Obtaining evidence base for the development of Feel4Diabetes intervention to prevent type 2 diabetes - a narrative literature review

Effects of Education and Income on Incident Type 2 Diabetes and Cardiovascular Diseases: a Dutch Prospective Study

BACKGROUND

Education and income, as two primary socioeconomic indicators, are often used interchangeably in health research. However, there is a lack of clear distinction between these two indicators concerning their associations with health.

OBJECTIVE

This study aimed to investigate the separate and combined effects of education and income in relation to incident type 2 diabetes and cardiovascular diseases in the general population.

DESIGN AND PARTICIPANTS

Participants aged between 30 and 65 years from the prospective Dutch Lifelines cohort study were included. Two sub-cohorts were subsequently created, including 83,759 and 91,083 participants for a type 2 diabetes cohort and a cardiovascular diseases cohort, respectively.

MAIN MEASURES

Education and income level were assessed by self-report questionnaires. The outcomes were incident type 2 diabetes and cardiovascular diseases (defined as the earliest non-fatal cardiovascular event).

KEY RESULTS

A total of 1228 new cases of type 2 diabetes (incidence 1.5%) and 3286 (incidence 3.6%) new cases of cardiovascular diseases were identified, after a median follow-up of 43 and 44 months, respectively. Low education and low income (<1000 euro/month) were both positively associated with a higher risk of incident type 2 diabetes (OR 1.24 [95%CI 1.04-1.48] and OR 1.71 [95%CI 1.30-2.26], respectively); and with a higher risk of incident cardiovascular diseases (OR 1.15 [95%CI 1.04-1.28] and OR 1.24 [95%CI 1.02-1.52], respectively); independent of age, sex, lifestyle factors, BMI, clinical biomarkers, comorbid conditions at baseline, and each other. Results from the combined associations of education and income showed that within each education group, a higher income was associated with better health; and similarly, a higher education was associated with better health within each income group, except for the low-income group.

CONCLUSIONS

Education and income were both independently associated with incident type 2 diabetes and cardiovascular diseases. The combined associations of these two socioeconomic indicators revealed that within each education or income level, substantial health disparities existed across strata of the other socioeconomic indicator. Education and income are two equally important socioeconomic indicators in health, and should be considered simultaneously in health research and policymaking.

Lifestyle patterns and incident type 2 diabetes in the Dutch lifelines cohort study

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Lifestyle factors clustered in behavioral patterns within the population.

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Different lifestyle patterns were differentially associated with risk of developing type 2 diabetes.

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A lifestyle pattern may be a proxy for an underlying variable that is relevant for the prevention of type 2 diabetes.

We aimed to identify the underlying subgroups of the population characterized by distinct lifestyle patterns, and to investigate the associations between lifestyle patterns and risk of incident type 2 diabetes. Using data from the Dutch Lifelines cohort study, latent class analysis was performed to derive lifestyle patterns on five lifestyle factors, i.e., smoking, diet quality, TV watching time, physical activity level, and risk drinking. Associations between lifestyle patterns and incident type 2 diabetes were estimated. Among 61,869 participants analyzed, we identified 900 cases of type 2 diabetes during follow-up (205,696 person-years; incidence rate 4.38 per 1000 person-years). Five lifestyle pattern groups were identified. Using the “healthy lifestyle group” as reference, the “unhealthy lifestyle group” had the highest risk for type 2 diabetes (HR 1.51 [95%CI 1.24, 1.85]), followed by the “poor diet and low physical activity group” (HR 1.26 [95%CI 1.03, 1.55]). The “risk drinker group” and the “couch potato group” (characterized by excessive TV watching) showed no significantly elevated risk. These models were adjusted for age, sex, total energy intake, education, BMI, family history of diabetes, and blood glucose level at baseline. Our study shows that lifestyle factors tended to cluster in unique behavioral patterns within the heterogeneous population. These lifestyle patterns were differentially associated with incident type 2 diabetes. Our findings support the relevance of considering lifestyle patterns in type 2 diabetes prevention. Tailored prevention strategies that target multiple lifestyle risk factors for different lifestyle pattern groups may optimize the effectiveness of diabetes prevention at the population level.

Urinary tract infection in patients with diabetes mellitus and the role of parental genetics in the emergence of the disease

This study aimed to assess the role of paternal genetics in the development of diabetic mellitus (DM) and determine the impact of DM on the urinary system by investigating the percentage of patients with urinary tract infection (UTI). The study included 100 people with DM; their ages ranged from 5 to 83 years. The DM and blood sugar levels were diagnosed clinically and at a laboratory in Al-Zahra Teaching Hospital and the outpatient clinics. The age, gender, and causes of DM and the family history of diabetes were reported. Isolation and identification of bacterial species were made depending on culture media and biochemical tests. The average age of patients was 47.7±5.5, and most of them were female (67%). The incidence of DM increased with age, and the main cause of DM was likely to be a genetic predisposition (family history), where 32% of patients appeared to have a positive family history and the presence of DM in both parents or only the mother had a significant role in increasing the genetic predisposition of developing DM. Among the non-genetic causes of DM, the most common was exposure to sudden psychological or nervous shock (41%). Obesity also had an important role in the development of diabetes, and also pregnancy and smoking. Moreover, 66% of patients with type 2 DM and all with type 1 DM suffered from UTIs. The main causative agents were E. coli (60%) and Proteus spp. (13%). The majority of patients suffering from UTIs (73%) were females. In conclusion, type 2 DM is the most common, especially in females, and increases with age. The main cause of DM was family genetic predisposition and sudden shocks. The current study also showed that most diabetic patients suffered from UTIs, especially females, and the main causes of UTI inflammation are E. coli isolates.

Association of breakfast consumption frequency with fasting glucose and insulin sensitivity/b cells function (HOMA-IR) in adults from high-risk families for type 2 diabetes in Europe: the Feel4Diabetes Study

PURPOSE

This study aimed to investigate the association of breakfast consumption frequency (BCF) with glycemic control indices in a cross-sectional sample of adults from families at high risk for type 2 diabetes mellitus (T2DM), exploring the role of sex and socioeconomic status (SES).

METHODS

In 2370 adults (40.8 ± 5.6 years) from 6 European countries, sociodemographic, lifestyle, anthropometric and biochemical characteristics were assessed through standardized procedures. Multivariable regression models were used to examine the association between fasting glucose (FG), fasting insulin (FI), and insulin resistance (HOMA-IR) (dependent variables) with BCF (independent variable) controlling for multiple possible confounders.

RESULTS

A linear association of BCF with FG (β = -0.557, 95% CI (-0.834, -0.280)) and a quadratic association with FI and HOMA-IR with the highest point of curve observed at BCF = 2.989 (times/week) and at BCF = 2.746, respectively, independent of the used covariates. In males and in participants of high SES, BCF was linearly and inversely associated with FG, while with FI and HOMA-IR there was an association with BCF in quadratic function. In females, BCF was linearly and inversely associated with FG and HOMA-IR, and there was a quadratic association with FI. In low SES there was only a linear association with FG, yet with no statistically significant findings for FI and HOMA-IR.

CONCLUSIONS

Regular breakfast consumption, especially >3 times/week is associated with improved indices of glycemic control. This association was diminished in low SES participants in the presence of the used covariates.

Efficacy of Residential, Group-Based, Intensive Holistic Lifestyle Intervention Among Type-2 Diabetes Patients - A Single Group Pre- And Post-intervention Study

Background The present study assessed the efficacy of the residential, group-based, intensive holistic lifestyle intervention on glycaemic control. Materials and methods A one-group pre and post-intervention study was conducted among 145 people with diabetes for a period of one year from February 2019 to January 2020. The study population underwent "Brahma Kumaris Raja Yoga lifestyle" intervention. Outcome variables were changes in HbA1c levels and anthropometric parameters (like weight, BMI, etc.). Paired t-test was used to compare normally distributed numeric variables. Results The mean age was 52.39±5.79 years, with a male-female ratio close to 1:1. Mean HbA1c at baseline was 9.06±2.1%. The mean weight and BMI were 71.03±12.84 kg and 28.28±4.83kg/m2, respectively. Mean HbA1c value had shown a reduction of 1.60% (95%CI 1.17 to 1.90, p <0.001) at three months and 1.58% (95% CI 1.13-1.87, p<0.001) reduction at a six-month follow-up. Between the third and sixth months, there was no significant change in the HbA1c value. Mean weight reduced by 0.79 kg (95% CI 0.08-1.08, p=0.023) at six-month follow-up and mean BMI decreased by 0.31 units from baseline to three months (95% CI 0.05-0.56, p=0.017). A statistically significant reduction was observed in waist circumference at the third month (MD=1.61 95% CI =0.95 to 2.28, P<0.001) and sixth month (MD=1.53, 95% CI 0.82-2.25, p<0.001) follow-up. Conclusion This residential, group-based, intensive holistic lifestyle intervention showed a significant decrease in HbA1c levels and anthropometric parameters at three- and six-months follow-up, thereby improving the overall health and wellbeing of people with diabetes.

Cost-effectiveness analysis of a school- and community-based intervention to promote a healthy lifestyle and prevent type 2 diabetes in vulnerable families across Europe: the Feel4Diabetes-study

The Feel4Diabetes-study implemented a school- and community-based intervention to promote healthy lifestyle and prevent type 2 diabetes mellitus (T2DM) in six European countries. The intervention included a special focus on families at increased T2DM risk. The current study evaluates the intervention's cost-effectiveness. A Markov-type health economic model was developed to predict the incidence of T2DM and its complications. Incremental cost-effectiveness ratios (lifetime horizon, societal perspective) were calculated based on the overall intervention effect on health behaviour, and stratified for low- and high-risk families. Sensitivity analyses captured input parameters uncertainty. A budget impact analysis was performed. The increase in children's water consumption and physical activity led to a modest gain in quality adjusted life years (QALYs) at a low intervention cost and budget impact. Medical cost savings due to avoided illness could only be achieved on the very long-term (>30 years). The intervention in its entirety was cost-effective (more QALYs at a reasonable investment) in Belgium, Finland, Bulgaria, and Hungary, while being dominant (net savings and more QALYs) in Greece and Spain. Results were cost-effective for the low-risk families, who only received the school- and community-based intervention component. Results for the high-risk families were only cost-effective (with considerable uncertainty) in Greece and Spain, but not when the intervention would need to be repeated. The Feel4Diabetes-intervention is potentially cost-effective, especially in countries with a high overweight and obesity prevalence, at a limited budget impact. The incremental financial investments to reach and support high-risk families did not result in the hoped-for health benefits.

Communication strategies in the prevention of type 2 diabetes and gestational diabetes in vulnerable groups: a scoping review

BACKGROUND

The global prevalence of diabetes is nearly 9%, with an upward trend in type 2 diabetes mellitus (T2DM) and gestational diabetes (GDM). Although evidence shows that vulnerable groups are affected disproportionally, these groups are difficult to reach in terms of preventive measures. Currently, there is no gold standard regarding communication strategies and/or public awareness campaigns.

METHODS

We conducted a scoping review in September 2019. Two reviewers independently screened the results of the electronic literature search in several databases, including Medline, EMBASE, and PsycINFO. Extracted data were charted, categorized, and summarized.

RESULTS

All of the included articles (n=24) targeted T2DM; none targeted GDM. We identified the following five different vulnerable groups within the identified studies: migrants (n=9), ethnic groups such as African Americans (n=8), people with low socioeconomic status (n=3), older people (n=1), and people in need of care (n=1). Three categories of communication strategies were identified as follows: adapted diabetes prevention programs (n=21), community health workers (n=5), and technical approaches (n=9).

CONCLUSION

We found different approaches for preventive interventions for T2DM. Some of these approaches were already adapted to known barriers. Communication strategies should be adapted to barriers and facilitating factors to increase participation and motivation.

Towards precision cardiometabolic prevention: results from a machine learning, semi-supervised clustering approach in the nationwide population-based ORISCAV-LUX 2 study

Given the rapid increase in the incidence of cardiometabolic conditions, there is an urgent need for better approaches to prevent as many cases as possible and move from a one-size-fits-all approach to a precision cardiometabolic prevention strategy in the general population. We used data from ORISCAV-LUX 2, a nationwide, cross-sectional, population-based study. On the 1356 participants, we used a machine learning semi-supervised cluster method guided by body mass index (BMI) and glycated hemoglobin (HbA1c), and a set of 29 cardiometabolic variables, to identify subgroups of interest for cardiometabolic health. Cluster stability was assessed with the Jaccard similarity index. We have observed 4 clusters with a very high stability (ranging between 92 and 100%). Based on distinctive features that deviate from the overall population distribution, we have labeled Cluster 1 (N = 729, 53.76%) as "Healthy", Cluster 2 (N = 508, 37.46%) as "Family history-Overweight-High Cholesterol ", Cluster 3 (N = 91, 6.71%) as "Severe Obesity-Prediabetes-Inflammation" and Cluster 4 (N = 28, 2.06%) as "Diabetes-Hypertension-Poor CV Health". Our work provides an in-depth characterization and thus, a better understanding of cardiometabolic health in the general population. Our data suggest that such a clustering approach could now be used to define more targeted and tailored strategies for the prevention of cardiometabolic diseases at a population level. This study provides a first step towards precision cardiometabolic prevention and should be externally validated in other contexts.

Salidroside protects against cardiomyocyte apoptosis and ventricular remodeling by AKT/HO-1 signaling pathways in a diabetic cardiomyopathy mouse model

BACKGROUND

Diabetic cardiomyopathy is characterized by both systolic and diastolic dysfunction due to decreased contractility, as well as reduced compliance of the myocardium. Oxidative stress plays a significant role in diabetes mellitus and its cardiovascular complications. Salidroside, a glucoside of the phenylpropanoid tyrosol, reportedly increases the levels of the antioxidative enzymes, nuclear factor erythroid 2-related factor 2, and heme oxygenase-1 (HO-1) to counteract oxidative stress; however, the underlying mechanisms are poorly understood.

PURPOSE

Here we investigate the potential cardio-protective effects of salidroside and its mechanism in a diabetic animal model.

METHODS

Male db/m, db/db, and age-matched wild-type mice were treated with salidroside at low dose (0.025 mg/kg) or high dose (0.05 mg/kg) by gavage every day for 12 weeks. Cardiac function and structure were assessed by echocardiography and histopathological examination. H9C2 cardiomyocytes were exposed in vitro to advanced glycosylation end products (400 μg/ml) and treated with salidroside (0.1, 1, or 10 μM). The expression of signaling-related genes were explored by western blotting and real-time PCR.

RESULTS

Salidroside treatment significantly improved diabetes-induced cardiac dysfunction, hypertrophy, and fibrosis in vivo. Mechanistically, salidroside markedly up-regulates HO-1 expression by activation of the AKT signaling pathway.

CONCLUSION

Salidroside protects against cardiomyocyte apoptosis and ventricular remodeling in diabetic mice. This cardio-protective effect of salidroside is dependent on AKT signaling activation.

T-Natural Killers and Interferon Gamma/Interleukin 4 in Augmentation of Infection in Foot Ulcer in Type 2 Diabetes

BACKGROUND

The link between immune system and type 2 diabetes mellitus (T2DM) pathogenesis attracted attention to demonstrate the role of immune cells and their secreted cytokines in T2DM development and its subsequent foot complications.

OBJECTIVE

To investigate the relation between T Natural killer cell (TNK) %, Interleukin 4 (IL4) and Interferon gamma (IFN-γ) and diabetic foot infection (DFI) development in patients with diabetic foot ulcer (DFU).

PATIENTS AND METHODS

Ninety patients with diabetes were included in this work, divided as T2DM group (n=30), DFU group (n=30), and DFI group (n=30). TNK% was detected using flow cytometry. Serum IL4 and IFN-γ were measured by ELISA. Diabetes biochemical parameters were also analyzed.

RESULTS

Significant decrease was detected in TNK% and IFN-γ in DFI group compared to other 2 groups (P<0.001). Significant decrease was detected in serum levels of IL4 in DFI group compared to T2DM group (P=0.006). IFN-γ/IL4 was significantly decreased in DFI compared to DFU group (P=0.020). There was a significant correlation of TNK% with both IL4 and IFN-γ (r=0.385, P<0.001; r=0.534, P<0.001, respectively). Significant negative correlation of TNK% with HbA1c and LDL was revealed (r=-0.631, P<0.001; and r=-0.261, P=0.013, respectively), while a positive correlation was seen with HDL (r=0.287, P=0.006). A significant negative correlation of IL4 with HbA1c  was found (r=-0.514, P<0.001;. As for IFN-γ, a significant negative correlation with HbA1c and LDL was detected (r=-0.369, P< 0.001; r=-0.229, P=0.030). TNK % and IFN-γ level showed negative correlations with disease duration/year (r=-0.546, P< 0.001; r=-0.338, P=0.001,respectively).

CONCLUSION

Decline in TNK frequency has essential role in T2DM pathogenesis and subsequent foot complications. Downregulation of TNK% and IFN-γ level have potential roles in predicting infection of diabetic ulcer and are correlated with disease duration.

Lifestyle Changes Observed among Adults Participating in a Family- and Community-Based Intervention for Diabetes Prevention in Europe: The 1st Year Results of the Feel4Diabetes-Study

The Feel4Diabetes intervention was a school and community-based intervention aiming to promote healthy lifestyle and tackle obesity and obesity-related metabolic risk factors for the prevention of type 2 diabetes (T2D) among families at risk of developing this disease. The current study aims to present the results on lifestyle behaviors obtained from parents during the first year of the Feel4Diabetes intervention. This multicomponent intervention had a cluster randomized design and was implemented in Belgium, Bulgaria, Finland, Greece, Hungary and Spain over two years (2016-2018). Standardized protocols and procedures were used by the participating centers in all countries to collect data on parents' lifestyle behaviors (diet, physical activity, sedentary behavior). The Feel4Diabetes intervention was registered at clinicaltrials.gov (registration number: NCT02393872). In total, 2110 high-risk parents participated in the baseline and 12-month follow-up examination measurements. Participants allocated to the intervention group reduced their daily consumption of sugary drinks (p = 0.037) and sweets (p = 0.031) and their daily screen time (p = 0.032), compared with the control group. In addition, participants in the intervention group in Greece and Spain increased their consumption of breakfast (p = 0.034) and fruits (p = 0.029), while in Belgium and Finland they increased their water intake (p = 0.024). These findings indicate that the first year of the Feel4Diabetes intervention resulted in the improvement of certain lifestyle behaviors in parents from high-risk families.