Effectiveness of psychoeducational interventions for the treatment of diabetes-specific emotional distress and glycaemic control in people with type 2 diabetes: A systematic review and meta-analysis.

AIMS: Psychological comorbidity, such as depression and/or diabetes-specific emotional distress (DSD), is highly prevalent in people with type 2 diabetes (T2DM) and associated with poorer treatment outcomes. While treatments for depression are well established, interventions specifically designed for DSD are sparse. The aim of this study was to determine interventions that successfully address DSD and HbA1c in people with T2DM. METHODS: Seven databases were searched to identify potentially relevant studies. Eligible studies were selected and appraised independently by two reviewers. Multiple meta-analyses and meta-regression analyses were performed to synthesise the data; the primary analyses determined the effect of interventions on DSD, with secondary analyses assessing the effect on HbA1c. RESULTS: Thirty-two studies (n = 5206) provided sufficient DSD data, of which 23 (n = 3818) reported data for HbA1c. Meta-analyses demonstrated that interventions significantly reduced DSD (p = 0.034) and HbA1c (p = 0.006) compared to controls, although subgroup meta-analyses and meta-regression to explore specific intervention characteristics that might mediate this effect yielded non-significant findings. CONCLUSIONS: The findings demonstrate that existing interventions successfully reduce DSD and HbA1c in people with T2DM. While promising, deductions should be interpreted tentatively, highlighting a stark need for further focused exploration of how best to treat psychological comorbidity in people with T2DM.

Moderate increases in daily step count are associated with reduced IL6 and CRP in women with PCOS.

Aims Physical activity has been proposed to be an effective non-pharmacological method of reducing systemic inflammation and therefore may prove particularly efficacious for women with polycystic ovary syndrome (PCOS) who have been shown to have high levels of inflammation and an increased risk of type 2 diabetes (T2DM) and cardiovascular disease (CVD). Therefore, the aim of the present study was to assess whether modest changes in daily step count could significantly reduce levels of inflammatory markers in women with PCOS. Subjects and Methods Sixty-five women with PCOS were assessed at baseline and again at 6 months. All had been provided with an accelerometer and encouraged to increase activity levels. Multivariate linear regression analyses (adjusted for age, ethnicity, baseline step count, change in BMI and change in accelerometer wear-time) were used to assess changes in daily step count against clinical and research biomarkers of inflammation, CVD and T2DM. Results Mean step count/day at baseline was 6337 (±270). An increase in step count (by 1000 steps) was associated with a 13% reduction in IL6 (ß: -0.81 ng/L; 95% CI, -1.37, -0.25, P = 0.005) and a 13% reduction in CRP (ß: -0.68 mg/L; 95% CI, -1.30, -0.06, P = 0.033). Additionally, there was a modest decrease in BMI (ß: 0.20 kg/m2; 95% CI, -0.38, -0.01, P = 0.038). Clinical markers of T2DM and CVD were not affected by increased step count. Conclusions Modest increases in step count/day can reduce levels of inflammatory markers in women with PCOS, which may reduce the future risk of T2DM and CVD.

The effect of exercise training on intrahepatic triglyceride and hepatic insulin sensitivity: a systematic review and meta-analysis.

This systematic review and meta-analysis determined the impact of structured exercise training, and the influence of associated weight loss, on intrahepatic triglyceride (IHTG) in individuals with non-alcoholic fatty liver disease (NAFLD). It also examined its effect on hepatic insulin sensitivity in individuals with or at increased risk of NAFLD. Analyses were restricted to studies using magnetic resonance spectroscopy or liver biopsy for the measurement of IHTG and isotope-labelled glucose tracer for assessment of hepatic insulin sensitivity. Pooling data from 17 studies (373 exercising participants), exercise training for one to 24 weeks (mode: 12 weeks) elicits an absolute reduction in IHTG of 3.31% (95% CI: -4.41 to -2.22%). Exercise reduces IHTG independent of significant weight change (-2.16 [-2.87 to -1.44]%), but benefits are substantially greater when weight loss occurs (-4.87 [-6.64 to -3.11]%). Furthermore, meta-regression identified a positive association between percentage weight loss and absolute reduction in IHTG (ß = 0.99 [0.62 to 1.36], P < 0.001). Pooling of six studies (94 participants) suggests that exercise training also improves basal hepatic insulin sensitivity (mean change in hepatic insulin sensitivity index: 0.13 [0.05 to 0.21] mg m-2  min-1 per µU mL-1 ), but available evidence is limited, and the impact of exercise on insulin-stimulated hepatic insulin sensitivity remains unclear.

Sleep duration, obesity and insulin resistance in a multi-ethnic UK population at high risk of diabetes.

AIMS: Investigating the association between sleep duration, obesity, adipokines and insulin resistance (via Leptin:Adiponectin ratio (LAR)), in those at high risk of type 2 diabetes mellitus (T2DM). METHODS: Adults with impaired glucose regulation (IGR) were included. Fasting bloods for inflammatory biomarkers and glycaemic status, 2-h glucose, anthropometrics, objective physical activity, and self-reported sleep were collected. The average number of hours slept in a 24 h period was categorised as ≤5.5, 6-6.5, 7-7.5, 8-8.5, and ≥9 h. Regression models were fitted with sleep (linear and quadratic) and logistic regression used for IGR and adjusted for age, sex, ethnicity, body mass index, waist circumference and objective physical activity. RESULTS: 2848 participants included (593 with inflammatory marker data). Short sleep and long sleep duration were significantly independently associated with higher body mass index (P < 0.001), body weight (P < 0.01), and waist circumference (P < 0.001). 6-7 h of sleep/24 h is associated with the lowest obesity measures. Fasting insulin and LAR were positively associated with sleep duration. Adiponectin levels were negatively associated with sleep duration. CONCLUSIONS: These results support the evidence of an association between short and long sleep duration and indices of obesity. We demonstrate an independent relationship between long sleep duration and insulin resistance.

The impact of neighbourhood walkability on the effectiveness of a structured education programme to increase objectively measured walking.

Background: Incorporating physical activity into daily activities is key for the effectiveness of lifestyle education interventions aimed at improving health outcomes; however, consideration of the environmental context in which individuals live is not always made. Walkability is a characteristic of the physical environment, and may be a potential facilitator to changing physical activity levels. Methods: Using data collected during the Walking Away from Diabetes randomized controlled trial, we examined the association between the walkability of the home neighbourhood and physical activity of participants. We also determined whether home neighbourhood walkability of participants was associated with the intervention effect of the education programme. Results: Data from 706 participants were available for analysis. Neighbourhood walkability was not significantly associated with any of the physical activity measures at baseline, or at 12, 24 or 36 months following the intervention (P > 0.05 for all). There was no association between walkability and change in purposeful steps/day from baseline to 36 months in the usual care or intervention arm; 25.77 (-99.04, 150.58) and 42.97 (-327.63, 413.45), respectively. Conclusion: Neighbourhood walkability appeared to have no association with objectively measured physical activity in this population. Furthermore, the walkability of participant's neighbourhood did not influence the effectiveness of a lifestyle programme.

Evaluating the impact of an enhanced primary care diabetes service on diabetes outcomes: A before-after study.

Diabetes is an ambulatory care-sensitive condition and a high quality primary care or risk factor control can lead to a decrease in the risk of non-elective hospitalisations while ensuring continuity of care with usual primary care teams. AIMS AND METHODS: In this before and after study, eight primary care practices providing a newer enhanced diabetes model of care in Leicester UK, were compared with matched neighbouring practices with comparable demographic features providing a more expensive integrated specialist-community care diabetes service. The primary outcome at twelve months was to demonstrate equivalence in non-elective bed days. The enhanced practices had primary care physicians and nurses with an interest in diabetes who attended monthly diabetes education meetings and provided care plans and audits. The control practices provided an integrated primary-specialist care service. RESULTS: The difference between the mean change in the non-elective bed days from baseline and at follow up in core and enhanced practices was not statistically significant (mean=2.20 per 100 patients, 95% CI=-0.92 to 5.31 per 100 patients, p=0.14). The analogous change for first outpatients' attendance were 0.23 per 100 patients (95% CI=-0.47 to 0.52 per 100 patients p=0.92) and for diabetes related complications admissions was 0.30 per 100 patients (95% CI=-0.85 to 1.45 per 100 patients p=0.55). CONCLUSION: A model of enhanced primary care based diabetes care appears unlikely to increase hospitalisations, outpatients' attendance or admissions for diabetes related complications.

Incident Type 2 diabetes and the effect of early regression to normoglycaemia in a population with impaired glucose regulation.

AIMS: To report contemporary regression rates from impaired glucose regulation to normal glucose tolerance, identify modifiable factors associated with early regression, and establish whether it affects subsequent diabetes risk in a population-based cohort. METHODS: Participants with impaired glucose regulation (impaired fasting glucose and/or impaired glucose tolerance on a 75-g oral glucose tolerance test) at baseline in the UK-based ADDITION-Leicester study had annual Type 2 diabetes re-screens for 5 years or until diabetes diagnosis. Logistic regression models investigated modifiable risk factors for regression to normal glucose tolerance at 1 year (n = 817). Cox regression models estimated subsequent diabetes risk (n = 630). RESULTS: At 1 year, 54% of participants had regressed to normal glucose tolerance, and 6% had progressed to diabetes. Regression to normal glucose tolerance was associated with weight loss of 0.1-3% [adjusted odds ratio 1.81 (95% CI 1.08, 3.03) compared with maintaining or gaining weight] and a waist circumference reduction of > 3 cm [adjusted odds ratio 1.78 (95% CI 1.03, 3.06) compared with maintaining or increasing waist circumference]. Those with normal glucose tolerance at 1 year subsequently had lower diabetes risk than those who remained with impaired glucose regulation [adjusted hazard ratio 0.19 (95% CI 0.10, 0.37)]. CONCLUSIONS: Early regression to normal glucose tolerance was associated with reduced diabetes incidence, and might be induced by small reductions in weight or waist circumference. If confirmed in experimental research, this could be a clear and achievable target for individuals diagnosed with impaired glucose regulation.

A systematic review of interventions targeting primary care or community based professionals on cardio-metabolic risk factor control in people with diabetes.

OBJECTIVE: To review the interventions targeting primary care or community based professionals on glycaemic and cardiovascular risk factor control in people with diabetes. RESEARCH DESIGN AND METHODS: A systematic review of randomised controlled trials evaluating the effectiveness of interventions targeting primary care or community based professionals on diabetes and cardiovascular risk factor control. We conducted searches in MEDLINE database from inception up to 27th September 2015. We also retrieved articles related to diabetes from the Cochrane EPOC database and EMBASE and scanned bibliographies for key articles. RESULTS: There was heterogeneity in terms of interventions and participants amongst the 30 studies (39,439 patients) that met the inclusion criteria. Nine of the studies focused on general or family practitioners, five on pharmacists, three on nurses and one each on dieticians and community workers. Twelve studies targeted multi-disciplinary teams. Educational interventions did not seem to have a positive impact on HbA1c, systolic blood pressure or lipid profiles. The use of telemedicine, clinician reminders and feedback showed mixed results but there was a level of consistency in improvement in HbA1c when multifaceted interventions on multidisciplinary teams were implemented. Targeting general or family physicians was largely ineffective in improving the cardiovascular risk factors considered, except when using a computer application on insulin handling of type 2 diabetes or customised simulated cases with feedbacks. Similarly, interventions targeting nurses did not improve outcomes compared to standard care. CONCLUSIONS: Multifaceted professional interventions were more effective than single interventions targeting single primary or community care professionals in improving glycaemic control.

A retrospective evaluation of the NHS Health Check Programme in a multi-ethnic population.

BACKGROUND: The NHS Health Check Programme was introduced in 2009 to improve primary prevention of coronary heart disease, stroke, diabetes and chronic kidney disease; however, there has been debate regarding the impact. We present a retrospective evaluation of Leicester City Clinical Commissioning Group. METHODS: Data are reported on diagnosis of type 2 diabetes, hypertension, chronic kidney disease, high risk of type 2 diabetes and high risk of cardiovascular disease. Data on management following the Health Check are also reported. RESULTS: Over a 5-year period, 53 799 health checks were performed, 16 388 (30%) people were diagnosed with at least one condition when diagnosis of being at high risk of cardiovascular disease was defined as ≥20%. This figure increased to 43% when diagnosis of high cardiovascular risk ≥10% was included. Of the 3063 (5.7%) individuals diagnosed with type 2 diabetes, 54% were prescribed metformin and 26% were referred for structured education. Of the 5797 (10.8%) individuals diagnosed at high risk of cardiovascular disease (≥20%), 64% were prescribed statins. CONCLUSIONS: A high proportion of new cases of people at risk of cardiovascular disease were identified by the NHS Health Check Programme. Data suggest that this has translated into appropriate preventative measures.

A cluster randomised controlled trial to investigate the effectiveness and cost effectiveness of the 'Girls Active' intervention: a study protocol.

BACKGROUND: Despite the health benefits of physical activity, data from the UK suggest that a large proportion of adolescents do not meet the recommended levels of moderate-to-vigorous physical activity (MVPA). This is particularly evident in girls, who are less active than boys across all ages and may display a faster rate of decline in physical activity throughout adolescence. The 'Girls Active' intervention has been designed by the Youth Sport Trust to target the lower participation rates observed in adolescent girls. 'Girls Active' uses peer leadership and marketing to empower girls to influence decision making in their school, develop as role models and promote physical activity to other girls. Schools are provided with training and resources to review their physical activity, sport and PE provision, culture and practices to ensure they are relevant and attractive to adolescent girls. METHODS/DESIGN: This study is a two-arm cluster randomised controlled trial (RCT) aiming to recruit 20 secondary schools. Clusters will be randomised at the school level (stratified by school size and proportion of Black and Minority Ethnic (BME) pupils) to receive either the 'Girls Active' intervention or carry on with usual practice (1:1). The 20 secondary schools will be recruited from state secondary schools within the Midlands area. We aim to recruit 80 girls aged 11-14 years in each school. Data will be collected at three time points; baseline and seven and 14 months after baseline. Our primary aim is to investigate whether 'Girls Active' leads to higher objectively measured (GENEActiv) moderate-to-vigorous physical activity in adolescent girls at 14 months after baseline assessment compared to the control group. Secondary outcomes include other objectively measured physical activity variables, adiposity, physical activity-related psychological factors and the cost-effectiveness of the 'Girls Active' intervention. A thorough process evaluation will be conducted during the course of the intervention delivery. DISCUSSION: The findings of this study will provide valuable information on whether this type of school-based approach to increasing physical activity in adolescent girls is both effective and cost-effective in the UK. TRIAL REGISTRATION: ISRCTN10688342. Registered 12 January 2015.

Self-monitoring of blood glucose versus self-monitoring of urine glucose in adults with newly diagnosed Type 2 diabetes receiving structured education: a cluster randomized controlled trial.

AIMS: To compare the effectiveness and acceptability of self-monitoring of blood glucose with self-monitoring of urine glucose in adults with newly diagnosed Type 2 diabetes. METHODS: We conducted a multi-site cluster randomized controlled trial with practice-level randomization. Participants attended a structured group education programme, which included a module on self-monitoring using blood glucose or urine glucose monitoring. HbA1c and other biomedical measures as well as psychosocial data were collected at 6, 12 and 18 months. A total of 292 participants with Type 2 diabetes were recruited from 75 practices. RESULTS: HbA1c levels were significantly lower at 18 months than at baseline in both the blood monitoring group [mean (se) -12 (2) mmol/mol; -1.1 (0.2) %] and the urine monitoring group [mean (se) -13 (2) mmol/mol; -1.2 (0.2)%], with no difference between groups [mean difference adjusted for cluster effect and baseline value = -1 mmol/mol (95% CI -3, 2); -0.1% (95% CI -0.3, 0.2)]. Similar improvements were observed for the other biomedical outcomes, with no differences between groups. Both groups showed improvements in total treatment satisfaction, generic well-being, and diabetes-specific well-being, and had a less threatening view of diabetes, with no differences between groups at 18 months. Approximately one in five participants in the urine monitoring arm switched to blood monitoring, while those in the blood monitoring arm rarely switched (18 vs 1% at 18 months; P < 0.001). CONCLUSIONS: Participants with newly diagnosed Type 2 diabetes who attended structured education showed similar improvements in HbA1c levels at 18 months, regardless of whether they were assigned to blood or urine self-monitoring.

Clinical characteristics of people experiencing biochemical hypoglycaemia during an oral glucose tolerance test: cross-sectional analyses from a UK multi-ethnic population.

AIMS: People who experience biochemical hypoglycaemia during an oral glucose tolerance test (OGTT) may be insulin resistant, but this has not been investigated robustly, therefore we examined this in a population-based multi-ethnic UK study. METHODS: Cross-sectional data from 6478 diabetes-free participants (849 with fasting insulin data available) who had an OGTT in the ADDITION-Leicester screening study (2005-2009) were analysed. People with biochemical hypoglycaemia (2-h glucose <3.3mmol/l) were compared with people with normal glucose tolerance (NGT) or impaired glucose regulation (IGR) using regression methods. RESULTS: 359 participants (5.5%) had biochemical hypoglycaemia, 1079 (16.7%) IGR and 5040 (77.8%) NGT. Biochemical hypoglycaemia was associated with younger age (P<0.01), white European ethnicity (P<0.001), higher HDL cholesterol (P<0.01), higher insulin sensitivity (P<0.05), and lower body mass index (P<0.001), blood pressure (P<0.01), fasting glucose (P<0.001), HbA1C (P<0.01), and triglycerides (P<0.01) compared with NGT and IGR separately in both unadjusted and adjusted (age, sex, ethnicity, body mass index, smoking status) models. CONCLUSIONS: Biochemical hypoglycaemia during an OGTT in the absence of diabetes or IGR was not associated with insulin resistance, but instead appeared to be associated with more favourable glycaemic risk profiles than IGR and NGT. Thus, clinicians may not need to intervene due to biochemical hypoglycaemia on a 2-h OGTT.

Type 2 diabetes mellitus and obesity in young adults: the extreme phenotype with early cardiovascular dysfunction.

AIM: A pilot study to phenotype young adults (< 40 years) with Type 2 diabetes mellitus. METHODS: Twenty people with Type 2 diabetes (aged 18-40 years), 10 lean and 10 obese control subjects underwent detailed assessment, including tagged cardiac magnetic resonance imaging, inflammatory proteins, lipids, vitamin D and maximal oxygen uptake. Outcomes were compared between the group with Type 2 diabetes and the control group. RESULTS: Mean (standard deviation) age, Type 2 diabetes duration and BMI in the group with Type 2 diabetes were 31.8 (6.6) years, 4.7 (4.0) years and 33.9 (5.8) kg/m(2) respectively. Compared with lean control subjects, those with Type 2 diabetes had more deleterious profiles of hyperlipidaemia, vitamin D deficiency, inflammation and maximal oxygen uptake relative to body mass. However, there was no difference between the group with Type 2 diabetes and the obese control group. The group with Type 2 diabetes had a higher left ventricular mass and a trend towards concentric remodelling compared with the lean control group (P = 0.002, P = 0.052) but not the obese control group (P > 0.05). Peak early diastolic strain rate was reduced in the group with Type 2 diabetes [1.51 (0.24)/s] compared with the lean control [1.97 (0.34)/s, P = 0.001] and obese control [1.78 (0.39)/s, P = 0.042] group. CONCLUSIONS: Young adults with Type 2 diabetes and those with obesity have similar adverse cardiovascular risk profiles, higher left ventricular mass and a trend towards left ventricular concentric remodelling. In addition, those with Type 2 diabetes demonstrate diastolic dysfunction, a known risk marker for future heart failure and mortality.