Sustained diabetes risk reduction after real life and primary health care setting implementation of the diabetes in Europe prevention using lifestyle, physical activity and nutritional intervention (DE-PLAN) project

Modeling chronic disease risk across equity factors using a population-based prediction model: the Chronic Disease Population Risk Tool (CDPoRT)

BACKGROUND

Predicting chronic disease incidence at a population level can help inform overall future chronic disease burden and opportunities for prevention. This study aimed to estimate the future burden of chronic disease in Ontario, Canada, using a population-level risk prediction algorithm and model interventions for equity-deserving groups who experience barriers to services and resources due to disadvantages and discrimination.

METHODS

The validated Chronic Disease Population Risk Tool (CDPoRT) estimates the 10-year risk and incidence of major chronic diseases. CDPoRT was applied to data from the 2017/2018 Canadian Community Health Survey to predict baseline 10-year chronic disease estimates to 2027/2028 in the adult population of Ontario, Canada, and among equity-deserving groups. CDPoRT was used to model prevention scenarios of 2% and 5% risk reductions over 10 years targeting high-risk equity-deserving groups.

RESULTS

Baseline chronic disease risk was highest among those with less than secondary school education (37.5%), severe food insecurity (19.5%), low income (21.2%) and extreme workplace stress (15.0%). CDPoRT predicted 1.42 million new chronic disease cases in Ontario from 2017/2018 to 2027/2028. Reducing chronic disease risk by 5% prevented 1500 cases among those with less than secondary school education, prevented 14 900 cases among those with low household income and prevented 2800 cases among food-insecure populations. Large reductions of 57 100 cases were found by applying a 5% risk reduction in individuals with quite a bit workplace stress.

CONCLUSION

Considerable reduction in chronic disease cases was predicted across equity-defined scenarios, suggesting the need for prevention strategies that consider upstream determinants affecting chronic disease risk.

Establishment of dynamic nomogram and risk score models for T2DM: a retrospective cohort study in Beijing

BACKGROUND

Health interventions can delay or prevent the occurrence and development of diabetes. Dynamic nomogram and risk score (RS) models were developed to predict the probability of developing type 2 diabetes mellitus (T2DM) and identify high-risk groups.

METHODS

Participants (n = 44,852) from the Beijing Physical Examination Center were followed up for 11 years (2006-2017); the mean follow-up time was 4.06 ± 2.09 years. Multivariable Cox regression was conducted in the training cohort to identify risk factors associated with T2DM and develop dynamic nomogram and RS models using weighted estimators corresponding to each covariate derived from the fitted Cox regression coefficients and variance estimates, and then undergone internal validation and sensitivity analysis. The concordance index (C-index) was used to assess the accuracy and reliability of the model.

RESULTS

Of the 44,852 individuals at baseline, 2,912 were diagnosed with T2DM during the follow-up period, and the incidence density rate per 1,000 person-years was 16.00. Multivariate analysis indicated that male sex (P < 0.001), older age (P < 0.001), high body mass index (BMI, P < 0.05), high fasting plasma glucose (FPG, P < 0.001), hypertension (P = 0.015), dyslipidaemia (P < 0.001), and low serum creatinine (sCr, P < 0.05) at presentation were risk factors for T2DM. The dynamic nomogram achieved a high C-index of 0.909 in the training set and 0.905 in the validation set. A tenfold cross-validation estimated the area under the curve of the nomogram at 0.909 (95% confidence interval 0.897-0.920). Moreover, the dynamic nomogram and RS model exhibited acceptable discrimination and clinical usefulness in subgroup and sensitivity analyses.

CONCLUSIONS

The T2DM dynamic nomogram and RS models offer clinicians and others who conduct physical examinations, respectively, simple-to-use tools to assess the risk of developing T2DM in the urban Chinese current or retired employees.

Relationship between Cardiometabolic Factors and the Response of Blood Pressure to a One-Year Primary Care Lifestyle Intervention in Metabolic Syndrome Patients

Systemic hypertension has been recognized as a modifiable traditional cardiovascular risk factor and influenced by many factors such as eating habits, physical activity, diabetes, and obesity. The objective of this cross-sectional study was to identify factors that predict changes in blood pressure induced by a one-year lifestyle intervention in primary care settings involving a collaboration between family physicians, dietitians, and exercise specialists. Patients with metabolic syndrome diagnosis were recruited by family physicians participating in primary care lifestyle intervention among several family care clinics across Canada. Participants for whom all cardiometabolic data at the beginning (T0) and the end (T12) of the one-year intervention were available were included in the present analysis (n = 101). Patients visited the dietitian and the exercise specialist weekly for the first three months and monthly for the last nine months. Diet quality, exercise capacity, anthropometric indicators, and cardiometabolic variables were evaluated at T0 and at T12. The intervention induced a statistically significant decrease in waist circumference (WC), systolic (SBP) and diastolic (DBP) blood pressure, and plasma triglycerides, and an increase in cardiorespiratory fitness (estimated VO2max). Body weight (p < 0.001), body mass index (BMI) (p < 0.001), and fasting blood glucose (p = 0.006) reduction, and VO2max increase (p = 0.048) were all related to changes in SBP. WC was the only variable for which changes were significantly correlated with those in both SBP (p < 0.0001) and DBP (p = 0.0004). Variations in DBP were not associated with changes in other cardiometabolic variables to a statistically significant extent. Twelve participants were identified as adverse responders (AR) in both SBP and DBP and displayed less favorable changes in WC. The beneficial effects of the primary care lifestyle intervention on blood pressure were significantly associated with cardiometabolic variables, especially WC. These findings suggest that a structured lifestyle intervention in primary care can help improve cardiometabolic risk factors in patients with metabolic syndrome and that WC should be systematically measured to better stratify the patient’s hypertension risk.

The positive impact of a care-physical activity initiative for people with a low socioeconomic status on health, quality of life and societal participation: a mixed-methods study

Background

Overweight and obesity rates are increasing worldwide, particularly among people with a low socioeconomic status (SES). Care–physical activity (care–PA) initiatives may improve participants’ lifestyles and thereby lower overweight and obesity rates. A two-year care–PA initiative specifically developed for citizens with a low SES, X-Fittt 2.0, was offered free of charge to participants, and included 12 weeks of intensive guidance and sports sessions, and 21 months of aftercare. Here, we study the impact of X-Fittt 2.0 on health, quality of life (QoL) and societal participation using a mixed-methods design.

Methods

Questionnaires and body measurements were taken from 208 participants at the start of X-Fittt 2.0 (t₀) and after 12 weeks (t₁), one year (t₂) and two to three years (t₃). We also held 17 group discussions (t₁, n = 71) and 68 semi-structured interviews (t₂ and t₃). Continuous variables were analysed using a linear mixed-model analysis (corrected for gender, age at t₀, height, education level and employment status at the different time points), while we used descriptive statistics for the categorical variables. Qualitative data were analysed using a thematic analysis.

Results

Body weight was significantly lower at all three post-initiative time points compared with the baseline, with a maximum of 3.8 kg difference at t₂. Body Mass Index, waist circumference, blood pressure and self-perceived health only significantly improved during the first 12 weeks. A positive trend regarding paid work was observed, while social visits decreased. The latter might be explained by the COVID-19 pandemic, as lockdowns limited social life. Furthermore, participants reported increased PA (including sports) and a few stopped smoking or drinking alcohol. Participants mentioned feeling healthier, fitter and more energetic. Additionally, participants’ self-esteem and stress levels improved, stimulating them to become more socially active. However, the participants also mentioned barriers to being physically active, such as a lack of money or time, or physical or mental health problems.

Conclusions

X-Fittt 2.0 improved the health, QoL and societal participation of the participants. Future initiatives should take into account the aforementioned barriers, and consider a longer intervention period for more sustainable results. More complete data are needed to confirm the findings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13936-w.

Beyond the Calorie Paradigm: Taking into Account in Practice the Balance of Fat and Carbohydrate Oxidation during Exercise?

Recent literature shows that exercise is not simply a way to generate a calorie deficit as an add-on to restrictive diets but exerts powerful additional biological effects via its impact on mitochondrial function, the release of chemical messengers induced by muscular activity, and its ability to reverse epigenetic alterations. This review aims to summarize the current literature dealing with the hypothesis that some of these effects of exercise unexplained by an energy deficit are related to the balance of substrates used as fuel by the exercising muscle. This balance of substrates can be measured with reliable techniques, which provide information about metabolic disturbances associated with sedentarity and obesity, as well as adaptations of fuel metabolism in trained individuals. The exercise intensity that elicits maximal oxidation of lipids, termed LIPOXmax, FATOXmax, or FATmax, provides a marker of the mitochondrial ability to oxidize fatty acids and predicts how much fat will be oxidized over 45–60 min of low- to moderate-intensity training performed at the corresponding intensity. LIPOXmax is a reproducible parameter that can be modified by many physiological and lifestyle influences (exercise, diet, gender, age, hormones such as catecholamines, and the growth hormone-Insulin-like growth factor I axis). Individuals told to select an exercise intensity to maintain for 45 min or more spontaneously select a level close to this intensity. There is increasing evidence that training targeted at this level is efficient for reducing fat mass, sparing muscle mass, increasing the ability to oxidize lipids during exercise, lowering blood pressure and low-grade inflammation, improving insulin secretion and insulin sensitivity, reducing blood glucose and HbA_1c in type 2 diabetes, and decreasing the circulating cholesterol level. Training protocols based on this concept are easy to implement and accept in very sedentary patients and have shown an unexpected efficacy over the long term. They also represent a useful add-on to bariatric surgery in order to maintain and improve its weight-lowering effect. Additional studies are required to confirm and more precisely analyze the determinants of LIPOXmax and the long-term effects of training at this level on body composition, metabolism, and health.

The Impact of Hypoglycemia on Patients with Diabetes Mellitus: A Cross-Sectional Analysis

The increasing mortality and morbidity in patients with diabetes mellitus constitute a severe public health problem. The condition is recognized as a cause of impaired quality of life, high costs, and diminished productivity. In this study, we performed a cross-sectional analysis among 300 Polish participants with type 1 and type 2 diabetes to determine and classify risk factors associated with increased incidences of hypoglycemia. Including an open-access knowledge about the correlations between diabetes rates and human’s lifestyle, we confirm that the frequency of smoking and drinking alcohol, low BMI, inappropriate diet, low physical activity, lack of vaccination against influenza and pneumococci, and co-existence of other comorbidities such as cardiovascular diseases, thyroid diseases, hyperlipidemia, retinopathy, and asthma elevate the risk of hypoglycemia. Furthermore, hypoglycemic patients were more often malnourished, depressed, irritated, and exposed to stress. In sum, the analysis of the interaction between diabetes and sociodemographic, environmental, or other disease-related risk factors provides strategies to optimize glycemic control and reduce the incidence of hypoglycemia. Furthermore, we believe our findings may constitute a basis for promoting health by adjusting available and implementing new preventive services reducing hypoglycemic episodes in diabetic patients.

A 12-Month Follow-Up of the Effects of a Digital Diabetes Prevention Program (VP Transform for Prediabetes) on Weight and Physical Activity Among Adults With Prediabetes: Secondary Analysis

Background

The prevalence of diabetes is increasing rapidly. Previous research has demonstrated the efficacy of a diabetes prevention program (DPP) in lifestyle modifications that can prevent or delay the onset of type 2 diabetes among individuals at risk. Digital DPPs have the potential to use technology, in conjunction with behavior change science, to prevent prediabetes on a national and global scale.

Objective

The aim of this study is to investigate the effects of a digital DPP (Virgin Pulse [VP] Transform for Prediabetes) on weight and physical activity among participants who had completed 12 months of the program.

Methods

This study was a secondary analysis of retrospective data of adults with prediabetes who were enrolled in VP Transform for Prediabetes for 12 months of the program. The program incorporates interactive mobile computing, remote monitoring, an evidence-based curriculum, behavior tracking tools, health coaching, and online peer support to prevent or delay the onset of type 2 diabetes.

Results

The sample (N=1095) was comprised of people with prediabetes who completed at least 9 months of the VP Transform for Prediabetes program. Participants were 67.7% (n=741) female, with a mean age of 53.6 (SD 9.75) years. After 12 months, participants decreased their weight by an average of 10.9 lbs (5.5%; P<.001) and increased their physical activity by 91.2 (P<.001) minutes.

Conclusions

These results suggest that VP Transform for Prediabetes is effective at preventing type 2 diabetes through a significant reduction in body weight and increase of physical activity. Furthermore, these results suggest that the DPP remains effective 12 months after beginning the program. A prospective randomized controlled clinical study is warranted to validate these findings.

Mobile Health Technology in the Primary Prevention of Type 2 Diabetes: a Systematic Review

PURPOSE OF REVIEW

The objective of this review was to summarize the current scientific evidence of mobile health technology in the primary prevention of type 2 diabetes in patients with prediabetes derived from randomized clinical trials.

RECENT FINDINGS

Few randomized clinical trials are available using mobile health technologies in the prevention of type 2 diabetes. There is heterogeneity in regard to the main study outcomes, duration of interventions, and study findings. Inconsistent findings have been reported whether mobile health technologies are effective in reducing HbA1C levels or the incidence of type 2 diabetes in patients with prediabetes. However, results are promising that mobile health interventions may decrease body weight. Future study may consistently measure changes in glycemic indicators as well as develop elements that better address behavior changes.

A non-traditional dietary pattern increases risk of coronary artery disease in the Nepalese population

OBJECTIVES

Several dietary patterns are associated with cardiovascular diseases. Traditional, Western, Mediterranean, and vegetarian are common dietary patterns, derived from principal component analysis (PCA) of dietary food intakes associated with cardiovascular diseases; however, these patterns were derived mostly from the diet habits of people in Western and European countries. Therefore, the present study aimed to determine dietary patterns linked with coronary artery disease (CAD) in the Nepalese population.

METHODS

Food frequency questionnaires were used to estimate dietary intakes in 306 people with CAD and 306 people in a control group matched for age and sex. PCA was performed to deduce the dietary patterns, and conditional logistic regression was executed to determine the association of the dietary patterns with CAD.

RESULTS

The component of PCA with higher loadings of refined grain, sugar, and meat and lower loadings of milk, whole grain, and fruit was named the non-traditional dietary pattern in the present study. We found a 34% increased risk of CAD (odds ratio, 1.34; 95% confidence interval, 1.14-1.58; P < 0.001) associated with this dietary pattern after adjusting for smoking, physical activity, and cardiometabolic risk factors. Dietary-pattern scores were further categorized into tertiles, and the third tertile was observed with significanly higher odds of CAD than the first tertile (odds ratio, 2.32; 95% confidence interval, 1.3-4.14; P for trend = 0.004).

CONCLUSIONS

PCA-derived non-traditional dietary patterns can be a risk for developing CAD in Nepalese people. However, further cohort studies or randomized community trials are suggested to confirm our findings.

The effect of a cluster-randomized controlled trial on lifestyle behaviors among families at risk for developing type 2 diabetes across Europe: the Feel4Diabetes-study

BACKGROUND

This study investigated the effect of the Feel4Diabetes-intervention, a 2-year multilevel intervention, on energy balance-related behaviors among European families at risk for developing type 2 diabetes. Intervention effects on self-reported physical activity, sedentary behavior and eating behaviors were investigated across and within the participating countries: Belgium, Finland, Greece, Spain, Hungary and Bulgaria.

METHODS

Families were recruited through schools, located in low socio-economic status areas. In total, 4484 families at risk for developing type 2 diabetes were selected using the FINDRISC-questionnaire. Parents' and children's energy balance-related behaviors data were collected by questionnaires at three time points (baseline, mid- and post intervention). Families assigned to the intervention group were invited to participate in a 2-year school-, community-, and family-based intervention to promote a healthier lifestyle, including counseling sessions (first intervention year) and text messages (second intervention year). Families assigned to the control group received standard care, including medical check-up results and recommendations and tips regarding a healthy lifestyle. To assess the intervention-effects, Mixed Models were conducted using the R-Package "lmer "with R v3.2.

RESULTS

Significant intervention effects were found on a certain number of families' lifestyle behaviors. Significant favorable intervention effects were detected on parents' water consumption and consumption of fruit and vegetables, and on children's consumption of sweets and moderate-to-vigorous physical activity. Analyses by country revealed significant favorable intervention effects on water consumption and on moderate-to-vigorous physical activity in Belgian parents and on fruit and vegetable consumption among Belgian children, on sweets consumption among Spanish parents and children, and on moderate-to-vigorous physical activity among Finnish children. Unfavorable intervention effects were found on the consumption of soft drinks and sugar-containing juices among Hungarian children and parents, while when examining the intervention effects for the overall population and per country, 10 from the 112 investigated outcome variables were improved in the intervention group compared to the control group (9%).

CONCLUSIONS

The Feel4Diabetes-intervention managed to improve a certain number of targeted lifestyle behaviors while the intervention was not effective on a large number of targeted lifestyle behaviors. The findings of the current study are encouraging, but further research is needed on how we can further improve effectiveness of lifestyle interventions to prevent type 2 diabetes in families at risk.

TRIAL REGISTRATION

The Feel4Diabetes-study is registered with the clinical trials registry http://clinicaltrials.gov , ID: 643708.

Long-term outcomes of lifestyle intervention to prevent type 2 diabetes in people at high risk in primary health care

AIMS

The Finnish National Diabetes Prevention Program (FIN-D2D) was the first large-scale diabetes prevention program in a primary health care setting in the world. The risk reduction of type 2 diabetes was 69% after one-year intervention in high-risk individuals who were able to lose 5% of their weight. We investigated long-term effects of one-year weight change on the incidence of type 2 diabetes, cardiovascular events, and all-cause mortality.

METHODS

A total of 10,149 high-risk individuals for type 2 diabetes were identified in primary health care centers and they were offered lifestyle intervention to prevent diabetes. Of these individuals who participated in the baseline screening, 8353 had an oral glucose tolerance test (OGTT). Complete follow-up data during one-year intervention were available for 2730 individuals and those were included in the follow-up analysis. The long-term outcome events were collected from national health registers after the median follow-up of 7.4 years.

RESULTS

Among individuals who lost weight 2.5-4.9% and 5% or more during the first year, the hazard ratio for the incidence of drug-treated diabetes was 0.63 (95% CI 0.49-0.81, p = 0.0001), and 0.71 (95% CI 0.56-0.90, p = 0.004), respectively, compared with those with stable weight. There were no significant differences in cardiovascular events or all-cause mortality among study participants according to one-year weight changes.

CONCLUSIONS

High-risk individuals for type 2 diabetes who achieved a moderate weight loss by one-year lifestyle counseling in primary health care had a long-term reduction in the incidence of drug-treated type 2 diabetes. The observed moderate weight loss was not associated with a reduction in cardiovascular events.

Effectiveness of two procedures for deploying a facilitated collaborative modeling implementation strategy-the PVS-PREDIAPS strategy-to optimize type 2 diabetes prevention in primary care: the PREDIAPS cluster randomized hybrid type II implementation trial

BACKGROUND

The most efficient procedures to engage and guide healthcare professionals in collaborative processes that seek to optimize practice are unknown. The PREDIAPS project aims to assess the effectiveness and feasibility of different procedures to perform a facilitated interprofessional collaborative process to optimize type 2 diabetes prevention in routine primary care.

METHODS

A type II hybrid cluster randomized implementation trial was conducted in nine primary care centers of the Basque Health Service. All centers received training on effective healthy lifestyle promotion. Headed by a local leader and an external facilitator, centers conducted a collaborative structured process-the PVS-PREDIAPS implementation strategy-to adapt the intervention and its implementation to their specific context. The centers were randomly allocated to one of two groups: one group applied the implementation strategy globally, promoting the cooperation of all health professionals from the beginning, and the other performed it sequentially, centered first on nurses, who later sought the pragmatic cooperation of physicians. The following patients were eligible for inclusion: all those aged ≥ 30 years old with at least one known cardiovascular risk factor and an impaired fasting glucose level (≥ 110-125 mg/dl) but without diabetes who attended centers during the study period. The main outcome measures concerned changes in type 2 diabetes prevention practice indicators after 12 months.

RESULTS

After 12 months, 3273 eligible patients at risk of type 2 diabetes had attended their family physician at least once, and of these, 490 (15%) have been addressed by assessing their healthy lifestyles in both comparison groups. The proportion of at-risk patients receiving a personalized prescription of lifestyle change was slightly higher (8.6%; range 13.5-5.9% vs 6.8%; range 7.2-5.8%) and 2.3 times more likely (95% CI for adjusted hazard ratio, 1.38-3.94) in the sequential than in the global centers, after 8 months of the intervention program implementation period. The probability of meeting the recommended levels of physical activity and fruit and vegetable intake were four- and threefold higher after the prescription of lifestyle change than only assessment and provision of advice. The procedure of engagement in and execution of the implementation strategy does not modify the effect of prescribing healthy habits (p interaction component of intervention by group, p > 0.05).

DISCUSSION

Our results show that the PVS-PREDIAPS implementation strategy manages to integrate interventions with proven efficacy in the prevention of type 2 diabetes in clinical practice in primary care. Further, they suggest that implementation outcomes were somewhat better with a sequential facilitated collaborative process focused on enhancing the autonomy and responsibility of nurses who subsequently seek a pragmatic cooperation of GPs.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT03254979 . Registered 16 August 2017-retrospectively registered.

Report from an effort to prevent type 2 diabetes development in primary care

BACKGROUND

In a clinical trial 2009-2012, individuals with prediabetes were randomised to a lifestyle intervention (LI) focused on physical activity or care as usual (CAU), with the aim of reducing development of type 2 diabetes (T2DM). At study termination after three years, there was a significantly less of an increase in insulin resistance in LI compared with the CAU group. The aim of this extended follow-up was to investigate whether positive results concerning metabolic variables remained five years after study termination.

METHOD

All participants from the original study were contacted for a new follow-up with an oral glucose tolerance test, anthropometric measurements, blood pressure and blood samples. Questionnaires about lifestyle were completed.

RESULTS

A total of 69 of the original 123 participants were examined, and personal data for another five participants were collected from the medical charts (n = 74). The LI group showed a decrease in diastolic blood pressure (-4 mmHg, CI 95% 0.8-6.8, p = 0.014) and body weight (-3 kg, CI 95% 1.2-4.9, p = 0.002) since base-line. Weight loss in the LI group was significantly greater compared with weight loss in the CAU group (-3 kg, CI 0.1-5.9, p = 0.044). Insulin resistance markers and incident T2DM were similar among the groups.

CONCLUSION

Although without modifying the incidence of diabetes or the level of insulin resistance, a physical activity intervention may be used to induce sustainable weight change in subjects with prediabetes at the primary care level.

Effectiveness of Lifestyle Interventions in an Active Duty Air Force Population

PURPOSE

To examine the effectiveness of 3 lifestyle intervention programs in an active duty military population.

DESIGN

Experimental design with stratified random assignment to 1 of 3 intervention groups. Measures were taken at baseline, 3 months and 6 months.

SETTING

A Military Treatment Facility in the western U.S.

SUBJECTS/INTERVENTION

122 active duty service members were enrolled and randomly assigned to 1 of 3 lifestyle intervention programs: the Diabetes Prevention Program-Group Lifestyle Balance (DPP-GLB), the Better Body Better Life (BBBL) program or the Fitness Improvement Program (FIP).

MEASURES

weight, abdominal circumference, lipid and HbA1c levels, physical activity, and well-being as measured by the RAND SF-36 questionnaire.

ANALYSIS

Statistical analyses were performed to assess changes over time.

RESULTS

83 participants completed the study (BBBL N = 23, FIP N = 30, DPP-GLB N = 30). The DPP-GLB participants had statistically significant decreases in weight (-3.1 pounds, p = .01) and abdominal circumference (-0.9 inches; p = .01) over time. HbA1c was also significantly lower in this group at 6 months compared to baseline (p = .036). There were no statistically significant changes in weight, abdominal circumference, or HbA1c in the FIP or BBBL groups. No significant changes were observed in lipids in any of the groups.

CONCLUSION

Results from this study indicate that the DPP-GLB program may be effective in reducing weight, abdominal circumference, and HbA1c in an active duty U.S. military population.

Nutritional intervention strategies for the management of overweight and obesity in primary health care: A systematic review with meta-analysis

A systematic review with meta-analysis (MA) was conducted to synthesize the effectiveness of nutrition intervention strategies for managing overweight and obesity in the adult population attending primary health care. Relevant articles were searched in the PubMed, Embase, Web of Science, Cochrane and LILACS databases from inception to January 2020. Seventy studies were identified: 45 randomized controlled trials (RCTs) and 25 uncontrolled before-after studies (UBAs). The MA of nutritional intervention revealed a reduced average estimate of the effect on weight in RCTs (weighted mean differences [WMD] = -1.80 kg, 95% confidence interval [CI], -2.40 to -1.19), BMI (WMD = -0.80 kg/m² , 95% CI, -1.11 to -0.49), and WC (WMD = -2.28 cm, 95% CI, -3.06 to -1.49); and for UBAs showed reductions in weight (WMD = -4.17 kg; 95% CI, -5.18 to -1.70), BMI (WMD = -1.26 kg/m² ; 95% CI, -1.81 to -0.72) and (WMD = -2.90 cm; 95%CI, -4.21 to -1.59). There was no association between treatment effect and follow-up for both designs. Nutritional interventions alone yielded a higher but nonsignificant average reduction on weight when compared with combined components intervention. Interventions delivered through individual or group sessions showed a similar positive effect on weight decrease. The dietary prescription approach yielded a greater effect on weight loss than did the behavioural approaches but only in UBA studies.

Impact of Work and Recreational Physical Activity on Prediabetes Condition among U.S. Adults: NHANES 2015-2016

More minutes of physical activity (PA) accumulated during a day are associated with a lower risk of diabetes mellitus type 2. However, it is less known if distinct dimensions of PA can produce a different protective effect in the prevention of prediabetes. The aim of this study was to analyze the impact of work and recreational PA on prediabetes among U.S. adults during the period 2015–2016 using the National Health and Nutrition Examination Survey (NHANES) database. Individuals (n = 4481) with hemoglobin A1c (HbA1c) test values of 5.7% to 6.4% were included. A logistic regression multivariate-adjusted analysis was conducted to estimate the association between the odds ratios (ORs) and 95% confidence intervals (CIs) of prediabetes, with work and recreational PA. The prevalence of prediabetes among U.S. adults was lower in physically active individuals both at work (~24%) and recreational (~21%) physical activities compared to individuals who were not physically active (27 to 30%). Individuals lacking practice of recreational PA had a high risk of prediabetes (OR = 1.26, 95% CI: 1.080 to 1.466). PA may be a protective factor for prediabetes conditions depending on gender, age, ethnic group, waist circumference, and thyroid disease.

Telephone based coaching for adults at risk of diabetes: impact of Australia's Get Healthy Service

The Get Healthy Information and Coaching Service (GHS), an effective 6-month telephone-based healthy lifestyle coaching service, includes a population-targeted diabetes prevention module (DPM) tailored for adults at risk for type 2 diabetes. This study determined DPM's reach and impact on anthropometric and lifestyle risk factors. Pre-post evaluation design examined self-reported anthropometric (body weight, waist circumference) and lifestyle risk factors (physical activity and dietary behaviors) of DPM participants. Descriptive and chi-square analyses were performed on sociodemographic variables. Behavioral changes were assessed using matched pairs analysis, independent samples analysis, and multivariate analysis. There were 4,222 DPM participants (76.0% female; 75.9% aged ≥ 50; 95.4% spoke English at home). The DPM included higher proportions of older adults (≥50) (75.9% vs. 46.5%; p < .001), retirees (28.7% vs. 18.5%; p < .0001), less educated (33.3% vs. 24.9%; p < .0001), more disadvantaged (41.7% vs. 34.8%; p < .001) and living in regional or rural areas (43.2% vs. 39.8%; p < .001) than the GHS program. DPM participants reported significant improvements at six months for all anthropometric (-3.3 kg weight; -1.2 BMI units; -4.3 cm waist circumference) and behavioral risk factors (+0.2 fruit serves/day; +0.7 vegetables serves/day; -0.2 sweetened drinks/day; -0.2 takeaway meals/week; +1.1 30-min walking sessions/week; +0.7 30-min moderate activity sessions/week; +0.2 20-min vigorous activity sessions/week). Nearly one-third (31.1%) of participants lost ≥5% body weight. The DPM reached priority population groups, those typically underrepresented in diabetes prevention programs and resulted in clinically relevant improvements in anthropometric and lifestyle risk factors in adults at increased risk for type 2 diabetes.

Evaluation of the Clinical and Economic Effects of a Primary Care Anchored, Collaborative, Electronic Health Lifestyle Coaching Program in Denmark: Protocol for a Two-Year Randomized Controlled Trial

BACKGROUND

Obesity is linked to a number of chronic health conditions, such as type 2 diabetes, heart disease, and cancer, and weight loss interventions are often expensive. Recent systematic reviews concluded that app and web-based interventions can improve lifestyle behaviors and weight loss at a reasonable cost, but long-term sustainability needs to be demonstrated.

OBJECTIVE

This study protocol is for a 2-year randomized controlled trial that aims to evaluate the clinical and economic effects of a primary care, anchored, collaborative, electronic health (eHealth) lifestyle coaching program (long-term Lifestyle change InterVention and eHealth Application [LIVA] 2.0) in obese participants with and without type 2 diabetes. The program's primary outcome is weight loss. Its secondary outcome is the hemoglobin A1c (HbA1c) level, and its tertiary outcomes are retention rate, quality of life (QOL), and cost effectiveness. Analytically, the focus is on associations of participant characteristics with outcomes and sustainability.

METHODS

We conduct a multicenter trial with a 1-year intervention and 1-year retention. LIVA 2.0 is implemented in municipalities within administrative regions in Denmark, specifically eight municipalities located within the Region of Southern Denmark and two municipalities located within the Capital Region of Denmark. The participants are assessed at baseline and at 6-, 12-, and 24-month follow-ups. Individual data from the LIVA 2.0 platform are combined with clinical measurements, questionnaires, and participants' usage of municipality and health care services. The participants have a BMI ≥30 but ≤45 kg/m2, and 50% of the participants have type 2 diabetes. The participants are randomized in an approximately 60:40 manner, and based on sample size calculations on weight loss and intention-to-treat statistics, 200 participants are randomized to an intervention group and 140 are randomized to a control group. The control group is offered the conventional preventive program of the municipality, and it is compared to the intervention group, which follows the LIVA 2.0 in addition to the conventional preventive program.

RESULTS

The first baseline assessments have been carried out in March 2018, and the 2-year follow-up will be carried out between March 2020 and April 2021. The hypothesis is that the trial results will demonstrate decreased body weight and that the number of patients who show normalization of their HbA1c levels in the intervention group will be much higher than that in the control group. The participants in the intervention group are also expected to show a greater decrease in their use of glucose-lowering medication and a greater improvement in their QOL when compared with the control group. Operational costs are expected to be lower than standard care, and the intervention is expected to be cost-effective.

CONCLUSIONS

This is the first time that an app and web-based eHealth lifestyle coaching program implemented in Danish municipalities will be clinically and economically evaluated. If the LIVA 2.0 eHealth lifestyle coaching program is proven to be effective, there is great potential for decreasing the rates of obesity, diabetes, and related chronic diseases.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03788915; https://clinicaltrials.gov/ct2/show/NCT03788915.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/19172.

Long-term weight loss maintenance, sex steroid hormones, and sex hormone-binding globulin

OBJECTIVE

We tested the effects of weight loss on serum estradiol, estrone, testosterone, and sex hormone-binding globulin (SHBG) in overweight/obese women 18 months after completing a year-long, 4-arm, randomized-controlled dietary weight loss and/or exercise trial.

METHODS

From 2005 to 2008, 439 overweight/obese, postmenopausal women (BMI >25 kg/m), 50 to 75 years, were randomized to a year-long intervention: diet (reduced calorie, 10% weight loss, N = 118), exercise (225 min/wk moderate-to-vigorous activity, N = 117), combined diet + exercise (N = 117), or control (N = 87). At 12 months, 399 women provided blood; of these, 156 returned at 30 months and gave a blood sample. Hormones and SHBG were measured by immunoassay. Changes were compared using generalized estimating equations, adjusting for confounders.

RESULTS

At 30 months, participants randomized to the diet + exercise intervention had statistically significant increases in SHBG levels versus controls (P = 0.001). There was no statistically significant change in SHBG in the exercise or diet intervention arms. Hormone levels did not vary by intervention arm from baseline to 30 months. Participants who maintained weight loss at 30 months had statistically significantly greater decreases in free estradiol and free testosterone (Ptrend = 0.02 and Ptrend = 0.04, respectively) and increases in SHBG (Ptrend < 0.0001) versus those who did not have sustained weight loss. Levels of other analytes did not vary by weight loss at 30 months.

CONCLUSIONS

Sustained weight loss results in reductions in free estradiol and testosterone and increases in SHBG 18-month post-intervention.

Changes in disease burden in Poland between 1990-2017 in comparison with other Central European countries: A systematic analysis for the Global Burden of Disease Study 2017

Background

Systematic collection of mortality/morbidity data over time is crucial for monitoring trends in population health, developing health policies, assessing the impact of health programs. In Poland, a comprehensive analysis describing trends in disease burden for major conditions has never been published. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) provides data on the burden of over 300 diseases in 195 countries since 1990. We used the GBD database to undertake an assessment of disease burden in Poland, evaluate changes in population health between 1990–2017, and compare Poland with other Central European (CE) countries.

Methods

The results of GBD 2017 for 1990 and 2017 for Poland and CE were used to assess rates and trends in years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life years (DALYs). Data came from cause-of-death registration systems, population health surveys, disease registries, hospitalization databases, and the scientific literature. Analytical approaches have been used to adjust for missing data, errors in cause-of-death certification, and differences in data collection methodology. Main estimation strategies were ensemble modelling for mortality and Bayesian meta-regression for disability.

Results

Between 1990–2017, age-standardized YLL rates for all causes declined in Poland by 46.0% (95% UI: 43.7–48.2), YLD rates declined by 4.0% (4.2–4.9), DALY rates by 31.7% (29.2–34.4). For both YLLs and YLDs, greater relative declines were observed for females. There was a large decrease in communicable, maternal, neonatal, and nutritional disease DALYs (48.2%; 46.3–50.4). DALYs due to non-communicable diseases (NCDs) decreased slightly (2.0%; 0.1–4.6). In 2017, Poland performed better than CE as a whole (ranked fourth for YLLs, sixth for YLDs, and fifth for DALYs) and achieved greater reductions in YLLs and DALYs than most CE countries. In 2017 and 1990, the leading cause of YLLs and DALYs in Poland and CE was ischaemic heart disease (IHD), and the leading cause of YLDs was low back pain. In 2017, the top 20 causes of YLLs and YLDs in Poland and CE were the same, although in different order. In Poland, age-standardized DALYs from neonatal causes, other cardiovascular and circulatory diseases, and road injuries declined substantially between 1990–2017, while alcohol use disorders and chronic liver diseases increased. The highest observed-to-expected ratios were seen for alcohol use disorders for YLLs, neonatal sepsis for YLDs, and falls for DALYs (3.21, 2.65, and 2.03, respectively).

Conclusions

There was relatively little geographical variation in premature death and disability in CE in 2017, although some between-country differences existed. Health in Poland has been improving since 1990; in 2017 Poland outperformed CE as a whole for YLLs, YLDs, and DALYs. While the health gap between Poland and Western Europe has diminished, it remains substantial. The shift to NCDs and chronic disability, together with marked between-gender health inequalities, poses a challenge for the Polish health-care system. IHD is still the leading cause of disease burden in Poland, but DALYs from IHD are declining. To further reduce disease burden, an integrated response focused on NCDs and population groups with disproportionally high burden is needed.

Evaluation of type 2 diabetes prevention through diet modification in people with impaired glucose regulation: A population-based study

PURPOSE

A few interventional studies to date have specifically assessed the association between dairy products and/or sugar consumption and the risk of type 2 diabetes mellitus (T2D) incidence. The aim of this study was to assess the effectiveness of diet modification in people with impaired glucose regulation (IGR) as defined by a glucose tolerance test (GTT).

METHODS

A quasi-experimental study design was used for this study. A total of 318 randomly selected 18-year-old or older participants from the rural area of the Kyiv region of Ukraine who had not been registered as T2D patients before underwent GTT between June 2013 and June 2017. For those who had been diagnosed with IGR, World Health Organization (WHO)/International Diabetes Federation criteria were used. Of 318 participants screened for T2D, 123 (74% of them females) were diagnosed with IGR. They were aged 18 to 79 years old with a median (Q_I - Q_III) age of 62 (52-68) years. They were repeatedly tested during the study and completed a questionnaire on average 2.8 (1.1) years (standard deviation [SD]), after they had received their lifestyle-based T2D prevention recommendations. In addition to basic recommendations, they were advised to consume approximately 200 g of low-fat dairy products and less than 25 g of sugar daily. Cases of screen-detected diabetes mellitus (SDDM) were diagnosed and reported as an outcome variable if a fast capillary blood glucose level reached 6.1 mmol/L and above. To define the association between implementation of recommendations and the risk of SDDM, the Cox proportional-hazards regression analysis was used.

RESULTS

During the study observation period, 56 (45.5%) of 123 IGR-positive participants were recognized as SDDM cases. Those individuals with IGR (n = 111) who confirmed their adherence to preventive recommendations had a significantly lower risk of identifying SDDM, age- and gender-adjusted hazard ratio (HR) 0.26 (95% CІ; 0.09-0.72). This effect appears to be related to the recommendation to reduce the daily intake of sugar to less than 25 g (n = 99), corresponding to age- and gender-adjusted HR 0.44 (95% CІ; 0.2-0.99). We cannot prove that increasing consumption of dairy products, vegetables, and fruit or increased physical activity had similar effectiveness.

CONCLUSIONS

After 2.8 years of follow-up, the individuals who are IGR-positive and who confirmed their adherence to lifestyle-based preventive recommendations had a significantly lower risk of identifying SDDM. This effect appears to be related to recommendations to reduce the daily intake of sugar to less than 25 g.

Double or hybrid diabetes: A systematic review on disease prevalence, characteristics and risk factors

Diabetes mellitus is a worldwide epidemic affecting the health of millions of people. While type 1 diabetes (T1D) is caused by autoimmune destruction of the insulin-producing beta cells of the pancreas, type 2 diabetes (T2D) results from a combination of insulin resistance and beta cell insulin secretory defect. Clear definition and diagnosis of these two types of diabetes has been increasing more and more difficult, leading to the inclusion of a new category, namely double or hybrid diabetes (DD) that demonstrates symptoms of both T1D and T2D via the accelerator hypothesis. In this review, we discuss the worldwide prevalence of DD, its main physiological characteristics, including beta-cell autoimmunity, insulin resistance, and cardiovascular disease, the main risk factors of developing DD, mainly genetics, obesity and lifestyle choices, as well as potential treatments, such as insulin titration, metformin and behavioural modifications. Increasing awareness of DD among the general population and primary care practitioners is necessary for successfully treating this complex, hybrid disease in the future.

The effectiveness of a community-based, type 2 diabetes prevention programme on health-related quality of life. The DE-PLAN study

Background and aims

The DE-PLAN was a European multicenter study, with the primary objective of testing whether a community-based lifestyle modification programme could serve as a means of primary prevention for type 2 diabetes (T2D) in high-risk individuals (based on the FINDRISC questionnaire). The aim of this study was to examine the impact of a 1-year community-based lifestyle intervention on health-related quality of life (HRQOL) in individuals from four participating European centers (Athens, Barcelona, Krakow, Kaunas), through a post-hoc analysis.

Materials and methods

Each center was allowed to implement different intervention strategies specifically tailored to the needs of their corresponding population sample. Before and after the intervention, participants underwent clinical evaluation, anthropometric measurements, an oral glucose tolerance test and lipid profile measurements. Health-related quality of life was assessed using the validated HRQOL-15D questionnaire. A difference of ±0.015 in the 15D questionnaire score was set as the threshold of clinically meaningful change.

Results

Data from 786 participants (67% females, mean age 59.7±9.4 years, BMI 31.5±4.5 kg/m²) with complete data regarding the HRQOL were analyzed (Athens: 104, Barcelona: 434, Krakow: 175, Kaunas: 70). After 1 year, a significant overall improvement in HRQOL was shown, as depicted by a change of 15D score from baseline value (0.88±0.9) to post-intervention (0.90±0.87, P<0.001), achieving the threshold of clinically meaningful change. A significant weight reduction was also observed (-0.8±4.0 kg, P<0.001). In multivariate analysis, improvement in HRQOL was independently associated with lower 15D score at baseline (P<0.001) and self-reported increase in overall exercise time (P<0.001) as assessed through specifically designed trial questionnaires.

Conclusion

A community-based lifestyle intervention programme aiming at T2D prevention, applied on a heterogeneous population and with varied methods, was shown to improve overall health-related quality of life to a clinically meaningful degree.

Early Lifestyle Interventions in People with Impaired Glucose Tolerance in Northern Colombia: The DEMOJUAN Project

BACKGROUND

The objective of the demonstration project for type 2 diabetes prevention in the Barranquilla and Juan Mina (DEMOJUAN) study was to investigate the extent to which it is possible to reach normal glucose metabolism with early lifestyle interventions in people at high risk of type 2 diabetes (prediabetes), compared with those who receive standard usual care.

METHODS

DEMOJUAN was a randomized controlled trial conducted in Juan Mina and Barranquilla, Northern Colombia. Eligible participants were randomized into one of three groups (control group, initial nutritional intervention, and initial physical activity intervention). The duration of the intervention was 24 months. The main study outcome in the present analysis was reversion to normoglycemia. Relative risks and their corresponding 95% confidence intervals were calculated for reversal to normoglycemia and T2D incidence.

RESULTS

There was no statistically significant association between the intervention groups and reversion to normoglycemia. The relative risk of reversion to normoglycemia was 0.88 (95% CI 0.70-1.12) for the initial nutritional intervention group participants and 0.95 (95% CI 0.75-1.20) for the initial physical activity intervention group participants.

CONCLUSIONS

Our study did not find any statistically significant differences in reversion to normoglycemia or the development of type 2 diabetes between the intervention groups and the control group in this population.

Two-year results of a community-based randomized controlled lifestyle intervention trial to control prehypertension and/or prediabetes in Thailand: a brief report

The aim of the study was to assess the 2-year effect of a community-based randomized controlled lifestyle intervention on glucose and blood pressure levels in Thailand. Participants (N=443, with prediabetes and/or prehypertension) received a six 2-hr group sessions lifestyle intervention (physical activity and nutrition) over 6 months. Measurements were at baseline, 12 months (89%) and at 24 months (84.7%). Statistically significant interaction effects on fasting plasma glucose and DBP at 12 months were not maintained at 24 months, while significant interaction effects were found on high-density lipoprotein and low-density lipoprotein cholesterol at 24 months. Improvements were found for fasting plasma glucose, SBP, DBP and total cholesterol, but no significant interaction effect was detected. The development of type 2 diabetes was higher in the control than in the intervention group, but it was not reaching significance (P=0.181), while 3.0% in the intervention group and 2.6% in the control group developed hypertension at 24 months. No significant group differences were found in psycho-behavioral variables. The lifestyle intervention did not provide additional benefits compared to the control group at 24-month follow-up. Trial registration number: TCTR20170721001.

Long-term Outcomes of Lifestyle Intervention to Prevent Diabetes in American Indian and Alaska Native Communities: The Special Diabetes Program for Indians Diabetes Prevention Program

OBJECTIVE

Evidence for long-term translational effectiveness of lifestyle interventions in minority populations is scarce. This article reports long-term outcomes, for up to 10 years, of such an intervention to prevent diabetes in American Indian and Alaska Native (AI/AN) communities.

RESEARCH DESIGN AND METHODS

From January 2006 to July 2016, the Special Diabetes Program for Indians Diabetes Prevention Program implemented the Diabetes Prevention Program lifestyle intervention among 46 AI/AN health care programs. Enrolled participants underwent a thorough clinical assessment at baseline, after completing the Lifestyle Balance Curriculum (postcurriculum assessment), and annually thereafter. Proportional hazards regression was used to estimate the association between diabetes incidence and postcurriculum weight loss status.

RESULTS

Of 8,652 enrolled participants, 65% finished the postcurriculum assessment. The assessment completion rate diminished over time to 13% in year 10. Among those with postcurriculum weight measurements, 2,028 (36%) lost >5% of their initial weight, 978 (17%) lost 3-5%, whereas 2,604 (47%) had <3% weight loss (average weight loss 3.8%). Compared with those with <3% weight loss, participants with >5% weight loss had a 64% (95% CI 54-72) lower risk of developing diabetes during the first 6 years of follow-up, whereas those with 3-5% weight loss had 40% (95% CI 24-53) lower risk.

CONCLUSIONS

Moderate to small weight loss was associated with substantially reduced long-term risk of diabetes in diverse AI/AN communities. High participant attrition rates and nonoptimal postcurriculum weight loss are important challenges found in this translational effort implemented in an underserved population.

Predictors of long term weight loss maintenance in patients at high risk of type 2 diabetes participating in a lifestyle intervention program in primary health care: The DE-PLAN study

Lifestyle interventions in type 2 diabetes (DM2) prevention implementation studies can be effective and lasting. Long-term weight loss maintenance enhances the intervention effect through a significant decrease in diabetes incidence over time. Our objective was to identify factors predicting long-term successful weight reduction maintenance achieved during a DM2 prevention program in patients with high DM2 risk in primary health care. Study participants (n = 263), middle-aged, slightly obese with baseline increased DM2 risk (Finnish Diabetes Risk Score (FINDRISC)>14), but no diabetes were invited to receive 11 lifestyle counselling sessions, guided physical activity sessions and motivational support during 10-months. The study participants had three clinical examinations during the study (baseline, one and three years). Stepwise regression analysis was used to determine demographic, clinical, and lifestyle predictors of weight reduction maintenance two years after the discontinuation of the intervention. Out of 105 patients who completed all three examinations (baseline age 56.6 (standard deviation (SD) = 10.7), body mass index 31.1 kg/m2 (SD = 4.9), FINDRISC 18.6 (SD = 3.1)), 73 patients (70%) showed weight loss during the intervention (mean weight loss 4.2 kg, SD = 5.1). The total weight loss achieved in the maintainers (27 of 73 study participants) two years after the intervention had finished was 6.54 kg (4.47 kg+2.0 kg). The non-maintainers, on the other hand, returned to their initial weight at the start of the intervention (+0.21 kg). In multivariable analysis baseline history of increased glucose (odds ratio (OR) = 3.7; 95% confidence interval (CI) 1.0-13.6) and reduction of total fat in diet during follow-up (OR = 4.3; 95% CI 1.5-12.2) were independent predictors of successful weight loss. Further studies exploring predictors of weight loss maintenance in diabetes prevention are needed to help health care providers to redesign interventions and improve long-term outcomes of real life interventions.

Implementation of the DP-TRANSFERS project in Catalonia: A translational method to improve diabetes screening and prevention in primary care

Background

The DE-PLAN-CAT project (Diabetes in Europe–Prevention using lifestyle, physical activity and nutritional intervention–Catalonia) has shown that an intensive lifestyle intervention is feasible in the primary care setting and substantially reduces the incidence of diabetes among high-risk Mediterranean participants. The DP-TRANSFERS project (Diabetes Prevention–Transferring findings from European research to society) is a large-scale national programme aimed at implementing this intervention in primary care centres whenever feasible.

Methods

A multidisciplinary committee first evaluated the programme in health professionals and then participants without diabetes aged 45–75 years identified as being at risk of developing diabetes: FINDRISC (Finnish Diabetes Risk Score)>11 and/or pre-diabetes diagnosis. Implementation was supported by a 4-channel transfer approach (institutional relationships, facilitator workshops, collaborative groupware, programme website) and built upon a 3-step (screening, intervention, follow-up) real-life strategy. The 2-year lifestyle intervention included a 9-hour basic module (6 sessions) and a subsequent 15-hour continuity module (10 sessions) delivered by trained primary healthcare professionals. A 3-level (centre, professionals and participants) descriptive analysis was conducted using cluster sampling to assess results and barriers identified one year after implementation.

Results

The programme was started in June-2016 and evaluated in July-2017. In all, 103 centres covering all the primary care services for 1.4 million inhabitants (27.9% of all centres in Catalonia) and 506 professionals agreed to develop the programme. At the end of the first year, 83 centres (80.6%) remained active and 305 professionals (60.3%) maintained regular web-based activities. Implementation was not feasible in 20 centres (19.4%), and 5 main barriers were prioritized: lack of healthcare manager commitment; discontinuity of the initial effort; substantial increase in staff workload; shift in professional status and lack of acceptance. Overall, 1819 people were screened and 1458 (80.1%) followed the lifestyle intervention, with 1190 (81.6% or 65.4% of those screened) participating in the basic module and 912 in the continuity module (62.5% or 50.1%, respectively).

Conclusions

A large-scale lifestyle intervention in primary care can be properly implemented within a reasonably short time using existing public healthcare resources. Regrettably, one fifth of the centres and more than one third of the professionals showed substantial resistance to performing these additional activities.

Predictors of completing a primary health care diabetes prevention intervention programme in people at high risk of type 2 diabetes: Experiences of the DE-PLAN project

It has been shown that real-life implementation studies for the prevention of type 2 diabetes (DM2) performed in different settings and populations can be effective. However, not enough information is available on factors influencing the reach of DM2 prevention programmes. This study examines the predictors of completing an intervention programme targeted at people at high risk of DM2 in Krakow, Poland as part of the DE-PLAN project.A total of 262 middle-aged people, everyday patients of 9 general practitioners' (GP) practices, at high risk of DM2 (Finnish Diabetes Risk Score (FINDRISK) >14) agreed to participate in the lifestyle intervention to prevent DM2. Intervention consisted of 11 lifestyle counseling sessions, organized physical activity sessions followed by motivational phone calls and letters. Measurements were performed at baseline and 1 year after the initiation of the intervention.Seventy percent of the study participants enrolled completed the core curriculum (n = 184), 22% were men. When compared to noncompleters, completers had a healthier baseline diabetes risk profile (P <.05). People who completed the intervention were less frequently employed versus noncompleters (P = .037), less often had hypertension (P = .043), and more frequently consumed vegetables and fruit daily (P = .055).In multiple logistic regression model, employment reduced the likelihood of completing the intervention 2 times (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.25-0.81). Higher glucose 2 hours after glucose load and hypertension were the independent factors decreasing the chance to participate in the intervention (OR 0.79, 95% 0.69-0.92 and OR 0.52, 95% CI 0.27-0.99, respectively). Daily consumption of vegetables and fruits increased the likelihood of completing the intervention (OR 1.86, 95% 1.01-3.41).In conclusion, people with healthier behavior and risk profile are more predisposed to complete diabetes prevention interventions. Male, those who work and those with a worse health profile, are less likely to participate and complete interventions. Targeted strategies are needed in real-life diabetes prevention interventions to improve male participation and to reach those who are working as well as people with a higher risk profile.

Determinants of weight outcomes in type 2 diabetes prevention intervention in primary health care setting (the DE-PLAN project)

BACKGROUND

Real life implementation studies performed in different settings have proved that lifestyle interventions in the prevention of type 2 diabetes (DM2) can be effective, although the weight reduction results are typically modest compared to randomized control trials. Our objective was to identify the factors that predict successful weight loss in a less intensive, lower budget, real life setting lifestyle diabetes prevention intervention.

METHODS

Study participants (n = 175) with increased DM2 risk (Finnish Diabetes Risk Score (FINDRISC) > 14) but no diabetes at baseline received ten group lifestyle counselling sessions, physical activity and motivation sessions during a ten-month intervention. Stepwise regression analysis was used to determine demographic, clinical, and lifestyle predictors of successful weight reduction defined as a reduction of ≥5% of the initial body weight.

RESULTS

At 12 months following the initiation of the intervention, 23.4% of study participants lost ≥5% weight (mean loss of 7.9 kg, SD = 5.8). Increased physical activity (44% vs 25%, p = 0.03), decreased total fat consumption (88% vs 65%, p = 0.006) and adherence to four-five lifestyle goals (71% vs 46%, p = 0.007) were more often reported among those who managed to lose ≥5% weight versus those who did not. In a multivariate analysis, meeting the ≥5% weight loss goal was most effective in individuals with a higher baseline BMI (OR 1.1, 95%CI 1.0-1.2), baseline and medium versus higher education (OR 5.4, 95% CI 1.2-24.7) and a history of increased glucose (OR 2.6, 95%CI 1.1-1.3). A reduction of total fat in the diet was an independent lifestyle predictor, increasing the probability of successful weight loss by 3.8 times (OR 3.8, 95% CI 1.2-11.4).

CONCLUSION

Baseline higher BMI, lower education and a history of increased glucose predicted the successful weight loss among individuals with a high risk for the DM2 following lifestyle intervention in a real life primary health care setting. People who manage to lose weight more often adhere to lifestyle changes, while the reduction of total fat in diet independently predicts successful weight loss. Further studies exploring the predictors of success in implementation studies in DM2 prevention should help health care providers redesign interventions to improve their effectiveness and outcomes.

TRIAL REGISTRATION

ISRCTN, ID ISRCTN96692060 , registered 03.08.2016 retrospectively.

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).

Electronic supplementary material

The online version of this article (10.1186/s12875-017-0671-8) contains supplementary material, which is available to authorized users.

Effectiveness of an intensive intervention to improve lifestyles in people with intermediate cardiovascular risk (DATE study): Study protocol for a randomized controlled trial

AIM

The aim of this study was to evaluate the effectiveness of an intensive intervention led by primary care nurses for lifestyle modification among people with intermediate cardiovascular risk.

BACKGROUND

Cardiovascular diseases may be prevented by adopting healthy lifestyles. Interventions focused on populations at risk are more efficient than those aimed at the general population. More than 50 per cent of cardiovascular events occur in people with intermediate cardiovascular risk, but only a few studies have targeted this population.

DESIGN

A randomized controlled trial approved in January 2017.

METHODS

We will recruit 208 participants aged 35-74 years who have intermediate cardiovascular risk. They will be selected by consecutive sampling and will be randomized into a control group or intervention group. Individual standardized brief counselling on healthy lifestyles will be provided to both groups. Additionally, individuals from the intervention group will receive four weekly group sessions focusing on cardiovascular risk, healthy diet, moderation in alcohol consumption, daily physical activity, stress management and smoking cessation and two motivational follow-up calls. The primary outcome will be the lifestyle modification measured by total steps recorded by a pedometer, total score on the Mediterranean Diet Adherence Screener and percentage of current smokers.

DISCUSSION

This study will allow us to investigate whether an intensive intervention based on a multifactorial group approach is more effective in lifestyle modification than individual standardized brief counseling among adults with intermediate cardiovascular risk. Our results could lead to the establishment of new strategies for cardiovascular risk management.

Toward research-tested mobile health interventions to prevent diabetes and cardiovascular disease among persons with pre-diabetes

Background

About 35% of US adults have pre-diabetes and an increased risk of diabetes. Consumer-facing devices such as the Fitbit help users become more physically active and manage their weight which reduces risk of diabetes and cardiovascular disease.

Methods

In this commentary we provide a summary of healthy lifestyle intervention studies involving persons with pre-diabetes including those conducted in routine clinical practice. We also provide an account of how such interventions might be enhanced through the use of wearable devices linked to smartphone applications.

Results

In initial trials focusing on overweight and obesity, consumer wearable devices have been shown to increase physical activity and reduce weight. However, the acceptability and effectiveness of these mHealth interventions among persons with impaired glucose tolerance or impaired fasting glucose is unknown; studies involving persons with pre-diabetes have not yet been reported.

Conclusions

Research is needed to determine the feasibility and efficacy of wearable devices in improving physical activity and weight management in persons with pre-diabetes who are at-risk of diabetes and cardiovascular disease.

Long-Term Effects of Weight Loss and Exercise on Biomarkers Associated with Angiogenesis

Background: We tested the effect of weight loss on circulating levels of the angiogenic factors VEGF and pigment epithelium-derived factor (PEDF) in postmenopausal overweight/obese women, 18 months after completing a year-long 4-arm randomized controlled trial of behavioral weight loss and/or exercise versus control (i.e., 30 months postrandomization).Methods: The 439 overweight/obese, postmenopausal women, ages 50 to 75 years, were randomized to: diet (goal: 10% weight loss, N = 118), exercise (225 min/wk moderate-to-vigorous activity, N = 117), diet + exercise (N = 117), or control (N = 87). At 12 months, 399 women gave a blood sample; 156 returned at 30 months. Biomarkers were measured by immunoassay. Changes were compared using generalized estimating equations, adjusting for baseline BMI, age, and race/ethnicity.Results: Participants randomized to diet, exercise, and diet + exercise arms had greater reductions in VEGF at 30 months (-14.1% P = 0.02; -19.7% P = 0.003; -14.5% P = 0.002, respectively) versus controls (-4.5%). There were no statistically significant changes in PEDF in any intervention arm. Participants maintaining ≥10% of baseline weight loss at 30 months had greater reductions in VEGF versus those who gained weight/had no weight change (-22.3% vs. -10.2% respectively, P = 0.002). Participants maintaining any weight loss had significantly lower levels of PEDF at 30 months versus those who gained weight/no weight change.Conclusions: Sustained weight loss via diet and/or exercise results in reductions in angiogenic factors, and can be maintained up to 30-month follow-up. Limitations include relatively small numbers, and possible bias toward more successful weight loss among women who returned at 30 months.Impact: Maintaining weight loss can achieve long-term reductions in biomarkers of angiogenesis that can persist up to 18 months after completion of a weight loss intervention. Cancer Epidemiol Biomarkers Prev; 26(12); 1788-94. ©2017 AACR.

Western Dietary Pattern Is Associated With Severe Coronary Artery Disease

The independent predictive value of an unhealthy diet on the severity of coronary artery disease (CAD) requires further investigation. We assessed the impact of dietary pattern on CAD severity. In this cohort study, we included 188 symptomatic stable patients with CAD. Patients were categorized as having severe CAD or nonsevere CAD by coronary angiography. Among several demographics and clinical characteristics, all patients were tested using a semiquantitative food frequency questionnaire. Concerning baseline demographic characteristics, there was no difference between patients with severe CAD and nonsevere CAD. Principal component analysis revealed 8 distinct dietary patterns. The first component Western dietary pattern (increased intake of fat, red meat, and carbohydrates and minimal consumption of fruits and green leafy vegetables) was predictive of severe CAD (area under the curve: 0.73, 95% confidence intervals: 0.64-0.83, P < .001). In conclusion, an unhealthy Western type of diet is associated with the severity of coronary artery lesions in patients with stable CAD. These findings highlight the role of dietary patterns when estimating cardiovascular risk for the management of patients with CAD.

Engagement and outcomes in a digital Diabetes Prevention Program: 3-year update

OBJECTIVE

Translations of the Diabetes Prevention Program (DPP) have proliferated in recent years, with increasing expansion to digital formats. Although these DPP translations have consistently shown favorable clinical outcomes, long-term data for digital formats are limited. This study's objective was to examine clinical outcomes up to 3 years post-baseline and the relationship between program engagement and clinical outcomes in a digital DPP.

RESEARCH DESIGN AND METHODS

In a single-arm, non-randomized trial, 220 patients previously diagnosed with prediabetes were enrolled in the Omada Health Program, a commercially available, 16-week DPP-based weight loss intervention followed by an ongoing weight maintenance intervention. Changes in body weight and A1c were assessed annually. Relationships between program engagement during the first year and clinical outcomes across 3 years were examined.

RESULTS

Participants were socioeconomically diverse (62% women, 50.2% non-Hispanic white, 51.7% college educated or higher). From baseline to 3 years, those participants who completed four or more lessons and nine or more lessons achieved significant sustained weight loss (-3.0% and -2.9%, respectively) and an absolute reduction in A1c (-0.31 and -0.33, respectively) with an average remission from the prediabetes range to the normal glycemic range. Factor analysis of engagement metrics during the first year revealed two underlying dimensions, one comprising lesson completion and health behavior tracking consistency, and the other comprising website logins and group participation. When these two factors were used to predict weight loss, only the logins and group participation factor was a significant predictor of weight loss at 16 weeks and 1 year.

CONCLUSIONS

This study demonstrates significant long-term reductions in body weight and A1c in a digital DPP and identifies patterns of program engagement that predict weight loss.