Reducing diabetes risk in American Indian women

The Medicine Wheel as a public health approach to lifestyle management interventions for indigenous populations in North America

This analytic essay intends to elevate Medicine Wheel, or generally "four directions" teachings, to encourage a more comprehensive alignment of lifestyle intervention components with traditional ecological knowledge systems of Indigenous cultures in North America. North American Medicine Wheels provided people with a way to orient themselves both within their traditional belief systems and to the seasonal changes in their areas, improving survivability. The wheel or circle is a sacred symbol, indicating the continuity and perpetuity of all of life. The four directions are iconized in many Indigenous cultures across North America with different directions representing different aspects of our world and of ourselves, different seasons of the year and of our lives, different beings of the earth and tribes of humans with a balance among those necessary for health and wellbeing. In the context of public health, teachings of the four directions warn that a lack of balance limits our ability to achieve optimal health. While there is much public health success in lifestyle interventions, existing practice is limited by a siloed and one size fits all approach. Medicine Wheel teachings lay out a path toward more holistic and Indigenous-based lifestyle intervention that is modifiable depending on tribal teachings and needs, may appeal to a variety of Indigenous communities and is in alignment with health behavior change theory. It is a public health imperative that lifestyle management interventions are fully optimized to rigorously determine what can be achieved when interventions are implemented in a holistic and Indigenous-based manner, and in alignment with an Indigenous model of health. This more complete alignment would allow for a stronger foundation to further explore and develop social determinants (i.e., housing, employment, etc.) and structural intervention enhancements to inform public health practice and promote health equity.

American Indian and Alaska Native recruitment strategies for health-related randomized controlled trials: A scoping review

BACKGROUND

Significant health disparities exist among American Indian and Alaska Natives (AI/ANs), yet AI/ANs are substantially underrepresented within health-related research, including randomized controlled trials (RCTs). Although research has previously charted representation inequities, there is however a gap in the literature documenting best practice for recruitment techniques of AI/ANs into RCTs. Therefore, the aim of this review was to systematically gather and analyze the published literature to identify common strategies for AI/AN participant recruitment for RCTs in the US.

METHODS

A scoping review methodology was engaged with a systematic search operationalized within relevant databases to February 19, 2022, with an additional updated search being carried out up until January 1, 2023: PubMed, Embase, Web of Science, PsycINFO, CINAHL, and Google Scholar. A two-stage article review process was engaged with double reviewers using Covidence review software. Content analysis was then carried out within the included articles by two reviewers using NVivo software to identify common categories within the data on the topic area.

RESULTS

Our review identified forty-one relevant articles with the main categories of recruitment strategies being: 1) recruitment methods for AI/ANs into RCTs (passive advertising recruitment approaches, individual-level recruitment approaches, relational methods of recruitment); 2) recruitment personnel used within RCTs; and, 3) relevant recruitment setting. The majority of the included studies used a culturally relevant intervention, as well as a community-involved approach to operationalizing the research.

CONCLUSION

Increasing AI/AN representation in RCTs is essential for generating evidence-based interventions that effectively address health disparities and improve health outcomes. Researchers and funding agencies should prioritize the engagement, inclusion, and leadership of AI/AN communities throughout the RCT research process. This includes early community involvement in study design, implementation of culturally tailored recruitment strategies, and dissemination of research findings in formats accessible to AI/AN communities.

Adapting a cooking, food budgeting and nutrition intervention for a rural community of American Indians with type 2 diabetes in the North-Central United States

American Indian (AI) communities experience persistent diabetes-related disparities, yet few nutrition interventions are designed for AI with type 2 diabetes or address socio-contextual barriers to healthy eating. We describe our process of adapting the evidence-based Cooking Matters® program for use by AI adults with type 2 diabetes in a rural and resource-limited setting in the North-Central United States. We conducted three focus groups with AI adults with diabetes to (i) identify Cooking Matters® adaptations and (ii) gather feedback on appropriateness of the adapted intervention using Barrera and Castro's cultural adaptation framework. Transcripts were coded using an inductive, constant comparison approach. Queries of codes were reviewed to identify themes. Contextual considerations included limited access to grocery stores and transportation barriers, reliance on government food assistance and the intergenerational burden of diabetes. Adaptations to content and delivery included incorporating traditional and locally available foods; appealing to children or others in multigenerational households and prioritizing visual over written content. Our use of Barrera and Castro's framework adds rigor and structure to the cultural adaptation process and increases the likelihood of future intervention success. Other researchers may benefit from using this framework to guide the adaptation of evidence-based interventions in AI communities.

Behavioral Counseling Interventions to Promote a Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Known Cardiovascular Disease Risk Factors: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Unhealthful dietary patterns, low levels of physical activity, and high sedentary time increase the risk of cardiovascular disease.

OBJECTIVE

To synthesize the evidence on benefits and harms of behavioral counseling interventions to promote a healthy diet and physical activity in adults without known cardiovascular disease (CVD) risk factors to inform a US Preventive Services Task Force recommendation.

DATA SOURCES

MEDLINE, PsycINFO, and the Cochrane Central Register of Controlled Trials through February 2021, with ongoing surveillance through February 2022.

STUDY SELECTION

Randomized clinical trials (RCTs) of behavioral counseling interventions targeting improved diet, increased physical activity, or decreased sedentary time among adults without known elevated blood pressure, elevated lipid levels, or impaired fasting glucose.

DATA EXTRACTION AND SYNTHESIS

Independent data abstraction and study quality rating and random effects meta-analysis.

MAIN OUTCOMES AND MEASURES

CVD events, CVD risk factors, diet and physical activity measures, and harms.

RESULTS

One-hundred thirteen RCTs were included (N = 129 993). Three RCTs reported CVD-related outcomes: 1 study (n = 47 179) found no significant differences between groups on any CVD outcome at up to 13.4 years of follow-up; a combined analysis of the other 2 RCTs (n = 1203) found a statistically significant association of the intervention with nonfatal CVD events (hazard ratio, 0.27 [95% CI, 0.08 to 0.88]) and fatal CVD events (hazard ratio, 0.31 [95% CI, 0.11 to 0.93]) at 4 years. Diet and physical activity behavioral counseling interventions were associated with small, statistically significant reductions in continuous measures of blood pressure (systolic mean difference, -0.8 [95% CI, -1.3 to -0.3]; 23 RCTs [n = 57 079]; diastolic mean difference, -0.4 [95% CI, -0.8 to -0.0]; 24 RCTs [n = 57 148]), low-density lipoprotein cholesterol level (mean difference, 2.2 mg/dL [95% CI, -3.8 to -0.6]; 15 RCTs [n = 6350]), adiposity-related outcomes (body mass index mean difference, -0.3 [95% CI, -0.5 to -0.1]; 27 RCTs [n = 59 239]), dietary outcomes, and physical activity at 6 months to 1.5 years of follow-up vs control conditions. There was no evidence of greater harm among intervention vs control groups.

CONCLUSIONS AND RELEVANCE

Healthy diet and physical activity behavioral counseling interventions for persons without a known risk of CVD were associated with small but statistically significant benefits across a variety of important intermediate health outcomes and small to moderate effects on dietary and physical activity behaviors. There was limited evidence regarding the long-term health outcomes or harmful effects of these interventions.

Metabolic Syndrome Among American Indian and Alaska Native Populations: Implications for Cardiovascular Health

PURPOSE OF REVIEW

The latest national data reports a 55% prevalence of metabolic syndrome in American Indian adults compared to 34.7% of the general US adult population. Metabolic syndrome is a strong predictor for diabetes, which is the leading cause of heart disease in American Indian and Alaska Native populations. Metabolic syndrome and associated risk factors disproportionately impact this population. We describe the presentation, etiology, and roles of structural racism and social determinants of health on metabolic syndrome.

RECENT FINDINGS

Much of what is known about metabolic syndrome in American Indian and Alaska Native populations comes from the Strong Heart Study as there is scant literature. American Indian and Alaska Native adults have an increased propensity towards metabolic syndrome as they are 1.1 times more likely to have high blood pressure, approximately three times more likely to have diabetes, and have higher rates of obesity compared with their non-Hispanic White counterparts. Culturally informed lifestyle and behavior interventions are promising approaches to address structural racism and social determinants of health that highly influence factors contributing to these rates. Among American Indian and Alaska Native populations, there is scarce updated literature evaluating the underlying causes of major risk factors for metabolic syndrome, and progression to cardiometabolic disease. As a result, the actual state of metabolic syndrome in this population is not well understood. Systemic and structural changes must occur to address the root causes of these disparities.

A Scoping Review of the Use of Indigenous Food Sovereignty Principles for Intervention and Future Directions

Indigenous food sovereignty (IFS) represents a community-led movement with potential to reduce health inequities, but no scoping review of the impact of taking an IFS approach on intervention research has been conducted. This review sought to: 1) describe intervention studies that employ IFS principles, and 2) describe the impact of studies using IFS principles on food access, eating patterns, diet quality, physical activity, and health. Through a literature review, 4 IFS principles were identified: 1) community ownership, 2) inclusion of traditional food knowledge, 3) inclusion and promotion of cultural foods, and 4) environmental/intervention sustainability. Twenty intervention studies published between January 1, 2000 and February 5, 2020 were included. Most of the studies that scored high in IFS principles saw a positive impact on diet. This review found evidence supporting the value of IFS principles in the development, implementation, and evaluation of health interventions for Indigenous communities.

Cooking for Health: a healthy food budgeting, purchasing, and cooking skills randomized controlled trial to improve diet among American Indians with type 2 diabetes

Background

The prevalence of poor diet quality and type 2 diabetes are exceedingly high in many rural American Indian (AI) communities. Because of limited resources and infrastructure in some communities, implementation of interventions to promote a healthy diet is challenging—which may exacerbate health disparities by region (urban/rural) and ethnicity (AIs/other populations). It is critical to adapt existing evidence-based healthy food budgeting, purchasing, and cooking programs to be relevant to underserved populations with a high burden of diabetes and related complications. The Cooking for Health Study will work in partnership with an AI community in South Dakota to develop a culturally-adapted 12-month distance-learning-based healthy food budgeting, purchasing, and cooking intervention to improve diet among AI adults with type 2 diabetes.

Methods

The study will enroll 165 AIs with physician-diagnosed type 2 diabetes who reside on the reservation. Participants will be randomized to an intervention or control arm. The intervention arm will receive a 12-month distance-learning curriculum adapted from Cooking Matters® that focuses on healthy food budgeting, purchasing, and cooking skills. In-person assessments at baseline, month 6 and month 12 will include completion of the Nutrition Assessment Shared Resources Food Frequency Questionnaire and a survey to assess frequency of healthy and unhealthy food purchases. Primary outcomes of interest are: (1) change in self-reported intake of sugar-sweetened beverages (SSBs); and (2) change in the frequency of healthy and unhealthy food purchases. Secondary outcomes include: (1) change in self-reported food budgeting skills; (2) change in self-reported cooking skills; and (3) a mixed-methods process evaluation to assess intervention reach, fidelity, satisfaction, and dose delivered/received.

Discussion

Targeted and sustainable interventions are needed to promote optimal health in rural AI communities. If effective, this intervention will reduce intake of SSBs and the purchase of unhealthy foods; increase the purchase of healthy foods; and improve healthy food budgeting and cooking skills among AIs with type 2 diabetes – a population at high risk of poor health outcomes. This work will help inform future health promotion efforts in resource-limited settings.

Trial registration

This study was registered on ClinicalTrials.gov on October 9, 2018 with Identifier NCT03699709.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10308-8.

Maternal diabetes-related malformations in Utah: A population study of birth prevalence 2001-2016

Maternal pregestational diabetes mellitus is associated with an increased risk for congenital malformations of about 2-4 times the background risk. Notably, the types and patterns of congenital malformations associated with maternal diabetes are nonrandom, with a well-established increased risk for specific classes of malformations, especially of the heart, central nervous system, and skeleton. While the increased risk in clinical and epidemiological studies is well documented in the literature, a precise estimate of overall birth prevalence of these specific congenital malformations among women with maternal pregestational diabetes, is lacking. The purpose of this study was to determine total prevalence of structural malformations associated with maternal pregestational diabetes mellitus in a population-based study. We identified infants with specific birth defects whose mother had pregestational diabetes mellitus in the Utah Birth Defect Network (UBDN), an active birth defects surveillance program that registers the occurrence of selected structural defects in the state of Utah. We defined specific maternal diabetes-related malformations based on epidemiologic and clinical studies in the literature. Of the 825,138 recorded Utah births between 2001 and 2016, a total of 91 cases were identified as likely having diabetic embryopathy within UBDN data. The prevalence of diabetes-related congenital malformation cases was calculated per year; the overall prevalence of diabetes-related malformations 2001-2016 was 1.1 per 10,000 births in Utah (95% CI, 0.9-1.3). Knowledge of the overall prevalence of diabetes-related malformations is important in predicting the number of cases that are potentially prevented with the implementation of programs to foster preconceptional management of maternal pregestational diabetes.

Maboo wirriya, be healthy: Community-directed development of an evidence-based diabetes prevention program for young Aboriginal people in a remote Australian town

Supporting healthy lifestyle behaviours is a key aspect of preventing type 2 diabetes which disproportionately affects disadvantaged groups from a younger age. Formative participatory research was undertaken to design a program for young Aboriginal people in a remote town in North West Australia with a high level of health needs and relatively few prevention initiatives. Focus groups and advisory discussions with Aboriginal community members were used to determine the nature of the program. The need for a comprehensive program was consistently expressed and limited healthy lifestyle knowledge and difficulties with healthy eating influenced by food environments were noted to be important. With guidance from the Derby Aboriginal Health Service, findings were integrated with previous international research evidence to develop a program tailored to local Aboriginal people aged 15-25 years and refine it after piloting. This 8-session program, 'Maboo wirriya, be healthy' involved an education component consistent with the US Diabetes Prevention Program and practical activities including group exercise. Changes to program structure and documentation were made after piloting for future use. The community-directed approach used in this study is vital to ensure relevance of localised chronic disease prevention programs in a range of settings.

Characterizing the local food environment and grocery-store decision making among a large American Indian community in the north-central USA: qualitative results from the Healthy Foods Healthy Families Feasibility Study

OBJECTIVE

Perceptions of social-contextual food environments and associated factors that influence food purchases are understudied in American Indian (AI) communities. The purpose of the present study was to: (i) understand the perceived local food environment; (ii) investigate social-contextual factors that influence family food-purchasing choices; and (iii) identify diet intervention strategies.

DESIGN

This qualitative study consisted of focus groups with primary household shoppers and key-informant interviews with food retailers, local government food assistance programme directors and a dietitian. An inductive, constant comparison approach was used to identify major themes.

SETTING

A large AI reservation community in the north-central USA.

PARTICIPANTS

Four focus groups (n 31) and seven key-informant interviews were conducted in February and May 2016.

RESULTS

Perceptions of both the higher cost of healthy foods and limited access to these foods influenced the types of foods participants purchased. Dependence on government assistance programmes and the timing of benefits also contributed to the types of foods purchased. Participants described purchasing foods based on the dietary needs and preferences of their children. Suggestions for improving the purchase and consumption of healthy foods included: culturally relevant and family-centred cooking classes and workshops focused on monthly food budgeting. Participants also emphasized the importance of involving the entire community in healthy eating initiatives.

CONCLUSIONS

Cost and access were the major perceived barriers to healthy eating in this large rural AI community. Recommended interventions included: (i) family-friendly and culturally relevant cooking classes; (ii) healthy food-budgeting skills training; and (iii) approaches that engage the entire community.

Environmental interventions to reduce the consumption of sugar-sweetened beverages and their effects on health

BACKGROUND

Frequent consumption of excess amounts of sugar-sweetened beverages (SSB) is a risk factor for obesity, type 2 diabetes, cardiovascular disease and dental caries. Environmental interventions, i.e. interventions that alter the physical or social environment in which individuals make beverage choices, have been advocated as a means to reduce the consumption of SSB.

OBJECTIVES

To assess the effects of environmental interventions (excluding taxation) on the consumption of sugar-sweetened beverages and sugar-sweetened milk, diet-related anthropometric measures and health outcomes, and on any reported unintended consequences or adverse outcomes.

SEARCH METHODS

We searched 11 general, specialist and regional databases from inception to 24 January 2018. We also searched trial registers, reference lists and citations, scanned websites of relevant organisations, and contacted study authors.

SELECTION CRITERIA

We included studies on interventions implemented at an environmental level, reporting effects on direct or indirect measures of SSB intake, diet-related anthropometric measures and health outcomes, or any reported adverse outcome. We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) and interrupted-time-series (ITS) studies, implemented in real-world settings with a combined length of intervention and follow-up of at least 12 weeks and at least 20 individuals in each of the intervention and control groups. We excluded studies in which participants were administered SSB as part of clinical trials, and multicomponent interventions which did not report SSB-specific outcome data. We excluded studies on the taxation of SSB, as these are the subject of a separate Cochrane Review.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion, extracted data and assessed the risks of bias of included studies. We classified interventions according to the NOURISHING framework, and synthesised results narratively and conducted meta-analyses for two outcomes relating to two intervention types. We assessed our confidence in the certainty of effect estimates with the GRADE framework as very low, low, moderate or high, and presented 'Summary of findings' tables.

MAIN RESULTS

We identified 14,488 unique records, and assessed 1030 in full text for eligibility. We found 58 studies meeting our inclusion criteria, including 22 RCTs, 3 NRCTs, 14 CBA studies, and 19 ITS studies, with a total of 1,180,096 participants. The median length of follow-up was 10 months. The studies included children, teenagers and adults, and were implemented in a variety of settings, including schools, retailing and food service establishments. We judged most studies to be at high or unclear risk of bias in at least one domain, and most studies used non-randomised designs. The studies examine a broad range of interventions, and we present results for these separately.Labelling interventions (8 studies): We found moderate-certainty evidence that traffic-light labelling is associated with decreasing sales of SSBs, and low-certainty evidence that nutritional rating score labelling is associated with decreasing sales of SSBs. For menu-board calorie labelling reported effects on SSB sales varied.Nutrition standards in public institutions (16 studies): We found low-certainty evidence that reduced availability of SSBs in schools is associated with decreased SSB consumption. We found very low-certainty evidence that improved availability of drinking water in schools and school fruit programmes are associated with decreased SSB consumption. Reported associations between improved availability of drinking water in schools and student body weight varied.Economic tools (7 studies): We found moderate-certainty evidence that price increases on SSBs are associated with decreasing SSB sales. For price discounts on low-calorie beverages reported effects on SSB sales varied.Whole food supply interventions (3 studies): Reported associations between voluntary industry initiatives to improve the whole food supply and SSB sales varied.Retail and food service interventions (7 studies): We found low-certainty evidence that healthier default beverages in children's menus in chain restaurants are associated with decreasing SSB sales, and moderate-certainty evidence that in-store promotion of healthier beverages in supermarkets is associated with decreasing SSB sales. We found very low-certainty evidence that urban planning restrictions on new fast-food restaurants and restrictions on the number of stores selling SSBs in remote communities are associated with decreasing SSB sales. Reported associations between promotion of healthier beverages in vending machines and SSB intake or sales varied.Intersectoral approaches (8 studies): We found moderate-certainty evidence that government food benefit programmes with restrictions on purchasing SSBs are associated with decreased SSB intake. For unrestricted food benefit programmes reported effects varied. We found moderate-certainty evidence that multicomponent community campaigns focused on SSBs are associated with decreasing SSB sales. Reported associations between trade and investment liberalisation and SSB sales varied.Home-based interventions (7 studies): We found moderate-certainty evidence that improved availability of low-calorie beverages in the home environment is associated with decreased SSB intake, and high-certainty evidence that it is associated with decreased body weight among adolescents with overweight or obesity and a high baseline consumption of SSBs.Adverse outcomes reported by studies, which may occur in some circumstances, included negative effects on revenue, compensatory SSB consumption outside school when the availability of SSBs in schools is reduced, reduced milk intake, stakeholder discontent, and increased total energy content of grocery purchases with price discounts on low-calorie beverages, among others. The certainty of evidence on adverse outcomes was low to very low for most outcomes.We analysed interventions targeting sugar-sweetened milk separately, and found low- to moderate-certainty evidence that emoticon labelling and small prizes for the selection of healthier beverages in elementary school cafeterias are associated with decreased consumption of sugar-sweetened milk. We found low-certainty evidence that improved placement of plain milk in school cafeterias is not associated with decreasing sugar-sweetened milk consumption.

AUTHORS' CONCLUSIONS

The evidence included in this review indicates that effective, scalable interventions addressing SSB consumption at a population level exist. Implementation should be accompanied by high-quality evaluations using appropriate study designs, with a particular focus on the long-term effects of approaches suitable for large-scale implementation.

Proximate determinants of tuberculosis in Indigenous peoples worldwide: a systematic review

BACKGROUND

Indigenous peoples worldwide carry a disproportionate tuberculosis burden. There is an increasing awareness of the effect of social determinants and proximate determinants such as alcohol use, overcrowding, type 1 and type 2 diabetes, substance misuse, HIV, food insecurity and malnutrition, and smoking on the burden of tuberculosis. We aimed to understand the potential contribution of such determinants to tuberculosis in Indigenous peoples and to document steps taken to address them.

METHODS

We did a systematic review using seven databases (MEDLINE, Embase, CINAHL, Global Health, BIOSIS Previews, Web of Science, and the Cochrane Library). We identified English language articles published from Jan 1, 1980, to Dec 20, 2017, reporting the prevalence of proximate determinants of tuberculosis and preventive programmes targeting these determinants in Indigenous communities worldwide. We included any randomised controlled trials, controlled studies, cohort studies, cross-sectional studies, case reports, and qualitative research. Exclusion criteria were articles in languages other than English, full text not available, population was not Indigenous, focused exclusively on children or older people, and studies that focused on pharmacological interventions.

FINDINGS

Of 34 255 articles identified, 475 were eligible for inclusion. Most studies confirmed a higher prevalence of proximate determinants in Indigenous communities than in the general population. Diabetes was more frequent in Indigenous communities within high-income countries versus in low-income countries. The prevalence of alcohol use was generally similar to that among non-Indigenous groups, although patterns of drinking often differed. Smoking prevalence and smokeless tobacco consumption were commonly higher in Indigenous groups than in non-Indigenous groups. Food insecurity was highly prevalent in most Indigenous communities evaluated. Substance use was more frequent in Indigenous inhabitants of high-income countries than of low-income countries, with wide variation across Indigenous communities. The literature pertaining to HIV, crowding, and housing conditions among Indigenous peoples was too scant to draw firm conclusions. Preventive programmes that are culturally appropriate targeting these determinants appear feasible, although their effectiveness is largely unproven.

INTERPRETATION

Indigenous peoples were generally reported to have a higher prevalence of several proximate determinants of tuberculosis than non-Indigenous peoples, with wide variation across Indigenous communities. These findings emphasise the need for community-led, culturally appropriate strategies to address smoking, food insecurity, and diabetes in Indigenous populations as important public health goals in their own right, and also to reduce the burden of tuberculosis.

FUNDING

Canadian Institutes of Health Research.

Community involvement in design, implementation and evaluation of nutrition interventions to reduce chronic diseases in indigenous populations in the U.S.: a systematic review

Background

Indigenous peoples of the United States disproportionately experience chronic diseases associated with poor nutrition, including obesity and diabetes. While chronic disease related health disparities among Indigenous people are well documented, it is unknown whether interventions adequately address these health disparities. In addition, it is unknown whether and to what extent interventions are culturally adapted or tailored to the unique culture, worldview and nutrition environments of Indigenous people. The aim of this review was to identify and characterize nutrition interventions conducted with Indigenous populations in the US, and to determine whether and to what degree communities are involved in intervention design, implementation and evaluation.

Methods

Peer-reviewed articles were identified using MEDLINE. Articles included were published in English in a refereed journal between 2000 and 2015, reported on a diet-related intervention in Indigenous populations in the US, and reported outcome data. Data extracted were program objectives and activities, target population, geographic region, formative research to inform design and evaluation, partnership, capacity building, involvement of the local food system, and outcomes. Narrative synthesis of intervention characteristics and the degree and type of community involvement was performed.

Results

Of 1060 records identified, 49 studies were included. Overall, interventions were successful in producing changes in knowledge, behavior or health (79%). Interventions mostly targeted adults in the Western region and used a pre-test, post-test design. Involvement of communities in intervention design, implementation, and evaluation varied from not at all to involvement at all stages. Of programs reporting significant changes in outcomes, more than half used at least three strategies to engage communities. However, formative research to inform the evaluation was not performed to a great degree, and fewer than half of the programs identified described involvement of the local food system.

Conclusions

The extent of use of strategies to promote community engagement in programs reporting significant outcomes is notable. In planning interventions in Indigenous groups, researchers should consider ways to involve the community in intervention design, execution and evaluation. There is a particular need for studies focused on Indigenous youth in diverse regions of the US to further address diet-related chronic conditions.

Diet, physical activity or both for prevention or delay of type 2 diabetes mellitus and its associated complications in people at increased risk of developing type 2 diabetes mellitus

BACKGROUND

The projected rise in the incidence of type 2 diabetes mellitus (T2DM) could develop into a substantial health problem worldwide. Whether diet, physical activity or both can prevent or delay T2DM and its associated complications in at-risk people is unknown.

OBJECTIVES

To assess the effects of diet, physical activity or both on the prevention or delay of T2DM and its associated complications in people at increased risk of developing T2DM.

SEARCH METHODS

This is an update of the Cochrane Review published in 2008. We searched the CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, ICTRP Search Portal and reference lists of systematic reviews, articles and health technology assessment reports. The date of the last search of all databases was January 2017. We continuously used a MEDLINE email alert service to identify newly published studies using the same search strategy as described for MEDLINE up to September 2017.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with a duration of two years or more.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology for data collection and analysis. We assessed the overall quality of the evidence using GRADE.

MAIN RESULTS

We included 12 RCTs randomising 5238 people. One trial contributed 41% of all participants. The duration of the interventions varied from two to six years. We judged none of the included trials at low risk of bias for all 'Risk of bias' domains.Eleven trials compared diet plus physical activity with standard or no treatment. Nine RCTs included participants with impaired glucose tolerance (IGT), one RCT included participants with IGT, impaired fasting blood glucose (IFG) or both, and one RCT included people with fasting glucose levels between 5.3 to 6.9 mmol/L. A total of 12 deaths occurred in 2049 participants in the diet plus physical activity groups compared with 10 in 2050 participants in the comparator groups (RR 1.12, 95% CI 0.50 to 2.50; 95% prediction interval 0.44 to 2.88; 4099 participants, 10 trials; very low-quality evidence). The definition of T2DM incidence varied among the included trials. Altogether 315 of 2122 diet plus physical activity participants (14.8%) developed T2DM compared with 614 of 2389 comparator participants (25.7%) (RR 0.57, 95% CI 0.50 to 0.64; 95% prediction interval 0.50 to 0.65; 4511 participants, 11 trials; moderate-quality evidence). Two trials reported serious adverse events. In one trial no adverse events occurred. In the other trial one of 51 diet plus physical activity participants compared with none of 51 comparator participants experienced a serious adverse event (low-quality evidence). Cardiovascular mortality was rarely reported (four of 1626 diet plus physical activity participants and four of 1637 comparator participants (the RR ranged between 0.94 and 3.16; 3263 participants, 7 trials; very low-quality evidence). Only one trial reported that no non-fatal myocardial infarction or non-fatal stroke had occurred (low-quality evidence). Two trials reported that none of the participants had experienced hypoglycaemia. One trial investigated health-related quality of life in 2144 participants and noted that a minimal important difference between intervention groups was not reached (very low-quality evidence). Three trials evaluated costs of the interventions in 2755 participants. The largest trial of these reported an analysis of costs from the health system perspective and society perspective reflecting USD 31,500 and USD 51,600 per quality-adjusted life year (QALY) with diet plus physical activity, respectively (low-quality evidence). There were no data on blindness or end-stage renal disease.One trial compared a diet-only intervention with a physical-activity intervention or standard treatment. The participants had IGT. Three of 130 participants in the diet group compared with none of the 141 participants in the physical activity group died (very low-quality evidence). None of the participants died because of cardiovascular disease (very low-quality evidence). Altogether 57 of 130 diet participants (43.8%) compared with 58 of 141 physical activity participants (41.1%) group developed T2DM (very low-quality evidence). No adverse events were recorded (very low-quality evidence). There were no data on non-fatal myocardial infarction, non-fatal stroke, blindness, end-stage renal disease, health-related quality of life or socioeconomic effects.Two trials compared physical activity with standard treatment in 397 participants. One trial included participants with IGT, the other trial included participants with IGT, IFG or both. One trial reported that none of the 141 physical activity participants compared with three of 133 control participants died. The other trial reported that three of 84 physical activity participants and one of 39 control participants died (very low-quality evidence). In one trial T2DM developed in 58 of 141 physical activity participants (41.1%) compared with 90 of 133 control participants (67.7%). In the other trial 10 of 84 physical activity participants (11.9%) compared with seven of 39 control participants (18%) developed T2DM (very low-quality evidence). Serious adverse events were rarely reported (one trial noted no events, one trial described events in three of 66 physical activity participants compared with one of 39 control participants - very low-quality evidence). Only one trial reported on cardiovascular mortality (none of 274 participants died - very low-quality evidence). Non-fatal myocardial infarction or stroke were rarely observed in the one trial randomising 123 participants (very low-quality evidence). One trial reported that none of the participants in the trial experienced hypoglycaemia. One trial investigating health-related quality of life in 123 participants showed no substantial differences between intervention groups (very low-quality evidence). There were no data on blindness or socioeconomic effects.

AUTHORS' CONCLUSIONS

There is no firm evidence that diet alone or physical activity alone compared to standard treatment influences the risk of T2DM and especially its associated complications in people at increased risk of developing T2DM. However, diet plus physical activity reduces or delays the incidence of T2DM in people with IGT. Data are lacking for the effect of diet plus physical activity for people with intermediate hyperglycaemia defined by other glycaemic variables. Most RCTs did not investigate patient-important outcomes.

Interventions to reduce consumption of sugar-sweetened beverages or increase water intake: evidence from a systematic review and meta-analysis

A systematic review and meta-analyses were conducted to evaluate the effects of interventions to reduce sugar-sweetened beverages (SSB) or increase water intakes and to examine the impact of behaviour change techniques (BCTs) in consumption patterns. Randomized and nonrandomized controlled trials published after January 1990 and until December 2016 reporting daily changes in intakes of SSB or water in volumetric measurements (mL d^-1 ) were included. References were retrieved through searches of electronic databases and quality appraisal followed Cochrane principles. We calculated mean differences (MD) and synthesized data with random-effects models. Forty studies with 16 505 participants were meta-analysed. Interventions significantly decreased consumption of SSB in children by 76 mL d^-1 (95% confidence interval [CI] -105 to -46; 23 studies, P < 0.01), and in adolescents (-66 mL d^-1 , 95% CI -130 to -2; 5 studies, P = 0.04) but not in adults (-13 mL d^-1 , 95% CI -44 to 18; 12 studies, P = 0.16). Pooled estimates of water intakes were only possible for interventions in children, and results were indicative of increases in water intake (MD +67 mL d^-1 , 95% CI 6 to 128; 7 studies, P = 0.04). For children, there was evidence to suggest that modelling/demonstrating the behaviour helped to reduce SSB intake and that interventions within the home environment had greater effects than school-based interventions. In conclusion, public health interventions - mainly via nutritional education/counselling - are moderately successful at reducing intakes of SSB and increasing water intakes in children. However, on average, only small reductions in SSBs have been achieved by interventions targeting adolescents and adults. Complementary measures may be needed to achieve greater improvements in both dietary behaviours across all age groups.

Nutrition-based interventions to address metabolic syndrome in the Navajo: a systematic review

AIMS AND OBJECTIVES

The objective of this systematic review is to identify nutrition-based interventions that may be effective for the prevention and treatment of metabolic syndrome in the Navajo.

BACKGROUND

Metabolic syndrome, a major risk factor for cardiovascular disease, affects almost half of the Navajo population. The diet of the Navajo, heavy in fat and refined carbohydrates, has been identified as an important contributing factor to the high rates of metabolic syndrome in this population.

DESIGN

A search was conducted on PubMed, EMBASE and CINAHL to identify studies published before October, 2013, involving nutrition-based interventions in adult populations similar to the Navajo targeting at least one measure of metabolic syndrome.

METHODS

Data on efficacy and participation were gathered and synthesised qualitatively.

RESULTS

Out of 19 studies included in this systematic review, 11 interventions were identified to be effective at improving at least one measure of metabolic syndrome. Level of exposure to the intervention, frequency of intervention activities, family and social support, cultural adaptation and case management were identified as factors that may improve the efficacy of an intervention.

CONCLUSIONS

Multiple nutrition-based interventions have been found to be effective in populations similar to the Navajo.

RELEVANCE TO CLINICAL PRACTICE

Development of a strategy to address metabolic syndrome in the Navajo may involve aspects from multiple interventions to increase efficacy and maximise participation.

A systematic review of barriers and facilitators to participation in randomized controlled trials by Indigenous people from New Zealand, Australia, Canada and the United States

ISSUE

Many randomized controlled trials (RCTs) are conducted each year but only a small proportion is specifically designed for Indigenous people. In this review we consider the challenges of participation in RCTs for Indigenous peoples from New Zealand, Australia, Canada and the United States and the opportunities for increasing participation.

APPROACH

The literature was systematically searched for published articles including information on the barriers and facilitators for Indigenous people's participation in health-related RCTs. Articles were identified using a key word search of electronic databases (Scopus, Medline and EMBASE). To be included, papers had to include in their published work at least one aspect of their RCT that was either a barrier and/or facilitator for participation identified from, for example, design of intervention, or discussion sections of articles. Articles that were reviews, discussions, opinion pieces or rationale/methodology were excluded. Results were analysed inductively, allowing themes to emerge from the data.

KEY FINDINGS

Facilitators enabling Indigenous people's participation in RCTs included relationship and partnership building, employing Indigenous staff, drawing on Indigenous knowledge models, targeted recruitment techniques and adapting study material. Challenges for participation included both participant-level factors (such as a distrust of research) and RCT-level factors (including inadequately addressing likely participant barriers (phone availability, travel costs), and a lack of recognition or incorporation of Indigenous knowledge systems.

IMPLICATION

The findings from our review add to the body of knowledge on elimination of health disparities, by identifying effective and practical strategies for conducting and engaging Indigenous peoples with RCTs. Future trials that seek to benefit Indigenous peoples should actively involve Indigenous research partners, and respect and draw on pertinent Indigenous knowledge and values. This review has the potential to assist in the design of such studies.

Patterns of Food Consumption are Associated with Obesity, Self-Reported Diabetes and Cardiovascular Disease in Five American Indian Communities

The relationship between dietary patterns and chronic disease is underexplored in indigenous populations. We assessed diets of 424 American Indian (AI) adults living in 5 rural AI communities. We identified four food patterns. Increased prevalence for cardiovascular disease was highly associated with the consumption of unhealthy snacks and high fat-food patterns (OR 3.6, CI=1.06, 12.3; and OR 6.0, CI=1.63, 22.1), respectively. Moreover, the food-consumption pattern appeared to be different by community setting (p<.05). We recommend culturally appropriate community-intervention programs to promote healthy behavior and to prevent diet-related chronic diseases in this high-risk population.

A comparison of the effectiveness of physical activity and sedentary behaviour interventions in reducing sedentary time in adults: a systematic review and meta-analysis of controlled trials

The objective of this study was to systematically review the literature and compare the effectiveness of controlled interventions with a focus on physical activity (PA) and/or sedentary behaviours (SBs) for reducing sedentary time in adults. Six electronic databases were searched to identify all studies that examined the effects of interventions that targeted PA and/or SBs and that reported on changes in SBs (sedentary, sitting or television time). A qualitative synthesis was performed for all studies, and meta-analyses conducted among studies with mean differences (min/d) of sedentary time.

PROSPERO

CRD42014006535. Sixty-five controlled studies met inclusion criteria; 33 were used in the meta-analyses. Interventions with a focus on PA or that included a PA and SB component produced less consistent findings and generally resulted in modest reductions in sedentary time (PA: standardized mean differences [SMD] = -0.22 [95% confidence interval {CI}: -0.35, -0.10], PA+SB: SMD= -0.37 [95% CI: -0.69, -0.05]). Moderate quality evidence from the randomized controlled trial meta-analysis coupled with the qualitative synthesis provides consistent evidence that large and clinically meaningful reductions in sedentary time can be expected from interventions with a focus on reducing SBs (SMD= -1.28 [95% CI: -1.68, -0.87] ). There is evidence to support the need for interventions to include a component focused on reducing SBs in order to generate clinically meaningful reductions in sedentary time.

Dietary outcomes of a community based intervention for mothers of young children: a randomised controlled trial

BACKGROUND

Unhealthy dietary behaviours are one of the key risk factors for many lifestyle-related diseases worldwide. This randomised controlled trial aimed to increase the level of fruit, vegetable and fibre intake and decrease the fat and sugar consumption of mothers with young children (0-5 years) via the playgroup setting.

METHODS

Playgroups located in 60 neighbourhoods in Perth, Western Australia were randomly assigned to an intervention (n = 249) or control group (n = 272). Those in the intervention group received a 6-month multi-strategy primarily home-based physical activity and nutrition program (data is only presented on dietary behaviours). Data on dietary consumption was collected via the Fat and Fibre Barometer and frequency of serves of fruit and vegetable and cups of soft drink, flavoured drink and fruit juice. The effects of the intervention on continuous outcome measures were assessed using analysis of variance (ANOVA), after adjusting for mother's age and the corresponding variables.

RESULTS

The outcomes of the intervention were positive with the intervention group showing statistically significant improvements, when compared to the control group in the overall consumption of fat and fibre (p < 0.0005); of fibre (p < 0.0005) - fruit and vegetables (p < 0.0005), wholegrain (p = 0.002): and fat (p = 0.005) - dairy products (p = 0.006) and lean meat and chicken (p = 0.041). There were no significant changes in the consumption of sweet drinks.

CONCLUSIONS

This intervention was successful in improving dietary intake in the intervention group participants. The moderate positive outcomes indicate that playgroups potentially provide quite a viable setting to recruit, engage and retain this hard to reach group of mothers of young children in programs that support the adoption of health-enhancing behaviours. This adds valuable information to this under researched area.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12609000718246.

The long-term effects of lifestyle change on blood pressure: One-year follow-up of the ENCORE study

BACKGROUND

There is a paucity of data describing the sustained benefits of lifestyle interventions on health behaviors and blood pressure (BP).

METHODS

We examined the persistence of changes in health habits and BP in the ENCORE study, a trial in which 144 overweight individuals with above-normal BP were randomized to one of the following 16-week interventions: Dietary Approaches to Stop Hypertension (DASH) diet alone (DASH-A), DASH diet plus a behavioral weight management intervention (DASH-WM), or Usual Care. Follow-up assessments were conducted 8 months after the end of treatment.

RESULTS

At 16 weeks, systolic BP was reduced by 16.1 (95% confidence interval (CI) = 13.0-19.2) mm Hg in the DASH-WM group, 11.2 (95% CI = 8.1-14.3) mm Hg in the DASH-A group, and 3.4 (95% CI = 0.4-6.4) mm Hg in the Usual Care group. A decrease in BP persisted for 8 months, with systolic BP lower than baseline by 11.7 (95% CI = 8.1-15.3) mm Hg in the DASH-WM group, 9.5 (95% CI = 6.7-12.1) mm Hg in the DASH-A group, and 3.9 (95% CI = 0.5-7.3) mm Hg in the Usual Care group (P < 0.001 for active treatments vs. Usual Care). DASH-WM subjects lost 8.7 kg during the intervention and remained 6.3 kg lighter on follow-up examination. Changes in diet content were sustained in both DASH intervention groups. Among those who participated in DASH-WM, however, caloric intake was no longer lower, and only 21% reported still exercising regularly 8 months after completing the intervention.

CONCLUSIONS

Changes in dietary habits, weight, and BP persisted for 8 months after completion of the 16-week ENCORE program, with some attenuation of the benefits. Additional research is needed to identify effective methods to promote long-term maintenance of the benefits of lifestyle modification programs.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT00571844.

Results of a randomized controlled trial to promote physical activity behaviours in mothers with young children

OBJECTIVE

Increasing levels of physical activity in mothers have long-term health benefits for the mother and family. The study aimed to evaluate the effect of a six-month, physical activity RCT for mothers of young children.

METHODS

Women were recruited via playgroups and randomly assigned to intervention (n=394) or control group (n=322). The intervention group received a six-month multi-strategy programme delivered via playgroups in Perth, Australia. measures were mean minutes per week of moderate (M) and vigorous (V) intensity physical activity (PA), and number of days/week of muscle strength exercises.

RESULTS

The intervention had a significant effect on mean time for vigorous (p=0.008), moderate (p=0.023) and total physical activity (p=0.001) when compared to the control group. The intervention group increased their vigorous activity by a mean of 24min/week, moderate activity by 23min/week and total physical activity by 72min/week.

CONCLUSIONS

A relatively minimum home based intervention was able to demonstrate modest but statistically significant improvements in physical activity in a hard to reach group. These changes if maintained over a longer period are likely to improve the health of mothers and have a positive impact on their partners and children. Australian and New Zealand Clinical Trials Registry ACTRN12609000735257.

Healthy Foods North improves diet among Inuit and Inuvialuit women of childbearing age in Arctic Canada

BACKGROUND

Healthy Foods North (HFN) is a community-based intervention designed to promote a healthy diet and lifestyle of Inuit and Inuvialuit populations in Arctic Canada. The objective of the present study was to determine the effects of HFN on the nutrient intake of women of childbearing age.

METHODS

Six communities in Nunavut (n = 3) and the Northwest Territories (n = 3) were selected for programme implementation; four received a 12-month intervention and two served as controls. Quantitative food frequency questionnaires were used to assess dietary intake at baseline and 1 year post-intervention. Among women participants aged 19-44 years (n = 136), 79 were exposed to the intervention and 57 were not. Mean daily energy and nutrient intake and density were determined. Dietary adequacy was assessed by comparing the women's daily nutrient intakes with dietary reference intakes (DRI).

RESULTS

Main outcomes were the pre- to post-intervention changes between intervention and control groups for energy and selected nutrient intakes, nutrient density and dietary adequacy. Among the participants, the intervention had a beneficial effect on vitamin A and D intake. The percentage of individuals with nutrient intakes below the DRI increased from pre- to post-intervention for vitamin A and D in the control group but only for vitamin A in the intervention group. The programme did not have a significant impact on calorie, sugar, or fat consumption.

CONCLUSIONS

The HFN programme is effective in mitigating some of the negative impacts of the nutrition transition on dietary adequacy among Inuit and Inuvialuit women of childbearing age.

Community-based efforts to promote physical activity: a systematic review of interventions considering mode of delivery, study quality and population subgroups

OBJECTIVES

Despite the known benefits of physical activity, the majority of adults in developed countries lead sedentary lifestyles. The community setting is a promising venue for physical activity-promoting interventions. Our objectives were to investigate the effectiveness of community-based physical activity interventions by mode of delivery, study quality and to analyse intervention effectiveness in different subgroups in the population.

DESIGN

We conducted a systematic literature review in Medline and other databases to identify controlled, community-based physical activity interventions published between 2001 and 2012.

METHODS

We performed several post hoc subgroup comparisons for mode of delivery, study quality and selected population characteristics, using net per cent change in physical activity outcomes between baseline and follow-up as an effect measure.

RESULTS

We identified 55 studies on exercise/walking sessions, face-to-face counselling, public campaigns and interventions by mail, the Internet and telephone presenting data on 20,532 participants. Overall, half of the studies reported positive physical activity outcomes (total net per cent change: 16.4%; p=0.159; net per cent change for high-quality studies, i.e. studies meeting more than 5 out of 7 quality criteria: 16.2%; p=0.010). Interventions using face-to-face counselling or group sessions were most effective (net per cent change: 35.0%; p=0.014). Net per cent change was also higher in studies exclusively tailored to women (27.7%; p=0.005) or specific ethnic groups (38.9%; p=0.034).

CONCLUSIONS

This systematic review supports the effectiveness of community-based physical activity interventions in high-quality studies. Our results suggest that interventions using personal contact as well as tailored interventions are most promising.

A Community-Based, Environmental Chronic Disease Prevention Intervention to Improve Healthy Eating Psychosocial Factors and Behaviors in Indigenous Populations in the Canadian Arctic

Diet-related chronic diseases are highly prevalent among indigenous populations in the Canadian Arctic. A community-based, multi-institutional nutritional and lifestyle intervention—Healthy Foods North—was implemented to improve food-related psychosocial factors and behaviors among Inuit and Inuvialuit in four intervention communities (with two comparison communities) in Nunavut and the Northwest Territories, Canada, in 2008. The 12-month program was developed from theory (social cognitive theory and social ecological models), formative research, and a community participatory process. It included an environmental component to increase healthy food availability in local stores and activities consisting of community-wide and point-of-purchase interactive educational taste tests and cooking demonstrations, media (e.g., radio ads, posters, shelf labels), and events held in multiple venues, including recreation centers and schools. The intervention was evaluated using pre- and postassessments with 246 adults from intervention and 133 from comparison communities (311 women, 68 men; mean age 42.4 years; 78.3% retention rate). Outcomes included psychosocial constructs (healthy eating knowledge, self-efficacy, and behavioral intentions), frequency of healthy and unhealthy food acquisition, healthiness of commonly used food preparation methods, and body mass index (kg/m2). After adjustment for demographic, socioeconomic status, and body mass index variables, respondents living in intervention communities showed significant improvements in food-related self-efficacy (β = 0.15, p = .003) and intentions (β = 0.16, p = .001) compared with comparison communities. More improvements from the intervention were seen in overweight, obese, and high socioeconomic status respondents. A community-based, multilevel intervention is an effective strategy to improve psychosocial factors for healthy nutritional behavior change to reduce chronic disease in indigenous Arctic populations.

Diabetes prevention research: a systematic review of external validity in lifestyle interventions

CONTEXT

Type 2 diabetes is a major contributor to disease burden globally. A number of systematic reviews support the efficacy of lifestyle interventions in preventing Type 2 diabetes in adults; however, relatively little attention has been paid to the generalizability of study findings. This study systematically reviews the reporting of external validity components and generalizability of diabetes prevention studies.

EVIDENCE ACQUISITION

Lifestyle intervention studies for the prevention of Type 2 diabetes in adults with at least 6 months' follow-up, published between 1990 and 2011, were identified through searches of major electronic databases. External validity reporting was rated using an assessment tool, and all analysis was undertaken in 2011.

EVIDENCE SYNTHESIS

A total of 31 primary studies (n=95 papers) met the selection criteria. All studies lacked full reporting on external validity elements. Description of the study sample, intervention, delivery agents, and participant attrition rates were reported by most studies. However, few studies reported on the representativeness of individuals and settings, methods for recruiting settings and delivery agents, costs, and how interventions could be institutionalized into routine service delivery. It is uncertain to what extent the findings of diabetes prevention studies apply to men, socioeconomically disadvantaged individuals, those living in rural and remote communities, and to low- and middle-income countries.

CONCLUSIONS

Reporting of external validity components in diabetes prevention studies needs to be enhanced to improve the evidence base for the translation and dissemination of these programs into policy and practice.

The relevancy of community-based methods: using diet within Native American and Alaska Native adult populations as an example

The rates of obesity, diabetes, and heart disease in Native Americans and Alaska Natives far exceed that of the general US population. There are many postulating reasons for these excessive rates including the transition from a traditional to a contemporary diet. Although information on the dietary intakes of Native American and Alaska Native communities are limited, there seems to be a consensus that the Native American and Alaska Native diet is high in total fat, saturated fat, cholesterol, and sodium. Further information on the diet needs to be attained so that dietary interventions can effectively be implemented in these communities. An approach that is community based is proposed as the best solution to understanding the Native diet and developing culturally tailored interventions to sustainably improve diet.

Changes in dietary habits and their association with metabolic markers after a non-intensive, community-based lifestyle intervention to prevent type 2 diabetes, in Greece. The DEPLAN study

AIMS

The aim of the present study was to evaluate the impact on dietary and activity habits of a non-intensive, community based lifestyle intervention for type 2 diabetes prevention, in high-risk Greek individuals.

METHODS

A total of 191 high-risk persons were invited to participate in a one-year lifestyle intervention program, consisting of six bi-monthly sessions with a dietician. The dietary aims of the intervention were: reduction of saturated fat, sugars and refined cereals intake and at least five servings of fruits and vegetables, daily. Demographic, dietary, anthropometric, medical and biochemical indices were recorded at baseline and at the end of the intervention.

RESULTS

The intervention was completed by 126 participants. At study end, participants reported decreased whole fat dairies and processed meats consumption (p=0.018 and 0.016, respectively), sugars (p=0.006) and refined cereals (p=0.045). Participants who improved their diet, decreased body weight (p=0.040), plasma triglycerides (p=0.020) and 2-h post-load plasma glucose (p=0.05) compared to those who had worsened their dietary habits. Total time spent daily on physical activity, remained unchanged throughout the intervention.

CONCLUSIONS

The implementation of a group-based, non-intensive dietary counseling proved to be practical and feasible in "real-world" community settings and was accompanied by favorable dietary changes and health benefits.

Formative assessment using social marketing principles to identify health and nutrition perspectives of Native American women living within the Chickasaw Nation boundaries in Oklahoma

OBJECTIVE

To identify health product and promotion channels for development of a Chickasaw Nation Supplemental Nutrition Assistance Education Program (SNAP-Ed) social marketing program.

METHODS

The study was qualitative and used social marketing principles to assess Native American women's views of health and nutrition. Focus groups (n = 8) and interviews (n = 4) were conducted to identify indigenous views of product, promotion, price, and place related to SNAP-Ed behavioral objectives.

RESULTS

The major theme identified for product was diabetes prevention. Participants (n = 42) indicated a preference for family-based education with promotion by elders, tribal leaders, and "everyday people." Participants identified tribe-specific community sites for program implementation at times conducive to work schedules.

CONCLUSIONS AND IMPLICATIONS

Culturally appropriate social marketing programs are necessary to address diabetes prevention with a focus on family, heritage, and tribal community. Additional research is necessary to explore the role of elders and tribal leaders in diabetes prevention efforts.

Type 2 diabetes in Indigenous populations: quality of intervention research over 20 years

BACKGROUND

A robust evidence base is needed to reduce the disproportionately high rates of diabetes-related mortality and complications among Indigenous peoples.

OBJECTIVE

This study aimed to evaluate the quantity and methodological quality of published intervention research on Type 2 and gestational diabetes in the Indigenous populations of Australia, Canada, New Zealand, and the United States from 1989 to 2008. A robust evidence base is needed to reduce the disproportionately high rates of diabetes-related mortality and complications among Indigenous peoples.

METHODS

Systematic searches of Medline, Embase, and EBM Reviews identified publications focused on Type 2 or gestational diabetes in Indigenous peoples published between 1 January 1989 and 31 December 2008. Total publication number and proportion of research involving interventions over time were examined. The quality of intervention studies was evaluated using Cochrane's Effective Practice and Organisation of Care (EPOC) criteria.

RESULTS

Total publication number increased significantly over the 20 years (p<0.004). Research was predominantly descriptive (87%), with the proportion of research involving interventions increasing from 3% in 1989-1993 to 12% in 2003-2008 (χ(2)=12.42, df=3, p=0.006). However, only 25% (95%CI: 9-41%) of intervention studies met the EPOC methodological quality criteria; other studies lacked sufficient controls or measurements over time.

CONCLUSIONS

Increases in the amount of high-quality intervention research for prevention and treatment of Type 2 and gestational diabetes among Indigenous populations of these countries are needed.

State of the science: a cultural view of Native Americans and diabetes prevention

The purpose of this article is to present a review of the literature on diabetes type 2 prevention interventions for Native American populations. The interrelation of the cultural role of food in Native American diets, educational policies related to food, outcomes of federal policies, and the historical background of diabetes are addressed. In addition, published studies of diabetes prevention interventions with Native American populations are examined. Lastly, exemplars of programs that represent best practices in the prevention of diabetes are described.

Exercise or exercise and diet for preventing type 2 diabetes mellitus

BACKGROUND

The incidence of type 2 diabetes is associated with the 'Westernised lifestyle', mainly in terms of dietary habits and physical activity. Thus an intensive diet and exercise intervention might prevent or delay the appearance of diabetes in persons at high risk.

OBJECTIVES

To assess the effects of exercise or exercise and diet for preventing type 2 diabetes mellitus.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, EMBASE, CINAHL, LILACS, SocioFile, databases of ongoing trials and reference lists of relevant reviews.

SELECTION CRITERIA

Studies were included if they were randomised controlled trials of exercise and diet interventions of at least six month duration and reported diabetes incidence in people at risk for type 2 diabetes.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. Study authors were contacted to obtain missing data. Data on diabetes incidence and secondary outcomes were analysed by means of random-effects meta-analysis.

MAIN RESULTS

We included eight trials that had an exercise plus diet (2241 participants) and a standard recommendation arm (2509 participants). Two studies had a diet only (167 participants) and exercise only arm (178 participants). Study duration ranged from one to six years. Overall, exercise plus diet interventions reduced the risk of diabetes compared with standard recommendations (RR 0.63, 95% CI 0.49 to 0.79). This had also favourable effects on weight and body mass index reduction, waist-to-hip ratio and waist circumference. However, statistical heterogeneity was very high for these outcomes. Exercise and diet interventions had a very modest effect on blood lipids. However, this intervention improved systolic and diastolic blood pressure levels (weighted mean difference -4 mmHg, 95% CI -5 to -2 and -2 mmHg, 95% CI -3 to -1, respectively). No statistical significant effects on diabetes incidence were observed when comparing exercise only interventions either with standard recommendations or with diet only interventions. No study reported relevant data on diabetes and cardiovascular related morbidity, mortality and quality of life.

AUTHORS' CONCLUSIONS

Interventions aimed at increasing exercise combined with diet are able to decrease the incidence of type 2 diabetes mellitus in high risk groups (people with impaired glucose tolerance or the metabolic syndrome). There is a need for studies exploring exercise only interventions and studies exploring the effect of exercise and diet on quality of life, morbidity and mortality, with special focus on cardiovascular outcomes.

Impact of periodic follow-up testing among urban American Indian women with impaired fasting glucose

INTRODUCTION

Impaired fasting glucose (IFG) often progresses to type 2 diabetes. Given the severity and prevalence of this disease, primary prevention is important. Intensive lifestyle counseling interventions have delayed or prevented the onset of type 2 diabetes, but it is not known whether less intensive, more easily replicable efforts can also be effective.

METHODS

In a lifestyle intervention study designed to reduce risks for type 2 diabetes, 200 American Indian women without diabetes, aged 18 to 40 years, were recruited from an urban community without regard to weight or IFG and block-randomized into intervention and control groups on the basis of fasting blood glucose (FBG). Dietary and physical activity behaviors were reported, and clinical metabolic, fitness, and body composition measures were taken at baseline and at periodic follow-up through 18 months. American Indian facilitators used a group-discussion format during the first 6 months to deliver a culturally influenced educational intervention on healthy eating, physical activity, social support, and goal setting. We analyzed a subset of young American Indian women with IFG at baseline (n = 42), selected from both the intervention and control groups.

RESULTS

Among the women with IFG, mean FBG significantly decreased from baseline to follow-up (P < .001) and converted to normal (<5.6 mmol/L or <100 mg/dL) in 62.0% of the 30 women who completed the 18-month follow-up, irrespective of participation in the group educational sessions. Other improved metabolic values included significant decreases in mean fasting blood total cholesterol and low-density lipoprotein cholesterol levels. The women reported significant overall mean decreases in intake of total energy, saturated fat, total fat, total sugar, sweetened beverages, proportion of sweet foods in the diet, and hours of TV watching.

CONCLUSION

Volunteers with IFG in this study benefited from learning their FBG values and reporting their dietary patterns; they made dietary changes and improved their FBG and lipid profiles. If confirmed in larger samples, these results support periodic dietary and body composition assessment, as well as glucose monitoring among women with IFG.