Real-world effectiveness of digital and group-based lifestyle interventions as compared with usual care to reduce type 2 diabetes risk - A stop diabetes pragmatic randomised trial

Digital Health Interventions to Prevent Type 2 Diabetes Mellitus: Systematic Review

BACKGROUND

Digital health interventions (DHIs) have rapidly evolved and significantly revolutionized the health care system. The quadruple aims of health care (improving population health, enhancing consumer experience, enhancing health care provider [HCP] experience, and decreasing health costs) serve as a strategic guiding framework for DHIs. It is unknown how DHIs can impact the burden of type 2 diabetes mellitus (T2DM), as measured by the quadruple aims.

OBJECTIVE

This study aimed to systematically review the effects of DHIs on improving the burden of T2DM, as measured by the quadruple aims.

METHODS

PubMed, Embase, CINAHL, and Web of Science were searched for studies published from January 2014 to March 2024. Primary outcomes were the development of T2DM, hemoglobin A1c (HbA1c) change, and blood glucose change (dysglycemia changes). Secondary outcomes were consumer experience, HCP experience, and health care costs. Outcomes were mapped to the quadruple aims. DHIs were categorized using the World Health Organization's DHI classification. For each study, DHI categories were assessed for their effects on each outcome, categorizing the effects as positive, negative, or neutral. The overall effects of each DHI category were determined by synthesizing all reported positive, neutral, or negative effects regardless of the number of studies supporting each effect. The Cochrane risk-of-bias version 2 (RoB 2) tool for randomized trials was used to assess the quality of randomized controlled trials (RCTs), while the ROBINS-I (risk of bias in nonrandomized studies of interventions) tool was applied for nonrandomized studies.

RESULTS

In total, 53 papers were included. For the T2DM development outcome, the effects of DHIs were positive in 1 (1.9%) study and neutral in 9 (17%) studies, and there were insufficient data to assess in 4 (7.5%) studies. For the dysglycemia outcome, the effects were positive in 23 (43.4%) studies and neutral in 24 (45.3%) studies, and there were insufficient data in 6 (11.3%) studies. There were mixed effects on consumer experience (n=13, 24.5%) and a lack of studies reporting HCP experience (n=1, 1.9%) and health care costs (n=3, 5.7%). All studies that reported positive population health outcomes used a minimum of 2 distinct categories of DHIs. Among these successful studies, the one that reported delaying the development of T2DM and 16 (69.6%) of those reporting improvements in dysglycemia involved HCP interaction. Targeted communication with persons (TCP), personal health tracking (PHT), and telemedicine (TM) showed some evidence as a potentially useful tool for T2DM prevention and dysglycemia.

CONCLUSIONS

The effects of DHIs on T2DM prevention, as measured by the quadruple aims, have not been comprehensively assessed, with proven benefits for population health, mixed results for consumer experience, and insufficient studies on HCP experience and health care costs. To maximize their effectiveness in preventing T2DM and managing dysglycemia, DHIs should be used in combination and strategically integrated with in-person or remote HCP interaction.

TRIAL REGISTRATION

PROSPERO CRD42024512690; https://www.crd.york.ac.uk/PROSPERO/view/CRD42024512690.

A digital health-supported and community pharmacy-based lifestyle intervention program for adults with pre-diabetes: a study protocol for a cluster randomised controlled trial

INTRODUCTION

Pre-diabetes indicates an elevated risk of developing type-2 diabetes and presents a window for preventive actions. The Pre-diabetes Intervention, Management and Evaluation (PRIME) programme is a community pharmacy-based pre-diabetes management programme that uses a mobile application for self-monitoring and pre-diabetes education, aiming to promote lifestyle changes among participants with pre-diabetes.

METHODS AND ANALYSIS

This is a protocol for a cluster randomised controlled trial that aims to evaluate the impact of the PRIME programme on participants' clinical outcomes and explore participants' and pharmacists' views towards its implementation. This protocol describes the development of the PRIME programme and mobile app, its feasibility and implementation in community pharmacy settings. 16 pharmacies from two states in Malaysia will be randomised to the intervention arm or standard care. The study will include overweight or obese adults with pre-diabetes. During each follow-up visit at the pharmacy, intervention participants will receive in-depth counselling from pharmacists after reviewing their self-monitoring data recorded in the PRIME app. They will also receive pre-diabetes education through the app and join a peer support chatgroup. The primary clinical outcome includes changes in body weight at 6 months, while the secondary clinical outcomes include changes in blood glucose profile, lipid profile, blood pressure and adiposity measures. The sustainability of the PRIME programme will be accessed using a follow-up questionnaire, while participants' engagement with the intervention will be evaluated using attendance rate and the app data. Focus group discussions and one-to-one interviews will be conducted for process evaluation. This study will inform the impact of community pharmacists-led digital health intervention in pre-diabetes management.

ETHICS AND DISSEMINATION

This study has been registered with clinicaltrials.gov (NCT04832984) and approved by the Monash University Human Research Ethics Committee (Project ID: 27512).

TRIAL REGISTRATION NUMBER

clinicaltrials.gov (NCT04832984).

Effectiveness of workplace choice architecture modification for healthy eating and daily physical activity

BACKGROUND

Modifying the choice architecture of behavioural contexts can facilitate health behaviour change, but existing evidence builds mostly on small-scale interventions limited in duration, targets, strategies, and settings. We evaluated the effectiveness of a one-year hybrid type 2 implementation-effectiveness trial aimed at promoting healthy eating and daily physical activity with subtle modifications to the choice architecture of heterogeneous worksites. The intervention was contextualised to and integrated into the routine operations of each worksite. Effectiveness was evaluated in a quasi-experimental pre-post design.

METHODS

Intervention sites (n = 21) implemented a median of two (range 1-9) intervention strategies for healthy eating and one (range 1-5) for physical activity. Questionnaires pre (n = 1126) and post (n = 943) intervention surveyed employees' behavioural patterns at work (food consumption: vegetables/roots, fruit/berries, nuts/almonds/seeds, sweet treats, fast food, water; physical activity: restorative movement, exercise equipment use, stair use). The post-intervention questionnaire also measured employees' perception of and response to three intervention strategies: a packed lunch recipe campaign, a fruit crew-strategy, and movement prompts. Multi- and single-level regression models evaluated effectiveness, treating intervention as a continuous predictor formed of the site-specific dose (n intervention strategies employed) and mean quality (three-point rating per strategy halfway and at the end of the intervention) of implementation relevant to each outcome.

RESULTS

Multinomial logistic regression models found the intervention significantly associated with a favourable change in employees' fruit and berry consumption (interaction effect of time and implementation p = 0.006) and with an unfavourable change in sweet treat consumption (p = 0.048). The evidence was strongest for the finding concerning fruit/berry consumption-an outcome that sites with greater dose and quality of implementation targeted by using strategies that reduced the physical effort required to have fruit/berries at work and by covering multiple eating-related contexts at the worksite. The quality of implementation was positively associated with the perception of (p = 0.044) and response to (p = 0.017) the packed lunch recipes, and with response to the fruit crew-strategy (p < 0.001).

CONCLUSIONS

The results suggest that a contextualised, multicomponent choice architecture intervention can positively influence eating behaviour in diverse real-world settings over a one-year period, and that higher implementation quality can enhance intervention perception and response. However, outcomes may depend on the type of intervention strategies used and the extent of their delivery.

Associations of Lifestyle Patterns with Glucose and Lipid Metabolism in Finnish Adults at Increased Risk of Type 2 Diabetes

SCOPE

Various lifestyle and sociodemographic factors have been associated with risk factors for type 2 diabetes (T2D). However, their combined associations with T2D risk factors have been studied much less.

MATERIALS AND RESULTS

This study investigates cross-sectional associations of lifestyle patterns with T2D risk factors among 2925 adults at increased risk participating in the Stop Diabetes study. Lifestyle patterns are determined using principal component analysis (PCA) with several lifestyle and sociodemographic factors. The associations of lifestyle patterns with measures of glucose and lipid metabolism and serum metabolites analyzed by nuclear magnetic resonance (NMR) spectroscopy are studied using linear regression analysis. "Healthy eating" pattern is associated with better glucose and insulin metabolism, more favorable lipoprotein and fatty acid profiles and lower serum concentrations of metabolites related to inflammation, insulin resistance, and T2D. "High socioeconomic status and low physical activity" pattern is associated with increased serum concentrations of branched-chain amino acids, as are "Meat and poultry" and "Sleeping hours" patterns. "Snacks" pattern is associated with lower serum concentrations of ketone bodies.

CONCLUSIONS

Our results show, in large scale primary care setting, that healthy eating is associated with better glucose and lipid metabolism and reveal novel associations of lifestyle patterns with metabolites related to glucose metabolism.

Acceptability of workplace choice architecture modification for healthy behaviours

BACKGROUND

Altering the choice architecture of decision contexts can assist behaviour change, but the acceptability of this approach has sparked debate. Considering hypothetical interventions, people generally welcome the approach for promoting health, but little evidence exists on acceptance in the real world. Furthermore, research has yet to explore the implementers' perspective, acknowledging the multidimensionality of the acceptability construct. Addressing these knowledge gaps, this study evaluated the acceptability of a quasi-experimental implementation-effectiveness trial that modified the worksite choice architecture for healthy eating and daily physical activity.

METHODS

Fifty-three worksites participated in the 12-month intervention and implemented altogether 23 choice architecture strategies (Mdn 3/site), including point-of-choice prompts and changes to choice availability or accessibility. Retrospective acceptability evaluation built on deductive qualitative content analysis of implementer interviews (n = 65) and quantitative analysis of an employee questionnaire (n = 1124). Qualitative analysis examined implementers' thoughts and observations of the intervention and its implementation, considering six domains of the Theoretical Framework of Acceptability: ethicality, affective attitude, burden, intervention coherence, opportunity costs, and perceived effectiveness. Quantitative analysis examined employees' acceptance (7-point Likert scale) of eight specific intervention strategies using Friedman test and mixed-effects logistic regression.

RESULTS

Implementers considered the choice architecture approach ethical for workplace health promotion, reported mostly positive affective attitudes to and little burden because of the intervention. Intervention coherence supported acceptance through increased interest in implementation, whereas low perceived utility and high intensity of implementation reduced cost acceptance. Perceived effectiveness was mixed and varied along factors related to the implementer, social/physical work environment, employer, and employee. Employees showed overall high acceptance of evaluated strategies (Mdn 7, IQR 6.4-7), though strategies replacing unhealthy foods with healthier alternatives appeared less supported than providing information or enhancing healthy option availability or accessibility (p-values < 0.02). Greater proportion of male employees per site predicted lower overall acceptance (OR 4.4, 95% CI 1.2-16.5).

CONCLUSIONS

Work communities appear to approve workplace choice architecture interventions for healthy eating and physical activity, but numerous factors influence acceptance and warrant consideration in future interventions. The study contributes with a theory-based, multidimensional evaluation that considered the perspectives of implementers and influenced individuals across heterogeneous real-world settings.

Potential roles of circulating microRNAs in the healing of type 1 diabetic wounds treated with green tea extract: molecular and biochemical study

Background

Circulating miRNAs have been implicated in various aspects of diabetic wound healing, including inflammation, angiogenesis, and extracellular matrix remodeling. Thus, in alternative herbal medicine strategies, miRNAs will be potential therapeutic molecular targets in nonhealing wounds. These could be valuable elements for understanding the molecular basis of diabetic wound healing and could be used as good elements in bioinformatics.

Objectives

To elucidate the molecular mechanisms of microRNAs in association with apoptosis-inducing genes in controlling skin wound healing in diabetic wounds treated with green tea polyphenols (GTPs).

Methods

Green tea hydro extract (GTE) at doses of100-200 mg/ml was topically applied to the skin tissues of rats with T1DM induced by a single dose of streptozotocin (STZ; 100 mg/kg, in 0.01 M sodium citrate, pH 4.3-4.5) injected intraperitoneally for seven consecutive days to induce T1DM. The rats were treated with green tea for three weeks. A sterile surgical blade was used to inflict a circular wound approximately 2 cm in diameter on the anterior-dorsal side of previously anesthetized rats by a combination of ketamine hydrochloride (50 mg/kg, i.e., body weight) and xylazine hydrochloride. Afterward, the molecular roles of the circulating miRNAs miR-21, miR-23a, miR-146a, and miR-29b and apoptotic genes were determined by quantitative real-time PCR to evaluate Bax, Caspase-3, and Bcl-2 in wound healing. In addition, HPLC analysis was also performed to estimate the active polyphenols (GTPs) present in the hydro extract of green tea leaves.

Results

Wound healing was improved in diabetic skin wounds following treatment with GTE at doses of 100-200 mg/dl for three weeks. The wound parameters contraction, epithelialization, and scar formation significantly improved in a short time (14 days) compared to the longer periods identified in diabetic non-treated rats (20 days) and the standard control (15.5 days). Molecular analyses reported a significant increase in the levels of miR-21, miR-23a, and miR-146a and a decrease in the levels of miR-29b in green tea-treated diabetic rats compared to those in the standard control and STZ-diabetic non-treated rats. In addition, the molecular apoptotic genes Bax and caspase-3 significantly increased, and the BcL-2 gene significantly decreased following treatment with green tea polyphenols.

Conclusions

The data showed that active green tea polyphenols (GTPs) present in GTE significantly improved diabetic wound healing by controlling apoptotic genes and the circulating microRNAs miR-21, miR-23a, miR-146a, and miR-29b, which might be involved in cellular apoptosis and angiogenesis processes. Thus, to establish a future model for the treatment of diabetic wounds, further studies are needed to understand the potential association of these biological parameters with the wound-healing process in diabetic wounds.