5. Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes-2022

Psychological Flexibility and Diabetes Self-Management: The Mediating Roles of Depressive Symptoms and Self-Efficacy

BACKGROUND

Psychological flexibility is the concept and focus of Acceptance and Commitment Therapy. It has been demonstrated to benefit self-efficacy and depressive symptoms. However, its role in diabetes self-management (DSM) and the potential mechanisms remain unknown.

PURPOSE

This study aimed to investigate the association between psychological flexibility and self-management and to explore the mediating effect of depressive symptoms and self-efficacy among people with diabetes in China.

METHODS

Using a cross-sectional study design, 249 people with type 2 diabetes in China were recruited from February 1, 2024, to April 30, 2024, and completed a structured online questionnaire.

RESULTS

Psychological flexibility and DSM showed a moderate correlation (r = 0.45, P < .001). Path analysis showed significant associations between the 3 subscales of psychological flexibility and depressive symptoms and self-efficacy. In addition, depressive symptoms partially mediated the relationship between the valued action subscale of psychological flexibility and DSM, while the mediation role of self-efficacy was not significant.

CONCLUSIONS

The findings highlight the potential mechanisms of how higher levels of psychological flexibility may affect depressive symptoms reduction and self-management promotion. Acceptance and Commitment Therapy that particularly aims to enhance valued action may be effective for alleviating depressive symptoms and enhancing self-management.

Evaluation of the Impact of Mobile Health App Vitadio in Patients With Type 2 Diabetes: Randomized Controlled Trial

BACKGROUND

Effective diabetes management requires a multimodal approach involving lifestyle changes, pharmacological treatment, and continuous patient education. Self-management demands can be overwhelming for patients, leading to lowered motivation, poor adherence, and compromised therapeutic outcomes. In this context, digital health apps are emerging as vital tools to provide personalized support and enhance diabetes management and clinical outcomes.

OBJECTIVE

This study evaluated the impact of the digital health application Vitadio on glycemic control in patients with type 2 diabetes mellitus (T2DM). Secondary objectives included evaluating its effects on cardiometabolic parameters (weight, BMI, waist circumference, blood pressure, and heart rate) and self-reported measures of diabetes distress and self-management.

METHODS

In this 6-month, 2-arm, multicenter, unblinded randomized controlled trial, patients aged 18 years or older diagnosed with T2DM were randomly assigned (1:1) to an intervention group (IG) receiving standard diabetes care reinforced by the digital health app Vitadio or to a control group (CG) provided solely with standard diabetes care. Vitadio provided a mobile-based self-management support tool featuring educational modules, motivational messages, peer support, personalized goal setting, and health monitoring. The personal consultant was available in the app to provide technical support for app-related issues. The primary outcome, assessed in the intention-to-treat population, was a change in glycated hemoglobin (HbA1c) levels at 6 months. Secondary outcomes included changes in cardiometabolic measures and self-reported outcomes. Data were collected in 2 study centers: diabetologist practice in Dessau-Roßlau and the University of Dresden.

RESULTS

Between November 2022 and June 2023, a total of 276 patients were screened for eligibility, with 149 randomized to in intervention group (IG; n=73) and a control group (CG; n=76). The majority of participants were male (91/149, 61%). The dropout rate at month 6 was 19% (121/149). While both groups achieved significant HbA1c reduction at 6 months (IG: mean -0.8, SD 0.9%, P<.001; CG: mean -0.3, SD 0.7%, P=.001), the primary confirmatory analysis revealed statistically significant advantage of the IG (adjusted mean difference: -0.53%, SD 0.15, 95% CI -0.24 to -0.82; P<.001; effect size [Cohen d]=0.67, 95% CI 0.33-1). Significant between-group differences in favor of the IG were also observed for weight loss (P=.002), BMI (P=.001) and systolic blood pressure (P<.03). In addition, Vitadio users experienced greater reduction in diabetes-related distress (P<.03) and obtained more pronounced improvements in self-care practices in the areas of general diet (P<.001), specific diet (P<.03), and exercise (P<.03).

CONCLUSIONS

This trial provides evidence for the superior efficacy of Vitadio in lowering the HbA1c levels in T2DM patients compared to standard care. In addition, Vitadio contributed to improvements in cardiometabolic health, reduced diabetes-related distress, and enhanced self-management, highlighting its potential as an accessible digital tool for comprehensive diabetes management.

TRIAL REGISTRATION

German Clinical Trials Registry DRKS00027405; https://drks.de/search/de/trial/DRKS00027405.

Clinical Impact of Personalized Physician's Education and Remote Feedback Via a Digital Platform on Glycemic Control: Pilot Randomized Controlled Trial

BACKGROUND

The digital education platform Doctorvice (iKooB Inc.) offers face-to-face physician-patient education during outpatient clinic visits, remote glucose monitoring, and the delivery of educational messages, and is expected to be effective for personalized diabetes care.

OBJECTIVE

This study aims to evaluate the effectiveness of the digital education platform for diabetes care by comparing cases that included both face-to-face education and remote monitoring with those that included only face-to-face education.

METHODS

This was a randomized clinical study conducted at the Diabetes Center of Seoul St. Mary's Hospital. Participants were aged ≥19 years and had glycated hemoglobin (HbA1c) levels between 7.5% and 9.5%. In the intervention group, physicians used the digital education platform to provide face-to-face education at enrollment and at the 3- and 6-month visits, along with remote monitoring during the first 3 months of the 6-month study period. The control group received conventional outpatient education. Both groups completed questionnaires-assessing satisfaction with diabetes treatment, diabetes-related stress, and adherence to diabetes medication-at the beginning and end of the study. The primary endpoint was the change in HbA1c levels.

RESULTS

A total of 66 participants were enrolled between August 1, 2022, and August 31, 2023. Of these, 26 in the intervention group and 30 in the control group were analyzed, excluding 10 participants who dropped out of the study. The mean baseline HbA1c levels were 8.3% (SD 0.6%) in the intervention group and 8.0% (SD 0.5%) in the control group. At the 3-month follow-up, mean HbA1c decreased by 0.5%-7.8% (SD 0.9%; P=.01) in the intervention group and by 0.2%-7.8% (SD 0.7%) in the control group. HbA1c levels substantially improved during the first 3 months with both face-to-face education and remote glucose monitoring. However, HbA1c tended to increase during the 3- to 6-month follow-up in the intervention group without the remote monitoring service. Satisfaction with diabetes treatment significantly improved at the end of the study compared with baseline in the intervention group (mean change +3.6 points; P=.006). Medication adherence improved in both groups, with no significant difference at 6 months (P=.59), although the intervention group showed a greater increase from baseline. Subgroup analysis indicated that the reduction in HbA1c was greater for patients with baseline HbA1c levels ≥8.0%, those aged ≥65 years, smokers, drinkers, and those with obesity in the intervention group.

CONCLUSIONS

The digital education platform for personalized diabetes management may be beneficial for glycemic control in type 2 diabetes mellitus. Its effectiveness appears to be enhanced when physicians provide personalized face-to-face education combined with remote feedback.

TRIAL REGISTRATION

Clinical Research Information Service (CRiS) of Republic of Korea KCT0007953; https://cris.nih.go.kr/cris/search/detailSearch.do?seq=23507&search_page=L.

Rural Culture and Diabetes Self-Management Beliefs, Behaviors, and Health Outcomes

BACKGROUND

Rural populations in the United States face a diabetes mortality penalty. Self-management is a core component of treatment for Type 2 diabetes, but there is low uptake of self-management education and support interventions in rural areas. Rural structural barriers to diabetes self-management have been described, yet the role of rural culture has not been extensively explored.

OBJECTIVE

The purpose was to examine the relationships among rural culture, diabetes beliefs, self-management behaviors, and health outcomes.

METHODS

A stratified random sample of 500 adults with Type 2 diabetes were recruited from a rural integrated healthcare system and invited to participate in this nonexperimental cross-sectional study. Participants completed a survey that included validated measures of rural identity, self-reliance, perceived diabetes threat, and diabetes self-management behaviors. The most recent A1c was collected from the medical record. Descriptive, bivariate, multivariate, and moderation analyses were conducted.

RESULTS

One hundred twenty-eight participants returned completed surveys. Having an A1c <8% was associated with better diabetes self-management behaviors, lower perceived threat, being female, and older age. Better diabetes self-management behaviors were associated with lower self-reliance, lower perceived threat, and older age. The combined moderation effect of both self-reliance and rural identity on the relationship between perceived threat and self-management behaviors was significant.

DISCUSSION

Findings highlight the complex relationship between diabetes beliefs and behavior in rural populations and demonstrate that components of the rural culture have both direct and moderating effects on diabetes beliefs and self-management behaviors. These findings have important ramifications for nurses practicing in rural settings.

Identifying impaired mental health in patients with type 2 diabetes: a cross-sectional study in general practice

BACKGROUND

Type two diabetes (T2D) is linked to impaired mental health. International guidelines emphasise the importance of including psychological aspects in diabetes care. Yet, no systematic approach has been implemented to assess mental health in patients with T2D in general practice.

AIM

To evaluate the mental health of patients with T2D in general practice, and to investigate the effectiveness of asking patients about their wellbeing by using a single-item question compared with the five-item World Health Organization-Five Wellbeing Index (WHO-5).

DESIGN & SETTING

A cross-sectional study was undertaken, which included 230 patients with T2D in Danish general practice, from 1 May 2023-31 January 2024.

METHOD

Eligible patients were recruited at the annual chronic care consultation. They answered a single-item question on wellbeing and four validated measures of general wellbeing (WHO-5), depression (Patient Health Questionnaire-9; PHQ-9), anxiety (Generalised Anxiety Disorder-7; GAD-7), and diabetes distress (Problem Areas in Diabetes-5; PAID-5).

RESULTS

Overall, 32% of patients expressed symptoms of impaired mental health. Notably, the WHO-5 identified 53% of these patients, whereas only 12% of patients were identified through the single-item question. Importantly, among the patients exhibiting symptoms of impaired mental health, those identified by the WHO-5 displayed statistically significantly lower mental health scores across all measures (except PAID-5) compared with those not identified by the WHO-5.

CONCLUSION

A significant proportion of patients with T2D in general practice are affected by mental health issues. Our findings indicate that a single-item question may not sufficiently detect these issues, highlighting the importance of incorporating tools, such as the WHO-5, to offer a more comprehensive approach in diabetes care.

Assessment and Intervention for Diabetes Distress in Primary Care Using Clinical and Technological Interventions: Protocol for a Single-Arm Pilot Trial

BACKGROUND

Diabetes distress (DD) is a common emotional response to living with diabetes. If not addressed, DD can have negative impacts on diabetes management, including the progression to mental health conditions such as depression and anxiety. Routine screening and treatment for DD is recommended, with primary care being an ideal setting given that the majority of people with diabetes receive their diabetes care from primary care providers. However, consistent screening of DD does not routinely occur in primary care settings. Research is needed to understand how to effectively and feasibly integrate DD screening and treatment into routine diabetes care.

OBJECTIVE

This study aims to (1) design and implement individualized technology-supported DD workflows, (2) evaluate the primary outcome of determining the acceptability and feasibility of integrating technology-based workflows to provide treatment for DD, and (3) evaluate the secondary outcomes of changes in DD, depression, and anxiety (baseline, 3 months, and 6 months) in patients receiving screening and personalized treatment.

METHODS

In total, 30 English and Spanish-speaking primary care patients with either type 1 or type 2 diabetes will receive screening for DD during clinical visits and subsequent support from an artificial intelligence (AI)-based health care chatbot with interactive tailored messaging. In addition, the use of electronic consultation with a specialist or referral to a behavioral health provider could occur depending on the severity and source of DD. The use of electronic consultations allows providers convenient and timely asynchronous access to a range of specialty care providers. Health outcomes will be measured through changes in validated screening measures for DD, depression, and anxiety. Digital outcomes will be measured through surveys assessing user experience with technology and system usability, and by system performance data. Qualitative data on acceptability and satisfaction with the clinical workflows and technological interventions will be collected through interviews with patients and clinical providers. Descriptive statistics will summarize quantitative outcome measures and responses to closed-ended survey items, and rapid thematic and content analysis will be conducted on open-ended survey and interview data.

RESULTS

Workflows for screening and treating DD have been approved and clinical staff have received training on the process. Electronic surveys for screening measure collection have been created. Data from visit screeners will be entered into the electronic medical record during the medical appointment. Recruitment will begin late June-July 2024.

CONCLUSIONS

This study is expected to demonstrate the feasibility and acceptability of integrating individualized workflows for DD into primary care. Improving clinical and digital interventions for addressing DD in primary care can provide alternative care options for busy clinical providers. This study is intended to deliver whole-person diabetes care to people with diabetes within a primary care setting.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/62916.

Examining How Adults With Diabetes Use Technologies to Support Diabetes Self-Management: Mixed Methods Study

BACKGROUND

Technologies such as mobile apps, continuous glucose monitors (CGMs), and activity trackers are available to support adults with diabetes, but it is not clear how they are used together for diabetes self-management.

OBJECTIVE

This study aims to understand how adults with diabetes with differing clinical profiles and digital health literacy levels integrate data from multiple behavior tracking technologies for diabetes self-management.

METHODS

Adults with type 1 or 2 diabetes who used ≥1 diabetes medications responded to a web-based survey about health app and activity tracker use in 6 categories: blood glucose level, diet, exercise and activity, weight, sleep, and stress. Digital health literacy was assessed using the Digital Health Care Literacy Scale, and general health literacy was assessed using the Brief Health Literacy Screen. We analyzed descriptive statistics among respondents and compared health technology use using independent 2-tailed t tests for continuous variables, chi-square for categorical variables, and Fisher exact tests for digital health literacy levels. Semistructured interviews examined how these technologies were and could be used to support daily diabetes self-management. We summarized interview themes using content analysis.

RESULTS

Of the 61 survey respondents, 21 (34%) were Black, 23 (38%) were female, and 29 (48%) were aged ≥45 years; moreover, 44 (72%) had type 2 diabetes, 36 (59%) used insulin, and 34 (56%) currently or previously used a CGM. Respondents had high levels of digital and general health literacy: 87% (46/53) used at least 1 health app, 59% (36/61) had used an activity tracker, and 62% (33/53) used apps to track ≥1 health behaviors. CGM users and nonusers used non-CGM health apps at similar rates (16/28, 57% vs 12/20, 60%; P=.84). Activity tracker use was also similar between CGM users and nonusers (20/33, 61% vs 14/22, 64%; P=.82). Respondents reported sharing self-monitor data with health care providers at similar rates across age groups (17/32, 53% for those aged 18-44 y vs 16/29, 55% for those aged 45-70 y; P=.87). Combined activity tracker and health app use was higher among those with higher Digital Health Care Literacy Scale scores, but this difference was not statistically significant (P=.09). Interviewees (18/61, 30%) described using blood glucose level tracking apps to personalize dietary choices but less frequently used data from apps or activity trackers to meet other self-management goals. Interviewees desired data that were passively collected, easily integrated across data sources, visually presented, and tailorable to self-management priorities.

CONCLUSIONS

Adults with diabetes commonly used apps and activity trackers, often alongside CGMs, to track multiple behaviors that impact diabetes self-management but found it challenging to link tracked behaviors to glycemic and diabetes self-management goals. The findings indicate that there are untapped opportunities to integrate data from apps and activity trackers to support patient-centered diabetes self-management.

Core Components of Cardiac Rehabilitation Programs: 2024 Update: A Scientific Statement From the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation: Endorsed by the American College of Cardiology

The science of cardiac rehabilitation and the secondary prevention of cardiovascular disease has progressed substantially since the most recent American Heart Association and American Association of Cardiovascular and Pulmonary Rehabilitation update on the core components of cardiac rehabilitation and secondary prevention programs was published in 2007. In addition, the advent of new care models, including virtual and remote delivery of cardiac rehabilitation services, has expanded the ways that cardiac rehabilitation programs can reach patients. In this scientific statement, we update the scientific basis of the core components of patient assessment, nutritional counseling, weight management and body composition, cardiovascular disease and risk factor management, psychosocial management, aerobic exercise training, strength training, and physical activity counseling. In addition, in recognition that high-quality cardiac rehabilitation programs regularly monitor their processes and outcomes and engage in an ongoing process of quality improvement, we introduce a new core component of program quality. High-quality program performance will be essential to improve widely documented low enrollment and adherence rates and reduce health disparities in cardiac rehabilitation access.

Four New Patient-Reported Outcome Measures Examining Health-Seeking Behavior in Persons With Type 2 Diabetes Mellitus (REDD-CAT): Instrument Development Study

BACKGROUND

The management of type 2 diabetes mellitus (T2DM) includes mastery of complex care activities, self-management skills, and routine health care encounters to optimize glucose control and achieve good health. Given the lifelong course of T2DM, patients are faced with navigating complex medical and disease-specific information. This health-seeking behavior is a driver of health disparities and is associated with hospitalization and readmission. Given that health-seeking behavior is a potentially intervenable social determinant of health, a better understanding of how people navigate these complex systems is warranted.

OBJECTIVE

To address this need, we aimed to develop new patient-reported outcome (PRO) measures that evaluate health-seeking behavior in persons with T2DM. These new PROs were designed to be included in the Re-Engineered Discharge for Diabetes-Computer Adaptive Test (REDD-CAT) measurement system, which includes several other PROs that capture the importance of social determinants of health.

METHODS

Overall, 225 participants with T2DM completed 56 self-report items that examined health-seeking behaviors. Classical Test Theory and Item Response Theory were used for measurement development. Exploratory factor analysis (EFA; criterion ratio of eigenvalue 1 to eigenvalue 2 being >4; variance for eigenvalue 1 ≥40%) and confirmatory factor analysis (CFA; criterion 1-factor CFA loading <.50; 1-factor CFA residual correlation >.20; comparative fit index ≥0.90; Tucker-Lewis index ≥0.90; root mean square error of approximation <0.15) were used to determine unidimensional sets of items. Items with sparse responses, low-adjusted total score correlations, nonmonotonicity, low factor loading, and high residual correlations of high error modification indices were candidates for exclusion. A constrained graded response model was used to examine item misfit, and differential item functioning was examined to identify item bias. Cronbach α was used to examine internal consistency reliability for the new PROs (criterion ≥0.70), and floor and ceiling effects were examined (criterion ≤20%).

RESULTS

Four unidimensional sets of items were supported by EFA (all EFA eigenvalue ratios >4; variance for eigenvalue 1=41.4%-67.3%) and CFA (fit statistics all exceeded criterion values). This included (1) "Health-Seeking Behavior: PCP-Specific" (6 items); (2) "Health-Seeking Behavior: General Beliefs" (13 items); (3) "Health-Seeking Behavior: Family or Friends-Specific" (5 items); and (4) "Health-Seeking Behavior: Internet-Specific" (4 items). All items were devoid of differential item functioning for age, sex, education, or socioeconomic status factors. "Health-Seeking Behavior: General Beliefs" was developed to include both a computer adaptive test and a 6-item short form version; all other PROs were developed as static short forms. The psychometric reliability of these new PROs was supported; internal consistency ranged from acceptable to excellent (Cronbach α=.78-.91), and measures were free of significant floor or ceiling effects (floor effects range: 0%-8.9%; ceiling effects range: 0%-8.4%).

CONCLUSIONS

The new REDD-CAT Health-Seeking Behavior PROs provide reliable assessments of health-seeking behaviors among those with T2DM.

Application of the integrated data platform combined with dietary management for adults with diabetes: A prospective randomized controlled trial

AIMS

To investigate the efficacy of the integrated data platform of cloud hospital combined with dietary management for adults with type 2 diabetes.

MATERIALS AND METHODS

We conducted a randomized controlled clinical trial. One hundred eighty patients with type 2 diabetes were randomly allocated into a control group (Group A) and an experimental group (Group B). Routine standard diabetes care was applied to the patients in Group A. The integrated data platform with dietary management was applied to Group B. Individualized diabetes education videos were sent to the patients through the platform. The primary endpoint was the change in HbA1c and change in body weight from baseline to Week 12 during the follow-up.

RESULTS

At Week 12, HbA1c was 7.4 ± 0.7%, 6.9 ± 0.9% in Groups A and B, P < 0.01. The rate of fasting blood glucose <7 mmol/L, and glycosylated hemoglobin <7% was higher in Group B than in Group A. At Week 12, there was a significant weight loss and body mass index decrease in the overweight or obese patients of the experimental group. Those overweight or obese patients in the experimental group utilizing the appetite suppressant semaglutide achieved the most significant weight loss, with a 13.4% reduction after 12 weeks.

CONCLUSIONS

The integrated data platform combined with personalized diabetes education video delivery was verified to be a more effective management mode for diabetes. For overweight or obese adults with diabetes, the use of semaglutide in conjunction with dietary management and the integrated data platform led to greater weight loss.

5-Year effects of a novel continuous remote care model with carbohydrate-restricted nutrition therapy including nutritional ketosis in type 2 diabetes: An extension study

AIMS

This study assessed the five-year effects of a continuous care intervention (CCI) delivered via telemedicine, counseling people with type 2 diabetes (T2D) on a very low carbohydrate diet with nutritional ketosis.

METHODS

Participants with T2D were enrolled in a 2-year, open-label, non-randomized study comparing CCI and usual care (UC). After 2 years, 194 of the 262 CCI participants were approached for a three-year extension. Of these, 169 consented, and 122 remained in the study for five years. Primary outcomes were changes in diabetes status assessed using McNemars' test, including remission and HbA1c < 6.5 % on no glucose lowering medication or only on metformin at 5 years. Changes in body mass, glycemia, and cardiometabolic markers from baseline to 5 years were assessed using linear mixed-effects models.

RESULTS

Twenty percent (n = 24) of the five-year completers achieved remission, with sustained remission observed over three years in 15.8 % (n = 19) and four years in 12.5 % (n = 15). Reversal to HbA1c < 6.5 % without medication or only metformin was seen in 32.5 % (n = 39). Sustained improvements were noted in body mass (-7.6 %), HbA1c (-0.3 %), triglycerides (-18.4 %), HDL-C (+17.4 %), and inflammatory markers, with no significant changes in LDL-C and total cholesterol.

CONCLUSIONS

Over five years, the very low carbohydrate intervention showed excellent retention and significant health benefits, including diabetes remission, weight loss, and improved cardiometabolic markers.

Comparing the Effectiveness of Different Dietary Educational Approaches for Carbohydrate Counting on Glycemic Control in Adults with Type 1 Diabetes: Findings from the DIET-CARB Study, a Randomized Controlled Trial

BACKGROUND/OBJECTIVES

Carbohydrate counting is recommended to improve glycemic control in type 1 diabetes (T1D), but the most effective educational methods are unclear. Despite its benefits, many individuals struggle with mastering carbohydrate counting, leading to inconsistent use and suboptimal glycemic outcomes. This study aimed to compare the effectiveness of two group-based programs with individual dietary counseling (standard care) for glycemic control.

METHODS

The trial was a randomized, controlled, open-label, parallel-group design. Adults with T1D on multiple daily insulin injections (MDIs) and with glycated hemoglobin A1c (HbA1c) 53-97 mmol/mol were randomly assigned (1:1:1) to basic (BCC), advanced carbohydrate counting (ACC), or standard care. Primary outcomes were the changes in HbA1c or mean amplitude of glycemic excursions (MAGEs) in BCC and ACC versus standard care after six months. Equivalence testing was performed to compare BCC and ACC.

RESULTS

Between November 2018 and August 2021, 63 participants were randomly assigned to BCC (N = 20), ACC (N = 21), or standard care (N = 22). After 6 months, HbA1c changed by -2 mmol/mol (95% CI -5 to 0 [-0.2%, -0.5 to 0]) in BCC, -4 mmol/mol (-6 to -1 [-0.4%, -0.6 to -0.1]) in ACC, and -3 mmol/mol (-6 to 0 [-0.3%, -0.6 to 0]) in standard care. The estimated difference in HbA1c compared to standard care was 1 mmol/mol (-3 to 5 [0.1%, -0.3 to 0.5]); p = 0.663 for BCC and -1 mmol/mol (-4 to 3 [-0.1%, -0.4 to 0.3]); p = 0.779 for ACC. For MAGEs, changes were -0.3 mmol/L (-1.5 to 0.8) in BCC, -0.0 mmol/L (-1.2 to 1.1) in ACC, and -0.7 mmol/L (-1.8 to 0.4) in standard care, with differences of 0.4 mmol/L (-1.1 to 1.9); p = 0.590 for BCC and 0.7 mmol/L (-0.8 to 2.1); p = 0.360 for ACC versus standard care. An equivalence in effect between BCC and ACC was found for HbA1c, but not for MAGEs.

CONCLUSIONS

Group-based education in BCC and ACC did not demonstrate a clear advantage over individualized dietary counseling for overall glycemic control in adults with T1D. Healthcare providers should consider flexible, patient-centered strategies that allow individuals to choose the format that best suits their learning preferences when selecting the most suitable dietary educational approach.

Core Components of Cardiac Rehabilitation Programs: 2024 Update: A Scientific Statement From the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation

The science of cardiac rehabilitation and the secondary prevention of cardiovascular disease has progressed substantially since the most recent American Heart Association and American Association of Cardiovascular and Pulmonary Rehabilitation update on the core components of cardiac rehabilitation and secondary prevention programs was published in 2007. In addition, the advent of new care models, including virtual and remote delivery of cardiac rehabilitation services, has expanded the ways that cardiac rehabilitation programs can reach patients. In this scientific statement, we update the scientific basis of the core components of patient assessment, nutritional counseling, weight management and body composition, cardiovascular disease and risk factor management, psychosocial management, aerobic exercise training, strength training, and physical activity counseling. In addition, in recognition that high-quality cardiac rehabilitation programs regularly monitor their processes and outcomes and engage in an ongoing process of quality improvement, we introduce a new core component of program quality. High-quality program performance will be essential to improve widely documented low enrollment and adherence rates and reduce health disparities in cardiac rehabilitation access.

Korean Food Exchange Lists for Diabetes Meal Planning: Revised 2023

A food exchange list is a tool developed to help diabetic patients control their energy intake and plan balanced meals. Korean food exchange lists were first developed in 1988, revised in 1995, and updated again in 2010. With rapidly changing dietary habits and increasing demand for diverse food cultures, the Korean Diabetes Association in cooperation with 4 related organizations established a Task Force Team (TFT) to revise food exchange lists in March 2022. Starting with a workshop, TFT held 11 official revision meetings, culminating in a public hearing in May 2023. The final revised version of Korean food exchange lists was published in December 2023. Key outcomes of the revision are summarized as follows: 1. Based on the National Standard Food Composition Table 10.0 database, the existing classification system and nutrient standards for each food group remain unchanged this time. 2. Based on a survey conducted among diabetes educators, the number of items on the food exchange lists has increased from 339 in 2010 to 435 this time. 3. Considering patients' usual eating habits, meal planning examples were developed distributing food group exchange units by energy level based on 3 types of proportions of carbohydrate energy (40%-45%, 50%-55%, 60%-65%). 4. Due to limitations in real-time updates for rapidly changing information, detailed guidance on how to access and interpret the data is provided. These revisions will help people with diabetes manage their blood sugar levels and facilitate the implementation of healthy meal planning in various other conditions, including obesity.

The Impact of Resistance Exercise Training on Glycemic Control Among Adults with Type 2 Diabetes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: The prevalence of type 2 diabetes mellitus (T2DM) presents a challenge for health organizations because of its high likelihood of morbidity and mortality. There is an increasing body of evidence exploring the efficacy of resistance training (RT) alone on glycemic control. Objective: To update the effectiveness of RT on glycosylated hemoglobin (HbA1c) and fasting glucose in adults diagnosed with T2DM. Methods: CINAHL (EBSDCO), PubMed, MEDLINE (Ovid), and EMBASE (Ovid) databases were searched from inception to 30 January 2024. Published randomized controlled trials (RCTs) of adult humans with T2DM assessing the impact of RT on HbA1c and fasting glucose compared with control condition were included. Data were pooled by the inverse-variance method and reported as mean differences (MDs) with 95% confidence intervals (CIs). Results: Forty-six RCTs totaling 2130 participants met the inclusion criteria. Meta-analysis demonstrated RT significantly reduced HbA1c (MD -0.50% [95% CI, -0.67, -0.34 %], p < .00,001) and fasting glucose (MD -12.03 mg/dl [95% CI, -19.36, -4.69 mg/dl], p = .001). Subgroup analyses found that exercise training durations, gender, and risk of bias had statistically significant effects on HbA1c levels and fasting glucose concentrations after resistance training. However, meta-regression analyses revealed that variables including year of publication, number of sessions per week, mean sample age, sample size, and study quality scores did not significantly affect the change in either HbA1c or glucose. Conclusion: Our meta-analysis with meta-regression delivers further evidence that RT programs are effective approach in attenuation of HbA1c and fasting glucose in individuals with T2DM.

Adherence to the nutritional recommendations according to diabetes status in Korean adults: a cross-sectional study

BACKGROUND

Nutritional therapy plays a crucial role in diabetes management. Assessing adherence to nutritional recommendations is critical for evaluating whether the current status of nutrition education is appropriate. This study aimed to evaluate adherence to nutritional recommendations according to diabetes status using data from the Korean National Health and Nutrition Examination Survey from 2016 to 2019.

METHODS

A total of 2,793 participants (55.4% male) were evaluated regarding their adherence to nutritional recommendations. The "aware" group comprised people who had been clinically diagnosed by a physician. The "treated" group comprised people receiving anti-diabetic medications. The "control" group comprised people who achieved an HbA1c level < 6.5%. The "educated" group comprised people who had received nutrition education or counseling at various locations.

RESULTS

Among the 1,918 individuals in the "aware" group, only 243 (8.7%) had received nutrition education. Adherence to nutritional recommendations was generally low, with people with diabetes showing slightly higher adherence to total energy intake (59.6% vs. 55.3%) and total sugar intake (88.0% vs. 84.5%) than people without diabetes. However, adherence to total carbohydrate intake was poor in both the treated and educated groups (34.3% and 26.0%, respectively) compared to the untreated and non-educated groups (44.4% and 36.0%, respectively).

CONCLUSIONS

These findings indicate inadequate nutritional management for people with diabetes in Korea. Nutrition education should be effectively strengthened to achieve nutritional goals.

Association between personality, lifestyle behaviors, and cardiovascular diseases in type 2 diabetes mellitus: a population-based cohort study of UK Biobank data

INTRODUCTION

Various strategies aim to better assess risks and refine prevention for patients with type 2 diabetes mellitus (T2DM), who vary in cardiovascular disease (CVD) risk. However, the prognostic value of personality and its association with lifestyle factors remain elusive.

RESEARCH DESIGN AND METHODS

We identified 8794 patients with T2DM from the UK Biobank database between 2006 and 2010 and followed them up until the end of 2021. We assessed personality traits using the Big Five proxies derived from UK Biobank data: sociability, warmth, diligence, curiosity, and nervousness. Healthy lifestyle behaviors were determined from information about obesity, smoking status, and physical activity. The primary outcome was a composite of incident CVD, including myocardial infarction (MI), ischemic stroke (IS), atrial fibrillation (AF), and heart failure (HF).

RESULTS

During a median follow-up of 13.6 years, a total of 2110 patients experienced CVDs. Among personality traits, diligence was significantly associated with a reduced risk of primary and secondary outcomes. The adjusted HRs with 95% CIs were: composite CVD, 0.93 (0.89-0.97); MI 0.90 (0.82-1.00); IS 0.83 (0.74-0.94); AF 0.92 (0.85-0.98); HF 0.84 (0.76-0.91). Healthy lifestyle behaviors significantly reduced the risk of composite CVDs in groups with high and low diligence. The findings of a structural equation model showed that diligence directly affected the risk of the primary outcome or indirectly by modifying lifestyle behaviors.

CONCLUSION

This study revealed which personality traits can influence CVD risk during T2DM and how patients might benefit from adopting healthy lifestyle behaviors in relation to personality.

Implementing a Diet Risk Score (DRS) for Spanish-Speaking Adults in a Clinical Setting: A Feasibility Study

Tools to briefly assess diet among US Spanish-speaking adults are needed to identify individuals at risk for cardiometabolic disease (CMD) related to diet. Two registered dietitian nutritionists (RDNs) recruited bilingual medical students to translate the validated Diet Risk Score (DRS) into Spanish (DRS-S). Participants were recruited from a federally qualified health center. Students administered the DRS-S and one 24-h recall (Automated Self-Administered 24-Hour (ASA24®) Dietary Assessment Tool) on one day; a second recall was administered within 1 week. Recalls were scored using the Healthy Eating Index (HEI)-2015, a measure of adherence to the Dietary Guidelines for Americans. Spearman correlations, weighted kappa, and ANOVA were conducted using SAS 9.4 to assess the relative validity of the DRS-S. Thirty-one Spanish-speaking adults (female: n = 17, 53%; mean age: 58 (42-69)) completed assessments. The mean DRS-S was 9 (SD = 4.2) (max: 27; higher score = higher risk) and the mean HEI-2015 score was 65.7 (SD = 9.7) (max: 100; higher score = lower risk), with significant agreement between measures (r: -0.45 (p = 0.01)), weighted kappa: -0.3 (p = 0.03). The DRS-S can be used in resource-constrained settings to assess diet for intervention and referral to RDNs. The DRS-S should be tested in clinical care to assess the impact of dietary changes to reduce CMD risk.

Putting person-centred psychosocial diabetes care into practice: two psychosocial care pathways based on outcome preferences of people with diabetes and healthcare professionals

BACKGROUND

Diabetes increases the risk of psychosocial health problems. Person-centred psychosocial care is therefore advocated. However, several barriers to implementation exist, including uncertainty about how to approach psychosocial problems in consultations.

OBJECTIVE

We aimed to explore which psychosocial outcomes patients and healthcare professionals consider important and whether certain characteristics are associated with this. We propose strategies for facilitating psychosocial diabetes care on this basis.

METHODS

The results of an international Delphi study aimed at achieving multi-stakeholder consensus on a diabetes outcome set were analysed. We compared the importance ratings of the two stakeholder groups for each psychosocial outcome. A multivariable linear regression analysis tested whether certain characteristics would predict the importance attributed to outcomes that were not generally considered important.

FINDINGS

Patients and healthcare professionals agreed on the importance of regularly assessing psychological well-being, diabetes distress and diabetes-specific quality of life, while they regarded it as less important to monitor depression, anxiety, eating problems, social support and sexual health. Being a woman, younger and living with type 1 diabetes were associated with considering it important to assess eating problems.

CONCLUSIONS

We propose two psychosocial care pathways that reflect the outcome preferences of patients and healthcare providers. They follow a stepped approach, starting with the assessment of psychological well-being and quality of life and proceeding from there.

CLINICAL IMPLICATIONS

Adopting this approach can facilitate the implementation of person-centred psychosocial diabetes care by reducing the burden and making psychosocial issues more accessible. This approach should be tested for feasibility, safety and effectiveness.

Recent Findings on Exercise Therapy for Blood Glucose Management in Patients with Gestational Diabetes

Inadequate management of blood glucose levels in gestational diabetes mellitus (GDM) poses risks for both pregnant women and the developing fetus. Attaining appropriate blood glucose control is crucial to mitigate potential adverse outcomes. This study aimed to consolidate the latest guidelines from representative professional societies, providing insights into exercise therapy for GDM patients and suggesting potential avenues for future research. The review was conducted with up-to-date exercise guidelines from prominent societies, such as the American College of Obstetricians and Gynecologists (ACOG), the Society of Obstetricians and Gynecologists of Canada (SOGC), the Canadian Society for Exercise Physiology (CSEP), the American College of Sports Medicine, the American Diabetes Association (ADA), and the Korean Diabetes Association. The ACOG and SOGC/CSEP recommend 150 min of low to moderate intensity exercise, 3-4 times a week, combining aerobic and resistance exercises. All guidelines advise against activities involving sudden directional changes, physical contact, a risk of falling, and exercises performed lying down. Despite cautions from the ADA and ACOG on blood glucose fluctuations during physical activity, the lack of specific methods and recommendations from other societies reveals a notable gap in evidence-based guidelines for GDM. For effective and safe blood glucose management in GDM patients, further research should be conducted on the exercise-related precautions outlined for GDM patients. Establishing ample evidence would facilitate the development of customized exercise guidelines for GDM patients.

The Role of Self-Efficacy Enhancement in Improving Self-Management Behavior for Type 2 Diabetes Mellitus Patients

Background

The effectiveness of a self-efficacy-focused structured education program for patients with diabetes mellitus has been verified. However, changes in self-efficacy for the behavior change mechanism in patients who participated in the program require clarification.

Aim

To analyze the mechanism of self-management behavioral variations in patients with type 2 diabetes mellitus who underwent a self-efficacy-focused structured education program.

Methods

A secondary analysis of patients who received a self-efficacy-focused structured education program was conducted using data from a multicenter randomized controlled trial. The relationships among the 3-, 6-, and 12-month changes in diabetes knowledge, self-efficacy, diabetes distress, and self-management behaviors in patients with type 2 diabetes mellitus were studied using a structural equation model.

Results

Enhancement of self-efficacy among patients receiving a self-efficacy-focused structured education program directly influenced improvements in self-management behaviors at 3, 6 and 12 months. The increase in diabetes knowledge directly and indirectly improved self-management behaviors at 3 months, but the direct effect on behavior disappeared at 6 months and the indirect effect on behavior by enhancing self-efficacy only lasted until 6 months. The decrease in diabetes distress directly influenced improvement in self-management behaviors at 3 months. While it did not directly influence self-management behavior improvement at 6 and 12 months, it indirectly affected behavior improvement by enhancing self-efficacy.

Conclusion

The enhancement of self-efficacy plays a core role in improving and maintaining self-management behaviors in patients with type 2 diabetes mellitus who receive self-efficacy-focused structured education programs. Patients' behaviors can be improved by gaining more diabetes knowledge and mitigating diabetes distress at the 3- and 6-month follow-up. Improvements in behaviors at the 12-month follow-up could be achieved by mitigating diabetes distress.

Efficacy of the Mediterranean Diet Containing Different Macronutrients on Non-Alcoholic Fatty Liver Disease

This study aimed to investigate the effects of the typical Mediterranean diet (TMD), low-carbohydrate Mediterranean diet (LCMD), and low-fat Mediterranean diet (LFMD) on biochemical findings, fatty liver index (FLI), anthropometric measurements, and body composition in individuals with obesity with non-alcoholic fatty liver disease (NAFLD) and insulin resistance. This study included 63 participants with obesity with insulin resistance diagnosed with NAFLD by ultrasonography to investigate the effects of an 8-week energy-restricted TMD, LCMD, and LFMD on biochemical findings, FLI, fibrosis-4 index (FIB-4), anthropometric measurements, and body composition. Patients were randomized into three groups and were interviewed face-to-face every week. According to the food consumption records (baseline end), the difference in the amount of sucrose and total fat consumed in the TMD group; the difference in energy intake from sucrose, monounsaturated fatty acids, and oleic acid in the LCMD group; and the difference in energy intake from fiber, sucrose, monounsaturated and polyunsaturated fatty acids, and cholesterol in the LFMD group showed significant correlations with liver enzymes and FLI (p < 0.05). In conclusion, although it has a different macronutrient composition, the Mediterranean diet may positively affect biochemical parameters and FLI in individuals with NAFLD, albeit in different ways.

Diabetes distress and diabetes burnout explored in various areas of life in patients with type 1 diabetes: effect of short-term psychological intervention

INTRODUCTION

Diabetes distress (DD) and diabetes burnout (DB) are recognized psychological phenomena in patients with T1DM (type 1 diabetes mellitus). Still, there is an urgent need to create professional psychological intervention procedures to provide patients with adequate care.

AIM

The aim of the study was to assess the level of DD and DB in T1DM patients at baseline and after 5 of sessions psychological intervention in the group of participants who applied for help.

METHODS

34 T1DM patients who requested psychological support (22 females, 12 males) and 30 patients in a control group (14 females, 16 males) participated in the study. At baseline clinical test results between groups were compared. Next, in the studied group measurements were repeated after a set of five psychological face-to-face individual interventions which lasted 30-60 min each. They were support sessions with elements of cognitive-behavioral interventions done by clinical psychologists. Session 1: introduction, interview and collection of test results; session 2-4: work on the indicated by the patient and test results most problematic aspect of diabetes, session 5: a summary and plan for further treatment if needed. The control group results were obtained only at baseline. Research tools: DDS; PAID, Diabetes Burnout test by Polonsky.

RESULTS

At the baseline, significant differences were observed between the studied group and control group: in DB/DD levels: DB (3.9 ± 1.7 vs 2.4 ± 1.6; p < 0.001); DDS (3.2 ± 1.0 vs 2.7 ± 1.0; p = 0.064); PAID (62.3 ± 14.1vs 34.4 ± 21.0; p < 0.001). There were also group differences in HbA1c levels (8.7 ± 2.4 vs 7.3 ± 1.5; p = 0.028). After psychological interventions, there was a significant improvement in DB (3.9 ± 1.7vs 2.9 ± 1.2; p < 0.001; DDS (3.2 ± 1 vs 3.0 ± 0.7; p = 0.03); PAID (62.3 ± 14.1 vs 51.8 ± 12.5; p < 0.001).

CONCLUSIONS

DD and DB constitute a significant problem in the group of T1DM patients, but providing appropriate specialist care may help them accept diabetes and improve life satisfaction, as well as regain control over their diabetes management.

Barriers and Enablers to Maintaining Behaviour Changes Following a Lifestyle Intervention for Adults With Type 2 Diabetes

Aim

To explore short-term barriers and enablers to maintaining behaviour changes in adults with type 2 diabetes who had completed a lifestyle behaviour change program.

Methods

Focus groups with 44 participants identified barriers and enablers at the end-of-program (n = 8 groups: anticipated); and, 1-month post-program (n = 6 groups: experienced). Thematic inductive analysis was undertaken independently by two authors, discussed, then deductively grouped according to the Capability (physical, psychological), Opportunity (physical, social), Motivation (automatic, reflective) - Behaviour (COM-B) model.

Results

Nine barriers were identified: two anticipated, one experienced, and six common to both timepoints. Key barriers related to physical capability (health ability), physical opportunity (difficulty accessing and using resources), social opportunity (unwillingness to invest in social networks), and reflective motivation (lack of internal drive). Eleven enablers were identified: all across both timepoints. Key enablers related to psychological capability (knowledge), physical opportunity (access and use of program resources), social opportunity (sense of belonging and safety within the program), automatic motivation (beliefs and awareness around perceived risk; monitoring of progress), and reflective motivation (committed to change).

Discussion

Findings suggest diabetes management programs should enable ongoing access to their resources. Investing in mechanisms to scaffold program graduates into suitable community-based activities may also be beneficial.

Knowledge, Attitudes, and Behaviors around Dietary Fats among People with Type 2 Diabetes: A Systematic Review

This systematic review assesses the knowledge, attitudes, and behaviors (KAB) surrounding dietary fat intake among people with type 2 diabetes mellitus (T2DM) and healthcare professionals. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, four databases were searched to identify studies published between 1995 and 2023 reporting people with T2DM or healthcare professionals that measured KAB towards dietary fat. This work was registered at PROSPERO (CRD42020140247). Twenty-four studies were included. Studies assessed knowledge of people with T2DM and reported poor nutrition knowledge regarding the health effect of fat consumption. Two opposing attitudes towards dietary fat was reported: (1) dietary fat should be limited, (2) promoted dietary fat intake through a low-carbohydrate diet. Participants reported behaviors of limiting fat intake, including trimming visible fat or choosing lower-fat alternatives. Total fat intake ranged between 10 and 66% of participants' total energy intake, while saturated fat intake ranged between 10 and 17%. People with T2DM reported poor knowledge of dietary fats in particular, and they were frequently unable to identify high-fat food. Attitudes towards dietary fat were heterogenous, and regarding behaviors, saturated fat intake was higher than recommended. Future studies should assess the KAB of people with T2DM based on dietary fat subtypes.

Could Online Education Replace Face-to-Face Education in Diabetes? A Systematic Review

OBJECTIVE

Diabetes Self-Management Education and Support (DSMES) is a critical component of diabetes care. This study aims to examine the effect of online-based educational interventions on diabetes management compared to face-to-face interventions.

METHODS

A systematic review was conducted by searching three databases for studies in English or Spanish between December 2023 and March 2024. The inclusion criteria were studies that compared face-to-face DSMES with online interventions.

RESULTS

The follow-up duration of the trials ranged from 1 to 12 months. Multidisciplinary teams delivered online DSMES through various means, including Short Message Service (SMS), telephone calls, video calls, websites, and applications. Online DSMES was found to be comparable to face-to-face interventions in terms of glycated hemoglobin (HbA1c) levels in people with type 1 diabetes (T1D). In contrast, online interventions that focus on weight management in people with type 2 diabetes (T2D) have shown a significant reduction in HbA1c compared to face-to-face interventions. Online DSMES was found to be superior in terms of quality of life and cost-effectiveness in both T1D and T2D. None of the analyzed studies explored the differences between individual and group methodologies.

CONCLUSIONS

The current evidence indicates that online DSMES services provide at least comparable biomedical benefits to face-to-face interventions, suggesting that online interventions could be incorporated into clinical practice as a complement or reinforcement. However, further research is needed to explore the potential benefits and effectiveness of online group sessions in DSMES.

Effects of basic carbohydrate counting versus standard dietary care for glycaemic control in type 2 diabetes (The BCC Study): a randomised, controlled trial

BACKGROUND

Clinical guidelines recommend basic carbohydrate counting (BCC), or similar methods to improve carbohydrate estimation skills and to strive for higher consistency in carbohydrate intake potentially improving glycaemic control. However, evidence for this approach in type 2 diabetes (T2D) is limited.

OBJECTIVE

To examine the efficacy of a structured education program in BCC as add-on to standard dietary care on glycaemic control in individuals with T2D.

METHODS

The BCC Study was a randomized, controlled, open-label, parallel-group trial. Individuals with T2D aged 18-75 years with glycated haemoglobin A1c (HbA1c) 53-97 mmol/mol (7.0-11.0%) were randomly assigned (1:1) to BCC or standard dietary care. The primary outcomes were differences in changes in HbA1c or glycaemic variability (calculated as mean amplitude of glycaemic excursions [MAGE]) between groups after six months of intervention.

RESULTS

Between September 2018 and July 2021, 48 participants were randomly assigned, 23 to BCC and 25 to standard dietary care. Seven participants did not receive the allocated intervention. From a baseline-adjusted mean of 65 mmol/mol (95% CI 62-68 [8.1%, 7.8-8.4]), HbA1c changed by -5 mmol/mol (-8 to -1 [-0.5%, -0.7 to -0.1]) in BCC and -3 mmol/mol (-7 to 1 [-0.3%, -0.6 to 0.1]) in standard care with an estimated treatment effect of -2 mmol/mol (-7 to 4 [-0.2%, -0.6 to 0.4]); p = 0.554. From a baseline-adjusted mean of 4.2 mmol/l (3.7 to 4.8), MAGE changed by -16% (-33 to 5) in BCC and by -3% (-21 to 20) in standard care with an estimated treatment effect of -14% (-36 to 16); p = 0.319. Only median carbohydrate estimation error in favour of BCC (estimated treatment difference -55% (-70 to -32); p < 0.001) remained significant after multiple testing adjustment.

CONCLUSIONS

No glycaemic effects were found but incorporating BCC as a supplementary component to standard dietary care led to improved skills in estimating carbohydrate intake among individuals with T2D.

Effectiveness of telehealth on the glycemic control of patients with type 2 diabetes mellitus during the COVID-19 pandemic: A systematic review and meta-analysis of randomised controlled trials

Background

During the COVID-19 pandemic, telehealth was employed to enhance clinical outcomes for patients with type 2 diabetes mellitus. However, the effectiveness of telehealth remains inconclusive.

Objective

This study aimed to examine the impact of telehealth on the glycemic control of individuals with type 2 diabetes mellitus during the pandemic.

Design

A systematic review and meta-analysis of randomized controlled trials.

Setting

N/A.

Participants

A total of 669 studies was sourced from electronic databases, including EMBASE, PubMed, and Scopus. Among these, twelve randomized controlled trials, comprising 1498 participants, were included.

Methods

A comprehensive search was performed in electronic databases. The quality of the included studies was assessed using the Cochrane Risk of Bias tool, and statistical heterogeneity was assessed using I² and Cochran's Q tests. A random-effects model was utilized to combine the outcomes. Grading of Recommendations, Assessment, Development, and Evaluations was used to evaluate the certainty of the evidence.

Results

The meta-analysis showed that participants receiving a telehealth intervention achieved a greater reduction in the glycated haemoglobin (HbA1C) compared to those receiving usual care, with a weighted-mean difference of -0.59 (95 % CI -0.84 to -0.35, p < .001, I² = 74.1 %, high certainty of evidence). Additionally, participants receiving telehealth interventions experienced better secondary outcomes, including a reduction in fasting blood sugar (16.06 %, 95 %CI -29.64 to -2.48, p = .02, high certainty of evidence), a decrease in body mass index (1.5 %, 95 %CI -1.98 to -1.02, p < .001, high certainty of evidence), and a decrease in low-density lipoprotein (7.8 %, 95 %CI -14.69 to -0.88, p = .027, low certainty of evidence).

Conclusions

In our review, we showed telehealth's positive impact on glycaemic control in type 2 diabetes mellitus patients. Healthcare professionals can use telehealth in diabetes care. Caution is needed due to heterogeneity of the results. Further research should explore the long-term impacts of telehealth interventions.

Registration

The study was registered with PROSPERO, CRD42022381879.

Self-Care of Diabetes and Diabetes Distress in Non-Hispanic Black Adults With Type 2 Diabetes

PURPOSE

The purpose of the study was to describe the level of self-care of diabetes and diabetes distress and examine their relationship in non-Hispanic Black adults living with type 2 diabetes.

METHODS

This cross-sectional, correlational study was conducted with 275 non-Hispanic Black adults with type 2 diabetes in North Carolina over 10 weeks, July 2022 to September 2022. An online survey collected sociodemographic and clinical characteristics, self-care measures of diabetes, and diabetes distress. The theory of self-care of chronic illness guided the study. Median regression examined the relationship between self-care of diabetes and diabetes distress.

RESULTS

Of the 275 participants, over half reported a diagnosis of type 2 diabetes at younger ages than expected, with a mean age of 40. The self-reported mean A1C of 9% exceeded the recommended goal of <7%, with an average of 2 diabetes-related comorbidities. The self-care of diabetes scale scores were low, and total diabetes distress scores were high. Significant positive associations were found between total diabetes distress and self-care monitoring and self-care management.

CONCLUSIONS

In this sample, non-Hispanic Black adults had low levels of self-care of diabetes and high levels of diabetes distress. The findings indicate a relationship between self-care of diabetes and diabetes distress; as diabetes distress increases, so do the attempted activities of self-care of diabetes. Health care professionals in diabetes care are uniquely positioned to address further the behavioral aspects of diabetes management, particularly diabetes distress, to support non-Hispanic Black adults living with type 2 diabetes.

The Impact of Hand Strength on HbA1c, Body Mass Index and Body Composition by Group According to Sedentary Behaviour: Cross-Sectional Study in Japanese Patients with Type 2 Diabetes Mellitus

Background

The impact of hand strength in consideration of sedentary behaviour on diabetes management in patients with type 2 diabetes mellitus (T2DM) is unclear. The purpose of this study was to examine the impact of hand strength on HbA1c, body mass index (BMI) and body composition by group according to the duration of sedentary behaviour in Japanese patients with T2DM.

Methods

In this retrospective, cross-sectional, single-centre study, hand strength standardised by bodyweight (GS) and sedentary time (ST), were obtained and analysed in a total of 270 Japanese T2DM outpatients in 2021. After dividing the patients into four categories of median values (high and low GS, and long and short ST), odds ratios (ORs) for good control of HbA1c, BMI, waist circumference (WC) and intra-abdominal fat (IAF) were investigated using logistic regression models.

Results

The high GS/short ST group was found to have a significantly higher (OR = 2.01; 95% CI: 1.00, 4.03; P = 0.049) for controlled HbA1c compared with that of the low GS/long ST group. The high GS/short ST and the high GS/long ST groups had significantly higher ORs for controlled BMI, WC and IAF compared with the OR of the low GS/long ST group. In addition, the ORs were significantly increased with a positive trend in order from low GS/long ST, low GS/short ST, high GS/long ST, to high GS/short ST in all models (P < 0.001 for trend).

Conclusion

Hand strength, with modest effects from sedentary behaviour, could be helpful for diabetes management in T2DM patients.

The Role of Family in Diabetes Management for Mexican American Adults

Introduction: The purpose of this study was to characterize how family influences diabetes self-management in Mexican American adults. Methods: Data were analyzed from previously collected data that included 34 semi-structured interviews with Hispanic adults with diabetes and six focus groups with 37 adults with diabetes and family members. Themes related to family and diabetes management were identified and analyzed using a modified template approach. Results: Family-related facilitators to T2DM self-management were (1) provides support, (2) provides motivation, and (3) desire to protect family from diabetes. Family-related challenges were (1) lack of support, (2) family responsibilities, and (3) stress related to family. Diabetes education was shared with family members. Family member perspectives on T2DM included (1) not knowing how to help, (2) effect on emotional wellbeing, (3) diabetes affects the whole family, and (4) family provides support. Conclusion: Most participants with T2DM felt supported by family, but many desired more social support and support surrounding dietary changes from family. Many felt family did not understand what living with diabetes meant for them. Most family members wished to learn more about how to help. Future interventions should include family members and teach them supportive strategies to support beneficial diabetes self-management behaviors.

Dietary Patterns and New-Onset Diabetes Mellitus in Southwest China: A Prospective Cohort Study in the China Multi-Ethnic Cohort (CMEC)

(1) Background: There is little known about the relationship between Dietary Approaches to Stop Hypertension (DASH) pattern and diabetes in cohort studies, and the dietary patterns in the Chongqing natural population are unknown. (2) Methods: 14,176 Chinese adults, aged 30-79 years old, participated in this prospective study, from September 2018 to October 2023. A dietary assessment was conducted using a food frequency questionnaire, and three main dietary patterns were extracted from the principal component analysis. DASH patterns were calculated by standards. (3) Results: During the 4.64 y follow-up, 875 developed diabetes (11.3/1000 person-years). Each posteriori diet pattern is named after its main dietary characteristics (meat pattern, dairy products-eggs pattern, and alcohol-wheat products pattern). The high consumption of DASH pattern diet reduced the risk of diabetes (Q5 vs. Q1 HR: 0.71; 95% CI: 0.40-0.56) while high consumption of alcohol-wheat product pattern diet was associated with a high risk of diabetes (Q5 vs. Q1 HR: 1.32; 95% CI: 1.04, 1.66). The other two dietary patterns were not associated with diabetes. In subgroup analysis, there was an interaction between DASH pattern and sex (P for interaction < 0.006), with a strong association in females. (4) Conclusions: DASH pattern may be associated with a reduced new-onset diabetes risk and Alcohol-wheat products pattern may be positively associated with new-onset diabetes. These findings may provide evidence for making dietary guidelines in southwest China to prevent diabetes.

Association of Ultraprocessed Food Consumption with Risk of Cardiovascular Disease Among Individuals with Type 2 Diabetes: Findings from the UK Biobank

SCOPE

Among patients with diabetes, who have modified nutritional behavior and a higher risk of cardiovascular disease (CVD), the influence of ultraprocessed foods (UPFs) on CVD remains unknown. The study aims to evaluate the association between UPF intake and the risk of CVD among individuals with type 2 diabetes (T2D) and further examine the potential biological pathways linking the association.

METHODS AND RESULTS

This study includes 5405 participants with T2D who provided at least one 24-h dietary recall from the UK Biobank study. In the fully adjusted models, a 10% increase in the proportion of UPFs is associated with higher hazards of overall CVD (hazard ratio [HR]: 1.10; 95% confidence interval [CI]: 1.04, 1.15), coronary heart disease (HR: 1.10; 95% CI: 1.04, 1.16), heart failure (HR: 1.14; 95% CI: 1.05, 1.25), but not stroke (HR: 1.01; 95% CI: 0.90, 1.12). Cystatin C, high-density lipoprotein cholesterol (HDL-C), apolipoprotein A, C-reactive protein, and body mass index collectively explain 26.9% (12.8%, 48.5%) of the association between UPF intake and the risk of overall CVD.

CONCLUSION

Higher UPF intakes are associated with increased hazards of CVD among individuals with T2D, and the association is partly mediated through worsening biomarkers of renal function, lipid metabolism, inflammation, and body weight.

Postprandial glucose-management strategies in type 1 diabetes: Current approaches and prospects with precision medicine and artificial intelligence

Postprandial glucose control can be challenging for individuals with type 1 diabetes, and this can be attributed to many factors, including suboptimal therapy parameters (carbohydrate ratios, correction factors, basal doses) because of physiological changes, meal macronutrients and engagement in postprandial physical activity. This narrative review aims to examine the current postprandial glucose-management strategies tested in clinical trials, including adjusting therapy settings, bolusing for meal macronutrients, adjusting pre-exercise and postexercise meal boluses for postprandial physical activity, and other therapeutic options, for individuals on open-loop and closed-loop therapies. Then we discuss their challenges and future avenues. Despite advancements in insulin delivery devices such as closed-loop systems and decision-support systems, many individuals with type 1 diabetes still struggle to manage their glucose levels. The main challenge is the lack of personalized recommendations, causing suboptimal postprandial glucose control. We suggest that postprandial glucose control can be improved by (i) providing personalized recommendations for meal macronutrients and postprandial activity; (ii) including behavioural recommendations; (iii) using other personalized therapeutic approaches (e.g. glucagon-like peptide-1 receptor agonists, sodium-glucose co-transporter inhibitors, amylin analogues, inhaled insulin) in addition to insulin therapy; and (iv) integrating an interpretability report to explain to individuals about changes in treatment therapy and behavioural recommendations. In addition, we suggest a future avenue to implement precision recommendations for individuals with type 1 diabetes utilizing the potential of deep reinforcement learning and foundation models (such as GPT and BERT), employing different modalities of data including diabetes-related and external background factors (i.e. behavioural, environmental, biological and abnormal events).

Analysis of dietary behavior and intake related to glycemic control in patients with type 2 diabetes aged 30 years or older in Korea: Utilizing the 8th Korea National Health and Nutrition Examination Survey (2019-2021)

BACKGROUND/OBJECTIVES

Over the past 10 yrs, the prevalence of diabetes in Korea has continued to incline, and the importance of lifestyle modification to manage diabetes has been highlighted. For patients with diabetes, carbohydrate intake reduction is effective in improving glycemic control; thus, we aimed to analyze the effect of carbohydrate intake ratio and suggest an appropriate carbohydrate intake ratio.

SUBJECTS/METHODS

Using the 8th Korea National Health and Nutrition Examination Survey (2019-2021), we analyzed the data including participants aged 30 yrs or older with diabetes, and they were stratified into good and poor glycemic control groups. To analyze the correlation between the dietary behavior characteristics of participants with diabetes and the carbohydrate intake ratio, sociodemographic characteristics, dietary behavior, and health behavior were adjusted, and multivariate logistic regression analysis was conducted to present the adjusted odds ratio and 95% confidence interval (CI).

RESULTS

In the unadjusted crude model, when carbohydrate intake ratio in total energy intake increased by 1%, the likelihood of poor glycemic control increased by 1.007-fold (95% CI, 0.998-1.016; P = 0.121). In model 1, which uses age and sex as adjustment variables, an increase of up to 1.011-fold was possible (95% CI, 1.001-1.021; P = 0.008). In model 2, which added variables such as diabetes duration, frequency of fruit consumption, frequency of lunch and, frequency of dinner, the risk of poor glycemic control increased by 1.010-fold as the carbohydrate intake ratio increased (95% CI, 0.998-1.022; P < 0.001).

CONCLUSION

This study confirmed that as the ratio of carbohydrate intake to total energy intake increases the likelihood of poor glycemic control also increases in patients with diabetes. Therefore, to improve glycemic control in patients with diabetes, controlling the carbohydrate intake may be helpful.

Advancing type 2 diabetes therapy with iGlarLixi in older people: Pooled analysis of four randomized controlled trials

AIM

To assess the efficacy and safety of iGlarLixi in older people (≥65 years) with type 2 diabetes (T2D) advancing or switching from oral agents, a glucagon-like peptide-1 receptor agonist (GLP-1RA), or basal insulin.

MATERIALS AND METHODS

The data of participants aged <65 years and ≥65 years from four LixiLan trials (LixiLan-O, LixiLan-G, LixiLan-L, SoliMix) were evaluated over 26 or 30 weeks.

RESULTS

Participants aged <65/≥65 years (n = 1039/n = 497) had a mean baseline body mass index of 31.4 and 30.7 kg/m2 and glycated haemoglobin (HbA1c) concentration of 66 mmol/mol (8.2%) and 65 mmol/mol (8.1%), respectively. Least squares mean HbA1c change from baseline to end of treatment (EOT) was -14.32 mmol/mol (-1.31%) (95% confidence interval [CI] -14.97, -13.77 [-1.37%, -1.26%]) for those aged <65 years and -13.66 mmol/mol (-1.25%) (95% CI -14.54, -12.79 [-1.33%, -1.17%]) for those aged ≥65 years. At EOT, achievement of HbA1c targets was similar between the group aged <65 years and the group aged ≥65 years: <53 mmol/mol (<7%) (59.0% and 56.5%, respectively), <59 mmol/mol (<7.5%) (75.5% and 73.0%, respectively) and <64 mmol/mol (<8%) (83.8% and 84.1%, respectively). The incidence and event rate of American Diabetes Association Level 1 hypoglycaemia during the studies were also comparable between the two groups: 26.7% and 28.2% and 1.7 and 2.1 events per patient-year for the group aged <65 years and the group aged ≥65 years, respectively. A clinically relevant reduction in HbA1c (>1% from baseline for HbA1c ≥64 mmol/mol [≥8%] or ≥0.5% from baseline for HbA1c <64 mmol/mol [<8%]) without hypoglycaemia was attained by 50.0% and 47.6% of participants aged <65 years and ≥65 years, respectively. Adverse events were similar between the two age groups.

CONCLUSIONS

iGlarLixi is a simple, well-tolerated, once-daily alternative for treatment advancement in older people with T2D that provides significant improvements in glycaemic control without increasing hypoglycaemia risk, thus reducing the treatment burden.

Leisure-time physical activity and all-cause mortality and cardiovascular disease in adults with type 2 diabetes: Cross-country comparison of cohort studies

PURPOSE

This study aimed to quantify the dose-response association and the minimal effective dose of leisure-time physical activity (PA) to prevent mortality and cardiovascular disease in adults with type 2 diabetes.

METHODS

Cross-country comparison of 2 prospective cohort studies including 14,913 and 17,457 population-based adults with type 2 diabetes from the UK and China. Baseline leisure-time PA was self-reported and categorized by metabolic equivalent hours per week (MET-h/week) according to World Health Organization recommendations: none, below recommendation (>0-7.49 MET-h/week); at recommended level (7.5-14.9 MET-h/week); above recommendation (≥15 MET-h/week). Mortality and cardiovascular disease data were obtained from national registries.

RESULTS

During a median follow-up of 12.4 and 9.7 years, in the UK and China cohorts, repectively, higher levels of leisure-time PA were inversely associated with all-cause (1571 and 2351 events) and cardiovascular mortality (392 and 1060 events), mostly consistent with a linear dose-response relationship. PA below, at, and above recommendations, compared with no activity, yielded all-cause mortality hazard ratios of 0.94 (95% confidence interval (95%CI): 0.79-1.12), 0.90 (95%CI: 0.74-1.10), and 0.85 (95%CI: 0.70-1.02) in British adults and 0.87 (95%CI: 0.68-1.10), 0.88 (95%CI: 0.74-1.03), and 0.77 (95%CI: 0.70-0.85) in Chinese adults. Associations with cardiovascular mortality were more pronounced in British adults (0.80 (95%CI: 0.58-1.11), 0.75 (95%CI: 0.52-1.09), and 0.69 (95%CI: 0.48-0.97)) but less pronounced in Chinese adults (1.06 (95%CI: 0.76-1.47), 1.01 (95%CI: 0.80-1.28), and 0.79 (95%CI: 0.69-0.92)). PA at recommended levels was not associated with lower rates of major adverse cardiovascular events (2345 and 4458 events).

CONCLUSION

Leisure-time PA at the recommended levels was not convincingly associated with lower mortality and had no association with risk of major adverse cardiovascular events in British or Chinese adults with type 2 diabetes. Leisure-time PA above current recommendations may be needed to prevent cardiovascular disease and premature mortality in adults with type 2 diabetes.

COMPAR-EU Recommendations on Self-Management Interventions in Type 2 Diabetes Mellitus

Self-management interventions (SMIs) offer a promising approach to actively engage patients in the management of their chronic diseases. Within the scope of the COMPAR-EU project, our goal is to provide evidence-based recommendations for the utilisation and implementation of SMIs in the care of adult individuals with type 2 diabetes mellitus (T2DM). A multidisciplinary panel of experts, utilising a core outcome set (COS), identified critical outcomes and established effect thresholds for each outcome. The panel formulated recommendations using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach, a transparent and rigorous framework for developing and presenting the best available evidence for the formulation of recommendations. All recommendations are based on systematic reviews (SR) of the effects and of values and preferences, a contextual analysis, and a cost-effectiveness analysis. The COMPAR-EU panel is in favour of using SMIs rather than usual care (UC) alone (conditional, very low certainty of the evidence). Furthermore, the panel specifically is in favour of using ten selected SMIs, rather than UC alone (conditional, low certainty of the evidence), mostly encompassing education, self-monitoring, and behavioural techniques. The panel acknowledges that, for most SMIs, moderate resource requirements exist, and cost-effectiveness analyses do not distinctly favour either the SMI or UC. Additionally, it recognises that SMIs are likely to enhance equity, deeming them acceptable and feasible for implementation.

Dietary Knowledge and Eating Habits among Patients with Type 2 Diabetes in Lebanon

Little is known about the dietary knowledge (DK) and eating habits (EHs) of patients with type 2 diabetes (T2D) in Lebanon. Therefore, the aim of this study was to assess the DK and EH of the population with T2D and determine their associated factors. A cross-sectional survey enrolling 351 patients with T2D was carried out, using the snowball sampling technique. The survey used the UK Diabetes and Diet Questionnaire and the Dietary Knowledge questionnaire to assess participants' EH including the frequency of consumption of certain foods and their knowledge of food groups and food choices. While a higher DK index indicated better knowledge, a higher EH index indicated less healthy EH. Independent sample T-test and Mann-Whitney test were used for dichotomous variables, and ANOVA and Kruskal-Wallis tests were used for polytomous variables. Correlation analysis tested the association between two continuous variables. Two multiple linear regression models were used to identify factors associated with DK and EH. Overall, 67% of participants had good or adequate DK, and around 25% and 75% of them had healthy and less healthy EH, respectively. Better knowledge was significantly related to occupation, BMI, presence of comorbidities, and HbA1c testing during the last 3 months. Higher family income, physical activity, family history of diabetes, receiving help in medication administration from family or friends, and higher DK level were factors associated with healthier EH. Nutrition education and awareness campaigns aimed at patients and their families are needed to empower patients with adequate DK and skills to facilitate the adoption of healthy EH.

First trans-diagnostic experiences with a novel micro-choice based concentrated group rehabilitation for patients with low back pain, long COVID, and type 2 diabetes: a pilot study

BACKGROUND

The health care is likely to break down unless we are able to increase the level of functioning for the growing number of patients with complex, chronic illnesses. Hence, novel high-capacity and cost-effective treatments with trans-diagnostic effects are warranted. In accordance with the protocol paper, we aimed to examine the acceptability, satisfaction, and effectiveness of an interdisciplinary micro-choice based concentrated group rehabilitation for patients with chronic low back pain, long COVID, and type 2 diabetes.

METHODS

Patients with low back pain > 4 months sick-leave, long COVID, or type 2 diabetes were included in this clinical trial with pre-post design and 3-month follow-up. The treatment consisted of three phases: (1) preparing for change, (2) the concentrated intervention for 3-4 days, and (3) integrating change into everyday life. Patients were taught and practiced how to monitor and target seemingly insignificant everyday micro-choices, in order to break the patterns where symptoms or habits contributed to decreased levels of functioning or increased health problems. The treatment was delivered to groups (max 10 people) with similar illnesses. Client Satisfaction Questionnaire (CSQ-8)) (1 week), Work and Social Adjustment Scale (WSAS), Brief Illness Perception Questionnaire (BIPQ), and self-rated health status (EQ-5D-5L) were registered at baseline and 3-month follow-up.

RESULTS

Of the 241 included participants (57% women, mean age 48 years, range 19-84), 99% completed the concentrated treatment. Treatment satisfaction was high with a 28.9 (3.2) mean CSQ-8-score. WSAS improved significantly from baseline to follow-up across diagnoses 20.59 (0.56) to 15.76 (0.56). BIPQ improved from: 22.30 (0.43) to 14.88 (0.47) and EQ-5D-5L: 0.715 (0.01) to 0.779 (0.01)), all P<0.001.

CONCLUSIONS

Across disorders, the novel approach was associated with high acceptability and clinically important improvements in functional levels, illness perception, and health status. As the concentrated micro-choice based treatment format might have the potential to change the way we deliver rehabilitation across diagnoses, we suggest to proceed with a controlled trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05234281.

Effect of Exercise Therapy on Incident Admission in Patients with Type 2Diabetes Mellitus Undergoing Inpatient Diabetes Self-manageme ntEducation and Support

BACKGROUND

Exercise therapy is the key to preventing admission of patients with type 2 diabetes mellitus (T2DM). However, a few studies have examined the effects of exercise therapy on patients with T2DM undergoing inpatient diabetes self-management education and support (IDSMES).

OBJECTIVE

This study investigated whether exercise therapy influenced the incidence of admission after discharge in patients with T2DM undergoing IDSMES.

METHODS

This retrospective cohort study included patients with T2DM who underwent IDSMES between June 2011 and May 2015. Overall, 258 patients were included in this study. The exercise therapy program was implemented in June 2013. Accordingly, patients diagnosed between June 2011 and May 2013 were categorized as the non-exercise therapy program group, while those diagnosed between June 2013 and May 2015 were categorized as the exercise therapy program group. Outcomes were incident diabetes-related and all-cause admissions within 1 year of discharge. Multiple logistic regression models were used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) of the exercise therapy program's impact on the outcomes.

RESULTS

Within 1 year of discharge, 27 (10.5%) patients underwent diabetes-related admissions and 62 (24.0%) underwent all-cause admissions. Multiple logistic regression analyses showed a significant association of the exercise therapy program with incident diabetes-related and allcause admissions [OR: 0.22 (95% CI: 0.08-0.59) and 0.44 (95% CI: 0.22-0.86), respectively].

CONCLUSION

Exercise therapy programs significantly lowered the incidences of diabetes-related and all-cause admissions. This indicates that implementing exercise therapy during hospitalization may be important for preventing admissions of patients with T2DM receiving IDSMES.

The specially designed nudging tableware promotes healthy food choices: Evidence from a randomized crossover trial in normal-weight young adults

PURPOSE

To evaluate the effects of the specially designed nudging tableware, including a plate and bowl, on individual food choices in normal-weight young adults and preliminarily explore its mechanisms. We hypothesized that the toolset could increase the choice of vegetables and decrease that of rice.

METHODS

A randomized, single-blind, two-period crossover trial was carried out among 40 normal-weight university students in China. All subjects completed two buffets separated by an interval of one week, wearing the eye tracker. Vegetable choice, evaluated through the proportion of vegetables, was the primary outcome, and the weight of vegetables and rice were the secondary outcomes. The mechanisms of the decision-making process were preliminarily explored through eye tracking.

RESULTS

The usage of the nudging tableware significantly increased the proportion of vegetables and decreased the amount of rice taken (P<0.05), while insignificantly increased the weight of vegetables (P = 0.079). Eye tracking shows that the nudging plate significantly prolonged the food-choosing process and fixation duration on vegetables (P<0.05), and the latter was positively correlated to the increased quantity of vegetables while using the nudging plate (r = 0.493, P<0.01).

CONCLUSION

The specially designed nudging tableware might be an effective and practical tool to promote the choice of less rice and more vegetables. Mechanisms behind this change might include automatic and unconscious processes with the inconspicuously smaller capacity of the bowl and larger portion size of the vegetable segment, and increased attention triggered by the vegetable patterns and larger green underpainting.

Achievement of Treatment Goals and Mortality in Individuals with Diabetes: The ELSA-Brasil Study

BACKGROUND

To prevent diabetes complications, the American Diabetes Association (ADA) has recommended the treatment of blood glucose, blood pressure, and LDL-cholesterol (LDL-c) to target levels. Our aim is to characterize the risk of death according to the achievement of these goals in subjects with diabetes participating in the ELSA-Brasil study.

METHODS

ELSA-Brasil is an occupational cohort study of middle-aged and elderly adults followed from a 2008-2010 baseline to 2019 by two additional clinic visits and annual telephone interviews. We ascertained known diabetes by self-reported diagnosis or anti-diabetic medication use. We used treatment targets based on the 2022 ADA guidelines. We ascertained deaths from any cause based on the annual surveillance confirmed by death certificates.

RESULTS

After 11 (1.8) years of follow-up, 261 subjects had died among 2423 with known diabetes. Within-target HbA1c was associated with the greatest protection (HR = 0.66; 95%CI 0.50-0.88) against all-cause mortality. Achieving both glycemic and blood pressure targets conferred substantial protection (HR = 0.54; 95%CI 0.37-0.78). Within-target LDL-c, however, was associated with increased mortality (HR = 1.44; 95%CI 1.11-1.88).

CONCLUSIONS

Glucose and blood pressure control, especially when concomitant, reduced mortality. The increased mortality associated with achieving the LDL-c target merits further investigation.

Qualitative evaluation of a Salutogenic Healthy Eating Programme for Dutch people with type 2 diabetes

The salutogenic model of health (SMH) is a health-promoting theory that focuses on resources, strengths, and coping capacities in everyday life as a way to improve health and wellbeing. The SMH was applied to develop a programme for enabling healthy eating practices among people with type 2 diabetes mellitus (T2DM): the SALUD programme. This study aims to gain insight in how participants with T2DM experienced the content and meaning of the SALUD programme. Three focus groups with participants (six to eight participants/group) that finished the SALUD programme were conducted. The focus groups were video-recorded, transcribed ad verbatim and thematically analysed. The SALUD programme was perceived by the participants as a positive, meaningful learning experience. Key factors why the participants described the programme as positive were that they felt a sense of social-belonging and (emotionally) safe (theme 1). The SALUD programme's positive encouraging approach presented by the coach invited participants to join an active learning process (theme 2). Performing trial-and-error experiments and weekly reflecting on goals is what characterized active learning. The meaningfulness of the learning process (theme 3) was derived from (i) positive self-confrontation; (ii) exploring mind-body connections and perceiving improved health and (iii) noticing positive changes in their social environment (theme 3). To conclude, the study uncovered that the SALUD programme incited a positive, meaningful learning process for healthy eating and the contextual factors important in this. Potential leads to further improve the SALUD programme are discussed in order to maximize the chance of inciting an inclusive, active learning process.

Prevalence of diagnosed depression, anxiety, and ADHD among youth with type 1 or type 2 diabetes mellitus

We examined the prevalence of diagnosed depression, anxiety, and ADHD among youth by diabetes type, insurance type, and race/ethnicity. These mental disorders were more prevalent among youth with diabetes, particularly those with type 2 diabetes, with non-Hispanic White youth with Medicaid and diabetes having a higher prevalence than other races/ethnicities.

Gammeltoft T, Christian Bygbjerg I, W. Meyrowitsch D, Søndergaard J. Pre-/-post-analyses of a feasibility study of a peer-based club intervention among people living with type 2 diabetes in Vietnam's rural communities

OBJECTIVES

Insufficient self-management is a significant barrier for people with type 2 diabetes (T2D) to achieve glycemic control and consequently reduce the risk of acute and long-term diabetes complications, negatively affecting their quality of life and increasing their risk of diabetes-related death. This pre-post study aimed to evaluate whether a peer-based club intervention might reduce glycated hemoglobin from baseline to post-intervention and enhance self-management among people living with T2D in two rural communities in Vietnam.

METHODS

A pre-post study was implemented with 222 adults with T2D residing in two rural communities in Vietnam. We used a structured questionnaire, clinical examination, and glycated hemoglobin to evaluate the possible effects of a diabetes club intervention by comparing Glycated Hemoglobin (HbA1c), Body Mass Index (BMI), Blood Pressure (BP), and diabetes-related self-management behaviors at baseline and post-intervention. The data were analyzed using SPSS 20, applying two related sample tests (Wilcoxon and McNemar test) and a paired-sample t-test at a significance level of less than 0.05.

RESULTS

The findings indicated that after implementation of the intervention, there were no significant statistical differences when comparing pre-and post-intervention levels of the primary outcome HbA1c, but some components of diabetes self-management showed statistically significant improvement.

CONCLUSIONS

After the peer support intervention in a Vietnamese rural community, there was no significant reduction in the primary outcome proportion of patients having an HbA1c less than 7%, but foot care knowledge and practice had improved.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05602441.

Macronutrient Intake in Children and Adolescents with Type 1 Diabetes and Its Association with Glycemic Outcomes

Aims

This study aimed to identify the quantity and range of protein, fat, and carbohydrate consumed in meals and snacks in children with Type 1 diabetes (T1D), and to explore associations between the variability in fat and protein intakes with the glycemic outcomes.

Methods

This was a cross-sectional dietary study of children 6-18 years attending pediatric diabetes service in Australia. Three-day weighed food records were analyzed for the macronutrient intake. Impacts of dietary intake on glycemic outcomes were explored.

Results

Forty-eight children (63% male) aged 11.7 ± 2.9 (mean ± SD) with HbA1c 6.7 ± 1.1% (mmol/mol), BMI Z-score 0.51 ± 0.83, and daily insulin dose 0.99 units/kg completed 3-day weighed food records. Mean intakes at breakfast were 47-g carbohydrate, 15-g protein, and 12-g fat. Lunch: 49-g carbohydrate, 19-g protein, and 19-g fat. Dinner: 57-g carbohydrate, 33-g protein, and 26-g fat. Fifty-five percent (n = 80) of the dinner meals met criteria for a high-fat, high-protein (HFHP) meal. In a subset (n = 16) of participants, exploratory analysis indicated a trend of reduced %TIR (58%) in the 8 hr following HFHP dinner, compared to %TIR (74%) following non-HFHP dinner (p=0.05). Seventy-eight percent of the participants aged 12-18 years intake at dinner varied by more than 20-g fat or more than 25-g protein. There was no association between the variability in fat and protein intake at dinner with HbA1c. Saturated fat contributed to 14.7% (±3.0) of participants energy intake.

Conclusions

Children with T1D frequently consume quantities of fat and protein at dinner that have been shown to cause delayed postprandial hyperglycemia. HFHP dinners were associated with the reduced %TIR over 8 hr, presenting an opportunity for insulin-dose adjustments. Future research that explores the meal dietary variability with postprandial glycemia in this population is needed. Excessive intake of the saturated fat highlights the need for dietary interventions to reduce CVD risk. This trial is registered with ACTRN12622000002785.

Digital health application integrating wearable data and behavioral patterns improves metabolic health

The effectiveness of lifestyle interventions in reducing caloric intake and increasing physical activity for preventing Type 2 Diabetes (T2D) has been previously demonstrated. The use of modern technologies can potentially further improve the success of these interventions, promote metabolic health, and prevent T2D at scale. To test this concept, we built a remote program that uses continuous glucose monitoring (CGM) and wearables to make lifestyle recommendations that improve health. We enrolled 2,217 participants with varying degrees of glucose levels (normal range, and prediabetes and T2D ranges), using continuous glucose monitoring (CGM) over 28 days to capture glucose patterns. Participants logged food intake, physical activity, and body weight via a smartphone app that integrated wearables data and provided daily insights, including overlaying glucose patterns with activity and food intake, macronutrient breakdown, glycemic index (GI), glycemic load (GL), and activity measures. The app furthermore provided personalized recommendations based on users' preferences, goals, and observed glycemic patterns. Users could interact with the app for an additional 2 months without CGM. Here we report significant improvements in hyperglycemia, glucose variability, and hypoglycemia, particularly in those who were not diabetic at baseline. Body weight decreased in all groups, especially those who were overweight or obese. Healthy eating habits improved significantly, with reduced daily caloric intake and carbohydrate-to-calorie ratio and increased intake of protein, fiber, and healthy fats relative to calories. These findings suggest that lifestyle recommendations, in addition to behavior logging and CGM data integration within a mobile app, can enhance the metabolic health of both nondiabetic and T2D individuals, leading to healthier lifestyle choices. This technology can be a valuable tool for T2D prevention and treatment.

Evaluation of an interprofessional follow-up intervention among people with type 2 diabetes in primary care-A randomized controlled trial with embedded qualitative interviews

With an ageing population and improved treatments people live longer with their chronic diseases, and primary care clinics face more costly and difficult-to-treat multimorbid patients. To meet these challenges, current guidelines for the management of type 2 diabetes suggest that an interprofessional team should collaborate to enhance the delivery of worthwhile self-management support interventions. In this study, we aimed to evaluate the effects of an empowerment-based interprofessional follow-up intervention in people with type 2 diabetes in primary care on patient-reported outcomes, biomarkers and weight, and to explore the experiences of patients attending the intervention. We invited patients during regular visits to their general practitioners. The 12-month intervention included 1) empowerment-based counselling; 2) a standardized medical report. The control group received consultations with physicians only. The primary outcome was the Patient Activation Measure, a patient-reported measure assessing individual knowledge, skills, and confidence integral to managing one's health and healthcare. After the trial we conducted qualitative interviews. We observed no difference in the primary outcome scores. On secondary outcomes we found a significant between-group intervention effect in favor of the intervention group, with mean differences in glycemic control after 12 months (B [95% CI] = -8.6 [-17.1, -0.1] mmol/l; p = 0.045), and significant within-group changes of weight (B [95% CI] = -1.8 kg [-3.3, -0.3]; p = 0.02) and waist circumference (B [95% CI] = -3.9 cm [-7.3, -0.6]; p = 0.02). The qualitative data showed that the intervention opened patients' eyes for reflections and greater awareness, but they needed time to take on actions. The patients emphasized that the intervention gave rise to other insights and a greater understanding of their health challenges. We suggest testing the intervention among patients with larger disease burden and a more expressed motivation for change.

Diet in the management of type 2 diabetes: umbrella review of systematic reviews with meta-analyses of randomised controlled trials

Objective

To systematically summarise and evaluate the existing evidence on the effect of diet on the management of type 2 diabetes and prevention of complications.

Design

Umbrella review of systematic reviews with meta-analyses of randomised controlled trials.

Data sources

PubMed, Embase, Epistemonikos, and Cochrane, from inception up to 5 June 2022.

Eligibility criteria for selecting studies

Systematic reviews with meta-analyses of randomised controlled trials reporting summary effect estimates on the effect of diet on any health outcome in populations with type 2 diabetes were included in the review. Only meta-analyses with randomised controlled trials with the duration of at least 12 weeks were eligible for inclusion. Summary data were extracted by two investigators independently. Summary effect estimates with 95% confidence intervals were recalculated with a random effects model if the information provided was insufficient. Methodological quality was assessed with the A MeaSurement Tool to Assess systematic Reviews (AMSTAR) 2 tool and the certainty of evidence with the Grading of Recommendations Assessment, Development, and Evaluations (GRADE) approach.

Results

88 publications with 312 meta-analyses of randomised controlled trials were included. Methodological quality was high to moderate in 23% and low to very low in 77% of the included publications. A high certainty of evidence was found for the beneficial effects of liquid meal replacement on reducing body weight (mean difference -2.37 kg, 95% confidence interval -3.30 to -1.44; n=9 randomised controlled trials included in the meta-analysis) and body mass index (-0.87, -1.32 to -0.43; n=8 randomised controlled trials), and of a low carbohydrate diet (<26% of total energy) on levels of haemoglobin A1c (-0.47%, -0.60% to -0.34%; n=17 randomised controlled trials) and triglycerides (-0.30 mmol/L, -0.43 to -0.17; n=19 randomised controlled trials). A moderate certainty of evidence was found for the beneficial effects of liquid meal replacement, plant based, Mediterranean, high protein, low glycaemic index, and low carbohydrate diets (<26% total energy) on various cardiometabolic measures. The remaining results had low to very low certainty of evidence.

Conclusions

The evidence indicated that diet has a multifaceted role in the management of type 2 diabetes. An energy restricted diet can reduce body weight and improve cardiometabolic health. Beyond energy restriction, dietary approaches such as plant based, Mediterranean, low carbohydrate (<26% total energy), or high protein diets, and a higher intake of omega 3 fatty acids can be beneficial for cardiometabolic health in individuals with type 2 diabetes.

Systematic review registration

PROSPERO CRD42021252309.