A position statement on screening and management of prediabetes in adults in primary care in Australia

The burden of type 2 diabetes in China from 1990 to 2021: A comparative analysis with G20 countries using the global burden of disease study 2021

OBJECTIVES

The study aims to evaluate the burden of Type 2 Diabetes (T2D) in China from 1990 to 2021, and compare to it across G20 countries.

METHODS

We utilized data from the Global Burden of Disease Study 2021 to examine the burden of T2D in China from 1990 to 2021. Prevalence, mortality, disability-adjusted life years (DALYs), years of life lost (YLLs), and years lived with disability (YLDs) were calculated. Comparative analyses were conducted with other G20 countries.

RESULTS

T2D prevalence in China increased between 1990 and 2021, with rates rising from 3519.8 (3138.3-3910.1) to 6055.5 (5510.1-6614.3) per 100,000. The death rates slightly decreased from 9.3 (8.2-10.5) per 100,000 to 8.7 (7.3-10.3). The DALYs rate increased from 438.7 (358.5-531.5) to 569.8 (435.4-734.2), with increases observed in YLDs and YLLs. Males had a heavier disease burden in China. Compared to G20 countries, China ranked high in prevalence but had relatively better mortality outcomes in older age groups.

CONCLUSION

This study reveals the enormous burden and remarkable control efforts of T2D in China. Comparative analysis emphasizes the importance of tailored public health interventions to address this growing health crisis.

Responses to lifestyle interventions among individuals with distinct pre-diabetes phenotypes: A systematic review and Meta-Analysis

AIMS

To assess responses to lifestyle interventions (LIs) among individuals with distinct pre-diabetes phenotypes (isolated impaired fasting glucose [i-IFG], isolated impaired glucose tolerance [i-IGT], and combined IFG + IGT) for reducing diabetes incidence, reversing pre-diabetes, and improving glycemic control and insulin sensitivity.

METHODS

PubMed, Embase, Cochrane Library, and Web of Science were searched until December 6th, 2023. We included randomized controlled trials examining responses to LIs (including diet and/or physical activity) among adults with i-IFG, i-IGT, and IFG + IGT. Outcomes included diabetes incidence, normoglycemia incidence, fasting plasma glucose (FPG), 2-hour plasma glucose (2 h-PG), hemoglobin A1c, fasting insulin (FI), and homeostasis model assessment-insulin resistance (HOMA-IR). Random-effects meta-analyses were performed to estimate risk ratios (RRs) and mean differences.

RESULTS

Twenty-seven studies were included. Meta-analysis of 10 studies that performed stratified analyses by pre-diabetes phenotype found that LIs significantly reduced diabetes incidence in i-IGT (RR = 0.69 [0.56; 0.85], I2 = 14 %) and IFG + IGT (RR = 0.56 [0.48; 0.66], I2 = 0 %) but not in i-IFG (RR = 0.85 [0.66; 1.11], I2 = 0 %; psubgroup = 0.02). Meta-analysis of 20 studies using IGT for participant recruitment showed that LIs significantly decreased diabetes incidence, increased normoglycemia incidence, and improved FPG, 2 h-PG, FI and HOMA-IR.

CONCLUSIONS

LIs are effective for IGT (with or without IFG), but tailored LIs are needed for i-IFG to prevent diabetes.

Health and Liver Diagnostic Markers Influencing Glycemia in Subjects with Prediabetes: Preview Study

INTRODUCTION

Glucose homeostasis may be dependent on liver conditions and influence health-related markers and quality of life (QoL) objective measurements. This study aimed to analyze the interactions of glycemia with liver and health status in a prediabetic population.

SUBJECTS AND METHODS

This study included 2220 overweight/obese prediabetics from the multinational PREVIEW project. Anthropometrics; clinical, metabolic and other health-related markers; and QoL variables were analyzed. Univariate and multilinear-adjusted regression models were run to explain the interrelationships and effect modification between glycemia, health-related QoL (applying SF-12) and metabolic/liver health (using the HSI, a putative marker of fatty liver).

RESULTS

Relevant age/sex interactions were found concerning the levels of insulin, HOMA-IR, C peptide and transaminases in this prediabetic population. Multivariate models identified age, sex, glucose, WC and QoL as important predictors of HSI variability (adj. R value = 0.1393, p < 0.001), whereas the QoL status was statistically related to age, sex, HOMA-IR and HSI (adj. R value = 0.1130, p < 0.001) in this glycemia-impaired group. Furthermore, the QoL values declined with increased HSI scores, where a significant interaction was found (p = 0.011) when the data were analyzed when comparing lower glycemia vs. higher glycemia in prediabetics. Indeed, an effect modification was featured depending on the glycemia levels concerning the QoL and HSI worsening.

CONCLUSION

Glycemia associations with the QoL status and liver metabolism markers were evidenced, with clinical implications for diabetes and liver disease precision management given the modification of the QoL outcomes depending on the liver status and glycemia concentrations. Notably, independent associations of circulating glucose with age, sex, adiposity, inflammation and C peptide levels were found.

Cultural Influences, Experiences and Interventions Targeting Self-Management Behaviours for Prediabetes or Type 2 Diabetes in First-Generation Immigrants: A Scoping Review

AIM

To map the existing evidence and identify research gaps regarding the self-management of prediabetes or type 2 diabetes among first-generation immigrants ≥ 18 years.

DESIGN

A scoping review followed the JBI guidelines and was in accordance with the PRISMA extension for Scoping Reviews.

METHODS

A systematic search of CINAHL, Cochrane, EMBASE, MEDLINE, PsycINFO, ProQuest, SCOPUS and the Web of Science was conducted. Grey literature and reference lists of included studies were searched for additional citations. Articles published in English from the database inception to February 2023 were included.

RESULTS

We included 96 studies, of which 28.1% were published within the last 5 years. Most studies (71.9%) were conducted in the United States. Study participants were recruited mainly from community settings and English was their second language. The most common study methodologies used were cross-sectional surveys and phenomenological interviews. Only two studies specifically focussed on individuals with prediabetes. Multiple factors, such as age, gender, country of origin and other societal, linguistic, cultural and resource barriers or facilitators, as well as patient's cultural unique experiences, were of particular significance for self-management behaviours. Although several studies reported that culturally tailored interventions were feasible and acceptable among first-generation immigrants living with type 2 diabetes but not prediabetes, the duration and intensity of these interventions varied.

CONCLUSION

Health professionals should consider various demographic, societal, linguistic and cultural factors, such as participants' low English language proficiency, and provide appropriate support for this group to ensure better self-management behaviours. Tailoring interventions to individual and cultural preferences in collaboration with key stakeholders is crucial for adult immigrants with prediabetes and type 2 diabetes across diverse cultural and ethnic groups.

IMPACT

Developing and applying culturally tailored self-management interventions for the targeted population, particularly those with prediabetes, should be an important direction for future research. No Patient or Public Contribution.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Knowledge, attitude, and practice of pre-diabetic older people regarding pre-diabetes

BACKGROUND

One of the risk factors of diabetes is the pre-diabetes stage which is significantly prevalent in older people. Knowledge, attitude, and practice of the pre-diabetic stage are of great importance and can decrease complications. The present study aimed to determine the knowledge, attitude, and practice of the pre-diabetic older people.

METHODS

This cross-sectional study was conducted from April 2022 to August 2022 on 219 pre-diabetic older people referring to Sina Hospital in Tabriz, one of the most populated cities in the northwest of Iran. Data were collected using questionnaires of Knowledge, Attitude, Practice-Prediabetes Assessment Questionnaire (KAP-PAQ). The data were analyzed by SPSS 21.

RESULTS

The mean scores of knowledge (in the range of 0-17), attitude (in the range of -10, + 10), and practice (in the range of 0-26) were 1.72 ± 1.0, 2.24 ± 1.92, and 5.76 ± 2.61, respectively. The older people's knowledge and practice levels in the pre-diabetes stage were low and about 50% of them had negative views. According to the Spearman correlation test, there was a positive significant relationship between the older people's knowledge and practice (p < 0.001, r = 0.234).

CONCLUSIONS

The older people in the pre-diabetes stage had low knowledge and attitude and a negative viewpoint towards correcting lifestyle on diet, exercising and physical activity, weight control, diagnostic and screening methods. Increased knowledge about pre-diabetes and strengthened positive attitude towards correcting lifestyle through counseling as well as empowering the pre-diabetic older people can increase the efficiency of pre-diabetes prevention and control programs and prevent its progression to the diabetes stage.

Increased TG Levels and HOMA-IR Score Are Associated With a High Risk of Prediabetes: A Prospective Study

This study aimed to determine the association of blood lipid and insulin levels with the development of prediabetes. In this prospective cohort study, we collected and analyzed data related to demographic characteristics, lipid profiles, and insulin parameters at baseline (2008-2012) and at follow-up (2019-2020). A total of 1205 participants were included. The study found that maintained or elevated Homeostatic Model Assessment for Insulin Resistance (HOMO-IR) score and elevated triglyceride (TG) levels from baseline to follow-up were associated with an increased risk of prediabetes. However, the interaction between blood lipids and insulin had no significant effect on the risk of prediabetes. Our findings indicate that elevated TG or HOMA-IR levels are associated with an increased risk of prediabetes. These findings emphasize the need to formulate initiatives that can help reduce dyslipidemia to prevent the onset of prediabetes and diabetes.

Do patients with prediabetes managed with metformin achieve better glycaemic control? A national study using primary care medical records

AIMS

To estimate the effectiveness of metformin on glycaemic parameters among participants with incident prediabetes attending Australian general practices.

METHODS

This retrospective cohort study used electronic health records of regular participants (3+ visits in two consecutive years) attending 383 Australian general practices (MedicineInsight). Participants with 'incident' prediabetes (newly recorded diagnosis between 2012 and 2017) and their glycaemic parameters (haemoglobin A1c [HbA1c] or fasting blood glucose [FBG]) at 6-, 12-, and 18-24 months post diagnosis (unexposed) or post-management with metformin (treatment) were identified from the database. We estimated the average treatment effect (ATE) of metformin management on glycaemic parameters using both linear regression and augmented inverse probability weighting.

RESULTS

Of the 4770 investigated participants with 'incident' prediabetes, 10.2% were managed with metformin. Participants on metformin had higher HbA1c levels at the baseline than those unexposed (mean 45 mmol/mol [6.2%] and 41 mmol/mol [5.9%], respectively), but no differences were observed at 6-12 months (mmol/mol ATE 0.0, 95% CI -0.4; 0.7) or 12-18 months (ATE -0.3, 95% CI -1.2; 0.3). However, participants on metformin had lower mean HbA1c mmol/mol at 18-24 months (ATE -1.1, 95% CI -2.0; 0.1) than those unexposed. Consistent results were observed for FBG (ATE at 6-12 months -0.14 [95% CI -0.25; -0.04], 12-18 months 0.02 [95% CI -0.08; 0.13] and 18-24 months -0.07 [95% CI -0.25; 0.12]).

CONCLUSION

The higher HbA1c and FBG baseline levels among participants with 'incident' prediabetes managed with metformin improved after 6-12 months of starting pharmacological management, and the effect persisted for up to 24 months. Management with metformin could prevent further deterioration of glycaemic levels.

Inflammation, oxidative stress and mitochondrial dysfunction in the progression of type II diabetes mellitus with coexisting hypertension

Introduction

Type II diabetes mellitus (T2DM) is a metabolic disorder that poses a serious health concern worldwide due to its rising prevalence. Hypertension (HT) is a frequent comorbidity of T2DM, with the co-occurrence of both conditions increasing the risk of diabetes-associated complications. Inflammation and oxidative stress (OS) have been identified as leading factors in the development and progression of both T2DM and HT. However, OS and inflammation processes associated with these two comorbidities are not fully understood. This study aimed to explore changes in the levels of plasma and urinary inflammatory and OS biomarkers, along with mitochondrial OS biomarkers connected to mitochondrial dysfunction (MitD). These markers may provide a more comprehensive perspective associated with disease progression from no diabetes, and prediabetes, to T2DM coexisting with HT in a cohort of patients attending a diabetes health clinic in Australia.

Methods

Three-hundred and eighty-four participants were divided into four groups according to disease status: 210 healthy controls, 55 prediabetic patients, 32 T2DM, and 87 patients with T2DM and HT (T2DM+HT). Kruskal-Wallis and χ2 tests were conducted between the four groups to detect significant differences for numerical and categorical variables, respectively.

Results and discussion

For the transition from prediabetes to T2DM, interleukin-10 (IL-10), C-reactive protein (CRP), 8-hydroxy-2'-deoxyguanosine (8-OHdG), humanin (HN), and p66^Shc were the most discriminatory biomarkers, generally displaying elevated levels of inflammation and OS in T2DM, in addition to disrupted mitochondrial function as revealed by p66^Shc and HN. Disease progression from T2DM to T2DM+HT indicated lower levels of inflammation and OS as revealed through IL-10, interleukin-6 (IL-6), interleukin-1β (IL-1β), 8-OHdG and oxidized glutathione (GSSG) levels, most likely due to antihypertensive medication use in the T2DM +HT patient group. The results also indicated better mitochondrial function in this group as shown through higher HN and lower p66^Shc levels, which can also be attributed to medication use. However, monocyte chemoattractant protein-1 (MCP-1) levels appeared to be independent of medication, providing an effective biomarker even in the presence of medication use. The results of this study suggest that a more comprehensive review of inflammation and OS biomarkers is more effective in discriminating between the stages of T2DM progression in the presence or absence of HT. Our results further indicate the usefulness of medication use, especially with respect to the known involvement of inflammation and OS in disease progression, highlighting specific biomarkers during disease progression and therefore allowing a more targeted individualized treatment plan.

Postpartum uptake of diabetes screening tests in women with gestational diabetes: The PANDORA study

AIMS

To determine rates and predictors of postpartum diabetes screening among Aboriginal and/or Torres Strait Islander and non-Indigenous women with gestational diabetes mellitus (GDM).

METHODS

PANDORA is a prospective longitudinal cohort of women recruited in pregnancy. Postpartum diabetes screening rates at 12 weeks (75-g oral glucose tolerance test (OGTT)) and 6, 12 and 18 months (OGTT, glycated haemoglobin [HbA1C ] or fasting plasma glucose) were assessed for women with GDM (n = 712). Associations between antenatal factors and screening with any test (OGTT, HbA1C , fasting plasma glucose) by 6 months postpartum were examined using Cox proportional hazards regression.

RESULTS

Postpartum screening rates with an OGTT by 12 weeks and 6 months postpartum were lower among Aboriginal and/or Torres Strait Islander women than non-Indigenous women (18% vs. 30% at 12 weeks, and 23% vs. 37% at 6 months, p < 0.001). Aboriginal and/or Torres Strait Islander women were more likely to have completed a 6-month HbA1C compared to non-Indigenous women (16% vs. 2%, p < 0.001). Screening by 6 months postpartum with any test was 41% for Aboriginal and/or Torres Strait Islander women and 45% for non-Indigenous women (p = 0.304). Characteristics associated with higher screening rates with any test by 6 months postpartum included, insulin use in pregnancy, first pregnancy, not smoking and lower BMI.

CONCLUSIONS

Given very high rates of type 2 diabetes among Aboriginal and Torres Strait Islander women, early postpartum screening with the most feasible test should be prioritised to detect prediabetes and diabetes for intervention.

Dichotomising the risk of hyperglycaemia into diabetes and prediabetes may render a disservice to patient care

Cardiovascular diseases (CVDs) are the leading cause of death worldwide, accounting for one-third of global mortality. Prediabetes increases the risk of CVDs as well as several other conditions, yet people with prediabetes may not seek intervention, thinking that they do not have diabetes, as the risk of progression may have not been emphasised by the healthcare professional. Accumulating evidence indicates that hyperglycaemia represents a continuum of CVD risk and dichotomising the risk into type 2 diabetes and prediabetes may deter early clinical intervention. It is proffered that the term 'prediabetes' is a misnomer that may disguise a serious condition, fostering complacency and undermining its prognostic significance.

Prevalence of, and factors associated with, diabetes mellitus in people with severe mental illness attending a multidisciplinary, outpatient cardiometabolic health assessment service

INTRODUCTION

Evaluate the prevalence of, and factors associated with, diabetes in people with severe mental illness (SMI) attending the Collaborative Centre for Cardiometabolic Health in Psychosis (ccCHiP) tertiary referral clinics.

RESEARCH DESIGN AND METHODS

Adult patients attending an initial ccCHiP clinic consultation (2014-2019) were studied. Diabetes was defined by an hemoglobin A1c of ≥6.5%, fasting blood glucose of ≥7.0 mmol/L, or a self-reported diagnosis of diabetes and prescription of antihyperglycemic medication.

RESULTS

Over 5 years, 1402 individuals attended a baseline consultation. Mean age of 43.9±12.8 years, 63.1% male and 63.5% had a diagnosis of schizophrenia. Prevalence of diabetes was 23.0% (n=322); an additional 19.5% fulfilled criteria for pre-diabetes. Of those with diabetes, 15.8% were newly diagnosed. Of those with pre-existing diabetes, 84.5% were receiving treatment with antihyperglycemic medication. Over 94% of individuals with diabetes had dyslipidemia; half were current smokers; and 46.4% reported sedentary behavior. On multivariate analysis, diabetes was associated with older age, Aboriginal, Indian or Middle Eastern maternal ethnicity, elevated waist-to-height ratio, family history of diabetes and use of antipsychotic medication.

CONCLUSION

Prevalence of diabetes mellitus in this multiethnic cohort with SMI is significantly higher than the Australian population. Targeted interventions via an assertive integrated approach are required to optimize cardiometabolic health in this population.

It is time for a more targeted approach to prediabetes in primary care in Aotearoa New Zealand

Type 2 diabetes (T2DM), its related morbidities and entrenched diabetes-related inequities pose significant challenges for health care delivery systems in Aotearoa New Zealand (NZ). Primary care services undertake the majority of diabetes prevention work by initially detecting and managing those with prediabetes. In this viewpoint, we present available NZ data to highlight NZ trends in prediabetes and consider the current NZ clinical guidelines and the prediabetes care pathway. Multiple areas for improvement are identified to optimise diabetes prevention, potentially reduce T2DM inequities, and sustain more effective prediabetes management in primary care in NZ.

Circulating microRNAs from early childhood and adolescence are associated with pre-diabetes at 18 years of age in women from the PMNS cohort

With type 2 diabetes presenting at younger ages, there is a growing need to identify biomarkers of future glucose intolerance. A high (20%) prevalence of glucose intolerance at 18 years was seen in women from the Pune Maternal Nutrition Study (PMNS) birth cohort. We investigated the potential of circulating microRNAs in risk stratification for future pre-diabetes in these women. Here, we provide preliminary longitudinal analyses of circulating microRNAs in normal glucose tolerant (NGT@18y, N = 10) and glucose intolerant (N = 8) women (ADA criteria) at 6, 12 and 17 years of their age using discovery analysis (OpenArray™ platform). Machine-learning workflows involving Lasso with bootstrapping/leave-one-out cross-validation identified microRNAs associated with glucose intolerance at 18 years of age. Several microRNAs, including miR-212-3p, miR-30e-3p and miR-638, stratified glucose-intolerant women from NGT at childhood. Our results suggest that circulating microRNAs, longitudinally assessed over 17 years of life, are dynamic biomarkers associated with and predictive of pre-diabetes at 18 years of age. Validation of these findings in males and remaining participants from the PMNS birth cohort will provide a unique opportunity to study novel epigenetic mechanisms in the life-course progression of glucose intolerance and enhance current clinical risk prediction of pre-diabetes and progression to type 2 diabetes.

Changes in hyperglycaemia-related testing for prediabetes and type 2 diabetes mellitus management: a prospective, cross-sectional survey of 16 years of general practice data from Australia

BACKGROUND

The rising prevalence of prediabetes increases the population risk of type 2 diabetes mellitus (T2DM), metabolic syndrome and cardiovascular disease. Early identification by General Practitioners (GPs) provides opportunities for lifestyle modifications that can lower these risks.

METHODS

This study examined 16 years of hyperglycaemia-related testing for patients in Australia aged 13 years or older with, or at risk of a diagnosis of T2DM. The Bettering the Evaluation and Care of Health (BEACH) study is a national cross-sectional survey, with a single-stage, cluster sampling design. Approximately 1,000 GPs were randomly selected annually (2000/01-20,015/16) from across Australia, who each recorded details of 100 consecutive clinical encounters with consenting patients. Point estimates were adjusted for intracluster correlation and GP characteristics.

RESULTS

Fifteen thousand six hundred seventy nine GPs recorded details of 1,387,190 clinical encounters with patients aged 13 + years. Prediabetes and T2DM were managed at 0.25% (95% CI: 0.24-0.27%) and 3.68% (95% CI: 3.62-3.73%) of encounters respectively. By the end of the study, the proportion of encounters where prediabetes was managed was 2.3 times higher and for T2DM, 1.5 times higher. The proportion of prediabetes (55.9%, 95% CI: 53.9-57.8%) and T2DM (27.3%, 95% CI: 26.7-27.9%) management occasions where one or more hyperglycaemia-related tests were requested were relatively stable. However, differences in the types of tests were observed. For prediabetes, glucose tolerance tests were most common but from 2014/15, requests for HbA1c tests began to increase. For T2DM, HbA1c tests were most common, and requests for one or more glucose tests gradually declined.

CONCLUSION

The observed 16-year annual trends align with the rising incidence of prediabetes and T2DM. GPs appeared to be strongly influenced by changes to the national insurance scheme and clinical guidelines for hyperglycaemia-related pathology testing. However, some GPs may have been pre-empting policy changes as there was also evidence of 'unendorsed' testing, notably for prediabetes, that warrants further investigation. The increasing proportion of encounters for prediabetes, coupled with a high proportion of management occasions where pathology was requested have substantial resource implications. Calls to lower the risk threshold for prediabetes screening therefore warrant an economic analysis. Ongoing, reliable, up-to-date data is needed to inform clinical practice guidelines and policy in Australia.

Referral Compliance Following a Diabetes Screening in a Dental Setting: A Scoping Review

With type 2 diabetes prevalence increasing in Australia, and the condition associated with significant morbidity and mortality, screening for dysglycaemia in the dental setting has been proposed to identify asymptomatic individuals. Screening commences with a risk assessment, and individuals identified at elevated risk for having diabetes are then referred to their medical practitioner for confirmation of their glycemic status. Therefore, for screening to be effective, individuals need to adhere to their oral health professionals' (OHP) advice and attend their medical follow-ups. This review aims to investigate the literature on referral compliance following a risk assessment in the dental setting and identify barriers and facilitators to screened individuals' referral compliance. A scoping review of the literature was undertaken, selecting studies of diabetes screening in a dental setting that recorded compliance to referral to follow-up, and explored any barriers and facilitators to adherence. Fourteen studies were selected. The referral compliance varied from 25 % to 90%. Six studies reported barriers and facilitators to attending medical follow-ups. Barriers identified included accessibility, cost, knowledge of the condition, and OHP characteristics.

Assessment and Management of Obesity and Self-Maintenance (AMOS): An Evaluation of a Rural, Regional Multidisciplinary Program

Obesity is common in rural areas, and reduced specialist healthcare access impedes its management. A pilot nurse-practitioner-led Assessment and Management of Obesity and Self-Maintenance (AMOS) Clinic focused on individualised obesity care in people living with type 2 diabetes delivered in a rural setting. This study aimed to explore participant and staff experiences of the multidisciplinary obesity clinic to identify barriers and facilitators to self-care, health, and well-being. A two-stage, mixed-method design was used. Initially, three focus groups involving a sample of AMOS participants and semi-structured staff interviews helped identify key barriers/facilitators. These findings informed a survey delivered to all AMOS participants. Qualitative data were analysed using an inductive two-step thematic networks technique to identify themes. Quantitative data were summarised using descriptive statistics. A total of 54 AMOS participants and 4 staff participated in the study. Four themes were identified to describe AMOS participant experiences': 1. affordability; 2. multidisciplinary care; 3. person-centred care; and 4. motivation. Specialised, multidisciplinary and individualised obesity care available through one clinic facilitated self-care and improved health and well-being. Dedicated multidisciplinary obesity clinics are recommended in rural and remote areas.

Trends in risk factors and management strategies used by people with type 2 diabetes in New South Wales, Australia

Adopting healthy lifestyle behaviours is an important component of Type 2 diabetes (T2D) self-management, which can lower risks of further health complications. Monitoring lifestyle risk factors including overweight or obesity, healthy diet and physical activity behaviours, alcohol consumption, smoking and psychological distress remain important. This study examined prevalence trends in these factors and adoption of three diabetes lifestyle self-management strategies in adults (aged 40+) with T2D in New South Wales (NSW), Australia. Analyses were conducted on NSW Adult Population Health Survey data, 2004-2019 (n = 142,168), using predicted probabilities from generalised linear models, weighted to population estimates. Throughout the study period overweight or obesity prevalence remained higher amongst those with T2D (83.1% to 81.7%) compared to those without diabetes (61.0 to 61.2%); only 8.9% of those with T2D were trying to lose weight. During the study period, there were declines in the proportions of those with T2D reporting sufficient fruit consumption [63.9% to 50.1%], moderate vegetable consumption (3 serves) [49.0% to 37.7%], and achieving sufficient physical activity [40.0% to 34.0%]. There were also declines in those reporting they manage their diabetes through following a special diet [73.6% to 55.9%] and exercising most days [33.5% to 22.2%]. This study highlights potential gaps in T2D secondary prevention and suggests more targeted diabetes education services are needed to address lifestyle risks. Increased understanding of why fewer people with T2D adopt these lifestyle management strategies is needed to inform policy and practice.

Diabetes Mellitus Diagnosis and Screening in Australian General Practice: A National Study

Aims

To investigate the epidemiology of diabetes diagnosis and screening in Australian general practice.

Methods

Cross-sectional study using electronic health records of 1,522,622 patients aged 18+ years attending 544 Australian general practices (MedicineInsight database). The prevalence of diagnosed diabetes and diabetes screening was explored using all recorded diagnoses, laboratory results, and prescriptions between 2016 and 2018. Their relationship with patient sociodemographic and clinical characteristics was also investigated.

Results

Overall, 7.5% (95% CI 7.3, 7.8) of adults had diabetes diagnosis, 0.7% (95% CI 0.6, 0.7) prediabetes, and 0.3% (95% CI 0.3, 0.3) unrecorded diabetes/prediabetes (elevated glucose levels without a recorded diagnosis). Patients with unrecorded diabetes/prediabetes had clinical characteristics similar to those with recorded diabetes, except for a lower prevalence of overweight/obesity (55.5% and 69.9%, respectively). Dyslipidaemia was 1.8 times higher (36.2% vs. 19.7%), and hypertension was 15% more likely (38.6% vs. 33.8%) among patients with prediabetes than with diabetes. Diabetes screening (last three years) among people at high risk of diabetes was 55.2% (95% CI 52.7, 57.7), with lower rates among young or elderly males.

Conclusions

Unrecorded diabetes/prediabetes is infrequent in Australian general practice, but prediabetes diagnosis was also lower than expected. Diabetes screening among high-risk individuals can be improved, especially in men, to enhance earlier diabetes diagnosis and management.

Appraisal of Triglyceride-Related Markers as Early Predictors of Metabolic Outcomes in the PREVIEW Lifestyle Intervention: A Controlled Post-hoc Trial

Background: Individuals with pre-diabetes are commonly overweight and benefit from dietary and physical activity strategies aimed at decreasing body weight and hyperglycemia. Early insulin resistance can be estimated via the triglyceride glucose index {TyG = Ln [TG (mg/dl) × fasting plasma glucose (FPG) (mg/dl)/2]} and the hypertriglyceridemic-high waist phenotype (TyG-waist), based on TyG x waist circumference (WC) measurements. Both indices may be useful for implementing personalized metabolic management. In this secondary analysis of a randomized controlled trial (RCT), we aimed to determine whether the differences in baseline TyG values and TyG-waist phenotype predicted individual responses to type-2 diabetes (T2D) prevention programs. Methods: The present post-hoc analyses were conducted within the Prevention of Diabetes through Lifestyle intervention and population studies in Europe and around the world (PREVIEW) study completers (n = 899), a multi-center RCT conducted in eight countries (NCT01777893). The study aimed to reduce the incidence of T2D in a population with pre-diabetes during a 3-year randomized intervention with two sequential phases. The first phase was a 2-month weight loss intervention to achieve ≥8% weight loss. The second phase was a 34-month weight loss maintenance intervention with two diets providing different amounts of protein and different glycemic indices, and two physical activity programs with different exercise intensities in a 2 x 2 factorial design. On investigation days, we assessed anthropometrics, glucose/lipid metabolism markers, and diet and exercise questionnaires under standardized procedures. Results: Diabetes-related markers improved during all four lifestyle interventions. Higher baseline TyG index (p < 0.001) was associated with greater reductions in body weight, fasting glucose, and triglyceride (TG), while a high TyG-waist phenotype predicted better TG responses, particularly in those randomized to physical activity (PA) of moderate intensity. Conclusions: Two novel indices of insulin resistance (TyG and TyG-waist) may allow for a more personalized approach to avoiding progression to T2D. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT01777893 reference, identifier: NCT01777893.

Is the Clinical Delivery of Cardiac Rehabilitation in an Australian Setting Associated with Changes in Physical Capacity and Cardiovascular Risk and Are Any Changes Maintained for 12 Months?

Long-term maintenance of changes in cardiovascular risk factors and physical capacity once patients leave the supervised program environment have not previously been reported. This study investigated the changes in physical capacity outcomes and cardiovascular risk factors in an Australian cardiac rehabilitation setting, and the maintenance of changes in these outcomes in the 12 months following cardiac rehabilitation attendance. Improvements in mean (95% CI) cardiorespiratory fitness (16.4% (13.2–19.6%), p < 0.001) and handgrip strength (8.0% (5.4–10.6%), p < 0.001) were observed over the course of the cardiac rehabilitation program, and these improvements were maintained in the 12 months following completion. Waist circumference (p = 0.003) and high-density lipoprotein cholesterol (p < 0.001) were the only traditional cardiovascular risk factors to improve during the cardiac rehabilitation program. Vigorous-intensity aerobic exercise was associated with significantly greater improvements in cardiorespiratory fitness, Framingham risk score, and waist circumference in comparison to moderate-intensity exercise. An increase in the intensity of the exercise prescribed during cardiac rehabilitation in Australia is recommended to induce larger improvements in physical capacity outcomes and cardiovascular risk. A standardized exercise test at the beginning of the rehabilitation program is recommended to facilitate appropriate prescription of exercise intensity.

Prediabetes and pregnancy: Early pregnancy HbA1c identifies Australian Aboriginal women with high-risk of gestational diabetes mellitus and adverse perinatal outcomes

AIMS

To assess whether early pregnancy HbA1c can predict gestational diabetes mellitus (GDM) and adverse birth outcomes in Australian women.

METHODS

Prospective study of 466 women without diabetes, aged ≥16-years at first antenatal presentation. Recruitment was from 27 primary healthcare sites in rural and remote Australia from 9-January 2015 to 31-May 2018. HbA1c was measured with first antenatal investigations (<20-weeks gestation). Primary outcome measure was predictive value of HbA1c for GDM, by routine 75 g oral glucose tolerance test (OGTT; ≥24-weeks gestation), and for large-for-gestational-age (LGA) newborn.

RESULTS

Of 396 (129 Aboriginal) women with routine OGTT, 28.8% had GDM (24.0% Aboriginal). HbA1c ≥5.6% (≥38 mmol/mol) was highly predictive (71.4%, 95% CI; 47.8-88.7%) for GDM in Aboriginal women, and in the total cohort increased risk for LGA newborn (RR 2.04, 95% CI; 1.03-4.01, P = 0.040). There were clear differences between Aboriginal and non-Aboriginal women: 16.3% v 5.2% (P < 0.001) had elevated HbA1c whereas 12.4% v 29.6% (P < 0.001) developed hyperglycemia during pregnancy.

CONCLUSIONS

Early pregnancy HbA1c ≥5.6% (≥38 mmol/mol) identifies Aboriginal women with apparent prediabetes and elevated risk of having an LGA newborn. Universal HbA1c at first antenatal presentation could facilitate earlier management of hyperglycemia and improved perinatal outcome in this high-risk population.

Analyses of short-chain fatty acids and exhaled breath volatiles in dietary intervention trials for metabolic diseases

As an alternative to pharmacological treatment to diseases, lifestyle interventions, such as dietary changes and physical activities, can help maintain healthy metabolic conditions. Recently, the emerging analyses of volatile organic compounds (VOCs) from breath and short-chain fatty acids (SCFAs) from plasma/feces have been considered as useful tools for the diagnosis and mechanistic understanding of metabolic diseases. Furthermore, diet-induced changes of SCFAs in individuals with diagnosed metabolic abnormalities have been correlated with the composition changes of the gut microbiome. More interestingly, the analysis of exhaled breath (breathomics) has gained attention as a useful technique to measure the human VOC profile altered as a result of dietary interventions. In this mini-review, we examined recent clinical trials that performed promising dietary interventions, SCFAs analysis in plasma/feces, and VOC profile analysis in exhaling breath to understand the relationship between dietary intervention and metabolic health.