Improvements in Glycemic, Micronutrient, and Mineral Indices in Arab Adults with Pre-Diabetes Post-Lifestyle Modification Program

Association of bone mineralization markers with dietary nutrient intake in adolescents with and without biochemical osteomalacia

Background

Dietary intake is widely known to play a crucial role in achieving peak bone mass among children and adolescents. Unfortunately, this information is lacking among Arab adolescents, an understudied demographic that has recently been observed to have a high prevalence of abnormal mineralization markers [low serum 25(OH)D, high serum alkaline phosphatase (ALP), low calcium (Ca) and/or inorganic phosphate (Pi)] suggestive of biochemical osteomalacia (OM, defined as any 2 of the 4 parameters). In order to fill this gap, we aimed to evaluate the associations of serum markers of biochemical OM with dietary intake of macronutrients, vitamins and trace minerals.

Methods

Saudi adolescents (N = 2,938, 57.8% girls), aged 12-17 years from 60 different schools in Riyadh, Saudi Arabia were included. Dietary intake of nutrients was calculated following a semi-quantitative 24 h dietary recall over 3 weekdays and 1 weekend-day using a validated food frequency questionnaire. Compliance to reference daily intake (RDI) of macronutrients, vitamins and trace minerals were calculated. Fasting blood samples were collected and circulating levels of 25(OH)D, ALP, Ca, and Pi were analyzed.

Results

A total of 1819 (1,083 girls and 736 boys) adolescents provided the dietary recall data. Biochemical OM was identified in 175 (9.6%) participants (13.5% in girls, 3.9% in boys, p < 0.01) while the rest served as controls (N = 1,644). All participants had serum 25(OH)D levels <50 nmoL/L. Most participants had very low dietary intakes of Ca (median ~ 290 mg) and vitamin D (median ~ 4 μg) which are far below the RDI of 1,300 mg/day and 20 μg/day, respectively. In contrast, excess dietary intakes of Pi, Na, K, and Fe were observed in all participants. In the biochemical OM group, thiamine and protein intake were significant predictors of serum 25(OH)D, explaining 4.3% of the variance perceived (r = 0.23, adjusted r² = 4.3%, p = 0.01). Among controls, dietary vitamin C and vitamin D explained 0.6% of the total variation in serum 25(OH)D (r = 0.09, adjusted r² = 0.6%, p = 0.004).

Conclusion

Arab adolescents do not meet the RDI for dietary Ca and vitamin D, and none have sufficient vitamin D status (25(OH)D levels >50 nmol/L) but they exceed the RDI for dietary Pi. Interpreting these data in the light of the increased prevalence of rickets in Arab countries, food fortification to optimise vitamin D and Ca intake in Saudi adolescents should be considered.

The Role of Copper Intake in the Development and Management of Type 2 Diabetes: A Systematic Review

Diabetes mellitus is a worldwide public health issue with numerous complications. Several risk factors are associated with diabetes, mainly due to patients following an unhealthy lifestyle. Copper is a crucial trace element, with various physiological actions. Different intake levels of copper might contribute to diabetes development due to its dual action as both an anti- and pro-oxidant. Aim: Due to the inconclusive findings regarding the relationship between copper consumption and the management of diabetes, we decided to conduct this extensive systematic review. Up to this date, no similar study has been available in the literature. In this review, we used the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Relevant articles were identified by searching the electronic databases CINAHL, EMBASE and Medline from their respective index dates to September 2022 using keywords such as “Copper Intake” and “Type 2 Diabetes”. Any paper that has investigated copper exposure through supplementation or any other method that indicates copper intake in human subjects with type 2 diabetes and measures at least one of the outcomes of interest related to diabetes was included in this review. This review is comprised of 4 cross-sectional studies, 3 cohort studies, 2 RCTs, and 2 interventional studies. Two cohort studies found positive associations between copper intake and the risk of developing T2DM, while no significant association was found in the third study. Regarding diabetes outcomes in the four cross-sectional studies, two found inverse associations, one found a positive relationship, and one found no significant association. In interventional studies, all studies found a protective effect of copper, including the RCT, while one found no significant association. The results are inconsistent concerning the association between copper consumption and the likelihood of developing diabetes are inconsistent. Individuals should receive an adequate dietary amount of copper that is within the RDA levels (900 µg/day) to avoid copper deficiency or toxicity. Further studies, especially RCTs, are strongly needed to enable researchers to elucidate more robust conclusions regarding this association.

Lifestyle Interventions for Prevention and Management of Diet-Linked Non-Communicable Diseases among Adults in Arab Countries

The increased incidences of diet-related non-communicable diseases (NCDs) such as diabetes, obesity, and cardiovascular diseases among adults are becoming the chief public health concern in most Arab countries. Economic expansion has contributed to a nutrition shift from a traditional seasonal diet to Westernized eating habits coupled with a sedentary lifestyle. Despite the rising concern for NCD mortality, public health policies are inadequately addressed. This narrative review aims to discuss the effectiveness of nutritional interventions focusing on diet and physical activity in the management of NCDs among Arab adults. A comprehensive literature search was performed using different database platforms such as Cochrane reviews, Scopus, and PubMed for articles published between 1 December 2012 and 31 December 2021. Fifteen recent research articles addressing NCDs, mainly diabetes and obesity, from different Arab countries were included in this review. Structured lifestyle interventions involving behavioral therapy approaches and personalized goals for diet and physical activity were found to improve specific health outcomes in most studies. Significant improvements in health outcomes were reported for longer-duration interventions with follow-ups. A combination of both online and face-to-face sessions was found to be effective. It is important to identify barriers to physical activity for a culturally acceptable lifestyle intervention and conduct further studies to evaluate interventions for the long-term maintenance of health outcomes.

Physical Activity Counseling in Saudi Arabia: A Systematic Review of Content, Outcomes, and Barriers

OBJECTIVES

This study aimed to map the characteristics and the predominant components of clinical physical activity (PA) counseling in Saudi Arabia for adult patients and outline evidence of outcomes and prevalent barriers to its implementation.

METHODS

We conducted a systematic literature search of four online databases: Web of Science, PubMed, ScienceDirect, and The Cochrane Library. Each study was assessed and evaluated using the Mixed Methods Appraisal Tool (MMAT) for methodological quality.

RESULTS

A total of 120 studies were screened, and 47 studies were sought for retrieval. In total, 25 articles were eligible and were subjected to extensive review. After a detailed evaluation, only nine studies met the inclusion criteria. All included were quantitative studies that compiled descriptive and numerical data on physical activity counseling. Four studies described PA counseling information in Saudi Arabia or prescription as lifestyle modification and program structure. The programs used various techniques to motivate patients to adhere to PA protocols. In general, practitioners indicated a high perceived competence in helping patients meet PA guidelines. The most frequently stated barrier was a lack of time for PA discussions with patients, followed by a lack of training in PA counseling, and a lack of patient compliance. Significant improvements in clinical parameters and smoking, food, and exercise habits were detected in experimental trials with respective intervention programs.

CONCLUSION

This review provides preliminary insights into the delivered intervention and standard care content, its outcomes, and clinicians' perceived competence and barriers regarding current PA counseling approaches in Saudi Arabia. Despite the small number of studies included, this review contributes to the limited understanding of current PA counseling practices in Saudi Arabia and serves as an informational source for clinicians and policymakers and a starting point for further research.

Hepatokines Fetuin-A and Fetuin-B status in obese Saudi patient with diabetes mellitus type 2

The present study aims to investigate the association of the serum levels of Fetuin-A and Fetuin-B with type 2 diabetes mellitus (T2DM) in obese Saudi patients and explore the mechanism that links obesity and T2DM in Saudi patients. In this study, a total of 240 adult Saudis (116 men and 124 women) in the age group of 42.7±11.6 years were divided into three groups based on fasting blood glucose (FBG) levels: controls, T2DM and prediabetic. The levels of FBG, lipid profile and serum insulin were measured. Enzyme-linked immunosorbent assay (ELISA) was done to measure Fetuin-A, Fetuin-B and C-reactive protein (CRP). The results show that participants of the prediabetic and T2DM groups had significantly higher body mass index (BMI) values and elevated blood pressure (BP), FBG, total cholesterol (TC), triglyceride (TG), insulin, homeostatic model assessment-IR (HOMA-IR) and homeostatic model assessment-β (HOMA-β) as compared to the control group (P<0.001). The T2DM group participants exhibited significantly higher BMI, BP, FBG, TG, insulin, HOMA-IR and HOMA-β as compared to the prediabetic group participants (P<0.001). The serum levels of high-density lipoprotein-cholesterol (HDL-C) and low-density lipoprotein-cholesterol (LDL-C) were not significantly different among the three tested groups. The serum concentrations of CRP, Fetuin-A and Fetuin-B were slightly higher in T2DM patients as compared to the control group, but the difference failed to reach statistical significance (P>0.05). When results were segregated according to gender, FBG and HDL-C were significantly elevated (P=0.043 and P=0.002, respectively) in T2DM women (12.6±3.6 mmol/l and 1.0±0.3 mmol/l, respectively) compared to T2DM men (11.0±3.3 mmol/l and 0.86±0.2 mmol/l, respectively). However, the diastolic BP and waist-hip ratio (WHR) were significantly increased (P=0.010 and P=0.006, respectively) in T2DM men. The BMI and TC and all other measured parameters were similar between the two genders. Fetuin-A was significantly and positively associated with insulin levels (R=0.19, P=0.05), HOMA-IR (R=0.25, P=0.01) and TG (R=0.20, P=0.01) among overall participants of this study. The T2DM participants exhibited a significantly positive correlation with body weight. Fetuin-A was significantly and positively correlated with Fetuin-B in prediabetic participants, but this relation was not observed in the T2DM participants. Fetuin-B correlated inversely (P<005) with systolic BP (R=-0.20, P=0.01) and diastolic BP (R=-0.18, P=0.05). Interestingly, a strong inverse correlation was observed between Fetuin-B and TG in overall participants (R=-0.21, P=0.01) and specifically in T2DM women (R=-0.41, P=0.01). In conclusion, our study did not find a significant association of Fetuin-A or Fetuin-B levels in serum with T2DM. However, our results suggest that Fetuin-A may influence insulin resistance and serum Fetuin-B concentrations were inversely associated with TG in the general adult Saudi population.

Effects of a 12-Month Hybrid (In-Person + Virtual) Education Program in the Glycemic Status of Arab Youth

This 12-month school-based intervention study investigated the effects of hybrid educational lifestyle modifications on glycemic control among Saudi youth with different glycemic statuses. A total of 2600 Arab adolescents aged 12−18 years were recruited from 60 randomly selected schools. Anthropometrics, blood glucose, and HbA1c were measured pre- and post-intervention. Participants were grouped according to baseline HbA1c into normal, prediabetes, and diabetes groups. All participants received lifestyle education at base line and at every 3-month interval to improve diet and exercise behavior. Diabetic and prediabetic participants received a tailored lifestyle intervention. Post-intervention, 643 participants were analyzed as follows: 20 participants from the diabetes group, 39 from prediabetes, and 584 from the normal group. A modest but significant improvement in the glycemic status of diabetic and prediabetic participants was observed, but not in the normal group. In the diabetes group, 11 (55%) participants achieved normal HbA1c levels, 5 had prediabetes levels, and only 4 remained within diabetes HbA1c levels. In the prediabetes group, 34 (87.2%) participants achieved normal HbA1c levels, while 2 (5.1%) participants remained prediabetic and 3 (7.7%) had diabetes HbA1c levels (p < 0.001). This hybrid lifestyle intervention program modestly reduces the risk of T2DM among youth with elevated HbA1c levels. The challenge of sustaining interest in adopting lifestyle changes for a longer duration should be addressed in further studies in this population.

Awareness, Knowledge and Attitude towards 'Superfood' Kale and Its Health Benefits among Arab Adults

This cross-sectional online survey aimed to determine the awareness of Arab adults on the benefits of consuming nutrient-dense foods, such as kale. A total of 1200 respondents completed the survey. The questionnaire included questions related to socio-economic information, e.g., whether the participants have consumed kale, if they observed any health effects, and 13 other questions to test their knowledge on this superfood. Only 276 (23%) of the participants had previously consumed kale, with 64.5% reporting favorable health outcomes, the most common of which was weight reduction, and only 17.8% reporting side effects, such as constipation and gastrointestinal irritation. From the 13 kale knowledge questions, the average total knowledge score, scaled from 0 to 10, was 3.5 and 3.7 for males and females, respectively. The regression analysis revealed that age, income, and educational status were significant contributors for predicting better knowledge scores, as older individuals with a higher income and higher education scored higher (odds ratio of 2.96, 2.00 and 4.58, respectively). To summarize, there is a dearth of awareness about kale and its health benefits in Saudi Arabia. Kale should be promoted as a super food in all segments, particularly among the younger, lower-income, and less-educated sections of the population.

Cardiometabolic Effects of a 12-Month, COVID-19 Lockdown-Interrupted Lifestyle Education Program for Arab Adolescents

BACKGROUND

Childhood obesity and pediatric metabolic syndrome (MetS) have steadily increased during the last decade in Saudi Arabia. Intervention programs to prevent cardiometabolic disorders in Arab youth are needed.

OBJECTIVE

In this multi-school intervention study which was disrupted by COVID-19-imposed lockdowns (September 2019-April 2021), a 12-month lifestyle education program focused on improving the cardiometabolic status of Arab adolescents was investigated.

METHODS

A total of 2,677 Saudi students aged 12-18 years were recruited from 60 different secondary and preparatory year schools in Riyadh city, Saudi Arabia. The intervention was initially in-person counseling sessions and the subsequent sessions conducted virtually post-pandemic. Baseline anthropometrics and fasting blood samples for glucose, HbA1c, and lipid assessments were collected at baseline and after 12 months (704 participants).

RESULTS

Only 704 out of 2,677 (73.7% dropout) completed the intervention. At baseline, 19.6% of the participants were overweight and 18.1% were obese. A modest but significant decrease in the prevalence of central obesity [11.2 vs. 6.7% (-4.5% change, p = 0.002)], hypertension [22.3 vs. 11.4% (-10.9% change, p < 0.001)], and low-HDL cholesterol [61.6 vs. 23.3% (-38.3% change, p < 0.001)] was noted. Consequently, the prevalence of hypertriglyceridemia increased from 22.7 to 56.3% (+ 33.6%, p < 0.001) overtime. Also, the proportion of subjects who were able to change their status from MetS to non-MetS was significantly more in overweight/obese at baseline than normal weight (16.9 vs. 3.6%, adjusted OR = 3.42, p < 0.001).

CONCLUSION

Interrupted lifestyle education programs secondary to COVID-19-imposed lockdowns still provided modest effects in improving cardiometabolic indices of Arab adolescents. Given the high digital literacy of Arab youth, improving the delivery of virtual lifestyle education programs may prove beneficial.

Mediterranean Diet and Healthy Eating in Subjects with Prediabetes from the Mollerussa Prospective Observational Cohort Study

We aimed to assess differences in dietary patterns (i.e., Mediterranean diet and healthy eating indexes) between participants with prediabetes and those with normal glucose tolerance. Secondarily, we analyzed factors related to prediabetes and dietary patterns. This was a cross-sectional study design. From a sample of 594 participants recruited in the Mollerussa study cohort, a total of 535 participants (216 with prediabetes and 319 with normal glucose tolerance) were included. The alternate Mediterranean Diet score (aMED) and the alternate Healthy Eating Index (aHEI) were calculated. Bivariable and multivariable analyses were performed. There was no difference in the mean aMED and aHEI scores between groups (3.2 (1.8) in the normoglycemic group and 3.4 (1.8) in the prediabetes group, p = 0.164 for the aMED and 38.6 (7.3) in the normoglycemic group and 38.7 (6.7) in the prediabetes group, p = 0.877 for the aHEI, respectively). Nevertheless, women had a higher mean of aMED and aHEI scores in the prediabetes group (3.7 (1.9), p = 0.001 and 40.5 (6.9), p < 0.001, respectively); moreover, they had a higher mean of aHEI in the group with normoglycemia (39.8 (6.6); p = 0.001). No differences were observed in daily food intake between both study groups; consistent with this finding, we did not find major differences in nutrient intake between groups. In the multivariable analyses, the aMED and aHEI were not associated with prediabetes (odds ratio (OR): 1.19, 95% confidence interval (CI): 0.75-1.87; p = 0.460 and OR: 1.32, 95% CI: 0.83-2.10; p = 0.246, respectively); however, age (OR: 1.04, 95% CI: 1.02-1.05; p < 0.001), dyslipidemia (OR: 2.02, 95% CI: 1.27-3.22; p = 0.003) and body mass index (BMI) (OR: 1.09, 95% CI: 1.05-1.14; p < 0.001) were positively associated with prediabetes. Physical activity was associated with a lower frequency of prediabetes (OR: 0.48, 95% CI: 0.31-0.72; p = 0.001). In conclusion, subjects with prediabetes did not show a different dietary pattern compared with a normal glucose tolerance group. However, further research is needed on this issue.

Awareness and Knowledge Regarding the Consumption of Dietary Fiber and Its Relation to Self-Reported Health Status in an Adult Arab Population: A Cross-Sectional Study

The objective of this study was to examine the awareness, knowledge, and habits regarding dietary fiber intake and to analyze its relationship with self-reported health status among Saudi adults. A survey-based study using face-to-face interview was designed, and 1363 apparently healthy adult Saudi males and females participated. Most participants were females (81.2%), aged 25 and above (87.2%), and were educated at least up to the secondary level of education (80.8%). The majority of the participants were aware of the role of fiber-rich foods in health conditions such as obesity (70.5%), cardiovascular diseases (68.9%), and regulation of blood sugar (68.9%), with females significantly having higher nutrition knowledge than males. A disconnect in translating this nutrition knowledge was observed particularly in food choices when eating out, where preferences for white bread (84.4%), fried potatoes (69.9%) and peeled fruits (60.6%) were significantly higher than preferences for cooked vegetables (29.6%) and brown bread (18.1%). The most common reason for this disconnect was due to perception that foods rich in dietary fibers were expensive (72.1%), have less health benefits (56.5%), were not readily available (51.6%), and participants’ disliking of the taste (52.8%). Participants in the highest quartile (Q4) for dietary fiber consumption reported a lower prevalence of constipation (odds ratio, 95% confidence interval of 0.40, 0.28–0.57, p < 0.01), high cholesterol (0.43, 0.27–0.68, p < 0.01) and obesity (0.67, 0.44–0.98, p = 0.03) than participants in the lowest quartile (Q1). Dietary fiber intake appears to be protective against constipation, high cholesterol and obesity in Saudi adults. However, a disparity observed between knowledge and attitude towards intake of dietary fibers could limit its health benefits. Further studies including adolescents should be conducted to impart knowledge on the emotional, cognitive and sensory factors related to food choices in order to minimize the gap between nutrition knowledge and the consumption of healthy high-fiber diets.

Effects of A 12-Month Intensive Lifestyle Monitoring Program in Predominantly Overweight/Obese Arab Adults with Prediabetes

This 12-month, randomized, controlled lifestyle intervention study was aimed at assessing the effectiveness of a lifestyle intervention in terms of (1) the reduction of at least 5% of body weight compared to baseline and (2) the percentage of participants in which fasting blood glucose (FBG) normalizes (<5.6 mmol/L) post-intervention, in predominantly overweight/obese Saudi adults with impaired fasting glucose. A total of 300 Saudi adults with prediabetes at baseline (FBG 5.6–6.9 mmol/L) were enrolled to receive either general advice (GA) or a rigorous, self-monitored, lifestyle modification program (intervention group, IG) for 12 months, focused on food choices, physical activity, and weight loss. Anthropometric and biochemical estimations were analyzed at baseline, 6, and 12 months. At baseline, 136/150 in the GA group (90.7%) and 127/150 in the IG group (84.7%) were either overweight or obese. A total of 14% (n = 21) of the subjects in the IG arm discontinued, compared to 8% (n = 12) in the GA arm. Data from completers (92% (n = 138) and 86% (n= 129) participants in GA and IG arms, respectively) were considered for the final analysis. Post-intervention, 37.2% (n = 48) of participants in the IG group had ≥5% weight reduction, as compared to 12.3% (n = 17) in the GA group (p < 0.01). Similarly, the percentage of participants who normalized their FBG post-intervention was 46.5% (n = 60) in the IG group compared to 21.7% (n = 30) in the GA group (p < 0.01). A 12-month Diabetes Prevention Program (DPP)-styled intensive lifestyle program translated effectively in decreasing weight and improving fasting glucose compared to the GA group in predominantly overweight/obese Saudi adults with prediabetes, suggesting that in the case of guided intervention programs, people are willing to participate and possibly change a sedentary lifestyle.