Efficacy of lifestyle interventions in patients with type 2 diabetes: A systematic review and meta-analysis

Td2Ast project: A pragmatic intervention on diet and physical activity for patients with type 2 diabetes mellitus

AIM

The purpose of this study was to assess the efficacy of an educational intervention based on the Behavior Change Wheel (BCW) framework for individuals with type 2 diabetes mellitus (T2DM) on dietary and physical activity recommendations in a Spanish region.

METHODS

A two-arm pragmatic randomized pilot trial was developed. The intervention consisted of a 6-month period with three components: face-to-face counseling, a phone call, and specially designed written guidelines focusing on dietary and physical activity recommendations The primary outcome was changes in dietary and physical activity recommendations. The secondary outcome, the impact of the intervention on HbA1c levels, body mass index, and the frequency of consultations to primary care.

RESULTS

n=208 patients were recruited. Individuals in the intervention experienced a significative improvement in adherence to dietary recommendations (+0.52; p-value<0.001), physical activity (+0.79; p-value<0.001), and a decrease in HbA1c levels (0.11 %; p-value=0.04).

CONCLUSION

The 6-month intervention, designed for T2DM patients and based on the BCW model, has demonstrated effectiveness in improving adherence to healthy dietary and physical activity recommendations, as well as reducing HbA1c levels.

Optimizing Blood Pressure Management in Type 2 Diabetes: A Comparative Investigation of One-Time Versus Periodic Lifestyle Modification Counseling

Background Type 2 diabetes mellitus (T2DM) often coexists with hypertension, significantly increasing cardiovascular risks. Lifestyle modification counseling has shown promise in managing T2DM and its comorbidities. However, the optimal frequency and structure of counseling for blood pressure control remain uncertain. Our study examines the best approach for managing blood pressure in T2DM patients by comparing the outcomes of two counseling strategies: a single session and periodic counseling over time. Methodology A total of 110 diabetic patients were enrolled, with 52 patients in each group after loss to follow-up. A randomized controlled trial compared one-time counseling (control) to six months of periodic counseling (intervention) on lifestyle modification. A weighing machine, stadiometer, 24-hour dietary recall, food frequency questionnaire, biochemical blood sugar level analysis, and telephonic follow-up were the essential tools used. The data were analyzed using SPSS version 24.0 (IBM Corp., Armonk, NY, USA), employing descriptive statistics, including frequencies, percentages, graphs, mean, and standard deviation. Statistical significance at the 5% level was tested using probability (p) calculations. The Kolmogorov-Smirnov test confirmed normal distribution (p > 0.05). Parametric tests, specifically independent t-tests, were used for between-group comparisons of continuous variables, while categorical variables were analyzed using the chi-square test or Fisher's exact test. Intragroup comparisons over time employed repeated-measures analysis of variance for continuous variables. Changes within groups after six months were assessed using paired t-tests. All statistical analyses adhered to a significance level of p < 0.05. Results The gender distribution at baseline was similar between the control (55.8% male, 44.2% female) and intervention (46.2% male, 53.8% female) groups, with no significant differences (p = 0.327). The mean weight was 66.67 ± 11.51 kg in the control group and 67.14 ± 11.19 kg in the intervention group (p = 0.835), and the body mass index was 25.61 ± 4.09 kg/m² and 26.29 ± 6.01 kg/m², respectively (p = 0.503). Clinical parameters such as fasting blood sugar, postprandial blood sugar, glycosylated hemoglobin, and blood pressure showed no significant differences between the control and intervention groups at baseline (p > 0.05). After six months, the intervention group exhibited a trend toward lower blood pressure compared to the control group, but the differences were not statistically significant. The mean systolic blood pressure was 132.15 ± 14.867 mmHg in the control group and 129.15 ± 9.123 mmHg in the intervention group (p = 0.218). Changes in blood pressure over the six-month period showed significant decreases within the intervention group, while changes in the control group did not reach statistical significance. The mean difference in systolic blood pressure in the intervention group was 5.54 ± 9.77 mmHg (p = 0.0001), indicating a notable reduction, while the control group had a smaller and statistically insignificant increase of 2.308 ± 9.388 mmHg (p = 0.082). Conclusions This study addresses a significant gap in the literature by comparing the efficacy of one-time vs. periodic counseling in T2DM management. While periodic counseling shows promise in improving diastolic blood pressure, further research is needed to understand its nuanced effects and optimize lifestyle interventions for T2DM patients.

Association of Intensive Lifestyle Intervention for Type 2 Diabetes With Labor Market Outcomes

Importance

An intensive lifestyle intervention (ILI) has been shown to improve diabetes management and physical function. These benefits could lead to better labor market outcomes, but this has not been previously studied.

Objective

To estimate the association of an ILI for weight loss in type 2 diabetes with employment, earnings, and disability benefit receipt during and after the intervention.

Design, Setting, and Participants

This cohort study included participants with type 2 diabetes and overweight or obesity and compared an ILI with a control condition of diabetes support and education. Data for the original trial were accrued from August 22, 2001, to September 14, 2012. Trial data were linked with Social Security Administration records to investigate whether, relative to the control group, the ILI was associated with improvements in labor market outcomes during and after the intervention period. Difference-in-differences models estimating relative changes in employment, earnings, and disability benefit receipt between the ILI and control groups were used, accounting for prerandomization differences in outcomes for linked participants. Outcome data were analyzed from July 13, 2020, to May 17, 2023.

Exposure

The ILI consisted of sessions with lifestyle counselors, dieticians, exercise specialists, and behavioral therapists on a weekly basis in the first 6 months, decreasing to a monthly basis by the fourth year, designed to achieve and maintain at least 7% weight loss. The control group received group-based diabetes education sessions 3 times annually during the first 4 years, with 1 annual session thereafter.

Main Outcomes and Measures

Employment and receipt of federal disability benefits (Supplemental Security Income and Social Security Disability Insurance), earnings, and disability benefit payments from 1994 through 2018.

Results

A total of 3091 trial participants were linked with Social Security Administration data (60.1% of 5145 participants initially randomized and 97.0% of 3188 of participants consenting to linkage). Among the 3091 with fully linked data, 1836 (59.4%) were women, and mean (SD) age was 58.4 (6.5) years. Baseline clinical and demographic characteristics were similar between linked participants in the ILI and control groups. Employment increased by 2.9 (95% CI, 0.3-5.5) percentage points for the ILI group relative to controls (P = .03) with no significant relative change in disability benefit receipt (-0.9 [95% CI, -2.1 to 0.3] percentage points; P = .13).

Conclusions and Relevance

The findings of this cohort study suggest that an ILI to prevent the progression and complications of type 2 diabetes was associated with higher levels of employment. Labor market productivity should be considered when evaluating interventions to manage chronic diseases.

Cost effectiveness review of text messaging, smartphone application, and website interventions targeting T2DM or hypertension

Digital health interventions have been shown to be clinically-effective for type 2 diabetes mellitus (T2DM) and hypertension prevention and treatment. This study synthesizes and compares the cost-effectiveness of text-messaging, smartphone application, and websites by searching CINAHL, Cochrane Central, Embase, Medline and PsycInfo for full economic or cost-minimisation studies of digital health interventions in adults with or at risk of T2DM and/or hypertension. Costs and health effects are synthesised narratively. Study quality appraisal using the Consensus on Health Economic Criteria (CHEC) list results in recommendations for future health economic evaluations of digital health interventions. Of 3056 records identified, 14 studies are included (7 studies applied text-messaging, 4 employed smartphone applications, and 5 used websites). Ten studies are cost-utility analyses: incremental cost-utility ratios (ICUR) vary from dominant to €75,233/quality-adjusted life year (QALY), with a median of €3840/QALY (interquartile range €16,179). One study finds no QALY difference. None of the three digital health intervention modes is associated with substantially better cost-effectiveness. Interventions are consistently cost-effective in populations with (pre)T2DM but not in populations with hypertension. Mean quality score is 63.0% (standard deviation 13.7%). Substandard application of time horizon, sensitivity analysis, and subgroup analysis next to transparency concerns (regarding competing alternatives, perspective, and costing) downgrades quality of evidence. In conclusion, smartphone application, text-messaging, and website-based interventions are cost-effective without substantial differences between the different delivery modes. Future health economic studies should increase transparency, conduct sufficient sensitivity analyses, and appraise the ICUR more critically in light of a reasoned willingness-to-pay threshold.Registration: PROSPERO (CRD42021247845).

Assessing the Feasibility and Acceptability of a Primary Care Socio-Ecological Approach to Improve Physical Activity Adherence among People with Type 2 Diabetes: The SENWI Project

Maintaining an active lifestyle is a key health behavior in people with type 2 diabetes (T2D). This study assessed the feasibility and acceptability of a socio-ecological Nordic walking intervention (SENWI) to enhance healthy behaviors in primary healthcare settings. Participants included individuals with T2D (n = 33; age 70 (95% CI 69-74)) and healthcare professionals (HCPs, n = 3). T2D participants were randomly assigned to a SENWI, active comparator, or control group for twelve weeks. Feasibility and acceptability were evaluated based on a mixed methodology. Quantitative data reported adherence information, differences between follow-up and dropout participants and pre- and post-intervention on physical activity, sedentary behavior, and health outcomes. Qualitative data acquisition was performed using focus groups and semi-structured interviews and analyzed using thematic analysis. Thirty-three T2D invited participants were recruited, and twenty-two (66.7%) provided post-intervention data. The SENWI was deemed acceptable and feasible, but participants highlighted the need to improve options, group schedules, gender inequities, and the intervention's expiration date. Healthcare professionals expressed a lack of institutional support and resources. Nevertheless, no significant difference between the SENWI follow-up and dropout participants or pre- and post- intervention was found (only between the active comparator and control group in the physical quality of life domain). Implementing the SENWI in primary healthcare settings is feasible and acceptable in real-world conditions. However, a larger sample is needed to assess the program's effectiveness in improving healthy behaviors and its impact on health-related outcomes in the long term.

MEW network self-management program characteristics and lessons learned through the RE-AIM framework

RATIONALE

The promotion of evidence-based self-management support for people living with chronic conditions such as epilepsy is a public health priority. Epilepsy self-management encompasses three general areas: (1) treatment management, (2) seizure management, and (3) lifestyle management. Interventions focusing on self-management have increased quality of life and adherence to treatment. This study assesses and synthesizes the Managing Epilepsy Well Network (MEWN) program implementation experiences using the RE-AIM framework. This research informs the quality and rigor of MEWN program dissemination and implementation efforts to assess whether these programs are being implemented and their scalability.

METHODS

The study data were derived from a MEWN Self-management Program Survey conducted with currently active MEWN researchers through an online survey and review of program publications and archival documents. Survey data were obtained from either the principal investigator or study team for the UPLIFT, HOBSCOTCH, SMART, MINDSET, TIME, and PACES programs. The survey questionnaire included 6 sections consisting of 68 questions and focused on the RE-AIM dimensions and respondent characteristics. The RE-AIM dimensions included: (1) Reach, (2) Effectiveness, (3) Adoption (number of and type of adopting sites), (4) Implementation (retention rate, barriers to implementation), and (5) Maintenance.

RESULTS

Across the MEWN programs, participation (44-120 individuals) and delivery methods (community, clinic, or asynchronous; group or individual) ranged with most programs predominantly reaching White or African American participants. Common program outcome measures included clinical outcomes (e.g., depression, quality of life, seizure frequency) and indicators of self-management behaviors (e.g., problem-solving; self-efficacy). Initial efficacy trials suggested programs were effective in changing some of their targeted outcomes (effectiveness). Most programs were implemented in clinical settings and several programs are being replicated or adapted to different geographical (e.g., urban, rural, suburban) or demographic (e.g., race, age) settings (adoption). Program delivery methods involved a mixture of program staff, peer educators, and researchers. Implementation enabling factors included partnerships with local epilepsy organizations and the inclusion of peer educators. Retention rates for all programs averaged 83.6%. Internal barriers included recruitment and lack of sufficient resources for participants. External barriers included clinical staff buy-in, staffing, and insufficient funding for support staff. Despite uncertain funding, all programs offered next steps to sustain their initiatives such as packaging their programs, initiating adoption with regional organizations, and supporting organizational readiness (maintenance). Dissemination efforts included partnering with other organizations, provision of training and technical assistance, and partnering with national organizations on grant opportunities to scale up existing programs.

CONCLUSION

These data showcase the impact of the MEWN self-management interventions on health and quality of life. These programs are employing training, readiness assessment, technical assistance, and development of partnerships to increase program scalability. Finally, program adaptations are being conducted to expand the interventions to other populations to address health inequalities. The lessons learned are critical for other interventions attempting to increase the translation of their programs to other settings.

Efficacy of lifestyle medicine on sleep quality: A meta-analysis of randomized controlled trials

OBJECTIVES

Randomized controlled trials (RCTs) on the efficacy of multicomponent lifestyle medicine (LM) interventions for improving sleep quality have yielded inconsistent findings. This study marks the first meta-analysis to evaluate the efficacy of multicomponent LM interventions in improving sleep quality.

METHODS

We searched six online databases for RCTs that compared multicomponent LM interventions to an active or inactive control group in an adult population and assessed subjective sleep quality as a primary or secondary outcome using validated sleep measures at any post-intervention time-point.

RESULTS

A total of 23 RCTs with 26 comparisons involving 2534 participants were included in the meta-analysis. After excluding outliers, the analysis revealed that multicomponent LM interventions significantly improved sleep quality at immediate post-intervention (d = 0.45) and at short-term follow-up (i.e., <three months) (d = 0.50) relative to an inactive control group. Regarding the comparison with active control, no significant between-group difference was found at any time-point. No meta-analysis was conducted at the medium- and long-term follow-up due to insufficient data. Subgroup analyses supported that multicomponent LM interventions had a more clinically relevant effect on improving sleep quality in participants with clinical levels of sleep disturbance (d = 1.02) relative to an inactive control at immediate post-intervention assessment. There was no evidence of publication bias.

CONCLUSION

Our findings provided preliminary evidence that multicomponent LM interventions were efficacious in improving sleep quality relative to an inactive control at immediate post-intervention and at short-term follow-up. Additional high-quality RCTs targeting individuals with clinically significant sleep disturbance and long-term follow-up are warranted.

Dynamics of Gut Microbiota and Clinical Variables after Ketogenic and Mediterranean Diets in Drug-Naïve Patients with Type 2 Diabetes Mellitus and Obesity

Type 2 diabetes mellitus (T2DM), the most common form of diabetes, is a progressive chronic metabolic disease that has increasingly spread worldwide, enhancing the mortality rate, particularly from cardiovascular diseases (CVD). Lifestyle improvement through diet and physical activity is, together with drug treatment, the cornerstone of T2DM management. The Mediterranean diet (MD), which favors a prevalence of unprocessed vegetable foods and a reduction in red meats and industrial foods, without excluding any food category, is usually recommended. Recently, scientific societies have promoted a very low-calorie ketogenic diet (VLCKD), a multiphasic protocol that limits carbohydrates and then gradually re-introduces them, with a favorable outcome on body weight and metabolic parameters. Indeed, gut microbiota (GM) modifications have been linked to overweight/obesity and metabolic alterations typical of T2DM. Diet is known to affect GM largely, but only a few studies have investigated the effects of VLCKD on GM, especially in T2DM. In this study, we have compared anthropometric, biochemical, lifestyle parameters, the quality of life, and the GM of eleven patients with recently diagnosed T2DM and overweight or obesity, randomly assigned to two groups of six and five patients who followed the VLCKD (KETO) or hypocaloric MD (MEDI) respectively; parameters were recorded at baseline (T0) and after two (T2) and three months (T3). The results showed that VLCKD had more significant beneficial effects than MD on anthropometric parameters, while biochemical improvements did not statistically differ. As for the GM, despite the lack of significant results regarding the alpha and beta diversity, and the Firmicutes/Bacteroidota ratio between the two groups, in the KETO group, a significant increase in beneficial microbial taxa such as Verrucomicrobiota phylum with its members Verrucomicrobiae, Verrucomicrobiales, Akkermansiaceae, and Akkermansia, Christensenellaceae family, Eubacterium spp., and a reduction in microbial taxa previously associated with obesity (Firmicutes and Actinobacteriota) or other diseases (Alistipes) was observed both at T2 and T3. With regards to the MEDI group, variations were limited to a significant increase in Actinobacteroidota phylum at T2 and T3 and Firmicutes phylum at T3. Moreover, a metagenomic alteration linked to some metabolic pathways was found exclusively in the KETO group. In conclusion, both dietary approaches allowed patients to improve their state of health, but VLCKD has shown better results on body composition as well as on GM profile.

Effects of a lifestyle intervention on depression and anxiety among adults at risk for diabetes in India: A secondary analysis of the Kerala Diabetes Prevention Program

The impact of lifestyle interventions on diabetes and mental health conditions have been documented among people with diabetes. However, the mental health benefits of lifestyle interventions designed for diabetes prevention have not been systematically investigated among people at high risk of diabetes, particularly in low- and middle-income countries. We examined the effects of a 12-month peer support lifestyle intervention designed for diabetes prevention on depression and anxiety symptomology in the sample population of the Kerala Diabetes Prevention Program. Mixed-effects linear regression models were used to examine the effect of the intervention on depression and anxiety scores at 12 and 24 months in the total sample of 1007 adults at risk for diabetes and among those with mild-severe depressive or anxiety symptoms at baseline (n = 326 for depression; n = 203 for anxiety). Among all participants, the intervention group had a significantly higher reduction of depressive symptoms as compared to the control group at 12 months (mean diff score = -0.51; 95% CI: -0.95, -0.07; P = 0.02). This effect was not sustained at 24 months. There were no significant intervention effects for anxiety. Among those with mild-severe symptoms at baseline, the intervention group had a significantly higher reduction of depressive symptoms (mean diff score = -1.55; 95% CI -2.50, -0.6; P = 0.001) and anxiety symptoms (mean diff score = -1.64; 95% CI -2.76, -0.52; P = 0.004) at 12 months. The effect was sustained at 24 months for depression, but not anxiety. Lifestyle interventions designed for prevention of diabetes might improve depressive and anxiety symptoms in the short-term, particularly among those with mild-severe symptoms.

Dietitian-supported dietary intervention leads to favorable dietary changes in patients with type 2 diabetes: A randomized controlled trial

AIMS/INTRODUCTION

It remains to be fully elucidated whether nutrition education by dietitians can lead to specific positive changes in the food choices of patients with diabetes.

MATERIALS AND METHODS

A total of 96 patients with type 2 diabetes and diabetic kidney disease were randomly assigned to the intensive intervention group that received nutritional education at every outpatient visit and the control group that received nutritional education once a year. The total energy intake, energy-providing nutrients and 18 food groups were analyzed at baseline, and 1 and 2 years after the intervention in 87 patients. Furthermore, the relationship between the changes in hemoglobin A1c, body composition and changes in the total energy or energy-producing nutrient intake was analyzed in 48 patients who did not use or change hypoglycemic agents during the study period.

RESULTS

The total energy intake, carbohydrates, cereals, confections, nuts and seeds, and seasonings significantly decreased, and fish and shellfish intake significantly increased during the study period in the intensive intervention group, whereas these changes were not observed in the control group. The decrease in the total energy intake and carbohydrates after 2 years was significantly greater in the intensive intervention group than in the control group. The change in the total energy and carbohydrate intake showed a significant positive correlation with that in muscle mass. The multivariate analysis showed that the decrease in total energy intake was independently associated with that in muscle mass.

CONCLUSION

Dietitian-supported intensive dietary intervention helps improve the diet of patients with type 2 diabetes.

A Social Media-Based Diabetes Intervention for Low-Income Mandarin-Speaking Chinese Immigrants in the United States: Feasibility Study

BACKGROUND

Chinese immigrants bear a high diabetes burden and face significant barriers to accessing diabetes self-management education (DSME) and counseling programs.

OBJECTIVE

The goal of this study was to examine the feasibility and acceptability and to pilot test the potential efficacy of a social media-based DSME intervention among low-income Chinese immigrants with type 2 diabetes (T2D) in New York City.

METHODS

This was a single group pretest and posttest study in 30 Chinese immigrants with T2D. The intervention included 24 culturally and linguistically tailored DSME videos, focusing on diabetes education and behavioral counseling techniques. Over 12 weeks, participants received 2 brief videos each week via WeChat, a free social media app popular among Chinese immigrants. Primary outcomes included the feasibility and acceptability of the intervention. Feasibility was evaluated by recruitment processes, retention rates, and the video watch rate. Acceptability was assessed via a satisfaction survey at 3 months. Secondary outcomes, that is, hemoglobin A_1c (HbA_1c), self-efficacy, dietary intake, and physical activity, were measured at baseline, 3 months, and 6 months. Descriptive statistics and paired 2-sided t tests were used to summarize the baseline characteristics and changes before and after the intervention.

RESULTS

The sample population (N=30) consisted of mostly females (21/30, 70%) who were married (19/30, 63%), with limited English proficiency (30/30, 100%), and the mean age was 61 (SD 7) years. Most reported an annual household income of <US $25,000 (24/30, 80%) and a high school education or less (19/30, 63%). Thirty participants were recruited within 2 months (January and February 2020), and 97% (29/30) of the participants were retained at 6 months. A video watch rate of 92% (28/30) was achieved. The mean baseline HbA_1c level was 7.3% (SD 1.3%), and this level declined by 0.5% (95% CI -0.8% to -0.2%; P=.003) at 6 months. The mean satisfaction score was 9.9 (SD 0.6) out of 10, indicating a high level of satisfaction with the program. All strongly agreed or agreed that they preferred this video-based DSME over face-to-face visits. Compared to baseline, there were significant improvements in self-efficacy, dietary, and physical activity behaviors at 6 months.

CONCLUSIONS

This pilot study demonstrated that a social media-based DSME intervention is feasible, acceptable, and potentially efficacious in a low-income Chinese immigrant population with T2D. Future studies need to examine the efficacy in an adequately powered clinical trial.

Oxidative stress in the pathophysiology of type 2 diabetes and related complications: Current therapeutics strategies and future perspectives

Type 2 diabetes (T2DM) is a persistent metabolic disorder rising rapidly worldwide. It is characterized by pancreatic insulin resistance and β-cell dysfunction. Hyperglycemia induced reactive oxygen species (ROS) production and oxidative stress are correlated with the pathogenesis and progression of this metabolic disease. To counteract the harmful effects of ROS, endogenous antioxidants of the body or exogenous antioxidants neutralise it and maintain bodily homeostasis. Under hyperglycemic conditions, the imbalance between the cellular antioxidant system and ROS production results in oxidative stress, which subsequently results in the development of diabetes. These ROS are produced in the endoplasmic reticulum, phagocytic cells and peroxisomes, with the mitochondrial electron transport chain (ETC) playing a pivotal role. The exacerbated ROS production can directly cause structural and functional modifications in proteins, lipids and nucleic acids. It also modulates several intracellular signaling pathways that lead to insulin resistance and impairment of β-cell function. In addition, the hyperglycemia-induced ROS production contributes to micro- and macro-vascular diabetic complications. Various in-vivo and in-vitro studies have demonstrated the anti-oxidative effects of natural products and their derived bioactive compounds. However, there is conflicting clinical evidence on the beneficial effects of these antioxidant therapies in diabetes prevention. This review article focused on the multifaceted role of oxidative stress caused by ROS overproduction in diabetes and related complications and possible antioxidative therapeutic strategies targeting ROS in this disease.

What Factors Predict the Adoption of Type 2 Diabetes Patients to Wearable Activity Trackers-Application of Diffusion of Innovation Theory

Background: Globally, diabetes has brought an enormous burden to public health resources, and the situation of disease burden caused by diabetes in China is especially severe. China is currently facing the dual threat of aging and diabetes, and wearable activity trackers could promote elderly diabetic patients' physical activity levels and help them to manage blood glucose control. Therefore, examining the influencing factors of elderly patients' adoption intention is critical as wearing adoption determines actual wearing behaviors. Objective: This study aims to explore the predicting factors of Chinese elderly type 2 diabetic patients' adoption intention to wearable activity trackers and their actual wearing behavior, using diffusion of innovation theory as the theoretical framework. We hope to provide insights into future interventions using wearable activity trackers as tools to improve the outcome of patients. Methods: Wearable activity trackers were freely distributed to type 2 diabetic patients in Beijing, China. A questionnaire survey was conducted to examine predicting factors of adoption intention after a week's try-on. Actual wearing behavior for 3-month was obtained from the exclusive cloud. Data were analyzed with structural equation modeling. Results: A total of 725 patients completed the questionnaire. Patients had a mean age of 60.3 ± 7.6 years old and the educational level was generally lower. The results indicated that observability was the primary influencing factor of patients' adoption intention (β = 0.775, P < 0.001). Relative advantage (β = 0.182, P = 0.014) and perceived social image (β = 0.080, P = 0.039) also had a positive influence while perceived risk (β = -0.148, P < 0.001) exerted a negative influence. In addition, results showed that the more intention led to the better actual wearing behavior (β = 0.127, P = 0.003). Observability (β = 0.103, P = 0.005), perceived ease (β = 0.085, P = 0.004), and relative advantage (β = 0.041, P = 0.009) also indirectly influenced the wearing behavior. Conclusion: The intentions of Chinese elderly type 2 diabetic patients to wearable activity trackers directly influenced the actual wearing behavior. In addition, their adoption intention to wearable activity trackers was mainly influenced by observability, perceived ease to use, relative advantage, perceived risk, and social image.

Dietary Intake of Polyphenols or Polyunsaturated Fatty Acids and Its Relationship with Metabolic and Inflammatory State in Patients with Type 2 Diabetes Mellitus

Background: The aim of the study was to evaluate the relationship between polyphenol or polyunsaturated fatty acids (PUFAs) consumption and the selected metabolic and inflammatory markers in type 2 diabetes (T2DM) patients. Methods: The study enrolled 129 diabetics (49 men, mean age 64.1 ± 9.8 years) with different amounts of polyphenol and PUFAs consumption. Results: A significant effect of polyphenol or PUFAs omega-3 consumption on fasting glucose concentration (FG) or glycated haemoglobin fraction (HbA1c) was reported. A negative association was observed between FG and total polyphenol, flavonoid, flavan-3-ol and stilbene intake. In the group with high flavonoid intake, the FG was significantly lower compared to the group characterised by low flavonoid intake. Polyphenols, except stilbenes, did not modulate HbA1c. Additionally, higher consumption of PUFAs omega-3 significantly decreased HbA1c, and the intake of eicosapentaenoic (EPA) and docosahexaenoic (DHA) acids negatively and significantly correlated with FG and HbA1c. Further analysis confirmed a significant association between EPA + DHA intake and HbA1c, with significant interactions with age and gender or with body mass index and waist-to-hip ratio. The dietary intake of polyphenols or PUFAs was independent of familial diabetes or diabetic diet application. Conclusions: Our study indicates a positive effect of high consumption of flavonoids, omega-3 PUFAs and stilbenes on the markers of carbohydrate metabolism balance and the absence of such an effect on other cardiometabolic markers and inflammatory conditions.

Correlations between Diabetes Mellitus Self-Care Activities and Glycaemic Control in the Adult Population: A Cross-Sectional Study

Although it is well known that lifestyle changes can affect plasma glucose levels, there is little formal evidence for the sustained effectiveness of exercise and diet in diabetes mellitus (DM) management. Self-care in DM refers to the real-life application of the knowledge that the patient gained during the education programmes. The goals are to bring about changes in the patient's behaviour, thus improving glycaemic control. We evaluated the influence of DM self-care activities (SCA) on glycaemic control in a total of 159 patients with DM. Plasma glycated haemoglobin (HbA1c) levels were used to monitor glycaemic control, while SCA were assessed using the standardised Diabetes Self-Management Questionnaire (DSMQ). In our study, 53% of the patients had a HbA1c ≥ 7%. In univariate linear regression models, a statistically significant inverse association was observed between the HbA1c (the dependent variable) and both the DSMQ Dietary Control Score (R2 = 0.037, p = 0.0145) and the DSMQ Sum Score (R2 = 0.06, p = 0.0014). The mean absolute change in the HbA1c% associated with one standard deviation (SD) change in the DSMQ Sum Score, independent of the other significant variables retained in the compacted multivariate regression model, was -0.419% (confidence interval: 95%: from -0.18 to -0.65). Although the impact of the DSMQ Score was modest when compared to the other independent variables in the multivariate model, the findings emphasise the importance of maintaining optimal lifestyle changes to avoid hyperglycaemia and its complications. In conclusion, enhanced self-management of DM is associated with improved glucose control. In patients with chronic diseases such as DM, the role of streamlining SCA encompassing physical activity and proper dietary choices is imperative because of a significantly reduced access to healthcare globally as a result of the COVID-19 pandemic.

Quality of Life and Metabolic Indicators of Patients with Type 2 Diabetes: A Cross-Sectional Study in Iran

BACKGROUND

The World Health Organization (WHO) has considered type 2 diabetes mellitus (T2DM) a major global health challenge because of its high prevalence worldwide. T2DM can affect patients' personal, social, and economic statuses. On the other hand, due to the increasing prevalence of T2DM, Quality of Life (QOL) has received more attention in recent years.

OBJECTIVE

The present study was conducted to investigate the relationships between QOL and physical activity level, body mass index, fasting blood sugar, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglyceride, total cholesterol, HbA1c, and systolic and diastolic blood pressure among Iranian patients with uncomplicated T2DM.

METHODS

This cross-sectional study was conducted on 135 participants selected through consecutive sampling. The study data were collected using International Physical Activity Questionnaire and Short-Form Health Survey Questionnaire. Then, the data were entered into the SPSS ver. 28 software, and Pearson's correlation was used to measure the correlation between the variables. Linear regression was also employed. The significance level was set at 0.05.

RESULTS

The significant association was observed between gender (p = 0.007), HDL level (p = 0.02), and gender-adjusted physical activity (p = 0.002) with QOL.

CONCLUSIONS

Due to the association between physical activity and HDL level with QOL in patients with uncomplicated T2DM, they should be given the necessary training to improve their physical activity and regulate HDL level. Also, empowering them in this matter improves their QOL.

A Community Health Volunteer Involvement Program for Glycated Hemoglobin Reduction Among Thai Patients With Uncontrolled Type 2 Diabetes: A Mixed-Method Study

Background:

Diabetes mellitus is increasing and a shortage exists of nurses to care for patients. Community health volunteers (CHVs) pose potential supportive networks in assisting patients to perform healthy behaviors.

Aim:

The study aimed to develop and investigate the effects of a CHV involvement program on reducing glycated hemoglobin (HbA_1c) levels among Thai patients with uncontrolled type 2 diabetes.

Methods:

This sequential mixed-method study was conducted from January to June 2019. Sixty patients with HbA_1c exceeding 7% were recruited from 2 communities assigned as the intervention and comparison groups. Using King’s General Systems Framework as a basis to develop the program, the study initially explored the perceptions of diabetes and its management among patients, family members, and CHVs. Then, a quasi-experimental study with 2 groups pretest-posttest design was conducted and compared with usual care. The intervention included educational sessions, home visits, and activities created by CHVs including a campaign, broadcasting, and health food shops. Quantitative data were collected at baseline and 20-week follow-up and analyzed by descriptive statistics, Independent t-test, and paired t-test.

Results:

The intervention group exhibited a lower mean HbA_1c (p < .001) and reported significant, improvement concerning diabetes knowledge, self-efficacy, perceived support, and behavior compared with the comparison group at the end of the study (Cohen’s d > 1.0, effect size large).

Conclusion:

Applying this framework to develop the program could benefit glycemic control among patients with uncontrolled diabetes residing in communities. Further studies should be conducted on a large sample to demonstrate the efficacy of the program.

The Long-Term Effects of Non-Pharmacological Interventions on Diabetes and Chronic Complication Outcomes in Patients With Hyperglycemia: A Systematic Review and Meta-Analysis

OBJECTIVE

This study aimed at examining the long-term effects of non-pharmacological interventions on reducing the diabetes incidence among patients with prediabetes and chronic complications events among patients with hyperglycemia (pre-diabetes and diabetes) by performing a systematic review and meta-analysis of randomized controlled trials (RCTs).

METHODS

PubMed, MEDLINE, EMBASE, the Cochrane Library, and the Web of Science Core Collection were searched for studies published between January 1990 and November 2021, looking for RCTs to evaluate the effects of non-pharmacological interventions on preventing the incidence of diabetes and chronic complications in comparison with medical therapy, placebo, or usual diabetes care. Two independent reviews extracted relevant data and quality assessment. Any discrepancies were resolved by a third reviewer.

RESULTS

In total, 20 articles involved 16 RCTs (follow-up ranged from 2 to 30 years) were included. Pooled analysis of intervention studies demonstrated clearly that non-pharmacological interventions have a significant effect on reducing the diabetes events in patients with prediabetes (RR 0.62; 95% CI 0.54, 0.71). Pooled analysis of extended follow-up studies showed that non-pharmacological interventions could effectively reduce the diabetes incidence in patients with prediabetes (RR 0.78; 95% CI 0.63, 0.96). Meta-regression and subgroup analysis indicates that the diabetes incidence of the long-term group (duration > 3 years) was clearly reduced by 0.05% compared with the relatively short-term group (duration ≤ 3 years). The incidence of microvascular complications in patients with hyperglycemia was effectively lowered by non-pharmacological interventions (RR 0.60; 95% CI 0.43, 0.83).

CONCLUSION

Non-pharmacological interventions have a long-term effect on reducing the diabetes incidence among prediabetic patients and effectively preventing microvascular complications on hyperglycemia.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/.

The impact of a community-based food education programme on dietary pattern in patients with type 2 diabetes: Results of a pilot randomised controlled trial in Portugal

The purpose of this study was to analyse the effects of a food education programme, with easy-to-implement strategies integrated in a community-based exercise programme, on dietary pattern of patients with type 2 diabetes (T2D). Thirty-three patients (65.4 ± 5.9 years old) were engaged in a 9-month randomised controlled trial: a supervised exercise programme (control group [CON]; n = 15; combined exercise; three sessions per week; 75 min per session) or the same exercise programme plus a concomitant 16-week food education programme (experimental group [EXP]; n = 18; 15-min. group classes and dual-task strategies during exercise). Dietary pattern was assessed using a 3-day food record at baseline and at 9 months. The intake of total fat, polyunsaturated fat, and the daily servings of vegetables significantly increased in EXP compared with the CON group. Retention and adherence to the programme were 54% and 49.5 ± 27.2%, respectively. This food education programme improved dietary pattern of patients with T2D. Special attention should be given to strategies that support participants' attendance.

A systematic review of adherence to physical activity interventions in individuals with type 2 diabetes

Lifestyle interventions are pivotal for successful management of type 2 diabetes (T2D), however, the proportion of people with T2D adhering to physical activity advice has not been thoroughly studied. The purpose of this systematic review was to summarise the evidence on adherence to exercise or physical activity components in lifestyle interventions in those with T2D. We searched MEDLINE EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and Scopus on 12 November 2019. Eligible studies enrolled adults with T2D and reported the proportion of adherence to lifestyle interventions as a primary or secondary outcome. We included 11 studies (nine randomised controlled trials (RCTs) enrolling 1717 patients and two nonrandomised studies enrolling 62 patients). Only one of the studies had low risk of bias. The proportion of participants adhering to physical activity varied from 32% to 100% with a median of 58%. Adherence was higher in interventions using supervised training and lowest in interventions using remote coaching and the adherence rate in observational studies was higher compared to RCTs (92% vs. 55%; p < 0.01). Study duration, risk of bias, or participants' sex, were not associated with adherence to physical activity. The proportion of those with T2D adhering to physical activity interventions for T2D varies widely and most of the included studies had a high risk of bias. These findings have important implications for planning and power analysis of future trials and when counselling patients about lifestyle interventions including physical activity or exercise components.

The effects of saffron petals and damask rose petals on biochemical and inflammatory measurements

OBJECTIVES

Diabetes is a chronic disease caused by high blood sugar greatly affected by diet. The chemical medicines applied to treat diabetes usually have side effects. This study aimed to investigate the effect of saffron petals, damask rose petals, and saffron-damask rose petal herbal teas on weight loss, fasting blood sugar, lipid profile, and the inflammatory factors of diabetic rats.

METHODS

In this study, 40 male Sprague Dawley rats with an average age of four weeks received a high-calorie, high-fat, high-sugar diet for nine weeks. The rats were then randomly assigned to five groups, including normal, control, saffron petal, damask rose petal, and saffron plus damask rose petal groups. For nine weeks, 3 mL of the herbal tea was administered to the intervention groups daily through oral gavage. The levels of FBS, lipid profile, Insulin-like growth factor 1 (IGF-1), the high-sensitivity C-reactive protein (hs-CRP), hemoglobin A1c (HbA1C), and glucose tolerance test (GTT) were measured following the intervention.

RESULTS

Saffron petals reduced weight gain, Triglyceride (TG), and HbA1c and increased hs-CRP and IGF-1 (all p < 0.05). The damask rose petal reduced weight gain, FBS, hs-CRP, and HbA1c and increased the IGF-1 (all p < 0.05). Saffron plus damask-rose petals reduced the weight gain, TG, hs-CRP and HbA1c, and increase IGF-1 factor (all p < 0.05) compared to the control group. No significant effect was found on visceral fat, LDL-C, and HDL-C. Compared with the normal group, saffron petals and damask rose petals increased the FBS, HDL, and LDL levels. Damask rose and the combination of saffron petals and damask rose decreased IGF-1 compared with the normal group (all p < 0.05).

CONCLUSIONS

Saffron and damask rose petals could have beneficial effects on improving the status of biochemical markers. The simultaneous use of saffron and damask rose may counteract the adverse effects of saffron on inflammatory indices.

Health Behavior Trajectories in High Cardiovascular Risk Populations: Secondary Analysis of a Clinical Trial

BACKGROUND

The application of latent class growth analysis (LCGA) has been limited in behavioral studies on high-cardiovascular-risk populations.

AIM

The current study aimed to identify distinct health behavior trajectories in high-cardiovascular-risk populations using LCGA. We also examined the baseline individual characteristics associated with different health behavior trajectories and determined which trajectory is associated with improved cardiovascular risk outcomes at 52 weeks.

METHODS

This secondary analysis of a clinical trial included 200 patients admitted to primary care clinics. Latent class growth analysis was conducted to identify the trajectories of physical activity and dietary intake; these were measured at 4 different time points during a 52-week study period. Analysis of variance/χ2 test was used to assess the associations between baseline individual characteristics and trajectories, and logistic regression analysis was used to identify associations between trajectories and cardiovascular risk outcomes at 52 weeks.

RESULTS

Three trajectories were identified for physical activity (low-, moderate-, and high-stable). Risk perception, patient activation, and depressive symptoms predicted the trajectories. High-stable trajectory for physical activity was associated with better cardiovascular risk outcomes at the 52-week follow-up. Two trajectories (low-stable and high-decreasing) were identified for percent energy from fat, but the factors that can predict trajectories were limited.

CONCLUSIONS

Interventions are needed to target patients who begin with a lower physical activity level, with the goal of enhanced cardiovascular health. The predictors identified in the study may facilitate earlier and more tailored interventions.

Benefits of adding food education sessions to an exercise programme on cardiovascular risk factors in patients with type 2 diabetes

To evaluate the impact of adding food education sessions to an exercise programme on cardiovascular risk factors in middle-aged and older patients with type 2 diabetes (T2D), a randomised parallel-group study was performed. Glycated haemoglobin, body mass index (BMI), waist circumference, fat mass (FM) and blood pressure were assessed at baseline and after 9 months. The recruitment was made in three primary healthcare centres from Vila Real, Portugal. Thirty-three patients (65⋅4 ± 5⋅9 years old) were engaged in a 9-month community-based lifestyle intervention programme: a supervised exercise programme (EX; n = 15; combined aerobic, resistance, agility/balance and flexibility exercise; three sessions per week; 75 min per session); or the same exercise programme plus concomitant food education sessions (EXFE; n = 18; 15-min lectures and dual-task strategies during exercise (answer nutrition questions while walking); 16 weeks). Significant differences between groups were identified in the evolution of BMI (P < 0.001, ) and FM (P < 0.001, ), with best improvements observed in the EXFE group. The addition of a simple food education dietary intervention to an exercise programme improved body weight and composition, but not glycaemic control and blood pressure in middle-aged and older patients with T2D.

Effect of diabetes nutrition education on the dietary feeding practices and lifestyle of type 2 diabetic patients

BACKGROUND

Type 2 diabetes mellitus (T2DM) is one of the most common global diseases of public concern. In developing countries like Uganda, dietary habits and sedentary lifestyle are the major factors for rapidly rising incidence of DM. Therefore, awareness about diabetes dietary practices and life style are paramount in the control of the disease.

METHODOLOGY

One hundred type 2 diabetic patients were randomly selected and divided into two groups of intervention and control (50 patients in each group) to participate in the study. The intervention consisted of two educational sessions each for 30 min with various learning segments. A conversation map for type 2 diabetes, 24-h dietary recall and glycemic load tables were used. Data were collected using a pre-tested questionnaire before intervention and on monthly basis for a period of four months of intervention. Data were entered and analyzed using SPSS software version 21.

RESULTS

There was a significant (p < 0.001) increase in water, vegetables, fruits, and number of meals intake per day coupled with quitting alcohol, soda, and beer among the intervention group. On the other hand, it was revealed that meat and milk consumption significantly reduced by 81.6 and 82.4% respectively among the intervention group. At the end of study period, milk, meat, vegetable, beer, soda, cigarettes intake, and duration of physical activity increased among the control group.

CONCLUSIONS

Nutrition education improves dietary feeding practices and lifestyle among type 2 diabetes patients within four months of intervention.

Lifestyle Interventions to Improve Glycemic Control in Adults with Type 2 Diabetes Living in Low-and-Middle Income Countries: A Systematic Review and Meta-Analysis of Randomized Controlled Trials (RCTs)

Alongside glucose lowering therapy, clinical guidelines recommend lifestyle interventions as cornerstone in the care of people living with type 2 diabetes (T2DM). There is a specific need for an up-to-date review assessing the effectiveness of lifestyle interventions for people with T2DM living in low-and-middle income countries (MICs). Four electronic databases were searched for RCTs published between 1990 and 2020. T2DM, lifestyle interventions, LMICs and their synonyms were used as search terms. Data codebooks were developed and data were extracted. Narrative synthesis and meta-analysis were conducted using random effects models to calculate mean differences (MD) and standardized mean differences (SMD) and 95% confidence intervals (CI). Of 1284 articles identified, 30 RCTs (n = 16,670 participants) met the inclusion criteria. Pooled analysis revealed significant improvement in HBA1c (MD −0.63; CI: −0.86, −0.40), FBG (SMD −0.35; CI: −0.54, −0.16) and BMI (MD −0.5; CI: −0.8, −0.2). In terms of intervention characteristics, those that included promoted self-management using multiple education components (e.g., diet, physical activity, medication adherence, smoking cessation) and were delivered by healthcare professionals in a hospital/clinic setting were deemed most effective. However, when interpreting these results, it is important to consider that most included studies were evaluated as being of low quality and there was a significant amount of intervention characteristics heterogeneity. There is a need for further well-designed studies to inform the evidence base on which lifestyle interventions are most effective for glycemic control in adults with T2DM living in LMICs.

Effectiveness of an adapted diabetes nutrition education program on clinical status, dietary behaviors and behavior mediators in adults with type 2 diabetes: a randomized controlled trial

PURPOSE

This study evaluated the effectiveness of an adapted social-cognitive theory underpinned diabetes nutrition education program (NEP) on: clinical (HbA1c, BMI, blood lipids, blood pressure) and selected dietary behaviors (starchy foods and energy intake, vegetables and fruit intake) and behavior mediators (knowledge and diabetes management self-efficacy) in patients with type 2 diabetes mellitus (T2DM).

METHODS

A tertiary hospital outpatient adults (40-70 years) with poorly controlled (HbA1c ≥ 8 %) T2DM were randomized to either intervention group (n = 39: NEP, 7-monthly group education sessions, bi-monthly follow-up sessions, 15-minute individual session, workbook + education materials) or control group (n = 38: education materials only). NEP aimed to improve clinical status through improved dietary behaviors and behavior mediators. Outcomes and changes in diabetes medication were assessed at six and 12 months. Intention-to-treat analysis was conducted. ANCOVA compared the groups (baseline values, age, sex adjustments).

RESULTS

Forty-eight (62.3 %) participants completed the study. Intervention group compared to the control group had lower (-0.53 %), clinically meaningful HbA1c (primary outcome) at 6 months, albeit not sustained at 12 months. Compared to the control group, the intervention group had significantly lower: (i) systolic blood pressure at six and 12 months (ii) diastolic pressure at 12 months, (iii) energy intake at six-months, (iv) up-titration of insulin at six and 12 months and higher diabetes knowledge scores at six months.

CONCLUSIONS

NEP had limited effects on HbA1c, targeted dietary behaviors and behavior mediators but showed positive effects on blood pressure. The NEP health cost savings potential supports the need for improving program participation.

TRIAL REGISTRATION

ClinicalTrials.gov. number NCT03334773; 7 November 2017 retrospectively registered.

Critical Reappraisal of the Role and Importance of Exercise Intervention in the Treatment of Obesity in Adults

In the treatment of obesity in adults, exercise intervention is recommended and some people with obesity even prefer exercise above dietary intervention as a single weight-loss strategy. However, evidence is accumulating that the long-term body weight and adipose tissue mass loss ​as a result of exercise intervention in these individuals is disappointingly small. Although this could be related to various clinical reasons, more recent evidence reveals that also (patho)physiological abnormalities are involved which cannot be remediated by exercise intervention, especially in metabolically compromised patients. As a result, the role and importance of exercise intervention in the treatment of obesity deserve significant reconsideration to avoid confusion and disappointment amongst clinicians, patients and society. Hence, to reduce adipose tissue mass and body weight, dietary intervention is much more effective than exercise intervention, and is, therefore, of key importance in this endeavour. However, dietary interventions must be supplemented by exercise training to induce clinically relevant changes in specific cardiovascular or metabolic risk factors like blood pressure, blood triglycerides and high-density lipoprotein cholesterol concentrations, as well as visceral adipose tissue mass, physical fitness, muscle mass and strength, quality of life and life expectancy. This allows individuals with obesity to preserve their cardiometabolic health or to shift from a metabolically unhealthy phenotype to a metabolically healthy phenotype. Signifying the true clinical value of exercise interventions might lead to a better understanding and appreciation of the goals and associated effects when implemented in the multidisciplinary treatment of obesity, for which a proper tailoring of exercise prescription is required.

A Novel User Utility Score for Diabetes Management Using Tailored Mobile Coaching: Secondary Analysis of a Randomized Controlled Trial

Background

Mobile health applications have been developed to support diabetes self-management, but their effectiveness could depend on patient engagement. Therefore, patient engagement must be examined through multifactorial tailored behavioral interventions from an individual perspective.

Objective

This study aims to evaluate the usefulness of a novel user utility score (UUS) as a tool to measure patient engagement by using a mobile health application for diabetes management.

Methods

We conducted a subanalysis of results from a 12-month randomized controlled trial of a tailored mobile coaching (TMC) system among insurance policyholders with type 2 diabetes. UUS was calculated as the sum of the scores for 4 major core components (range 0-8): frequency of self-monitoring blood glucose testing, dietary and exercise records, and message reading rate. We explored the association between UUS for the first 3 months and glycemic control over 12 months. In addition, we investigated the relationship of UUS with blood pressure, lipid profile, and self-report scales assessing diabetes self-management.

Results

We divided 72 participants into 2 groups based on UUS for the first 3 months: UUS:0-4 (n=38) and UUS:5-8 (n=34). There was a significant between-group difference in glycated hemoglobin test (HbA_1c) levels for the 12-months study period (P=.011). The HbA_1c decrement at 12 months in the UUS:5-8 group was greater than that of the UUS:0-4 group [–0.92 (SD 1.24%) vs –0.33 (SD 0.80%); P=.049]. After adjusting for confounding factors, UUS was significantly associated with changes in HbA_1c at 3, 6, and 12 months; the regression coefficients were –0.113 (SD 0.040; P=.006), –0.143 (SD 0.045; P=.002), and –0.136 (SD 0.052; P=.011), respectively. Change differences in other health outcomes between the 2 groups were not observed throughout a 12-month follow-up.

Conclusions

UUS as a measure of patient engagement was associated with changes in HbA_1c over the study period of the TMC system and could be used to predict improved glycemic control in diabetes self-management through mobile health interventions.

Trial Registration

ClinicalTrial.gov NCT03033407; https://clinicaltrials.gov/ct2/show/NCT03033407

Effectiveness of dietetic intervention for people with type 2 diabetes: A meta-analysis

BACKGROUND

Diet is central to treatment of type 2 diabetes. This review aimed to compare the effectiveness of nutrition therapy delivered by dietitians to nutrition advice delivered by other healthcare professionals in adults with type 2 diabetes on metabolic parameters.

METHODS

Cochrane CENTRAL, CINAHL, EMBASE, MEDLINE and PsychINFO were searched for randomised controlled trials of three months duration or longer, published from 1st January 2008 to 18th June 2019. Relevant data were extracted from studies with additional author information. Random-effects meta-analysis assessed mean changes in HbA1c and other clinical parameters. PROSPERO registration number: CRD42019130528.

RESULTS

Of 2477 records identified, fourteen studies, involving 3338 participants, were eligible for qualitative synthesis and meta-analysis. The mean changes [95% CI] at follow-up in HbA1c, BMI, weight, LDL cholesterol, systolic and diastolic blood pressure were -0·47 [-0·92, -0·02] %, -0·38 [-0·63, -0·13] kg/m², -1·49 [-2·14, -0·84] kg, -0·15 [-0·33, 0·04] mmol/L, -0·75 [-2·45, 0·96] mm Hg and -1·17 [-4·52, 2·17] mm Hg respectively in favour of the intervention group. The quality of evidence was limited due to heterogeneity, risk of bias, publication bias and indirectness.

CONCLUSIONS

Nutrition therapy provided by dietitians was associated with better clinical parameters of type 2 diabetes, including clinically significant improved glycaemic control, across diverse multiethnic patient groups from all six inhabited continents. This conclusion should be reflected in clinical guidelines.

Motiva.DM2 project. A pilot behavioral intervention on diet and exercise for individuals with type 2 diabetes mellitus

AIM

The purpose of this study was to assess the efficacy of an educational intervention based on the Behavior Change Wheel (BCW) framework for individuals with type 2 diabetes mellitus (DM2) on dietary and exercise behavior in a Spanish region.

METHODS

A two-arm pilot research was developed. The intervention consisted of a 6-month period with guidelines and 4 in-person interventions. The outcome was changes in behaviors, motivation, competence, autonomy, social support to implement the recommendations, HbA1c, and body composition.

RESULTS

n = 111 patients were recruited. Individuals in the intervention experienced a significative improvement on adherence to dietary recommendations (+1.23; p = 0.026), exercise (+0.86; p = 0.001), and a decrease in HbA1c levels (-0.6%; p = 0.002) and BMI (-0.73; p < 0.001).

CONCLUSION

The intervention for DM2 individuals, based on the BCW framework, developed, and implemented by primary care nurses has been effective in improving the adherence to healthy eating, exercise, HbA1c levels, and body composition.

Effectiveness of Yoga-based Exercise Program Compared to Usual Care, in Improving HbA1c in Individuals with Type 2 Diabetes: A Randomized Control Trial

Background:

This study was designed to evaluate the effectiveness of a yoga-based exercise program (YBEP) in improving glycemic control in people with type 2 diabetes mellitus.

Materials and Methods:

Patients on stable oral glucose-lowering agents for at least 3 months and HbA1c 7.5%–10% were randomized in 1:1 ratio. The primary outcome measure was the difference of change in mean HbA1c between groups.

Results:

The participants (n = 81) had mean (±standard deviation) age of 50.6 (±8.5) years and HbA1c of 8.5 ± 0.7% (68.97 ± 7.42 mmol/mol). The follow-up data were available in 96% (78/81) of participants. Of 40 participants, 25 (62.5%) attended ≥75% (≥10 out of 13) of the sessions in YBEP. On the intention to treat analysis, a favorable reduction (0.21% 95% confidence interval [−0.34, 0.75], P = 0.454) in HbA1c was seen in YBEP group as compared to usual care. The reduction in HbA1c by ≥0.5% was observed in 44.7% of participants in YBEP as compared to 37.5% in usual care arm, respectively. Those who attended ≥75% of the sessions had better HbA1c reduction of 0.3% in comparison to 0.1% reduction seen in those who attended <75% of the sessions.

Conclusions:

YBEP demonstrated a clinically relevant HbA1c reduction compared to usual care in participants who had attended at least 75% of the yoga sessions. The reduction in HbA1c by >0.5% in 44.7% in the yoga group, suggests, that it can be prescribed as an exercise to individuals who are unable to walk either due to limited joint mobility, adverse weather conditions, lack of space for walking, cultural or religious prohibitions for women for outdoor physical activity, and so on.

CTRI registration no: CTRI/2017/05/008564.

Do Health Professionals Sufficiently Address Patients' Disposition Toward Changing Their Nutritional and Physical Activity Habits? Findings from a Pilot Study among People with Type 2 Diabetes in Northern Italy

The aim of our study was to evaluate the disposition of individuals with type 2 diabetes mellitus (DM2) toward changing their nutritional and physical activity habits and associated factors—particularly their perceptions about interacting and communicating with four health professions. Working with a local patients’ association, we invited 364 individuals with DM2, all at least 18 years old, to complete a paper-based survey with questions addressing their experiences of interacting and communicating with general practitioners, nurses, dieticians and diabetologists and about their readiness to change targeted habits, their health literacy and their clinical status. Of the 109 questionnaires collected, 100 were eligible for descriptive and inferential statistical analysis. Regarding nutritional habits, the highest percentage of participants were at the maintenance stage (26%), whereas regarding physical activity habits the highest percentage of participants were at the preparation stage (31%). Significant differences between the habits emerged for four of the five stages and for two psychological processes. The precontemplation stage was most associated with communication-related variables, whereas the maintenance stage was associated with higher health literacy for both habits, and waist-to-height ratio was associated with several stages of change and psychological processes for physical activity habits. Considering aggregated stages (i.e., active or passive stage), significant differences were observed for all psychological processes except readiness to change nutritional habits. Logistic regression analysis revealed associations of the active stage with higher self-efficacy and lower discrepancy processes for both habits. Nutritional habits were associated with normal HbA1c values and physical activity habits with high cholesterol. Understanding the combination of the stages of change and how they relate to psychological processes can afford meaningful insights into the potential internal and external communication skills of health professions and should be examined as possible elements for a patient evaluation model.

Living on the Own Island? Aligned Collaboration Between Family Physicians, Nurses, Dieticians, and Patients With Diabetes Type 2 in an Outpatient Care Setting in Northern Italy: Findings From a Qualitative Study

Introduction: Diabetes mellitus type 2 (DM2), one of the four most important chronic diseases worldwide, is generally considered to be preventable. However, it is not yet sufficiently clear whether an aligned collaboration between different health professions could facilitate behavioral changes to be made by patients with DM2 regarding their eating and physical activity habits. Objective: To explore if and how far in current outpatient care for 3 health-care professions it is an objective to collaborate with each other supporting patients with DM2 in changing their eating and physical activity habits. Methods: We conducted 18 qualitative problem centered interviews with selected family physicians, nurses, dieticians working in outpatient setting and patients with DM2, transcribed verbatim, and analyzed with qualitative content analysis. Results: Issues identified ranged from description and reflection of current health-care practice, strategies, and hindrances to cope with changes of eating and physical activity behaviors as well as for health-care practice regarding interprofessional collaboration and patient-centered care up to considerations about collaboration and patient centricity (for health professionals and patients to achieve goals) and changes and ideas of “ideal care practice”. Discussion: The included professional groups work predominantly for themselves. Collaboration currently only takes place when individually triggered and neither structured nor organized.

Associations of Intensive Lifestyle Intervention in Type 2 Diabetes With Health Care Use, Spending, and Disability: An Ancillary Study of the Look AHEAD Study

IMPORTANCE

Intensive lifestyle interventions focused on diet and exercise can reduce weight and improve diabetes management. However, the long-term effects on health care use and spending are unclear, especially for public payers.

OBJECTIVE

To estimate the association of effective intensive lifestyle intervention for weight loss with long-term health care use and Medicare spending.

DESIGN, SETTING, AND PARTICIPANTS

This ancillary study used data from the Look AHEAD randomized clinical trial, which randomized participants with type 2 diabetes to an intensive lifestyle intervention or control group (ie, diabetes support and education), provided ongoing intervention from 2001 to 2012, and demonstrated improved diabetes management and reduced health care costs during the intervention. This study compared Medicare data between study arms from 2012 to 2015 to determine whether the intervention was associated with persistent reductions in health care spending.

EXPOSURE

Starting in 2001, Look AHEAD's intervention group participated in sessions with lifestyle counselors, dieticians, exercise specialists, and behavioral therapists with the goal of reducing weight 7% in the first year. Sessions occurred weekly in the first 6 months of the intervention and decreased over the intervention period. The controls participated in periodic group education sessions that occurred 3 times per year in the first year and decreased to 1 time per year later in the trial.

MAIN OUTCOMES AND MEASURES

Outcomes included total Medicare spending, Part D prescription drug costs, Part A and Part B Medicare spending, hospital admissions, emergency department visits, and disability-related Medicare eligibility.

RESULTS

This study matched Medicare administrative records for 2796 Look AHEAD study participants (54% of 5145 participants initially randomized and 86% of 3246 participants consenting to linkages). Linked intervention and control participants were of a similar age (mean [SD] age, 59.6 [5.4] years vs 59.6 [5.5] years at randomization) and sex (818 [58.1%] women vs 822 [59.3%] women). There was no statistically significant difference in total Medicare spending between groups (difference, -$133 [95% CI, -$1946 to $1681]; P = .89). In the intervention group, compared with the control group, there was statistically significantly higher Part B spending (difference, $513 [95% CI, $70 to $955]; P = .02) but lower prescription drug costs (difference, -$803 [95% CI, -$1522 to -$83]; P = .03).

CONCLUSIONS AND RELEVANCE

This ancillary study of a randomized clinical trial found that reductions in health care use and spending associated with an intensive lifestyle intervention for type 2 diabetes diminished as participants aged. Intensive lifestyle interventions may need to be sustained to reduce long-term health care spending.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03952728.

Which Physical Exercise Interventions Increase HDL-Cholesterol Levels? A Systematic Review of Meta-analyses of Randomized Controlled Trials

BACKGROUND

Meta-analyses of randomized controlled trials (RCTs) have shown the beneficial effect of exercise on HDL-cholesterol (HDL-C) levels. However, systematic reviews are not free of bias, and this could call into question their results.

OBJECTIVES

The aim of this work was to conduct a critical assessment of meta-analyses of RCTs that analyze the association between exercise and HDL-C levels, evaluating their results and the risk of bias (RoB).

METHODS

This systematic review of MEDLINE and EMBASE included meta-analyses of RCTs that studied the effects of exercise on HDL-C levels in healthy adults or patients at cardiovascular risk. The RoB was determined using AMSTAR-2, and information was obtained on exercise and the variation in HDL-C levels.

RESULTS

Twenty-three meta-analyses were included. Great variability was found in exercise (different types, frequencies or intensities in the studied interventions). All the analyses found an improvement in HDL-C levels, ranging from 0.27 to 5.41 mg/dl, in comparison with the control group (no exercise). The RoB was very high, with 18 reviews obtaining a critically low confidence level and the remaining works obtaining the highest confidence level.

CONCLUSIONS

Only one meta-analysis showed good quality, in which HDL-C levels increased by 3.09 mg/dl in healthy adults and patients at high cardiovascular risk who practiced yoga. The rest had high RoB. Therefore, new systematic reviews with low RoB are needed to apply the results to clinical practice. Register: CRD42020158471 (PROSPERO).

Lifestyle factors, self-management and patient empowerment in diabetes care

Although management of diabetes mellitus is improving, inadequately managed cases still exist. Prevention of diabetes mellitus requires an integrated and holistic approach based on the origin of the disease. In Europe only half of diagnosed patients with diabetes mellitus have good glycaemic control. Inadequate glycaemic control is significantly increasing the use of healthcare resources, the medical costs and mortality rates. A review was conducted in order to summarise and discuss central themes for prevention. A search of the databases PubMed, CINAHL, Cochrane and Google Scholar between January 2010-May 2019 was undertaken. The following keywords: 'diabetes mellitus', 'cardiovascular diseases', 'empowerment', 'self-management education' and 'lifestyle factors' were used in different combinations to identify eligible articles. Important variables for the prevention of diabetes mellitus and its complications are self-management of diabetes mellitus and the management of risk factors. Education and support for self-management are fundamental when caring for people with a chronic disease like diabetes mellitus. In order to achieve effective self-management including lifestyle modification it is also crucial to motivate people. In this review, the role of the three main pillars in diabetes care are identified and discussed; patient empowerment, self-management education and lifestyle modification in the management of people with diabetes mellitus.

Effectiveness of a Diabetes Education Program based on Tailored interventions and Theory of Planned Behaviour: Cluster randomized controlled trial protocol

AIM

To measure the Effectiveness of a Diabetes Education Program for people with T2DM, based on Tailored interventions and the Theory of Planned Behaviour.

DESIGN

Cluster randomized controlled clinical trial.

METHODS

This multicentre study will be carried out at 30 primary healthcare centres, where 436 persons with Type 2 Diabetes Mellitus (T2DM), aged between 18-75 years, will be recruited. The experimental educational program to be applied is modelled using components obtained from a systematic review and prior qualitative analysis. In addition, a taxonomy of nursing practice is used to standardize the program, based on the Theory of Planned Behaviour as a conceptual model. The intervention will be carried out by community nurses, using ADAPP-Ti^® , an application developed with FileMaker Pro v.18. The control group will receive usual care and data will be collected at 6, 12, and 18 months, for both groups. The primary outcome considered will be glycosylated haemoglobin and cardiovascular factors, while the secondary ones will be tobacco consumption, body mass index, barriers to self-care, health-related quality of life, and lifestyle modification. The protocol was approved by the Ethics Committee of the Province of Malaga (Spain) in November 2014.

DISCUSSION

The degree of metabolic control in T2DM is not always associated with healthy lifestyles and significant levels of medication are often prescribed to achieve clinical objectives. An intervention focused on needs, based on the best available evidence and a solid conceptual framework, might successfully consolidate appropriate self-care behaviour in this population.

IMPACT

The study will result in the publication of an educational program featuring well-defined interventions and activities that will enable clinicians to tailor health care to the individual's needs and to combat treatment inertia in attending this population.

Weight maintenance interventions for people with type 2 diabetes mellitus: a systematic review protocol

BACKGROUND

Weight loss maintenance is a challenge for people with type 2 diabetes mellitus (T2DM), which attenuates the long-term benefits of weight loss for diabetes management. Medication, specific dietary requirements and the psychosocial burden of T2DM signify that weight loss maintenance designed for obesity may not suit people with T2DM. The primary objective of this review is to comprehensively evaluate existing weight maintenance interventions for people with or at high risk of T2DM.

METHODS

We registered a protocol for the systematic review and meta-analysis of randomised and non-randomised weight maintenance interventions for T2DM. Studies included will have been carried out in adults with clinical diagnosis of T2DM or pre-diabetes. All intervention types will be accepted (e.g. behavioural/lifestyle change and pharmacological). The primary outcomes will be weight control, glycaemic control and adverse effects. Secondary outcomes will include cardiovascular risk factors (e.g. total cholesterol, LDL-cholesterol, blood pressure control), psychological wellbeing (including health-related quality of life), change in glucose medication and waist circumference. Multiple electronic databases will be searched such as MEDLINE, EMBASE, Web of Science, PsychINFO and international registers (e.g. Cochrane Central Register of Controlled Trials, WHO ICTRP). OpenGrey will be searched for grey literature. Two researchers will screen all citations and abstracts. This process will also be conducted by an additional researcher using a semi-automated tool to reduce human error. Full-text articles will be further examined by the researchers to select a final set for further analysis, and a narrative synthesis of the evidence will be presented. Potential sources of heterogeneity will be assessed, and a meta-analysis will be conducted if feasible. Risk of bias will be evaluated using the Cochrane risk of bias tool and the certainty of evidence using the GRADE (grading of recommendations, assessment, development and evaluation) approach.

DISCUSSION

This review will critically appraise existing weight maintenance interventions targeting T2DM. Findings will inform future intervention development to support people with T2DM delay weight regain and prolong successful diabetes management.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020168032.

Does the effect of lifestyle intervention for individuals with diabetes vary by food insecurity status? A preplanned subgroup analysis of the REAL HEALTH randomized clinical trial

INTRODUCTION

We aimed to test the effectiveness of a lifestyle intervention (LI) for individuals with food insecurity and type 2 diabetes.

RESEARCH DESIGN AND METHODS

Adults with type 2 diabetes, body mass index ≥25 kg/m2 (or ≥23 kg/m2 if Asian), hemoglobin A1c of 6.5%-11.5% (48-97 mmol/mol) and who were willing to lose 5%-7% bodyweight were enrolled in REAL HEALTH-Diabetes. This practice-based randomized clinical trial compared LI (delivered inperson or by telephone) with medical nutrition therapy (MNT) on weight loss at 6 and 12 months. Two or more affirmative responses on the six-item US Department of Agriculture Food Security Survey Module indicated food insecurity. In this prespecified subgroup analysis, we tested using linear mixed effects models whether the intervention effect varied by food security status.

RESULTS

Of 208 participants, 13% were food insecure. Those with food insecurity were more likely to be racial/ethnic minorities (p<0.001) and have lower education (p<0.001). LI, versus MNT, led to greater weight loss at 6 months (5.1% lost vs 1.1% lost; p<0.0001) and 12 months (4.7% lost vs 2.0% lost; p=0.0005). The intervention effect was similar regardless of food security status (5.1% bodyweight lost vs 1.1% in food secure participants and 5.1% bodyweight lost vs 1.3% in food insecure participants at 6 months; 4.7% bodyweight lost vs 2.1% in food secure participants and 4.5% bodyweight lost vs 0.9% in food insecure participants at 12 months; p for interaction=0.99).

CONCLUSIONS

The REAL HEALTH-Diabetes lifestyle intervention led to meaningful weight loss for individuals with food insecurity and type 2 diabetes.

TRIAL REGISTRATION NUMBER

NCT02320253.

Psychological Stress Accompanied by a Low-Variety Diet Is Positively Associated with Type 2 Diabetes in Middle-Aged Adults

Psychological stress is generally known to affect dietary intakes and cause chronic diseases. This study aims to investigate the association between psychological stress and the risk of type 2 diabetes in relation to dietary variety. A total of 126,405 middle-aged adults were enrolled in the Korean Genome and Epidemiology Study. Stress levels were measured using the psychosocial well-being index. Dietary variety score (DVS) was defined as the number of different foods consumed over a day. Stress levels were positively associated with the risks of diabetes (odds ratio (OR) for tertile 3 compared with tertile 1, men: OR = 1.34 (95% CI: 1.24-1.45); women: OR = 1.29 (1.19-1.4)). As the stress levels rose, the intake of grains increased, and the intake of fruits and vegetables decreased. Participants with higher stress levels showed lower DVS than those with lower stress levels. Furthermore, participants with higher stress levels and lower DVS had a significantly higher OR for diabetes than those with lower stress levels and higher DVS (men: OR = 1.83 (1.58-2.12); women: OR = 1.85 (1.59-2.51)). These results suggest that the high risk of type 2 diabetes for people with high stress levels may be associated with low dietary variety.

A New Instrument for Measuring Dietary Knowledge in Patients With Diabetes: Psychometric Testing of the CoNOCidiet-Diabetes

PURPOSE

To determine the psychometric properties of the CoNOCidiet-Diabetes, a new instrument based on nursing outcome "Knowledge: prescribed diet."

METHODS

Methodological design. The participant were 359 patients diagnosed with diabetes visiting 27 primary healthcare centers in Spain. Reliability (internal consistency and test-retest), validity (convergent criterion validity, concurrent content validity and known-groups validity), and sensitivity to change was tested.

FINDINGS

CoNOCidiet-Diabetes has shown evidence of acceptable psychometric properties as instrument but some items should be revised.

CONCLUSIONS

This research provides a new instrument developed to specifically measure dietary knowledge in individuals with diabetes.

IMPLICATIONS

For nursing practice: The literalness of the CoNOCidiet-Diabetes with the nursing outcome "Knowledge: prescribed diet" facilitate its measurement using the patient's statements.

The effect of type 2 diabetes diagnosis in the elderly

In this paper, I use a novel approach based on biomarkers data to examine the effect of type 2 diabetes (T2D) diagnosis on both physical and mental health for a sample of individuals aged 50 and above. In order to retrieve reliable estimates, I exploit the fact that medical guidelines cause a discontinuity in the probability that General Practitioners (GP) diagnose their patients with T2D as a function of exact blood test cut-off in a regression discontinuity design (RDD) approach. Using data from the English Longitudinal Study of Ageing (ELSA), I find compelling evidence that health information, in the form of T2D diagnosis, influences the protection of health into old age. Specifically, after receiving T2D diagnosis, over time, individuals reported a 2.1 lower body mass index (BMI) as well as 5.5 cm lower waist circumference, relative to their counterparts. With respect to self-reported physical health, the results imply that those diagnosed with T2D reported a 0.19 and 0.70 higher score in increased activities of daily living (ADL) and body mobility indexes, respectively. Finally, while I find evidence that T2D-diagnosed patients reported a significant, 0.5 higher, score in the word listening test, I find no evidence that T2D diagnosis impacted self-reported depression levels. I provide a wide variety of evidence on the validity of the results.

Educational weight loss interventions in obese and overweight adults with type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials

AIM

The worldwide prevalence of type 2 diabetes mellitus is increasing, with most individuals with the disease being overweight or obese. Weight loss can reduce disease-related morbidity and mortality and weight losses of 10-15 kg have been shown to reverse type 2 diabetes. This review aimed to determine the effectiveness of community-based educational interventions for weight loss in type 2 diabetes.

METHODS

This is a systematic review and meta-analysis of randomized controlled trials (RCT) in obese or overweight adults, aged 18-75 years, with a diagnosis of type 2 diabetes. Primary outcomes were weight and/or BMI. CINAHL, MEDLINE, Embase, Scopus and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from inception to June 2019. Trials were classified into specified a priori comparisons according to intervention type. A pooled standardized mean difference (SMD) (from baseline to follow-up) and 95% confidence intervals (95% CI) between trial groups (difference-in-difference) were estimated through random-effects meta-analyses using the inverse variance method. Heterogeneity was quantified using I² and publication bias was explored visually using funnel plots.

RESULTS

Some 7383 records were screened; 228 full-text articles were assessed and 49 RCTs (n = 12 461 participants) were included in this review, with 44 being suitable for inclusion into the meta-analysis. Pooled estimates of education combined with low-calorie, low-carbohydrate meal replacements (SMD = -2.48, 95% CI -3.59, -1.49, I²  = 98%) or diets (SMD = -1.25, 95% CI -2.11, -0.39, I²  = 95%) or low-fat meal replacements (SMD = -1.15, 95%CI -2.05, -1.09, I²  = 85%) appeared most effective.

CONCLUSION

Low-calorie, low-carbohydrate meal replacements or diets combined with education appear the most promising interventions to achieve the largest weight and BMI reductions in people with type 2 diabetes.

Effectiveness of a Video-Based Lifestyle Education Program Compared to Usual Care in Improving HbA1c and Other Metabolic Parameters in Individuals with Type 2 Diabetes: An Open-Label Parallel Arm Randomized Control Trial (RCT)

INTRODUCTION

This study was designed to investigate the effectiveness of a video-based lifestyle education program (VBLEP) in improving glycemic control in people with type 2 diabetes mellitus compared with usual care.

METHODS

Patients on stable oral glucose-lowering agents for at least 3 months and HbA1c 7.5-10% were randomized in a 1:1 ratio. Primary outcome measure was the difference in change in mean HbA1c between groups.

RESULTS

The participants (n = 81) had mean (± SD) age of 50.1 (± 9.4) years and HbA1c of 8.5 ± 0.7% (68.87 ± 7.56 mmol/mol). The follow-up data were available in 96% (78/81) of participants. Of 40 participants, 36 (90%) attended ≥ 75% (≥ 3 out of 4) of the sessions in the VBLEP. In the intention-to-treat analysis, a significant reduction [0.6% 95% CI (0.1, 1.1), p = 0.013] in HbA1c was seen in the VBLEP group compared with usual care. A ≥ 1% reduction in HbA1c was observed in 39.5% of participants in the VBLEP compared with 15% in the usual care arm. However, a ≥ 0.5% reduction in HbA1c was observed in 65.8% of participants in the VBLEP compared with 37.5% in the usual care arm (p = 0.012). There was a significant change in weight and body mass index in the VBLEP group compared with usual care. The participants who were employed, had a family history of diabetes, had no diabetes-related complications, and were in the VBLEP group had higher odds of having a favorable HbA1c reduction (≥ 0.5%, combined analysis both groups) from baseline.

CONCLUSION

The VBLEP demonstrated a significant and clinically relevant HbA1c reduction compared with usual care. A simple VBLEP, when delivered in an interactive manner, can aid in improving glycemic outcomes in the Indian population.

TRIAL REGISTRATION

CTRI/2017/05/008564.

Evaluation of provider documentation patterns as a tool to deliver ongoing patient-centred diabetes education and support

BACKGROUND

Diabetes mellitus (DM) is one of the most common chronic diseases in the world. As a disease with long-term complications requiring changes in management, DM requires not only education at the time of diagnosis, but ongoing diabetes self-management education and support (DSME/S). In the United States, however, only a small proportion of people with DM receive DSME/S, although evidence supports benefits of ongoing DSME/S. The diabetes education that providers deliver during follow-up visits may be an important source for DSME/S for many people with DM.

METHODS

We collected 200 clinic notes of follow-up visits for 100 adults with DM and studied the History of Present Illness (HPI) and Impression and Plan (I&P) sections. Using a codebook based on the seven principles of American Association of Diabetes Educators Self-Care Behaviors (AADE7), we conducted a multi-step deductive thematic analysis to determine the patterns of DSME/S information occurrence in clinic notes. Additionally, we used the generalised linear mixed models for investigating whether providers delivered DSME/S to people with DM based on patient characteristics.

RESULTS

During follow-up visits, Monitoring was the most common self-care behaviour mentioned in both HPI and I&P sections. Being Active was the least common self-care behaviour mentioned in the HPI section and Healthy Coping was the least common self-care behaviour mentioned in the I&P section. We found providers delivered more information on Healthy Eating to men compared to women in I&P section. Generally, providers delivered DSME/S to people with DM regardless of patient characteristics.

CONCLUSIONS

This study focused on the frequency distribution of information providers delivered to the people with DM during follow-up clinic visits based on the AADE7. The results may indicate a lack of patient-centred education when people with DM visit providers for ongoing management. Further studies are needed to identify the underlying reasons why providers have difficulty delivering patient-centred education.

Effect of Tai Chi on Quality of Life, Body Mass Index, and Waist-Hip Ratio in Patients With Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a worldwide public health concern with high morbidity and various progressive diabetes complications that result in serious economic expenditure and social burden. This systematic review aims to evaluate the effect of Tai Chi on improving quality of life (QoL), body mass index (BMI) and waist-hip ratio (WHR) in patients with T2DM.

METHOD

A systematic review and meta-analysis was performed following PRISMA recommendation. Four English databases and three Chinese databases were searched. The PEDro scale was used to assess the methodological quality of including studies. Study inclusion criteria: randomized controlled trials (RCTs) and quasi-experimental studies were included, patients with T2DM that adopted Tai Chi as intervention and QoL, BMI and/or WHR as outcome measurements.

RESULTS

Eighteen trials were included. The aggregated results of seven trials showed that Tai Chi statistically significantly improved QoL measured by the SF-36 on every domains (physical function: MD = 7.73, 95% confidence interval (CI) = 1.76 to 13.71, p = 0.01; role-physical function: MD = 9.76, 95% CI = 6.05 to 13.47, p < 0.001; body pain: MD = 8.49, 95% CI = 1.18 to 15.8, p = 0.02; general health: MD = 9.80, 95% CI = 5.77 to 13.82, p < 0.001; vitality: MD = 6.70, 95% CI = 0.45 to 12.94, p = 0.04; social function: MD = 9.1, 95% CI = 4.75 to 13.45, p < 0.001; role-emotional function: MD = 7.88, 95% CI = 4.03 to 11.72, p < 0.001; mental health: MD = 5.62, 95% CI = 1.57 to 9.67, p = 0.006) and BMI (MD = -1.53, 95% CI = -2.71 to -0.36, p < 0.001) compared with control group (wait list; no intervention; usual care; sham exercise).

CONCLUSION

Tai Chi could improve QoL and decrease BMI for patients with T2DM, more studies are needed to be conducted in accordance with suggestions mentioned in this review.