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

The effectiveness of medical nutrition therapy provided by a dietitian in adults with prediabetes: a systematic review and meta-analysis

BACKGROUND

A total of 374 million adults worldwide are living with prediabetes, 70% of whom will develop type 2 diabetes mellitus (T2DM) in their lifetime. Medical nutrition therapy (MNT) provided by a dietitian, such as that found in lifestyle interventions, has the potential to improve glycemic control and prevent progression to T2DM.

OBJECTIVES

The objective of this systematic review was to examine the effectiveness of MNT provided by a dietitian, compared with standard care, on glycemic, cardiometabolic, and anthropometric outcomes in adults with prediabetes.

METHODS

Searches were conducted for randomized controlled trials (RCTs) published between 1995 and 2022 using electronic databases MEDLINE, CINHAL, and Cochrane Central. The risk of bias was assessed using version 2 of the Cochrane risk-of-bias tool for RCTs. Meta-analyses were conducted using a random-effects model. The certainty of evidence was assessed for each outcome using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method, and a summary of findings table was created using the GRADEpro Guideline Development Tool.

RESULTS

Thirteen RCTs were included in the analysis, showcasing a variety of MNT interventions delivered by dietitians. Intervention durations ranged from 3 to 24 mo. Compared with standard care, MNT improved hemoglobin A1c (HbA1c) (mean difference [95% confidence interval]: -0.30% [-0.49, -0.12]) and fasting blood glucose (FBG) (-4.97 mg/dL [-6.24, -3.71]). Statistically significant improvements were found in anthropometrics (weight, body mass index, and waist circumference), cholesterol (total, high-, and low-density lipoproteins), and blood pressure (systolic and diastolic). No significant effect was found on T2DM or triglycerides. The certainty of evidence was moderate for FBG and low for HbA1c and incidence of T2DM.

CONCLUSIONS

In adults with prediabetes, MNT was effective in improving glycemic outcomes, anthropometrics, blood pressure, and most lipid levels. However, most studies had a risk of bias because of the randomization process or deviations from intended interventions. MNT plays a key role in improving cardiometabolic risk factors in adults with prediabetes.

TRIAL REGISTRATION NUMBER

This study was registered with the registration ID #351421, available from https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=351421.

Acute Glycemic Control in Prediabetes Individuals Favorably Alters Serum NLRP3 Inflammasome and Related Interleukins

Hyperglycemia associated with prediabetes (PD) alters NLRP3 inflammasome activity and related interleukins, yet no study has evaluated the expression of the NLRP3 inflammasome complex and related interleukins in individuals with a PD condition that did or did not develop type 2 diabetes mellitus (T2DM). This study investigated the effect of 6 months of lifestyle modification on the expression of the NLRP3 inflammasome and related interleukins (1α, 1β, 18, 33 and 37) in the sera of individuals with a PD condition that did or did not develop T2DM. This interventional study included 67 Saudi adults (mean age = 41.9 ± 8.0 years, mean BMI = 33.2 ± 5.5 kg/m2). Overnight-fasting serum samples were collected at baseline and at the 6-month follow-up. Serum levels of NLRP3, capsase-1 and related ILs were analyzed at both visits using commercially available immunoassay kits. Results showed that IL-1α increased in the PD group that developed T2DM (p = 0.046), IL-33 decreased in the PD group that reverted to normal (p < 0.001) and NLRP3 decreased in the PD group that remained PD (p = 0.01). Results also showed a positive over-time correlation between NLRP3 and both IL-1α and IL-33 (p < 0.001 and p = 0.028, respectively). In conclusion, glycemic control favorably altered NLRP3 inflammasome complex activity, and lifestyle modification in PD individuals is crucial in reversing harmful metabolic and inflammatory phenotypes.

Attendance-Based Adherence and Outcomes of Obesity Management Program in Arab Adolescents

Pediatric obesity has become a global pandemic in the last century, contributing to short and long-term medical conditions that heighten the risk of morbidity and mortality in children. The 12-month school-based obesity management educational program aims to assess the effect of adherence to the lifestyle educational program and target outcomes, obesity, and hypertension. A total of 363 (nonadherent, N = 179; adherent, N = 184) Saudi school adolescents aged 12-18 were recruited from 60 schools in Riyadh City, Saudi Arabia. Anthropometrics, lipid profile, and blood glucose were measured at baseline and post-intervention. The level of adherence was based on the number of attended educational sessions, and participants were grouped accordingly into two groups: adherent group (attended ≥ 3 sessions) and nonadherent group (attended 1-2 sessions) out of a total of five sessions. Results demonstrated that significantly more participants in the adherent group achieved the primary program goal of reducing obesity indices [body weight, body mass index (BMI), and BMI z-score] than the nonadherent group. Additionally, among adherent obese participants, BMI z-score significantly decreased after the 12-month intervention (post-intervention: 1.5 ± 0.7 vs. baseline: 1.7 ± 0.6, p < 0.05), while the trend in BMI z-score modestly increased in the nonadherent obese participants post-intervention (post-intervention: 1.8 ± 0.7 vs. baseline: 1.7 ± 0.6, p > 0.05). Moreover, there was a substantial reduction in hypertension prevalence only in the adherent group (p = 0.003) and among adherent obese participants in particular (p = 0.03). Furthermore, adherence to session attendance was higher in girls than boys, which led to better outcomes among girls than boys. For the secondary outcomes, lipid profile indices increased in both groups, while no changes were observed in the glycemic profile. In conclusion, greater adherence to educational sessions achieved modest but favorable weight changes and improved blood pressure among obese adolescents. Future intervention studies should take into consideration the need to improve attendance to enhance adherence to the program among adolescents at risk.

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.

Prevalence, risk factors, and interventions for obesity in Saudi Arabia: A systematic review

Saudi Arabia (SA) has a reported obesity prevalence greater than the global average. Here, we systematically review firstly the prevalence and associated factors (59 studies) and secondly the pharmacological, lifestyle, and surgical interventions for obesity (body mass index, >30 kg/m² ) in SA (29 studies) between December 2020 and March 2021 in PubMed, Medline, Embase, PsycINFO, and Cochrane. Peer-reviewed articles in Arabic and English on human adults (aged >18 years) were searched. Among the eight largest studies with sample sizes over 10,000 people, the maximum-reported obesity prevalence was 35.6%, with notable variations in gender and geographic region. Diet, specifically the move towards Western diet and heavy consumption of sugary beverages, and high levels of inactivity are major contributing factors to obesity. The reported obesity-risk polymorphisms are not specific. Bariatric surgery is underrepresented, and in general, there is a lack of nationally coordinated studies on weight loss interventions. In particular, the systematic review did not find a body of research on psychological interventions. There is no trial data for the use of GLP-1 analogs in SA, despite their widespread use. These findings can help policymakers, and practitioners prioritize future research efforts to reduce obesity prevalence in SA.

Patterns and Associations of Physical Activity, Screen Time, Sleep, and Dietary Habits among Saudi Females Participating in Fitness Centers

This study was designed to investigate the level and associations of physical activity, sedentary behavior, sleep, and dietary habits among Saudi women attending fitness centers in Riyadh. A descriptive cross-sectional study was carried out from 12 fitness centers in Riyadh, Saudi Arabia. A total of 460 participants answered a two-part survey self-administered questionnaire, which included information about the demographic characteristics and lifestyle. The analysis found significant differences between the two groups in terms of age, weight, BMI, and combined prevalence of being overweight and obese. Compared with less active females, high active females showed significantly more favorable dietary habits (p < 0.05). Significantly higher values were observed for the total physical activity energy expenditure in METs-min/week (p = 0.028). Moreover, females with high screen time (>3 h per day) were younger, less active, slept longer, and had higher intakes of fast foods and chocolates/candy intake (p = 0.001). Overall, the participants were highly active, exceeding the recommended physical activity needed to enhance health. The analysis also showed sufficient sleep duration (>7 h/night) was significantly associated with the diet and nutrition of the participants. Health education programs are needed to reduce the risks of sedentary behavior, sleep problems, and dietary habits.

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.

Interventions for Reversing Prediabetes: A Systematic Review and Meta-Analysis

INTRODUCTION

Several interventions have been found to be effective for reversing prediabetes in adults. This systematic review and meta-analysis aims to compare the effectiveness of such interventions.

METHODS

MEDLINE, Embase, and Cochrane Library databases were searched for articles published between January 1, 2000 and June 27, 2018. RCTs in adults with prediabetes, testing nonsurgical interventions lasting for ≥3 months, and reporting the number of participants achieving normal glucose levels at intervention end were eligible. The pooled risk difference and number needed to treat for achieving normoglycemia were estimated using a random-effects, arm-based network meta-analysis. The strength of the evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation. Data were obtained in 2018 and analyzed in 2019 and 2021.

RESULTS

Of 54 studies included in the systematic review, 47 were meta-analyzed (n=26,460, mean age=53 years, 46% male, 31% White). Studies included 27 arms testing lifestyle modification interventions, 25 testing medications, 5 testing dietary supplements, and 10 testing Chinese medicine. There were 35 control/placebo arms. At a median follow-up of 1.6 years, more participants in the lifestyle modification groups achieved normoglycemia than those in the control (risk difference=0.18, number needed to treat=6). The strength of the evidence was strong for lifestyle modification. Over a median follow-up of 2.7 years, more participants receiving glucagon-like peptide-1 receptor agonists (risk difference=0.47, number needed to treat=2), α-glucosidase inhibitors (risk difference=0.29, number needed to treat=4), and insulin sensitizers (risk difference=0.23, number needed to treat=4) achieved normoglycemia than control. The strength of evidence was moderate for these medications.

DISCUSSION

Although several pharmacological approaches can reverse prediabetes, lifestyle modification provides the strongest evidence of effectiveness and should remain the recommended approach to address this condition.

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.

Long-Term Weight Loss Strategies for Obesity

CONTEXT

Obesity is a chronic disease that is difficult to manage without holistic therapy. The therapeutic armamentarium for obesity primarily consists of 4 forms of therapy: lifestyle modification (ie, diet and exercise), cognitive behavioral therapy, pharmacotherapy, and bariatric surgery.

EVIDENCE ACQUISITION

Evidence was consolidated from randomized controlled trials, observational studies, and meta-analyses.

EVIDENCE SYNTHESIS

After 2 years, lifestyle interventions can facilitate weight loss that equates to ~5%. Even though lifestyle interventions are plagued by weight regain, they can have substantial effects on type 2 diabetes and cardiovascular disease risk. Although 10-year percentage excess weight loss can surpass 50% after bariatric surgery, weight regain is likely. To mitigate weight regain, instituting a multifactorial maintenance program is imperative. Such a program can integrate diet, exercise, and pharmacotherapy. Moreover, behavioral therapy can complement a maintenance program well.

CONCLUSIONS

Obesity is best managed by a multidisciplinary clinical team that integrates diet, exercise, and pharmacotherapy. Bariatric surgery is needed to manage type 2 diabetes and obesity in select patients.

Exploring the effectiveness of a 1.5-Year weight management intervention for adults with obesity

BACKGROUND & AIM

Obesity is a growing healthcare problem in Arabic-speaking countries although the effectiveness of the lifestyle modification program for weight management in this region is still lacking. Accordingly, this study aimed to assess long-term outcomes following an adapted lifestyle modification program based on cognitive behavioral therapy for obesity (CBT-OB) in Lebanon.

METHODS

Forty-five adult participants with obesity were recruited consecutively at the Outpatient Clinic of the Department of Nutrition and Dietetics at Beirut Arab University (Lebanon). Patients were offered an individualized form of CBT-OB lasting 18 months comprising two phases (a weight loss phase of 6 months and a weight-maintenance phase of 12 months).

RESULTS

Twenty-five patients completed the treatment, with a mean weight loss of -11.58% after 6 months (-11.46% in the intention-to-treat analysis) and -8.84% after 18 months (-9.51% in the intention-to-treat analysis). Weight loss was associated with improvement in Health-Related Quality of Life (HRQoL) at six-month follow-up and in glycated hemoglobin (HbA1c) and body composition patterns at 18-month follow-up.

CONCLUSION

Our findings provide evidence supporting the use of CBT-OB for obesity as a standard in 'real-world' clinical setting in Lebanon. Future studies are needed on larger samples and other populations in Arab-speaking countries.

Two-Phase Evaluation of a Community-Based Lifestyle Intervention for Palestinian Women in East Jerusalem: A Quasi-Experimental Study Followed by Dissemination

Palestinian-Arab women are at increased risk of cardiovascular disease due to high prevalence of diabetes and other risk factors. The current study investigates the effectiveness of an intensive group-based intervention on lifestyle habits that can prevent diabetes and cardiovascular disease. To that end, we conducted a group-based intervention based on the diabetes prevention program in two consecutive phases. The first phase consisted of a quasi-experimental study and the second phase included community-wide dissemination, with a 6-month follow-up. Findings from the quasi-experiment indicate increased consumption of fruit, vegetables and whole grains, weight reduction (-2.21 kg, p < 0.01), and a significant increase in the average daily steps in the intervention group (from 4456 to 6404). Findings from the dissemination indicate that average daily vegetables consumption increased from 1.76 to 2.32/day as did physical activity and average daily steps (from 4804 to 5827). There was a significant reduction in blood pressure, total cholesterol and LDL. These gains were sustained over 6 months following the intervention. This community-based, culturally adapted, health-promotion intervention led to improved nutrition and physical activity which were maintained after 6 months. Collaboration with community centers and local community partners created an effective channel for dissemination of the program to pre-clinical individuals.

The Prediabetes Outcome at National Guard Primary Health Care Centers in Riyadh, Saudi Arabia: Retrospective Chart Review

Objectives

To identify the outcome of prediabetes and the interventions that have been implemented for prediabetic patients at primary healthcare centers (PHCs) affiliated with King Abdulaziz Medical City, Riyadh, Saudi Arabia.

Methodology

This retrospective chart-review study was carried out using the BestCare electronic health records (EHRs) system. Data from the PHCs of King Abdulaziz Medical City, Riyadh, Saudi Arabia were extracted. Inclusion criteria were patients with prediabetes who were diagnosed between January 2015 and December 2016, with at least one follow-up visit. Variables included demographics, comorbidities, blood sugar lab results, and lipid profile measurements at each visit and intervention at the time of the initial diagnosis. Fisher's Exact test, sign test, and Kruskal-Wallis test were used to assess the differences for non-normally-distributed variables, while a paired t-test was conducted for paired and normally distributed continuous variables. Data were analyzed using the statistical program SAS, version 9.4 (SAS Institute Inc. Cary, NC).

Result

Of the 92 patients followed up with for three years, 76.08% remained in the prediabetic range, while 16.4% regressed to a normal glycemic state (NGS) and 7.6% progressed to the diabetic range after intervention and follow-up for three years. Metformin use was not significant in the glycemic outcome. In comparison to the baseline, there was a considerable reduction in fasting blood sugar (FBS) and glycosylated hemoglobulin A1c (HbA1c) at the end of the follow-up.

Conclusion

We found that most of the patients remained in the prediabetic range after the three-year follow-up, with or without intervention. A commonly prescribed pharmacological intervention like metformin showed no regression benefit in most patients. More extensive prospective studies are needed to evaluate the outcome and adherence to different interventions.

The Prevalence and Awareness Concerning Dietary Supplement Use among Saudi Adolescents

Current dietary supplement (DS) use among Saudi school students is not well described. In this study, we aim to investigate the prevalence and predictors of DS use among adolescents. This cross-sectional study collected data via self-administered questionnaire from 1221 students (12 to 18 years). The overall prevalence of DS use was 26.2%, significantly higher in females than males (33% vs. 17.9%, p < 0.001). High proportion of female DS users demonstrated normal BMI than males (84% vs. 56.5%, p < 0.001). High percentage of male DS users were engaged in vigorous and/or high physical activity (PA) levels than female DS users (58.2% vs. 43%, p = 0.022; and 57.1% vs. 20.7%, p < 0.001, respectively). The main reasons for DS use among females were vitamin deficiency (63.3%), hair condition (37.6%) and nail health (23.5%) while in males, the main reasons were vitamin deficiency (58.4%) and body building (34.4%). The predictors of DS use in Saudi adolescents included being female, having high family income and being physically active. In conclusion, the overall prevalence and preference of DS use, though low among Saudi adolescents, was driven mostly by gender, physical activity levels and socioeconomic factors like family income. DS use guidelines and counselling among Saudi adolescents are warranted to improve public health.

Reversal of Prediabetes in Saudi Adults: Results from an 18 Month Lifestyle Intervention

Aim: This 18 month intervention study aims to determine the efficacy of a lifestyle modification program on prediabetes reversal among Saudi adults. Methods: An 18 month randomized, multicenter trial was conducted among Saudis with prediabetes aged 25–60 recruited from King Salman Hospital and primary care centers in Riyadh, Saudi Arabia. A total of 180 consenting individuals were randomized (1:1) to receive either intensive lifestyle intervention (ILIG) or guidance (control group, CG). ILIG was provided with a personalized lifestyle counseling by nutritionists every 3 months to improve diet and exercise behaviors. CG was given booklets containing information on prediabetes and its prevention. Data from lifestyle assessments and laboratory measurements were analyzed at baseline and every 6 months. The primary outcome was the reversal rate of prediabetes. Results: 158 participants were analyzed (CG:85, ILIG:73) at the 12 month follow-up and 28 participants (CG:11 and ILIG:17) completed the entire 18 month study. Post-intervention, the cumulative incidence of prediabetes reversal in the ILIG was 38 participants (52.1%) which was significantly higher than CG with 26 participants (30.6%) (p = 0.02). Conclusion: A tailored lifestyle intervention is effective in reversing prediabetes, at least for a year, among Arab adults with prediabetes. The challenge of sustaining interest in adopting lifestyle changes for a longer duration should be addressed in this population.