Diabetes Prevention at the Tipping Point: Aligning Clinical and Public Health Recommendations

Moms in motion: weight loss intervention for postpartum mothers after gestational diabetes: a randomized controlled trial

Background

Up to 50 % of women with gestational diabetes mellitus (GDM) will receive a diagnosis of type 2 diabetes mellitus (T2DM) within a decade after pregnancy. While excess postpartum weight retention exacerbates T2DM risk, lifestyle changes and behavior modifications can promote healthy postpartum weight loss and contribute to T2DM prevention efforts. However, some women have difficulty prioritizing self-care during this life stage. Efficacious interventions that women can balance with motherhood to reduce T2DM risk remain a goal. The objective of the Moms in Motion study is to evaluate the efficacy of a simple, novel, activity-boosting intervention using ankle weights worn with daily activities during a 6-month postpartum intervention among women with GDM. We hypothesize that women randomized to the 6-month intensity-modifying intervention will (1) demonstrate greater weight loss and (2) greater improvement in body composition and biomarker profile versus controls.

Methods

This study will be a parallel two-arm randomized controlled trial (n = 160). Women will be allocated 1:1 to an ankle weight intervention group or a standard-of-care control group. The intervention uses ankle weights (1.1 kg) worn on each ankle during routine daily activities (e.g., cleaning, childcare). Primary outcomes include pre- and post-assessments of weight from Visit 2 to Visit 3. Secondary outcomes include body composition, glycemia (2-h, 75 g oral glucose tolerance test), and fasting insulin. Exploratory outcomes include energy expenditure, diet, and psychosocial well-being.

Discussion

Beyond the expected significance of this study in its direct health impacts from weight loss, it will contribute to exploring (1) the mechanism(s) by which the intervention is successful (mediating effects of energy expenditure and diet on weight loss) and (2) the effects of the intervention on body composition and biomarkers associated with insulin resistance and metabolic health. Additionally, we expect the findings to be meaningful regarding the intervention’s effectiveness on engaging women with GDM in the postpartum period to reduce T2DM risk.

Trial registration

The ClinicalTrials.gov Identifier, is NCT03664089. The trial registration date is September 10, 2018. The trial sponsor is Dr. Sarah A. Keim.

Adapting the "Resist Diabetes" Resistance Training Intervention for Veterans

PURPOSE

The Resist Diabetes trial demonstrated that twice-per-week resistance training reduced prediabetes prevalence and improved strength among older adults with prediabetes. Our objective was to determine initial perceptions of patients and care providers in a Veterans Affairs Medical Center (VAMC) regarding Resist Diabetes (RD), and ultimately, inform adaptations to improve uptake of RD in the Veterans Health Administration.

METHODS

A mixed-methods approach was utilized. Care providers (n=20) and veterans with prediabetes (n=12) were recruited to gauge perceptions of the RD program and identify barriers and facilitators to the program referral process and program implementation. Care provider perceptions of the acceptability, appropriateness and feasibility were determined using a validated survey. Open-ended questionnaires and interview guides, based upon the Consolidated Framework for Implementation Research, were utilized to determine major and minor themes within the provider and veteran responses. To identify the dissemination potential of RD, the availability of onsite fitness facilities at VAMC facilities nationally (n=159) was assessed.

RESULTS

Providers rated (scaled 1-5; 1=completely disagree, 5=completely agree) the RD program as appealing (4.8+/-0.1), appropriate (4.8+/-0.0), and feasible (4.6+/-0.2). Providers reported that prediabetes/diabetes is a significant problem in the VAMC, and that different prevention programs will appeal to different types of VAMC patients. Patients (n=12; 58% female; aged 65+/-10yrs; BMI 34+/-6 kg/m²; HbA1c 5.7+/-1.8%) expressed interest in an exercise-focused diabetes prevention program and defined key barriers: travel, transportation, and time constraints. Among the responding national VAMC sites, 85% (97/114) reported having an onsite fitness facility.

CONCLUSION

Salem VAMC care providers and veteran patients demonstrated positive perceptions of the Resist Diabetes program. Program adaptations are needed to address barriers to patient participation including travel, transportation and time constraints.

Resist diabetes: A randomized clinical trial for resistance training maintenance in adults with prediabetes

Objective

To determine whether a social cognitive theory (SCT)-based intervention improves resistance training (RT) maintenance and strength, and reduces prediabetes prevalence.

Research design and methods

Sedentary, overweight/obese (BMI: 25–39.9 kg/m²) adults aged 50–69 (N = 170) with prediabetes participated in the 15-month trial. Participants completed a supervised 3-month RT (2×/wk) phase and were randomly assigned (N = 159) to one of two 6-month maintenance conditions: SCT or standard care. Participants continued RT at a self-selected facility. The final 6-month period involved no contact. Assessments occurred at baseline and months 3, 9, and 15. The SCT faded-contact intervention consisted of nine tailored transition (i.e., supervised training to training alone) and nine follow-up sessions. Standard care involved six generic follow-up sessions. Primary outcomes were prevalence of normoglycemia and muscular strength.

Results

The retention rate was 76%. Four serious adverse events were reported. After 3 months of RT, 34% of participants were no longer prediabetic. This prevalence of normoglycemia was maintained through month 15 (30%), with no group difference. There was an 18% increase in the odds of being normoglycemic for each % increase in fat-free mass. Increases in muscular strength were evident at month 3 and maintained through month 15 (P<0.001), which represented improvements of 21% and 14% for chest and leg press, respectively. Results did not demonstrate a greater reduction in prediabetes prevalence in the SCT condition.

Conclusions

Resistance training is an effective, maintainable strategy for reducing prediabetes prevalence and increasing muscular strength. Future research which promotes RT initiation and maintenance in clinical and community settings is warranted.

Trial Registration

ClinicalTrials.gov NCT01112709.

Which foods are displaced in the diets of adults with type 2 diabetes with the inclusion of eggs in their diets? A randomized, controlled, crossover trial

BACKGROUND

The inclusion or exclusion of specific foods from the overall diet inevitably affects other food choices, and this matter is routinely neglected in dietary guidance and nutritional epidemiology. We examined how the inclusion of eggs in the diets of type 2 diabetics affected dietary pattern.

METHODS

Randomized, controlled, single-blind, crossover trial of 34 adults (mean age 64.5 years; 14 women, 20 men) with type 2 diabetes assigned to one of two possible sequence permutations of two different 12-week treatments (two eggs/day or egg exclusion), with 6-week washout periods. For the egg inclusion phase, participants received advice from a dietitian on how to preserve an isocaloric condition relative to the egg exclusion phase. To assess changes in dietary pattern in the diets of our study participants, we analyzed the 12 components of the 2010 Healthy Eating Index.

RESULTS

The inclusion of eggs was associated with reduced consumption of refined grains nearing statistical significance (-0.7±3.4 vs 0.7±2.2; p=0.0530). The consumption of total protein foods significantly increased from baseline (0.3±0.7; p=0.0153) with the inclusion of eggs for 12 weeks, while the consumption of dairy products significantly decreased with the exclusion of eggs from their diets (-1.3±2.9; p=0.0188).

CONCLUSIONS

Eggs in the diets of type 2 diabetics may lead to increased consumption of some healthful foods and reduced consumption of some less healthful foods.

TRIAL REGISTRATION NUMBER

NCT02052037; Post-results.

Elevated serum total bilirubin levels are negatively associated with major diabetic complications among Chinese senile diabetic patients

AIMS

This study aimed to evaluate the association between total bilirubin (TBiL) and major diabetic complications among Chinese senile diabetic patients.

METHODS

A cross-sectional study was conducted in all the cadre sanitariums in Beijing, between May 2012 and December 2014. All the diagnoses of diabetic complications were extracted from the medical records including chronic kidney disease, retinopathy, peripheral vascular disease, coronary heart disease, and ischemic stroke.

RESULTS

The mean age of the 1839 senile diabetic patients were 87.4±4.0 (80-102years) and mean TBiL level was 13.2±6.0μmol/L. The prevalence of chronic kidney disease, retinopathy, peripheral vascular disease, coronary heart disease and ischemic stroke was 13.8%, 17.8%, 5.8%, 62.5%, and 44.5%, respectively. TBiL level was negatively correlated with age, weight, SBP, TC, FBG, 2hPG, diabetic duration and positively correlated with HDL-C. Prevalence of all five diseases gradually decreased with the increase of TBiL level (p<0.05). Also, number of diabetic complications showed a decreasing trend along with TBiL tertiaries. After adjusted age, education, marital status, current smoking, current drinking, physical activity ≥0.5h/day, BMI, hypertension, dyslipidemia, treatment and control status of diabetes, patients with higher TBiL level were at significantly decreased ORs for prevalence of major diabetic complications. The ORs were 0.97 (95%CI: 0.96-0.99), 0.90 (95%CI: 0.87-0.93), 0.98 (95%CI: 0.97-0.99), 0.97 (95%CI: 0.95-.99) and 0.98 (95%CI: 0.97-0.99) for chronic kidney disease, retinopathy, peripheral vascular disease, coronary heart disease and ischemic stroke (p<0.005). Similar results were obtained when TBiL was used as tertiary variable.

CONCLUSION

Higher TBiL was significantly associated with lower prevalence of major diabetic complication among senile diabetic patients, and this association was graded with TBiL level and independent of age and control status of diabetes.

"Prediabetes": Are There Problems With This Label? Yes, the Label Creates Further Problems!

The category of "prediabetes" defined by the American Diabetes Association comprises a range of intermediate hyperglycemia based on fasting or 2-h postload glucose or on HbA1c Over the recent past, the "cut points" identifying this stage have changed, i.e., a lower fasting glucose level is used. On one hand, it can be argued that the change to a lower cut point identifies a group of individuals still at higher risk and provides heightened awareness for a condition associated with higher risk for cardiovascular disease. In addition, identification of individuals at this stage may represent a chance of earlier intervention in the disease. However, the argument against this definition of "prediabetes" is that it disguises the differences in the three subcategories and creates problems in interpreting observations on interventions and outcomes. In addition, it can be argued that the enormous numbers of people identified with the criteria far exceeds the capacity of health care systems to respond through individual care, particularly without evidence that interventions benefit any category other than impaired glucose tolerance. Thus, there does not appear to be consensus on the definition using the cut points identified. Controversy also remains as to whether there are glycemic metrics beyond HbA1c that can be used in addition to HbA1c to help assess risk of an individual developing diabetes complications. Given the current controversy, a Point-Counterpoint debate on this issue is provided herein. In the point narrative below, Dr. Yudkin provides his argument that there are significant problems with this label. In the counterpoint narrative that follows Dr. Yudkin's contribution, Dr. Cefalu argues that the cut points are appropriate and do provide useful and important information in trying to reduce the future burden of diabetes.-William T. CefaluEditor in Chief, Diabetes Care.

Egg ingestion in adults with type 2 diabetes: effects on glycemic control, anthropometry, and diet quality-a randomized, controlled, crossover trial

BACKGROUND

The inclusion of eggs as part of a healthful diet for adults with diabetes is controversial. We examined the effects of including eggs in the diet of adults with type 2 diabetes on cardiometabolic risk factors.

METHODS

Randomized, controlled, single-blind, crossover trial of 34 adults (mean age 64.5 years; 14 postmenopausal women, 20 men) with type 2 diabetes assigned to one of two possible sequence permutations of two different 12-week treatments (two eggs/day inclusion or egg exclusion), with 6-week washout periods. For the egg inclusion phase, participants received advice from a dietitian on how to preserve an isocaloric condition relative to the egg exclusion phase. The primary outcome was glycemic control as measured by glycated hemoglobin. Secondary measures included anthropometry, blood pressure, and diet quality.

RESULTS

Compared with the exclusion of eggs in the habitual diet, the inclusion of eggs did not measurably affect glycated hemoglobin (0.01±0.5% vs -0.24±0.7%; p=0.115) and systolic blood pressure (-0.8±13.0 vs -3.0±10.0 mm Hg; p=0.438); and significantly reduced body mass index (0.06±0.8 vs -0.4±0.8 kg/m²; p=0.013) and visceral fat rating (0.2±1.1 vs -0.4±1.0; p=0.016). The inclusion of eggs in the habitual diet of diabetics significantly reduced waist circumference (-0.4±1.2 cm; p=0.004) and percent body fat (-0.7±1.8; p=0.033) from baseline.

CONCLUSIONS

Short-term daily inclusion of eggs in the habitual diet of adults with type 2 diabetes does not improve glycemic control but can improve anthropometric measures.

TRIAL REGISTRATION NUMBER

NCT02052037; results.