Diabetes Prevention in Australia: 10 Years Results and Experience

Understanding diabetes risk in the Y Community of Greater Brisbane: Findings from a cross-sectional survey

BACKGROUND

This cross-sectional study aimed to understand the need and desire for a diabetes prevention program within the Y (formerly YMCA: Young Men's Christian Association) of the Greater Brisbane region, Queensland, Australia.

METHODS

An anonymous online survey was distributed (March-April 2023) by The Y Queensland targeting adults within the Greater Brisbane Y community. Data were collected on Y membership and branch attended, postcode, diabetes risk in the next 5 years (low, medium, or high), and interest in participation in a diabetes prevention program. Data were analysed via descriptives and cross tabulation with statistical significance considered at p < .05.

RESULTS

Respondents (n = 575) were primarily female (65%), attending a Y branch located in the outer city (51%), and aged under 55 years (68%). Twenty Y sites were represented, with a mix of inner-city, outer-city, and regional areas. Overall, 46% (n = 241/530) of respondents were at high diabetes risk, with those living in relatively socio-economically disadvantaged areas more likely (p < .001) to be at high-risk (57%) than intermediate (26%) or low-risk (18%). Most (68%) respondents were interested/potentially interested in program participation; those at high risk of developing diabetes in the next 5 years were most interested (55%).

CONCLUSIONS

The Y in Greater Brisbane may provide a suitable setting to host a community-based diabetes prevention program. Locations outside the inner city should be prioritised to target those who are relatively socio-economically disadvantaged to align with higher need and demand. SO WHAT?: Findings inform the implementation and prioritisation of a community-delivered diabetes prevention program.

A critical realist exploration of factors influencing engagement in diabetes prevention programs in rural settings

BACKGROUND

Diabetes prevention programs are intended to reduce progression to type 2 diabetes, but are underutilised. This study aimed to explore people with prediabetes' knowledge and attitudes about prediabetes, and their perceptions about engagement in preventive programs in a rural setting. The findings will inform strategies and recommendations to increase preventive health program engagement.

METHODS

Using a qualitative approach with a critical realist methodology, semi-structured interviews were conducted with 20 rural participants with prediabetes from the Northern New South Wales Local Health District in 2021. Interviews were audio-recorded, transcribed verbatim and thematically analysed. The social-ecological model was used as a framework to interpret and action the study findings.

RESULTS

Factors that empowered participants and facilitated a desire to engage in preventive programs included knowledge about prediabetes, a high level of social support, trusting and supportive relationships with health professionals, and a strong desire not to progress to diabetes. Barriers to program engagement included low health literacy levels, limited support, negative experiences with health services, and social and physical constraints. The factors that influenced engagement with preventive health programs were mapped to an individual, interpersonal, organisational, community and policy level, which highlighted the complex nature of behaviour change and the influence of underlying mechanisms.

CONCLUSIONS

Engagement in diabetes prevention programs was dependent on individual agency factors and structural barriers, each of which related to a level of the social-ecological model. Understanding the perceptions of people with prediabetes will inform strategies to overcome multi-level barriers to preventive health program engagement in rural settings.

Implementation of a diabetes prevention programme in a multi-ethnic community in primary care in England: An evaluation using constructs from the RE-AIM Framework

AIMS

To implement a diabetes prevention programme in primary care METHODS: The programme was implemented for 12 months in two neighbouring towns, served by eight general practices. Practices requested a referral pathway involving an external administrator running electronic searches and sending postal invitations. If interested, people called and booked a place on the programme. Practices were also provided with resources to refer people directly. Six Educators were trained to deliver the programme. The RE-AIM constructs "Adoption", "Reach" and "Uptake" were assessed.

RESULTS

All practices engaged in the searches and postal invitations. Overall, 3.9 % of those aged ≥ 25 years had an HbA1c level indicative of non-diabetic hyperglycaemia (NDH) and were invited. Overall uptake (attended as percentage of invited) was 16 % (practice range 10.5-26.6 %) and was highest in two practices where the invitation was followed by a telephone call. Four people were referred directly by their practice. Groups at risk of being excluded were the Bengali population and those unable to attend because of issues such as health, mobility and frailty.

CONCLUSIONS

Comprehensive electronic searches meant everyone previously diagnosed with NDH was invited to attend. Follow-up telephone call improved uptake and providing practices with resources to make these calls themselves would likely increase uptake further.

A multiple case study of pre-diabetes care undertaken by general practice in Aotearoa/New Zealand: de-incentivised and de-prioritised work

BACKGROUND

In Aotearoa/New Zealand (NZ) general practices diagnose and manage pre-diabetes. This work is important as it has the potential to delay or prevent the onset of Type 2 Diabetes (T2DM), reduce NZ's health inequities, and the burden that T2DM places on health care services. However, no study has previously examined how this work routinely occurs in NZ.

METHODS

Two case studies of practices serving ethnically and socio-economically diverse populations, followed by cross-case analysis.

RESULTS

The NZ health care context including funding mechanisms, reporting targets, and the disease centred focus of care, acted together to dis-incentivise and de-prioritise pre-diabetes care in general practices. The social determinants of health differentially influenced patients' ability to engage with and respond to pre-diabetes care, significantly impacting this work. Differing perspectives about the significance of pre-diabetes and gaps in systematic screening practices were identified. Interventions used were inconsistent and lacked comprehensive ongoing support.

CONCLUSIONS

Complex multi-layered factors impact on pre-diabetes care, and many of the barriers cannot be addressed at the general practice level. The practice serving the most disadvantaged population who concurrently have higher rates of pre-diabetes/T2DM were more adversely affected by the barriers identified.

Miscarriage, stillbirth and the risk of diabetes in women: A systematic review and meta-analysis

AIMS

Whether women with a history of miscarriage or stillbirth have an increased risk of diabetes is inconclusive. We aimed to systematically assess the association between them.

METHODS

We searched PubMed, Web of Science and Scopus through November 2022. Random-effect model for meta-analysis was applied to calculate pooled odds ratios and corresponding 95 % confidence intervals (CIs) when heterogeneity was > 40 %.

RESULTS

Thirteen cohort studies and eight case-control studies with a total of 529,990 participants were included. Women ever experiencing a miscarriage had a 1.15-fold risk of non-gestational diabetes (95% CI: 1.02-1.28) and a 1.62-fold risk of gestational diabetes (95% CI: 1.32-1.98) compared to those never experiencing a miscarriage. Of them, women with three or more miscarriages had a 1.99-fold risk of non-gestational diabetes (95% CI: 1.36-2.91). The risk of non-gestational diabetes among women ever experiencing a stillbirth was 1.21 times compared with those never experiencing a stillbirth (95% CI: 1.03-1.41). Pooled results did not support a stable association between stillbirth and gestational diabetes risk (odds ratio:1.91, 95% CI: 1.00-3.64).

CONCLUSIONS

A history of miscarriage or stillbirth was associated with an increased risk of diabetes in women. Future studies are needed to explore whether prediabetic metabolic conditions contribute to this association.

It is time for a more targeted approach to prediabetes in primary care in Aotearoa New Zealand

Type 2 diabetes (T2DM), its related morbidities and entrenched diabetes-related inequities pose significant challenges for health care delivery systems in Aotearoa New Zealand (NZ). Primary care services undertake the majority of diabetes prevention work by initially detecting and managing those with prediabetes. In this viewpoint, we present available NZ data to highlight NZ trends in prediabetes and consider the current NZ clinical guidelines and the prediabetes care pathway. Multiple areas for improvement are identified to optimise diabetes prevention, potentially reduce T2DM inequities, and sustain more effective prediabetes management in primary care in NZ.

Delivering the Diabetes Remission Clinical Trial (DiRECT) in primary care: Experiences of healthcare professionals

OBJECTIVE

The Diabetes Remission Clinical Trial (DiRECT) used a formula total diet replacement programme followed by structured weight loss maintenance to induce and sustain weight loss and remission of type 2 diabetes (T2D) in 36% of participants after 2 years. Nurses and dietitians delivering DiRECT in 22 primary care practices in Tyneside and Scotland provided behavioural support to participants. Participant experiences with DiRECT highlighted the key role of support by healthcare professionals (HCPs). We evaluated HCPs' experiences with DiRECT.

RESEARCH DESIGN AND METHODS

Healthcare professionals delivering DiRECT were interviewed at 12 months, while general practices (GPs) were sent an implementation questionnaire. The interviews were analysed thematically. The questionnaires were analysed using frequencies and a narrative synthesis.

RESULTS

Healthcare professionals representing 11 of 22 intervention practices were interviewed and 10 of 22 GPs completed questionnaires. HCPs' initial concerns over perceived potential negative intervention effects, particularly withdrawing anti-diabetes and anti-hypertensive medications, were barriers to engagement. Trust of HCPs towards the research team and perceived credibility of the study facilitated engagement and adoption. Ongoing support by research dietitians was key to the management of participants. Involvement in DiRECT inspired more focus on behaviour modification in the treatment of other people living with T2D in routine practice.

CONCLUSIONS

Diabetes Remission Clinical Trial was considered highly appropriate for the management of T2D in primary care when supported by trained dietitians. Addressing limitations, including varying training needs of HCPs may improve intervention scale-up and tailoring to clinical contexts.

Implementing a national diabetes prevention programme in England: lessons learned

Background

Type 2 diabetes mellitus is preventable through lifestyle intervention. Diabetes prevention programmes (DPPs) aim to deliver prevention-based behaviour change interventions to reduce incidence. Such programmes vary from usual primary care in terms of where, how, and by whom they are delivered. Implementation is therefore likely to face new commissioning, incentive and delivery challenges. We report on the implementation of a national DPP in NHS England, and identify lessons learned in addressing the implementation challenges.

Methods

In 2017/18, we conducted 20 semi-structured telephone interviews covering 16 sampled case sites with the designated lead(s) responsible for local implementation of the programme. Interviews explored the process of implementation, including organisation of the programme, expectations and attitudes to the programme, funding, target populations and referral and clinical pathways. We drew on constant comparative methods to analyse the data and generate over-arching themes. We complemented our qualitative data with a survey focused on variation in the financial incentives used across sites to ensure usual primary care services recruited patients to new providers.

Results

We identified five over-arching areas of learning for implementing this large-scale programme: 1) managing new providers; 2) promoting awareness of services; 3) recruiting patients; 4) incentive payments; and 5) mechanisms for sharing learning. In general, tensions appeared to be caused by a lack of clear roles/responsibilities between hierarchical actors, and lack of communication. Both local sites and the national NHS coordination team gained experience through learning by doing. Initial tensions with roles and expectations have been worked out during implementation.

Conclusions

Implementing a national disease prevention programme is a major task, and one that will be increasingly faced by health systems globally as they aim to adjust to demand pressures. We provide practical learning opportunities for the wider uptake and sustainability of prevention programmes. Future implementers might wish to define clear responsibilities for each actor prior to implementation, ensure early engagement with new providers, offer mechanisms/forums for sharing learning, generate evidence and provide advice on incentive payments, and prioritise public and professional awareness of the programme.

How do we identify people at high risk of Type 2 diabetes and help prevent the condition from developing?

AIMS

To review the evidence regarding the identification of those at high risk of Type 2 diabetes and the conceptual and clinical criteria defining high risk, the prevention or delay of onset of Type 2 diabetes through lifestyle interventions, and the evolution of evidence from efficacy trials, through effectiveness trials in real-world settings, to implementation programmes at scale.

METHOD

The wide scope of this review precluded a systematic approach, therefore, we present a narrative review that highlights key themes and contemporary developments, drawing on landmark studies, previous systematic and expert reviews, and previous meta-analyses.

RESULTS

While the diagnostic thresholds for Type 2 diabetes are accepted, international consensus on whether, and how, to classify those at high risk of Type 2 diabetes has not been achieved. There is ongoing debate about which laboratory test to use and each test's corresponding inclusion threshold, about where the balance of clinical benefits and harms sit when defining thresholds, and about how affordability of subsequent preventative interventions might influence the derivation of such thresholds within any particular population. A remarkable international effort has seen the evolution of interventions for those at high risk move from efficacy trials, through effectiveness trials, to implementation at scale, and the evidence supporting each stage is reviewed.

CONCLUSIONS

To achieve healthcare system sustainability, many countries are now focusing on disease prevention. To complement population-level interventions that address the obesogenic environment, lifestyle interventions that empower individuals at high risk of Type 2 diabetes to modify this risk beneficially are now being implemented at scale.

Associations between physical activity and cataract treated surgically in patients with diabetes: findings from the 45 and Up Study

AIM

To investigate the association between physical activity (PA) and incidence of cataract surgery among patients with diabetes.

METHODS

We obtained data from all diabetic subjects aged 45-65 years from the baseline of the prospective 45 and Up Study from 2006 to 2009 and linked to the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) until 2016. Diabetes was defined as self-reported on questionnaire or diabetes medication history based on PBS. Cataract surgery was determined based on the MBS, and metabolic equivalent intensity level number of PA sessions per week was used to assess PA. Cox regression was used to assess the association between baseline PA and cataract surgery during the follow-up.

RESULTS

A total of 9113 diabetic participants in the 45 and Up Study were included in the current analysis with a mean age of 57.3±5.2 years (43.6% female). During a mean follow-up of 8.8 years, 950 participants (10.4% of baseline) received cataract surgery with a corresponding incidence of 12.4/1000 person-years. Cox regression analysis showed that people with less PA (p=0.01), older age (p<0.001), female gender (p<0.001), higher educational level (p<0.001) and longer diabetic duration (p<0.001) had significantly higher cataract surgery risk. Participants with a PA level of ≥14 sessions per week had 19% decreased risk of cataract surgery compared to those with <5 sessions per week. Stratification analysis showed that participants with more obesity (p value for interaction=0.03), not taking insulin (p value for interaction=0.01) and without cardiovascular disease (p value for interaction=0.008) could benefit significantly more from PA in reducing their cataract surgery risk.

CONCLUSIONS

More vigorous PA was independently associated with a reduced risk of cataract surgery in working-aged patients with diabetes.

Usefulness of a Novel Mobile Diabetes Prevention Program Delivery Platform With Human Coaching: 65-Week Observational Follow-Up

BACKGROUND

It is widely recognized that the prevalence of obesity and comorbidities including prediabetes and type 2 diabetes continue to increase worldwide. Results from a 24-week Diabetes Prevention Program (DPP) fully mobile pilot intervention were previously published showing promising evidence of the usefulness of DPP-based eHealth interventions on weight loss.

OBJECTIVE

This pilot study extends previous findings to evaluate weight loss results of core (up to week 16) and maintenance (postcore weeks) DPP interventions at 65 weeks from baseline.

METHODS

Originally, 140 participants were invited and 43 overweight or obese adult participants with a diagnosis of prediabetes signed up to receive a 24-week virtual DPP with human coaching through a mobile platform. At 65 weeks, this pilot study evaluates weight loss and engagement in maintenance participants by means of repeated measures analysis of variances and backward multiple linear regression to examine predictors of weight loss. Last observation carried forward was used for endpoint measurements.

RESULTS

At 65 weeks, mean weight loss was 6.15% in starters who read 1 or more lessons per week on 4 or more core weeks, 7.36% in completers who read 9 or more lessons per week on core weeks, and 8.98% in maintenance completers who did any action in postcore weeks (all P<.001). Participants were highly engaged, with 80% (47/59) of the sample completing 9 lessons or more and 69% (32/47) of those completing the maintenance phase. In-app actions related to self-monitoring significantly predicted weight loss.

CONCLUSIONS

In comparison to eHealth programs, this pilot study shows that a fully mobile DPP can produce transformative weight loss. A fully mobile DPP intervention resulted in significant weight loss and high engagement during the maintenance phase, providing evidence for long-term potential as an alternative to in-person DPP by removing many of the barriers associated with in-person and other forms of virtual DPP.

Dietary habits, physical activity and diabetes perception among patients with type 2 diabetes mellitus in Tabuk City, Saudi Arabia

Background

Medical nutritional therapy is an important aspect of diabetes care, there is an increasing awareness of breakfast skipping, late dinner and meal contents on diabetes control.

Aim

To assess dietary habits, physical activity and diabetes perception among patients with type 2 diabetes.

Methods

This case-control study was conducted among patients with diabetes mellitus at the diabetes center in Tabuk City, Saudi Arabia during the period from March through June 2017. One hundred patients with type 2 diabetes and 150 control subjects were interviewed to collect demographic data regarding, breakfast skipping, late dinner intake, and fruit, vegetables, sweet food, and fast food consumption. Diabetic patients’ perception of their disease was also assessed. (If diabetes is serious, it can be prevented and reversible). Data were analyzed by SPSS version 20 using Chi-square and independent-samples t-test.

Results

In the present study, body mass index (BMI) (p<0.001), fast food consumption (p<0.001), fruit consumption (p=0.004), and breakfast skipping (p<0.001) were higher among patients with diabetes compared to controls. No differences were found regarding the level of exercise, smoking, late dinner intake and diabetes perception. A significant statistical difference was observed between poor and accepted control regarding sweet food intake (p=0.046) and exercise (p=0.017).

Conclusion

Patients with type 2 diabetes had higher BMI, and were more likely to skip breakfast, consume less fast food and more fruits than control subjects. More physical activity and less sweet food consumption was observed among patients with accepted glycemic control.