5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2024

A Minimally Time-Consuming Method for Regular, Ongoing Outcome Assessments in a Rural Diabetes Self-Management Education and Support Program: Validation via Retrospective Pre-Post Studies

PurposeThe purpose of this study was to introduce and validate a minimally time-consuming method for regular, ongoing assessments of practice- and individual-level outcomes in a rural diabetes self-management education and support (DSMES) program.MethodsThe method involves a report developed within an electronic health record system to capture the initial A1C data of patients in the program and their most recent A1C data at the time the report is run. To validate the method's ability to continuously assess outcomes, 3 retrospective pre-post studies were conducted over 3 consecutive months: October, November, and December 2023. The subjects were individuals with type 2 or type 1 diabetes who completed their initial visits in the program during these months. A1C changes in patient cohorts and their statistical significance were analyzed as practice-level outcomes, and individual-level outcomes were monitored by plotting and analyzing patient data.ResultsThe report accurately captured data, enabling minimally time-consuming analyses. The method allowed both continuous assessment of program effectiveness based on A1C changes and monitoring of individual patient progress. Statistically significant reductions in average A1C were observed for subjects seen in October and December 2023 (but not in November) and across the combined data from all 3 months. Data plotting helped identify individual subjects who may benefit from follow-up.ConclusionsThe method is feasible and accurate for ongoing outcome assessments, providing timely feedback to clinicians and promoting practice changes to improve patient outcomes. It is also flexible and adaptable to other DSMES programs.

Hypoglycemia knowledge assessment tool - Development and validation of the Hypoglycemia Management Knowledge Scale in Taiwan

BACKGROUND

Knowledge can guide and support behaviors. With accurate knowledge, patients are better equipped to engage in appropriate self-care behaviors and effectively manage hypoglycemia. However, there is currently a lack of reliable and valid assessment scales specifically designed to measure hypoglycemia knowledge, which could serve as valuable clinical evaluation tools for healthcare professionals.

AIM

To develop and validate a reliable and valid hypoglycemia management knowledge scale to assess the knowledge of hypoglycemia management in patients with diabetes.

METHODS

A cross-sectional study was conducted, recruiting 300 patients with type 2 diabetes who had experienced hypoglycemic events from a medical center and a primary care clinic in southern Taiwan between December 2021 and September 2023.

RESULTS

Initially, 25 questions were selected, achieving a content validity index of 0.92. Through exploratory factor analysis and confirmatory factor analysis, the scale was refined into an 8-factor and 3-factor model, with factor loadings ranging from 0.5 to 0.9. The questions were categorized into three factors: blood glucose determination, carbohydrate supplementation, and blood glucose testing. The internal consistency, measured using the Kuder-Richardson 20 (KR-20), was 0.758.

CONCLUSIONS

The hypoglycemia management knowledge scale developed in this study demonstrated sufficient validity and reliability, making it a useful tool for quickly assessing patients' knowledge of hypoglycemia management and serving as a reference for hypoglycemia education.

Modifiable risk factors and plasma proteomics in relation to complications of type 2 diabetes

A comprehensive assessment of combined modifiable risk factors with common complications of type 2 diabetes (T2D) is lacking, and the potential role of proteomics remains unclear. Here, we examine the associations of cardiovascular health (CVH) score and degree of risk factor control with common diabetic complications using data from the UK Biobank (n = 14,102). Furthermore, we explore the mediation effects of plasma proteomics in a subset with proteomic data (n = 1287). Over median follow-ups of 12.4-13.4 years, higher CVH score and higher degree of risk factor control are associated with lower risks of 30 and 22 of 45 adverse outcomes among individuals with T2D, respectively. Mediation analyses reveal that mortality and multiple vascular diseases share common mediators, such as uromodulin and pro-adrenomedullin. These findings highlight the importance of risk factors modification in reducing disease burden among people with T2D and facilitate the understanding of mediation effects of plasma proteins underlying these associations.

Gratitude Interventions in Individuals With Diabetes: An Integrative Review

Diabetes is a chronic, complex condition, which requires intensive daily management for adequate glycemic control. The burden of daily tasks necessary for diabetes self-management can negatively impact psychosocial outcomes. The practice of gratitude in patients with chronic conditions has demonstrated improvement in poor psychosocial outcomes. The purpose of this review is to examine the effect of gratitude interventions on glycemic and psychosocial outcomes in individuals with diabetes. We searched 5 databases in September 2024 to identify research articles that met inclusion criteria. Six studies met inclusion criteria. Interventions included gratitude journaling, gratitude therapy, writing a gratitude letter, and gratitude reflection. Results indicate gratitude is a feasible intervention and may improve anxiety and depressive symptoms, quality of life, and coping with diabetes. There was heterogeneity in intervention delivery and results. Further research is required to ascertain the extent of correlation between gratitude, and glycemic and psychosocial outcomes.

Determinants of Qigong, Tai Chi, and Yoga Use for Health Conditions: A Systematic Review Protocol

INTRODUCTION

Mind-body movement interventions such as qi gong, tai chi, and yoga are recommended in clinical practice guidelines to improve outcomes for several health conditions. However, use of these interventions for health conditions, or the integration of these interventions within healthcare settings, is low. A systematic synthesis of implementation determinants (i.e., barriers and facilitators) is needed to increase adoption. Similarly, determinants may influence other implementation outcomes, such as scalability or sustainability of these interventions in a healthcare system or community organization. Thus, in conducting this review we aim to identify determinants of qi gong, tai chi, and yoga use for health conditions. The secondary aim is to evaluate whether barriers and facilitators differ by intervention type, health condition, implementation setting, or implementation outcome.

METHODS AND ANALYSIS

We conducted a comprehensive search of electronic databases (MEDLINE, EMBASE, Web of Science, CINAHL, PsycInfo) through May 2024 and a grey literature search (Google Scholar, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov , the WHO Clinical Trials database) through March 2025. We will include original research articles in English that identify barriers and facilitators to adoption of qi gong, tai chi, and yoga by adults with health conditions. Study quality will be assessed using the Mixed Methods Appraisal Tool. We will code each article using a codebook informed by the Consolidated Framework for Implementation Research (CFIR), a comprehensive taxonomy of implementation determinants. Findings will be presented as a narrative synthesis. We will report on how barriers and facilitators may relate to intervention type (qi gong, tai chi, yoga), health condition (e.g., low back pain, fall prevention), implementation settings (e.g., primary care clinic, community organization) or implementation outcome (e.g., adoption, sustainability).

ETHICS AND DISSEMINATION

Ethics approval will not be obtained for this review of published, publicly accessible data. The results from this systematic review will be disseminated through conference presentations and journal publications.

STRENGTHS AND LIMITATIONS OF THIS STUDY

There are no prior comprehensive reviews of the determinants (i.e., barriers and facilitators) of qi gong, tai chi and yoga use. This review will examine whether barriers and/or facilitators vary by type of mind-body movement intervention, health condition, implementation setting, or implementation outcome.Our search has been guided by librarians with expertise in systematic review methodology and informed by the PEER Review of Electronic Search Strategies (PRESS) guidelines. Reporting of results will be informed by the PRISMA-P checklist for systematic reviews.We will use the updated version of the Consolidated Framework for Implementation Research (CFIR, version 2.0) to report implementation factors using consistent concepts to facilitate use of the review by researchers, healthcare systems, and community organizations. Our findings will support the development of implementation strategies to increase the adoption of qi gong, tai chi, and yoga for health conditions.Due to the complex nature of describing implementation determinants and characterizing them within the Consolidated Framework for Implementation Research, our review is limited to papers written in English which may restrict the generalizability of our implementation findings to predominantly English-speaking healthcare settings.

Trends in cardiometabolic risk factors according to body mass index in Peru between 2015 and 2023

BACKGROUND

Global evidence has shown rising trends in the prevalence of cardiometabolic risk factors. Whether the same trends are observed according to body mass index (BMI) cut-offs is unknown, though critical to focus on specific BMI populations.

METHODS

We conducted a pooled analysis of national health surveys in Peru, grouped into three-year periods (2015-17 [n = 97,079], 2018-20 [n = 98,540], 2021-23 [n = 94,850]). BMI (kg/m²) was classified into four categories: normal weight (18-24.9), overweight (25-29.9), obesity I (30-34.9), and obesity II (≥35). For each period-BMI category, we computed the age-sex-standardized prevalence of cardiometabolic risk factors: raised blood pressure with and without self-reported antihypertensive treatment, self-reported diabetes with and without treatment, daily smoking, alcohol consumption in the last month, and fruits/vegetables consumption in the last week.

RESULTS

The proportion of people with raised blood pressure increased in the overweight and obesity groups, with the largest increase observed in the obesity II group (22 % relative increase). Diabetes prevalence rose substantially among normal weight (89 %) and overweight individuals (58 %). Smoking, alcohol, and fruit/vegetable consumption showed no major changes across BMI categories.

CONCLUSIONS

The prevalence of raised blood pressure has increased between 2015 and 17 and 2020-23, with greater increases observed in the overweight and obesity groups; conversely, the prevalence of self-reported diabetes has increased across BMI categories. These findings highlight the need for tailored interventions targeting both overweight/obese individuals and normal weight populations with diabetes risk.

Consumption of fruits and vegetables among Peruvian adults: Analysis of a national health survey 2017-2018

The WHO recommends consuming ≥400 g/day of fruits and vegetables daily as part of a healthy diet to prevent non-communicable diseases (NCDs). Data on fruits and vegetables intake is scarce in several countries, including Peru. However, it remains crucial to monitor policies to reduce the burden of non-communicable diseases. Cross-sectional analysis of a representative at the national level survey of Peruvian adults conducted in 2017-2018. Consumption of fruits and vegetables, stratified by socio-demographic and health-related variables, was estimated from a single 24-hour dietary recall questionnaire. Regression models were conducted to assess the potential association with low consumption of fruits and vegetables. The mean consumption of fruits and vegetables was 153.8 (95% CI: 133.4-174.2) g/day. Only 13.6% of the population consumed ≥400 g/day of fruits and vegetables. People with obesity (120 g/day), unaware diabetes (79.6 g/day) and unaware hypertension (51.1 g/day) had the lowest mean consumption. A consumption of <400 g/day was associated with obesity (OR): 2.56 (95% CI: 1.22-5.37) and having hypertension (OR: 3.32 (95% CI: 1.16-9.5)). Only 14 out of 100 Peruvian adults consume the recommended daily amount of fruits and vegetables and the mean consumption of fruits and vegetables is less than 2 portions a day. There is an urgent need for multi-sectoral health policies focused on increasing the access and consumption of fruits and vegetables as part of a healthy diet to reduce the burden of NCDs.

Effects of Lifestyle Interventions to Promote Physical Activity on Physical Activity and Glycated Hemoglobin in Patients with Type 2 Diabetes: a Systematic Review and Meta-Analysis

BACKGROUND

Numerous studies have explored the impact of controlled exercise interventions in type 2 diabetes, as physical activity can positively influence its progression. However, our understanding of how broader lifestyle interventions can effectively promote physical activity in practical real-world scenarios remains limited.

OBJECTIVE

This systematic review and meta-analysis aimed to investigate the potential of lifestyle interventions targeting the promotion of physical activity on physical activity outcomes and glycated hemoglobin (HbA1c), providing a comprehensive understanding of both behavioral and clinical impacts.

METHODS

We performed a systematic review and meta-analysis, searching three databases and examined the study design, structure, and content of the lifestyle interventions. We assessed physical activity and HbA1c as endpoints and performed a multivariate meta-regression to explore physical activity's impact on HbA1c.

RESULTS

This review incorporated 13 studies (n = 5301 patients), with heterogeneity in intervention designs, components, and durations. Lifestyle interventions showed a slight increase in physical activity, equivalent to an average of 9.0 min more total physical activity per day (95% confidence interval 5.8, 12.2) and 1.7 min more moderate-to-vigorous physical activity per day (95% confidence interval 1.1, 2.3), irrespective of objective (e.g., accelerometers) or subjective measurement (e.g., questionnaires) method. However, HbA1c reduction through these interventions was minimal 0.09% (95% confidence interval - 0.20, 0.03). The effect of physical activity was - 0.04 (standard error = 0.05, 95% confidence interval - 0.15, 0.06), suggesting that physical activity does not act as a moderator for changes in HbA1c.

CONCLUSIONS

Lifestyle interventions effectively increase physical activity but have limited impact on HbA1c compared to controls. The role of physical activity as a moderator for changes in HbA1c remains uncertain. Further research is needed to enhance the efficacy of these interventions in reducing HbA1c in individuals with type 2 diabetes.

Integrating neural substrates, diabetes self-management, and behavior change for tailored lifestyle interventions in type-2 diabetes: A neurobehavioral perspective

Understanding the neural mechanisms that underlie behavior change is critical for improving lifestyle management in type 2 diabetes. Individuals with type 2 diabetes face unique challenges in adopting and maintaining healthy behaviors, which can be influenced by alterations in brain function and plasticity, potentially leading to cognitive impairment. Diabetes self-management education and support (DSMES) programs aim to enhance lifestyle changes and promote better health outcomes while reducing cognitive decline. However, complex neural disruptions in critical regions for cognitive processes like the prefrontal cortex and parietal lobe present significant challenges. Given the likely role of neural mechanisms in behavioral choices, understanding how type 2 diabetes affects these neural substrates is crucial for developing effective interventions. Despite considerable research efforts aimed at testing lifestyle interventions, a critical gap remains in understanding the cognitive and behavioral components of successful diabetes self-management, the neural substrates of those components, and the impact of diabetes on those neural substrates. Bridging this gap necessitates a comprehensive examination integrating neural processes, DSMES strategies, and behavior change models. Thus, this perspective review highlights the urgent need to address the knowledge gaps surrounding the neural correlates of diabetes self-management and the integration of behavioral models into intervention frameworks. We propose a hypothesis-generating question and present preliminary findings comparing neural plasticity, executive functions, and lifestyle behavior among individuals with type 2 diabetes, pre-diabetes, and healthy controls. By elucidating the neural substrates underpinning diabetes and exploring their implications for DSMES and readiness to change, we can pave the way for more effective, personalized approaches to diabetes care.

Development and Impact of a Community-Delivered, Multisectoral Lifestyle Management Service for People Living With Type 2 Diabetes (Logan Healthy Living): Protocol for a Pragmatic, Single-Arm Intervention Study

BACKGROUND

Type 2 diabetes is the fastest-growing chronic condition in Australia, with higher prevalence in disadvantaged groups. Logan Healthy Living by UQ Health Care is a proof-of-concept, interprofessional allied health clinic focused on supporting people with and at risk of type 2 diabetes in Logan, a region in South East Queensland, Australia, with high levels of health inequity. Logan Healthy Living is supported by the Queensland Government through Health and Wellbeing Queensland and a broader multisectoral alliance including primary health care; tertiary hospital and health services; and government, community, and university sectors.

OBJECTIVE

This paper describes the establishment of Logan Healthy Living and outlines the evaluation protocol for the service's type 2 diabetes lifestyle management program.

METHODS

The context and setting of Logan Healthy Living are presented, and the process for establishing the multisectoral partnerships, development and governance of the service, and the facility are described. The lifestyle management program is an 8-week, group-based program that includes 1 hour of education and 1 hour of supervised, individually tailored exercise each week. The theoretical underpinnings and the program are described in detail. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework will guide evaluation of the program and inform key questions regarding the number and characteristics of the clients (reach); diabetes-related distress, health behaviors (physical activity and diet), quality of life, self-management self-efficacy, loneliness, community involvement, anthropometric measures, hemoglobin A1c levels, physical function, and health care use (effectiveness); referral pathways (adoption); fidelity, appropriateness, acceptability, and costs (implementation); and long-term effectiveness (maintenance). Data will be drawn from a purposefully embedded minimum dataset and data registry, with the process for designing and embedding data collection into practice (via surveys, in-person measures, and client management software) described in detail.

RESULTS

Ethics approval has been obtained for the data registry. Logan Healthy Living is a 4-year proof of concept that concludes on December 31, 2024, with findings expected to be reported starting in 2025.

CONCLUSIONS

While multisectoral responses are needed for complex community health challenges, the processes for achieving these are rarely documented, and the description of the development of Logan Healthy Living has the potential to inform future partnerships. The findings of the evaluation will provide important new knowledge on the impact of a community-delivered type 2 diabetes program on individuals, the community, and the health system in an area of high health inequity.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/69477.

Acute effects of a single bout structured resistance and combined exercise on blood glucose profile during exercise in patients with type 2 diabetes and healthy adults: A randomized crossover study

AIMS

The effects of postprandial resistance and combined exercise on blood glucose profiles, particularly in patients with type 2 diabetes, remain unclear. Comprehending these responses may aid in diabetes management.

METHODS

Three trials were conducted: trial A examined aerobic, resistance, and combined exercise; trials B and C focused on three intensities of resistance and combined exercise. Participants including patients with type 2 diabetes and healthy adults completed a randomized crossover experiment with two arrangements of three interventions and continuous glucose monitoring. Blood glucose iAUC and slope were analyzed via repeated measures two-way ANOVA.

RESULTS

A total of 21 patients with type 2 diabetes (47.81±11.88 years) and 26 healthy adults (31.77±6.66 years) were assigned. In trials A-C, the main effect of subject group on iAUC/min was significant (p＜0.001, p = 0.003, and p＜0.001). The exercise in trial A (p = 0.006) and subject group in trial C (p = 0.005) significantly impacted the blood glucose slope.

CONCLUSIONS

Resistance and combined exercise reduce postprandial hyperglycemia in type 2 diabetes patients. Monitoring glucose before exercise may help prevent extreme events.

Effects of exercise training and physical activity advice on HbA1c in people with type 2 diabetes: A network meta-analysis of randomized controlled trials

AIMS

To compare the magnitude of the benefit of different exercise modalities on glycemic control, including aerobic training (AT), resistance training (RT), combined training (CT), high-intensity interval training (HIIT) and physical activity advice.

METHODS

A network meta-analysis was conducted. Seven databases were searched from inception to May 2024. We included randomized clinical trials of at least 12 weeks' duration evaluating different types of physical exercise and physical activity advice to reduce HbA1c in people with type 2 diabetes.

RESULTS

158 studies (17,059 participants) were included. Compared with the control group, all types of exercise were associated with lower HbA1c: HIIT [-0.61 % (95 % CrI -0.84; -0.37)], CT [-0.58 % (95 % CrI -0.73; -0.42], AT [-0.58 % (95 % CrI -0.70; -0.45)], RT [-0.40 % (95 % CrI -0.59; -0.21)] and physical activity advice [-0.35 % (95 % CrI -0.53; -0.16)]. HIIT was the most effective treatment for HbA1c reduction (SUCRA = 82 %), followed by CT (SUCRA = 77 %), AT (SUCRA = 76 %), RT (SUCRA = 37 %) and physical activity advice (SUCRA = 29 %).

CONCLUSIONS

HIIT was associated with the greatest reduction in HbA1c. Physical activity advice, which is easy to implement, accessible and unsupervised, should also be offered to people with type 2 diabetes to improve glycemic control.

The Effect of Nutrition Education on Glycemic Outcomes in People With Type 1 Diabetes Initiating the Use of Glucose Sensors

AIM

To determine whether people with type 1 diabetes (T1D) initiating glucose sensor monitoring experience greater improvements in HbA1c when provided with education on carbohydrate counting and flexible insulin dosing than those who do not receive nutrition education.

MATERIALS AND METHODS

Our retrospective observational study included 329 people with T1D initiating glucose sensor monitoring between 2015 and 2021. The participants were divided into two groups: one group attended at least one structured educational session with a registered dietitian (n = 126), while the other group did not receive structured education (n = 203). After 12 months of glucose sensor initiation, we compared glycaemic outcomes and CGM metrics between the two groups.

RESULTS

At glucose sensor initiation, both groups with and without education had similar HbA1c levels (7.64% [60.0 mmol/mol] vs. 7.66% [60.2 mmol/mol]). After twelve months, the education group demonstrated greater improvement in glycemic outcomes (HbA1c 7.17% [54.9mmol/mol] vs. 7.37% [57.1 mmol/mol], p < 0.05) and spent significantly more time in the target range than did the group without structured education (68.8% vs. 64.1%, p < 0.05). We observed an inverse correlation between the number of completed educational sessions and HbA1c after 12 months, as well as between the number of educational sessions and the change in HbA1c.

CONCLUSIONS

People with T1D who initiated glucose sensor monitoring alongside nutrition education showed greater improvements in HbA1c and increased time spent in the target glucose range compared to individuals who did not receive structured education.

TRAIL REGISTRATION

ClinicalTrials.gov identifier: NCT06264271.

Current Medical Nutrition Therapy Recommendations for the Person with Diabetes

This article will discuss the current medical nutrition therapy (MNT) recommendations for non-hospitalized people with diabetes based on published standards, general principles for healthy meal planning, common dietary methods used with people with diabetes, and matching the prandial insulin dose to food(s) consumed. This article will also discuss MNT for hospitalized patients with diabetes including assessing for malnutrition and identifying contributing factors for the development of malnutrition. Common dietary methods used in the hospital setting will be discussed, as well as the current recommendations for managing diabetes in patients on clear liquid diets, enteral nutrition, and parenteral nutrition.

Translating Evidence for a Mediterranean-Style Dietary Pattern into Routine Care for Coronary Heart Disease and Type 2 Diabetes: Implementation and Evaluation in a Targeted Public Health Service in Australia

Background: A Mediterranean-style dietary pattern (MDP) is embedded across coronary heart disease (CHD) and type 2 diabetes (T2D) clinical guidelines. However, MDP evidence has not consistently been translated into practice. This study aimed to develop, integrate and evaluate implementation strategies to support clinicians in translating MDP evidence into routine care for CHD and T2D in the local context of a public health service. Methods: This study documents the implementation and evaluation phases of a broader knowledge translation project guided by the Knowledge-to-Action cycle. Multi-disciplinary clinicians in the cardiology and diabetes services of two large metropolitan hospitals and a post-acute community service were targeted. Strategies were prioritised utilising theory and stakeholder engagement and included facilitation, building a coalition, the engagement of clinical champions and local opinion leaders, educational meetings, consensus discussions, sharing local knowledge, consumer consultation, and the development and distribution of education materials. Surveys were conducted with clinicians and patients of targeted services to evaluate the reach, acceptability, feasibility, adoption and perceived sustainability of MDP in practice. Results: In total, 57 clinicians (7 dietitians, 29 nurses/diabetes educators, 15 doctors and 6 other allied health professionals) and 55 patients completed post-implementation evaluation surveys. The majority of clinicians agreed an MDP is appropriate to recommend in their clinical setting (95%), and most of the time/always their advice (85%) aligns. Education sessions were attended by 65% of clinicians, of which the majority indicated improved knowledge (100%) and change in practice (86%). Factors deemed most important to maintaining an MDP approach in practice were hard-copy education materials (85%) and access to a dietitian (62%). Of the patients who had received care from a dietitian of targeted services (n = 32, 58%), 100% recalled having discussed ≥1 MDP topic and 89% received education material. Of the patients who had received dietary advice from non-dietetic clinicians (n = 33, 60%), 67% recalled having discussed ≥1 MDP topic and 70% received education material. Conclusions: Targeted and theory-informed implementation reached the majority of surveyed clinicians and patients, and positively influenced the adoption, acceptability and feasibility of an MDP approach in routine care. Ongoing sustainability strategies are crucial with rotating clinician roles.

Mind Matters: Mental Health and Diabetes Management

CONTEXT

Managing diabetes is an intensive, lifelong responsibility that significantly impacts a person's mental health and diabetes outcomes such as glycemic stability and complications. This mini-review examines the research leading to this conclusion as well as the implications for screening and treatment of mental health issues in people with diabetes within an interdisciplinary care model.

EVIDENCE ACQUISITION

We searched the literature for the past 10 years, including original articles, reviews, and meta-analyses from PubMed and OVID using the search terms diabetes and mental health.

EVIDENCE SYNTHESIS

Diabetes is a lifelong burden, and people with the disease grapple with intensive management, financial burden, fear of hypoglycemia, chronic hyperglycemia complications, and diabetes stigma. These stressors have a debilitating emotional impact, making it difficult to carry out diabetes care tasks, which in turn is associated with poorer short-term glycemic stability and greater mental health symptoms. Psychological syndromes related to a diabetes diagnosis, management, or coping with the disease include major depressive disorder, diabetes distress, anxiety, and eating disorders. Providers managing people with diabetes can leverage 4 validated screening instruments to assess for these syndromes. The main psychological interventions studied to treat these mental health conditions include cognitive behavioral therapy, cognitive conceptualization, dialectical behavioral therapy, relational therapy, and psychoeducation.

CONCLUSION

It is pertinent to address the mental health of people with diabetes as rates of psychological syndromes are significantly higher than among those without diabetes. Interdisciplinary care involving endocrinologists, mental health providers, diabetes educators, and medical nutritionists could improve diabetes self-care and glycemic control.

Tailoring Exercise Prescription for Effective Diabetes Glucose Management

CONTEXT

Physical activity, exercise, or both are a staple of lifestyle management approaches both for type 1 diabetes mellitus (T1DM) and type 2 diabetes (T2DM). While the current literature supports both physical activity and exercise for improving glycemic control, reducing cardiovascular risk, maintaining proper weight, and enhancing overall well-being, the optimal prescription regimen remains debated.

EVIDENCE ACQUISITION

We searched PubMed and Google Scholar databases for relevant studies on exercise, insulin sensitivity, and glycemic control in people with T1DM and T2DM.

EVIDENCE SYNTHESIS

In patients with T1DM, exercise generally improves cardiovascular fitness, muscle strength, and glucose levels. However, limited work has evaluated the effect of aerobic plus resistance exercise compared to either exercise type alone on glycemic outcomes. Moreover, less research has evaluated breaks in sedentary behavior with physical activity. When considering the factors that may cause hypoglycemic effects during exercise in T1DM, we found that insulin therapy, meal timing, and neuroendocrine regulation of glucose homeostasis are all important. In T2DM, physical activity is a recommended therapy independent of weight loss. Contemporary consideration of timing of exercise relative to meals and time of day, potential medication interactions, and breaks in sedentary behavior have gained recognition as potentially novel approaches that enhance glucose management.

CONCLUSION

Physical activity or exercise is, overall, an effective treatment for glycemia in people with diabetes independent of weight loss. However, additional research surrounding exercise is needed to maximize the health benefit, particularly in "free-living" settings.

Are strategies to increase muscle mass and strength as effective in people with type 2 diabetes?

People with type 2 diabetes (T2D) have a 2-3-time higher risk of developing sarcopenia, a musculoskeletal disease marked by a progressive loss of skeletal muscle mass and strength, compared to people without T2D. This narrative review examines the effectiveness of lifestyle interventions in enhancing muscle mass and strength in people with T2D, emphasizing their growing importance with advancements in obesity treatments. PubMed and Google Scholar were utilized to identify the most relevant published studies based on the authors' knowledge. The maintenance of skeletal muscle strength and mass in people with T2D is becoming more prominent due to the advent of weight loss therapies such as low-energy diets, bariatric surgery and pharmacotherapies. Although the weight loss is to be commended, a large proportion (20-50%) of the weight loss comes from lean mass, indicative of a loss in muscle mass. There are currently no pharmacotherapies to increase, or mitigate the loss of, lean mass, with lifestyle strategies prominent in this arena. Resistance exercise is the most effective method to increase muscle mass and strength in people with T2D, but there is some evidence of an anabolic resistance. Aerobic exercise and increased dietary protein intake may result in small increases in muscle mass and strength, with no evidence of an anabolic resistance to these stimuli. Exercise and protein supplementation can increase, or aid in the retention of, muscle strength and mass in individuals with T2D, but further research is needed to explore their benefits in patients undergoing concomitant pharmaceutical and surgical treatments.

Role of Diabetes Self-management Education for Our Health Systems and Economy

CONTEXT

Diabetes mellitus is a global health burden, with factors contributing to its prevalence and costs. Educating people with diabetes improves outcomes and affects the economic burden on the individual and health systems.

EVIDENCE ACQUISITION

We included recent diabetes data from the Centers for Disease Control and Prevention and articles from PubMed and Ovid MEDLINE.

EVIDENCE SYNTHESIS

Diabetes prevalence in the United States increased from 10.3% in 2001 to 14.7% in 2021. Factors contributing are an aging population, increased obesity, and social determinants of health. Total costs for diabetes in 2022 reached $412.9 billion, consisting of 74% direct medical and around 26% indirect costs. The highest medical expenses were hospital inpatient services ($96.2 billion), and indirect costs were decreased productivity while at work ($35.8 billion). The effect on the health economy in the United States and globally is only increasing. Interventions to improve disease outcomes such as diabetes education programs that teach self-management skills, healthy lifestyle behaviors, and coping strategies have improved glycated hemoglobin A1c and other outcomes. The economic effect of education is not well studied. However, the Diabetes Prevention Program demonstrated the benefits of lifestyle-based education in preventing or delaying the development of type 2 diabetes in high-risk people and in being cost-effective long term.

CONCLUSION

High direct and indirect costs and the prevalence of diabetes require urgent global awareness and interventions from many angles. We encourage clinicians and agencies to prioritize the education of people living with diabetes to prevent and treat diabetes and its complications.

Enhancing communication skills in diabetes care: an observational study regarding the impact of role-playing training for medical staff

INTRODUCTION

Effective communication is crucial for supporting people with diabetes, yet many medical staff feel unsure about their skills in this area. We evaluated role-playing seminars as a method to improve communication skills among medical staff.

METHODS

From 2008 to 2024, we conducted 78 seminars with 2,458 participants, including nurses, dietitians, and pharmacists. Participants engaged in realistic simulated scenarios based on common clinical situations of patient-medical staff interactions, taking on roles as patients (patient performers), medical staff (medical staff performers), and observers. Due to the COVID-19 pandemic, some seminars were held online. Participants were asked to answer a questionnaire regarding their background, impressions of playing individual roles, general comments regarding the seminar, changes in their patient interactions, the possibility of conducting this seminar at their facilities, and impressions of online seminars compared with those of in-person seminars.

RESULTS

The responses of the participants to these seminars were mostly positive. The representative responses indicated that patient performers understood better patients' feelings and medical staff performers had a chance to recognize their insufficient knowledge. The observers also had the chance to learn new communication skills by observing the conversations of other role-players. Compared with in-person seminars, the positive aspects of online seminars were a reduction in time and travel costs and the removal of geographical obstacles. The negative aspects were mostly technology-related concerns.

CONCLUSION

Training seminars using in-person or online role-playing provided medical staff with opportunities and support to improve their communication skills. Further research on measures to improve the communication skills of medical staff and ways to evaluate their efficacy is warranted.

The influence of cyclothymic and hyperthymic affective temperaments on glycemic control in patients with type 2 diabetes

Affective temperaments are inherited parts of personality determining mood and activity, affecting the management of somatic conditions. We aimed to investigate the association between affective temperaments, depressive symptoms, and self-care (physical activity, smoking, alcohol consumption), and their effect on glycemic control, among patients with type 2 diabetes (T2DM) in general practice, in a cross-sectional study enrolling 338 consecutive patients from six primary care practices in Hungary. A self-administered questionnaire (history, anthropometric, socioeconomic, laboratory parameters), the Beck Depression Inventory (BDI), the Hamilton Anxiety Scale, and the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire were used. Cyclothymic affective temperament determined HbA1c levels in regression analysis (p = 0.002), and the BDI score (p = 0.048). In causal mediation analyses, cyclothymic affective temperament was directly associated with higher HbA1c (p = 0.008). Hyperthymic affective temperament was indirectly associated with lower HbA1c, mediated by BDI (p = 0.034). Depressive, anxious, and irritable affective temperaments, and lifestyle factors were not associated with HbA1c neither in regression nor in mediation analysis as direct or mediating factors. Among primary care patients with T2DM, cyclothymic temperament correlates with worse glycemic control, independently of depressive symptoms. Hyperthymic temperament reduces depressive symptoms, thereby improving glycemic control. Identifying affective temperaments may improve diabetes care.

The Interconnected Complexity of Diabetes and Depression

Diabetes and depression have a bidirectional relationship, with negative impacts on glycemia, self-care, long-term complications, quality of life, and mortality. This review highlights key aspects of the interconnected and complex relationship between diabetes and depression, including how it affects health outcomes, depression duration and recurrence, age-specific manifestations, and recommendations for screening and nonpharmacological treatment.

Connecting Health and Technology: Validation of Instant Messaging for Use as Diabetes Mellitus Control Strategy in Older Brazilian Adults

BACKGROUND

Digital technologies are increasingly being used to promote effective health interventions in the older adult population. This study aimed to develop and validate instant messages with educational content related to glycemic control, delivered via an instant messaging application, as a type 2 DM control strategy for older adults.

METHODS

This was a methodological study that developed instant messages containing text and images. The validation process was conducted by a panel of experts composed of nursing, nutrition, and physical education professionals. SPSS version 25.0 was used for the statistical analysis. A CVI was used to measure the experts' agreement regarding the validity of the content of the educational messages. An exact test of binomial distribution with p > 0.05, indicating statistical significance, and a 0.95 proportion of agreement was used to estimate the statistical reliability of the CVI.

RESULTS

Sixty-one text messages were prepared with illustrations as support, and were divided into three themes. The educational messages were validated by experts, with an average CVI score above 0.80 for all indicators.

CONCLUSIONS

The educational messages developed in this study were considered relevant and clear for older adults and could be applied in the digital environment, with the objective of helping older adults manage type 2 DM.

Perceptions and management of diabetes and obesity among people living with HIV in Côte d'Ivoire: a qualitative study

INTRODUCTION

The prevalence of both type 2 diabetes mellitus (T2DM) and obesity is increasing among people living with HIV (PLHIV) in sub-Saharan Africa. We examined the perceptions and management of these two conditions among PLHIV and healthcare workers in Côte D'Ivoire.

METHOD

From June to August 2022, we conducted semi-structured face-to-face interviews with PLHIV diagnosed with T2DM and/or obesity, as well as healthcare workers, in one of the major HIV clinics in Abidjan, Cote d'Ivoire. We explored topics such as experiences, perceptions and acceptability of the diagnosis and management of T2DM and obesity among PLHIV. Among healthcare workers, professional experience, professional relationships with patients diagnosed with T2DM/obesity, involvement in patient management and care provision were explored. Interviews were audio recorded and transcribed manually. Data were analysed using thematic analysis.

RESULTS

A total of 15 PLHIV and 5 healthcare workers participated in semi-structured in-depth interviews. Perceptions towards T2DM and obesity were largely influenced by cultural factors, PLHIV reported negative perceptions of T2DM and positive perceptions of obesity. Both patients and healthcare providers considered the management of these conditions as sub-optimal. Patient-reported barriers to care for these metabolic disorders were mainly socio-economic and environmental, while healthcare workers emphasized patients' denial of their illness and the limited range of treatment options available at the clinic.

CONCLUSION

These results highlight the complexity surrounding the perceptions and management of T2DM and obesity among PLHIV in Abidjan, Côte d'Ivoire. In order to implement innovative and efficient intervention strategies to prevent and treat these metabolic conditions, cultural beliefs as well as socio-economic barriers must be addressed.

A pilot mixed methods randomized control trial investigating the feasibility and acceptability of a culturally tailored intervention focused on beliefs, mistrust and race-congruent peer support for Black adults with diabetes

Introduction

Black adults disproportionately experience poor glycemic control and medication nonadherence, yet few diabetes self-management programs address their unique health beliefs, provider mistrust and sociocultural barriers to taking diabetes medications. This 6-month pilot randomized feasibility trial compared a culturally tailored diabetes self-management program, incorporating beliefs about diabetes, mistrust, and race-congruent peer support to a standard diabetes program.

Methods

An embedded mixed methods design examined the feasibility of the pilot trial, including recruitment, retention, intervention adherence and participant acceptability. Data were collected through participant self-reported questionnaires, field notes, semi-structured interviews, and focus groups. Qualitative content analysis inductively explored participants' feedback on the program, participation barriers and potential strategies to overcome the challenges. Mixed methods integration was implemented using a side-by-side joint display to compare, synthesize and interconnect the quantitative and qualitative results across all feasibility domains.

Results

Thirteen participants (93%) completed the trial, demonstrating high adherence and retention. Community outreach and a prerequisite orientation using motivational interviewing were feasible and appropriate to recruit potential participants. Participants expressed high satisfaction and acceptability, highlighting the importance of peer support, cultural relevant content and a safe space for sharing experiences. Barriers to participation were identified including schedule conflicts and difficulties in engagement.

Discussion

Future large-scale effectiveness trials should consider combining multimedia into recruitment methods, tailoring the program to address medication-taking goals, and addressing social and environmental barriers to support sustained lifestyle changes.

Associations of carbohydrate quality and cardiovascular risk factors vary among diabetes subtypes

BACKGROUND

Assess the intake of carbohydrate quality and their association with cardiovascular risk factors among diabetes subtypes.

METHODS

Participants of the German Diabetes Study (GDS) (recent-onset diabetes (n = 487) and 5-years thereafter (n = 209)) were allocated into severe autoimmune diabetes (SAID, 35%), severe insulin-deficient diabetes (SIDD, 3%), severe insulin-resistant diabetes (SIRD, 5%), mild obesity-related diabetes (MOD, 28%), and mild age-related diabetes (MARD, 29%). Dietary glycemic index (GI), glycemic load (GL), and intake of higher- (≥ 55) and low-GI (< 55) foods, dietary fiber, and total sugar were derived from a validated food frequency questionnaire and cross-sectionally associated with cardiovascular risk factors (blood lipids, subclinical inflammation, blood pressure, fatty liver index) using multivariable linear regression analysis for subtypes with prevalences ≥ 10%.

RESULTS

Intake of carbohydrate quality parameters was broadly comparable between the subtypes. Among SAID higher total sugar intake was associated with lower HDL-cholesterol (ß (95% CI) relative change per 1 SD increment: - 3.4% (- 6.7; - 0.1)). No clear associations were seen among MOD. Among MARD, a higher dietary GL and higher-GI carbohydrate intake were associated with higher serum triglycerides (10.9% (2.4; 20.1), 12.4% (3.9; 21.5)) and fatty liver index (absolute change: 0.18 (0.06; 0.31), 0.17 (0.05; 0.28)) and lower HDL-cholesterol (- 4.1% (- 7.6; - 0.4), - 4.4% (- 7.8; - 0.8)), whilst higher intake of low-GI carbohydrates and dietary fiber were associated with lower high-sensitivity C-reactive protein (- 16.0% (- 25.7; - 5.1), - 13.9% (- 24.2; - 2.2)).

CONCLUSIONS

Associations of carbohydrate quality parameters with blood lipids, subclinical inflammation, and fatty liver index differed between diabetes subtypes. However, evidence is too preliminary to derive subtype-specific recommendations.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT01055093.

Self-Management Practices Among Adults With Diabetes in the United States: An Analysis of the 2017-2020 National Health and Nutrition Examination Survey (NHANES)

PURPOSE

The purpose of the study was to examine the extent to which adults with diabetes engage in self-management practices to lower their blood glucose levels and determine factors associated with these engagements.

METHODS

The study analyzed data from the 2017-2020 National Health and Nutrition Examination Survey (NHANES). The sample included 1171 adults ages 20 and older with a laboratory A1C level of 6.5% or greater. The statistical analyses used included descriptive, chi-square, and logistic regression.

RESULTS

The study revealed that 36% of participants used insulin, and 28% visited a diabetes specialist yearly. Additionally, 68% took medication to lower blood glucose, and 65% monitored their blood glucose daily. Although 86% checked their A1C level annually, only 14% adhered to a diabetes diet plan. A small percentage of respondents (11%) reported engaging in recreational activities at least 5 days a week. The engagement of American adults with diabetes in self-management practices is associated, to varying extents, with the type of diabetes diagnosis, diabetes status, and social determinants of health in adults with diabetes.

CONCLUSION

The recommended self-management practices among adults with diabetes in the United States are not fully embraced and are associated with several factors. Study findings also indicated that the numbers of undiagnosed and dated-diagnosed diabetes as prediabetes continue to be a problem.

Glucometer versus analyzer: comparable results with negligible clinical risk

This study assessed the reliability of Roche Accu-Chek Inform II glucometers in a real-world setting. A retrospective analysis was conducted on 6,695 paired results. Capillary samples were tested using Roche Accu-Chek Inform II glucometers, while venous samples were analyzed using Roche Cobas c503/702 analyzers. Compliance was assessed using modified criteria based on the ISO 15197 guideline and the CLSI EP09-A3 guideline using Passing-Bablok regression analysis, Bland-Altman plots, and Surveillance Error Grid (SEG) analysis. The overall compliance of glucometer results within ±15% or 0.83 mmol/L (15 mg/dL) of the reference method was 81.5%, below the acceptance criterion of 94.6%. SEG analysis showed that 90.3% of the paired results fell within the No-risk zone, with less than 0.001% in the moderate/lower-risk zone. The Emergency Department results indicated 87.8% overall compliance and 92.2% of pairs falling in the No-risk zone. Based on the regression analysis, the glucometer results showed a positive constant bias of nearly 0.33 mmol/L (6 mg/dL). The Bland-Altman plots showed a positive mean difference of 0.43 mmol/L for results ≤5.55 mmol/L (≤100 mg/dL) and a positive mean percentage difference of 3.77% for results >5.55 mmol/L (>100 mg/dL), within the permissible deviation. The compliance values ranged from 76.0% to 90.3% for clinical concentration groups, with the highest compliance found between >16.65-22.20 mmol/L (>300-400 mg/dL). The Accu-Chek Inform II glucometers demonstrated in real-world reliability, with most results falling within acceptable risk categories. However, compliance still needs improvement, so manufacturers should assess opportunities for advancement.

Effectiveness of Different Intervention Modes in Lifestyle Intervention for the Prevention of Type 2 Diabetes and the Reversion to Normoglycemia in Adults With Prediabetes: Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Lifestyle interventions have been acknowledged as effective strategies for preventing type 2 diabetes mellitus (T2DM). However, the accessibility of conventional face-to-face interventions is often limited. Digital health intervention has been suggested as a potential solution to overcome the limitation. Despite this, there remains a significant gap in understanding the effectiveness of digital health for individuals with prediabetes, particularly in reducing T2DM incidence and reverting to normoglycemia.

OBJECTIVE

This study aimed to assess the effectiveness of different intervention modes of digital health, face-to-face, and blended interventions, particularly the benefits of digital health intervention, in reducing T2DM incidence and facilitating the reversion to normoglycemia in adults with prediabetes compared to the usual care.

METHODS

We conducted a comprehensive search in 9 electronic databases, namely MEDLINE, Embase, ACP Journal Club, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Cochrane Clinical Answers, Cochrane Methodology Register, Health Technology Assessment, and NHS Economic Evaluation Database through Ovid, from the inception to October 2024. This review included randomized controlled trials (RCTs) that studied the effectiveness of lifestyle interventions in adults with prediabetes. The overall intervention effect was synthesized using a random-effects model. The I² statistic was used to assess heterogeneity across the RCTs. We performed a subgroup analysis to explore the effectiveness of digital health, face-to-face, and blended interventions compared with the control group, which received usual care.

RESULTS

From an initial 7868 records retrieved from 9 databases, we identified 54 articles from 31 RCTs. Our analysis showed that face-to-face interventions demonstrated a significant 46% risk reduction in T2DM incidence (risk ratio [RR] 0.54, 95% CI 0.47-0.63; I²=43%; P<.001), and a 46% increase in the reversion to normoglycemia (RR 1.46, 95% CI 1.11-1.91; I²=82%; P=.006), when compared with the control group. On the other hand, digital health interventions, compared with the control group, were associated with a 12% risk reduction in T2DM incidence (RR 0.88, 95% CI 0.77-1.01; I²=0.6%; P=.06). Moreover, the blended interventions combining digital and face-to-face interventions suggested a 37% risk reduction in T2DM incidence (RR 0.63, 95% CI 0.49-0.81;I²<0.01%; P<.001) and an 87% increase in the reversion to normoglycemia (RR 1.87, 95% CI 1.30-2.69; I²=23%; P=.001). However, no significant effect on the reversal of prediabetes to normoglycemia was observed from the digital health interventions.

CONCLUSIONS

Face-to-face interventions have consistently demonstrated promising effectiveness in both reductions in T2DM incidence and reversion to normoglycemia in adults with prediabetes. However, the effectiveness of digital health interventions in these areas has not been sufficiently proven. Given these results, further research is required to provide more definitive evidence of digital health and blended interventions in T2DM prevention in the future.

TRIAL REGISTRATION

PROSPERO CRD42023414313; https://tinyurl.com/55ac4j4n.

Addressing Diabetes Distress in Primary Care: Where Are We Now, and Where Do We Need to Go?

PURPOSE OF REVIEW

Addressing diabetes distress (DD), the emotional demands of living with diabetes, is a crucial component of diabetes care. Most individuals with type 2 diabetes and approximately half of adults with type 1 diabetes receive their care in the primary care setting. This review will provide guidance on addressing DD and implementing targeted techniques that can be tailored to primary care patients.

RECENT FINDINGS

Structured educational, behavioral, and emotion-focused techniques have promise for treating DD. These interventions are unlikely to require advanced training and can be feasibly integrated into primary care settings without creating additional burdens on time or resources. Interventional studies examining treatment for DD are limited, leaving a gap for clear direction and consensus on how to target and treat DD in primary care patients. This review consolidates recommendations and approaches from recent findings on how to treat DD within the context of primary care.

"Now I can see it works!" Perspectives on Using a Nutrition-Focused Approach When Initiating Continuous Glucose Monitoring in People with Type 2 Diabetes: Qualitative Interview Study

BACKGROUND

Food choices play a significant role in achieving glycemic goals and optimizing overall health for people with type 2 diabetes (T2D). Continuous glucose monitoring (CGM) can provide a comprehensive look at the impact of foods and other behaviors on glucose in real time and over the course of time. The impact of using a nutrition-focused approach (NFA) when initiating CGM in people with T2D is unknown.

OBJECTIVE

This study aims to understand the perspectives and behaviors of people with T2D who participated in an NFA during CGM initiation.

METHODS

Semistructured qualitative interviews were conducted with UNITE (Using Nutrition to Improve Time in Range) study participants. UNITE was a 2-session intervention designed to introduce and initiate CGM using an NFA in people with T2D who do not use insulin. The intervention included CGM initiation materials that emphasized the continuous glucose monitor as a tool to guide evidence-based food choices. The materials were designed to support conversation between the CGM user and diabetes care provider conducting the sessions. A rapid matrix analysis approach was designed to answer two main questions: (1) How do people who participate in an NFA during CGM initiation describe this experience? and (2) How do people who participate in an NFA during CGM initiation use CGM data to make food-related decisions, and what food-related changes do they make?

RESULTS

Overall, 15 people completed interviews after completion of the UNITE study intervention: 87% (n=13) identified as White, 60% (n=9) identified as male, mean age of 64 (SD 7.4) years, mean T2D duration of 7.5 (SD 3.8) years, and mean hemoglobin A1c level of 7.5% (SD 0.4%). Participants fluently discussed glycemic metrics such as time in range (percent time with glucose 70-180 mg/dL) and reported regularly using real-time and retrospective CGM data. Participants liked the simplicity of the intervention materials (eg, images and messaging), which demonstrated how to use CGM data to learn the glycemic impact of food choices and suggested how to adjust food choices for improved glycemia. Participants reported that CGM data impacted how they thought about food, and most participants made changes because of seeing these data. Many of the reported changes aligned with evidence-based guidance for a healthy lifestyle, including prioritizing nonstarchy vegetables, reducing foods with added sugar, or walking more; however, some people reported behavior changes, such as skipping or delaying meals to stay in the target glucose range. A few participants reported that the CGM amplified negative feelings about food or eating.

CONCLUSIONS

Participants agreed that pairing nutrition information with CGM initiation instructions was helpful for their diabetes care. In general, the NFA during CGM initiation was well received and led to positive changes in food choices and behaviors during a 2-month intervention.

Pre-Type 1 Diabetes in Adolescents and Teens: Screening, Nutritional Interventions, Beta-Cell Preservation, and Psychosocial Impacts

Type 1 Diabetes (T1D) is a progressive autoimmune disease often identified in childhood or adolescence, with early stages detectable through pre-diabetic markers such as autoantibodies and subclinical beta-cell dysfunction. The identification of the pre-T1D stage is critical for preventing complications, such as diabetic ketoacidosis, and for enabling timely interventions that may alter disease progression. This review examines the multifaceted approach to managing T1D risk in adolescents and teens, emphasizing early detection, nutritional interventions, beta-cell preservation strategies, and psychosocial support. Screening for T1D-associated autoantibodies offers predictive insight into disease risk, particularly when combined with education and family resources that promote lifestyle adjustments. Although nutritional interventions alone are not capable of preventing T1D, certain lifestyle interventions, such as weight management and specific nutritional choices, have shown the potential to preserve insulin sensitivity, reduce inflammation, and mitigate metabolic strain. Pharmacological strategies, including immune-modulating drugs like teplizumab, alongside emerging regenerative and cell-based therapies, offer the potential to delay disease onset by protecting beta-cell function. The social and psychological impacts of a T1D risk diagnosis are also significant, affecting adolescents' quality of life, family dynamics, and mental health. Supportive interventions, including counseling, cognitive-behavioral therapy (CBT), and group support, are recommended for managing the emotional burden of pre-diabetes. Future directions call for integrating universal or targeted screening programs within schools or primary care, advancing research into nutrition and psychosocial support, and promoting policies that enhance access to preventive resources. Advocacy for the insurance coverage of screening, nutritional counseling, and mental health services is also crucial to support families in managing T1D risk. By addressing these areas, healthcare systems can promote early intervention, improve beta-cell preservation, and support the overall well-being of adolescents at risk of T1D.

Preparing Australian diabetes educators for practice: workforce perceptions of the credentialling pathway

The Australian Credentialled Diabetes Educator (CDE) registered trademark signifies quality care and education to those with diabetes. A review of the Australian Diabetes Educators Association (ADEA) CDE pathway was undertaken to ensure the quality of the CDE credential. The purpose of this study was to examine perceptions of the diabetes education workforce on the current pathway for educating and qualifying CDEs for practice. Stakeholders (e.g. CDEs, students, supervisors, course coordinators) were invited via the ADEA email, e-newsletter and Facebook to complete a 34-item online survey exploring their perceptions of the pathway, focusing on the requisite graduate certificate and subsequent credentialling requirements. Most (80%) of the 319 respondents were CDEs, 15% were CDEs in training and 12% were supervisors or employers. Half of participants (46%) indicated that graduate certificate course alumni were somewhat or very unprepared to take on the role of a diabetes educator (DE) prior to undertaking credentialling to become a CDE. Seventy-one percent of participants indicated more, and a greater variety, of clinical experiences are necessary within the course. Participants recommended formal assessment of competence within the clinical setting. Fifty-four percent of participants disagreed or were unsure that the subsequent credentialling pathway equips CDEs well for practice, indicating it is too onerous, and supported a more streamlined pathway. Findings highlight the need for education and skills-based training beyond the graduate certificate, and assessment of competence in conducting core diabetes skills to better equip CDEs for their role.

A data-driven machine learning algorithm to predict the effectiveness of inulin intervention against type II diabetes

Introduction

The incidence of type 2 diabetes mellitus (T2DM) has increased in recent years. Alongside traditional pharmacological treatments, nutritional therapy has emerged as a crucial aspect of T2DM management. Inulin, a fructan-type soluble fiber that promotes the growth of probiotic species like Bifidobacterium and Lactobacillus, is commonly used in nutritional interventions for T2DM. However, it remains unclear which type of T2DM patients are suitable for inulin intervention. The aim of this study was to predict the effectiveness of inulin treatment for T2DM using a machine learning model.

Methods

Original data were obtained from a previous study. After screening T2DM patients, feature election was conducted using LASSO regression, and a machine learning model was developed using XGBoost. The model's performance was evaluated based on accuracy, specificity, positive predictive value, negative predictive value and further analyzed using receiver operating curves, calibration curves, and decision curves.

Results

Out of the 758 T2DM patients included, 477 had their glycated hemoglobin (HbA1c) levels reduced to less than 6.5% after inulin intervention, resulting in an incidence rate of 62.93%. LASSO regression identified six key factors in patients prior to inulin treatment. The SHAP values for interpretation ranked the characteristic variables in descending order of importance: HbA1c, difference between fasting and 2 h-postprandial glucose levels, fasting blood glucose, high-density lipoprotein, age, and body mass index. The XGBoost prediction model demonstrated a training set accuracy of 0.819, specificity of 0.913, positive predictive value of 0.818, and negative predictive value of 0.820. The testing set showed an accuracy of 0.709, specificity of 0.909, positive predictive value of 0.705, and negative predictive value of 0.710.

Conclusion

The XGBoost-SHAP framework for predicting the impact of inulin intervention in T2DM treatment proves to be effective. It allows for the comparison of prediction effect based on different features of an individual, assessment of prediction abilities for different individuals given their features, and establishes a connection between machine learning and nutritional intervention in T2DM treatment. This offers valuable insights for researchers in this field.

Meeting People Where They Are: Improving Diabetes Care and Outcomes Through Education and Collaboration

This article is adapted from the address Dr. Neumiller delivered as the recipient of the American Diabetes Association's Outstanding Educator in Diabetes Award for 2024. He delivered the address in June 2024 during the Association's 84th Scientific Sessions.

The Power of Movement: Linking Physical Activity with Nutritional Health and Blood Sugar Balance in a Dalmatian Type 2 Diabetic Population

BACKGROUND AND OBJECTIVES

Regular physical activity (PA) and Mediterranean diet (MeDi) adherence independently improve glycemic control and clinical outcomes in type 2 diabetes mellitus (T2DM). This study examined the associations between PA, body composition (BC), MeDi adherence, and glycemic control in Dalmatian T2DM patients.

MATERIALS AND METHODS

A cross-sectional study was conducted at the University Hospital of Split (November-December 2023) during an open call for T2DM patients. Data collected included blood/urine samples, blood pressure, BC, and anthropometrics. MeDi adherence and PA were assessed via the Mediterranean Diet Service Score and the International PA Questionnaire-Short Form.

RESULTS

Among 252 participants (median age: 67 years, IQR: 60-73; 51.6% women; median T2DM duration: 10 years, IQR: 6-20), PA levels were low (31.4%, N = 79), moderate (45.2%, N = 114), and high (23.4%, N = 59), with uniformly low MeDi adherence across groups. Low PA was associated with higher body mass index (BMI) and lower phase angle (PhA). PA negatively correlated with fat mass (FM; %) and visceral adiposity. Positive BMI predictors included FM (kg), total body water, visceral fat level, and PhA, while fat-free mass, intracellular water, and FM (%) were negative predictors. The estimated glomerular filtration rate was the only positive predictor of the total metabolic equivalent of the task score.

CONCLUSIONS

PA enhances BC and metabolic health, but inadequate MeDi adherence limits these benefits in the T2DM population. To optimize glucose control and health outcomes, public health initiatives must emphasize MeDi adherence and a combination of aerobic and resistance training.

Relationship among nursing support for parents of adolescents diagnosed with Type 1 Diabetes, parental monitoring of adolescents and the self-efficacy of adolescents with Type 1 Diabetes

BACKGROUND

This study aims to explore the connection between parental monitoring in the treatment of adolescents with type 1 diabetes mellitus (T1DM), the self-efficacy of adolescents with diabetes, and nurse assistance provided to parents of adolescents with T1DM.

METHODS

This cross-sectional descriptive study consisted of 115 adolescents aged 10-18 with T1DM and their parents. Study data were collected through the "Diabetes Management Self-Efficacy Scale in Adolescents with T1DM", "Introductory Information Form", "Nurse-Parent Support Tool (NPST)" and "Parental Monitoring of Diabetes Care Questionnaire in Adolescents with T1DM".

RESULTS

Only 31.3 % of the study adolescent participants reported monitoring their blood sugar less than four times per day, and the frequency of blood sugar monitoring increased with increasing parental supervision (p = 0.021). When diabetes was managed only by parents, adolescents' perceptions of their self-management were statistically significant and high (p = 0.015). Neither the level of nurse-parent support nor the connection between parental monitoring and adolescents' self-efficacy was statistically significant.

CONCLUSIONS

Adolescents with T1DM should receive support from both parents and medical professionals. In particular, nurses should closely inquire about the adolescent's and family's disease management strategies during hospital visits and health monitoring.

Balanced diets are associated with a lower risk of type 2 diabetes than plant-based diets

BACKGROUND & AIMS

Plant-based diets benefit human health, while the deficient in some nutrients limits its application. We aimed to examine whether balanced diets could be better in reducing diabetes risk than plant-based diets.

METHODS

In cross-sectional analysis of Environment-Inflammation-Metabolic-Diseases Study (EIMDS), we used a questionnaire to investigate the habit of balanced and plant-based diets. In the prospective analysis of UK Biobank, we used the plant-based diet index of health (hPDI) and unhealth (uPDI) to evaluate the plant-based diets, and defined the balanced diet as a daily intake of 5 categories and at least 12 types of food. After analyzing proteomic data in UK Biobank, we explored the causal relationship between signature proteins of balanced diets and incident diabetes based on summary-data-based Mendelian randomization (SMR).

RESULTS

Compared to participants who had plant-based diets, those who had balanced diets showed a lower risk of diabetes in EIMDS (Odd Ratio 0.65, 95%CI 0.44-0.95). In UK Biobank, after excluding participants with unhealthy plant-based diets, participants with balanced diets still showed a lower diabetes risk than participants with plant-based diets (Hazard Ratio 0.86, 95%CI 0.77-0.95). Proteomic analysis identified 107 downregulated and 2 upregulated proteins that were associated with higher and lower risk of diabetes, respectively. In SMR analyses, the downregulated signature proteins of balanced diets (AGR2, DBI, IL17RA and SERPINH1) were causally associated with diabetes incidence.

CONCLUSION

Adhered to a balanced diet is associated with a lower risk of diabetes compared to plant-based diet, which might be attributed to signature proteins such as AGR2, DBI, IL17RA and SERPINH1.

Validity of the international physical activity questionnaire short form for assessing physical activity in Japanese adults with type 1 diabetes

Objective

To examine the validity of the International Physical Activity Questionnaire short form (IPAQ-SF) against an objective method for assessing physical activity (PA) in Japanese adults with type 1 diabetes (T1D).

Methods

This cross-sectional study included 126 adults with T1D (aged 20-74 years). The participants wore a triaxial accelerometer for 7 consecutive days and completed the IPAQ-SF (a recall survey for the last 7 days) on the day following the 7-day accelerometer period. This ensured alignment between the periods assessed by both the methods.

Results

A total of 112 participants were analyzed. The IPAQ-SF group had lower daily time in sedentary behavior (SB), total moderate-intensity PA (MPA) (including walking), vigorous-intensity PA (VPA), total PA (including walking), and daily metabolic equivalent (MET)-min in total PA than those in the accelerometer group. Significant correlations were observed between the methods for all variables: daily time in SB, total MPA, VPA, total PA, and daily MET-min in total PA (ρ = 0.203-0.527). In addition, walking time reported in the IPAQ-SF correlated with the step counts recorded by the accelerometer (ρ = 0.444). However, among these parameters, only daily time in VPA was able to provide acceptable levels of validity (≥ 0.50) and predict values recorded by the accelerometer.

Conclusion

These results indicate that the IPAQ-SF scores have a weak correlation with each type of accelerometer-measured PA, while the IPAQ-SF may underestimate each type of PA compared to an accelerometer in Japanese adults with T1D.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13340-024-00759-w.

Overcoming therapeutic inertia in newly diagnosed type 2 diabetes: Protocol of a randomized, quality improvement trial

Therapeutic inertia, the delay in the appropriate initiation and intensification of recommended therapies, is a major contributor to the lack of improvement in type 2 diabetes outcomes over the past decade. Therapeutic inertia during the period following diagnosis, when improvements in glycemic control can have lasting benefits, is often overlooked. Technology and team-based care approaches can effectively address therapeutic inertia. Here, we describe the protocol for a randomized, quality improvement trial targeting metformin-related therapeutic inertia among adults with recently diagnosed type 2 diabetes and a hemoglobin A1c <8 %. Service areas within an integrated healthcare delivery system were randomized to 1) usual care, 2) physician education on therapeutic inertia, and 3) physician education on therapeutic inertia paired with proactive outreach by a clinical pharmacist. The physician education sessions were offered to primary care providers working in the service areas randomized to Arm 2 and Arm 3, and proactive outreach by a clinical pharmacist was performed for patients of the providers in service areas randomized to Arm 3. Outcomes will be abstracted from the EHR at 6, 12, and 18 months following the physician education sessions. The primary outcome will be the proportion of patients with an HbA1c <7 % at each of the follow-up time points. Outcome abstraction and analyses will occur in late 2024. This trial seeks to rigorously evaluate care strategies that can shift stagnant type 2 diabetes outcomes. Our protocol, along with the pending results, may offer examples to other healthcare systems working to improve type 2 diabetes care.

Comparison of the Accuracy, Completeness, Reproducibility, and Consistency of Different AI Chatbots in Providing Nutritional Advice: An Exploratory Study

Background: The use of artificial intelligence (AI) chatbots for obtaining healthcare advice is greatly increased in the general population. This study assessed the performance of general-purpose AI chatbots in giving nutritional advice for patients with obesity with or without multiple comorbidities. Methods: The case of a 35-year-old male with obesity without comorbidities (Case 1), and the case of a 65-year-old female with obesity, type 2 diabetes mellitus, sarcopenia, and chronic kidney disease (Case 2) were submitted to 10 different AI chatbots on three consecutive days. Accuracy (the ability to provide advice aligned with guidelines), completeness, and reproducibility (replicability of the information over the three days) of the chatbots' responses were evaluated by three registered dietitians. Nutritional consistency was evaluated by comparing the nutrient content provided by the chatbots with values calculated by dietitians. Results: Case 1: ChatGPT 3.5 demonstrated the highest accuracy rate (67.2%) and Copilot the lowest (21.1%). ChatGPT 3.5 and ChatGPT 4.0 achieved the highest completeness (both 87.3%), whereas Gemini and Copilot recorded the lowest scores (55.6%, 42.9%, respectively). Reproducibility was highest for Chatsonic (86.1%) and lowest for ChatGPT 4.0 (50%) and ChatGPT 3.5 (52.8%). Case 2: Overall accuracy was low, with no chatbot achieving 50% accuracy. Completeness was highest for ChatGPT 4.0 and Claude (both 77.8%), and lowest for Copilot (23.3%). ChatGPT 4.0 and Pi Ai showed the lowest reproducibility. Major inconsistencies regarded the amount of protein recommended by most chatbots, which suggested simultaneously to both reduce and increase protein intake. Conclusions: General-purpose AI chatbots exhibited limited accuracy, reproducibility, and consistency in giving dietary advice in complex clinical scenarios and cannot replace the work of an expert dietitian.

Effectiveness of Dietitian-Involved Lifestyle Interventions in Diabetes Management Among Arab Populations: A Systematic Review and Meta-Analysis

BACKGROUND/OBJECTIVES

Diabetes prevalence is high among Arab populations, where cultural practices present barriers to effective glycemic control. Despite guidelines recommending the involvement of dietitians in diabetes management, evidence of the effectiveness of dietitian-involved interventions in these populations remains limited. This systematic review and meta-analysis evaluated the effectiveness of dietitian-involved lifestyle interventions among Arab populations with prediabetes or diabetes.

METHODS

PubMed, CINAHL, and the Cochrane Library were systematically searched for studies employing experimental and quasi-experimental designs with interventions involving dietitians. All reported outcomes were considered to ensure a comprehensive review. The protocol was registered in PROSPERO (registration number CRD42024555668).

RESULTS

The meta-analysis showed significant reductions in glycosylated hemoglobin (HbA1c) levels (-0.41; 95% CI: -0.67, -0.16), body mass index (BMI) (-0.28; 95% CI: -0.36, -0.19), and increases in high-density lipoprotein cholesterol HDL-C) (0.60; 95% CI: 0.36, 0.85) compared to usual care. Subgroup analysis indicated variations based on follow-up duration. The certainty of the evidence was low due to heterogeneity and potential biases, emphasizing the need for further high-quality research to confirm these findings.

CONCLUSIONS

Interventions involving dietitians improve glycemic control and metabolic outcomes among Arab populations. Given the unique cultural challenges in this population, culturally tailored and personalized interventions are essential to overcome barriers and improve diabetes-related outcomes. Future studies should focus on expanding the evidence base, integrating these findings into healthcare policies, and exploring strategies for long-term sustainability and broader application.

International Society for Pediatric and Adolescent Diabetes Clinical Practice Consensus Guidelines 2024: Diabetes Technologies - Insulin Delivery

The International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines represent a rich repository that serves as the only comprehensive set of clinical recommendations for children, adolescents, and young adults living with diabetes worldwide. This chapter builds on the 2022 ISPAD guidelines, and summarizes recent advances in the technology behind insulin administration, with special emphasis on insulin pump therapy, especially on glucose-responsive integrated technology that is feasible with the use of automated insulin delivery (AID) systems in children and adolescents. The International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines represent a rich repository that serves as the only comprehensive set of clinical recommendations for children, adolescents, and young adults living with diabetes worldwide. This chapter builds on the 2022 ISPAD guidelines, and summarizes recent advances in the technology behind insulin administration, with special emphasis on insulin pump therapy, especially on glucose-responsive integrated technology that is feasible with the use of automated insulin delivery (AID) systems in children and adolescents.

Handgrip strength, cardiometabolic risk and body composition in youth with type 1 diabetes: the Diactive-1 Cohort Study

Objective

This study aimed to explore the association between handgrip strength, cardiometabolic risk (CMR) and body composition in youth with type 1 diabetes.

Methods

For this prospective cohort study, muscular fitness was assessed via handgrip test and relativised by weight, and body composition, evaluated through dual-energy X-ray absorptiometry in type 1 diabetes patients aged 6-18 years. CMR score included z-scores for total body fat, blood pressure, glycated haemoglobin (HbA1c), low-density lipoprotein cholesterol, high-density lipoprotein cholesterol and triglyceride-glucose index.

Results

Eighty-three patients were analysed at baseline and 1-year follow-up (44.6% females, mean age 12.77 years). Individuals with high handgrip strength tended to have lower CMR and body fat compared with those with low handgrip strength. Over a year, individuals with high handgrip strength showed reduced HbA1c, CMR and subcutaneous fat. Consistently meeting high handgrip strength criteria resulted in reductions in HbA1c levels, CMR score and subcutaneous adipose tissue compared with those who never complied or lost compliance during follow-up. Additionally, subjects classified with high handgrip strength both at baseline and follow-up had a lower likelihood of being classified with high CMR (OR=0.241, 95% CI 0.121 to 0.947, p=0.044).

Conclusions

High handgrip strength was associated with significant cardiometabolic and body composition benefits in youth with type 1 diabetes. This tool could be considered of potential clinical value for incorporating assessments like handgrip tests to monitor and address cardiometabolic health.

Adequate sleep duration accentuates the effect of glucagon-like peptide-1 receptor variant on HbA1c: A gene-environment interaction study

BACKGROUND

Both glucagon-like peptide-1 receptor (GLP1R) agonists and lifestyle modifications are widely adopted in managing glycemia. However, the joint effects of GLP1R agonists with lifestyle on glycemic traits have not been evaluated.

METHODS

This gene-environment study tested the interaction between GLP1R-rs10305492 variant, consistent with the effect of GLP1R agonist therapies, and four lifestyle factors (diet, physical activity, sleep duration, and chronotype) for glucose and glycated hemoglobin (HbA1c) levels among 263,846 UK Biobank participants. Linear regression models were conducted to evaluate the effects of the rs10305492 and lifestyle factors on glucose and HbA1c levels.

RESULTS

GLP1R-rs10305492-AA/AG genotype combined a healthy diet, regular physical activity, adequate sleep duration, or morning chronotype were associated with lower glucose and HbA1c levels (all P for trend < 0.001). A synergistic effect was found between rs10305492 and sleep duration on HbA1c, suggesting a recommended adequate sleep duration (7-8 h/day) may amplify the HbA1c lowering effect of GLP1R agonists. Joint effects of the rs10305492 and adequate sleep were associated with a 26 % reduced risk of hyperglycemia (>7.8 mmol/L) risk and a 22 % lower of high HbA1c (>39 mmol/mol or 5.7 %).

CONCLUSIONS

Combining GLP1R agonists with adequate sleep may provide additional benefits for glycemic control in clinical practice.

Common mistakes concerning diabetes management in daily clinical practice

Diabetes mellitus is a chronic metabolic disease, potentially leading to dire complications. Although there are numerous pharmaceutical treatments available, management of the disease is frequently not optimal. Managing diabetes in daily clinical practice can be challenging, and several common mistakes may occur. Healthcare providers must be aware of these errors to provide adequate patient care. In this review, some frequent mistakes in diabetes management are analyzed, focusing on factors such as medication management, blood glucose level monitoring, inadequate addressing of complications and comorbidities, lifestyle choices, patient education, and overall health counselling.

Health beyond biology: the extended health hypothesis and technology

There are ethical dilemmas faced by clinicians when responding to using unregistered medical devices, such as innovative internet technologies for managing type 1 diabetes mellitus. This chronic disease significantly impacts patients' health, requiring intensive daily activities like blood glucose monitoring, insulin injections, and specific dietary recommendations. Recent technological advances, including continuous glucose monitors and insulin pumps, have been shown to improve glycemic control. Di-it Yourself Artificial Pancreas Systems are emerging open-source automated delivery methods initiated by the diabetes community, although they are not clinically evaluated and present a liability challenge for healthcare providers. To use them or not? Should parents and healthcare providers use such technology that helps, but is not proven?Having all of that in mind, we argue that the World Health Organization's (WHO) definition of health is outdated, advocating for the "Extended Health Hypothesis". This hypothesis claims that health extends beyond traditional biological boundaries to include essential functional structures like diabetes-related technology, making technology a part of a patient's health. This view aligns with the "Extended Mind Hypothesis," suggesting that health should include elements beyond organic material if they are vital to a patient's functions.In the commentary, we highlight that both naturalist and normative conceptions of health support the extended health hypothesis, emphasizing that human health is not confined to organic material. This perspective raises critical questions about whether devices like insulin pumps and continuous glucose monitors are integral to a patient's health and whether their malfunction constitutes a form of disease. Devices are considered integral to health, there is no ethical dilemma in using unregistered medical devices for managing type 1 diabetes. Finally, we call for reevaluating the definitions of health and patients, particularly for children with type 1 diabetes using advanced technologies. It asserts that the optimal use of such devices represents a new form of health, creating a health-device symbiosis that should be evaluated with the child's best interests in mind.

Evaluation of diabetes care parameters in patients with diabetes: A population-based cross-sectional study in Khuzestan province (southwest of Iran)

Background

Diabetes is becoming a worldwide concern. Optimal diabetes control reduces diabetes complications.

Objectives

We aimed to measure the principal diabetes care parameters to recognize the main deficits in care for patients with diabetes in the region.

Methods

This cross-sectional study is based on the Khuzestan Comprehensive Health Study (KCHS) data. Of all participants, 4673 (15.3%) were identified to have diabetes. We invited the known cases of diabetes to complete a checklist about their diabetes through face-to-face interviews, and we obtained a blood sample to measure their HbA1c.

Results

Of all participants of the KCHS study, 312 patients with diabetes who met the inclusion criteria were identified. Mean (± SD) HbA1c was 8.5% (± 1.8), and 225 (72.1%) of the participants had poor glycemic control. About 45.2% had blood pressure less than 130/80 mmHg, and 24% had FBS lower than 130 mg/dl. Nearly 37.8% of the participants had LDL < 100 mg/dl and 40% TG < 150 mg/dl. Of all participants, 38.5% had undergone retinal examination, 13.8% had their foot examined, and 39.4% had done urine micro-albumin /Cr test. HbA1c level had a statistically significant relationship with gender (P = 0.012), occupation (P = 0.007), nephropathy (P = 0.004) and retinopathy (P < 0.001).

Conclusions

This study showed that less than half of the participants achieved the optimal ADA goals for diabetes care, therefore it is necessary to revise the basic protocols of diabetes care in the region to improve diabetes management.