Dietary fibre in hypertension and cardiovascular disease management: systematic review and meta-analyses.

BACKGROUND: Higher dietary fibre intakes are associated with a reduced risk of developing cardiovascular disease (CVD), and increasing intake has been shown to reduce blood pressure and other cardiometabolic risk factors. The extent to which dietary fibre can further reduce risk for those with CVD and treated with cardioprotective drugs has not been clearly established. We have examined the evidence for dietary fibre as adjunct therapy in those with CVD or hypertension. METHODS: Ovid MEDLINE, Embase, PubMed, and CENTRAL were searched to June 2021. Prospective observational studies reporting on fibre intakes and mortality in those with pre-existing CVD and controlled trials of increasing fibre intakes on cardiometabolic risk factors in those with CVD or hypertension were eligible. Outcomes were mortality (studies) and cardiometabolic risk factors (trials). Data synthesis was with random effects and dose response. Certainty of evidence was assessed using GRADE. RESULTS: Three prospective studies including 7469 adults with CVD, and 12 trials of 878 adults with CVD or hypertension were identified. Moderate certainty evidence indicates reduced all-cause mortality (relative risk, RR0.75 (95% confidence interval, CI 0.58-0.97)) when comparing higher with lower fibre intakes. Low certainty evidence from trials of adults with cardiovascular disease indicates increasing fibre intakes reduced total (mean difference, MD - 0.42 mmol/L (95%CI - 0.78 to - 0.05) and low-density lipoprotein (LDL) cholesterol (MD - 0.47mmol/L (95%CI - 0.85 to - 0.10)). High certainty evidence from trials of adults with hypertension indicates increasing fibre intakes reduces systolic (MD 4.3 mmHg (95% CI 2.2 to 5.8)) and diastolic blood pressure (MD 3.1 mmHg (95% CI 1.7 to 4.4)). Moderate and low certainty evidence indicated improvements in fasting blood glucose (MD 0.48 mmol/L (- 0.91 to - 0.05)) and LDL cholesterol (MD 0.29 mmol/L (95% CI 0.17 to 0.40)). Benefits were observed irrespective of cardioprotective drug use. CONCLUSIONS: These findings emphasise the likely benefits of promoting greater dietary fibre intakes for patients with CVD and hypertension. Further trials and cohort analyses in this area would increase confidence in these results.

Gelatinisation and milling whole-wheat increases postprandial blood glucose: randomised crossover study of adults with type 2 diabetes.

AIMS/HYPOTHESES: We examined the effects of milling and cooking whole grains in water to achieve starch gelatinisation on postprandial blood glucose using a randomised crossover open-label design. Participants were adults with type 2 diabetes whose body weight or medications had not changed in at least 3 months. METHODS: Postprandial blood glucose (measured as incremental AUC [iAUC]) was measured following consumption of four nutrient-matched whole-wheat porridge test-meals. Test-meals included gelatinised or native starch and were made with either finely milled or intact whole-wheat. RESULTS: Eighteen adults (63.1 ± 9.8 years, HbA1c 57.0 ± 11.5 mmol/mol [7.4 ± 3.2%]) completed the study. iAUC was higher following cooked meals (gelatinised starch) than following uncooked meals (native starch) (mean difference [MD] 268, 95% CI 188, 348 mmol/l × min). Consuming finely milled whole-wheat produced a higher iAUC compared with intact whole-wheat (MD 173, 95% CI 80, 266 mmol/l × min). There was no evidence of an interaction effect (p = 0.841). CONCLUSIONS: Both the nature of starch and the grain structure of whole-wheat influence the glycaemic response of adults with type 2 diabetes mellitus. FUNDING: Baking Industry Research Trust of New Zealand and the Riddet Centre of Research Excellence. TRIAL REGISTRATION: www.anzctr.org.au ACTRN12617000328370.

Dietary fat intakes and cardiovascular disease risk in adults with type 2 diabetes: a systematic review and meta-analysis.

PURPOSE: Advice regarding the intake of dietary fats is particularly relevant to those with type 2 diabetes, given their increased risk of cardiovascular disease. METHODS: We have undertaken a systematic review of fat intakes and cardiovascular disease risk in adults with type 2 diabetes using an online search strategy to 24 April 2020, augmented with hand searching. Searches, extraction, and risk of bias assessments were undertaken by two researchers. The quality of evidence was assessed with GRADE protocols. RESULTS: We identified five eligible prospective studies of 22,591 participants followed for on average 9.8 years, and one trial of 14 participants with type 2 diabetes. Limited data were available; however, replacement analyses of saturated fat with polyunsaturated fat (RR for 2% energy replacement 0.87 95% CI: 0.77-0.99) or carbohydrate (RR for 5% energy replacement 0.82 95% CI: 0.67-1.00) was associated with reduced cardiovascular disease occurrence. Higher polyunsaturated: saturated fat intake was also associated with reduced cardiovascular disease occurrence (RR 0.75 95% CI: 0.57-0.98). The quality of evidence was low to very-low. CONCLUSION: Although only limited data were available, replacement of saturated fats with other macronutrients, such as polyunsaturated fats, was associated with reduced cardiovascular disease occurrence. Supporting evidence from research in the general population increases confidence in these findings. Until more data are available to better comment on dietary fat intakes in cardiovascular disease risk of those with type 2 diabetes, it appears appropriate that saturated fats be replaced in the diet with other macronutrients, such as polyunsaturated fats.

Dietary fibre and whole grains in diabetes management: Systematic review and meta-analyses.

BACKGROUND: Fibre is promoted as part of a healthy dietary pattern and in diabetes management. We have considered the role of high-fibre diets on mortality and increasing fibre intake on glycaemic control and other cardiometabolic risk factors of adults with prediabetes or diabetes. METHODS AND FINDINGS: We conducted a systematic review of published literature to identify prospective studies or controlled trials that have examined the effects of a higher fibre intake without additional dietary or other lifestyle modification in adults with prediabetes, gestational diabetes, type 1 diabetes, and type 2 diabetes. Meta-analyses were undertaken to determine the effects of higher fibre intake on all-cause and cardiovascular mortality and increasing fibre intake on glycaemic control and a range of cardiometabolic risk factors. For trials, meta regression analyses identified further variables that influenced the pooled findings. Dose response testing was undertaken; Grading of Recommendations Assessment, Development and Evaluation (GRADE) protocols were followed to assess the quality of evidence. Two multicountry cohorts of 8,300 adults with type 1 or type 2 diabetes followed on average for 8.8 years and 42 trials including 1,789 adults with prediabetes, type 1, or type 2 diabetes were identified. Prospective cohort data indicate an absolute reduction of 14 fewer deaths (95% confidence interval (CI) 4-19) per 1,000 participants over the study duration, when comparing a daily dietary fibre intake of 35 g with the average intake of 19 g, with a clear dose response relationship apparent. Increased fibre intakes reduced glycated haemoglobin (HbA1c; mean difference [MD] -2.00 mmol/mol, 95% CI -3.30 to -0.71 from 33 trials), fasting plasma glucose (MD -0.56 mmol/L, 95% CI -0.73 to -0.38 from 34 trials), insulin (standardised mean difference [SMD] -2.03, 95% CI -2.92 to -1.13 from 19 trials), homeostatic model assessment of insulin resistance (HOMA IR; MD -1.24 mg/dL, 95% CI -1.72 to -0.76 from 9 trials), total cholesterol (MD -0.34 mmol/L, 95% CI -0.46 to -0.22 from 27 trials), low-density lipoprotein (LDL) cholesterol (MD -0.17 mmol/L, 95% CI -0.27 to -0.08 from 21 trials), triglycerides (MD -0.16 mmol/L, 95% CI -0.23 to -0.09 from 28 trials), body weight (MD -0.56 kg, 95% CI -0.98 to -0.13 from 18 trials), Body Mass Index (BMI; MD -0.36, 95% CI -0·55 to -0·16 from 14 trials), and C-reactive protein (SMD -2.80, 95% CI -4.52 to -1.09 from 7 trials) when compared with lower fibre diets. All trial analyses were subject to high heterogeneity. Key variables beyond increasing fibre intake were the fibre intake at baseline, the global region where the trials were conducted, and participant inclusion criteria other than diabetes type. Potential limitations were the lack of prospective cohort data in non-European countries and the lack of long-term (12 months or greater) controlled trials of increasing fibre intakes in adults with diabetes. CONCLUSIONS: Higher-fibre diets are an important component of diabetes management, resulting in improvements in measures of glycaemic control, blood lipids, body weight, and inflammation, as well as a reduction in premature mortality. These benefits were not confined to any fibre type or to any type of diabetes and were apparent across the range of intakes, although greater improvements in glycaemic control were observed for those moving from low to moderate or high intakes. Based on these findings, increasing daily fibre intake by 15 g or to 35 g might be a reasonable target that would be expected to reduce risk of premature mortality in adults with diabetes.

Dietary fibre intake in childhood or adolescence and subsequent health outcomes: A systematic review of prospective observational studies.

AIM: To determine whether higher fibre intakes during childhood or adolescence effect a broad range of intermediate markers of cardiometabolic risk or other health related issues. MATERIALS AND METHODS: We used online searches up to January 2020 and manual searches to identify prospective observational studies reporting on childhood or adolescent intakes of dietary fibre, vegetables, fruit and refined or whole grains. Outcomes measured later in life were body weight, blood lipids, blood pressure, glycaemia, bone health, cognition, growth and bowel habits. Potential age-specific ranges for dietary fibre were extrapolated from published adult data. RESULTS: We identified 45 publications reporting on 44 354 participants from 30 cohort studies. Mean age at dietary assessment varied from 1 to 19.3 years. Follow-up duration varied from 4 months to 27 years. Although well-conducted studies reported improvements in body weight, blood lipids and glycaemia, the diverse nature of studies precluded meta analysis. The quality of evidence was very low to low given the limited data available per outcome and the inability to synthesize results from multiple studies. Potential dietary fibre intake begins at 13-16 g a day for 2-year-olds and increases until the age of 10 years, when values are comparable with an adult range of 25-30 g a day. CONCLUSIONS: Given the inconsistency in findings from cohort studies other than an absence of detrimental effects, it seems appropriate that recommendations regarding childhood fibre intake are extrapolated from relevant adult data.

Glycated albumin is stable in plasma when exposed to common laboratory conditions and comparable when drawn from venous or capillary sites.

BACKGROUND: Circulating glycated albumin is a marker of blood glucose reflecting the previous 2 weeks. However, the effects of storage conditions and draw site on glycated albumin values are not fully understood. METHODS: Fifteen plasma samples from people with type 2 diabetes were assessed during repeated freeze-thaw rounds for 10 cycles. A further 15 samples were stored at 4°C and assessed over 3 days. Another 40 samples drawn concurrently from capillary and venous sites had their glycated albumin content compared. RESULTS: Glycated albumin concentration did not alter over 10 freeze-thaw cycles (P=.856), or after 72 hours at 4°C (P=.962). Capillary and venous samples did not differ in their percentage of glycated albumin (P=.379), although lower concentrations of albumin and glycated albumin (g/dL) were observed in the capillary sample (P<.001). CONCLUSION: Glycated albumin in plasma appears relatively stable when exposed to common laboratory conditions, reducing a potential confounder to its use as a marker of blood glucose control. The glycated albumin (%) in samples from capillary and venous sites was comparable, suggesting the potential of rapid or portable assessment devices that require a finger prick.

Maternal adherence with recommendations for folic acid and iodine supplements: A cross-sectional survey.

We conducted a survey of 535 New Zealand women to determine supplement use pre-pregnancy, during pregnancy and while breastfeeding to evaluate adherence with national recommendations for folic acid and iodine supplementation. Our findings suggest that despite these women being well-educated and motivated to complete an online survey, there was low adherence to recommendations for folic acid and iodine supplements. Only 38% of women reported supplement intake that met both folic acid and iodine recommendations. This cross-sectional survey provides information useful to policy makers, clinicians and researchers seeking to protect and promote maternal and infant health.

Glycated albumin is associated with body mass index in euglycemic adults but is not predictive of postprandial blood glucose response.

BACKGROUND: The level of glycated albumin in circulation is an indicator of blood glucose control over the preceding 2 weeks. It is not known if the level of glycated albumin in circulation relates to an individual's postprandial blood glucose response. METHODS: Eighty-four euglycemic young adults (21.1 [3.9] years, BMI 23.9 [4.0] kg/m2 ) primarily of European descent underwent a fasted meal test of 50 g carbohydrate from white bread. Capillary blood was then sampled at regular intervals over 2 hours. Correlations were sought between glycated albumin, fasted and 2-hour post-load blood glucose measurements, incremental area under the blood glucose curve, glycemic range, body mass index (BMI), and C-reactive protein (CRP). RESULTS: When adjusted for age and sex, glycated albumin was inversely correlated with BMI (r=-.25, P=.027). No significant correlations existed for glycated albumin and postprandial markers of blood glucose control. BMI and CRP values correlate in this population (r=.30, P=.009). CONCLUSIONS: Glycated albumin in circulation is not related to postprandial blood glucose response in young euglycemic adults. Glycated albumin is lower in euglycemic adults with higher BMI values. Contrary to research with older adults or those with impaired glucose control, glycated albumin did not correlate to CRP.

Advice to walk after meals is more effective for lowering postprandial glycaemia in type 2 diabetes mellitus than advice that does not specify timing: a randomised crossover study.

AIMS/HYPOTHESIS: Regular physical activity is a cornerstone of diabetes management. We conducted a study to evaluate whether specifying the timing of walking in relation to meals enhances the benefits conferred by current physical activity guidelines. METHODS: A total of 41 adults with type 2 diabetes mellitus (mean ± SD age 60 ± 9.9 years; mean diabetes duration 10 years) participated in this randomised, crossover study. Randomisation was by a computer-generated protocol. For periods of 2 weeks, advice to walk 30 min each day was compared with advice to walk for 10 min after each main meal. Both sets of advice met current physical activity guidelines for people with type 2 diabetes mellitus. Physical activity was measured by accelerometry over the full intervention, and glycaemia was measured using continuous glucose monitoring in 5 min intervals over 7 days. The primary outcome of postprandial glycaemia was assessed during the 3 h after a meal by the incremental area under the blood glucose curve (iAUC). RESULTS: The iAUC was significantly lower when participants walked after meals compared with on a single daily occasion (ratio of geometric means 0.88, 95% CI 0.78, 0.99). The improvement was particularly striking after the evening meal (0.78, 95% CI 0.67, 0.91) when the most carbohydrate was consumed and sedentary behaviours were highest. One participant died during the 30 day washout period between interventions, but participation in this study was not judged to contribute to this unfortunate event. CONCLUSIONS/INTERPRETATION: The benefits relating to physical activity following meals suggest that current guidelines should be amended to specify post-meal activity, particularly when meals contain a substantial amount of carbohydrate. TRIAL REGISTRATION: ACTRN12613000832774 FUNDING: : This study was supported by grants from the University of Otago and the New Zealand Artificial Limb Service. Glycated albumin reagents were provided by Asahi Kasei.

The broader health benefits of optimised dietary thresholds proposed for type 2 diabetes prevention in Aotearoa New Zealand: simulation modelling.

AIM: Optimised dietary thresholds for type 2 diabetes prevention exist; however, they likely have additional benefits beyond diabetes prevention. We have modelled the effects of the proposed dietary thresholds on Health-Adjusted Life Years (HALY), health inequities and health system cost in Aotearoa New Zealand. METHODS: We created a national diet scenario using the optimised thresholds and compared it with current intakes using an established multistate life table. The primary model considered change in outcome from increasing intakes of fruits, vegetables, nuts and seeds while decreasing red meat and sugar-sweetened beverages. A separate secondary nutrient-based model considered change due to increasing whole grains and yoghurt while decreasing refined grains, potatoes and fruit juice. Both models considered the direct non-weight mediated associations between diet and disease. RESULTS: In the primary model, adopting the dietary thresholds produced clear benefit to Aotearoa New Zealand in terms of HALY (1.2 million years [95%UI 1.0-1.5]), and a health system cost saving of $17.9 billion (95%UI 13.6-23.2) over the population life course. HALY gain was at least 1.8 times higher for Maori than non-Maori. The secondary model indicated further gains in HALY for all population groups and health systems costs. CONCLUSION: These striking benefits of altering current dietary intakes provide strong evidence of the need for change. Such change requires government commitment to an overarching food strategy in Aotearoa New Zealand to build supportive food environments that enable healthy choices at affordable prices.

Experiences and Acceptability of a Weight Loss Intervention for Diabetes (Diabetes Remission Clinical Trial-DiRECT) in Aotearoa New Zealand: A Qualitative Study within a Pilot Randomised Controlled Trial.

The Diabetes Remission Clinical Trial (DiRECT) demonstrated that substantial weight loss and remission from type 2 diabetes can be achieved with low-energy total diet replacement and behavioural support. However, the acceptability of the DiRECT intervention in diverse populations with strong cultural emphases on food and shared eating remains unclear. We conducted a qualitative study nested within a pilot randomised controlled trial of DiRECT in one Maori (the Indigenous people of New Zealand) primary care provider in Aotearoa New Zealand. Participants with type 2 diabetes or prediabetes, obesity, and a desire to lose weight were randomised to either dietitian-supported usual care or the dietitian-supported DiRECT intervention for twelve months. The DiRECT intervention included three months of total diet replacement, then food reintroduction and supported weight loss maintenance. At three and twelve months, semi-structured interviews explored the acceptability of DiRECT and participants' experiences of each intervention. Interview transcripts from 25 participants (aged 48 ± 10 years, 76% female, 78% Maori or Pacific) at three months and 15 participants at twelve months were analysed. Participants viewed their pre-enrolment selves as unhealthy people with poor eating habits and desired professional weight loss support. For DiRECT participants, the total diet replacement phase was challenging but well-received, due to rapid improvements in weight and health. Food reintroduction and weight loss maintenance each presented unique challenges requiring effective strategies and adaptability. All participants considered individualised and empathetic dietetic support crucial to success. Sociocultural factors influencing success were experienced in both interventions: family and social networks provided support and motivation; however, eating-related norms were identified as challenges. The DiRECT intervention was considered an acceptable approach to weight loss in participants with type 2 diabetes or prediabetes with strong cultural emphases on food and shared eating. Our findings highlight the importance of individualised and culturally relevant behavioural support for effective weight loss and weight loss maintenance.

The neglected potential of red and processed meat replacement with alternative protein sources: Simulation modelling and systematic review.

Background: What we eat is fundamental to human and planetary health, with the current global dietary transition towards increased red meat intakes and ultra-processed foods likely detrimental. Methods: We modelled five red and processed meat replacement scenarios to consider health, equity, greenhouse gas emissions (GHGe), and cost outcomes using an established multistate life table model using data from New Zealand as a case study of a developed, westernised country. Current red and processed meat intakes were replaced with: minimally or ultra-processed plant based meat alternatives, cellular meat, or diets in line with EAT-Lancet or Heart Foundation recommendations on red meat intake. We then conducted a systematic review of literature from database inception to 14 November 2022 to identify implemented population-level meat replacement strategies which could inform evidence-based recommendations to achieve any benefits observed in modelling. PROSPERO CRD42020200023. Findings: When compared with current red and processed meat intakes, all red and processed meat replacement scenarios were nutritionally adequate and improved overall Quality Adjusted Life Years (159-297 per 1000 people over life course for the five scenarios modelled). Age standardised per capita health gain for Maori was 1.6-2.3 times that of non-Maori. Health system cost savings were $2530-$5096 per adult, and GHGe reduced 19-35%. Finally, grocery cost varied (↓7%-↑2%) per modelled scenario when compared with baseline costs. The greatest benefits for all outcomes were achieved by meat replacement with minimally-processed plant-based foods, such as legumes. The systematic review identified only two implemented population-level strategies to reduce meat intakes within the academic literature. Interpretation: All meat replacement scenarios considered indicated appreciable health gains and GHGe reductions. Replacement with minimally-processed plant-based foods appeared consistently superior than other scenarios. Evidence of real-world population strategies to achieve these benefits however is currently lacking. Funding: Healthier Lives National Science Challenge (Grant UOOX1902).

Healthy grocery delivery in the usual care for adults recovering from an acute coronary event: protocol for a three-arm randomised controlled trial.

INTRODUCTION: Coronary heart disease is a major contributor to the global burden of disease. Appropriate nutrition is a cornerstone of the prevention and treatment of coronary heart disease; however, barriers including cost and access to recommended foods limits long-term adherence for many. We are conducting, in adults with coronary heart disease, a randomised controlled trial comparing usual care with two dietary interventions in which usual care is augmented by 12 weeks free delivered groceries. METHODS AND ANALYSIS: Three hundred adults recovering from an acute coronary event will be recruited from outpatient cardiovascular services in three regions of Aotearoa New Zealand. Participants will be randomly allocated to three arms: usual care (control group), usual care and the free delivery of foods high in dietary fibre or usual care and the free delivery of foods high in unsaturated fats. Interventions duration is 12 weeks, with a further 12 months follow-up. The primary outcome measures are change in low-density lipoprotein (LDL) cholesterol concentration following the intervention, and a cost-effectiveness analysis of healthcare access and social costs in the year after the intervention. A broad range of secondary outcome measures include other blood lipids, anthropometry, glycaemia, inflammatory markers, gut microbiome, dietary biomarkers, food acceptability, dietary change and the facilitators and barriers to dietary change. The trial will determine whether the free provision of groceries known to reduce cardiovascular risk within usual care will be clinically beneficial and justify the cost of doing so. Results may also provide an indication of the relative benefit of foods rich in dietary fibre or unsaturated fats in coronary heart disease management. ETHICS AND DISSEMINATION: This trial, The Healthy Heart Study, has Health and Disability Ethics Committee approval (20/NTB/121), underwent Maori consultation, and has locality authority to be conducted in Canterbury, Otago and Southland. TRIAL REGISTRATION NUMBER: ACTRN12620000689976, U1111-1250-1499.

Bidirectional associations between sleep quality or quantity, and dietary intakes or eating behaviors in children 6-12 years old: a systematic review with evidence mapping.

CONTEXT: Although dietary advice has long been a cornerstone of a healthy lifestyle, how sleep quality and quantity may interact with dietary intake or eating behaviors remains unclear. OBJECTIVE: To consider a bidirectional relationship between sleep and diet in children aged 6-12 years via a systematic review following PRISMA guidelines. DATA SOURCES: Relevant trials and observational studies were identified by searching the PubMed, Medline, Embase, and CENTRAL databases up to June 1, 2019, without language or date restrictions and supplemented with hand searching. Recognized procedures and reporting standards were applied. DATA EXTRACTION: Data on participant characteristics, study parameters, diet measures, sleep measures, and findings of study quality assessment criteria were collected. DATA ANALYSIS: Forty-five articles involving 308 332 participants on a diverse range of topics were included. Meta-analyses were planned but were impossible to perform due to high study heterogeneity. Most studies (82%) were cross-sectional, which prevented examining directionality of the observed associations. Risk of bias was assessed for trial, cohort studies, and cross-sectional studies, using the Cochrane Risk of Bias Tool or Newcastle Ottawa Scale. RESULTS: Of 16 studies in which the effect of sleep on dietary intake was investigated, 81% (n = 13) reported a significant association. All studies (n = 8) of sugar-sweetened or caffeinated beverages reported a negative association with sleep, and in 6 of 7 studies in which eating behaviors were investigated, associations with sleep were reported. The use of objective measures of sleep and diet were scarce, with most trials and studies relying on subjective measures of sleep (68%) or diet (93%). CONCLUSION: Because most studies investigating the relationship between sleep and diet in this age group are cross-sectional, temporality could not be determined. Additional randomized controlled trials and long-term cohort studies in middle childhood, particularly those using objective rather than questionnaire measures of sleep, are required to better understand interactions between diet and sleep. SYSTEMATIC REVIEW REGISTRATION: Prospectively registered with PROSPERO International Prospective Register of Systematic Reviews (CRD42018091647).

Do sleep interventions change sleep duration in children aged 0-5 years? A systematic review and meta-analysis of randomised controlled trials.

This review investigated whether randomised controlled trials attempting to improve sleep or prevent sleep problems in 0-5 year olds influenced nocturnal sleep duration, day-time naps, or 24-h sleep. Medline (Ovid), EMBASE, and CINAHL were searched from inception until 9 July 2020 and supplemented with hand searching. Search results were screened, eligible data were extracted, and risk of bias was assessed by at least two reviewers. Of 8571 publications considered, 32 trials which used a variety of subjective and objective sleep measurements were included in generic inverse variance random effects meta-analysis of nocturnal (n = 24), day-time (n = 14), and 24-h (n = 13) sleep duration. Overall, sleep interventions increased nocturnal sleep duration by a mean of 9 min (95% CI 4.1 to 13.8, I228%) per night when compared with no sleep intervention. Increases were predominantly seen in sleep-only, rather than multi-component interventions. Total 24-h sleep duration tended to increase by a similar amount (8.6 min (95% CI -2.7 to 19.8, I2 = 59%)), but this was mainly only seen in studies that assessed sleep using diaries. There was no evidence that interventions changed day-time sleep duration. Future studies should involve sleep-only rather than multi-component interventions, and use objective sleep measures (reviewregistry857).

Blood glucose testing in the community: who are the users and do they have elevated blood glucose?

INTRODUCTION On-the-spot blood glucose testing is a health service performed in public spaces to raise diabetes awareness and screen for elevated blood glucose levels. AIM To describe the users of this service and the frequency of detecting elevated blood glucose. METHODS Data collected at point-of-testing on a standardised form over 20 months in two regions of New Zealand were audited. Descriptive and simple inferential statistics report on population demographics and presence of elevated blood glucose (mmol/L). RESULTS Data from 2156 individuals were audited. Most (1680, 78%) were female, the mean age was 52 years (standard deviation 18 years) and all major ethnic groups and socioeconomic quintiles were represented. For 53% of responders, this was their first blood glucose test. In total, 153 (7.1%) cases with elevated blood glucose were identified, including 94 who did not report a previous pre-diabetes or diabetes diagnosis. Blood glucose was not correlated with socioeconomic status (r=0.04; P=0.07), but weakly correlated with age (r=0.19; P<0.001). Blood glucose values did not appear to differ between ethnicities (P=0.052). Men had a higher mean value than women (P=0.003). People with elevated blood glucose access their general practitioner more often than people with normal blood glucose, irrespective of a diabetes diagnosis (P=0.002). DISCUSSION On-the-spot blood glucose testing is a health service accessed by a wide range of people, although more commonly by women than men. Future interventions targeting men may better engage them in health screening. Alongside awareness raising, on-the-spot community testing identified previously unknown elevated blood glucose levels at a rate of 1-in-22, and may lead to the earlier identification and treatment of prediabetes or diabetes.

How do we support walking prescriptions for type 2 diabetes management? Facilitators and barriers following a 3-month prescription.

INTRODUCTION Prescribing physical activity is an inexpensive method to promote patients' long-term health, but determinants of adherence with physical activity prescriptions are seldom considered. AIM To identify facilitators and barriers experienced by adults with type 2 diabetes when prescribed regular walking. METHODS Participants were prescribed a regular walking routine that met current physical activity guidelines for type 2 diabetes management for a period of 3 months. Pre- and post-intervention questions considered participants' self-rated health and physical activity amount. Thematic analysis of recorded interviews held after the 3-month prescription identified barriers and facilitators to adherence for participants. RESULTS Twenty-eight adults (aged 60±9 years, body mass index 32.3±4.0kg/m2, HbA1c 59±16mmol/mol) participated in the 3-month intervention, providing 7 years of lived experience. Self-rated health (14%; 95% confidence interval (CI) 7-22%) and time spent walking (+11 min/day; 95% CI 4-18 min/day) increased following the prescription. Major themes motivating participants were: establishing a walking routine; the support of their family members; observing health benefits; and being monitored by a health professional. The greatest barriers were associated with walking in the evening and included feelings of insecurity in the dark or a preference for sedentary behaviour. DISCUSSION A prescription to walk increased time spent in physical activity and self-rated health in adults with type 2 diabetes. Health-care professionals can support walking prescriptions by promoting facilitators and reducing barriers to prescription adherence. Practical solutions to barriers include identifying alternative physical activity opportunities within the house or advice to develop support networks to provide company while walking.

Whole-Grain Processing and Glycemic Control in Type 2 Diabetes: A Randomized Crossover Trial.

OBJECTIVE: To consider the effects of whole-grain processing, specifically milling, on glycemic control in free-living adults with type 2 diabetes. RESEARCH DESIGN AND METHODS: Participants of this crossover trial were randomized to two interventions of 2 weeks, separated by washout. They were advised to replace the grain foods they normally consumed with intervention foods. Intervention foods were nutrient-matched whole-grain products of wheat, oats, and brown rice that differed in their degree of processing. No other lifestyle advice was given. Continuous glucose monitoring systems were worn. Other cardiometabolic risk factors and alkylresorcinols (a biomarker of whole-grain intake) were measured pre- and postintervention. RESULTS: Thirty-one adults with type 2 diabetes (63 ± 13 years old, BMI 32.4 ± 7 kg/m2, HbA1c 7.5 ± 3.4% [59 ± 14 mmol/mol]) commenced the trial; 28 (90%) completed both interventions. The increase in alkylresorcinols did not differ between interventions, and there was no difference in reported energy intake. Postprandial responses were 9% (95% CI 3-15) lower following breakfast and 6% (1-10) lower following all meals of less-processed whole grains when compared with finely milled grains. Day-long glycemic variability also was reduced when measured by 24-h SD (-0.16 mmol/L [95% CI -0.25 to -0.06]) and mean amplitude of glycemic excursion (-0.36 [95% CI -0.65 to -0.08]). Mean change in body weight differed by 0.81 kg (95% CI 0.62-1.05) between interventions, increasing during the finely milled intervention and decreasing during the less-processed whole-grain intervention. This was not a mediating factor for the glycemic variables considered. CONCLUSIONS: Consuming less-processed whole-grain foods over 2 weeks improved measures of glycemia in free-living adults with type 2 diabetes compared with an equivalent amount of whole-grain foods that were finely milled. Dietary advice should promote the consumption of minimally processed whole grains.