Physical activity in U.S. adults with diabetes and at risk for developing diabetes, 2003

Physical Activity According to Diabetes and Metropolitan Status, U.S., 2020 and 2022

INTRODUCTION

Physical activity can reduce morbidity and mortality among adults with diabetes. Although rural disparities in physical activity exist among the general population, it is not known how these disparities manifest among adults with diabetes.

METHODS

Data from the 2020 and 2022 National Health Interview Survey were analyzed in 2023 to assess the prevalence of meeting aerobic and muscle-strengthening recommendations according to the 2018 Physical Activity Guidelines for Americans during leisure time. Physical activity prevalence was computed by diabetes status, type of physical activity, and urban/rural residence (large central metropolitan, large fringe metropolitan, medium/small metropolitan, and nonmetropolitan). Logistic regression models were used to estimate prevalence and prevalence ratios of meeting physical activity recommendations by urban/rural residence across diabetes status.

RESULTS

Among adults with diabetes in nonmetropolitan counties, only 23.8% met aerobic, 10.9% met muscle-strengthening, and 6.2% met both physical activity recommendations. By contrast, among adults with diabetes in large fringe metropolitan counties, 32.1% met aerobic, 19.7% met strengthening, and 12.0% met both guidelines. Multivariable adjusted prevalence of meeting muscle-strengthening recommendations was higher among participants with diabetes in large fringe metropolitan than among large central metropolitan counties (prevalence ratio=1.27; 95% CI=1.03, 1.56). Among those without diabetes, adjusted prevalence of meeting each recommendation or both was lower in nonmetropolitan and small/medium metropolitan than in large central metropolitan counties.

CONCLUSIONS

Adults with diabetes are less likely to meet the physical activity recommendations than those without, and differences exist according to urban/rural status. Improving physical activity among rural residents with diabetes may mitigate disparities in diabetes-related mortality.

Effect of treadmill ambulatory training on glucose control and blood pressure in persons with type 2 diabetes: A pilot study

BACKGROUND

Lack of time is often cited by persons with type 2 diabetes for non-participation in regular exercise. This highlights the need to explores ways to help persons with type 2 diabetes to engage in an active lifestyle. This study evaluated the effect of a short duration norm intensity exercise on blood glucose and blood pressure in persons with type 2 diabetes.

METHODS

Twenty persons with type 2 diabetes were randomly assigned to either training group (n = 10) or control group (n = 10). The training group received 4-weeks ambulatory training on a motor-driven treadmill (2 x 20 min per week at 60% target heart rate). The control group received no training. Blood glucose, and systolic and diastolic blood pressures were assessed before and after the 4-weeks training. Repeated measures ANOVA were used to examine training effect.

RESULTS

Training significantly improved blood glucose (mean difference = -2.73; p = 0.03). No effects were found for systolic blood pressure (mean difference = -0.30; p = 0.96) and diastolic blood pressure (mean difference = -0.90; p = 0.82).

CONCLUSION

Training improved blood glucose but not blood pressure. A short-duration ambulatory training is an appropriate exercise mode to elicit beneficial effect, and exercise adoption in persons with type 2 diabetes.

TRIAL REGISTRATION

This pilot trial is registered with the Pan African Clinical Trial Registry at pactr.samrc.ac.za (PACTR202306601940612).

Determinants of health and mortality in undiagnosed diabetes: A nationally representative US adult, 2011-2020

AIM

This study examines the determinants of health and mortality associated with undiagnosed diabetes among a nationally representative sample of US adults.

METHODS

Data are from the National Health and Nutrition Examination Survey between 2011 and 2012 and 2019-2020. Diabetes status is categorized into three groups: undiagnosed diabetes, diagnosed diabetes, and no diabetes. Multiple logistic regression is used to estimate the association between undiagnosed diabetes and three domains of risk factors, including sociodemographic and health behavioral and clinical factors. Cox proportional hazards models are performed to compare excess mortality risk between the three groups.

RESULTS

Young adults, racial minorities, the foreign-born, and individuals with limited access to health care are more likely to be unaware of their diabetes. Moreover, adults without a family history of diabetes and chronic conditions have a higher chance of undiagnosed diabetes. No health behavioral factors are found to be associated with undiagnosed diabetes. Adults with undiagnosed diabetes have a lower risk of all-cause and cardiovascular disease mortality compared to those with diagnosed diabetes, but a higher risk of all-cause mortality than those with no diabetes.

CONCLUSION

Targeted public health approaches should address sociodemographic and clinical factors to reduce the burden of undiagnosed diabetes.

Effect of physical activity on incident atrial fibrillation in individuals with varying duration of diabetes: a nationwide population study

BACKGROUND

Diabetes mellitus (DM) duration affects incident atrial fibrillation (AF) risk; the effect of physical activity on mitigating AF risk related to varying DM duration remains unknown. We assessed the effect of physical activity on incident AF in patients with DM with respect to known DM duration.

METHODS

Patients with type 2 DM who underwent the Korean National Health Insurance Service health examination in 2015-2016 were grouped by DM duration: new onset and < 5, 5-9, and ≥ 10 years. Physical activity was classified into four levels: 0, < 500, 500-999, 1,000-1,499, and ≥ 1,500 metabolic equivalent task (MET)-min/week, with the primary outcome being new-onset AF.

RESULTS

The study enrolled 2,392,486 patients (aged 59.3 ± 12.0 years, 39.8% female) with an average follow-up of 3.9 ± 0.8 years and mean DM duration of 5.3 ± 5.1 years. Greater physical activity was associated with a lower AF risk. Lowering of incident AF risk varied with different amounts of physical activity in relation to known DM duration. Among patients with new-onset DM, DM duration < 5 years and 5-9 years and 1,000-1,499 MET-min/week exhibited the lowest AF risk. Physical activity ≥ 1,500 MET-min/week was associated with the lowest incident AF risk in patients with DM duration ≥ 10 years (by 15%), followed DM duration of 5-9 years (12%) and < 5 years (9%) (p-for-interaction = 0.002).

CONCLUSIONS

Longer DM duration was associated with a high risk of incident AF, while increased physical activity generally reduced AF risk. Engaging in > 1,500 MET-min/week was associated with the greatest AF risk reduction in patients with longer DM duration, highlighting the potential benefits of higher activity levels for AF prevention.

Effects of acute and chronic stair-climbing exercise on metabolic health: A systematic review

Stair climbing exercise (SE) provides a feasible approach to elevate physical activity, but the effects on metabolic health are unclear. We systematically reviewed the currently available evidence on the effects of SE on fasting and postprandial glycaemia and lipidaemia. Studies were included if they investigated the effects of acute or chronic (at least 2 weeks) SE on fasting and/or postprandial glycaemic (insulin and glucose) and lipidaemic (triacylglycerols and non-esterified fatty acids) responses in healthy, prediabetic or type 2 diabetic adult populations. PubMed, Web of Science and Scopus were searched for eligible studies until July 2022. A total of 25 studies (14 acute and 11 chronic) were eligible for review. Acute bout(s) of SE can reduce postprandial glycaemia in individuals with prediabetes and type 2 diabetes (8 of 9 studies), but not in normoglycemic individuals. The effects of acute SE on postprandial lipidaemic responses and SE training on both fasting and postprandial glycaemia/lipidaemia were unclear. Acute SE may reduce postprandial glucose concentrations in people with impaired glycaemic control, but high-quality studies are needed. More studies are needed to determine the effect of chronic SE training on postprandial glucose and lipid responses, and the acute effects of SE on lipid responses.

Pedometer- and accelerometer- based physical activity interventions in Type 2 diabetes: A systematic review and meta-analysis

AIMS

Although accelerometer- and pedometer-based physical activity (PA) interventions can increase PA, there is no solid evidence for their benefits in patients with type 2 diabetes (T2DM). The aim of this systematic review and meta-analysis of randomized controlled clinical trials (RCTs) was to determine the effects of accelerometer- and pedometer-based PA interventions on hemoglobin A1c (HbA1c), fasting glucose, weight, BMI, blood pressure, lipids, and PA in adults with T2DM.

DATA SYNTHESIS

Records from MEDLINE/PubMed, EMBASE, LILACS, and Scopus were searched from inception through March 28th, 2022. RCTs of at least two weeks of duration evaluated the effectiveness of pedometers or accelerometers as motivating tools for increasing PA in T2DM patients. This study was registered with PROSPERO and followed the PRISMA reporting guide. Of the 7131 non-duplicated articles retrieved, 24 RCTs (1969 patients) were included. The mean baseline HbA1c of the experimental group of included studies varied from 6.3 ± 0.9 % to 9.0 ± 0.01 %. The accelerometer- and pedometer-based PA interventions resulted in a greater improvement in HbA1c (-0.22 %; 95%CI, -0.4 % to -0.05 %; I2 = 77 %) and triglycerides (-13.11 mg/dL; 95%CI, -25.21 to -1.02; I2 = 22 %) versus control participants. Pedometer ambulatory use as a motivating tool significantly increased PA by 2,131 steps/day (95 % CI, 1,348 to 2,914; I2 = 74 %) in T2DM patients.

CONCLUSIONS

Pedometers and accelerometers are associated with reductions in HbA1c and triglycerides when used as motivating tools. Larger and higher-quality studies are required to determine the full effects of PA as motivated by trackers in T2DM population.

Is there a different rating of perceived exertion in men with type 2 diabetes mellitus?

Objective

Studies show that patients with type 2 diabetes mellitus (T2DM) do not engage in regular exercise as often as individuals without T2DM. In addition to numerous barriers to engaging in regular exercise, a different rating of perceived exertion (RPE) during physical activity has been hypothesized to play a role. Therefore, this study investigates whether T2DM affects RPE.

Methods

RPE values (BORG scale ratings) and heart rate (HR) data were analyzed during an endurance step test (25 W + 25 W every 2 min) at different workloads relative to the individual maximum load (50%, 70% and 90% of peak workload (Wpeak)) in patients with T2DM and in non-diabetic control (CON) subjects (n = 12 in each group). Furthermore, in a larger group of overweight patients with T2DM (n = 81), it was investigated whether glycated hemoglobin (HbA1c) levels correlate with RPE values at the different relative loads.

Results

Neither RPE nor HR values significantly differed between T2DM and CON subjects at 50%, 70% or 90% of Wpeak. No significant correlations were identified between HbA1c levels and RPE values.

Conclusion

There is no evidence in our study that T2DM leads to a different perception of physical exertion. Other causes must therefore be responsible for the increased lack of motivation of T2DM patients to engage in regular exercise.

Trends in health behaviors of US adults with and without Diabetes: 2007-2018

AIMS

Understanding health behaviors of people with diabetes can inform strategies to reduce diabetes-related burdens.

METHODS

We used serial cross-sectional National Health and Nutrition Examination Surveys over 2007-2018 to characterize self-reported health behaviors among non-pregnant adults, with and without self-reported diabetes. We estimated weighted proportions meeting recommended health behaviors overall and by sociodemographic and glycemic levels.

RESULTS

During 2007-2010, proportions of adults with diabetes meeting recommendations were: 61.9 % for added sugar consumption (<10 % of total calories), 17.2 % for physical activity, 68.2 % for weight management, 14.4 % avoided alcohol, 57.5 % avoided tobacco, 34.1 % got adequate sleep, and 97.5 % saw a healthcare provider (compared with 19.2 %, 33.6 %, 68.8 %, 8.5 %, 44.2 %, 33.0 %, and 82.6 % respectively, among those without diabetes). During 2015-2018, adjusted analyses showed more adults with diabetes met sleep (+16.7 percentage-points[pp]; 95 % CI: 10.6,22.8) and physical activity goals (+8.3 pp; 95 % CI: 3.8,12.8), and fewer met added sugar recommendations (-8.8 pp; 95 % CI -14.7, -2.9). Meeting added sugar, physical activity, and weight management varied by age, education, and glycemic level, but not race and ethnicity.

CONCLUSIONS

During 2007-2018, there was some improvement in health behaviors. Improving self-management may require targeted interventions for different segments, like age groups or glycemic levels, among those with diabetes.

Improved endurance capacity of diabetic mice during SGLT2 inhibition: Role of AICARP, an AMPK activator in the soleus

BACKGROUND

Diabetes is associated with an increased risk of deleterious changes in muscle mass and function or sarcopenia, leading to physical inactivity and worsening glycaemic control. Given the negative energy balance during sodium-glucose cotransporter-2 (SGLT2) inhibition, whether SGLT2 inhibitors affect skeletal muscle mass and function is a matter of concern. However, how SGLT2 inhibition affects the skeletal muscle function in patients with diabetes remains insufficiently explored. We aimed to explore the effects of canagliflozin (CANA), an SGLT2 inhibitor, on skeletal muscles in genetically diabetic db/db mice focusing on the differential responses of oxidative and glycolytic muscles.

METHODS

Db/db mice were treated with CANA for 4 weeks. We measured running distance and handgrip strength to assess skeletal muscle function during CANA treatment. At the end of the experiment, we performed a targeted metabolome analysis of the skeletal muscles.

RESULTS

CANA treatment improved the reduced endurance capacity, as revealed by running distance in db/db mice (414.9 ± 52.8 vs. 88.7 ± 22.7 m, P < 0.05). Targeted metabolome analysis revealed that 5-aminoimidazole-4-carboxamide-1-β-D-ribofuranosyl 5'-monophosphate (AICARP), a naturally occurring AMP-activated protein kinase (AMPK) activator, increased in the oxidative soleus muscle (P < 0.05), but not in the glycolytic extensor digitorum longus muscle (P = 0.4376), with increased levels of AMPK phosphorylation (P < 0.01).

CONCLUSIONS

This study highlights the potential role of the AICARP/AMPK pathway in oxidative rather than glycolytic skeletal muscles during SGLT2 inhibition, providing novel insights into the mechanism by which SGLT2 inhibitors improve endurance capacity in patients with type 2 diabetes.

The Impact of Diabetes Mellitus on Patient-Reported Outcomes of Chronic Low Back Pain with Modic Changes at One Year: A Prospective Cohort Study

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

Diabetes mellitus (DM) is associated with unfavourable patient-reported outcomes after spine surgery. Chronic low back pain (CLBP) with Modic Changes (MCs) in the lumbar vertebrae, as observed on MRI, forms a specific subgroup. This study aims to investigate the potential influence of DM on CLBP with MCs.

METHODS

This study involved 259 patients with CLBP accompanied MCs. We recorded the patient-reported outcomes (visual analogue scale (VAS), Oswestry Disability Index (ODI), and Roland-Morris Disability Questionnaire (RMDQ)) at baseline, 3, 6, and 12 months. Multivariable linear regression analyses were performed to determine predictors of patient-reported outcomes.

RESULTS

103 patients had DM. Patients with DM exhibited higher VAS (P < .05), ODI (P < .001), and RMDQ (P < .001) scores at 3, 6, and 12 months, while patients without DM experienced more significant improvements in the scores over time (P < .001). Patients with DM reported longer durations of physical exercise (P = .007). Additionally, patients without DM had a significantly higher patient satisfaction index (P < .001) and a lower prevalence of hypertension (P < .001). Notably, significant differences were observed in the distribution of MCs of lumbar vertebrae (P = .034) and Pfirrmann grades of intervertebral disc degeneration between two groups (P < .001).

CONCLUSION

Patients with DM demonstrated poorer patient-reported outcomes compared to those without DM in 1-year. DM emerged as an independent predictor of adverse patient-reported outcomes. It can be utilized to enhance the management and treatment of CLBP in patients with MCs.

Trends in physical activity and sedentary time among U.S. adults with diabetes: 2007-2020

AIMS

To examine temporal trends in physical activity and sedentary time among U.S. adults with diabetes from 2007 to 2020.

METHODS

We performed serial cross-sectional analyses for participants aged ≥ 20 years with diagnosed diabetes from the U.S. National Health and Nutrition Examination Survey from 2007 to 2020. Participants completed the Global Physical Activity Questionnaire.

RESULTS

The analytic sample comprised 5096 adults with diabetes (mean age: 60.3 years; 48.2% females; 60.1% White people; mean body mass index: 33.0 kg/m2). From 2007-2008 through 2017-March 2020, the proportion of being physically sufficiently active increased from 41.5% (95% CI, 35.9%-47.2%) to 55.8% (95% CI, 51.3%-60.3%) (P-trend<0.001), whereas that of physical inactivity declined from 43.7% (95% CI, 38.1%-49.2%) to 31.0% (95% CI, 27.7%-34.3%) (P-trend<0.001). The decline was driven by increasing engagement in work-related and leisure-time activity. However, engagement in transportation-related activity stayed persistently low (16.7% [95% CI, 14.8%-18.8%] in 2017-March 2020) (P-trend = 0.25), and the mean daily sitting hours remained unaltered (6.2 [95% CI, 5.9-6.5] in 2017-March 2020) (P-trend = 0.60). Adults who were middle-aged or older, or with class III obesity, cardiovascular or chronic kidney concomitants were less likely to be sufficiently active and prone to prolonged sitting.

CONCLUSIONS

Physical activity levels in U.S. adults with diabetes have increased from 2007 to 2020, but about one in two remains inactive or insufficiently active. Sedentary time has not decreased. For diabetes management, nationwide efforts are needed to promote transportation-related physical activity while minimizing prolonged sitting, especially among those who are middle-aged or older, or with severe obesity or other complications.

''I felt marvellous e-cycling. If I had long hair I would have flicked it": a qualitative investigation of the factors associated with e-cycling engagement among adults with type 2 diabetes

Background

Physical activity (PA) is a key component in the management of type 2 diabetes. However, this population have low rates of PA engagement. Electrically assisted cycling has been identified as a means through which to increase PA by incorporating activity into daily life, while overcoming some of the barriers to conventional cycling. The determinants of e-cycling among people living with chronic disease are largely unknown. The aim of this research was to explore the determinants of e-cycling among individuals with type 2 diabetes using the Theoretical Domains Framework (TDF) and the Capability, Opportunity and Motivation for Behaviour change model (COM-B). This information is important for determining the suitability of future e-cycling initiatives and, if appropriate, inform future e-cycling interventions.

Method

One-to-one semi structured interviews were conducted with 16 participants from the e-cycling arm of a pilot randomised controlled trial between September 2019 and April 2020. The TDF was used to develop the interview guide. The framework method of analysis was used, incorporating both deductive and inductive reasoning. A conceptual model of the factors that influence e-cycling in this population was created.

Results

The most commonly reported TDF domains were skills, knowledge, belief about capabilities, belief about consequences and environmental context and resources. Specifically, e-bike training facilitated e-cycling engagement by providing participants with the skills, knowledge, and confidence needed to ride the e-bike and ride on the road. In addition, the enjoyment of e-cycling was a key facilitator to engagement. Participants engaged in e-cycling to improve their health rather than for environmental reasons. Most barriers to e-cycling related to the natural or physical environment.

Conclusion

This study provides insight into the personal, social, and environmental factors associated with e-cycling in this population. The findings of this study can be used to develop a more refined e-cycling intervention targeting the factors identified as influencing e-cycling engagement. In addition, this information will help in the selection of mechanistic outcome measures for evaluation.

Detailed descriptions of physical activity patterns among individuals with diabetes and prediabetes: the Lolland-Falster Health Study

INTRODUCTION

This study aimed to describe objectively measured physical activity patterns, including daily activity according to day type (weekdays and weekend days) and the four seasons, frequency, distribution, and timing of engagement in activity during the day in individuals with diabetes and prediabetes and compared with individuals with no diabetes.

RESEARCH DESIGN AND METHODS

This cross-sectional study included data from the Danish household-based, mixed rural-provincial population study, The Lolland-Falster Health Study from 2016 to 2020. Participants were categorized into diabetes, prediabetes, and no diabetes based on their glycated hemoglobin level and self-reported use of diabetes medication. Outcome was physical activity in terms of intensity (time spent in sedentary, light, moderate, vigorous, and moderate to vigorous physical activity (MVPA) intensities), adherence to recommendations, frequency and distribution of highly inactive days (<5 min MVPA/day), and timing of engagement in activity assessed with a lower-back worn accelerometer.

RESULTS

Among 3157 participants, 181 (5.7 %) had diabetes and 568 (18.0 %) had prediabetes. Of participants with diabetes, 63.2% did not adhere to the WHO recommendations of weekly MVPA, while numbers of participants with prediabetes and participants with no diabetes were 59.5% and 49.6%, respectively. Around a third of participants with diabetes were highly inactive daily (<5 min MVPA/day) and had >2 consecutive days of inactivity during a 7-days period. Mean time spent physically active at any intensity (light, moderate, and vigorous) during a day was lower among participants with diabetes compared with participants with no diabetes and particularly from 12:00 to 15:00 (mean difference of -6.3 min MVPA (95% CI -10.2 to -2.4)). Following adjustments, significant differences in physical activity persisted between diabetes versus no diabetes, but between participants with prediabetes versus no diabetes, results were non-significant after adjusting for body mass index.

CONCLUSIONS

Inactivity was highly prevalent among individuals with diabetes and prediabetes, and distinct daily activity patterns surfaced when comparing these groups with those having no diabetes. This highlights a need to optimize current diabetes treatment and prevention to accommodate the large differences in activity engagement.

Accumulated Short Bouts of Walking in Older Adults With Type 2 Diabetes: Effects on Glycosylated Hemoglobin (HbA1c) and Homeostasis Model Assessment of Insulin Resistance (HOMA-IR)

The current study examined the effects of accumulated short bouts of walking on glycosylated hemoglobin (HbA1c) and homeostasis model assessment of insulin resistance (HOMA-IR) of older adults with type 2 diabetes. Differences in variables between models of accumulated bouts of walking and 10,000 steps were also investigated. Sedentary participants (N = 38) were randomized into one of three groups: accumulated 10-minute bouts of walking at 100 steps/min (10/100MW), accumulated 10,000 steps (10KS), or control. HbA1c, HOMA-IR, blood lipids, and cardiorespiratory fitness (VO2max) were assessed before and after the intervention. VO2max, HbA1c, and HOMA-IR in the 10/100MW and 10KS groups showed significant and comparable improvements postintervention compared to preintervention (p < 0.05). Furthermore, the change in average daily step count was significantly associated with the change in HbA1c of the two walking groups (r = -0.61 for 10KS and r = -0.63 for 10/100MW; p < 0.05). Accumulated short bouts of walking at 100 steps/min and 10,000 steps daily improved HbA1c and HOMA-IR of older adults with type 2 diabetes. [Research in Gerontological Nursing, 16(5), 250-258.].

A narrative review of exercise participation among adults with prediabetes or type 2 diabetes: barriers and solutions

Type 2 diabetes (T2D) has been rising in prevalence over the past few decades in the US and worldwide. T2D contributes to significant morbidity and premature mortality, primarily due to cardiovascular disease (CVD). Exercise is a major cornerstone of therapy for T2D as a result of its positive effects on glycemic control, blood pressure, weight loss and cardiovascular risk as well as other measures of health. However, studies show that a majority of people with T2D do not exercise regularly. The reasons given as to why exercise goals are not met are varied and include physiological, psychological, social, cultural and environmental barriers to exercise. One potential cause of inactivity in people with T2D is impaired cardiorespiratory fitness, even in the absence of clinically evident complications. The exercise impairment, although present in both sexes, is greater in women than men with T2D. Women with T2D also experience greater perceived exertion with exercise than their counterparts without diabetes. These physiological barriers are in addition to constructed societal barriers including cultural expectations of bearing the burden of childrearing for women and in some cultures, having limited access to exercise because of additional cultural expectations. People at risk for and with diabetes more commonly experience unfavorable social determinants of health (SDOH) than people without diabetes, represented by neighborhood deprivation. Neighborhood deprivation measures lack of resources in an area influencing socioeconomic status including many SDOH such as income, housing conditions, living environment, education and employment. Higher indices of neighborhood deprivation have been associated with increased risk of all-cause, cardiovascular and cancer related mortality. Unfavorable SDOH is also associated with obesity and lower levels of physical activity. Ideally regular physical activity should be incorporated into all communities as part of a productive and healthy lifestyle. One potential solution to improve access to physical activity is designing and building environments with increased walkability, greenspace and safe recreational areas. Other potential solutions include the use of continuous glucose monitors as real-time feedback tools aimed to increase motivation for physical activity, counseling aimed at improving self-efficacy towards exercise and even acquiring a dog to increase walking time. In this narrative review, we aim to examine some traditional and novel barriers to exercise, as well as present evidence on novel interventions or solutions to overcome barriers to increase exercise and physical activity in all people with prediabetes and T2D.

Association between non-pharmacological therapy and healthcare use and expenditure of patients with diabetes mellitus

This study explored the sociodemographic and clinical characteristics of patients with diabetes who incorporated two non-pharmacological therapies into their lifestyle and the association between non-pharmacological therapy and healthcare utilization and expenditure. In the USA, 26.4 million people were reportedly diagnosed with diabetes and treated with diet modification or physical activity in the 2019 Medical Expenditure Panel Survey. Physical activity was defined as moderate-to-vigorous physical exercise five times per week, whereas dietary modification involved healthy eating that reduced glucose levels. Only 4.8 million patients with diabetes did not integrate any non-pharmacological intervention into their therapy regimen. Those who did not include non-pharmacological interventions had higher annual total healthcare expenditures (M = $18,428) than those who incorporated either single (M = $17,058) or dual intervention (M = $15,134). A significant difference was observed in prescribed medicine utilization per year for those who did not include lifestyle modifications or non-pharmacological interventions. Propensity score-matched participants revealed significant differences in hospital stays, outpatient visits, and emergency department expenditures. Patients with diabetes who adhered to two non-pharmacological interventions showed significantly lower healthcare utilization. Being active and following a healthy diet can help prevent the progression of diabetes mellitus complications and reduce the cost associated with diabetes.

Where to Start? Physical Assessment, Readiness, and Exercise Recommendations for People With Type 1 or Type 2 Diabetes

Exercise plays an important role in the management of diabetes and is associated with many benefits such as decreased morbidity and mortality. For people exhibiting signs and symptoms of cardiovascular disease, pre-exercise medical clearance is warranted; however, requiring broad screening requirements can lead to unnecessary barriers to initiating an exercise program. Robust evidence supports the promotion of both aerobic and resistance training, with evidence emerging on the importance of reducing sedentary time. For people with type 1 diabetes, there are special considerations, including hypoglycemia risk and prevention, exercise timing (including prandial status), and differences in glycemic responses based on biological sex.

GI factors, potential to predict prostate motion during radiotherapy; a scoping review

Purpose

A scoping literature review was conducted to identify gastrointestinal (GI) factors most likely to influence prostate motion during radiotherapy. We proffer that patient specific measurement of these GI factors could predict motion uncertainty during radiotherapy, facilitating personalised care by optimising treatment technique e.g., daily adaption or via bespoke patient pre-habilitation and preparation.

Methods

The scoping review was undertaken as per JBI guidelines. Searches were conducted across four databases: Ovid Medline®, EMBASE, CINAHL and EBSCO discovery. Articles written in English from 2010-present were included. Those pertaining to paediatrics, biological women exclusively, infectious and post-treatment GI morbidity and diet were excluded.Common GI factors impacting men were identified and related symptoms, incidence and measurement tools examined. Prevalence among persons with prostate cancer was explored and suitable assessment tools discussed.

Results

A preliminary search identified four prominent GI-factors: mental health, co-morbidity and medication, physical activity, and pelvic floor disorder. The scoping search found 3644 articles; 1646 were removed as duplicates. A further 1249 were excluded after title and abstract screening, 162 remained subsequent to full text review: 42 mental health, 53 co-morbidity and medication, 39 physical activity and 28 pelvic floor disorder.Six GI factors prevalent in the prostate cancer population and estimated most likely to influence prostate motion were identified: depression, anxiety, diabetes, obesity, low physical activity, and pelvic floor disorder. Reliable, quick, and easy to use tools are available to quantify these factors.

Conclusion

A comprehensive GI factor assessment package suitable to implement into the radiotherapy clinic has been created. Unveiling these GI factors upfront will guide improved personalisation of radiotherapy.

Electrically assisted cycling for individuals with type 2 diabetes mellitus: a pilot randomized controlled trial

BACKGROUND

Type 2 diabetes mellitus (T2DM) and its associated complications puts considerable strain on healthcare systems. With the global incidence of T2DM increasing, effective disease management is essential. Physical activity (PA) is a key component of T2DM management; however, rates of PA engagement are low in this population. Developing effective and sustainable interventions that encourage PA is a high priority. Electrically assisted bicycles are becoming increasingly popular and may increase PA in healthy adults. This study aimed to provide evidence of the feasibility of conducting a randomized controlled trial to evaluate the efficacy of an e-cycling intervention to increase PA and improve health in individuals with T2DM.

METHODS

A parallel-group two-arm randomized, waitlist-controlled pilot study was conducted. Individuals were randomized to either an e-bike intervention or standard care. The intervention incorporated two one-to-one e-bike skills training and behavioural counselling sessions delivered by a community-based cycling charity, followed by a 12-week e-bike loan with two further sessions with the instructors. Feasibility was assessed via measures related to recruitment, retention and intervention implementation. Post-intervention interviews with instructors and participants explored the acceptability of the study procedures and intervention. Clinical, physiological and behavioural outcomes were collected at baseline and post-intervention to evaluate the intervention's potential.

RESULTS

Forty participants (M_age = 57) were randomized, of which 34 were recruited from primary care practices. Thirty-five participants were retained in the trial. The intervention was conducted with high fidelity (> 80% content delivered). E-bike training provided participants with the skills, knowledge and confidence needed to e-bike independently. Instructors reported being more confident delivering the skills training than behavioural counselling, despite acknowledging its importance. The study procedures were found to be acceptable to participants. Between-group differences in change during the intervention were indicative of the interventions potential for improving glucose control, health-related quality of life and cardiorespiratory fitness. Increases in overall device measured moderate-to-vigorous PA behaviour following the intervention were found, and there was evidence that this population self-selected to e-cycle at a moderate intensity.

CONCLUSIONS

The study's recruitment, retention, acceptability and potential efficacy support the development of a definitive trial subject to identified refinements.

TRIAL REGISTRATION

ISRCTN, ISRCTN67421464 . Registered 17/12/2018.

Sex and Age Differences in Association between Physical Activity and Metabolic Syndrome: Results from NHANES 2003-2006

OBJECTIVE

To examine whether and how sex and age modify the association between accelerometer-based physical activity (PA) and metabolic syndrome (MetS) among American (US) adults.

METHOD

Adults aged ≥20 years old who participated in the mobile center examination during 2003-2006 in the National Health and Nutrition Examination Survey were included for analysis. The total minutes per day of moderate-to-vigorous PA (MVPA) was estimated using ActiGraph. Multivariable logistic regression was used to estimate the odds ratio (OR) of having MetS at an increasing MVPA time. The modification effects of gender and age on the association between MetS and MVPA time were examined by testing for two-way and three-way interaction terms of MVPA time, sex, and age in the model after adjusting for relevant covariates.

RESULTS

The prevalence of MetS generally decreased with the MVPA time and was lower in females than in males, although the sex difference varied across age groups. After adjusting for demographic and lifestyle covariates, there was a significant sex difference in how an increased MVPA time lowered the odds of MetS. This interactive effect also varied with age. MVPA benefitted young and middle-age populations up until about 65 years old for both sexes, and the protective effect weakened with age. Although the effect of MVPA was stronger for males than females at young ages, the rate at which it attenuated was quicker in males. The OR of MetS between males and females per unit change of MVPA time was 0.73 (95% CI: [0.57, 0.93]) at age = 25 years, compared to OR = 1.00 (95% CI: [0.88, 1.16]) at age = 60 years. Before the age of 50, the gender difference in the protective effect on MetS was larger at low MVPA levels and became smaller at higher MVPA levels. The male advantage was quite stable with an increasing MVPA time for ages 50-60, and no longer significant at older ages.

CONCLUSIONS

Young and middle-age populations benefitted from MVPA, lowering the risk of MetS for both sexes. A longer MVPA time was associated with a greater decrease in the risk of MetS in young men than in women, but the sex difference reduced with age and was no longer apparent in older populations.

Translation, Cross-Cultural Adaptation, and Validation of the Persian Version of the Lifetime Total Physical Activity Questionnaire

BACKGROUND

This study aimed to translate and cross-culturally adapt the Lifetime Total Physical Activity Questionnaire (LTPAQ) for use in Persian-speaking countries as well as evaluate its validity and reliability.

METHODS

There were 3 stages to this study. First, a forward-backward translation method was used to develop a Persian version of the LTPAQ. In the second stage, the Persian version of the LTPAQ was evaluated for its face validity and content validity. Finally, test-retest reliability and known-group validity were assessed. The LTPAQ has occupational and volunteer activities, including travel to work, exercise and sports, and household activities. Frequency, duration, and estimated metabolic costs of activities with light, moderate, and heavy intensities were used to calculate the metabolic equivalent of each domain during life (in metabolic equivalent-hour/week). Metabolic equivalents of each domain and in total were used to evaluate the reliability and validity of the questionnaire.

RESULTS

In total, 60 people (41.7% females) with a mean age of 33.9 (SD = 11.5) years participated in this study. All domains showed excellent test-retest reliability (intraclass correlation coefficient > .9). All items had content validity indexes higher than 0.85. In addition, males had significantly higher physical activity levels than females (P = .022), indicating the known-group validity of the questionnaire.

CONCLUSIONS

The LTPAQ was translated into Persian and trans-culturally adapted. This study indicates that the Persian version of the LTPAQ has adequate reliability and validity and can be utilized in future studies to assess physical activity in the Persian population.

Prevalence and associated factors of physical inactivity among adult diabetes mellitus patients in Felege Hiwot Referral Hospital, Bahir Dar, Northwest Ethiopia

Physical inactivity has been viewed as an emerging public health problem in developing countries including Ethiopia. Diabetes mellitus (DM) is a group metabolic disorder characterized by chronic hyperglycemia resulting from defects in insulin secretion, function, or both. Its prevalence increases with changing lifestyles including physical inactivity across the globe. However, there is limited research, and not yet received attention in Ethiopia. This study aimed to assess the prevalence and associated factors of physical inactivity among adult diabetic patients in Felege Hiwot Referral Hospital, Bahir Dar, Northwest Ethiopia. An institutional-based cross-sectional study design was conducted among 308 participants from February to June 2018 at Felege Hiwot Referral Hospital. A face-to-face interview was conducted using a structured questionnaire by trained data collectors. Participants were selected through a systematic random sampling technique. Physical inactivity was assessed by the international physical activity questionnaire (IPAQ). Collected data were entered in Epi info version 7 and transferred to SPSS version 20 for analysis. A summary of descriptive statistics and multiple binary logistic regression analyses were computed to identify associated factors of physical inactivity among adult diabetic patients. P < 0.05 with 95% CI was considered statistically significant. The overall prevalence of physical inactivity among diabetic patients was 30.5% ( 95% CI: 22.8-33.5%). Gender (AOR = 1.5, 95% CI: 1.1, 3.62), Old age (AOR = 18.17, 95% CI: 22.7, 61.9) Residence (AOR = 4.24, 95% CI: 1,12,16.028), Low self-efficacy (AOR = 20.59, 95% CI: 10.598, 41.608), Poor attitude (AOR = 2.75, 95%CI: 1.44,5.28), and Lack of social support (AOR = 4.22, 95% CI: 1.28,4.07) were found significantly predictor factors of physical inactivity. The prevalence of physical inactivity in this study was high. Being female, old age, dwelling in an urban, having low efficacy, poor attitude, and lack of social support was greater risk factors for being physically inactive. Diabetic education should focus on engagement in physical activity by overcoming barriers to performing physical activity. Government and health professionals should emphasize that evidence-based physical activity important to change their attitudes and require reaching a consensus on social support by their families.

Low physical activity among middle-aged type-2 diabetic outpatients of two peripheral hospitals in Bangladesh

Physical activity (PA) is an important lifestyle recommendation for managing type-2 diabetes mellitus (T2DM). However, low PA among them is a global public health concern, including Bangladesh. We aimed to investigate the prevalence of low PA levels and its associated sociodemographic factors particularly among middle-aged T2DM subjects, which is quite limited globally and unknown in Bangladesh. In this cross-sectional study, we conveniently recruited 356 T2DM subjects (aged 40-60 years) from outpatient departments of the corresponding diabetic hospitals from Pirojpur and Dinajpur, the southern and northern districts, respectively. The primary outcome was low PA (via metabolic equivalents <600), using the Global Physical Activity Questionnaire. Univariable and multivariable binary logistic regression analyses were used to identify the factors associated with low PA. Among the participants (mean age 51.0±6.9 years), men and women were with almost equal proportions (48.9% and 51.1%, respectively). The prevalence (95% Confidence Intervals [CI]) of low PA was 34.8% (29.9-39.7). The median sitting or reclining time was 6 hours on a typical day. The odds (OR [95% CI]; P) of low PA was found to be significantly higher in respondents with primary or no education compared to the above-primary level, in unadjusted (1.6 [1.1-2.6]; 0.029) and adjusted (2.0 [1.1-3.7]; 0.028) associations both. In conclusion, over one-third of the middle-aged study subjects had a low PA level, which was associated with education. There is a high demand for designing and implementing PA enhancing interventions among them.

Effectiveness of a Community-Based Structured Physical Activity Program for Adults With Type 2 Diabetes: A Randomized Clinical Trial

IMPORTANCE

The efficacy of physical activity interventions among individuals with type 2 diabetes has been established; however, practical approaches to translate and extend these findings into community settings have not been well explored.

OBJECTIVE

To test the effectiveness of providing varying frequencies of weekly structured exercise sessions to improve diabetes control.

DESIGN, SETTING, AND PARTICIPANTS

The IMPACT (Initiate and Maintain Physical Activity in Communities Trial) study was a controlled randomized clinical trial (randomization occurred from October 2016 to April 2019) that included a 6-month, structured exercise intervention either once or thrice weekly vs usual care (UC; advice only). The exercise intervention was conducted at community-based fitness centers. Follow-up visits were conducted in a university research clinic. Participants included adults with type 2 diabetes (hemoglobin A1c [HbA1c] 6.5%-13.0%, not taking insulin, and no precluding health issues). Data analysis was performed from January to April 2022.

INTERVENTIONS

A once-weekly structured exercise group, a thrice-weekly structured exercise group, or UC.

MAIN OUTCOMES AND MEASURES

The primary outcome was HbA1c at 6 months.

RESULTS

A total of 357 participants (143 women [40.1%]) with a mean (SD) age of 57.4 (11.1) years were randomized (119 each to the UC, once-weekly exercise, and thrice-weekly exercise groups). There was no significant difference in HbA1c change by study group in the intention-to-treat analysis at 6 months. Specifically, HbA1c changed by -0.23% (95% CI, -0.48% to 0.01%) in the thrice-weekly exercise group and by -0.16% (95% CI, -0.41% to 0.09%) in the once-weekly exercise group. A total of 62 participants (52.1%) in the once-weekly exercise group and 56 participants (47.1%) in the thrice-weekly exercise group were at least 50% adherent to the assigned structured exercise regimen and were included in the per-protocol analysis. Per-protocol analysis showed that HbA1c changed by -0.35% (95% CI, -0.60% to -0.10%; P = .005) at 3 months and by -0.38% (95% CI, -0.65% to -0.12%; P = .005) at 6 months in the thrice-weekly exercise group compared with UC. There was no significant decrease in HbA1c in the once-weekly exercise group. The exercise intervention was effective in improving self-reported minutes of metabolic equivalent tasks per week for participants in the thrice-weekly exercise group (both overall and per protocol).

CONCLUSIONS AND RELEVANCE

Although the intervention was not effective in the intention-to-treat analysis, participants in the thrice-weekly exercise group who attended at least 50% of the sessions during the 6-month exercise intervention program improved HbA1c levels at 6 months. Future efforts should focus on improving adherence to thrice-weekly structured exercise programs to meet exercise guidelines.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02061579.

Effects of Combined Inorganic Nitrate and Nitrite Supplementation on Cardiorespiratory Fitness and Skeletal Muscle Oxidative Capacity in Type 2 Diabetes: A Pilot Randomized Controlled Trial

Nitric oxide (NO) stimulates mitochondrial biogenesis in skeletal muscle. However, NO metabolism is disrupted in individuals with type 2 diabetes mellitus (T2DM) potentially contributing to their decreased cardiorespiratory fitness (i.e., VO2max) and skeletal muscle oxidative capacity. We used a randomized, double-blind, placebo-controlled, 8-week trial with beetroot juice containing nitrate (NO3−) and nitrite (NO2−) (250 mg and 20 mg/day) to test potential benefits on VO2max and skeletal muscle oxidative capacity in T2DM. T2DM (N = 36, Age = 59 ± 9 years; BMI = 31.9 ± 5.0 kg/m2) and age- and BMI-matched non-diabetic controls (N = 15, Age = 60 ± 9 years; BMI = 29.5 ± 4.6 kg/m2) were studied. Mitochondrial respiratory capacity was assessed in muscle biopsies from a subgroup of T2DM and controls (N = 19 and N = 10, respectively). At baseline, T2DM had higher plasma NO3− (100%; p < 0.001) and lower plasma NO2− levels (−46.8%; p < 0.0001) than controls. VO2max was lower in T2DM (−26.4%; p < 0.001), as was maximal carbohydrate- and fatty acid-supported oxygen consumption in permeabilized muscle fibers (−26.1% and −25.5%, respectively; p < 0.05). NO3−/NO2− supplementation increased VO2max (5.3%; p < 0.01). Further, circulating NO2−, but not NO3−, positively correlated with VO2max after supplementation (R2= 0.40; p < 0.05). Within the NO3−/NO2− group, 42% of subjects presented improvements in both carbohydrate- and fatty acid-supported oxygen consumption in skeletal muscle (vs. 0% in placebo; p < 0.05). VO2max improvements in these individuals tended to be larger than in the rest of the NO3−/NO2− group (1.21 ± 0.51 mL/(kg*min) vs. 0.31 ± 0.10 mL/(kg*min); p = 0.09). NO3−/NO2− supplementation increases VO2max in T2DM individuals and improvements in skeletal muscle oxidative capacity appear to occur in those with more pronounced increases in VO2max.

Applying the Reasoned Action Approach and Planning to Understand Diabetes Self-Management Behaviors

Individuals managing diabetes are required to adhere to self-management behaviors to ensure the optimal regulation of their blood glucose levels. This study examined the psychological determinants underlying three important diabetes self-management behaviors (e.g., physical activity, diet, and blood glucose monitoring) using the reasoned action approach (RAA) and planning. A cross-sectional design was used, with participants (N = 273) completing measures of RAA constructs (e.g., experiential and instrumental attitude, descriptive and injunctive norm, and capacity and autonomy) and planning (e.g., action and control planning) at time 1 and participation in the behaviors one week later at time 2. Regressions showed that RAA constructs accounted for good variance in intention and behavior in all behaviors. Intention towards diet and blood glucose monitoring was significantly predicted by instrumental attitude, injunctive norm, and capacity. Intention towards physical activity was significantly predicted by instrumental attitude, experiential attitude, injunctive norm, capacity, and autonomy. All behaviors were significantly predicted by intention, action planning, and coping planning. Additionally, capacity significantly predicted physical activity and autonomy significantly predicted diet and blood glucose monitoring. Successfully intervening in the influential psychological constructs identified in the study could ensure optimal blood glucose regulation in those managing diabetes.

Start with reducing sedentary behavior: A stepwise approach to physical activity counseling in clinical practice

Recently, sedentary behavior recommendations have been included in the public health guidelines of multiple countries, pointing to new opportunities for prevention of chronic disease as well as a potential strategy for initiating long-term behavior change.

OBJECTIVE

To propose an evidence-informed approach to physical activity counseling that starts with a focus on reducing sedentary time.

METHODS

We put forward a case for addressing changes in sedentary behavior in clinical practice using a narrative review. We also propose a new approach for the assessment and counselling of patients with respect to movement behaviors.

RESULTS

There is evidence to support a stepwise approach to physical activity counseling that starts with targeting sedentary behavior, particularly in those who are highly sedentary, or those who have chronic disease, or physical impairments.

CONCLUSIONS

Our approach encourages clinicians to consider sedentary behavior counseling as a critical first step to physical activity counseling. For many patients, this initial step of reducing sedentary behavior could build a pathway to an active lifestyle.

PRACTICAL IMPLICATIONS

A shift from long periods of sedentary time to daily routines incorporating more light intensity physical activity could result in meaningful health improvements. Importantly, this approach may be more feasible for highly inactive patients.

The Role of Physical Activity in Long-term Weight Loss: 36-month Results From a Randomized Controlled Trial

BACKGROUND

Physical activity (PA) may promote long-term weight loss, but facilitating high levels of PA in behavioral weight loss programs is challenging.

PURPOSE

This study reports the 36-month follow-up of a behavioral weight loss trial that tested the efficacy of increasing the emphasis on PA during treatment and using traditional or acceptance-based therapy (ABT) for this purpose. We also examined the extent to which long-term weight loss differed by PA pattern and tested if individual differences in eating behavior moderated this relationship.

METHODS

Participants (N = 320) were randomized to (1) standard behavioral weight loss treatment (BT), (2) BT with a focus on PA, or (3) ABT with a focus on PA. Weight loss and PA were measured at 24- and 36-month follow-up.

RESULTS

There were no differences between conditions in weight loss or PA at 24 or 36 months. Participants consistently engaging in high PA experienced the greatest weight losses. The positive impact of PA on weight loss was more pronounced among those with low emotional eating and those who believed that exercise did not affect their appetite.

CONCLUSIONS

Findings emphasize the difficulty of improving long-term PA among adults with overweight/obesity beyond what standard behavioral weight loss treatment achieves. This study highlights the need to develop new PA treatment strategies, and suggests that ABT for weight loss may be more effective when applied to eating behavior versus PA. Results also demonstrate the importance of addressing problematic eating behavior and cognitions to fully realize the benefits of PA for weight loss.

CLINICAL TRIAL INFORMATION

ClinicalTrials.gov identifier: NCT02363010.

Dietary intake and physical activity in Japanese patients with type 2 diabetes: the Japan Diabetes Complication and its Prevention prospective study (JDCP study 8)

Medical nutrition therapy and exercise therapy are the cornerstones of treatment for patients with type 2 diabetes; however, there has not been a nationwide study on the actual dietary intake and physical activity status of patients since the 2000s. We aimed to clarify this in Japanese patients with type 2 diabetes using data from the Japan Diabetes Complication and its Prevention prospective (JDCP), a nationwide study launched in 2007. A total of 1992 patients with type 2 diabetes, aged 40-75 years, completed either the Brief-type, self-administered Diet History Questionnaire (1643 patients) or International Physical Activity Questionnaire (1834 patients), and their data were analyzed in this study. Mean daily energy intake for all participants was 1686.8 kcal/day, and the mean proportions of carbohydrate, protein, and fat comprising total energy intake were 60.2, 16.2, and 23.6%, respectively. The patients in this study had similar energy and nutrient intake status to patients in the 1996 Japan Diabetes Complications Study; however, Japanese patients still had higher carbohydrate and lower fat consumption than patients with diabetes in Western countries. The physical activity questionnaire reported that 31.0% of patients did not have exercise habits; this was particularly noticeable in female patients and patients under the age of 65. BMI increased from 22.7 to 24.1 kg/m² in men and 23.2 to 24.8 kg/m² in women from 1996 to 2007, respectively. Further research is required to investigate how dietary intake and physical activity associates with the risk of developing complications in type 2 diabetes patients.

Personal Activity Intelligence e-Health Program in People with Type 2 Diabetes: A Pilot Randomized Controlled Trial

INTRODUCTION

Innovative strategies are needed to enable people with type 2 diabetes (T2D) to self-manage physical activity (PA). Personal Activity Intelligence (PAI) is a new metric that uses the heart rate response to PA to inform the user as to whether they are doing enough PA to reduce the risk of premature mortality. The PAI score reflects PA over the previous 7 d with the goal to maintain a score ≥100. The aim of this study was to investigate the feasibility, acceptability, and efficacy of the PAI e-Health Program in people with T2D.

METHODS

Thirty participants with T2D who were not meeting PA guidelines were randomly assigned to 12 wk of either 1) PAI e-Health Program or 2) PA attention control. The PAI e-Health Program consisted of receiving a wrist-worn heart rate monitor and an app with the PAI metric, and attending 4 × 2 h·wk-1 sessions of exercise and counseling. Feasibility and acceptability of the program were evaluated by achievement of a PAI score ≥100 and participant feedback. Efficacy was determined from changes in glycemic control, cardiorespiratory fitness, exercise capacity (time-on-test), body composition, sleep time, and health-related quality of life.

RESULTS

Program participants in the PAI e-Health Program had a mean ± SD PAI score of 119.7 ± 60.6 and achieved ≥100 PAI on 56.4% of the days. The majority of participants (80%) intended to continue to use PAI monitoring. Compared with control, the PAI group significantly improved their exercise capacity (mean difference, 95% confidence interval) (63 s, 17.9-108.0 s), sleep time (67.2 min, 7.2-127.1 min), total percent body fat (-1.3%, -2.6% to -0.1%), and gynoid fat percent (-1.5%, -2.6 to -0.5).

CONCLUSIONS

The PAI e-Health Program is feasible, acceptable, and efficacious in people with T2D.

Relationships of Changes in Physical Activity and Sedentary Behavior With Changes in Physical Fitness and Cardiometabolic Risk Profile in Individuals With Type 2 Diabetes: The Italian Diabetes and Exercise Study 2 (IDES_2)

OBJECTIVE

In the Italian Diabetes and Exercise Study_2 (IDES_2), behavioral counseling promoted a sustained increase in physical activity (PA) volume (+3.3 MET h ⋅ week-1), moderate- to vigorous-intensity PA (MVPA) (+6.4 min ⋅ day-1), and light-intensity PA (LPA) (+0.8 h ⋅ day-1) and decrease in sedentary time (SED-time) (-0.8 h ⋅ day-1). Here, we investigated the relationships of changes in PA/SED-time with changes in physical fitness and cardiometabolic risk profile in individuals with type 2 diabetes.

RESEARCH DESIGN AND METHODS

In this 3-year randomized clinical trial, 300 physically inactive and sedentary patients were randomized 1:1 to receive 1-month theoretical and practical counseling once a year or standard care. Changes in physical fitness and cardiovascular risk factors/scores according to quartiles of accelerometer-measured changes in PA/SED-time were assessed, together with univariate and multivariable associations between these parameters, in the whole cohort and by study arm.

RESULTS

Physical fitness increased and HbA1c and coronary heart disease 10-year risk scores decreased with quartiles of MVPA and SED-time change. In quartile IV of MVPA increase and SED-time decrease, cardiorespiratory fitness increased by 5.23 and 4.49 mL ⋅ min-1 ⋅ kg-1 and HbA1c decreased by 0.73 and 0.85%, respectively. Univariate correlations confirmed these relationships, and mean changes in both MPVA and SED-time predicted changes in physical fitness and cardiovascular risk factors/scores independently of one another and of other confounders. Similar findings were observed with LPA and PA volume and in each group separately.

CONCLUSIONS

Even modest increments in MVPA may have a clinically meaningful impact, and reallocating SED-time to LPA may also contribute to improved outcomes, possibly by increasing total energy expenditure.

Does engagement in frequent physical activity improve diabetes mellitus among older adults in India? A propensity score matching approach

BACKGROUND AND AIMS

Diabetes is a major chronic condition and was identified as one of the four priority non-communicable diseases that the United Nations targeted because of its increasing disease burden. The present study aims to examine the impact of physical activity on improving diabetes mellitus among older adults in India.

METHODS

This study utilizes data from India's first nationally representative longitudinal ageing survey (2017-18). Descriptive along with bivariate analysis was used to present the preliminary results. Additionally, Propensity score matching (PSM) analysis was used.

RESULTS

About 14% of older adults suffered from diabetes. Eighteen percent of older adults did frequent physical activity. The estimated average treatment effect on the treated (ATT) values in treated and control groups were 0.123 and 0.147, respectively, indicating that the prevalence of diabetes among older adults was reduced by 2.5% points because of frequent physical activity. The average treatment effect on the untreated (ATU) results indicates that among older adults who did not do frequent physical activity, if they did frequent physical activity, the prevalence of diabetes is likely to decrease by 2.2% points.

CONCLUSION

Our findings show that frequent physical activity is associated with a lower risk of diabetes in older adults. The results underscore the need to develop strategies of promoting an active lifestyle by maintaining physical activity to combat the diabetes epidemic in the older population.

Sitting less elicits metabolic responses similar to exercise and enhances insulin sensitivity in postmenopausal women

AIMS/HYPOTHESIS

In our current society sedentary behaviour predominates in most people and is associated with the risk of developing type 2 diabetes. It has been suggested that replacing sitting time by standing and walking could be beneficial for individuals with type 2 diabetes but the underlying mechanisms are unknown and direct comparisons with exercise are lacking. Our objective was to directly compare metabolic responses of either sitting less or exercising, relative to being sedentary.

METHODS

We performed a randomised, crossover intervention study in 12 overweight women who performed three well-controlled 4 day activity regimens: (1) sitting regimen (sitting 14 h/day); (2) exercise regimen (sitting 13 h/day, exercise 1 h/day); and (3) sitting less regimen (sitting 9 h/day, standing 4 h/day and walking 3 h/day). The primary outcome was insulin sensitivity measured by a two-step hyperinsulinaemic-euglycaemic clamp. We additionally performed metabolomics on muscle biopsies taken before the clamp to identify changes at the molecular level.

RESULTS

Replacing sitting time by standing and walking over 4 days resulted in improved peripheral insulin sensitivity, comparable with the improvement achieved by moderate-to-vigorous exercise. Specifically, we report a significant improvement in peripheral insulin sensitivity in the sitting less (~13%) and the exercise regimen (~20%), compared with the sitting regimen. Furthermore, sitting less shifted the underlying muscle metabolome towards that seen with moderate-to-vigorous exercise, compared with the sitting regimen.

CONCLUSIONS/INTERPRETATIONS

Replacing sitting time by standing and walking is an attractive alternative to moderate-to-vigorous exercise for improving metabolic health.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03912922.

Mobile Health Biometrics to Enhance Exercise and Physical Activity Adherence in Type 2 Diabetes (MOTIVATE-T2D): protocol for a feasibility randomised controlled trial

INTRODUCTION

Exercise and physical activity (PA) are fundamental to the treatment of type 2 diabetes. Current exercise and PA strategies for newly diagnosed individuals with type 2 diabetes are either clinically effective but unsuitable in routine practice (supervised exercise) or suitable in routine practice but clinically ineffective (PA advice). Mobile health (mHealth) technologies, offering biometric data to patients and healthcare professionals, may bridge the gap between supervised exercise and PA advice, enabling patients to engage in regular long-term physically active lifestyles. This feasibility randomised controlled trial (RCT) will evaluate the use of mHealth technology when incorporated into a structured home-based exercise and PA intervention, in those recently diagnosed with type 2 diabetes.

METHODS AND ANALYSIS

This feasibility multicentre, parallel group RCT will recruit 120 individuals with type 2 diabetes (diagnosis within 5-24 months, aged 40-75 years) in the UK (n=60) and Canada (n=60). Participants will undertake a 6-month structured exercise and PA intervention and be supported by an exercise specialist (active control). The intervention group will receive additional support from a smartwatch and phone app, providing real-time feedback and enabling improved communication between the exercise specialist and participant. Primary outcomes are recruitment rate, adherence to exercise and loss to follow-up. Secondary outcomes include a qualitative process evaluation and piloting of potential clinical outcome measures for a future RCT.

ETHICS AND DISSEMINATION

The trial was approved in the UK by the South East Scotland Research Ethics Committee 01 (20/SS/0101) and in Canada by the Clinical Research Ethics Board of the University of British Columbia (H20-01936), and is being conducted in accordance with the Declaration of Helsinki and Good Clinical Practice. Results will be published in peer-reviewed journals and presented at national and international scientific meetings.

TRIAL REGISTRATION NUMBERS

ISRCTN14335124; ClinicalTrials.gov: NCT04653532.

Gender-based comparison of factors affecting regular exercise of patients with Non-Insulin Dependent Diabetes Mellitus (NIDDM) based on the 7th Korea National Health and Nutrition Examination Survey (KNHANES)

OBJECTIVE

This study aimed to determine the gender factors that influence regular exercise in patients with non-insulin-dependent diabetes mellitus (NIDDM) in Korea.

METHODS

A total of 1,432 patients with NIDDM were recruited using raw data from the Korea National Health and Nutrition Survey conducted between 2016 and 2018. SAS 9.4 was adopted for data analyses, and the distributional difference was measured with multinomial logistic regression and Rao-Scott x2 statistics to identify the factors that influence the regular physical activities of patients. that the analysis only provides associations.

RESULTS

Based on general characteristics, health behaviors, and conditions, patients with NIDDM in Korea were less physically active. In addition, patients with higher educational attainment, higher income, and higher subjective health conditions had a higher odds ratio for regular exercise. Meanwhile, the ratio was lower for smokers and those stressed up.

CONCLUSION

A professional guide for the initial phase of training and consistent management is required to increase the involvement of patients with NIDDM in regular exercise. Therefore, it is important to maintain their motivation to continue exercising. Rather than providing a universal guideline, it is more important to provide customized programs and management plans which reflect factors that influence their engagement in physical activities, such as individual physical strength, stress level, alcohol consumption, and arthritis.

Effect of a Behavioural Intervention for Adoption and Maintenance of a Physically Active Lifestyle on Psychological Well-Being and Quality of Life in Patients with Type 2 Diabetes: The IDES_2 Randomized Clinical Trial

Background

Psychological well-being and quality of life (QoL) are important outcomes of lifestyle interventions, as a positive impact may favour long-term maintenance of behaviour change.

Objective

This study investigated the effect of a behavioural intervention for adopting and maintaining an active lifestyle on psychological well-being and health-related QoL in individuals with type 2 diabetes.

Methods

Three hundred physically inactive and sedentary patients were randomized 1:1 to receive 1 month’s theoretical and practical counselling once a year (intervention group, INT) or standard care (control group, CON) for 3 years. Psychological well-being and QoL, assessed using the World Health Organization (WHO)-5 and the 36-Item Short Form (SF-36) questionnaire, respectively, were pre-specified secondary endpoints. The primary endpoint was sustained behaviour change, as assessed by accelerometer-based measurement of physical activity (PA) and sedentary time.

Results

WHO-5 and SF-36 physical and mental component summary (PCS and MCS) scores increased progressively in the INT group and decreased in the CON group, resulting in significant between-group differences (WHO-5: mean difference 7.35 (95% confidence interval (CI) 3.15–11.55), P = 0.0007; PCS 4.20 (95% CI 2.25–6.15), P < 0.0001; MCS 3.04 (95% CI 1.09–4.99), P = 0.0025). Percentage of participants with likely depression decreased in the INT group and increased in the CON group. PA volume changes were independently associated with WHO-5 changes, which were significantly higher in participants who accumulated > 150 min·wk⁻¹ of moderate-to-vigorous intensity PA versus those who did not (13.06 (95% CI 7.51–18.61), P < 0.0001), whereas no relationship was detected for QoL.

Conclusion

A counselling intervention that was effective in promoting a sustained change in PA and sedentary behaviour significantly improved psychological well-being and QoL.

Trial Registration

ClinicalTrials.gov; NCT01600937; 10 October 2012.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40279-021-01556-0.

Association of Cycling With All-Cause and Cardiovascular Disease Mortality Among Persons With Diabetes: The European Prospective Investigation Into Cancer and Nutrition (EPIC) Study

Importance

Premature death from all causes and cardiovascular disease (CVD) causes is higher among persons with diabetes.

Objective

To investigate the association between time spent cycling and all-cause and CVD mortality among persons with diabetes, as well as to evaluate the association between change in time spent cycling and risk of all-cause and CVD mortality.

Design, Setting, and Participants

This prospective cohort study included 7459 adults with diabetes from the European Prospective Investigation into Cancer and Nutrition study. Questionnaires regarding medical history, sociodemographic, and lifestyle information were administered in 10 Western European countries from 1992 through 2000 (baseline examination) and at a second examination 5 years after baseline. A total of 5423 participants with diabetes completed both examinations. The final updated primary analysis was conducted on November 13, 2020.

Exposures

The primary exposure was self-reported time spent cycling per week at the baseline examination. The secondary exposure was change in cycling status from baseline to the second examination.

Main Outcomes and Measures

The primary and secondary outcomes were all-cause and CVD mortality, respectively, adjusted for other physical activity modalities, diabetes duration, and sociodemographic and lifestyle factors.

Results

Of the 7459 adults with diabetes included in the analysis, the mean (SD) age was 55.9 (7.7) years, and 3924 (52.6%) were female. During 110 944 person-years of follow-up, 1673 deaths from all causes were registered. Compared with the reference group of people who reported no cycling at baseline (0 min/wk), the multivariable-adjusted hazard ratios for all-cause mortality were 0.78 (95% CI, 0.61-0.99), 0.76 (95% CI, 0.65-0.88), 0.68 (95% CI, 0.57-0.82), and 0.76 (95% CI, 0.63-0.91) for cycling 1 to 59, 60 to 149, 150 to 299, and 300 or more min/wk, respectively. In an analysis of change in time spent cycling with 57 802 person-years of follow-up, a total of 975 deaths from all causes were recorded. Compared with people who reported no cycling at both examinations, the multivariable-adjusted hazard ratios for all-cause mortality were 0.90 (95% CI, 0.71-1.14) in those who cycled and then stopped, 0.65 (95% CI, 0.46-0.92) in initial noncyclists who started cycling, and 0.65 (95% CI, 0.53-0.80) for people who reported cycling at both examinations. Similar results were observed for CVD mortality.

Conclusion and Relevance

In this cohort study, cycling was associated with lower all-cause and CVD mortality risk among people with diabetes independent of practicing other types of physical activity. Participants who took up cycling between the baseline and second examination had a considerably lower risk of both all-cause and CVD mortality compared with consistent noncyclists.

Gamifying accelerometer use increases physical activity levels of individuals pre-disposed to type II diabetes

Physical activity is important for preventing obesity and diabetes, but most obese and pre-diabetic patients are not physically active. We developed a Fitbit-based game called MapTrek that promotes walking. We recruited obese and pre-diabetic patients. Half were randomly assigned to the control group and given a Fitbit alone. The others were given a Fitbit plus MapTrek. The MapTrek group participated in 6 months of weekly virtual races. Each week, participants were placed in a race with 9 others who achieved a similar number of steps in the previous week's race. Participants moved along the virtual route by the steps recorded on their Fitbit and received daily walking challenges via text message. Text messages also had links to the race map and leaderboard. We used a Bayesian mixed effects model to analyze the number of steps taken during the intervention. A total of 192 (89%) participants in the control group and 196 (91%) in the MapTrek group were included in the analyses. MapTrek significantly increased step counts when it began: MapTrek participants walked almost 1,700 steps more than the control group on the first day of the intervention. We estimate that there is a 97% probability that the effect of MapTrek is at least 1,000 additional steps per day throughout the course of the 6-month intervention and that MapTrek participants would have walked an additional 81 miles, on average, before the effect ended. Our MapTrek intervention led to significant extra walking by the MapTrek participants.

The Management of Diabetes in Everyday Life (MODEL) program: development of a tailored text message intervention to improve diabetes self-care activities among underserved African-American adults

Tailoring health-related materials is an effective mechanism to encourage behavior change; however, little research has described processes and critical characteristics for effective tailoring in underserved populations. The purpose of this study is to describe a process using input from content experts and lay patient advisors to tailor text messages focused on improving self-care behaviors of African-American adults with diabetes and identify characteristics of messages perceived to be most effective. An initial library of tailorable messages was created using theory-based approaches, expert opinion, and publicly available materials. A study-specific advisory council representing the program's intended population provided sequential individual and focus group review of a sample of draft messages focused on medication use, healthy eating, and physical activity. Messages were reviewed for content, tone, and applicability to African-American adults with diabetes from underserved communities. Based on this feedback, messages were revised and a final library of tailorable messages was constructed for use in a text messaging intervention. The initial library had over 5,000 tailorable messages. Participants preferred messages that included: (1) encouraging statements without condescension; (2) short sentences in lay language; (3) specific, actionable instructions; and (4) content relatable to daily activities of living. When possible, messages with similar themes should be repeated over short periods of time to improve the odds of material being absorbed and action being taken. Input from patient participants and advisors is essential for designing deeply tailored messages that honor the preferences, values, and norms of the population under study and promote health behavior change.

TRIAL REGISTRATION

NCT02957513.

Is Self-Determined Motivation a Useful Agent to Overcome Perceived Exercise Barriers in Patients With Type 2 Diabetes Mellitus?

Background: Devising a program to increase physical activity (PA)/exercise behavior in patients with type 2 diabetes mellitus (T2DM) can meet with limited effectiveness in real-world settings because of the variety of barriers to PA/exercise that individuals need to overcome. An alternative approach is to explore whether targeting motivation as a facilitator may be effective to increase PA/exercise. This study aimed to understand attitudes toward perceived barriers to PA/exercise by examining individual levels of motivation, grounded on self-determination theory, in patients with T2DM. Methods: This study used an integrated approach combining qualitative and quantitative analysis. Sixteen patients with T2DM were grouped (n = 8 for each group) into either a higher self-motivation (HSM) or lower self-motivation (LSM) group via the Relative Autonomy Index. Thematic and deductive analysis were used to identify attitudes based on ten preconceived barrier themes: apathy, dislike, no priority, lack of support, health problems, lack of knowledge, unfavorable environment, tiredness, lack of time, and financial constraints. Quantitative analysis was to assess statistical differences in the volume of PA/exercise across the two groups, and a mixed-methods analysis was employed to highlight unique cases. Results: Patients in the HSM group expressed positive attitudes toward barriers to PA/exercise, while patients in the LSM group expressed a greater degree of hindrance. Although regular PA/exercise is necessary for T2DM management, patients with LSM considered PA/exercise a lesser priority displaying negative attitudes such as apathy and dislike. Conversely, patients with HSM placed greater emphasis on the benefits of PA/exercise regardless of apathy and dislike. Lack of time and health problems were commonly reported in both groups. The volume of PA/exercise corresponded to motivation levels, but there were some unique cases which arose from active commuting habits and severe health problems. Conclusion: These findings provide insights on how attitudes to perceived barriers to PA/exercise differ by levels of motivation. One insight was that examining motivation should be an essential consideration when designing practical strategies to overcome PA/exercise barriers in patients with T2DM. Lack of time and health problems exist regardless of motivation levels. Future research requires a tailored approach to managing barriers to PA/exercise in patients with T2DM.

The impact of mental and somatic stressors on physical activity and sedentary behaviour in adults with type 2 diabetes mellitus: a diary study

Background

Adopting an active lifestyle is key in the management of type 2 diabetes mellitus (T2DM). Nevertheless, the majority of individuals with T2DM fails to do so. Additionally, individuals with T2DM are likely to experience mental (e.g., stress) and somatic (e.g., pain) stressors. Research investigating the link between these stressors and activity levels within this group is largely lacking. Therefore, current research aimed to investigate how daily fluctuations in mental and somatic stressors predict daily levels of physical activity (PA) and sedentary behaviour among adults with T2DM.

Methods

Individuals with T2DM (N = 54) were instructed to complete a morning diary assessing mental and somatic stressors and to wear an accelerometer for 10 consecutive days. The associations between the mental and somatic stressors and participants’ levels of PA and sedentary behaviour were examined using (generalized) linear mixed effect models.

Results

Valid data were provided by 38 participants. We found no evidence that intra-individual increases in mental and somatic stressors detrimentally affected participants’ activity levels. Similarly, levels of sedentary behaviour nor levels of PA were predicted by inter-individual differences in the mental and somatic stressors.

Comparison Between Isometric and Concentric Motor Fatigability in Persons With Multiple Sclerosis and Healthy Controls - exploring central and peripheral contributions of motor fatigability

BACKGROUND

Motor fatigability (i.e. contraction-induced reduction in muscle strength) from a concentric task associate stronger to walking and perception of fatigue in persons with multiple sclerosis (pwMS), compared with an isometric task. However, the central and peripheral contributions of motor fatigability between these tasks have not been investigated.

OBJECTIVE

Compare the central and peripheral contributions of motor fatigability in the knee extensors in a sustained isometric fatigability protocol versus a concentric fatigability protocol and in pwMS versus healthy controls (HCs).

METHODS

Participants (n=31 pwMS; n=15 HCs) underwent neuromuscular testing before and immediately after two knee extensor fatigability tasks (sustained isometric and concentric) in an isokinetic dynamometer. Neuromuscular testing of fatigability consisted of maximal voluntary contraction, voluntary activation (central/neural contributor), and resting twitch (peripheral/muscular contributor) determined by the interpolated twitch technique.

RESULTS

Sustained isometric and concentric fatigability protocols resulted in motor fatigability for both pwMS and HCs, with no between-protocols differences for either group. Regression analysis showed that motor fatigability variance in pwMS was mainly attributed to central fatigability in the sustained isometric protocol and to both central and peripheral fatigability in the concentric protocol. In HCs, the variance in sustained isometric and concentric fatigability were attributed to both peripheral and central fatigability.

CONCLUSION

Central and peripheral contributions of motor fatigability differed between sustained isometric and concentric protocols as well as between pwMS and HCs. These between-protocol differences in pwMS provide a neuromuscular dimension to the reported difference in the strength of associations of concentric and isometric tasks to walking and perception of fatigue in pwMS.

The antidiabetic potential of endophytic fungi: Future prospects as therapeutic agents

Diabetes mellitus is one of the most common systemic diseases in the world, and it occurs when the body becomes resistant to insulin or does not make enough insulin. As described by the World Health Organization, diabetes mellitus of all types has exponentially grown in the past decades across the globe and it is estimated to be 629 million by 2045. Despite this alarming prevalence of diabetes mellitus, there is still the lack of harmless preventive medicines. Natural products and compounds obtained from plants, fungi, bacteria, and other living organisms have been used for many decades in folklore medicine to prepare a varied range of natural formulations to treat multiple diseases and illnesses. Endophytic fungi reside inside the plant while causing no harm to the host plant and are relatively less explored as the primary source for the bioactive metabolites such as anticancer, antioxidant, antimicrobial, antidiabetic, and industrial enzymes. This mini-review summarizes the potential of compounds and extracts from endophytic fungi against diabetes mellitus. Not much research has been dedicated in-depth understanding of the role of extracts of endophytic fungi and their effect on diabetes mellitus. Therefore, this article will focus on recent work and warrant further commentaries on the published articles.

Level of physical activity and barriers to exercise in adults with type 2 diabetes

Introduction

Physical activity (PA) is an important element in type 2 diabetes mellitus (T2DM) management. The aims of this study were to assess the percentage of adults with T2DM who perform PA, according to the intensity level and to describe barriers to exercise and the association between metabolic control and other clinical variables.

Methods

Multicenter, observational, cross-sectional study. Data were collected through the International PA Questionnaire (IPAQ) and the PA Barrier Questionnaire. Adults (18–65 years old) with T2DM from 17 Argentine diabetes centers were included, from May to July 2018.

Results

A total of 270 men (54.9 ± 9.8 years) and 225 women (55.3 ± 9.6 years) were included. Duration of diabetes: 8.2 ± 6.3 years. The BMI in men was 32 ± 10.6 kg/m², whereas that in women was 32.5 ± 7.2 kg/m². The last two HbA1c values were 7.6 ± 1.7% and 7.5 ± 1.6. Results also showed that 12.7% had clinical heart disease, 13.7% had nephropathy, 20.8% had neuropathy, 6.1% had diabetic foot and 14.1% had retinopathy. The level of PA was low in 52.3% of the patients studied and moderate in 30.5%. The most frequent barriers were: “lack of will” (59.6%) and “lack of energy” (37.2%). The low level of PA was associated with age (OR: 1.05 per year of age; p < 0.001), HbA1c (OR: 1.16 per 1%; p < 0.05), BMI (OR: 1.06 per kg/m²; p < 0.001) and sex (OR: 1.69 for women; p < 0.01).

Conclusions

PA in a cornerstone in management T2DM. Nevertheless, in this study, 52.3% of T2DM adults showed low level of PA. The main barriers reported were related to low personal motivation. These factors should be taken into account to implement programs to promote physical activity.

Walking for subjects with type 2 diabetes: a systematic review and joint AMD/SID/SISMES evidence-based practical guideline

Aims

Regular exercise is considered a cornerstone in the management of type 2 diabetes mellitus (T2DM). It improves glucose control and cardiovascular risk factors, contributes to weight loss, and also improves general well-being, likely playing a role in the prevention of chronic complications of diabetes. However, compliance to exercise recommendations is generally inadequate in subjects with T2DM. Walking is the most ancestral form of physical activity in humans, easily applicable in daily life. It may represent, in many patients, a first simple step towards lifestyle changes. Nevertheless, while most diabetic patients do not engage in any weekly walking, exercise guidelines do not generally detail how to improve its use. The aims of this document are to conduct a systematic review of available literature on walking as a therapeutic tool for people with T2DM, and to provide practical, evidence-based clinical recommendations regarding its utilization in these subjects.

Data synthesis

Analysis of available RCTs proved that regular walking training, especially when supervised, improves glucose control in subjects with T2DM, with favorable effects also on cardiorespiratory fitness, body weight, and blood pressure. Moreover, some recent studies have shown that even short bouts of walking, used for breaking prolonged sitting, can ameliorate glucose profiles in diabetic patients with sedentary behavior.

Conclusions

There is sufficient evidence to recognize that walking is a useful therapeutic tool for people with T2DM. This document discusses theoretical and practical issues for improving its use.

Lifestyle is associated with atrial fibrillation development in patients with type 2 diabetes mellitus

We evaluated the impacts of lifestyle behaviors, namely smoking, alcohol consumption, and physical activity, on the development of new-onset AF in patients with DM. Using the Korean Nationwide database, we identified subjects diagnosed with type 2 DM and without previous history of AF between 2009 and 2012. Self-reported lifestyle behaviors were analyzed. Among 2,551,036 included subjects, AF was newly diagnosed in 73,988 patients (median follow-up 7.1 years). Both ex-smokers (hazard ratio [HR] 1.05, 95% confidence interval [CI] 1.02–1.07) and current smokers (HR 1.06, 95% CI 1.03–1.08) demonstrated a higher risk of AF than never smokers. Patients with moderate (15–29 g/day) (HR 1.12, 95% CI 1.09–1.15) and heavy (≥ 30 g/day) (HR 1.24, 95% CI 1.21–1.28) alcohol consumption exhibited an increased risk of AF, while subjects with mild alcohol consumption (< 15 g/day) (HR 1.01, 95% CI 0.99–1.03) had an AF risk similar to that of non-drinkers. Patients who engaged in moderate-to-vigorous physical activity showed a lower risk of AF (HR 0.93, 95% CI 0.91–0.94) than those who did not. This study suggests that smoking, alcohol consumption, and physical activity are associated with new-onset AF in patients with DM, and lifestyle management might reduce the risk of AF in this population.

A Web-Based Computer-Tailored Program to Improve Treatment Adherence in Patients With Type 2 Diabetes: Randomized Controlled Trial

Background

Adherence to core type 2 diabetes mellitus (T2DM) treatment behaviors is suboptimal, and nonadherence is generally not limited to one treatment behavior. The internet holds promise for programs that aim to improve adherence. We developed a computer-tailored eHealth program for patients with T2DM to improve their treatment adherence, that is, adherence to both a healthy lifestyle and medical behaviors.

Objective

The objective of this study is to examine the effectiveness of the eHealth program in a randomized controlled trial.

Methods

Patients with T2DM were recruited by their health professionals and randomized into either the intervention group, that is, access to the eHealth program for 6 months, or a waiting-list control group. In total, 478 participants completed the baseline questionnaire, of which 234 gained access to the eHealth program. Of the 478 participants, 323 were male and 155 were female, the mean age was 60 years, and the participants had unfavorable BMI and HbA_1c levels on average. Outcome data were collected through web-based assessments on physical activity (PA) levels, caloric intake from unhealthy snacks, and adherence to oral hypoglycemic agents (OHAs) and insulin therapy. Changes to separate behaviors were standardized and summed into a composite change score representing changes in the overall treatment adherence. Further standardization of this composite change score yielded the primary outcome, which can be interpreted as Cohen d (effect size). Standardized change scores observed in separate behaviors acted as secondary outcomes. Mixed linear regression analyses were conducted to examine the effectiveness of the intervention on overall and separate treatment behavior adherence, accommodating relevant covariates and patient nesting.

Results

After the 6-month follow-up assessment, 47.4% (111/234) of participants in the intervention group and 72.5% (177/244) of participants in the control group were retained. The overall treatment adherence improved significantly in the intervention group compared with the control group, reflected by a small effect size (d=0.27; 95% CI 0.032 to 0.509; P=.03). When considering changes in separate treatment behaviors, a significant decrease was observed only in caloric intake from unhealthy snacks in comparison with the control group (d=0.36; 95% CI 0.136 to 0.584; P=.002). For adherence to PA (d=−0.14; 95% CI −0.388 to 0.109; P=.27), OHAs (d=0.27; 95% CI −0.027 to 0.457; P=.08), and insulin therapy (d=0.35; 95% CI −0.066 to 0.773; P=.10), no significant changes were observed. These results from the unadjusted analyses were comparable with the results of the adjusted analyses, the per-protocol analyses, and the sensitivity analyses.

Conclusions

Our multibehavior program significantly improved the overall treatment adherence compared with the control group. To further enhance the impact of the intervention in the personal, societal, and economic areas, a wide-scale implementation of our eHealth intervention is suggested.

Trial Registration

Netherlands Trial Register NL664; https://www.trialregister.nl/trial/6664