Lifestyle intervention for type 2 diabetes patients: trial protocol of The Copenhagen Type 2 Diabetes Rehabilitation Project

Effects of Lifestyle Modifications on Prediabetic Patients: A Quasi-Experimental Trial

INTRODUCTION

Prediabetes is characterized by impaired fasting glucose or impaired glucose tolerance (IGT), which can lead to cardiovascular complications. This study aims to determine the effects of lifestyle modification on glycemic outcomes in prediabetic individuals.

METHODS

This quasi-experimental trial was conducted at the Department of Adult Cardiology, Phoenix Hospital, Abu Dhabi. Participants aged ≥18 years, of either gender, diagnosed with prediabetes as defined by hemoglobin A1c (HbA1c) levels between 5.7% and 6.4% were included in the study. Participants underwent a three-month lifestyle modification, adapted from cardiac rehabilitation principles, which included glycemic control, nutritional counseling, physical activity counseling, and exercise training. The primary outcome was the change in HbA1c levels following the intervention. Data analysis was performed using RStudio (Posit Software, Boston, MA).

RESULTS

A total number of 101 participants were enrolled, and 96 people completed the study. The average age of the participants was 44.80 ± 8.27 years. Most individuals were males, 85 (88.5%), and 11 females accounted for 11.5%. Postintervention, 25 participants (26%) reverted to normoglycemia, while 67 (69.8%) remained prediabetic, and 4 (4.2%) progressed to diabetes. Significant reductions in HbA1c levels were observed (p < 0.05). Subgroup analysis revealed no significant differences in outcomes based on age, gender, or clinical characteristics. The program demonstrated strong adherence, with a retention rate of 95%.

CONCLUSION

Lifestyle modification effectively improved glycemic control and reduced the progression of diabetes in prediabetic individuals. The findings support the integration of lifestyle interventions for managing prediabetes.

Global comparison of the effect of non-pharmacological interventions on glycemic control in patients with type 2 diabetes: A network meta-analysis from 107 randomized controlled trials

OBJECTIVE

To investigate the effectiveness of non-pharmacological interventions (NPIs) on glycemic control in patients with type 2 diabetes (T2D) and to provide guidance for clinical healthcare-giver.

DESIGN

Network meta-analysis (NMA).

SETTING AND PARTICIPANTS

Randomized controlled trials comparing the effect of NPIs with usual care, waitlist, or other NPIs on glycemic control in patients with T2D.

METHODS

This NMA was guided by frequentist framework. PubMed, Embase, the Cochrane Library Central Register of Controlled Trials, Cumulated Index to Nursing and Allied Health Literature, and Web of Science were searched from their inception until January 2023. The primary outcome was HbA1c and secondary outcomes were cardiovascular risk scores and related psychosocial scores. Mean differences and standardized mean differences were pooled using NMA. Study quality was assessed with the Confidence in Network Meta-analysis.

RESULTS

A total of 107 studies (10,496 participants) were included. The median sample size of the included studies was 64 (range, 10-563) and the median duration was 3 months (range, 1-24). Compared to usual care, all NPIs except acupuncture (MD: -0.28; 95 % CI: -1.02, 0.26) and psychological therapy (MD: -0.29; 95 % CI: -0.66, 0.08) showed significantly differences in improving glycemic control in patients with T2D. And according to the results of surface under the cumulative ranking analysis and Cluster ranking, meditation therapy was considered to the best choice when balancing the efficacy of glycemic control with self-efficacy and diabetes related problems, while nutrition therapy was considered to the best choice when balancing quality of life with risk of cardiovascular complications.

CONCLUSIONS

These findings validate the efficacy of NPIs for glycemic control in patients with T2D and suggest that healthcare-giver should consider both the efficacy of interventions and the psychosocial needs of patients when developing NPIs programs.

Effect of Treadmill Exercise and Trans-Cinnamaldehyde against d-Galactose- and Aluminum Chloride-Induced Cognitive Dysfunction in Mice

Mild cognitive impairment (MCI) generally refers to impairment in cognition above that which accompanies the normal age-related cognitive decline and has attracted attention in recent years. Trans-cinnamaldehyde (TCA), which is isolated from cinnamon, has anti-inflammatory and antioxidant properties. Treadmill exercise also has diverse positive effects. The purpose of this study was to investigate the combination effects of TCA and treadmill exercise on learning and memory in a cognitive impairment mouse induced by a combination of d-galactose (d-gal) and aluminum chloride (AlCl₃). We found that exercise and TCA attenuated cognitive impairment in mice with induced MCI. This effect was further increased by costimulation of exercise and TCA. To clarify the mechanisms of the positive effects of TCA and exercise, we analyzed the nuclear factor erythroid 2-related factor (Nrf2) and related signaling pathways. We found that TCA and exercise upregulated Nrf2, NAD(P)H dehydrogenase quinone 1 (NQO-1), heme oxygenase 1 (HO-1), and superoxide dismutase 1 (SOD-1); this suggests that TCA and exercise attenuate cognitive dysfunction by reducing oxidative stress. We also found that Nrf2-related signaling pathways, i.e., the AMP-activated protein kinase (AMPK)/Nrf2 and SIRT1/PGC-1a/Nrf2-ARE pathways, exerted antioxidant effects. Together, these results suggest that costimulation with TCA and exercise may be a therapeutic candidate for mild cognitive impairment.

Exercise effects on brain and behavior in healthy mice, Alzheimer's disease and Parkinson's disease model-A systematic review and meta-analysis

This systematic review and meta-analysis examines how exercise modifies brain and behavior in healthy mice, dementia (D) and Parkinson disease (PD) models. A search was performed on the Medline and Scopus electronic databases (2008-2019). Search terms were "mice", "brain", "treadmill", "exercise", "physical exercise". In the total, 430 were found but only 103 were included. Animals n = 1,172; exercised 4-8 weeks (Range 24 h to 32 weeks), 60 min/day (Range 8-120 min per day), and 10/12 m/min (Range 0.2 m/min to 36 m/min). Hippocampus, cerebral cortex, striatum and whole brain were more frequently investigated. Exercise improved learning and memory. Meta-analysis showed that exercise increased: cerebral BDNF in health (n = 150; z = 5.8, CI 3.43-12.05; p < 0.001 I2 = 94.3 %), D (n = 124; z = 4.18, CI = 2.22-9.12; p < 0.001; I2 = 93.7 %) and PD (n = 16 z = 4.26, CI 5.03-48.73 p < 0.001 I2 = 94.8 %). TrkB improved in health (n = 84 z = 5.49, CI 3.8-17.73 p < 0.001, I2 = 0.000) and PD (n = 22; z = 3.1, CI = 2.58-67.3, p < 0.002 I2 = 93.8 %). Neurogenesis increased in health (n = 68; z = 7.08, CI 5.65-21.25 p < 0.001; I2 17.58) and D model (n = 116; z = 4.18, CI 2.22-9.12 p < 0.001 I2 93.7 %). Exercise augmented amyloid clearance (n = 166; z = 7.51 CI = 4.86-14.85, p < 0.001 I2 = 58.72) and reduced amyloid plaques in D models (n = 49; z = 4.65, CI = 3.94-15.3 p < 0.001 I2 = 0.000). In conclusion, exercise improved brain and behavior, neurogenesis in healthy and dementia models, reduced toxicity and cerebral amyloid. Evidence regarding inflammation, oxidative stress and energy metabolism were scarce. Studies examining acute vs chronic exercise, extreme training and the durability of exercise benefit were rare. Vascular or glucose metabolism changes were seldom reported.

What predicts regression from pre-diabetes to normal glucose regulation following a primary care nurse-delivered dietary intervention? A study protocol for a prospective cohort study

INTRODUCTION

Pre-diabetes is a high-risk state for the development of type 2 diabetes mellitus (T2DM) and cardiovascular disease. Regression to normoglycaemia, even if transient, significantly reduces the risk of developing T2DM. The primary aim of this mixed-methods study is to determine if there are clinically relevant differences among those with pre-diabetes and excess weight who regress to normoglycaemia, those who have persistent pre-diabetes and those who progress to T2DM following participation in a 6-month primary care nurse-delivered pre-diabetes dietary intervention. Incidence of T2DM at 2 years will be examined.

METHODS AND ANALYSIS

Four hundred participants with pre-diabetes (New Zealand definition glycated haemoglobin 41-49 mmol/mol) and a body mass index >25 kg/m² will be recruited through eight primary care practices in Hawke's Bay, New Zealand. Trained primary care nurses will deliver a 6-month structured dietary intervention, followed by quarterly reviews for 18 months post-intervention. Clinical data, data on lifestyle factors and health-related quality of life (HR-QoL) and blood samples will be collected at baseline, 6 months, 12 months and 24 months. Sixty participants purposefully selected will complete a semi-structured interview following the 6-month intervention. Poisson regression with robust standard errors and clustered by practice will be used to identify predictors of regression or progression at 6 months, and risk factors for developing T2DM at 2 years. Qualitative data will be analysed thematically. Changes in HR-QoL will be described and potential cost savings will be estimated from a funder's perspective at 2 years.

ETHICS AND DISSEMINATION

This study was approved by the Northern A Health and Disability Ethics Committee, New Zealand (Ethics Reference: 17/NTA/24). Study results will be presented to participants, published in peer-reviewed journals and presented at relevant conferences.

TRIAL REGISTRATION NUMBER

ACTRN12617000591358; Pre-results.

Health-promoting Lifestyle, Illness Control Beliefs and Well-being of the Obese Diabetic Women

The study examines the role of health-promoting lifestyle and illness control beliefs in well-being of obese diabetic women. Measures of illness control belief, health-promoting lifestyle and obesity-related well-being were given to 100 obese diabetic women selected from outdoors of hospitals in Varanasi. Analysis revealed patients’ stronger belief in ‘doctor-control’ and ‘supernatural-control’ than ‘self-control’ of the disease. Nutrition, interpersonal relations, physical activity and stress management were given more importance in health promotion than spiritual growth-related practices. Belief in ‘self-control’ and ‘doctor-control’ of disease was negatively correlated with ‘psychosocial discomfort’, ‘physical discomfort’ and ‘psychosocial impact’ aspects of obesity, whereas ‘supernatural-control’ showed positive relationship with all aspects. All components of ‘health-promoting lifestyle’ were negatively correlated with ‘physical discomfort’, ‘psychosocial discomfort’ and ‘psychosocial impact’ aspects of obesity. Multiple regression analysis brought out ‘self-control’, ‘supernatural-control’, ‘health responsibility’, ‘physical activity’ and ‘stress management’ as significant predictors of ‘well-being’ of the obese diabetic women.

The effectiveness of a primary care nursing-led dietary intervention for prediabetes: a mixed methods pilot study

BACKGROUND

Primary care nurse-led prediabetes interventions are seldom reported. We examined the implementation and feasibility of a 6-month multilevel primary care nurse-led prediabetes lifestyle intervention compared with current practice in patients with prediabetes, with weight and glycated haemoglobin (HbA1c) as outcomes.

METHODS

This study used a convergent mixed methods design involving a 6-month pragmatic non-randomised pilot study with a qualitative process evaluation, and was conducted in two neighbouring provincial cities in New Zealand, with indigenous Māori populations comprising 18.2% and 23.0%, respectively. Participants were non-pregnant adults aged ≤ 70 years with newly diagnosed prediabetes (HbA1c 41-49 mmol/mol), body mass index (BMI) ≥ 25 kg/m2 and not prescribed Metformin. A structured dietary intervention tool delivered by primary care nurses with visits at baseline, 2-3 weeks, 3 months and 6 months was implemented in four intervention practices. Four control practices continued to provide usual care. Primary quantitative outcome measures were weight and HbA1c. Linear and quantile regression models were used to compare each outcome between the two groups at follow-up. Qualitative data included: observations of nurse training sessions and steering group meetings; document review; semi-structured interviews with a purposive sample of key informants (n = 17) and intervention patients (n = 20). Thematic analysis was used.

RESULTS

One hundred fifty-seven patients with prediabetes enrolled (85 intervention, 72 control), 47.8% female and 31.2% Māori. Co-morbidities were common, particularly hypertension (49.7%), dyslipidaemia (40.1%) and gout (15.9%). Baseline and 6 month measures were available for 91% control and 79% intervention participants. After adjustment, the intervention group lost a mean 1.3 kg more than the control group (p < 0.001). Mean HbA1c, BMI and waist circumference decreased in the intervention group and increased in the control group, but differences were not statistically significant. Implementation fidelity was high, and it was feasible to implement the intervention in busy general practice settings. The intervention was highly acceptable to both patients and key stakeholders, especially primary care nurses.

CONCLUSIONS

Study findings confirm the feasibility and acceptability of primary care nurses providing structured dietary advice to patients with prediabetes in busy general practice settings. The small but potentially beneficial mean weight loss among the intervention group supports further investigation.

TRIAL REGISTRATION

ANZCTR ACTRN12615000806561 . Registered 3 August 2015 (Retrospectively registered).

Intensive versus conventional glycaemic control for treating diabetic foot ulcers

BACKGROUND

The estimated likelihood of lower limb amputation is 10 to 30 times higher amongst people with diabetes compared to those without diabetes. Of all non-traumatic amputations in people with diabetes, 85% are preceded by a foot ulcer. Foot ulceration associated with diabetes (diabetic foot ulcers) is caused by the interplay of several factors, most notably diabetic peripheral neuropathy (DPN), peripheral arterial disease (PAD) and changes in foot structure. These factors have been linked to chronic hyperglycaemia (high levels of glucose in the blood) and the altered metabolic state of diabetes. Control of hyperglycaemia may be important in the healing of ulcers.

OBJECTIVES

To assess the effects of intensive glycaemic control compared to conventional control on the outcome of foot ulcers in people with type 1 and type 2 diabetes.

SEARCH METHODS

In December 2015 we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; EBSCO CINAHL; Elsevier SCOPUS; ISI Web of Knowledge Web of Science; BioMed Central and LILACS. We also searched clinical trial databases, pharmaceutical trial databases and current international and national clinical guidelines on diabetes foot management for relevant published, non-published, ongoing and terminated clinical trials. There were no restrictions based on language or date of publication or study setting.

SELECTION CRITERIA

Published, unpublished and ongoing randomised controlled trials (RCTs) were considered for inclusion where they investigated the effects of intensive glycaemic control on the outcome of active foot ulcers in people with diabetes. Non randomised and quasi-randomised trials were excluded. In order to be included the trial had to have: 1) attempted to maintain or control blood glucose levels and measured changes in markers of glycaemic control (HbA1c or fasting, random, mean, home capillary or urine glucose), and 2) documented the effect of these interventions on active foot ulcer outcomes. Glycaemic interventions included subcutaneous insulin administration, continuous insulin infusion, oral anti-diabetes agents, lifestyle interventions or a combination of these interventions. The definition of the interventional (intensive) group was that it should have a lower glycaemic target than the comparison (conventional) group.

DATA COLLECTION AND ANALYSIS

All review authors independently evaluated the papers identified by the search strategy against the inclusion criteria. Two review authors then independently reviewed all potential full-text articles and trials registry results for inclusion.

MAIN RESULTS

We only identified one trial that met the inclusion criteria but this trial did not have any results so we could not perform the planned subgroup and sensitivity analyses in the absence of data. Two ongoing trials were identified which may provide data for analyses in a later version of this review. The completion date of these trials is currently unknown.

AUTHORS' CONCLUSIONS

The current review failed to find any completed randomised clinical trials with results. Therefore we are unable to conclude whether intensive glycaemic control when compared to conventional glycaemic control has a positive or detrimental effect on the treatment of foot ulcers in people with diabetes. Previous evidence has however highlighted a reduction in risk of limb amputation (from various causes) in people with type 2 diabetes with intensive glycaemic control. Whether this applies to people with foot ulcers in particular is unknown. The exact role that intensive glycaemic control has in treating foot ulcers in multidisciplinary care (alongside other interventions targeted at treating foot ulcers) requires further investigation.

Client perceptions of group education in the management of type 2 diabetes mellitus in South Australia

Type 2 diabetes mellitus (T2DM) is a progressive chronic disease that requires significant self-surveillance and adherence to the treatment protocols for successful management and future health. There is a growing body of evidence suggesting that diabetes education is beneficial for patient outcomes. However, there is some debate about how best to deliver diabetes education, whether individually or in groups. Although several studies have investigated the role of group education in improving the management of T2DM, few studies have examined this issue from the client's perspective. It is here that this study makes a contribution to understanding diabetes management. Drawing on systematic observation of group education sessions provided by diabetic resource nurses and in-depth interviews with clients, this paper describes the experiences, perspectives and significance of these sessions to clients. Our results suggest that group education sessions were seen as valuable to the clients for: the opportunity they provided to meet others living with diabetes; to improve motivation for managing the disease; and to enhance knowledge of diabetes, its management and long-term implications. In short, this study demonstrates that the clients value group education sessions for the social contact, increasing knowledge about the disease for self-management and support they provide; factors recognised as important to maintaining health. In addition, group education sessions appear to be a cost-effective method for diabetes self-management that funders need to consider.

WITHDRAWN: Group based diabetes self-management education compared to routine treatment, waiting list control or no intervention for people with type 2 diabetes mellitus

The review authors of this review update are unable to continue with their work. The Cochrane Metabolic and Endocrine Disorders Review Group is seeking very experienced new authors to perform an update on this complex intervention review.

At June 2015, this review has been withdrawn. This review is out of date although it is correct as the date of publication. The latest version is available in the 'Other versions' tab on the Cochrane Library, and may still be useful to readers.

The editorial group responsible for this previously published document have withdrawn it from publication.

A novel multidisciplinary intervention for long-term weight loss and glycaemic control in obese patients with diabetes

INTRODUCTION

Obesity and diabetes are difficult to treat in public clinics. We sought to determine the effectiveness of the Metabolic Rehabilitation Program (MRP) in achieving long-term weight loss and improving glycaemic control versus "best practice" diabetes clinic (DC) in obese patients using a retrospective cohort study.

METHODS

Patients with diabetes and BMI > 30 kg/m(2) who attended the MRP, which consisted of supervised exercise and intense allied health integration, or the DC were selected. Primary outcomes were improvements in weight and glycaemia with secondary outcomes of improvements in blood pressure and lipid profile at 12 and 30 months.

RESULTS

Baseline characteristics of both cohorts (40 MRP and 40 DC patients) were similar at baseline other than age (63 in MRP versus 68 years in DC, P = 0.002). At 12 months, MRP patients lost 7.65 ± 1.74 kg versus 1.76 ± 2.60 kg in the DC group (P < 0.0001) and 9.70 ± 2.13 kg versus 0.98 ± 2.65 kg at 30 months (P < 0.0001). Similarly, MRP patients had significant absolute reductions in %HbA1c at 30 months versus the DC group (-0.86 ± 0.31% versus 0.12% ± 0.33%, P < 0.038), with nonsignificant improvements in lipids and blood pressure in MRP patients.

CONCLUSION

Further research is needed to establish the MRP as an effective strategy for achieving sustained weight loss and improving glycaemic control in obese patients with type 2 diabetes.

Mechanistic studies of lifestyle interventions in type 2 diabetes

AIM: To investigate the effect of lifestyle interventions in the non-pharmacological management of type 2 diabetes via a mechanistic approach.

METHODS: A randomized controlled trial was carried out on 60 type 2 diabetic male and female volunteers that fulfilled the inclusion criteria, with their proper consent and permission of the International Electrotechnical Commission for 1 year. 30 patients were included in the test group and 30 patients in the control group. Demographic details, anthropometrical status, physical activity, food habits and blood glucose lipid profile of the volunteers were recorded at baseline, the test group was directed for lifestyle intervention and final blood glucose lipid data were collected at the end of one year of patient follow-up.

RESULTS: After 1 year, the test group who had a lifestyle intervention was found to show a significant improvement in blood glucose lipid profile. The fasting plasma glucose level (FPG), postprandial plasma glucose level (PPG), glycosylated hemoglobin (HbA1c) and body mass index (BMI) values of the test group were reduced significantly, up to 145 ± 2.52, 174 ± 2.59, 6.3 ± 0.32 and 25 ± 0.41 respectively at the end of the study period, in comparison to the control group where FPG, PPG, HbA1c and BMI values were 193 ± 3.36, 249 ± 4.24, 7.2 ± 0.42 and 26 ± 0.65 respectively. Improvement in the total cholesterol (TC), triglyceride (TG), high-density lipoproteins (HDL) and low-density lipoproteins (LDL) values of the test group was also remarkable in comparison to the control group. The TC, TG, HDL and LDL values of the test group were reduced significantly, up to 149 ± 3.32, 124 ± 2.16, 58 ± 0.62 and 118 ± 2.31, respectively.

CONCLUSION: The significant improvement in the blood glucose lipid profile of the test group after 1 year signifies the value of non-pharmacological management of type 2 diabetes via lifestyle intervention strategies.

Predictors of effects of lifestyle intervention on diabetes mellitus type 2 patients

The main aim of the study was to identify predictors of the effects of lifestyle intervention on diabetes mellitus type 2 patients by means of multivariate analysis. Data from a previously published randomised clinical trial, which compared the effects of a rehabilitation programme including standardised education and physical training sessions in the municipality's health care centre with the same duration of individual counseling in the diabetes outpatient clinic, were used. Data from 143 diabetes patients were analysed. The merged lifestyle intervention resulted in statistically significant improvements in patients' systolic blood pressure, waist circumference, exercise capacity, glycaemic control, and some aspects of general health-related quality of life. The linear multivariate regression models explained 45% to 80% of the variance in these improvements. The baseline outcomes in accordance to the logic of the regression to the mean phenomenon were the only statistically significant and robust predictors in all regression models. These results are important from a clinical point of view as they highlight the more urgent need for and better outcomes following lifestyle intervention for those patients who have worse general and disease-specific health.

Using electronic medical records analysis to investigate the effectiveness of lifestyle programs in real-world primary care is challenging: a case study in diabetes mellitus

OBJECTIVE

The increasing prevalence of diabetes suggests a gap between real world and controlled trial effectiveness of lifestyle interventions, but real-world investigations are rare. Electronic medical registration facilitates research on real-world effectiveness, although such investigations may require specific methodology and statistics. We investigated the effects of real-world primary care for patients with type 2 diabetes mellitus (T2DM).

STUDY DESIGN AND SETTING

We used medical records of patients (n=2,549) with T2DM from 10 primary health care centers. A mixed-effects regression model for repeated measurements was used to evaluate the changes in weight and Hemoglobin A1c (HbA1c) over time.

RESULTS

There was no statistically significant change in weight (+0.07 kg, P=0.832) and HbA1c (+0.03%, P=0.657) during the observation period of 972 days. Most patients maintained their physical activity level (70%), and 54 % had an insufficient activity level. The variability in the course of weight and HbA1c was because of differences between patients and not between health care providers.

CONCLUSION

Despite effective lifestyle interventions in controlled trial settings, we found that real-world primary care is only able to stabilize weight and HbA1c in patients with T2DM over time. Medical registration can be used to monitor the actual effectiveness of interventions in primary care.

Health-related quality of life and self-related health in patients with type 2 diabetes: effects of group-based rehabilitation versus individual counselling

Background

Type 2 diabetes can seriously affect patients' health-related quality of life and their self-rated health. Most often, evaluation of diabetes interventions assess effects on glycemic control with little consideration of quality of life. The aim of the current study was to study the effectiveness of group-based rehabilitation versus individual counselling on health-related quality of life (HRQOL) and self-rated health in type 2 diabetes patients.

Methods

We randomised 143 type 2 diabetes patients to either a six-month multidisciplinary group-based rehabilitation programme including patient education, supervised exercise and a cooking-course or a six-month individual counselling programme. HRQOL was measured by Medical Outcomes Study Short Form 36-item Health Survey (SF-36) and self-rated health was measured by Diabetes Symptom Checklist - Revised (DCS-R).

Results

In both groups, the lowest estimated mean scores of the SF36 questionnaire at baseline were "vitality" and "general health". There were no significant differences in the change of any item between the two groups after the six-month intervention period. However, vitality-score increased 5.2 points (p = 0.12) within the rehabilitation group and 5.6 points (p = 0.03) points among individual counselling participants.

In both groups, the highest estimated mean scores of the DSC-R questionnaire at baseline were "Fatigue" and "Hyperglycaemia". Hyperglycaemic and hypoglycaemic distress decreased significantly after individual counselling than after group-based rehabilitation (difference -0.3 points, p = 0.04). No between-group differences occurred for any other items. However, fatigue distress decreased 0.40 points within the rehabilitation group (p = 0.01) and 0.34 points within the individual counselling group (p < 0.01). In the rehabilitation group cardiovascular distress decreased 0.25 points (p = 0.01).

Conclusions

A group-based rehabilitation programme did not improve health-related quality of life and self-rated health more than an individual counselling programme. In fact, the individual group experienced a significant relief in hyper- and hypoglycaemic distress compared with the rehabilitation group.

However, the positive findings of several items in both groups indicate that lifestyle intervention is an important part of the management of type 2 diabetes patients.

Efficacy of lifestyle interventions in physical health management of patients with severe mental illness

Awareness of the importance of maintaining physical health for patients with severe mental illnesses has recently been on the increase. Although there are several elements contributing to poor physical health among these patients as compared with the general population, risk factors for cardiovascular disease such as smoking, diabetes mellitus, hypertension, dyslipidemia, metabolic syndrome, and obesity are of particular significance due to their relationship with mortality and morbidity. These patients present higher vulnerability to cardiovascular risk factors based on several issues, such as genetic predisposition to certain pathologies, poor eating habits and sedentary lifestyles, high proportions of smokers and drug abusers, less access to regular health care services, and potential adverse events during pharmacological treatment. Nevertheless, there is ample scientific evidence supporting the benefits of lifestyle interventions based on diet and exercise designed to minimize and reduce the negative impact of these risk factors on the physical health of patients with severe mental illnesses.

Effect of a group-based rehabilitation programme on glycaemic control and cardiovascular risk factors in type 2 diabetes patients: the Copenhagen Type 2 Diabetes Rehabilitation Project

OBJECTIVE

To compare the effectiveness of a group-based rehabilitation programme with an individual counselling programme at improving glycaemic control and cardiovascular risk factors among patients with type 2 diabetes.

METHODS

We randomised 143 adult type 2 diabetes patients to either a 6-month multidisciplinary group-based rehabilitation programme or a 6-month individual counselling programme. Outcome measures included glycated haemoglobin (HbA(1c)), blood pressure, lipid profile, weight, and waist circumference.

RESULTS

Mean HbA(1c) decreased 0.3%-point (95% confidence interval [CI] = -0.5, -0.1) in the rehabilitation group and 0.6%-point (95% CI = -0.8, -0.4) among individual counselling participants (p<0.05). Within both groups, equal reductions occurred in body weight, waist circumference, systolic blood pressure and diastolic blood pressure, but no significant between-group differences between occurred for any of the cardiovascular outcomes. The group-based rehabilitation programme consumed twice as many personnel resources.

CONCLUSION

The group-based rehabilitation programme resulted in changes in glycaemic control and cardiovascular risk factor reduction that were equivalent or inferior to those of an individual counselling programme.

PRACTICE IMPLICATIONS

The group-based rehabilitation programme, tested in the current design, did not offer additionally improved outcomes and consumed more personnel resources than the individual counselling programme; its broad implementation is not supported by this study. Trial registration Clinicaltrials.gov NCT00284609.

Safety during the monitoring of diabetic patients: trial teaching course on health professionals and diabetics - SEGUDIAB study

Background

Safety for diabetic patients means providing the most suitable treatment for each type of diabetic in order to improve monitoring and to prevent the adverse effects of drugs and complications arising from the disease. The aim of this study is to analyze the effect of imparting educational interventions to health professionals regarding the safety of patients with Diabetes Mellitus (DM).

Methods

Design: A cluster randomized trial with a control group.

Setting and sample: The study analyzed ten primary healthcare centres (PHC) covering approximately 150,000 inhabitants. Two groups of 5 PHC were selected on the basis of their geographic location (urban, semi-urban and rural), their socio-economic status and the size of their PHC, The interventions and control groups were assigned at random. The study uses computerized patient records to individually assess subjects aged 45 to 75 diagnosed with type 1 and type 2 DM, who met the inclusion conditions and who had the variables of particular interest to the study.

Trial: The educational interventions consisted of a standardized teaching course aimed at doctors and nurses. The course lasted 6 hours and was split into three 2-hour blocks with subsequent monthly refresher courses.

Measurement: For the health professionals, the study used the Diabetes Attitude Scale (DAS-3) to assess their attitudes and motivation when monitoring diabetes. For the patients, the study assessed factors related to their degree of control over the disease at onset, 6, 12 and 24 months.

Main variables: levels of HbA1c.

Analysis: The study analyzed the effect of the educational interventions both on the attitudes and motivations of health professionals and on the degree of control over the diabetes in both groups.

Discussion

Imparting educational interventions to health professionals would improve the monitoring of diabetic patients. The most effective model involves imparting the course to both doctors and nurses. However, these models have not been tested on our Spanish population within the framework of primary healthcare.

Trial registration

ClinicalTrials.gov: NCT01087541

The Happy Life Club™ study protocol: a cluster randomised controlled trial of a type 2 diabetes health coach intervention

BACKGROUND

The Happy Life Club™ is an intervention that utilises health coaches trained in behavioural change and motivational interviewing techniques to assist with the management of type 2 diabetes mellitus (T2DM) in primary care settings in China. Health coaches will support participants to improve modifiable risk factors and adhere to effective self-management treatments associated with T2DM.

METHODS/DESIGN

A cluster randomised controlled trial involving 22 Community Health Centres (CHCs) in Fengtai District of Beijing, China. CHCs will be randomised into a control or intervention group, facilitating recruitment of at least 1320 individual participants with T2DM into the study. Participants in the intervention group will receive a combination of both telephone and face-to-face health coaching over 18 months, in addition to usual care received by the control group. Health coaching will be performed by CHC doctors and nurses certified in coach-assisted chronic disease management. Outcomes will be assessed at baseline and again at 6, 12 and 18 months by means of a clinical health check and self-administered questionnaire. The primary outcome measure is HbA1c level. Secondary outcomes include metabolic, physiological and psychological variables.

DISCUSSION

This cluster RCT has been developed to suit the Chinese health care system and will contribute to the evidence base for the management of patients with T2DM. With a strong focus on self-management and health coach support, the study has the potential to be adapted to other chronic diseases, as well as other regions of China.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN01010526.

Effects of lifestyle education program for type 2 diabetes patients in clinics: study design of a cluster randomized trial

Background

The number of patients with type 2 diabetes is drastically increasing worldwide. It is a serious health problem in Japan as well. Lifestyle interventions can reduce progression from impaired glucose tolerance to type 2 diabetes, and glycemic control has been shown to improve postprandial plasma glucose levels. Moreover, several studies have suggested that continuous interventions (combined diet and exercise) can improve the plasma glucose level and reduce dosage of hypoglycemic agents.

Although many interventional studies of lifestyle education for persons with diabetes in hospitals have been reported, only a few have been clinic-based studies employing an evidence-based lifestyle education program. This article describes the design of a cluster randomized controlled trial of the effectiveness of lifestyle education for patients with type 2 diabetes in clinics by registered dietitians.

Methods/Design

In Japan, general practitioners generally have their own medical clinics to provide medical care for outpatients in the community, including those with type 2 diabetes. With the collaboration of such general practitioners, the study patients were enrolled in the present study. Twenty general practitioners were randomly allocated to each provide patients for entry into either an intervention group (10) or a control group (10). In total, 200 participants will be included in the study. The intervention group will receive intensive education on lifestyle improvement related to type 2 diabetes by registered dietitians in clinics. Lifestyle education will be conducted several times during the study period. The control group will receive information on dietary intake and standard advice on glycemic control by registered dietitians. The primary endpoint is the change from the baseline value of HbA1c at 6 months. Data on health behavior and related issues will be gathered continuously over a 6-month period.

Discussion

This is the first study to evaluate lifestyle education in clinics by a cluster randomization trial in Japan. The proposed study will provide practical information about the usefulness of the intensive lifestyle improvement education program in primary care settings. The study was started in September 2007 and entry of subjects was completed in December 2010. Data on the effect evaluation will be available in 2011.

Trial Registration

UMIN000004049

Integration of healthcare rehabilitation in chronic conditions

Introduction

Quality of care provided to people with chronic conditions does not often fulfil standards of care in Denmark and in other countries. Inadequate organisation of healthcare systems has been identified as one of the most important causes for observed performance inadequacies, and providing integrated healthcare has been identified as an important organisational challenge for healthcare systems. Three entities—Bispebjerg University Hospital, the City of Copenhagen, and the GPs in Copenhagen—collaborated on a quality improvement project focusing on integration and implementation of rehabilitation programmes in four conditions.

Description of care practice

Four multidisciplinary rehabilitation intervention programmes, one for each chronic condition: chronic obstructive pulmonary disease, type 2 diabetes, chronic heart failure, and falls in elderly people were developed and implemented during the project period. The chronic care model was used as a framework for support of implementing and integration of the four rehabilitation programmes.

Conclusion and discussion

The chronic care model provided support for implementing rehabilitation programmes for four chronic conditions in Bispebjerg University Hospital, the City of Copenhagen, and GPs' offices. New management practices were developed, known practices were improved to support integration, and known practices were used for implementation purposes. Several barriers to integrated care were identified.