An outpatient-based clinical program for type 2 diabetes prevention

Are Diabetes Prevention Programs Reaching Those Most at Risk? A Scoping Review

OBJECTIVES

Previous reviews have highlighted the efficacy of lifestyle diabetes prevention programs (DPPs) in decreasing type 2 diabetes (T2D) risk, but the participating populations were predominantly white. This is concerning as ethnically diverse populations are disproportionately affected by T2D. The objective of this scoping review was to: 1) summarize existing tailored DPPs and 2) provide recommendations for future program implementation to improve access and reach for diverse populations.

METHODS

This work represents a subanalysis of a larger scoping review synthesizing DPPs. Several databases were searched for studies relating to T2D risk and lifestyle programs. Study characteristics were systematically extracted using the Template for Intervention Description and Replication checklist.

RESULTS

Of 25,110 screened publications, 351 (220 programs) were included in the larger review. Only 29% (64 programs) of the 220 programs were identified as specifically serving ethnically diverse populations and were included in this subanalysis. An updated search was run that identified an additional 10 publications (10 programs). Over a third (35%) of programs reported strategies used to tailor their intervention to the target population; of those that reported, 62% tailored the content of the intervention to be culturally appropriate and relevant as well as accommodate the geographic and cultural context.

CONCLUSIONS

Based on recruitment, tailoring, and provision strategies used in DPPs targeting specific underresourced populations, this review provides recommendations on how future program developers can increase access and reach, improving individual- and population-level health outcomes via T2D reduction in those at highest risk.

A systematic review of the mechanisms influencing engagement in diabetes prevention programmes for people with pre-diabetes

AIMS

To identify barriers and enablers that influence engagement in and acceptability of diabetes prevention programmes for people with pre-diabetes. The results will provide insights for developing strategies and recommendations to improve design and delivery of diabetes prevention programmes with enhanced engagement and acceptability for people with pre-diabetes.

METHODS

This review used a critical realist approach to examine context and mechanisms of diabetes prevention programmes. Medline, Embase, PsycInfo, Cinahl, Web of Science, Scopus and Pre-Medline were searched for English language studies published between 2000 and 2023. A quality assessment was conducted using Joanna Briggs Institute critical appraisal tools.

RESULTS

A total of 90 papers met inclusion criteria. The included studies used a variety of quantitative and qualitative methodologies. Data extracted focused on barriers and enablers to engagement in and acceptability of diabetes prevention programmes, with seven key mechanisms identified. These included financial, environmental, personal, healthcare, social and cultural, demographic and programme mechanisms. Findings highlighted diverse factors that influenced engagement in preventive programmes and the importance of considering these factors when planning, developing and implementing future diabetes prevention programmes.

CONCLUSIONS

Mechanisms identified in this review can inform design and development of diabetes prevention programmes for people with pre-diabetes and provide guidance for healthcare professionals and policymakers. This will facilitate increased participation and engagement in preventive programmes, potentially reducing progression and/or incidence of pre-diabetes to type 2 diabetes and improving health outcomes.

A Randomized Controlled Pilot Study of the Food Order Behavioral Intervention in Prediabetes

(1) Background: Prior research in individuals with overweight/obesity and prediabetes or type 2 diabetes has shown that the ingestion of protein-rich food and non-starchy vegetables before concentrated carbohydrates (a carbohydrate-last food order) led to lower postprandial glucose excursions over 180 min, compared to eating the same foods in the reverse order. To expand upon this research, we sought to examine the feasibility and impact of carbohydrate-last food order behavioral intervention on glucose tolerance (GT), HbA1c, weight, and nutrient intake in adults with prediabetes in the real world over a 16-week span. (2) Methods: A total of 45 adults with overweight/obesity and prediabetes were randomized to receive 4-monthly standard nutritional counseling (C) or standard nutritional counseling plus carbohydrate-last food order counseling (FO) sessions (NCT# NCT03896360). (3) Results: The FO group decreased in body weight (-3.6 ± 5.7 lbs, p = 0.017), and trended toward lower HbA1c (-0.1 ± 0.2, p = 0.054). The C group weight trended lower (-2.6 ± 6.8 lbs, p = 0.102) without altering HbA1c (-0.03 ± 0.3, p = 0.605). GT was unchanged in both groups after 16 weeks. Changes in weight, HbA1c, and GT were similar between groups. Sensitivity analysis of pre-COVID participants showed significant weight loss in the FO group (-5.9 ± 5.3 lbs, p = 0.003) but not in C group (-1.0 ± 6.8 lbs, p = 0.608). After 16 weeks, the C group significantly reduced its daily intake of calories, fat, protein, and grains whereas the FO group increased its daily intake of vegetables and protein. There were 17 (94%) FO participants that reported high intervention adherence and 13 (72%) reported it was easy to eat protein/vegetables before carbohydrates. (4) Conclusions: A carbohydrate-last food order is a feasible behavioral strategy in individuals with prediabetes that improves diet quality, notably increasing protein and vegetable intake.

A comparative review of nutrition education intervention duration and impact on reduction of prediabetes or Type 2 diabetes mellitus among adults aged 45 years or older

Prediabetes and Type 2 diabetes mellitus (T2DM) is increasingly prevalent and both conditions have a variety of comorbidities. There are many programs aimed at the reduction or prevention of prediabetes and/or T2DM. However, only a few studies have evaluated the effect of intervention duration and evidence-based frameworks on specific populations at risk for prediabetes or T2DM. This review evaluated evidence-based lifestyle intervention programs to determine whether the duration of programming relates to the efficacy of evidence-based lifestyle change interventions. The aim was to assess relevant outcomes of these interventions in prediabetic or T2DM individuals aged 45 and older. The PRISMA framework was followed. Searches systematically screened and evaluated 2654 articles. Thirteen articles met the inclusion/exclusion criteria. Databases searched included: PubMed; SCOPUS; ProQuest; Biomed Central; SpringerLink; ScienceDirect; EBSCOHost; JSTOR; Taylor & Francis; Wiley Online; BioOne; CINAHL; SAGE Journal; and Google Scholar (2009-2022). Identifying the most effective timeframe for lifestyle intervention programming to reduce the risks associated with prediabetes/T2DM can help providers develop appropriate educational initiatives for patients at risk for pre-diabetes and/or T2DM. After screening, there were 13 studies which met the review criteria. All of the studies included in this comparative review used evidence-based interventions. Evidence-based lifestyle intervention programs that are ≥12 months produced significant and consistent results in mediating outcomes related to prediabetes/T2DM than <12-month programs in adults aged 45 years and older.

Evaluation of physical activity reporting in community Diabetes Prevention Program lifestyle intervention efforts: A systematic review

INTRODUCTION

The Diabetes Prevention Program (DPP) lifestyle intervention has been translated to community settings using the DPP goals of 7% weight loss and 150min of moderate physical activity (PA) per week. Given that PA is a primary lifestyle goal and has been linked to improvements in metabolic health in the DPP, it is important to understand the role that PA plays in translation effort success. The purpose of this review is to thoroughly evaluate the reporting of PA methodology and results in DPP-based translations in order to guide future prevention efforts.

METHODS

PubMed and Ovid databases were searched to identify peer-reviewed original research articles on DPP-based translations for adults at-risk for developing diabetes or cardiovascular disease, limited to English language publications from January 2002-March 2015.

RESULTS

72 original research articles describing 57 translation studies met eligibility criteria. All 57 study interventions included a PA goal, 47 studies (82%) collected participant PA information, and 34 (60%) provided PA results.

CONCLUSIONS

Despite PA being a primary intervention goal, PA methodology and results are under-reported in published DPP translation studies. This absence and inconsistency in reporting PA needs addressed in order to fully understand translation efforts' impact on participant health.

Efficacy of interventions that include diet, aerobic and resistance training components for type 2 diabetes prevention: a systematic review with meta-analysis

Current recommendations for the prevention of type 2 diabetes advise modification of diet and exercise behaviors including both aerobic and resistance training. However, the efficacy of multi-component interventions involving a combination of these three components has not been established. The aims of this review were to systematically review and meta-analyze the evidence on multi-component (diet + aerobic exercise + resistance training) lifestyle interventions for type 2 diabetes prevention. Eight electronic databases (Medline, Embase, SportDiscus, Web of Science, CINAHL, Informit health collection, Cochrane library and Scopus) were searched up to June 2013. Eligible studies 1) recruited prediabetic adults or individuals at risk of type 2 diabetes; 2) conducted diet and exercise [including both physical activity/aerobic and resistance training] programs; and 3) reported weight and plasma glucose outcomes. In total, 23 articles from eight studies were eligible including five randomized controlled trials, one quasi-experimental, one two-group comparison and one single-group pre-post study. Four studies had a low risk of bias (score ≥ 6/10). Median intervention length was 12 months (range 4-48 months) with a follow-up of 18 months (range 6.5-48 months). The diet and exercise interventions varied slightly in terms of their specific prescriptions. Meta-analysis favored interventions over controls for weight loss (-3.79 kg [-6.13, -1.46; 95% CI], Z = 3.19, P = 0.001) and fasting plasma glucose (-0.13 mmol.L⁻¹ [-0.24, -0.02; 95% CI], Z = 2.42, P = 0.02). Diabetes incidence was only reported in two studies, with reductions of 58% and 56% versus control groups. In summary, multi-component lifestyle type 2 diabetes prevention interventions that include diet and both aerobic and resistance exercise training are modestly effective in inducing weight loss and improving impaired fasting glucose, glucose tolerance, dietary and exercise outcomes in at risk and prediabetic adult populations. These results support the current exercise guidelines for the inclusion of resistance training in type 2 diabetes prevention, however there remains a need for more rigorous studies, with long-term follow-up evaluating program efficacy, muscular fitness outcomes, diabetes incidence and risk reduction.

Efficacy of interventions that include diet, aerobic and resistance training components for type 2 diabetes prevention: a systematic review with meta-analysis

Current recommendations for the prevention of type 2 diabetes advise modification of diet and exercise behaviors including both aerobic and resistance training. However, the efficacy of multi-component interventions involving a combination of these three components has not been established. The aims of this review were to systematically review and meta-analyze the evidence on multi-component (diet + aerobic exercise + resistance training) lifestyle interventions for type 2 diabetes prevention. Eight electronic databases (Medline, Embase, SportDiscus, Web of Science, CINAHL, Informit health collection, Cochrane library and Scopus) were searched up to June 2013. Eligible studies 1) recruited prediabetic adults or individuals at risk of type 2 diabetes; 2) conducted diet and exercise [including both physical activity/aerobic and resistance training] programs; and 3) reported weight and plasma glucose outcomes. In total, 23 articles from eight studies were eligible including five randomized controlled trials, one quasi-experimental, one two-group comparison and one single-group pre-post study. Four studies had a low risk of bias (score ≥ 6/10). Median intervention length was 12 months (range 4–48 months) with a follow-up of 18 months (range 6.5 - 48 months). The diet and exercise interventions varied slightly in terms of their specific prescriptions. Meta-analysis favored interventions over controls for weight loss (-3.79 kg [-6.13, -1.46; 95% CI], Z = 3.19, P = 0.001) and fasting plasma glucose (-0.13 mmol.L^-1 [-0.24, -0.02; 95% CI], Z = 2.42, P = 0.02). Diabetes incidence was only reported in two studies, with reductions of 58% and 56% versus control groups. In summary, multi-component lifestyle type 2 diabetes prevention interventions that include diet and both aerobic and resistance exercise training are modestly effective in inducing weight loss and improving impaired fasting glucose, glucose tolerance, dietary and exercise outcomes in at risk and prediabetic adult populations. These results support the current exercise guidelines for the inclusion of resistance training in type 2 diabetes prevention, however there remains a need for more rigorous studies, with long-term follow-up evaluating program efficacy, muscular fitness outcomes, diabetes incidence and risk reduction.

The challenge of obtaining information necessary for multi-criteria decision analysis implementation: the case of physiotherapy services in Canada

BACKGROUND

As fiscal constraints dominate health policy discussions across Canada and globally, priority-setting exercises are becoming more common to guide the difficult choices that must be made. In this context, it becomes highly desirable to have accurate estimates of the value of specific health care interventions.Economic evaluation is a well-accepted method to estimate the value of health care interventions. However, economic evaluation has significant limitations, which have lead to an increase in the use of Multi-Criteria Decision Analysis (MCDA). One key concern with MCDA is the availability of the information necessary for implementation. In the Fall 2011, the Canadian Physiotherapy Association embarked on a project aimed at providing a valuation of physiotherapy services that is both evidence-based and relevant to resource allocation decisions. The framework selected for this project was MCDA. We report on how we addressed the challenge of obtaining some of the information necessary for MCDA implementation.

METHODS

MCDA criteria were selected and areas of physiotherapy practices were identified. The building up of the necessary information base was a three step process. First, there was a literature review for each practice area, on each criterion. The next step was to conduct interviews with experts in each of the practice areas to critique the results of the literature review and to fill in gaps where there was no or insufficient literature. Finally, the results of the individual interviews were validated by a national committee to ensure consistency across all practice areas and that a national level perspective is applied.

RESULTS

Despite a lack of research evidence on many of the considerations relevant to the estimation of the value of physiotherapy services (the criteria), sufficient information was obtained to facilitate MCDA implementation at the local level.

CONCLUSIONS

The results of this research project serve two purposes: 1) a method to obtain information necessary to implement MCDA is described, and 2) the results in terms of information on the benefits provided by each of the twelve areas of physiotherapy practice can be used by decision-makers as a starting point in the implementation of MCDA at the local level.

Diabetes prevention and the role of risk factor reduction in the Medicare population

Medicare is keenly aware of the secular changes in weight gain and of the nearly parallel increases in both the incidence and prevalence of type 2 diabetes throughout the U.S. population. The Medicare population, however, differs from the population at large because of its advanced age and frequency of comorbid conditions and/or disability. These factors affect life span as well as participation in and potential benefit from lifestyle modification and risk-factor reduction activities. Further, macrovascular disease is the greatest burden for older beneficiaries with diabetes, and its risks may antedate the appearance of hyperglycemia. Both diabetes prevention and treatment must be considered in this context. Medicare benefits focus on reduction of cardiovascular risk and mitigation of more temporally immediate complications of weight gain and glucose elevation. These preventive services and interventions are described.

An outpatient-based clinical program for diabetes prevention: an update

OBJECTIVE

To update outcomes of the Diet-Exercise-Activity-Lifestyle (DEAL) program, a clinic-based diabetes prevention intervention.

METHODS

Changes in weight, fasting blood glucose, and 2-hour glucose after a 75-g oral glucose tolerance test were evaluated in patients who enrolled in the DEAL program between January 2007 and August 2009.

RESULTS

The 221 qualified participants had a mean age of 62 years, weight of 87.4 kg, body mass index of 31.2 kg/m², fasting glucose level of 109 mg/dL, and 2-hour glucose value of 138 mg/dL. Among the program participants, 67% were women and 88% were white; 56% had isolated impaired fasting glucose, 5% had impaired glucose tolerance only, and 39% had both. The 6-month follow-up medical appointment was kept by 72% of program participants, but only 56% attended the 12-month visit. By 6 months after baseline, 59% had significantly lower fasting glucose concentrations, 59% had improvement in 2-hour glucose levels, and 61% had weight loss. Nearly 40%, however, were nonresponders and had increased fasting glucose, 2-hour glucose, and weight by 6 months. By the 12-month visit, significant declines in fasting glucose (P<.001), 2-hour glucose (P<.001), and weight (P = .008) occurred in comparison with baseline values; however, no significant changes occurred in these measures between the 6- and 12-month visits (P>.30 for all).

CONCLUSION

Most DEAL participants showed improvement in glucose levels and weight, but some patients exhibited worsening glucose intolerance. Factors underlying nonresponse need to be identified. Ongoing experience and analysis should help revise the DEAL program so that outcomes for all participating patients will improve.

Hemoglobin A1c testing alone does not sufficiently identify patients with prediabetes

Whether hemoglobin A(1c) (HbA(1c)) values are suitable for diagnosing diabetes has been debated. We sought to assess the prevalence of elevated HbA(1c) levels in a prediabetes patient population. Oral glucose tolerance tests and HbA(1c) levels were analyzed for patients entering a diabetes prevention program between January 1, 2007, and September 13, 2009. We calculated the percentage of patients with impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT) who had HbA(1c) values in the 6.0% to 6.4% range or in the 5.7% to 6.4% range. The mean age of the 242 patients was 62 years; 64.0% were women, and 88.0% were white. Isolated IFG was detected in about 56.2% of patients and combined IFG and IGT in about 37.2%. Only 28.5% of patients had HbA(1c) values in the 6.0% to 6.4% range, whereas 65.3% had values in the 5.7% to 6.4% range. Our data suggest that reliance on HbA(1c) testing alone to identify candidates for a diabetes prevention program would miss a substantial number of eligible patients.

Self-reported physical activity preferences in individuals with prediabetes

PURPOSE

The primary objective of this study was to determine the physical activity (PA) preferences in a sample of individuals with prediabetes.

METHODS

Individuals with prediabetes (N = 232) residing in Northern Alberta, Canada completed a mailed questionnaire that assessed demographic and health variables, self-reported PA (Godin Leisure-Time Exercise Questionnaire), and PA preferences.

RESULTS

Respondents indicated they would like to be counseled about PA (75%), were physically able to participate (96%), were interested in a PA program for individuals with prediabetes (86%), and were most interested in walking (71%). Activity status, number of comorbidities, level of employment, marital status, body mass index, and time since diagnosis with prediabetes all demonstrated significant influence on different PA preference variables.

CONCLUSIONS

There is a demand for PA-related programs for individuals with prediabetes. Incorporating identified PA preferences of those with prediabetes might aid in the development of relevant intervention tools, programs, and strategies to support PA.

Sex difference in the association of metabolic syndrome with high sensitivity C-reactive protein in a Taiwanese population

BACKGROUND

Although sex differences have been reported for associations between components of metabolic syndrome and inflammation, the question of whether there is an effect modification by sex in the association between inflammation and metabolic syndrome has not been investigated in detail. Therefore, the aim of this study was to compare associations of high sensitivity C-creative protein (hs-CRP) with metabolic syndrome and its components between men and women.

METHODS

A total of 1,305 subjects aged 40 years and over were recruited in 2004 in a metropolitan city in Taiwan. The biochemical indices, such as hs-CRP, fasting glucose levels, lipid profiles, urinary albumin, urinary creatinine and anthropometric indices, were measured. Metabolic syndrome was defined using the American Heart Association and the National Heart, lung and Blood Institute (AHA/NHLBI) definition. The relationship between metabolic syndrome and hs-CRP was examined using multivariate logistic regression analysis.

RESULTS

After adjustment for age and lifestyle factors including smoking, and alcohol intake, elevated concentrations of hs-CRP showed a stronger association with metabolic syndrome in women (odds ratio comparing tertile extremes 4.80 [95% CI: 3.31-6.97]) than in men (2.30 [1.65-3.21]). The p value for the sex interaction was 0.002. All components were more strongly associated with metabolic syndrome in women than in men, and all sex interactions were significant except for hypertension.

CONCLUSIONS

Our data suggest that inflammatory processes may be of particular importance in the pathogenesis of metabolic syndrome in women.