Reducing risk of Type 2 diabetes in HIV: a mixed-methods investigation of the STOP-Diabetes diet and physical activity intervention

Effect of a Supervised Aerobic Exercise Training Program and Ginkgo Biloba Extract on Metabolic Parameters and Functional Capacity in HIV-Infected Subjects

Background: A remarkable increase in metabolic comorbidities occur in people living with HIV infection (PLWH). Supervised physical activity provides significant health benefits. Ginkgo biloba (GKB) extract has been reported to have a wide range of metabolic advantages. This study aimed to examine the effects of an exercise training (ET) program and a GKB extract on PLWH. Methods: This was a randomized placebo-controlled double-blind study. Twenty-eight PLWH were assigned to receive a placebo (n = 10), GKB extract (n = 10), or statins (n = 8). All patients underwent a supervised ET program 3-5 times per week. Anthropometric measurements, functional capacities, and metabolic parameters were assessed in all participants at baseline and after 12 weeks of follow-up. Results: After the 12-week intervention, body fat decreased significantly by 2-3% in all groups relative to their baseline values (p < 0.05). Total cholesterol and LDL-c were significantly decreased in the ET + statin group (p = 0.04, and p = 0.007, respectively) compared to baseline values, while HbA1c and the HOMA-IR index were significantly decreased in the ET + GKB group (p = 0.03 and p = 0.02, respectively) compared to baseline values, and a significant increase in CD4+ T cell mean was observed in the ET + placebo group (p = 0.005) compared to baseline values. A significant increase in cardiorespiratory capacity (VO2max) from their baseline values was observed in all groups (p < 0.001) after 12 weeks of intervention from their baseline values. Conclusions: Body fat and cardiorespiratory fitness significantly improved after a 12-week supervised ET program. GKB extract significantly decreased insulin resistance.

Are Diabetes Prevention Programs Reaching Those Most at Risk? A Scoping Review

OBJECTIVES

Previous reviews have highlighted the efficacy of lifestyle diabetes prevention programs (DPPs) in decreasing type 2 diabetes (T2D) risk, but the participating populations were predominantly White. This is concerning, as ethnically diverse populations are disproportionately affected by T2D. The objective of this scoping review was to 1) summarize existing tailored DPPs and 2) provide recommendations for future program implementation to improve access and reach for diverse populations.

METHODS

This work represents a subanalysis of a larger scoping review synthesizing DPPs. Several databases were searched for studies relating to T2D risk and lifestyle programs. Study characteristics were systematically extracted using the Template for Intervention Description and Replication checklist.

RESULTS

Of 25,110 screened publications, 351 (220 programs) were included in the larger review. Only 29% (64 programs) of the 220 programs were identified as specifically serving ethnically diverse populations and were included in this subanalysis. An updated search was run that identified an additional 10 publications (10 programs). Over a third (35%) of programs reported strategies used to tailor their intervention to the target population; of those that reported, 62% tailored the content of the intervention to be culturally appropriate and relevant as well as accommodate the geographic and cultural context.

CONCLUSIONS

Based on recruitment, tailoring, and provision strategies used in DPPs targeting specific underresourced populations, this review provides recommendations on how future program developers can increase access and reach, improving individual- and population-level health outcomes via T2D reduction in those at highest risk.

Insulin resistance and beta-cell dysfunction in adults with different patterns of diet: a cross-sectional study in north-western Tanzania

BACKGROUND

The diabetes burden in sub-Saharan Africa is rising, but there is little African data on associations between diet, insulin resistance, and beta-cell dysfunction.

OBJECTIVE

We investigated the association between dietary patterns and insulin resistance and beta-cell dysfunction among adults in Mwanza, Tanzania.

METHODS

In a cross-sectional study involving adults with or without HIV, insulin resistance and beta-cell dysfunction were calculated from plasma insulin and glucose measures during an oral glucose tolerance test. Diet data were collected using a validated food frequency questionnaire and dietary patterns were derived by principal component analysis and reduced rank regression. Logistic regression analysis was used to assess the association between exposure variables (dietary patterns terciles) with outcome variables (insulin resistance and beta-cell dysfunction), adjusting for HIV status, age, sex, body mass index, alcohol consumption, and smoking.

RESULTS

Of 462 participants, the mean age was 42 (±12) years, 58% were females, and 60% were HIV-infected. Carbohydrate-dense patterns were associated with more insulin resistance by HOMA-IR (aOR 2.7, 95% CI 1.5; 4.8) and Matsuda index (aOR 3.7, 95% CI 2.0; 6.7), but not with either HOMA-β, insulinogenic index or oral disposition index. The level of adherence to either the vegetable-rich or vegetable-poor pattern was not associated with any of the markers of insulin resistance or beta-cell dysfunction. HIV infection did not affect the association between patterns of diet and glucose metabolism outcomes.

CONCLUSION

The lack of association between either vegetable-rich or vegetable-poor patterns with insulin resistance or beta cell dysfunction requires further research.

Perceptions and management of diabetes and obesity among people living with HIV in Côte d'Ivoire: a qualitative study

INTRODUCTION

The prevalence of both type 2 diabetes mellitus (T2DM) and obesity is increasing among people living with HIV (PLHIV) in sub-Saharan Africa. We examined the perceptions and management of these two conditions among PLHIV and healthcare workers in Côte D'Ivoire.

METHOD

From June to August 2022, we conducted semi-structured face-to-face interviews with PLHIV diagnosed with T2DM and/or obesity, as well as healthcare workers, in one of the major HIV clinics in Abidjan, Cote d'Ivoire. We explored topics such as experiences, perceptions and acceptability of the diagnosis and management of T2DM and obesity among PLHIV. Among healthcare workers, professional experience, professional relationships with patients diagnosed with T2DM/obesity, involvement in patient management and care provision were explored. Interviews were audio recorded and transcribed manually. Data were analysed using thematic analysis.

RESULTS

A total of 15 PLHIV and 5 healthcare workers participated in semi-structured in-depth interviews. Perceptions towards T2DM and obesity were largely influenced by cultural factors, PLHIV reported negative perceptions of T2DM and positive perceptions of obesity. Both patients and healthcare providers considered the management of these conditions as sub-optimal. Patient-reported barriers to care for these metabolic disorders were mainly socio-economic and environmental, while healthcare workers emphasized patients' denial of their illness and the limited range of treatment options available at the clinic.

CONCLUSION

These results highlight the complexity surrounding the perceptions and management of T2DM and obesity among PLHIV in Abidjan, Côte d'Ivoire. In order to implement innovative and efficient intervention strategies to prevent and treat these metabolic conditions, cultural beliefs as well as socio-economic barriers must be addressed.

A systematic review and meta-analysis evaluating the effectiveness of minimally supervised home and community exercise interventions in improving physical activity, body adiposity and quality of life in adults living with HIV

People living with HIV (PLWH) are physically inactive and risk cardiometabolic dysfunction. Home and community exercise (HCE) is pragmatic, cost-effective and improves health in varied chronic conditions. This review aimed to synthesize evidence on the effectiveness of minimally supervised HCE for physical activity (PA), adiposity, quality of life (QoL), and other physical and psychological health indices for PLWH.

METHODS

Databases were searched for studies published January 2000 to April 2023. Risk of bias in experimental and quasi-experimental studies was assessed with the Cochrane Risk-of-Bias for Randomized Trials and Risk-of-Bias in Non-Randomized Studies of Interventions tools, respectively. A random-effects meta-analysis was conducted.

RESULTS

From 9648 records, 13 studies (14 HCE groups) with 857 PLWH (average ages 29-56 years) were included; 12 comparator and one single group trial. Aerobic and strength HCE significantly improved PA relative to control by 0.377 units (95 %CI = 0.097, 0.657; p = 0.008) and 1097steps/day (95 %CI = 39.27, 2156.62; p = 0.042). There was a reduction from baseline in percent body fat of 3.36 % (95 %CI = -6.10, 0.42; p = 0.025), but no change in BMI (-0.21 kg/m2; 95 %CI = -0.67, 0.24; p = 0.351) relative to control. HCE improved QoL relative to control in the physical domain by 13points (95 %CI = 6.15, 19.86; p < 0.001), but not in other domains like general health (6.6points; 95 %CI = -1.19, 14.36; p < 0.097). HCE completed at moderate intensity or higher was associated with improvement in outcomes more so than lower intensity HCE. Walking-only interventions were at least as beneficial as other activities. No adverse events were recorded.

CONCLUSION

Minimally supervised HCE can improve PA, body fat, physical QoL and other health indices in PLWH.

Physical activity and diet for Type 2 Diabetes reduction among older people living with HIV in Harare

Background

People living with HIV (PLWH) are ageing, and face increased risk for developing Type 2 Diabetes. Physical activity and diet are effective in reducing Type 2 Diabetes risk. However, there is variation in how older PLWH engage in physical activity and healthy eating.

Aim

To describe older PLWHs' engagement in physical activity and diet for Type 2 Diabetes risk reduction in Harare.

Setting

The study was conducted in five polyclinics in Harare urban district from low socio-economic areas.

Methods

A qualitative approach and an exploratory descriptive design was used. Twenty-three participants were selected purposively based on the researchers' judgement of age among PLWH. Data were collected using a semi-structured interview schedule and analysed using Braun and Clark's six steps of thematic content analysis. Ethical approval was obtained, and each participant provided informed consent.

Results

The mean age of participants was 62 years. Participants performed varied physical activities through; economic activities, walking, exercise, and domestic chores. Diet included indigenous, unrefined grains, vegetables and fruit, influenced by rural background. Diet consisted of larger proportions of carbohydrates with lesser varying portions of protein and vegetables and fruit. Healthy eating among participants was facilitated by the proximity of markets and family.

Conclusion

Health education to reduce Type 2 Diabetes risk should focus on fostering current physical activities to meet prescribed standards and increasing fruit and vegetable consumption.

Contribution

The physical activity and diet self-care practices among older PLWH are inadequate in reducing Type 2 Diabetes risk, emphasising the need for appropriate health education.

Diabetes mellitus and associated factors among HIV-positive patients at primary health care facilities in Harare, Zimbabwe: a descriptive cross-sectional study

BACKGROUND

Highly active antiretroviral therapy (HAART) has improved the life expectancy of people living with HIV (PLWH) and has increased the risk of chronic non-communicable diseases. Comorbid HIV and diabetes mellitus (DM) significantly increase cardiovascular disease and mortality risk. This study aimed to determine the prevalence of type 2 diabetes mellitus among HIV-positive patients receiving HAART in Zimbabwe and its associated risk factors.

METHODS

This cross-sectional study was conducted at eight primary healthcare facilities in Harare, Zimbabwe, between January 2022 and March 2023. Non-probability convenience sampling was used to recruit adult HIV-positive patients undergoing HAART attending the facilities. Data were captured on clinical history and socio-demographic and behavioral characteristics, and analyzed using descriptive statistics to determine DM prevalence rates. Additionally, bivariate and multivariate logistic regression models were employed to examine factors associated with HIV and DM comorbidities.

RESULTS

A total of 450 participants were included in this study, of which 57.6% (n = 259) were female. The majority were married (73.8%) and older than 35 years (80.2%). Most participants had completed high school (87.6%) and 68.9% were employed either formally or self-employed. The prevalence of diabetes mellitus (DM) was 14.9%. HIV/DM comorbidity was more prevalent in patients who were female, self-employed, and smoked (p < 0.05). Multivariate logistic regression analysis revealed that the factors associated with DM-HIV comorbidity were gender, age, education, marital status, employment status, smoking, physical activities, duration of HAART, and diet. Age, level of education, marital status, and occupation were not associated with HIV-DM comorbidity. Obesity (body mass index > 30 kg/m2), smoking, and alcohol consumption were associated with an increased risk of DM. Regular physical activity is associated with a reduced risk of DM.

CONCLUSION

A substantial burden of DM was found in PLWH. The intersectoral integration approach is advocated, and active screening for DM is recommended. Gender-specific interventions are necessary to target diseases and health behaviors that differ between men and women. These interventions should be customized to the specific diseases and behaviors of each group.

Effects of a smartphone app-based diet and physical activity program for men living with HIV who have dyslipidemia: A pilot randomized controlled trial

AIMS

People living with HIV are at a high risk for cardiovascular disease owing to antiretroviral therapy use and chronic inflammation. There is limited evidence on the evaluation of serum lipid levels through lifestyle modification. This study aims to evaluate the effect of a smartphone application-based diet and exercise improvement program on men living with HIV and dyslipidemia.

METHODS

This was a randomized controlled trial recruiting Japanese men living with HIV who have dyslipidemia: intervention group (n = 19) and control group (n = 19). The intervention group received a third individual guidance session during the 6-month intervention and was encouraged to record their diet on a smartphone application. An intention-to-treat analysis of the results was conducted.

RESULTS

The intervention group showed significantly reduced change in low-density lipoprotein levels compared to the control group (-4.00 ± 20.2 mg/dL vs. 10.11 ± 21.1 mg/dL) (p = .042) from baseline to 6 months post-intervention. No significant differences were found in other serum lipid levels. Abdominal circumference decreased significantly in the intervention group (p = .048) from baseline to 6 months post-intervention. Total energy, protein, carbohydrate, fat, and salt intake, dietary and physical activity behavior change stages and social support, dietary self-efficacy, and loneliness significantly improved in the intervention group (p < .05) from baseline to 6 months post-intervention.

CONCLUSIONS

A diet and physical activity improvement program using a smartphone application based on Japanese-specific health guidance may reduce low-density lipoprotein cholesterol levels in this population. Further sample expansion and examination of long-term effects are needed.

Effectiveness of a 6-Month Nutrition Intervention in People Living with HIV and Prediabetes Progressing through Stages of Change towards Positive Health Behavior

The prevalence of prediabetes in people living with human immunodeficiency virus (HIV) is two to three times higher than that of the general population. The aim of this study was to assess the effectiveness of an intervention in guiding low-income people living with HIV (PLWH) and prediabetes through the stages of change and promote self-efficacy of positive health behavior.

METHODS

A 6- month randomized, controlled intervention was conducted where participants (N = 38) were randomized into the intervention group (n = 20) or the control group (n = 18). The participants' stages of change, nutrition knowledge, and self-efficacy were assessed using questionnaires. Participants were recruited in August 2017-December 2018, were HIV seropositive, had undetectable viral load, were prediabetic, and not currently receiving glucose-altering medications. Participants randomized into the intervention group received medical nutrition therapy/counseling and nutrition education; participants randomized into the control group received educational material related to nutrition, HIV, and prediabetes at baseline. Primary outcome measures were progression through the stages of change as measured by the transtheoretical ("stages of change") model, improvements in nutrition knowledge, and self-efficacy of the participants.

RESULTS

Significant improvement in stage of behavioral change was observed in the intervention group for physical activity, fruit/vegetable intake, fiber intake as well as nutrition knowledge and self-efficacy; however, no significant changes were observed in the control group.

CONCLUSIONS

A nutrition intervention was effective in promoting positive health behavior by progressing participants through the stages of behavioral change in low-income people living with HIV and prediabetes.

Obesity and diabetes in people of African ancestry with HIV

Obesity is a chronic disease with multiple adverse effects on health. The prevalence of obesity is increasing worldwide, and people of African ancestry are disproportionally affected. Several widely used antiretrovirals have been associated with weight gain and contribute to the rising burden of obesity in people with HIV. Obesity and weight gain on antiretroviral therapy are risk factors for the development of type 2 diabetes mellitus, a condition which also disproportionally affects black populations. In this review, we discuss recent data on weight gain in relation to initiating or switching antiretroviral therapy and advances in the management of obesity. Availability of highly effective treatments for obesity have the potential to address, and potentially reverse, the epidemics of obesity and diabetes mellitus in people with HIV.

A Step Closer to the "Fourth 90": A Practical Narrative Review of Diagnosis and Management of Nutritional Issues of People Living with HIV

The quality of life of people living with HIV (PLWH) has remarkably increased thanks to the introduction of combined antiretroviral therapy. Still, PLWH are exposed to an increased risk of cardiovascular diseases, diabetes, chronic kidney disease, and liver disease. Hence, the purpose of this review is to summarize the current knowledge about diagnosis and nutritional management with specific indication of macro and micronutrients intake for the main comorbidities of PLWH. In fact, a prompt diagnosis and management of lifestyle behaviors are fundamental steps to reach the "fourth 90". To achieve an early diagnosis of these comorbidities, clinicians have at their disposal algorithms such as the Framingham Score to assess cardiovascular risk; transient elastography and liver biopsy to detect NAFLD and NASH; and markers such as the oral glucose tolerance test and GFR to identify glucose impairment and renal failure, respectively. Furthermore, maintenance of ideal body weight is the goal for reducing cardiovascular risk and to improve diabetes, steatosis and fibrosis; while Mediterranean and low-carbohydrate diets are the dietetic approaches proposed for cardioprotective effects and for glycemic control, respectively. Conversely, diet management of chronic kidney disease requires different nutritional assessment, especially regarding protein intake, according to disease stage and eventually concomitant diabetes.

Effects of an intensive lifestyle intervention and the role of sleep in people living with HIV and prediabetes: a pilot and feasibility study

Objectives

Prediabetes is prevalent in people living with HIV (PLWH). Insufficient and irregular sleep are linked to abnormal glucose metabolism. This study aimed to investigate the differences in sleep characteristics between PLWH with and without prediabetes, determine the acceptability/feasibility and effects of a pilot six-month intensive lifestyle intervention (ILI) program on glucose metabolism in those with prediabetes, and determine how sleep modulates these effects.

Results

Thirty-nine PLWH (20 normoglycemia and 19 prediabetes) participated. There were no differences in sleep characteristics between individuals with normoglycemia and prediabetes. Next, thirteen individuals with prediabetes completed a six-month ILI program. The ILI program resulted in significant body weight reduction at 6 months (63.5 ± 13.9 to 61.9 ± 14.0 kg, p = 0.012), which was maintained at 12 months (p < 0.001). Waist circumferences were significantly decreased at 12 months (85.4 ± 11.7 to 82.9 ± 12.7 cm, p = 0.014). An increase in sleep variability was significantly associated with an increase in 2-h plasma glucose, independent of changes in BMI (b = 0.603), and physical activity (b = 0.774). This pilot study suggested that ILI in PLWH with prediabetes is feasible and effective in improving metabolic control, with its effects possibly modulated by sleep variability. These findings should be confirmed in a larger study to reduce diabetes risk in this population.

Trail registration: ClinicalTrial.gov, NCT03545217 (date of registration: May 22, 2018)

Non-communicable Diseases in Pregnant and Postpartum Women Living with HIV: Implications for Health Throughout the Life Course

PURPOSE OF REVIEW

The development of non-communicable diseases (NCDs) in pregnant women living with HIV can be a harbinger of future NCD-related morbidity and mortality. This review focuses on the NCDs that complicate pregnancy and the postpartum period, including hypertensive complications, hyperglycemic disorders, excessive gestational weight gain, and bone mineral density losses. For each disease process, we explore the role of HIV as a possible driver of excess risk, the immediate consequences of these complications on pregnancy outcomes and maternal and infant health, and possible implications for long-term women's health.

RECENT FINDINGS

Countries with the highest burden of HIV also shoulder a high burden of NCDs that complicate pregnancy, including hypertensive disorders, hyperglycemic disorders, weight gain, and osteopenia. This double burden of disease is a significant public health threat for reproductive-age women, with the potential for serious short- and long-term consequences for both women and their infants. Additionally, as the global first-line antiretroviral therapy regimens increasingly include integrase inhibitors, unhealthy weight gain associated with this drug class poses additional risk for NCD-related pregnancy complications and their persistence postpartum. Further research is needed to better define prevalence of NCD complications in pregnancy, elucidate HIV-specific and traditional factors associated with poor outcomes, and to develop interventions to reduce risk and avoid downstream complications in those at highest risk.

Contemporary Lifestyle Modification Interventions to Improve Metabolic Comorbidities in HIV

PURPOSE OF REVIEW

Metabolic comorbidities including diabetes, obesity, dyslipidemia, and hypertension, all of which are traditional cardiovascular disease risk factors that are highly prevalent in people with HIV (PWH). Bone disease including osteopenia, osteoporosis, and fragility fractures is also prevalent in PWH. These comorbidities may be prevented and treated in part with lifestyle modification, including changes to dietary and physical habits. The purpose of this review is to highlight recent literature that characterizes current lifestyle habits in PWH as well as the effectiveness of lifestyle strategies to improve metabolic comorbidities prevalent in PWH.

RECENT FINDINGS

Recent studies have expanded our knowledge regarding the current lifestyle habits of PWH as well as the potential for lifestyle modification to prevent or improve comorbidities prevalent in PWH. Clinical trials focusing on lifestyle modification have shown some benefit of such interventions on traditional risk factors for comorbidities; however, significant heterogeneity exists between studies and results are not consistent. Further clinical trials are needed including developing lifestyle strategies that are feasible, effective, and sustainable to prevent and decrease prevalence of comorbidities in this population.

Behavioral Weight Loss: A Promising Treatment for Obesity in Adults with HIV

Obesity and chronic disease are growing problems among people living with HIV (PLWH) across the globe. While a variety of treatments have been developed to address cardiovascular and metabolic disease among PLWH, few treatments have focused on helping PLWH and obesity lose weight. In the general population, behavioral weight loss interventions (i.e., diet, physical activity, and behavior therapy) are the first-line treatment for adults for whom weight loss is recommended. However, little research has tested whether the benefits of these programs translate to PLWH. This paper highlights the key components of behavioral weight loss programs, their outcomes in the general population and in the few studies of PLWH, and suggestions for tailoring these programs for PLWH. Behavioral weight loss programs are a strong potential treatment for reducing the burden of obesity among PLWH and merit future research attention.