Healthy food prescription incentive programme for adults with type 2 diabetes who are experiencing food insecurity: protocol for a randomised controlled trial, modelling and implementation studies

INTRODUCTION

The high cost of many healthy foods poses a challenge to maintaining optimal blood glucose levels for adults with type 2 diabetes mellitus who are experiencing food insecurity, leading to diabetes complications and excess acute care usage and costs. Healthy food prescription programmes may reduce food insecurity and support patients to improve their diet quality, prevent diabetes complications and avoid acute care use. We will use a type 2 hybrid-effectiveness design to examine the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) of a healthy food prescription incentive programme for adults experiencing food insecurity and persistent hyperglycaemia. A randomised controlled trial (RCT) will investigate programme effectiveness via impact on glycosylated haemoglobin (primary outcome), food insecurity, diet quality and other clinical and patient-reported outcomes. A modelling study will estimate longer-term programme effectiveness in reducing diabetes-related complications, resource use and costs. An implementation study will examine all RE-AIM domains to understand determinants of effective implementation and reasons behind programme successes and failures.

METHODS AND ANALYSIS

594 adults who are experiencing food insecurity and persistent hyperglycaemia will be randomised to a healthy food prescription incentive (n=297) or a healthy food prescription comparison group (n=297). Both groups will receive a healthy food prescription. The incentive group will additionally receive a weekly incentive (CDN$10.50/household member) to purchase healthy foods in supermarkets for 6 months. Outcomes will be assessed at baseline and follow-up (6 months) in the RCT and analysed using mixed-effects regression. Longer-term outcomes will be modelled using the UK Prospective Diabetes Study outcomes simulation model-2. Implementation processes and outcomes will be continuously measured via quantitative and qualitative data.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of Calgary and the University of Alberta. Findings will be disseminated through reports, lay summaries, policy briefs, academic publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04725630.

PROTOCOL VERSION

Version 1.1; February 2022.

A Subsidized Healthy Food Prescription Program for Adults With Type 2 Diabetes Who Are Experiencing Food Insecurity: Protocol for a Randomized Controlled Trial

Objectives

It is vital for individuals with type 2 diabetes (T2DM) to adhere to a healthy dietary pattern to maintain optimal blood glucose levels and overall health. Increasing costs of healthy foods, however, are a barrier to maintaining healthful dietary patterns, particularly for individuals with T2DM who are experiencing food insecurity. Poor diet quality may result in difficulties maintaining optimal blood glucose levels, leading to higher rates of diabetes complications, and increased acute care usage and costs. Although the adverse impacts of food insecurity on maintaining optimal blood glucose levels are well documented, effective strategies to this among individuals with T2DM are lacking. One approach is providing subsidies to purchase healthy foods through subsidized healthy food prescription programs. These programs may help reduce food insecurity and improve diet quality, thereby improving blood glucose levels and reducing diabetes complications over time.

Methods

A parallel group randomized controlled trial will examine the effectiveness of a subsidized healthy food prescription program compared to a healthy food prescription alone in improving average blood glucose levels (primary outcome), and other secondary outcomes among 404 adults who are experiencing food insecurity and persistent hyperglycemia. The subsidized healthy food prescription program consists of two core elements: 1) A one-time healthy food prescription pamphlet that outlines an evidence-based healthy dietary pattern; 2) A healthy food subsidy of $1.50/day/household member to purchase healthy foods in participating supermarkets for 6 months. At baseline and 6-month follow-up, participants will provide responses to sociodemographic and health-related items, and a variety of patient-reported outcomes. Biochemical and physical measurements will also be obtained.

Results

The study's theory of change posits that reducing food insecurity and improving diet quality will be key mediators in improving blood glucose levels, which may reduce diabetes complications, and healthcare usage and costs over time.

Conclusions

The results of this study will demonstrate if a subsidized healthy food prescription program results in meaningful changes in average blood glucose levels and other clinically relevant outcomes.

Funding Sources

Alberta Innovates, Alberta Health Services.

Usefulness of novel martin/hopkins and sampson equations over friedewald equation in cardiology outpatient: CVSCORE-TR substudy

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

CVSCORE-TR study group

Background

Friedewald equation (LDL-Cf) is known to produce inaccurate estimations of low-density lipoprotein cholesterol (LDL-C) when triglycerides are high (>400 mg/dl) or LDL-C is low (<70 mg/dl). Martin/Hopkins (LDL-Cmh) and Sampson (LDL-Cs) equations were developed to overcome these limitations, but few data are available whether these equations offer incremental usefulness over LDL-Cf.

Purpose

  In this pragmatic study, we aimed to evaluate the agreement between LDL-C calculated using LDL-Cmh, LDL-Cs and LDL-Cf equations and to understand whether using LDL-Cmh or LDL-Cs instead of LDL-Cf leads to significant changes on the clinical decision-making 

Methods

4196 cardiology outpatient cases that were included in a multicenter registry database were analyzed. Each case was assigned into a cardiovascular risk class using web-based SCORE (Systematic COronary Risk Evaluation) algorithm calibrated for high-risk European countries, and relevant European guidelines were used to assess LDL-C targets. LDL-Cf, LDL-Cs and LDL-Cmh were calculated as previously described. 

Results

Compared to LDL-Cmh and LDL-Cs, LDL-Cf was able to correctly identify 96.9%-98.08% of cases as within or out of LDL-C target, respectively, while 1.95%-2.8% of cases were falsely identified as within LDL-C target. Kappa coefficients for agreement between LDL-Cf vs. LDL-Cmh and LDL-Cf vs. LDL-Cs were 0.868 and 0.918 (p < 0.001 for both). For patients not on anticholesterolemic drugs, decision to initiate treatment would be different in 1.2%-1.8% of cases if LDL-Cs or LDL-Cmh were used, respectively. For those already on anticholesterolemic drugs, decisions regarding to treatment intensification would be different in 1.5%-2.4% of cases if LDL-Cs or LDL-Cmh were used.

Conclusions

Friedewald equation had an excellent degree of agreement with the novel Martin/Hopkins and Sampson formulas in most cardiology outpatients, especially those within the lower end of the cardiovascular risk spectrum. In selected patients, especially those with high or very high risk in whom LDL-Cf < 70 mg/dl or those with a TG > 400 mg/dl, agreement was far worse and thus novel equations might have an incremental usefulness for clinical decision making.

Table 1 Reference Comparison Correct estimation Underestimation Overestimation Kappa (p value) All patients that were not on cholesterol-lowering treatment LDL-Cmh LDL-Cf 2785 (98.1%) 51 (1.8%) 3 (0.1%) 0.962 (<0.001) LDL-Cs LDL-Cf 2804 (98.8%) 35 (1.2%) 0 (0.0%) 0.975 (<0.001) Agreement for the indication of cholesterol-lowering treatment for patients not already on cholesterol-lowering drugs. Leftmost column shows the reference method, and the second row shows equation which is compared to the reference method.

Abstract Figure

Low-dose quinine is effective in the treatment of chloroquine-resistant Plasmodium falciparum malaria in eastern Sudan

In November-December 2002, 98 patients presented at the Elhara Eloula health centre, in the New Halfa area of eastern Sudan, with Plasmodium falciparum malaria that had failed to respond to chloroquine treatment. After informed consent was obtained, 93 of these patients were randomly allocated to one of three regimens for quinine treatment, being given the drug, orally and sometimes intravenously, for 7 days, at doses of 10 mg/kg thrice daily (32 patients), 10 mg/kg twice daily (31 patients) or 15 mg/kg once daily (30 patients). All the patients were followed daily until day 7 and then weekly until day 28. There was no significant difference in the parasite-clearance times observed in the three groups. Parasitaemias re-occurred by day 28 in 12 patients: two (6.3%) of the patients treated thrice daily, five (16.1%) of those treated twice daily, and five (16.7%) of those treated once daily (P > 0.05). Genotyping indicated that in nine of these 12 patients the parasitaemias that developed post-treatment represented true recrudescences and not re-infections. In the treatment of chloroquine-resistant, P. falciparum malaria in Sudan, once-daily treatment with quinine, in a relatively low daily dose (15 mg/kg. day), appears as effective as the thrice-daily treatment (at 30 mg/kg. day) often recommended.

The effect of salinomycin on the immune response of chicks

The effect of salinomycin drug on the immune system of chickens was investigated. By using the recommended dose 60 mg/kg feed salinomycin was given as anticoccidial drug continuously for 49 days. There was no noticeable significant effect on the humoral and cell-mediated immune responses to Newcastle Disease Virus (NDV) Vaccine. A drastic immunosuppressive effect was manifested by using a dose of 120 mg/kg and characterized by lowered titers of antibodies to NDV, decrease in the relative weight of lymphoid organs, lowered mitogenic response of peripheral blood lymphocytes (PBL) to phytohaemagglutinin (PHA) with reduction of heterophils percentage, as well as reduced protection rate to intramuscular challenge with the velogenic viscerotropic (VV) strain of NDV.