Feasibility of Fit24, a Digital Diabetes Prevention Program for Hispanic Adolescents: Qualitative Evaluation Study

BACKGROUND

Digital health interventions are promising for reaching and engaging high-risk youth in disease prevention opportunities; however, few digital prevention interventions have been developed for Hispanic youth, limiting our knowledge of these strategies among this population.

OBJECTIVE

This study qualitatively assessed the feasibility and acceptability of Fit24, a 12-week goal-setting intervention that uses a Fitbit watch (Fitbit Inc) and theoretically grounded SMS text messages to promote physical activity and sleep among Hispanic adolescents (aged between 14 and 16 years) with obesity.

METHODS

After completing the intervention, a subsample of youth (N=15) participated in an in-depth interview. We categorized the themes into dimensions based on participant perspectives using the Practical, Robust Implementation, and Sustainability Model (PRISM) framework.

RESULTS

Participants shared positive perceptions of wearing the Fitbit and receiving SMS text messages. Youth were highly engaged in monitoring their behaviors and perceived increased activity and sleep. Almost all youth organically received social support from a peer or family member and suggested the use of a group chat or team challenge for integrating peers into future interventions. However, most youth also expressed the need to take personal responsibility for the change in their behavior. Barriers that impacted the feasibility of the study included the skin-irritating material on the Fitbit watch band and environmental barriers (eg, lack of resources and school schedules), that limited participation in activity suggestions. Additionally, sync issues with the Fitbit limited the transmission of data, leading to inaccurate feedback.

CONCLUSIONS

Fit24 is a promising approach for engaging Hispanic youth in a diabetes prevention program. Strategies are needed to address technical issues with the Fitbit and environmental issues such as message timing. While integrating peer social support may be desired by some, peer support strategies should be mindful of youth's desire to foster personal motivation for behavior change. Findings from this study will inform future diabetes prevention trials of Fit24 and other digital health interventions for high-risk pediatric populations.

Healthy Outcomes through Peer Educators: Feasibility of a peer support diabetes prevention programme for African-American grandmother caregivers

AIM

To assess the protocol feasibility and intervention acceptability of a community-based, peer support diabetes prevention programme (DPP) for African-American (AA) grandmother caregivers at risk for diabetes.

MATERIALS AND METHODS

Grandmother caregivers were randomized in a 2:1 ratio to DPP (active comparator) or DPP plus HOPE (Healthy Outcomes through Peer Educators; intervention). DPP + HOPE incorporated support from a peer educator who met with participants in person or by telephone every week during the 1-year intervention. Outcomes included: (1) recruitment rates, outcome assessment, and participation adherence rates assessed quantitatively; and (2) acceptability of the programme assessed through end-of-programme focus groups.

RESULTS

We successfully consented and enrolled 78% (n = 35) of the 45 AA grandmothers screened for eligibility. Eighty percent of participants (aged 64.4 ± 5.7 years) were retained up to Week 48 (74% for DPP [n = 17] and 92% for DPP + HOPE [n = 11]). All grandmothers identified social support, neighbourhood safety, and access to grocery stores as influences on their health behaviours. At Month 12, the active comparator (DPP) group and the intervention group (DPP + HOPE) had a mean change in body weight from baseline of -3.5 ± 5.5 (-0.68, -6.29) kg and - 4.4 ± 5.7 (-0.59, -8.2) kg, respectively.

CONCLUSIONS

This viable study met the aim of educating and equipping AA grandmothers with the practical and sustained support needed to work toward better health for themselves and their grandchildren, who may be at risk for diabetes. The intervention was both feasible and acceptable to participating grandmothers and their organizations.

Transitioning From an In-Person Intervention to Augmented Text Messaging During COVID-19 in Mexican Americans With Prediabetes: The Starr County Diabetes Prevention Randomized Clinical Trial

PURPOSE

The purpose of the study was to explore the feasibility of using commonly available technology, such as text messaging, for diabetes prevention in rural Mexican American communities during COVID-19.

METHODS

Participants were selected from a diabetes prevention study funded by the National Institutes of Health that, prior to COVID-19, involved in-person group intervention sessions. Participants were predominantly female adults born in Mexico and Spanish-speaking. A subsample (n = 140) was divided into 3 cohorts: (1) 50 who completed the initial in-person intervention prior to the COVID-19 research pause, (2) 60 who needed additional support sessions to complete the intervention and thus received 10 text messages with links to relevant online diabetes prevention videos (TM+), and (3) 30 who received enhanced usual care involving health guidance offered during data collection (control). Repeated measures analysis of covariance was used to evaluate cohort differences at 24 months post baseline.

RESULTS

No significant cohort differences were found for depression, eating self-efficacy, alcohol intake, fat avoidance, or sedentary behaviors. Differences in A1C showed both in-person and TM+ cohorts having lower mean A1C levels (5.5%) than the control cohort (5.7%). The TM+ cohort had lower body mass index than other cohorts and a lower diabetes conversion rate (22.2%) compared to the control cohort (28%). Participants indicated preferences for in-person/TM+ combination interventions. The strongest positive feedback was for the TM+ intervention cooking demonstration videos.

CONCLUSIONS

Augmented text messaging combined with in-person sessions had similar outcomes to the all in-person strategy and thus has the potential for expanding the reach of diabetes prevention to many Mexican American communities.

Integrating Community Health Workers' Dual Clinic-Community Role in Safety-Net Primary Care: Implementation Lessons from a Pragmatic Diabetes-Prevention Trial

BACKGROUND

Over a third of US adults carry a diagnosis of prediabetes, 70% of whom may progress to type 2 diabetes mellitus ("diabetes"). Community health workers (CHWs) can help patients undertake healthy behavior to prevent diabetes. However, there is limited guidance to integrate CHWs in primary care, specifically to address CHWs' dual clinic-based and community-oriented role.

OBJECTIVE

Using evidence from CHWs' adaptations of a diabetes-prevention intervention in safety-net hospitals in New York City, we examine the nature, intent, and possible consequences of CHWs' actions on program fidelity. We propose strategies for integrating CHWs in primary care.

DESIGN

Case study drawing on the Model for Adaptation Design and Impact (MADI) to analyze CHWs' actions during implementation of CHORD (Community Health Outreach to Reduce Diabetes), a cluster-randomized pragmatic trial (2017-2022) at Manhattan VA and Bellevue Hospital.

PARTICIPANTS

CHWs and clinicians in the CHORD study, with a focus in this analysis on CHWs.

APPROACH

Semi-structured interviews and focus group discussion with CHWs (n=4); semi-structured interviews with clinicians (n=17). Interpretivist approach to explain CHWs' adaptations using a mix of inductive and deductive analysis.

KEY RESULTS

CHWs' adaptations extended the intervention in three ways: by extending social assistance, healthcare access, and operational tasks. The adaptations were intended to improve fit, reach, and retention, but likely had ripple effects on implementation outcomes. CHWs' focus on patients' complex social needs could divert them from judiciously managing their caseload.

CONCLUSIONS

CHWs' community knowledge can support patient engagement, but overextension of social assistance may detract from protocolized health-coaching goals. CHW programs in primary care should explicitly delineate CHWs' non-health support to patients, include multiprofessional teams or partnerships with community-based organizations, establish formal communication between CHWs and clinicians, and institute mechanisms to review and iterate CHWs' work to resolve challenges in their community-oriented role.

Experiences of online group support for engaging and supporting participants in the National Health Service Digital Diabetes Prevention Programme: A qualitative interview study

OBJECTIVES

The National Health Service Digital Diabetes Prevention Programme is a nine-month behavioural intervention for adults in England at risk of type 2 diabetes. This qualitative study aimed to explore how service users engaged with the group support available within the programme.

METHODS

The majority of participants (n = 33), all service users, were interviewed twice via telephone, at 2-4 months into the programme, and at the end of the programme at 8-10 months. Semi-structured interviews covered participants' experiences of online group support functions and how such groups served as a route of support to aid participants' behavioural changes. Data were analysed using manifest thematic analysis.

RESULTS

The majority of participants valued the format of closed group chats, which provided an interactive platform to offer and receive support during their behaviour change journey. However, engagement with group chats reduced over time, and some participants did not find them useful when there was a lack of common interests within the group. Health coaches helped to promote engagement and build rapport among participants within the group chats. Participants reported mixed experiences of discussion forums.

CONCLUSIONS

Programme developers should consider how to optimise online group support to help service users make behavioural changes, in terms of format, participant composition and use of health coach moderators. Further research is required to better understand who might benefit most from 'group chat' or 'discussion forum' support. Health coach moderation of online support groups is likely to facilitate engagement.

Overview of Ethnobotanical-Pharmacological Studies Carried Out on Medicinal Plants from the Serra da Estrela Natural Park: Focus on Their Antidiabetic Potential

The Serra da Estrela Natural Park (NPSE) in Portugal stands out as a well-preserved region abundant in medicinal plants, particularly known for their pharmaceutical applications in diabetes prevention and treatment. This comprehensive review explores these plants' botanical diversity, traditional uses, pharmacological applications, and chemical composition. The NPSE boast a rich diversity with 138 medicinal plants across 55 families identified as traditionally and pharmacologically used against diabetes globally. Notably, the Asteraceae and Lamiaceae families are prevalent in antidiabetic applications. In vitro studies have revealed their significant inhibition of carbohydrate-metabolizing enzymes, and certain plant co-products regulate genes involved in carbohydrate metabolism and insulin secretion. In vivo trials have demonstrated antidiabetic effects, including glycaemia regulation, insulin secretion, antioxidant activity, and lipid profile modulation. Medicinal plants in NPSE exhibit various activities beyond antidiabetic, such as antioxidant, anti-inflammatory, antibacterial, anti-cancer, and more. Chemical analyses have identified over fifty compounds like phenolic acids, flavonoids, terpenoids, and polysaccharides responsible for their efficacy against diabetes. These findings underscore the potential of NPSE medicinal plants as antidiabetic candidates, urging further research to develop effective plant-based antidiabetic drugs, beverages, and supplements.

Association Between Dietary Habits and Type 2 Diabetes Mellitus in Thai Adults: A Case-Control Study

Background

The prevalence of T2DM is escalating in Thailand affecting over 10% of adults aged 20-79 years old. It is imperative to identify modifiable risk factors that can potentially help mitigate the risk of developing diabetes.

Objective

This study aimed to investigate the relationship between dietary habits and type 2 diabetes in Chiang Mai, Thailand.

Methods

This case-control study involved 300 individuals aged 25-74 years residing in Chiang Mai, Thailand including 150 newly diagnosed T2DM patients (cases) and 150 community residents without diabetes (controls). Dietary habits were assessed based on Food Frequency Questionnaire (FFQ). Socio-demographic characteristics and anthropometric information of the participants were collected. Data analysis was performed using the STATA-17.

Results

The case group participants were older and had a higher proportion of males compared to the control group. The case group exhibited a significantly higher consumption of meat, beans, nuts, soft drinks, and topping seasonings (p<0.001), conversely, a lower intake of vegetables (p<0.001), fruits (p=0.006), fish, rice (p<0.001), eggs (p=0.032), milk products, coffee, and tea (p<0.001) compared to the control group. Furthermore, the case group demonstrated a higher level of certain dietary practices such as a greater frequency of having meals with family, not removing visible fat from food (p<0.001), and eating snacks between meals compared to controls. Multiple logistic regression analysis showed that after adjusting for potential confounding factors not removing visible fat from food (aOR 5.61, 95% CI: 2.29-13.7, p<0.001) and using topping seasonings (aOR 3.52 95% CI: 1.69-7.32 p=0.001) were significantly associated with the risk of T2DM, whereas daily vegetable intake (aOR 0.32 95% CI: 0.15-0.68 p=0.003) was inversely associated with T2DM.

Conclusion

The study findings caution against the consumption of food rich in fat and using salty seasonings, while advocating for an increased intake of vegetables to prevent the prevalence of T2DM.

Leveraging Generative AI Tools to Support the Development of Digital Solutions in Health Care Research: Case Study

BACKGROUND

Generative artificial intelligence has the potential to revolutionize health technology product development by improving coding quality, efficiency, documentation, quality assessment and review, and troubleshooting.

OBJECTIVE

This paper explores the application of a commercially available generative artificial intelligence tool (ChatGPT) to the development of a digital health behavior change intervention designed to support patient engagement in a commercial digital diabetes prevention program.

METHODS

We examined the capacity, advantages, and limitations of ChatGPT to support digital product idea conceptualization, intervention content development, and the software engineering process, including software requirement generation, software design, and code production. In total, 11 evaluators, each with at least 10 years of experience in fields of study ranging from medicine and implementation science to computer science, participated in the output review process (ChatGPT vs human-generated output). All had familiarity or prior exposure to the original personalized automatic messaging system intervention. The evaluators rated the ChatGPT-produced outputs in terms of understandability, usability, novelty, relevance, completeness, and efficiency.

RESULTS

Most metrics received positive scores. We identified that ChatGPT can (1) support developers to achieve high-quality products faster and (2) facilitate nontechnical communication and system understanding between technical and nontechnical team members around the development goal of rapid and easy-to-build computational solutions for medical technologies.

CONCLUSIONS

ChatGPT can serve as a usable facilitator for researchers engaging in the software development life cycle, from product conceptualization to feature identification and user story development to code generation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04049500; https://clinicaltrials.gov/ct2/show/NCT04049500.

Identification of Intervention Characteristics Within Diabetes Prevention Programs Using the Template for Intervention Description and Replication: A Scoping Review

OBJECTIVES

Diabetes prevention programs (DPPs) targeting dietary and physical activity behaviour change have been shown to decrease the incidence of type 2 diabetes; however, a more thorough reporting of intervention characteristics is needed to expedite the translation of such programs into different communities. In this scoping review we aim to synthesize how DPPs are being reported and implemented.

METHODS

A scoping review using Arkey and O'Malley methods was conducted in accordance with the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analysis. MEDLINE, CINAHL, PsycINFO, EMBASE, and SPORTDiscus were searched for studies relating to diabetes prevention, and diet/exercise interventions. Only studies delivering a diet/exercise intervention for adults identified as "at risk" for developing type 2 diabetes were included. The Template for Intervention Description and Replication (TIDieR) was used to guide data extraction, and each DPP was scored on a scale from 0 to 2 for how thoroughly it reported each of the items (0 = did not report, 2 = reported in full; total score out of 26).

RESULTS

Of the 25,110 publications screened, 351 (based on 220 programs) met the inclusion criteria and were included for data extraction. No studies comprehensively reported on all TIDieR domains (mean TIDieR score: 15.7 of 26; range 7 to 25). Reporting was particularly poor among domains related to "modifications," "tailoring," and "how well (planned/actual)." "How well (planned)" assesses the intended delivery of an intervention, detailing the initial strategies and components as per the original design, whereas "how well (actual)" evaluates the extent to which the intervention was executed as planned during the study, including any deviations or modifications made in practice.

CONCLUSIONS

Although there is evidence to suggest that DPPs are efficacious, a more thorough reporting of program content and delivery is needed to improve the ability for effective programs to be implemented or translated into different communities.

Prevention aid in qualitative analysis of dermatoglyphic patterns in relation to type 2 diabetes mellitus: a pilot study

OBJECTIVES

The significant differences in the fingerprint pattern frequencies in type 2 diabetes mellitus (T2DM) patients and controls could be a possible way to identify patients with a risk of developing T2DM. The results could be used in the earlier diagnosis and treatment. The study was undertaken to find out the reliability of fingerprint patterns as a possible predictive tool for T2DM diagnosis.

METHODS

A total of 1,260 fingerprints were acquired using the optical contact sensor DactyScan 26i. The results of the qualitative analysis of the fingerprint pattern frequencies have been compared between T2DM patients and controls and also between the fingers to each other. We have detected the frequency of patterns: plain arch (Ap) and tented arch (At), radial loop (Lr), ulnar loop (Lu), double loop (Ld), spiral whorl (W), and plain whorl (concentric) (Wp). Statistical analysis was performed using Pearson's chi-square by Statistica ver. 12.

RESULTS

We found statistically significant differences (p < 0.05) in the frequency of individual dermatoglyphic patterns among patients with diabetes and healthy controls as follows: in the left thumb (L1) in a radial loop, double loop and spiral whorl pattern; in the left middle finger (L3) in a tented arch and radial loop; in the right ring finger (R4) in a tented arch, spiral and plain whorl; and in the right little finger (R5) in a tented arch and spiral whorl.

CONCLUSION

Fingerprint pattern frequencies might be used as another screening tool and indicator in T2DM prevention. Qualitative analysis of fingerprint patterns could be useful regarding the additional prevention diagnostics of T2DM in the population.

A co-designed, community-based intensive health behavior intervention promotes participation and engagement in youth with risk factors for type 2 diabetes

Background

Obesity among youth (children and adolescents) is associated with increased risk for youth-onset type 2 diabetes. Lifestyle change can delay or prevent the development of type 2 diabetes, yet real-world implementation of health behavior recommendations is challenging. We previously engaged youth with risk factors for type 2 diabetes, their caregivers, and professionals in a human-centered design study to co-design a lifestyle change program. Here we report the outcomes for this 16-week co-designed lifestyle change program for youth at risk for T2D and their caregivers.

Research design and methods

This single-arm family-based cohort study included youth aged 7-18 years, with BMI ≥85th percentile (overweight or obese) and at least one additional risk factor for type 2 diabetes, and their caregivers. Clinical (BMI, HbA1c), self-reported physical activity, and quality of life outcomes were evaluated at baseline (B), post-intervention (M4), and 1 year (M12) following the intervention.

Results

Seventy-eight youth (mean age 12.4 ± 2.7y, 67% female, 37.8% white) and 65 caregivers were included in the data analysis. Youth baseline BMI z-scores (2.26 ± 0.47) and HbA1c (5.3 ± 0.3) were unchanged at follow up time points [BMI z-scores M4 (2.25 ± 0.52), M12 (2.16 ± 0.58), p-value 0.46], [HbA1c M4 (5.3 ± 0.3), M12 (5.2 ± 0.3), p-value (0.04)]. Youth reported increased physical activity at M4 (p = 0.004), but not at M12. Youth quality of life scores increased at M12 (p=0.01). Families who attended at least one session (n=41) attended an average of 9 out of 16 sessions, and 37 percent of families attended 13 or more sessions.

Conclusion

A co-designed, community-based lifestyle intervention promotes increased physical activity, improved quality of life, maintenance of BMI z-scores and HbA1c, and engagement in youth with risk factors for T2D.

The Development of Text Messages to Support People at Risk of Diabetes in Low-Resourced Communities: The South African Diabetes Prevention Programme

Emerging evidence suggests that the addition of text messages to standard healthy lifestyle interventions may improve the outcomes of diabetes prevention programs (DPP). This paper describes the process of developing text messages targeting behavior change in people at risk of developing diabetes in low-resourced communities as part of the South African DPP (SA-DPP). The development comprised multiple steps led by nutrition and physical activity experts. The steps included the following: (1) text message development based on the existing SA-DPP curriculum and its formative research; (2) text message evaluation for readability/understandability in terms of content, language, and quality, with 75 participants from two low-resourced areas in Cape Town; (3) text message refinement by the expert panel; (4) evaluation of the refined text messages by participants from Step 2; and (5) text bank finalization. Based on the readability survey, 37 of the 67 formulated text messages [24 of the 44 encouraged healthy eating, and 13 of the 23 promoted physical activity] were refined. Based on focused discussions with participants, seven more messages were refined to consider alternative terminology. The final text bank includes a total of 67 messages comprising topics related to fruit and vegetable consumption as well as the importance of having variety in the diet (n = 15), limiting fat intake (n = 10), avoiding sugar (n = 11), avoiding salt (n = 5), promoting fiber-rich foods (n = 1), messages promoting physical activity (n = 21), and general check-in messages (n = 4). Most of the text messages were acceptable, understandable, and largely feasible to all participants, with some of the nutrition-related messages being less feasible for participants due to their socioeconomic position. The next step is to assess the text messages in the SA-DPP intervention trial.

Predisposition to Type 2 Diabetes in Aspects of the Glycemic Curve and Glycated Hemoglobin in Healthy, Young Adults: A Cross-sectional Study

OBJECTIVES

Our aim in this study was to identify predictors for diabetes among the characteristics of the glycemic curve and glycated hemoglobin (A1C) in healthy, young adults.

METHODS

We used a cross-sectional study to establish predictors for diabetes based on earlier studies and evaluated occurrence of the condition in 81 healthy, young adult subjects. These volunteers underwent analysis of fasting plasma glucose, oral glucose tolerance test plasma glucose, A1C, and inflammatory markers (leukocytes, monocytes, and C-reactive protein). The nonparametric Mann-Whitney U test, Fisher's exact test, chi-square test, Kruskal-Wallis test, and multiple-comparisons test were used to analyze the data.

RESULTS

We studied 2 age groups, homogeneous in terms of family history of diabetes: one group ranged in age from ≥18 to <28 years (median 20 years; body mass index [BMI] 24 kg/m2) and the other group ranged in age from ≥28 to <45 years (median 35 years; BMI 24 kg/m2). The older group had a higher incidence of predictors (p=0.0005) and was associated with the predictors 30-minute blood glucose ≥164 mg/dL (p=0.0190), 60-minute blood glucose ≥125 mg/dL (p=0.0346), and A1C ≥5.5% (p=0.0162), with a monophasic glycemic curve (p=0.007). The younger group was associated with the 2-hour plasma glucose predictor ≥140 mg/dL (p=0.014). All subjects had fasting glucose in the normal range.

CONCLUSIONS

Healthy, young adults may already have predictors of diabetes, identified mainly by aspects of the glycemic curve and A1C, but at more modest levels than those with prediabetes.

Motivation for Behavior Change among Women with Recent Gestational Diabetes and Their Partners-A Qualitative Investigation among Participants in the Face-It Intervention

Promoting diet and physical activity is important for women with recent gestational diabetes mellitus (GDM) and their partners to reduce the risk of future type 2 diabetes (T2D). The study aimed to understand how motivation for changing diet and physical activity behaviors among women with recent GDM and their partners was experienced after participation in the Danish Face-it intervention. Fourteen couples' interviews were conducted. Data analysis followed a reflexive thematic analysis. Guided by self-determination theory and interdependence theory, we identified four themes affecting couples' motivation for health behavior change: (1) The need to feel understood after delivery; (2) adjusting health expectations; (3) individual and mutual preferences for health behaviors; and (4) the health threat of future T2D as a cue to action. We found that couples in general perceived the Face-it intervention as useful and motivating. Using couple interviews increased our understanding of how the women and partners influenced each other's perspectives after a GDM-affected pregnancy and thus how targeting couples as opposed to women alone may motivate health behavior change.

The characteristics and acceptance of Technology-Enabled diabetes prevention programs (t-DPP) amongst individuals with prediabetes: A scoping review

AIM AND OBJECTIVE

As rising global prevalence of diabetes burdens an overstrained healthcare system, it would be prudent to employ primary prevention strategies. This review aims to detail characteristics of technology-enabled diabetes prevention programs (t-DPP) and the technology acceptance amongst prediabetic individuals.

DESIGN

A scoping review.

REVIEW METHODS

Summative and direct content analysis.

DATA SOURCES

Seven electronic databases-PubMed, Cochrane, Embase, CINAHL, Scopus, PsycINFO and Web of Science-were searched from inception till 9 June 2022 for primary studies conducted on t-DPP. Initial search identified 2412 unique articles. Removal of duplicates and irrelevant articles resulted in 58 full text articles screened and 17 articles meeting the eligibility criteria. There was no limitation to study type or year of publication, but language was limited to English.

RESULTS

Common t-DPP characteristics include physical activity (n = 17), diet control (n = 16), coaching (n = 12), social support (n = 9) and skills acquisition (n = 12). Technological acceptance of t-DPPs were generally positive as participants found them useful (n = 5) and easy to use (n = 4), with majority of the participants interested (n = 5) and engaging well with it (n = 13). However, personal-, design- and technological-level factors were found to negatively influence t-DPPs acceptance.

CONCLUSION

This review reported a generally positive technological acceptance. The result encourages remote delivery of diabetes prevention programs, offering researchers a guide to t-DPP development. However, it also highlights the need for integration of behavioural change theories and socio-cultural considerations, with gaps in knowledge amongst men and young adults.

IMPLICATIONS FOR NURSING

The success of t-DPP can reinforce clinical advice and sustain health behaviours advocated by nurses. Involvement of diabetes-trained nurses would enable continual risk assessment, monitoring and timely intervention to prevent diabetes and potential complications.

REPORTING METHOD

PRISMA-ScR checklist.

Design and Early Use of the Nationally Implemented Healthier You National Health Service Digital Diabetes Prevention Programme: Mixed Methods Study

BACKGROUND

The Healthier You National Health Service Digital Diabetes Prevention Programme (NHS-digital-DPP) is a 9-month digital behavior change intervention delivered by 4 independent providers that is implemented nationally across England. No studies have explored the design features included by service providers of digital diabetes prevention programs to promote engagement, and little is known about how participants of nationally implemented digital diabetes prevention programs such as this one make use of them.

OBJECTIVE

This study aimed to understand engagement with the NHS-digital-DPP. The specific objectives were to describe how engagement with the NHS-digital-DPP is promoted via design features and strategies and describe participants' early engagement with the NHS-digital-DPP apps.

METHODS

Mixed methods were used. The qualitative study was a secondary analysis of documents detailing the NHS-digital-DPP intervention design and interviews with program developers (n=6). Data were deductively coded according to an established framework of engagement with digital health interventions. For the quantitative study, anonymous use data collected over 9 months for each provider representing participants' first 30 days of use of the apps were obtained for participants enrolled in the NHS-digital-DPP. Use data fields were categorized into 4 intervention features (Track, Learn, Coach Interactions, and Peer Support). The amount of engagement with the intervention features was calculated for the entire cohort, and the differences between providers were explored statistically.

RESULTS

Data were available for 12,857 participants who enrolled in the NHS-digital-DPP during the data collection phase. Overall, 94.37% (12,133/12,857) of those enrolled engaged with the apps in the first 30 days. The median (IQR) number of days of use was 11 (2-25). Track features were engaged with the most (number of tracking events: median 46, IQR 3-22), and Peer Support features were the least engaged with, a median value of 0 (IQR 0-0). Differences in engagement with features were observed across providers. Qualitative findings offer explanations for the variations, including suggesting the importance of health coaches, reminders, and regular content updates to facilitate early engagement.

CONCLUSIONS

Almost all participants in the NHS-digital-DPP started using the apps. Differences across providers identified by the mixed methods analysis provide the opportunity to identify features that are important for engagement with digital health interventions and could inform the design of other digital behavior change interventions.

A Mediterranean Diet May Be Protective in the Development of Diabetic Retinopathy

The Mediterranean diet is recognized as one of the healthiest available dietary patterns. This perception results from its beneficial effects on the cardiovascular system and, also, on hypertension, diabetes, and cancer compared with other diets. Its impact on the course of diabetes is assessed in the available scientific literature; however, little information is available about its impact on diabetic retinopathy. The MD is characterized mainly by the consumption of fish, seafood, foods of plant origin, and fresh fruit and vegetables. It is also recommended to consume legumes, which are a source of folic acid, magnesium, iron, and dietary fiber. High consumption of nuts and unrefined grains is also recommended in the MD. Marine fish provide polyunsaturated acids from the omega-3 group. Olive oil plays a very important role, especially olive oil obtained from mechanical pressing. Additionally, olive oil contains vitamins E, K, and polyphenols. Polyphenols, which are present in a diverse range of vegetables, fruits, and seeds, have the ability to decrease oxidative stress, inflammation, and insulin resistance. Resveratrol is naturally found in grape skins and seeds, as well as in peanuts and berries, and is a constituent of red wine. Resveratrol can inhibit increased vascular leakage and loss of pericytes and regulate the level of VEGF protein in the retina, thus inhibiting the development of DR. Consumption of fruits, vegetables, fish, and olive oil may be correlated with a lower risk of diabetic retinopathy. This paper presents the definition of the Mediterranean diet and its influence on the course of diabetes and diabetic retinopathy.

The Outlook of Healthcare Providers on the Involvement of Diabetic Patients as Health Promoters for Diabetes Prevention Among Their Family Members: A Qualitative Study

Background and objective Examples of patients becoming health promoters for diabetes prevention in their own families, although few, are on the rise. Nevertheless, despite this increase in patient involvement in diabetes prevention, there is scarce research regarding healthcare providers' perspectives on the active engagement of patients as health promoters for their family members. In light of this, we aimed to explore the perspectives of healthcare providers working at primary health clinics regarding patient involvement in diabetes prevention among their own family members and close relatives. Methodology This study was conducted between July and December 2022 at the Primary Healthcare Clinics at King Abdulaziz Medical City, Ministry of National Guard Health Affairs, in Riyadh and Jeddah, Saudi Arabia. Semistructured interviews based on purposive sampling were conducted with 13 participants, and their data were thematically analyzed. Results Two main themes emerged from the interviews: the patients' readiness to be health promoters and the willingness of healthcare staff to support promoter patients. Healthcare providers perceived the involvement of diabetes patients in promoting the health of their family members and close relatives as beneficial; however, several barriers may prevent these patients from becoming effective health promoters. Conclusions Healthcare providers understand the significance of involving patients with diabetes as health promoters for their family members and close relatives. Patients can offer unique insights into the lived experience of diabetes management, as well as provide practical advice for lifestyle adjustments. Nevertheless, healthcare providers should also recognize the limits of patients' knowledge and skills and ensure that patients receive proper training and support to serve as effective health educators.

Effect of intratrial mean 25(OH)D concentration on diabetes risk, by race and weight: an ancillary analysis in the D2d study

BACKGROUND

Higher serum 25-hydroxyvitamin D [25(OH)D] is associated with lower type 2 diabetes risk. 25(OH)D varies due to skin pigmentation and weight.

OBJECTIVES

This analysis aims to determine whether the effect of vitamin D differs among people of color and those with overweight/obesity (who have higher diabetes risk) compared with individuals who are White or have normal weight.

METHODS

The D2d study is a randomized clinical trial in people with prediabetes that tested the effects of daily vitamin D3 4000 IU vs. placebo on diabetes risk (median followup 2.5 y). We compared baseline and intratrial mean 25(OH)D concentrations, defined as the mean of all available annual 25(OH)D values, among groups defined by self-reported race and body mass index (BMI). We used Cox proportional hazards models to assess the associations between intratrial mean 25(OH)D and diabetes risk by race- and BMI-based groups.

RESULTS

Asian (n=130), Black (n=616), and White (n=1616) participants were included. Both baseline and intratrial mean 25(OH)D concentrations differed significantly by race groups (both P < 0.001) and were lower in Asian and Black vs. White participants, and in those with higher vs. lower BMI adjusted for race (both P < 0.001). Compared with those with lower concentrations, Black and White participants with intratrial mean 25(OH)D ≥ 40 ng/mL had significantly reduced diabetes risk [HR (95% CI): Black: 0.51 (0.29, 0.92); White: 0.42 (0.30, 0.60)] and with a similar reduction in diabetes risk among Asian participants: 0.39 (0.14, 1.11). Compared with those with lower concentrations, participants with baseline BMI < 40 kg/m2 who achieved intratrial mean 25(OH)D concentrations ≥ 40 ng/mL had a significantly reduced diabetes risk. There was no statistically significant interaction between intratrial 25(OH)D and race or between intratrial 25(OH)D and BMI on diabetes risk.

CONCLUSIONS

Among people with prediabetes, particularly for Black and White race groups and those with BMI < 40 kg/m2, the optimal 25(OH)D concentration may be ≥ 40 ng/mL to optimize diabetes-prevention efforts. This trial was registered at clinicaltrials.gov as NCT01942694.

Rethinking diabetes in the United States

Despite the availability of effective medical treatments, the diabetes epidemic has accelerated in the United States, efforts to translate treatments into routine clinical practice have stalled, and health inequities have persisted. The National Clinical Care Commission (NCCC) was established by the Congress to make recommendations to better leverage federal policies and programs to more effectively prevent and control diabetes and its complications. The NCCC developed a guiding framework that incorporated elements of the Socioecological and Chronic Care Models. It gathered information from both health-related and non-health-related federal agencies, held 12 public meetings, solicited public comments, met with interested parties and key informants, and performed comprehensive literature reviews. The final report of the NCCC was transmitted to the Congress in January 2022. It called for a rethinking of the problem of diabetes in the United States, including the recognition that the lack of progress is due to a failure to confront diabetes as both a complex societal problem as well as a biomedical problem. To prevent and control diabetes, public policies and programs must be aligned to address both social and environmental determinants of health and health care delivery as they impact diabetes. In this article, we discuss the findings and recommendations of the NCCC as they relate to the social and environmental factors that influence the risk of type 2 diabetes and argue that the prevention and control of type 2 diabetes in the U.S. must begin with concrete population-level interventions to address social and environmental determinants of health.

Mental health diagnosis attenuates weight loss among older adults in a digital diabetes prevention program

Objective

Diabetes Prevention Programs (DPP) are effective at reducing diabetes incidence via clinically significant weight loss. Co-morbid mental health condition(s) may reduce the effect of DPP administered in-person and telephonically but this has not been assessed for digital DPP. This report examines the moderating effect of mental health diagnosis on weight change among individuals who enrolled in digital DPP (enrollees) at 12 and 24 months.

Methods

Secondary analysis of prospective, electronic health record data from a study of digital DPP among adults (N = 3904) aged 65-75 with prediabetes (HbA1c 5.7%-6.4%) and obesity (BMI ≥30 kg/m²).

Results

Mental health diagnosis only moderated the effect of digital DPP on weight change during the first 7 months (p = 0.003) and the effect attenuated at 12 and 24 months. Results were unchanged after adjusting for psychotropic medication use. Among those without a mental health diagnosis, digital DPP enrollees lost more weight than non-enrollees: -4.17 kg (95% CI, -5.22 to -3.13) at 12 months and -1.88 kg (95% CI, -3.00 to -0.76) at 24 months, whereas among individuals with a mental health diagnosis, there was no difference in weight loss between enrollees and non-enrollees at 12 and 24 months (-1.25 kg [95% CI, -2.77 to 0.26] and 0.02 kg [95% CI, -1.69-1.73], respectively).

Conclusions

Digital DPP appears less effective for weight loss among individuals with a mental health condition, similar to prior findings for in-person and telephonic modalities. Findings suggest a need for tailoring DPP to address mental health conditions.

Inflammatory Mediators and Type 2 Diabetes Risk Factors before and in Response to Lifestyle Intervention among Latino Adolescents with Obesity

Obesity is associated with chronic inflammation that may contribute to T2D among youth. We examined the association between inflammatory biomarkers and insulin sensitivity and β-cell function and response to lifestyle intervention among Latino youth with obesity. Latino youth (n = 64) were randomized to six months of lifestyle intervention (INT, n = 40) or usual care (UC, n = 24). INT included nutrition education and physical activity. UC involved meeting with a pediatric endocrinologist and registered dietitian to discuss healthy lifestyles. At baseline, multiple linear regression assessed fasting serum interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), monocyte chemoattractant protein-1 (MCP-1), high-molecular weight adiponectin (HMW Adpn), IL-10, IL-1 receptor antagonist (IL-1ra) as predictors of insulin sensitivity (whole-body insulin sensitivity index, WBISI) and β-cell function (oral disposition index, oDI). Changes in outcomes between groups were assessed using covariance pattern models. At baseline, MCP-1 (β ± SE, -0.12 ± 0.05, p = 0.027) and IL-1ra (-0.03 ± 0.01, p = 0.005) were negatively associated with WBISI. Treatment effects were not observed for inflammatory markers. WBISI was significantly increased among both INT (from 1.8 ± 0.2 to 2.6 ± 0.4, p = 0.005) and UC (from 1.6 ± 0.2 to 2.8 ± 0.5, p = 0.002) with no significant differences between the groups. Obesity-related inflammatory mediators were associated with T2D risk factors but were unaffected by lifestyle intervention among Latino youth.

Study protocol: BRInging the Diabetes prevention program to GEriatric Populations

In the Diabetes Prevention Program (DPP) randomized, controlled clinical trial, participants who were  ≥ 60 years of age in the intensive lifestyle (diet and physical activity) intervention had a 71% reduction in incident diabetes over the 3-year trial. However, few of the 26.4 million American adults age ≥65 years with prediabetes are participating in the National DPP. The BRInging the Diabetes prevention program to GEriatric Populations (BRIDGE) randomized trial compares an in-person DPP program Tailored for Older AdulTs (DPP-TOAT) to a DPP-TOAT delivered via group virtual sessions (V-DPP-TOAT) in a randomized, controlled trial design (N = 230). Eligible patients are recruited through electronic health records (EHRs) and randomized to the DPP-TOAT or V-DPP-TOAT arm. The primary effectiveness outcome is 6-month weight loss and the primary implementation outcome is intervention session attendance with a non-inferiority design. Findings will inform best practices in the delivery of an evidence-based intervention.

A very low-carbohydrate diabetes prevention program for veterans with prediabetes: a single-arm mixed methods pilot study

Introduction

All Veterans Affairs (VA) Medical Centers offer the MOVE! Weight Management Program to help patients achieve and maintain a healthy weight through a calorie-restricted, low-fat diet and increased physical activity. Yet, most MOVE! participants do not achieve clinically significant weight loss of ≥5%. A carbohydrate-restricted diet may help more Veterans to achieve ≥5% weight loss.

Methods

This was a single-arm explanatory sequential mixed methods pilot study conducted in one VA health care system. Veterans with prediabetes and body mass index ≥25 kg/m2 were invited to participate in a group-based, virtual, very low-carbohydrate Diabetes Prevention Program (VLC-DPP) consisting of 23 sessions over 12 months. Participants were taught to follow a very low-carbohydrate eating pattern, defined as 20-35 grams of net carbohydrates per day. The primary outcomes were measures of feasibility and acceptability, including program uptake and session attendance. Secondary outcomes included change in weight, hemoglobin A1c, lipids, and patient-reported measures of food cravings, stress eating, perceived health status, and motivation. Interviews were conducted at 6 months to identify factors that facilitated or hindered participants' achievement of ≥5% weight loss.

Results

Among 108 screened Veterans, 21 enrolled in the study (19%), and 18 were included in the analytic cohort. On average, participants attended 12.4/16 weekly sessions and 3.6/8 bimonthly or monthly sessions. At 12 months, mean percent weight loss was 9.4% (SD = 10.7) with 9 participants (50%) achieving ≥5% weight loss. Three factors facilitated achievement of ≥5% weight loss among 10/16 interviewees: (1) enjoyment of low-carbohydrate foods; (2) careful monitoring of carbohydrate intake; and (3) reduced hunger and food cravings. Three factors hindered achievement of ≥5% weight loss among 6/16 interviewees: (1) food cravings, particularly for sweets; (2) challenges with maintaining a food log; and (3) difficulty with meal planning.

Conclusion

A VLC-DPP is feasible and acceptable and shows preliminary efficacy among Veterans with prediabetes. The program's weight loss effectiveness compared to standard MOVE! should be evaluated in a larger-scale trial. Such a program may be offered in addition to the standard MOVE! program to expand the menu of evidence-based lifestyle counseling options for Veterans.

Clinical Trial Registration

https://clinicaltrials.gov/ct2/show/NCT04881890, identifier NCT04881890.

The association between immigration status and the development of type 2 diabetes in women with a prior diagnosis of gestational diabetes: a population-based study

AIMS

To examine the influence of immigration status and region of origin on the risk of type 2 diabetes in women with prior gestational diabetes (GDM).

METHODS

This retrospective population-based cohort study included women with gestational diabetes (GDM) aged 16 to 50 years in Ontario, Canada who gave birth between 2006-2014. We compared the incidence of type 2 diabetes after delivery between long-term residents and immigrants - overall, by time since immigration, and by region of origin - using Cox regression adjusted for age, year, neighbourhood income, rurality, infant birth weight, and presence of hypertensive disorders of pregnancy (HDP).

RESULTS

Among 38,515 women with prior GDM (42% immigrants), immigrants had a significantly higher risk of type 2 diabetes compared to long-term residents [adjusted hazard ratio (HR) 1.19, 95% confidence interval (CI) 1.13- 1.26], with no meaningful difference based on time since immigration. The highest adjusted relative risks of type 2 diabetes compared to long-term residents were found for immigrants from Sub-Saharan Africa (HR 1.63, 95% CI 1.40-1.90), Latin America/Caribbean (HR 1.44, 95% CI 1.28-1.62) and South Asia (HR 1.34, 95% CI 1.25-1.44).

CONCLUSIONS

Immigration is associated with a significantly higher risk of type 2 diabetes after GDM, particularly for women from certain low- and middle-income countries. Diabetes prevention strategies will need to consider the unique needs of immigrants from these regions.

Acceptability and adoption of the Face-it health promotion intervention targeting women with prior gestational diabetes and their partners: a qualitative study of the perspectives of healthcare professionals

AIM

In this study, we investigated healthcare professionals' (HCPs) experiences with delivering home visits and digital coaching in the Face-it health promotion intervention targeting women with recent GDM and their families. Understanding the acceptability and adoption of a health promotion intervention can provide insights into intervention fidelity and future scalability.

METHODS

In total, 13 HCPs were interviewed. Data were analysed thematically through an abductive approach using Sekhon et al.'s theoretical framework of acceptability and Greenhalgh et al.'s framework for non-adoption, abandonment, scale-up, spread, and sustainability.

RESULTS

Acceptability and adoption of the intervention among HCPs were influenced by 1) skills and technology, 2) values, and 3) organisation. The intervention was experienced as acceptable to HCPs because the dialogue tool, visualising different topics, used in the home visits and digital coaching through the LIVA app were flexible and enabled them to address psychosocial health and personalise goal setting in families. However, delivering asynchronous and non-verbal communication was experienced as straining HCPs' relationship with families, which misaligned with HCPs' values. Establishing a non-judgemental environment was needed to increase intervention acceptability among HCPs towards addressing type 2 diabetes risk after GDM. Increased collaboration between HCPs may have aligned advice and support to families and could have benefitted delivery.

CONCLUSIONS

When delivering health promotion to women with prior GDM, flexible intervention components which support psychosocial- and mental health topics may increase acceptability and adoption of the intervention among HCPs. HCPs' skills, values and organisational factors should be considered prior and during implementation.

Adapting and Developing A Diabetes Prevention Intervention Programme for South Africa: Curriculum and Tools

The South African Diabetes Prevention Programme (SA-DPP) is a lifestyle intervention targeting individuals at high risk of developing type 2 diabetes mellitus (T2DM). In this paper we describe the mixed-method staged approach that was used to develop and refine the SA-DPP intervention curriculum and the appropriate tools for local resource-poor communities. During the preparation phase, existing evidence on similar DPP interventions was reviewed, focus group discussions with individuals from the target population were conducted as part of a needs assessment, and experts were consulted. The curriculum booklet, a participant workbook and facilitator workbook were developed, and the content was evaluated by experts in the field. The design and layout of the booklet and workbooks needed to be culturally and contextually appropriate. The printed material was evaluated for readability and acceptability by participants of the target population; based on their feedback, the design and layout were refined and the printed material was translated. The suitability of the intervention was tested in a pilot study; based on feedback from the participants and facilitator, the curriculum was revised where needed and finalised. Through this process a context specific intervention and printed materials were developed. A complete evaluation of this culturally relevant model for T2DM prevention in South Africa is pending.

Influences on Patient Uptake of and Engagement With the National Health Service Digital Diabetes Prevention Programme: Qualitative Interview Study

BACKGROUND

Digital diabetes prevention programs (digital-DPPs) are being implemented as population-based approaches to type 2 diabetes mellitus prevention in several countries to address problems with the uptake of traditional face-to-face diabetes prevention programs. However, assessments of digital-DPPs have largely focused on clinical outcomes and usability among those who have taken them up, whereas crucial information on decision-making about uptake (eg, whether a user downloads and registers on an app) and engagement (eg, the extent of use of an app or its components over time) is limited. Greater understanding of factors that influence uptake and engagement decisions may support large-scale deployments of digital-DPPs in real-world settings.

OBJECTIVE

This study aimed to explore the key influences on uptake and engagement decisions of individuals who were offered the National Health Service Healthier You: Digital Diabetes Prevention Programme (NHS-digital-DPP).

METHODS

A qualitative interview study was conducted using semistructured interviews. Participants were adults, aged ≥18 years, diagnosed with nondiabetic hyperglycemia, and those who had been offered the NHS-digital-DPP. Recruitment was conducted via 4 providers of the NHS-digital-DPP and 3 primary care practices in England. Interviews were conducted remotely and were guided by a theoretically informed topic guide. Analysis of interviews was conducted using an inductive thematic analysis approach.

RESULTS

Interviews were conducted with 32 participants who had either accepted or declined the NHS-digital-DPP. In total, 7 overarching themes were identified as important factors in both decisions to take up and to engage with the NHS-digital-DPP. These were knowledge and understanding, referral process, self-efficacy, self-identity, motivation and support, advantages of digital service, and reflexive monitoring. Perceptions of accessibility and convenience of the NHS-digital-DPP were particularly important for uptake, and barriers in terms of the referral process and health care professionals' engagement were reported. Specific digital features including health coaches and monitoring tools were important for engagement.

CONCLUSIONS

This study adds to the literature on factors that influence the uptake of and engagement with digital-DPPs and suggests that digital-DPPs can overcome many barriers to the uptake of face-to-face diabetes prevention programs in supporting lifestyle changes aimed at diabetes prevention.

Type 2 Diabetes Prevention Programs-From Proof-of-Concept Trials to National Intervention and Beyond

The prevention of type 2 diabetes (T2D) in high-risk people with lifestyle interventions has been demonstrated by several randomized controlled trials. The intervention effect has sustained up to 20 years in post-trial monitoring of T2D incidence. In 2000, Finland launched the national T2D prevention plan. For screening for high T2D risk, the non-laboratory Finnish Diabetes Risk Score was developed and widely used, also in other countries. The incidence of drug-treated T2D has decreased steadily since 2010. The US congress authorized public funding for a national diabetes prevention program (NDPP) in 2010. It was built around a 16-visit program that relies on referral from primary care and self-referral of persons with either prediabetes or by a diabetes risk test. The program uses a train-the-trainer program. In 2015 the program started the inclusion of online programs. There has been limited implementation of nationwide T2D prevention programs in other countries. Despite the convincing results from RCTs in China and India, no translation to the national level was introduced there. T2D prevention efforts in low-and middle-income countries are still limited, but results have been promising. Barriers to efficient interventions are greater in these countries than in high-income countries, where many barriers also exist. Health disparities by socioeconomic status exist for T2D and its risk factors and form a challenge for preventive interventions. It seems that a stronger commitment to T2D prevention is needed, such as the successful WHO Framework Convention on Tobacco Control, which legally binds the countries to act.

Development and Validation of a Diabetes Questionnaire for Middle School Students

OBJECTIVE

To develop and validate a questionnaire to assess diabetes knowledge, attitudes, beliefs, and intent to change among middle school students.

DESIGN

A cross-sectional validation analysis.

SETTING

Students in 3 urban middle schools in Utah participated in this study.

PARTICIPANTS

The 25-item questionnaire was validated in independent samples of 277 and 304 students in the seventh and eighth grades.

VARIABLES MEASURED

The questionnaire includes the following variables: diabetes knowledge, attitudes, beliefs, and intent to change dietary and physical activity behaviors.

ANALYSIS

Rigorous statistical approaches, including Cronbach's α (goodness of fit) calculation, test-retest reliability, and exploratory and confirmatory factor analyses, were employed to examine the reliability and construct validity.

RESULTS

The Cronbach's α coefficients were 0.7 for both subscales demonstrating acceptable internal consistency. All factor loadings were > 0.4, revealing close relations between factors and items. The confirmatory factor analysis model fit was 0.9 for the comparative fit index and Tucker-Lewis Index, indicating a reasonable model-data fit.

CONCLUSIONS AND IMPLICATIONS

This study demonstrated the validity of a diabetes questionnaire for middle school students. Future work is needed to validate its use in a diabetes prevention program, given the growing need for diabetes education among young adolescents.

Engaging Payors and Primary Care Physicians Together in Improving Diabetes Prevention

BACKGROUND

Type 2 diabetes can be prevented through lifestyle programs like the Diabetes Prevention Programs (DPP), but few people with prediabetes participate in them, in part because their insurance does not reliably cover DPPs. Prior studies have not focused on payor-level barriers.

OBJECTIVE

To understand barriers to DPP uptake that exist and intersect at different levels (patients, PCPs, and payors) to inform strategies to improve diabetes prevention in primary care settings through interviews with PCPs and payors.

DESIGN

From May 2020 to October 2021, we conducted remote, semi-structured interviews with PCPs and payors.

PARTICIPANTS

PCPs were from primary care practices affiliated with one mid-Atlantic academic system. Payor leaders were from regional commercial, Medicare, and Medicaid plans.

APPROACH

Using a standardized interview guide focused on barriers, facilitators, and potential intervention components, interviews were audio-recorded using Zoom and professionally transcribed. Two reviewers double-coded transcripts using the framework analytic approach.

KEY RESULTS

We interviewed 16 PCPs from 13 primary care clinics and 7 payor leaders representing 6 insurance plans. Two themes emerged from PCP reports of patient-level barriers: (1) lack of programs and insurance coverage of resources to address nutrition and exercise and (2) inadequate resources to address social determinants of health that impact diabetes prevention. Among barriers PCPs faced, we identified two themes: (1) low PCP knowledge about DPPs and misperceptions of insurance coverage of DPPs and (2) inadequate clinical staff to address diabetes prevention. Barriers common to PCPs and payors included (1) absence of prediabetes quality measures and (2) inadequate engagement of PCPs and patients with payors.

CONCLUSIONS

Discussions with PCPs and payors revealed systemic barriers that suggest important priorities to improve prediabetes clinical care, including universal coverage of DPPs, clarity about coverage benefits, data reporting and outreach by payors to PCPs, and adoption of appropriate prediabetes quality measures.

How the Behavior Change Content of a Nationally Implemented Digital Diabetes Prevention Program Is Understood and Used by Participants: Qualitative Study of Fidelity of Receipt and Enactment

BACKGROUND

The National Health Service Digital Diabetes Prevention Programme (NHS-DDPP) is a program for adults in England at risk of developing type 2 diabetes mellitus (T2DM). It is based on NHS England specifications that stipulate specific behavior change techniques (BCTs), that is, active ingredients to produce behavior change to target diet and physical activity. Now rolled out nationally, the NHS-DDPP is being delivered by 4 independent providers as a 9-month intervention via apps, educational material, and remote health coaching. To optimize effectiveness, participants need to be able to understand and use behavior change content (eg, goal setting and problem solving) of an intervention delivered to them digitally. Previous research has shown that people benefit from support to aid the understanding and use of BCTs.

OBJECTIVE

The objectives of this qualitative study were to evaluate how participants in the NHS-DDPP understand and use BCT content, investigate how participants describe the role of health coaches in supporting their behavior change, and examine how the understanding and use of behavior change content of the NHS-DDPP varies across providers.

METHODS

In total, 45 service users were interviewed twice by telephone at 2 to 4 months into, and at the end of, the program. Topics included participants' understanding and use of key BCTs to support self-regulation (eg, goal setting) and the support they received via the program. Transcripts were analyzed thematically, informed by the framework method.

RESULTS

Participants described their understanding and use of some behavior change content of the program as straightforward: use of BCTs (eg, self-monitoring of behavior) delivered digitally via provider apps. Participants valued the role of health coaches in supporting their behavior change through the emotional support they offered and their direct role in delivery and application of some BCTs (eg, problem solving) to their specific circumstances. Participants expressed frustration over the lack of monitoring or feedback regarding their T2DM risk within the program. Variations in the understanding and use of behavior change content of the NHS-DDPP were present across provider programs.

CONCLUSIONS

Health coaches' support in delivery of key components of the program seems to be pivotal. To improve the understanding and use of BCTs in digital interventions, it is important to consider routes of delivery that offer additional interactive human support. Understanding of some self-regulatory BCTs may benefit from this support more than others; thus, identifying the optimal mode of delivery for behavior change content is a priority for future research. The NHS-DDPP could be improved by explicitly setting out the need for health coaches to support understanding of some self-regulatory BCT content such as problem solving in the service specification and amending the discharge process so that knowledge of any change in T2DM risk is available to participants.

Salud Latina: feasibility of a synchronous online chat for latinos at risk for type 2 diabetes

This study examined the feasibility of Salud Latina, a weekly synchronous online chat intervention, aimed at engaging Latinos in diabetes prevention conversations. Participants were Latino English- and Spanish-speaking individuals. Salud Latina comprised of six synchronous weekly online chats moderated by bilingual Latina moderators trained in diabetes and online engagement. Online chats used open-ended questions. We assessed feasibility, acceptability, and satisfaction of the intervention and qualitatively analyzed the chats to identify barriers and facilitators to healthy behaviors and identify types of support exchanged. Participants (N = 20) were mostly female and English/Spanish bilingual and 80% completed at least four chats. Salud Latina was acceptable, feasible and highly satisfactory. Four themes were identified: (1) barriers to engaging in healthy behaviors, (2) facilitators of healthy behaviors, (3) Salud Latina provides a community of support, and (4) the need to build a Latino culture of health. Participants recognized the importance of engaging in healthy behaviors to prevent or delay T2D. Findings provide insight in how a synchronous online chat intervention could be used to build a social media community within a Latino population to support healthy behaviors. Future research could explore combining synchronous online chats with in-person community or family-level interventions.

Identifying Adult Population at Risk for Undiagnosed Diabetes Mellitus in Medan City, Indonesia Targeted on Diabetes Prevention

Background

Diabetes mellitus is a health problem in Indonesia, where its prevalence rises annually. The condition may negatively impact one's quality of life and lead to significant complications-over 50% of patients with type 2 diabetes mellitus, the most common diabetes type worldwide. To implement diabetic prevention interventions and achieve effective diabetes mellitus control, screening for undiagnosed diabetes mellitus in high-risk populations is essential.

Objective

This study aimed to identify people at risk for undiagnosed diabetes mellitus using the Finnish Diabetes Risk Score (FINDRISC) and oral glucose tolerance test (OGTT).

Methods

This cross-sectional study was carried out, which involved 300 people in Medan City between the ages of 30-75. The study was conducted between July 14 and October 20, 2020. The Finnish Diabetes Risk Score and anthropometric measurements (weight, height, and waist circumference) were used to evaluate each respondent. Low, medium, and high-risk outcome categories were created. All responders underwent oral glucose tolerance tests, with results classified as normal, prediabetes, or diabetes. The Chi-square test was used to examine the data and identify potential risk variables for diabetes mellitus.

Results

Of 300 individuals, 91.7% were female, and 8.3% were male. 33.7% of participants had a low risk of acquiring diabetes, 55.0% had an intermediate risk, and 11.3% had a high risk. 70% of participants who took an oral glucose tolerance test had blood glucose levels that were normal (less than 100 mg/dl), 18.7% had blood glucose levels suggestive of prediabetes (between 100 and 125 mg/dl), and 11.3% had blood glucose levels suggestive of diabetes (126 mg/dl or higher). Ages 54 to 64 years and older, high body mass index and central obesity, a lack of vegetables and fruits in the daily diet, inactivity, uncontrolled hypertension, a history of hyperglycemia, and a family history of diabetes were all linked to a significant increase in the risk of developing diabetes. Most respondents at low risk of developing type 2 diabetes had normal blood sugar levels, while those at high risk of developing type 2 diabetes had high blood glucose levels (p = 0.005).

Conclusion

Oral glucose tolerance testing and the FINDRISC questionnaire may be used to identify individuals who are at high risk for developing diabetes and to encourage them to adopt healthy behaviours.

A randomized controlled trial to test the effectiveness of two technology-enhanced diabetes prevention programs in primary care: The DiaBEAT-it study

Objective

To evaluate the effectiveness of two technology-enhanced interventions for diabetes prevention among adults at risk for developing diabetes in a primary care setting.

Methods

The DiaBEAT-it study employed a hybrid 2-group preference (Choice) and 3-group randomized controlled (RCT) design. This paper presents weight related primary outcomes of the RCT arm. Patients from Southwest Virginia were identified through the Carilion Clinic electronic health records. Eligible participants (18 and older, BMI ≥ 25, no Type 2 Diabetes) were randomized to either Choice (n = 264) or RCT (n = 334). RCT individuals were further randomized to one of three groups: (1) a 2-h small group class to help patients develop a personal action plan to prevent diabetes (SC, n = 117); (2) a 2-h small group class plus automated telephone calls using an interactive voice response system (IVR) to help participants initiate weight loss through a healthful diet and regular physical activity (Class/IVR, n = 110); or (3) a DVD with same content as the class plus the same IVR calls over a period of 12 months (DVD/IVR, n = 107).

Results

Of the 334 participants that were randomized, 232 (69%) had study measured weights at 6 months, 221 (66%) at 12 months, and 208 (62%) at 18 months. Class/IVR participants were less likely to complete weight measures than SC or DVD/IVR. Intention to treat analyses, controlling for gender, race, age and baseline BMI, showed that DVD/IVR and Class/IVR led to reductions in BMI at 6 (DVD/IVR -0.94, p < 0.001; Class/IVR -0.70, p < 0.01), 12 (DVD/IVR -0.88, p < 0.001; Class/IVR-0.82, p < 0.001) and 18 (DVD/IVR -0.78, p < 0.001; Class/IVR -0.58, p < 0.01) months. All three groups showed a significant number of participants losing at least 5% of their body weight at 12 months (DVD/IVR 26.87%; Class/IVR 21.62%; SC 16.85%). When comparing groups, DVD/IVR were significantly more likely to decrease BMI at 6 months (p < 0.05) and maintain the reduction at 18 months (p < 0.05) when compared to SC. There were no differences between the other groups.

Conclusions

The DiaBEAT-it interventions show promise in responding to the need for scalable, effective methods to manage obesity and prevent diabetes in primary care settings that do not over burden primary care clinics and providers.

Registration

https://clinicaltrials.gov/ct2/show/NCT02162901, identifier: NCT02162901.

Alpha-Lipoic Acid and Glucose Metabolism: A Comprehensive Update on Biochemical and Therapeutic Features

Alpha-lipoic acid (ALA) is a natural compound with antioxidant and pro-oxidant properties which has effects on the regulation of insulin sensitivity and insulin secretion. ALA is widely prescribed in patients with diabetic polyneuropathy due to its positive effects on nerve conduction and alleviation of symptoms. It is, moreover, also prescribed in other insulin resistance conditions such as metabolic syndrome (SM), polycystic ovary syndrome (PCOS) and obesity. However, several cases of Insulin Autoimmune Syndrome (IAS) have been reported in subjects taking ALA. The aim of the present review is to describe the main chemical and biological functions of ALA in glucose metabolism, focusing on its antioxidant activity, its role in modulating insulin sensitivity and secretion and in symptomatic peripheral diabetic polyneuropathy. We also provide a potential explanation for increased risk for the development of IAS.

A Culturally Sensitive and Theory-Based Intervention on Prevention and Management of Diabetes: A Cluster Randomized Control Trial

Type 2 diabetes is an emerging concern in Kenya. This clustered-randomized trial of peri-urban communities included a theory-based and culturally sensitive intervention to improve diabetes knowledge, health beliefs, dietary intake, physical activity, and weight status among Kenyan adults. Those in the intervention group (IG) received a culturally sensitive diabetes education intervention which applied the Health Belief Model in changing knowledge, health beliefs and behavior. Participants attended daily education sessions for 5 days, each lasting 3 h and received mobile phone messages for an additional 4 weeks. The control group (CG) received standard education on COVID-19. Data was collected at baseline, post-intervention (1 week), and follow-up assessment (5 weeks). Linear mixed effect analysis was performed to assess within and across group differences. Compared to the control, IG significantly increased diabetes knowledge (p < 0.001), health beliefs including perceived susceptibility (p = 0.05), perceived benefits (p = 0.04) and self-efficacy (p = 0.02). IG decreased consumption of oils (p = 0.03), refined grains (p = 0.01), and increased intake of fruits (p = 0.01). Perceived barriers, physical activity, and weight status were not significantly different between both groups. The findings demonstrate the potential of diabetes education in improving diabetes knowledge, health beliefs, and in changing dietary intake of among adults in Kenya.

Clinical Care Among Individuals with Prediabetes in Primary Care: a Retrospective Cohort Study

BACKGROUND

The incidence of diabetes in the general US population (6.7 per 1000 adults in 2018) has not changed significantly since 2000, suggesting that individuals with prediabetes are not connecting to evidence-based interventions.

OBJECTIVE

We sought to describe the clinical care of individuals with prediabetes, determine patient factors associated with this care, and evaluate risk for diabetes development.

DESIGN

Retrospective cohort study using linked claims and electronic health record data.

PARTICIPANTS

We created a cohort of adults with prediabetes based on laboratory measures. We excluded patients with a prior history of diabetes, pregnancy in prior 6 months, or recent steroid use.

MAIN MEASURES

We measured ordering and completion of clinical services targeting prediabetes management and diabetes incidence within 12 months following cohort entry. We tested the strength of the association between individuals' characteristics and outcomes of interest using bivariate and multiple logistic regression.

RESULTS

Our cohort included 3888 patients with a laboratory diagnosis of prediabetes (incident or prevalent prediabetes). Within 12 months, 63.4% had repeat glycemic testing, yet only 10.4% had coded diagnoses of prediabetes, 1.0% were referred for nutrition services, and 5.4% were prescribed metformin. Most patients completed labs and nutrition visits when referred and filled metformin when prescribed. Individuals with a higher glycemic level or BMI were more likely to receive prediabetes clinical care. Six percent of individuals developed diabetes within 12 months of cohort entry and had higher glycemic levels and BMI ≥ 30 kg/m². In the adjusted model, Black individuals had 1.4 times higher odds of developing diabetes than White individuals.

CONCLUSIONS

Rates of prediabetes clinical care activities are low and have not improved. Strategies are urgently needed to improve prediabetes care delivery thereby preventing or delaying incident diabetes.

Implementing primary care diabetes prevention for women with previous gestational diabetes: a mixed-methods study

BACKGROUND

The implementation of diabetes prevention for women with previous gestational diabetes (GDM) has been stymied by many barriers that are located within routine general practice (GP). We aimed to unpack the GP factors and understand the mechanisms that explain why a diabetes prevention intervention for this population succeeds or fails.

METHODS

We performed a mixed-methods study with a Normalization Process Theory framework that included clinical audits, semistructured interviews, and focus groups within mixed urban and rural primary care practices in Victoria, Australia. Staff of primary care practices and external support staff who provide services to women with previous GDM participated in a 12-month quality improvement collaborative intervention. We compared diabetes screening and prevention activity planning with the strategies and factors identified through a process evaluation of full-, moderate-, and low-active participating practices.

RESULTS

The intervention doubled screening rates (26%-61%) and 1-in-10 women received a diabetes prevention planning consultation. Critical improvement factors were: mothers being seen as participants in the quality improvement work; staff collectively building care strategies; staff taking a long-term care of a community perspective rather than episodic service delivery; and feedback processes being provided and acted on across the practice. The observable factors from the external perspective were: leadership by identified practice staff, reminder systems in action and practice staff driving the process collectively.

CONCLUSIONS

Successful engagement in diabetes prevention for women with previous GDM requires proactive building of the critical improvement factors and audit feedback into routine GP.

Improving Machine Learning Diabetes Prediction Models for the Utmost Clinical Effectiveness

The early prediction of diabetes can facilitate interventions to prevent or delay it. This study proposes a diabetes prediction model based on machine learning (ML) to encourage individuals at risk of diabetes to employ healthy interventions. A total of 38,379 subjects were included. We trained the model on 80% of the subjects and verified its predictive performance on the remaining 20%. Furthermore, the performances of several algorithms were compared, including logistic regression, decision tree, random forest, eXtreme Gradient Boosting (XGBoost), Cox regression, and XGBoost Survival Embedding (XGBSE). The area under the receiver operating characteristic curve (AUROC) of the XGBoost model was the largest, followed by those of the decision tree, logistic regression, and random forest models. For the survival analysis, XGBSE yielded an AUROC exceeding 0.9 for the 2- to 9-year predictions and a C-index of 0.934, while the Cox regression achieved a C-index of 0.921. After lowering the threshold from 0.5 to 0.25, the sensitivity increased from 0.011 to 0.236 for the 2-year prediction model and from 0.607 to 0.994 for the 9-year prediction model, while the specificity showed negligible changes. We developed a high-performance diabetes prediction model that applied the XGBSE algorithm with threshold adjustment. We plan to use this prediction model in real clinical practice for diabetes prevention after simplifying and validating it externally.

Predicting Factors for Metabolic Non-Response to a Complex Lifestyle Intervention-A Replication Analysis to a Randomized-Controlled Trial

BACKGROUND

T2DM heterogeneity affects responsiveness to lifestyle treatment. Beta-cell failure and nonalcoholic fatty liver disease (NAFLD) independently predict T2DM, but NAFLD inconsistently predicts metabolic response to lifestyle intervention.

AIM

We attempt to replicate a prediction model deducted from the Tübinger Lifestyle Intervention Program by assessing similar metabolic factors to predict conversion to normal glucose regulation (NGR) in a comparable lifestyle intervention trial.

METHODS

In the Optimal Fiber Trial (OptiFiT), 131 Caucasian participants with prediabetes completed a one-year lifestyle intervention program and received a fiber or placebo supplement. We compared baseline parameters for responders and non-responders, assessed correlations of major metabolic changes and conducted a logistic regression analysis for predictors of remission to NGR.

RESULTS

NGR was achieved by 33 participants, respectively. At baseline, for the placebo group only, 1 h and 2 h glucose levels, glucose AUC and Cederholm index predicted conversion to NGR. HOMA-beta, HOMA-IR or liver fat indices did not differ between responders and non-responders of the placebo or the fiber group. Changes in waist circumference or fatty liver index correlated with changes in glycemia and insulin resistance, but not with changes in insulin secretion. Insulin-resistant NAFLD did not predict non-response. Differences in compliance did not explain the results.

CONCLUSIONS

Higher post-challenge glucose levels strongly predicted the metabolic non-response to complex lifestyle intervention in our cohort. Depending on the specific intervention and the investigated cohort, fasting glucose levels and insulin sensitivity might contribute to the risk pattern. Beta-cell function did not improve in accordance with other metabolic improvements, qualifying as a potential risk factor for non-response. We could not replicate previous data suggesting that an insulin-resistant fatty liver is a specific risk factor for treatment failure. Replication studies are required.

Peer support facilitator and peer perspectives of an inner-regional Australian diabetes prevention and self-management peer support program

Peer support programmes have been shown to facilitate diabetes prevention and improvements in diabetes self-management. Worldwide, few studies have qualitatively evaluated peer support programs in inner-regional (semi-rural) areas, and none involving mixtures of people with and without diabetes. This study researched an inner-regional peer support programme underway over 2 years in Australia. Fifteen participants, including ten peers and five peer support facilitators (PSFs) were interviewed using semi-structured focus group and one-to-one interviews with the aim of understanding their perceptions and experiences of the programme, barriers, and ways of overcoming barriers. Participants were those with and without diabetes. The main themes identified were; benefits of the programme, factors affecting recruitment and retention, challenges and barriers to programme participation, PSF reflections on peer support training, and recommendations to improve the programme. Participants identified increased knowledge of diet, diabetes and complications as key benefits, with greater social support and well-being the main reasons for initial participation. The main challenges for the programme were the lack of wide community engagement before setting up the peer groups, difficulty with peer recruitment and personal difficulties in maintaining a healthy lifestyle. The peer support programme was well received within an inner-regional area and was perceived as useful in providing support and motivation to make lifestyle behavioural changes from shared experiences with peers. Whilst considered beneficial to those with and without diabetes, ways of overcoming identified challenges are required.

INnoVative trial design for testing the Efficacy, Safety and Tolerability of 6-month treatment with incretin-based therapy to prevent type 1 DIAbetes in autoantibody positive participants: A protocol for three parallel double-blind, randomised controlled trials (INVESTDIA)

AIMS

β-cell stress and dysfunction may contribute to islet autoimmunity and progression to clinical type 1 diabetes. We present a protocol of three randomised controlled trials assessing the effects of glucagon-like peptide 1 (GLP - 1) analogue liraglutide in three early stages of type 1 diabetes.

METHODS

We will test 10- to 30-year-old people with multiple islet autoantibodies for their glucose metabolism and randomise participants with stage 1 (multiple islet autoantibodies and normoglycaemia), stage 2 (multiple islet autoantibodies and dysglycaemia) and early stage 3 (clinical diagnosis) type 1 diabetes, 10-14 persons in each, to a 6-month intervention with liraglutide or placebo with 6-month follow-up in the stage 2 and stage 3 trials and 18-month follow-up in the stage 1 trial. Primary efficacy outcome in the stage 1 and stage 2 trials is a first-phase insulin response in an intravenous glucose tolerance test and C-peptide area under the curve in a 2-h mixed-meal tolerance test in the stage 3 trial. In addition, safety and tolerability of liraglutide treatment will be assessed.

CONCLUSIONS

Most prevention trials of type 1 diabetes have targeted the immune system. Treatment with GLP-1 analogue liraglutide supports the pancreatic β-cells, which should likewise attenuate islet autoimmunity. Our innovative study design allows simultaneous investigation of an intervention in three groups of people who represent various early stages of type 1 diabetes and maximises the eligibility to participate.

TRIAL REGISTRATION

NCT02611232 (stage 1 trial), NCT02898506 (stage 2 trial), NCT02908087 (stage 3 trial).

A Pilot Study to Examine the Feasibility and Acceptability of a Virtual Adaptation of an In-Person Adolescent Diabetes Prevention Program

BACKGROUND

Rates of prediabetes and type 2 diabetes are alarmingly high among racial/ethnic minority youth. The current study examines the virtual adaptation of an in-person peer-led youth diabetes prevention program.

METHODS

The initial phase involved the study team adapting workshop sessions from an in-person to a virtual format (Zoom). We conducted a 2-h feasibility pilot in December 2020 and implemented the full 12 session pilot program from June to September 2021 with 14 prediabetic adolescents recruited from our hospital-based general pediatric clinic. Weekly sessions were led by trained peer educators and focused on promoting healthy eating and physical activity using behavioral techniques (e.g., goal setting, brainstorming, and problem solving).

RESULTS

The virtual adaptation of our program was shown to be feasible and acceptable among our pilot participants. We were able to deliver the same workshop content and behavioral skills development as the in-person workshop using a variety of Zoom features.

CONCLUSIONS

Our peer-led youth diabetes prevention program was successfully adapted and implemented in a virtual format and was well accepted by at-risk youth. Future research is needed to examine the impact of virtual youth lifestyle interventions on behavioral and clinical outcomes such as weight and diabetes risk.

A Clinical Update on Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) traditionally refers to abnormal glucose tolerance with onset or first recognition during pregnancy. GDM has long been associated with obstetric and neonatal complications primarily relating to higher infant birthweight and is increasingly recognized as a risk factor for future maternal and offspring cardiometabolic disease. The prevalence of GDM continues to rise internationally due to epidemiological factors including the increase in background rates of obesity in women of reproductive age and rising maternal age and the implementation of the revised International Association of the Diabetes and Pregnancy Study Groups' criteria and diagnostic procedures for GDM. The current lack of international consensus for the diagnosis of GDM reflects its complex historical evolution and pragmatic antenatal resource considerations given GDM is now 1 of the most common complications of pregnancy. Regardless, the contemporary clinical approach to GDM should be informed not only by its short-term complications but also by its longer term prognosis. Recent data demonstrate the effect of early in utero exposure to maternal hyperglycemia, with evidence for fetal overgrowth present prior to the traditional diagnosis of GDM from 24 weeks' gestation, as well as the durable adverse impact of maternal hyperglycemia on child and adolescent metabolism. The major contribution of GDM to the global epidemic of intergenerational cardiometabolic disease highlights the importance of identifying GDM as an early risk factor for type 2 diabetes and cardiovascular disease, broadening the prevailing clinical approach to address longer term maternal and offspring complications following a diagnosis of GDM.

Objectively-Measured Physical Activity and Sedentary Behaviors and Related Factors in Chinese Immigrants in the US with Prior Gestational Diabetes Mellitus

Chinese immigrants in the US are disproportionately affected by gestational diabetes mellitus (GDM) and type 2 diabetes (T2D). The aims of this study were to describe their physical activity (PA) and sedentary behaviors (SB) patterns and to identify determinates of objectively-measured PA and SB among Chinese immigrants in the US with prior GDM. We conducted a cross-sectional study among 106 Chinese immigrants with prior GDM across the US. PA and SB were measured by GT9X+ hip accelerometers for 7 consecutive days. Validated questionnaires in English and Chinese were used to assess knowledge and risk perceptions as well as cultural and psychosocial characteristics. Descriptive, bivariate, and multiple regression analyses were performed. Only 27% of participants met the PA guidelines. The median duration of moderate-vigorous-intensity PA (MVPA) per week was 79 (IQR 38-151) minutes. Participants had an average of 9.2 ± 1.4 h of sedentary time per day. Living with parents (who may provide family support) was associated with more MVPA minutes per week, more steps per day, and a greater likelihood of meeting PA guidelines. Higher levels of acculturative stress were associated with fewer MVPA minutes per week. Being employed and having a lower BMI were associated with more SB. Strategies are needed to increase MVPA among this high-risk group, including decreasing acculturative stress and increasing family support. Different strategies are needed to decrease SB among this population.

A Mobile Phone App for the Prevention of Type 2 Diabetes in Malaysian Women With Gestational Diabetes Mellitus: Protocol for a Feasibility Randomized Controlled Trial

BACKGROUND

Over 50% of women with a history of gestational diabetes mellitus (GDM) will develop type 2 diabetes (T2D) in later life. Asian women experience a disproportionate risk of both GDM and T2D compared to women from other ethnic backgrounds. Lifestyle interventions and behavior change can delay or even prevent the onset of T2D. We have developed a digitalized diabetes prevention intervention for the prevention of T2D in Malaysian women with GDM.

OBJECTIVE

The protocol describes a randomized controlled trial (RCT) to test the feasibility of undertaking a definitive trial of a diabetes prevention intervention, including a smartphone app and group support. Secondary aims are to summarize anthropometric, biomedical, psychological, and lifestyle outcomes overall and by allocation group, and to undertake a process evaluation.

METHODS

This is a two-arm parallel feasibility RCT. A total of 60 Malaysian women with GDM will be randomized in the antenatal period to receive the intervention or standard care until 12 months post partum. The intervention is a diabetes prevention intervention delivered via a smartphone app developed based on the Information-Motivation-Behavioral Skills model of behavior change and group support using motivational interviewing. The intervention provides women with tailored information and support to encourage weight loss through adapted dietary intake and physical activity. Women in the control arm will receive standard care. The Malaysian Ministry of Health's Medical Research and Ethics Committee has approved the trial (NMRR-21-1667-60212).

RESULTS

Recruitment and enrollment began in February 2022. Future outcomes will be published in peer-reviewed health-related research journals and presented at national, regional, or state professional meetings and conferences. This publication is based on protocol version 2, January 19, 2022.

CONCLUSIONS

To our knowledge, this will be the first study in Malaysia that aims to determine the feasibility of a digital intervention in T2D prevention among women with GDM. Findings from this feasibility study will inform the design of a full-scale RCT in the future.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05204706; https://clinicaltrials.gov/ct2/show/NCT05204706.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/37288.

The use of metformin for type 2 diabetes prevention: Observational multicenter study from Saudi Arabia

Background

Patients with prediabetes are at higher risk of developing type 2 diabetes. While intensive lifestyle modification is the primary approach to delaying diabetes, metformin has been shown to be effective, especially among patients younger than 60 years and obese (body mass index (BMI) > 35 kg/m²), patients with fasting blood glucose ≥ 6.1 mmol/L or HbA1c ≥ 6%, and women with history of gestational diabetes. Thus, metformin is now recommended as an option for diabetes prevention by the American Diabetes Association (ADA). The use of metformin among patients with prediabetes in Saudi Arabia and their adherence to the guideline's recommendation for the prevention of type 2 diabetes is unknown. This study aimed to identify the prevalence of metformin use among prediabetes patients overall and patients who are more likely to benefit from metformin use per the ADA guidelines.

Methods

A retrospective cohort study was conducted encompassing data from three tertiary care hospitals between January 2015 and June 2019. All patients aged 20 to 70 years with prediabetes (HbA1c of 5.7-6.4%) were included, while patients with an established diagnosis of diabetes, creatinine clearance <45 ml/min, using antihyperglycemic medications other than metformin, or on metformin for other indications were excluded. Prediabetes patients who are most likely to benefit from metformin for type 2 diabetes prevention are those younger than 60 years with a BMI ≥ 35 kg/m², patients with fasting blood glucose ≥ 6.1 mmol/L or HbA1c ≥ 6%, and women with history of gestational diabetes. This study examined the prevalence of metformin use among all patients with prediabetes, as well as patients who would be more likely to benefit from metformin use per the ADA guidelines.

Results

A total of 251 patients were included in this study; 52.2% were female, with a mean age of 47.0 (11.9) years and BMI of 32.3 (6.5) kg/m², and the median HbA1c at baseline was 5.8% (5.7-6.0). Among the overall sample, 18 patients (7.2%) received metformin for the prevention of type 2 diabetes, 14 of those were from the groups that are more likely to benefit from metformin use per the ADA guidelines (9.9%).

Conclusions

Among individuals with prediabetes in Saudi Arabia, metformin use was very low despite the evidence supporting its safety, convenience, and efficacy. Healthcare providers seemed hesitant to medicalize prediabetes; furthermore, the low use of metformin suggests the existence of several barriers that need to be identified and resolved. Increasing providers' knowledge and awareness regarding screening and management of prediabetes is highly encouraged.

Use of Focus Groups to Inform a New Community-Based Youth Diabetes Prevention Program

There have been few youth-led diabetes prevention programs. Our objective was to conduct focus groups to explore peer influences on adolescent lifestyle behaviors and strategies for implementing a youth peer education model for diabetes prevention. We conducted six focus groups with 52 youth (ages 13-22; 62% male, 38% female; 64% Hispanic, 36% non-Hispanic Black) from East Harlem, NYC. We used a Thematic Analysis approach to identify major themes, compared findings, and resolved differences through discussion and consensus. Three dominant themes arose: (1) Adolescents generally encounter more unhealthy peer influences on diet and more healthy peer influences on physical activity; (2) Adolescents endorse youth-led diabetes prevention strategies and describe ideal qualities for peer leaders and methods to support and evaluate leaders; (3) Adolescents prefer text messaging to monitor behaviors, track goals, and receive personalized guidance. Using study findings, our Community Action Board developed a peer-led diabetes prevention program for prediabetic adolescents.