Intensive lifestyle intervention is particularly advantageous in poorly controlled type 2 diabetes

BACKGROUND AND AIMS

It is unknown whether lifestyle change is effective in people with type 2 diabetes with inadequate glucose control. The aim of this study was to asses, in a group of people with type 2 diabetes, the impact of baseline values of glycosylated haemoglobin (HbA1c) on the effects of an intensive lifestyle intervention on metabolic, clinical and strength parameters.

METHODS AND RESULTS

222 people with type 2 diabetes with mean ± standard deviation baseline HBA1c of 7.50% ± 1.27 (range 5.1-12.7%), were enrolled in a 3-month structured multidisciplinary lifestyle intervention. Anthropometric, biochemical, clinical and fitness measurements were collected at baseline, at the end of the lifestyle intervention program and at two-year follow-up visit. Significant improvements in glycometabolic control (HbA1c: p ≤ 0.0001); anthropometric parameters (BMI p ≤ 0.0001; waist circumference: p ≤ 0.0001); and systemic blood pressure (p ≤ 0.0001) were observed both at the end of the three month intensive lifestyle program and at the two-year follow up visit. In addition, defined daily doses of hypoglycaemic treatment significantly decreased (p = 0.001). Fitness measures exhibited significant increments in the whole sample at the end of the intensive intervention program (p ≤ 0.0001). When patients were divided into tertiles considering the baseline value of HbA1c, the most marked improvements in HbA1c, blood glucose and triglycerides were observed in the group with inadequate glucose control (Hba1c ≥ 7.71%), both at the three-month and two-year follow-ups.

CONCLUSION

These results demonstrate that an intensive lifestyle intervention should be recommended for people with type 2 diabetes, particularly those with the most inadequate glycaemic control.

REGISTRATION NUMBER

CURIAMO trial was registered in the Australian New Zealand Clinical Trials Registry, (ACTRN12611000255987).

Description of the EUROBIS program: a combination of an Epode community-based and a clinical care intervention to improve the lifestyles of children and adolescents with overweight or obesity

The present paper describes the Epode Umbria Region Obesity Prevention Study (EUROBIS) and aims to implement the C.U.R.I.A.MO. model through the EPODE methodology. The main goal of the EUROBIS is to change the pendency of slope of the actual trend towards the increase in the yearly rates of childhood overweight and obesity in Umbria and to improve healthy lifestyles of children and their parents. The project is the first EPODE program to be performed in Italy. The aims of the Italian EUROBIS study are: (1) a community-based intervention program (CBP) carrying out activities in all primary schools of the Umbria Region and family settings as first step, to reverse the current obesity trend on a long-term basis, and (2) a clinical care program for childhood and adolescent by C.U.R.I.A.MO. model. C.U.R.I.A.MO. model is a multidisciplinary approach to improve three key aspects of healthy lifestyles: nutrition, exercise, and psychological aspects with the strategy of a family-based approach. The community-based intervention and clinical trial provide an innovative valuable model to address the childhood obesity prevention and treatment in Italy.

Multidisciplinary lifestyle intervention in the obese: its impact on patients' perception of the disease, food and physical exercise

BACKGROUND AND AIMS

To be successful, lifestyle intervention in obesity must take into account patients' views. The aim of the present study, conducted using a narrative-autobiographical approach, was to report on the perception of disease, food and physical exercise in a group of 80 obese patients during a structured multidisciplinary lifestyle intervention.

METHODS AND RESULTS

Patients underwent lifestyle intervention, of three months' duration, structured in the following steps: 1) an initial medical examination; 2) an interview by a psychologist; 3) an assessment by a dietician, 4) a physical examination by a specialist in sports medicine; 5) an individualized program consisting of 24 sessions (two per week) of structured indoor exercise 6) eight sessions of group therapeutic education; 7) Nordic walking activity combined with walking excursions during weekends. All the narrative autobiographic texts obtained during the lifestyle intervention were submitted for content analysis; data were analysed according to the ''grounded theory'' method. According to patients' descriptions at the end of the intervention, lifestyle intervention resulted in enhanced self-efficacy and a reduction in their dependency on food and people; their fear of change was also diminished because, by undergoing intervention, they had experienced change.

CONCLUSION

The findings made in the present qualitative analysis suggest that whenever multidisciplinary lifestyle intervention is planned for patients with obesity, it is of the utmost importance to tailor the approach while taking the following key aspects into account: motivation, barriers and/or facilitators in lifestyle change, patients' perceptions of obesity and relationship with food, diet and exercise.

Mutual interactions between depression/quality of life and adherence to a multidisciplinary lifestyle intervention in obesity

CONTEXT

There is scarce knowledge of the interaction between depression/health-related quality of life (HRQOL) and lifestyle intervention in obesity.

OBJECTIVE

The aim of the study was to establish whether baseline mood status or HRQOL affects attendance to educational or exercise sessions and whether attendance to these two components of the intervention affects mood and/or HRQOL in obesity.

DESIGN

A total of 282 overweight/obese subjects (body mass index, 33.4 ± 5.9 kg/m(2); 103 males, 179 females; age, 53.8 ± 13.0 yr, mean ± sd) were consecutively enrolled in a multidisciplinary lifestyle intervention program. During the intensive phase of the intervention (3 months) patients were invited to attend eight educational sessions and 26 exercise group sessions.

RESULTS

Poor adherence to exercise sessions is predicted by baseline depressive mood (P =0.006) and by low levels of HRQOL (domains of Vitality, Physical Role Functioning, Social Functioning, Mental Composite, Physical Composite Scores) (P < 0.05). Attendance to the educational sessions is associated with beneficial effects of the lifestyle intervention on depressive symptoms (P < 0.013) and on several mental domains of HRQOL (P < 0.041); attendance to the exercise sessions predicted the beneficial effects on perceived general health (P < 0.021) and body mass index (P < 0.011). Attendance to both educational and exercise components is associated (P < 0.05) with the reductions in waist circumference, fat mass, and blood pressure observed after the intensive phase of the intervention.

CONCLUSIONS

Measurement of depressive mood and HRQOL before lifestyle intervention allows identification of patients at increased risk of attrition with exercise and educational sessions. Both the exercise and the educational sessions are essential for gaining the full spectrum of psychological and clinical benefits from multidisciplinary lifestyle intervention in obesity.

An innovative model for changing the lifestyles of persons with obesity and/or Type 2 diabetes mellitus

AIM

To describe the multidisciplinary lifestyle intervention model used in an experimental CURIAMO (Centro Universitario Ricerca Interdipartimentale Attività Motoria) project designed to validate the short- and long-term efficacy of the model in obesity and Type 2 diabetes.

RESEARCH DESIGN AND METHODS

Over a 3-yr period, about 1000 adults (70% diabetes-free and overweight or obese; 30% with Type 2 diabetes and overweight or obese).

INCLUSION CRITERIA

Age range 18-80 yr, body mass index >27 kg/m2 with or without Type 2 diabetes mellitus; participants will be divided into three age groups (18-45, 45-65, 65-80 yr). The study duration will be from 5 to 6 yr: 1 yr of intervention followed by a mean follow-up period of 4 yr. In the first years, after a 4- month intensive lifestyle intervention, subjects will follow a maintenance programme. The intervention, which includes seven steps, involves the following experts: endocrinologists, sport medicine doctors or cardiologists, psychologists, dietitians, educators, nurses, exercise physiologists, and promoters of outdoor activities.

RESULTS

The main endpoint of the study is to measure the efficacy of the lifestyle improvement intervention, defined as a loss of at least 7% of body weight combined with an increase of at least 10 MET/h-1·week-1 of energy expenditure by physical activity, after 1 yr and during the follow-up. A cost/utility analysis of the model will be made in participants with diabetes.

CONCLUSIONS

We expect that the CURIAMO model will be highly effective, and that the aim of the intervention will be achieved in more than 70% of cases.

Two weekly sessions of combined aerobic and resistance exercise are sufficient to provide beneficial effects in subjects with Type 2 diabetes mellitus and metabolic syndrome

This study was performed to establish whether only 2 sessions per week of combined aerobic and resistance exercise are enough to reduce glycated hemoglobin (HbA(1c)) and to induce changes in skeletal muscle gene expression in Type 2 diabetes mellitus (DM2) subjects with metabolic syndrome. Eight DM2 subjects underwent a 1-yr exercise program consisting of 2 weekly sessions of 140 min that combined aerobic [at 55-70% of maximal oxygen uptake (VO(2max))] and resistance circuit training [at 60-80% of 1 repetition maximum (RM)]. The training significantly improved VO(2max) (from 33.5+/-3.8 ml/kg/min to 38.2+/-3.5 ml/kg/min, p=0.0085) and muscle strength (p<0.05). Changes over baseline were significant for HbA(1c), reduced by 0.45% (p=0.0084), fasting blood glucose (from 8.8+/-1.5 to 6.9+/-2.2 mmol/l, p=0.0132), waist circumference (from 98.9+/-4.8 to 95.9+/-4.6 cm, p=0.0054), body weight (from 87.5+/-10.7 to 85.7+/-10.1 kg, p=0.0375), systolic blood pressure (from 137+/-15 to 126+/-8 mmHg, p=0.0455), total cholesterol (from 220+/-24 to 184+/-13 mg/dl, p=0.0057), and LDL-cholesterol (from 150+/-16 to 105+/-15 mg/dl, p=0.0004). Mitochondrial DNA/nuclear DNA ratio at 6 and 12 months did not change. There was a significant increase of mRNA of peroxisome proliferator- activated receptor (PPAR)-gamma after 6 months of train - ing (p=0.024); PPARalpha mRNA levels were significantly increased at 6 (p=0.035) and 12 months (p=0.044). The mRNA quantification of other genes measured [mitochondrially encoded cytochrome c oxidase subunit II (MTCO2), cytochrome c oxidase subunit Vb (COX5b), PPARgamma coactivator 1alpha (PGC- 1alpha), glucose transporter 4 (GLUT 4), forkhead transcription factor BOX O1 (FOXO-1), carnitine palmitoyltransferase 1 (CPT-1), lipoprotein lipase (LPL), and insulin receptor substrate 1 (IRS-1)] did not show significant changes at 6 and 12 months. This study suggests that a twice-per-week frequency of exercise is sufficient to improve glucose control and the expression of skeletal muscle PPARgamma and PPARalpha in DM2 subjects with metabolic syndrome.

Fine needle aspiration coupled with real-time PCR: a painless methodology to study adaptive functional changes in skeletal muscle

BACKGROUND AND AIM

In this study we developed a new methodology for obtaining human skeletal muscle samples to evaluate gene expression. This approach is based on a fine needle aspiration technique, which allows us to extract a small tissue sample in a significantly less invasive manner than with classic biopsy.

METHODS AND RESULTS

Multiplex tandem RT-PCR was used to determine the mRNA levels of genes involved in ATP production and mitochondrial biogenesis in muscle tissue. Samples of vastus lateralis muscle were obtained from 21 healthy subjects with different fitness levels. The principal findings in our study show a strong correlation between PGC-1alpha and COX5B (p<0.001) and between PGC-1alpha and MT-CO2 (p=0.017) expression. Furthermore, a significant positive correlation between mtDNA content and the percentage of MHCI present in the aspired samples were found (p=0.028). These data are in agreement with current knowledge on skeletal muscle physiology and show the reliability of the proposed method.

CONCLUSION

This painless methodology can be used to investigate, in vivo, human muscle RNA and DNA adaptations in response to either physiological and/or pharmacological stimuli. This method has major clinical relevance, such as its application in clarifying the mechanisms underling metabolic and systemic disorders.

A randomized controlled trial to evaluate the efficacy of ultrasound-guided laser photocoagulation for treatment of benign thyroid nodules

This randomized controlled study was designed to test the efficacy and safety of percutaneous ultrasound (US)-guided laser photocoagulation (PLP) for treatment of subjects with compressive symptoms due to benign thyroid nodules and/or at high surgical risk. Twenty six subjects were randomized to the intervention (no. 13, age 68+/-3 yr, mean+/-SEM) or observation (no. 13, age 71+/-2 yr) groups. In the control group, the volume of nodules did not significantly change over the 30 week period of observation. In the intervention group, median nodule volume at baseline was 8.2 ml (range 2.8-26.9) and was not significantly different from that of the control group. Nodules decreased significantly (p<0.0001) by 22% after 2 weeks (6.5 ml; range 2.4-16.7) and by 44% after 30 weeks (4.6 ml; range 0.69-14.2). Energy given was correlated (p<0.05) with the reduction of thyroid nodule volume. All patients tolerated the treatment well and reported relief from compressive and cosmetic complaints (p<0.05). At the time of enrolment 7/13 (54%) and 6/13 (46%) of patients in the intervention and control groups, respectively, had sub clinical hyperthyroidism. PLP normalized thyroid function at 6 and 30 weeks after treatment. In conclusion, PLP is a promising safe and effective procedure for treatment of benign thyroid nodules in patients at high surgical risk.

Exercise and diabetes

Physical activity activates has acute and chronic effects on glucose, lipid and protein metabolism. In type 1 diabetic subjects, the lack of the physiological inhibition of insulin secretion during exercise results in a potential risk of hypoglycemia. On the other hand, exercise-induced activation of counterregulatory hormones might trigger an acute metabolic derangement in severe insulin-deficient subjects. Thus, diabetic patients, before starting exercise sessions, must be carefully educated about the consequences of physical activity on their blood glucose and the appropriate modifications of diet and insulin therapy. Long-term effects of regular exercise are particularly advantageous for type 2 diabetic patients. Regular aerobic exercise reduces of visceral fat mass and body weight without decreasing lean body mass, ameliorates insulin sensitivity, glucose and blood pressure control, lipid profile and reduces the cardiovascular risk. For these reasons, regular aerobic physical activity must be considered an essential component of the cure of type 2 diabetes mellitus. In this regard, individual behavioral strategies have been documented to be effective in motivating sedentary type 2 diabetic subjects to the adoption and the maintenance of regular physical activity.

Metabolic and endocrine effects of physiological increments in plasma ghrelin concentrations

BACKGROUND

Growing evidence indicates that the administration of large amounts of ghrelin to humans increases circulating concentrations of several pituitary and adrenal hormones, induces hyperglycemia and reduces serum insulin concentrations. At present, it is not known whether physiological increments in plasma ghrelin concentrations affect glucose kinetics or hormone concentrations in humans.

METHODS AND RESULTS

We compared the effects of two- and three-fold increments in plasma ghrelin concentrations in eight healthy subjects during a 2 h intravenous infusion of 7.5 (GHRE7.5), 15 (GHRE15) pmol kg(-1) min(-1) acylated human ghrelin or placebo (PL), in a randomized double-blind study. Compared with PL (146 +/- 24 pM) plasma ghrelin concentrations increased at 120 min (p<0.001) about two-fold after GHRE7.5 (300 +/- 35 pM) and three-fold after GHRE15 (494 +/- 30 pM). GHRE15 significantly increased circulating concentrations of NEFA, GH, ACTH, epinephrine, and prolactin (p<0.01). GHRELIN7.5 significantly (p<0.01) increased only serum GH concentrations. Neither ghrelin infusions changed glucose flux or circulating concentrations of glucose, insulin, C-peptide, glucagon, IGF-1, cortisol and norepinephrine.

CONCLUSIONS

GH secretion is the only response that is stimulated by physiological increments in plasma ghrelin concentrations; about three-fold increases in plasma ghrelin concentrations are required to elicit the responses of epinephrine, prolactin, ACTH and NEFA.

Make your diabetic patients walk: long-term impact of different amounts of physical activity on type 2 diabetes

OBJECTIVE

To establish the impact of different amounts of increased energy expenditure on type 2 diabetes care.

RESEARCH DESIGN AND METHODS

Post hoc analysis of long-term effects of different amounts of increased energy expenditure (metabolic equivalents [METS] per hour per week) through voluntary aerobic physical activity was performed in 179 type 2 diabetic subjects (age 62 +/- 1 years [mean +/- SE]) randomized to a physical activity counseling intervention. Subjects were followed for 2 years and divided into six groups based on their increments in METs per hour per week: group 0 (no activity, n = 28), group 1-10 (6.8 +/- 0.3, n = 27), group 11-20 (17.1 +/- 0.4, n = 31), group 21-30 (27.0 +/- 0.5, n = 27), group 31-40 (37.5 +/- 0.5, n = 32), and group >40 (58.3 +/- 1.8, n = 34).

RESULTS

At baseline, the six groups did not differ for energy expenditure, age, sex, diabetes duration, and all parameters measured. After 2 years, in group 0 and in group 1-10, no parameter changed; in groups 11-20, 21-30, 31-40, and >40, HbA(1c), blood pressure, total serum cholesterol, triglycerides, and estimated percent of 10-year coronary heart disease risk improved (P < 0.05). In group 21-30, 31-40, and >40, body weight, waist circumference, heart rate, fasting plasma glucose, serum LDL and HDL cholesterol also improved (P < 0.05). METs per hour per week correlated positively with changes of HDL cholesterol and negatively with those of other parameters (P < 0.001). After 2 years, per capita yearly costs of medications increased (P = 0.008) by USD393 in group 0, did not significantly change in group 1-10 (USD 206, P = 0.09), and decreased in group 11-20 (USD -196, P = 0.01), group 21-30 (USD -593, P = 0.009), group 31-40 (USD -660, P = 0.003), and group >40 (USD -579, P = 0.001).

CONCLUSIONS

Energy expenditure >10 METs . h(-1) . week(-1) obtained through aerobic leisure time physical activity is sufficient to achieve health and financial advantages, but full benefits are achieved with energy expenditure >20 METs . h(-1) . week(-1).

Meal intake similarly reduces circulating concentrations of octanoyl and total ghrelin in humans

ABSTRACT. Several data show that meal intake and nutritional status regulate circulating ghrelin concentrations in humans. Ghrelin mainly circulates in two different forms: octanoyl and des-octanoyl ghrelin. Most circulating ghrelin is des-octanoyl ghrelin which is considered inactive because it lacks endocrine activity. However, recent evidence suggests that des-octanoyl ghrelin exerts biological activity such as stimulation of adipogenesis, cardiovascular effects and control of cell growth. In healthy humans, although the total ghrelin concentration is known to peak before meals and to be reduced by food intake, no data are available about the octanoyl ghrelin response in the absorptive state. Therefore, after an overnight fast, we compared the effects of a mixed meal ingestion (meal study) or of additional 240 min fasting (control study) on plasma concentrations of octanoyl and total ghrelin in 6 healthy subjects (body mass index: 23 +/- 0.7). At baseline, octanoyl-ghrelin accounted for 3.15 +/- 0.2% of total circulating ghrelin without differences between the two sessions. A similar ratio was maintained in the absorptive state with no differences between the studies and basal values. Compared with control, meal intake significantly suppressed (nadir at 90 min) octanoyl and total ghrelin by 38 +/- 3 and 40 +/- 3% of basal values, respectively. In the meal study, multivariate analysis of variance showed that serum insulin best predicted plasma octanoyl-ghrelin concentrations accounting for 97% of its variation (r2 = -0.97,p = 0.0016).

IN CONCLUSION

in healthy humans, octanoyl-ghrelin represents about 3-4% of total circula-ting ghrelin and this ratio is closely maintained in post-absorptive and absorptive states.

Insulin is required for prandial ghrelin suppression in humans

Accumulating evidence indicates that ghrelin plays a role in regulating food intake and energy homeostasis. In normal subjects, circulating ghrelin concentrations decrease after meal ingestion and increase progressively before meals. At present, it is not clear whether nutrients suppress the plasma ghrelin concentration directly or indirectly by stimulating insulin secretion. To test the hypothesis that insulin regulates postprandial plasma ghrelin concentrations in humans, we compared the effects of meal ingestion on plasma ghrelin levels in six C-peptide-negative subjects with type 1 diabetes and in six healthy subjects matched for age, sex, and BMI. Diabetic subjects were studied during absence of insulin (insulin withdrawal study), with intravenous infusion of basal insulin (basal insulin study) and subcutaneous administration of a prandial insulin dose (prandial insulin study). Meal intake suppressed plasma ghrelin concentrations (nadir at 105 min) by 32 +/- 4% in normal control subjects, 57 +/- 3% in diabetic patients during the prandial insulin study (P < 0.002 vs. control subjects), and 38 +/- 8% during basal insulin study (P = 0.0016 vs. hyperinsulinemia; P = NS vs. control subjects) but did not have any effect in the insulin withdrawal study (P < 0.001 vs. other studies). In conclusion, 1). insulin is essential for meal-induced plasma ghrelin suppression, 2). basal insulin availability is sufficient for postprandial ghrelin suppression in type 1 diabetic subjects, and 3). lack of meal-induced ghrelin suppression caused by severe insulin deficiency may explain hyperphagia of uncontrolled type 1 diabetic subjects.