the National Institute for Health and Care Excellence and devolved health departments were also invited to observe the WG. The WG was jointly chaired by SACN and Diabetes UK.