Dietary Patterns Associated with Abnormal Glucose Tolerance following Gestational Diabetes Mellitus: The MyNutritype Study.

Abnormal glucose tolerance (AGT), which includes type 2 diabetes and pre-diabetes, is highly prevalent in women post gestational diabetes mellitus (post-GDM). Dietary patterns have been associated with the risk of developing AGT in women post-GDM, but evidence in Asian populations is sparse. This study aimed to determine the association between a posteriori dietary patterns and AGT in women post-GDM. This cross-sectional study recruited 157 women post-GDM (mean age 34.8 years) from Seri Kembangan Health Clinic and Universiti Putra Malaysia. AGT was diagnosed according to the Malaysian Clinical Practice Guidelines using a 75 g 2 h oral glucose tolerance test or HbA1c. Food intake was assessed using the 2014 Malaysian Adult Nutrition Survey food frequency questionnaire. Five dietary patterns were derived using principal component analysis: 'Unhealthy', 'Fish-eggs-fruits-vegetables', 'Cereals-confectionaries', 'Legumes-dairy', and 'Meat-sugar-sweetened-beverages'. After adjusting for sociodemographic characteristics and total energy intake, the 'Cereals-confectionaries' dietary pattern was significantly associated with AGT (adjusted odds ratio 1.536, p = 0.049). Targeted lifestyle modification, including dietary intervention, for women post-GDM is warranted to reduce their risk of AGT and its complications.

Dietary patterns associated with the risk of type 2 diabetes in women with and without a history of gestational diabetes mellitus: A pilot study

@#Introduction: There is limited evidence on dietary patterns and the risk of type 2 diabetes (T2D) in women with a history of gestational diabetes mellitus (GDM) compared to their non-GDM counterparts, especially in the Asian population. The pilot study investigated dietary patterns in women with a history of GDM (HGDM) and without a history of GDM (non-HGDM), and the association with T2D risk. Methods: This comparative cross-sectional study involved 64 women (32 HGDM, 32 non-HGDM). Food intake was assessed using a validated food frequency questionnaire. Principal component analysis derived the dietary patterns. T2D risk score was determined using the Finnish Diabetes Risk Score tool. Results: HGDM group had significantly higher proportion of first-degree family history of diabetes; higher risk of T2D and better diabetes knowledge; lower gestational weight gain and postpartum weight retention; and consumed more fast food than nonHGDM. ‘Rice-noodle-pasta-meat’ dietary pattern was significantly associated with increased T2D risk after adjusting for age (β=0.272, p=0.032). ‘Bread-cereals-fast food-meat’ dietary pattern was positively and significantly associated with T2D risk after adjusting for confounders, including age, education level, family history of diabetes, diabetes knowledge score, gestational weight gain, and postpartum weight retention (β=0.251, p=0.012). Conclusion: Dietary patterns high in bread, cereals and cereal products, fast food and meat, as well as rice, noodle, pasta and meat were associated with an elevated T2D risk. A more extensive study is warranted to establish the association between dietary patterns and risk of T2D, focusing on women with a history of GDM.

Maternal and Dietary Factors Are Associated with Metabolic Syndrome in Women with a Previous History of Gestational Diabetes Mellitus.

While it is known that women with a previous history of gestational diabetes mellitus (post-GDM) have a higher risk of metabolic syndrome (MetS), evidence of lifestyle practices from low- and middle-income countries (LMICs) is still scarce. This study aimed to determine the factors associated with MetS in women post-GDM. This cross-sectional study involved 157 women post-GDM (mean age 34.8 ± 5.6 years) sampled from Selangor, Malaysia. We collected data on sociodemographic characteristics and obstetric history. Food intake was assessed using a food frequency questionnaire, and dietary patterns were derived from principal component analysis. MetS was diagnosed according to the 2009 Harmonized criteria. The prevalence of MetS in this study was 22.3%. Western dietary pattern consumption was correlated with MetS, body mass index (BMI), waist circumference, and triglyceride levels. Independent factors associated with MetS were lower education level (odds ratio, OR 4.017, p = 0.007), pre-pregnancy BMI (OR 1.192, p = 0.002), and Caesarean delivery (OR 3.798, p = 0.009). The study identified the maternal and dietary factors associated with MetS in women post-GDM in Malaysia. Community-based interventions that include dietary modification are warranted to prevent MetS and its complications, thus helping to reduce the overall disease burden.

"We don't routinely check vaccination background in adults": a national qualitative study of barriers and facilitators to vaccine delivery and uptake in adult migrants through UK primary care.

OBJECTIVES: Explore primary care professionals' views around barriers/facilitators to catch-up vaccination in adult migrants (foreign-born; over 18 years of age) with incomplete/uncertain vaccination status and for routine vaccines to inform development of interventions to improve vaccine uptake and coverage. DESIGN: Qualitative interview study with purposive sampling and thematic analysis. SETTING: UK primary care. PARTICIPANTS: 64 primary care professionals (PCPs): 48 clinical-staff including general practitioners, practice nurses and healthcare assistants; 16 administrative-staff including practice managers and receptionists (mean age 45 years; 84.4% women; a range of ethnicities). RESULTS: Participants highlighted direct and indirect barriers to catch-up vaccines in adult migrants who may have missed vaccines as children, missed boosters and not be aligned with the UK's vaccine schedule, from both personal and service-delivery levels, with themes including: lack of training and knowledge of guidance among staff; unclear or incomplete vaccine records; and lack of incentivisation (including financial) and dedicated time and care pathways. Adult migrants were reported as being excluded from many vaccination initiatives, most of which focus exclusively on children. Where delivery models existed, they were diverse and fragmented, but included a combination of opportunistic and proactive programmes. PCPs noted that migrants expressed to them a range of views around vaccines, from positivity to uncertainty, to refusal, with specific nationality groups reported as more hesitant about specific vaccines, including measles, mumps and rubella (MMR). CONCLUSIONS: WHO's new Immunization Agenda 2030 calls for greater focus to be placed on delivering vaccination across the life course, targeting underimmunised groups for catch-up vaccination at any age, and UK primary care services therefore have a key role. Vaccine uptake in adult migrants could be improved through implementing new financial incentives or inclusion of adult migrant vaccination targets in Quality Outcomes Framework, strengthening care pathways and training and working directly with local community-groups to improve understanding around the benefits of vaccination at all ages.

Dietary Patterns, Metabolomic Profile, and Nutritype Signatures Associated with Type 2 Diabetes in Women with Postgestational Diabetes Mellitus: MyNutritype Study Protocol.

Women with previous gestational diabetes mellitus (post-GDM) have an increased risk of cardiometabolic diseases including type 2 diabetes (T2D). Current diabetes screening is based on the oral glucose tolerance test without nutritional assessments, even though unhealthy dietary patterns were found to expedite disease progression in women post-GDM. While a healthful dietary pattern reduces T2D risk, limited data support a dietary pattern tailored to the Asian population, especially in the Malaysian context. Metabolomic profiles associated with dietary patterns in this population are also lacking. The proposed study aims to investigate both components of dietary patterns and metabolomic profile, known as nutritype signatures, and their association with T2D in women post-GDM. The comparative cross-sectional study will involve a minimum of 126 Malaysian women post-GDM aged 18-49 years. Dietary patterns will be analysed using principal component analysis. Plasma and urinary metabolites will be quantified using one-dimensional proton nuclear magnetic resonance (1H NMR) spectroscopy. The aim of the study is identifying the nutritype signatures associated with T2D. The findings will support the development of early prevention measures against T2D in women post-GDM.

Effects of structured Ramadan Nutrition Plan on glycemic control and variability using continuous glucose monitoring in individuals with type 2 diabetes: A pilot study.

BACKGROUND AND AIMS: Continuous glucose monitoring (CGM) has been increasingly used in recent years to evaluate glycemic control and variability in individuals with diabetes observing Ramadan fasting. However, the effectiveness of the Ramadan Nutrition Plan (RNP) in individuals with type 2 diabetes (T2D) using CGM-derived measures has not been investigated. The study aimed to evaluate the effects of structured RNP versus standard care using CGM in individuals with T2D. METHODS: This parallel non-randomized interventional study with patients' preference design involved 21 individuals with T2D (mean age: 49 ± 10 years, BMI: 30.0 ± 6.2 kg/m2). Participants chose to receive either structured RNP (sRNT; structured Ramadan Nutrition Therapy group; n = 14) or standard care (SC; n = 7). Participants wore CGM 5 days before Ramadan and during Ramadan. CGM-derived measures of glycemic variability were calculated using Glyculator version 2.0. RESULTS: Compared to the SC group, the sRNT group significantly reduced their fasting blood glucose levels, HbA1c, total cholesterol, diastolic blood pressure, and increased dietary fiber intake. CGM data showed the sRNT group had significantly lower average sensor glucose, peak sensor value, estimated A1c, percentage and duration of time-above-range, J-index, mean amplitude of glycemic excursion (MAGE), and continuous overall net glycemic action (CONGA); and a significantly higher percentage of time-in-range (TIR). CONCLUSIONS: The structured RNP significantly improved clinical outcomes, glycemic control and variability in individuals with T2D. The study highlights the importance of utilizing CGM sensor data to monitor glycemic excursions during Ramadan fasting. Adequately powered randomized controlled trials are needed to confirm the findings.

Defining the determinants of vaccine uptake and undervaccination in migrant populations in Europe to improve routine and COVID-19 vaccine uptake: a systematic review.

Understanding why some migrants in Europe are at risk of underimmunisation and show lower vaccination uptake for routine and COVID-19 vaccines is critical if we are to address vaccination inequities and meet the goals of WHO's new Immunisation Agenda 2030. We did a systematic review (PROSPERO: CRD42020219214) exploring barriers and facilitators of vaccine uptake (categorised using the 5As taxonomy: access, awareness, affordability, acceptance, activation) and sociodemographic determinants of undervaccination among migrants in the EU and European Economic Area, the UK, and Switzerland. We searched MEDLINE, CINAHL, and PsycINFO from 2000 to 2021 for primary research, with no restrictions on language. 5259 data sources were screened, with 67 studies included from 16 countries, representing 366 529 migrants. We identified multiple access barriers-including language, literacy, and communication barriers, practical and legal barriers to accessing and delivering vaccination services, and service barriers such as lack of specific guidelines and knowledge of health-care professionals-for key vaccines including measles-mumps-rubella, diphtheria-pertussis-tetanus, human papillomavirus, influenza, polio, and COVID-19 vaccines. Acceptance barriers were mostly reported in eastern European and Muslim migrants for human papillomavirus, measles, and influenza vaccines. We identified 23 significant determinants of undervaccination in migrants (p<0·05), including African origin, recent migration, and being a refugee or asylum seeker. We did not identify a strong overall association with gender or age. Tailored vaccination messaging, community outreach, and behavioural nudges facilitated uptake. Migrants' barriers to accessing health care are already well documented, and this Review confirms their role in limiting vaccine uptake. These findings hold immediate relevance to strengthening vaccination programmes in high-income countries, including for COVID-19, and suggest that tailored, culturally sensitive, and evidence-informed strategies, unambiguous public health messaging, and health system strengthening are needed to address access and acceptance barriers to vaccination in migrants and create opportunities and pathways for offering catch-up vaccinations to migrants.

Changes in dietary intake improve glycemic control following a structured nutrition therapy during Ramadan in individuals with type 2 diabetes.

BACKGROUND AND AIMS: It is unknown whether dietary modifications during Ramadan could influence glycemic control in diabetes. This study assessed dietary intake following structured Ramadan nutrition therapy and determined the association between changes in dietary intake and glycemic control parameters in patients with type 2 diabetes. METHODS: This was an 8-week, parallel-group, non-randomised study of 60 type 2 diabetes patients who opted for structured Ramadan Nutrition Therapy (sRNT; n = 38) or standard care (SC; n = 22) group. The sRNT group received a structured Ramadan Nutrition Plan incorporated with diabetes-specific formula throughout the study, while SC received standard nutrition care. The 3-day food records assessed dietary intake at three-time points. RESULTS: At baseline, dietary characteristics were comparable; both groups had macronutrient intakes within the recommended range, but inadequate intakes of fiber and 11 essential micronutrients. After 8 weeks, the sRNT group significantly reduced intakes of carbohydrate, dietary glycemic index, glycemic load, and increased percentage of total energy intake from protein, fiber, pyridoxine, vitamin C, vitamin D, calcium, and chromium compared with the SC group. In the sRNT group, compliance to diabetes-specific formula predicted changes in HbA1c (p = 0.024), while fiber intake predicted fasting plasma glucose (p = 0.035), after adjusting for age, sex, weight changes and other dietary variables. CONCLUSION: Intakes of certain nutrients improved significantly in sRNT group after 8 weeks of receiving a structured Ramadan Nutrition Plan compared to the standard care. The structured Ramadan Nutrition Plan with the incorporation of diabetes-specific formula significantly improved glycemic control and dietary adequacy during Ramadan fasting.

Strategies and action points to ensure equitable uptake of COVID-19 vaccinations: A national qualitative interview study to explore the views of undocumented migrants, asylum seekers, and refugees.

INTRODUCTION: Early evidence confirms lower COVID-19 vaccine uptake in established ethnic minority populations, yet there has been little focus on understanding vaccine hesitancy and barriers to vaccination in migrants. Growing populations of precarious migrants (including undocumented migrants, asylum seekers and refugees) in the UK and Europe are considered to be under-immunised groups and may be excluded from health systems, yet little is known about their views on COVID-19 vaccines specifically, which are essential to identify key solutions and action points to strengthen vaccine roll-out. METHODS: We did an in-depth semi-structured qualitative interview study of recently arrived migrants (foreign-born, >18 years old; <10 years in the UK) to the UK with precarious immigration status between September 2020 and March 2021, seeking their input into strategies to strengthen COVID-19 vaccine delivery and uptake. We used the 'Three Cs' model (confidence, complacency and convenience) to explore COVID-19 vaccine hesitancy, barriers and access. Data were analysed using a thematic framework approach. Data collection continued until data saturation was reached, and no novel concepts were arising. The study was approved by the University of London ethics committee (REC 2020.00630). RESULTS: We approached 20 migrant support groups nationwide, recruiting 32 migrants (mean age 37.1 years; 21 [66%] female; mean time in the UK 5.6 years [SD 3.7 years]), including refugees (n = 3), asylum seekers (n = 19), undocumented migrants (n = 8) and migrants with limited leave to remain (n = 2) from 15 different countries (5 WHO regions). 23 (72%) of 32 migrants reported being hesitant about accepting a COVID-19 vaccine and two (6%) would definitely not accept a vaccine. Participants communicated concerns over vaccine content, side-effects, lack of accessible information in an appropriate language, lack of trust in the health system and low perceived need. A range of barriers to accessing the COVID-19 vaccine were reported and concerns expressed that their communities would be excluded from or de-prioritised in the roll-out. Undocumented migrants described fears over being charged and facing immigration checks if they present for a vaccine. Participants (n = 10) interviewed after recent government announcements that COVID-19 vaccines can be accessed without facing immigration checks remained unaware of this. Participants stated that convenience of access would be a key factor in their decision around whether to accept a vaccine and proposed alternative access points to primary care services (for example, walk-in centres in trusted places such as foodbanks, community centres and charities), alongside promoting registration with primary care for all, and working closely with communities to produce accessible information on COVID-19 vaccination. CONCLUSIONS: Precarious migrants may be hesitant about accepting a COVID-19 vaccine and face multiple and unique barriers to access, requiring simple but innovative solutions to ensure equitable access and uptake. Vaccine hesitancy and low awareness around entitlement and relevant access points could be easily addressed with clear, accessible, and tailored information campaigns, co-produced and delivered by trusted sources within marginalised migrant communities. These findings have immediate relevance to the COVID-19 vaccination initiatives in the UK and in other European and high-income countries with diverse migrant populations. FUNDING: NIHR.

A Comparison of Nutritional Status, Knowledge and Type 2 Diabetes Risk Among Malaysian Young Adults With and Without Family History of Diabetes.

BACKGROUND: Genetic factors increase the risk of type 2 diabetes mellitus (T2DM). Thus, family history status may be a useful public health tool for disease prevention. This study compared the nutritional status, knowledge level, and T2DM risk among young adults with and without a family history of diabetes in Malaysia. METHODS: A total of 288 university students aged 18 to 29 years participated in this comparative cross-sectional study. We assessed dietary intake, level of physical activity, knowledge of diabetes and T2DM risk. RESULTS: Respondents with a family history of diabetes had significantly higher weight (P = 0.003), body mass index (P < 0.001), waist circumference (P < 0.001), diabetes knowledge level (P < 0.005) and T2DM risk (P < 0.001). Ethnicity, fibre intake, T2DM risk score and knowledge about diabetes were significant contributors toward family history of diabetes (P = 0.025, 0.034, < 0.001 and 0.004, respectively). CONCLUSION: Young adults with a family history of diabetes had suboptimal nutritional status. Despite being more knowledgeable about diabetes, they did not practice a healthy lifestyle. Family history status can be used to screen young adults at the risk of developing T2DM for primary disease prevention.

Ramadan-focused nutrition therapy for people with diabetes: A narrative review.

AIMS: This narrative review aimed to synthesize the evidence on the effects of Ramadan-focused nutrition therapy for people with diabetes. METHODS: We searched MEDLINE (via PubMed) and Science Direct databases for articles that included the component of nutrition for adult patients with type 2 diabetes (T2D), published in English between 2010 and 2020. RESULTS: Fourteen studies met the criteria. Eight of 14 studies had an intervention with a control arm. In comparison to the control group, all studies (n = 8) showed a reduction in hypoglycemic events. However, only half of these studies (n = 4) had shown at least one positive clinical outcome. Features of nutrition therapy that appeared to have favorable clinical outcomes include individualized caloric prescription; distributing carbohydrates equally between Suhoor, Iftar and snacks; providing meal plans; adjusting food intake to suit Ramadan; and incorporating diabetes-specific formula as part of Suhoor or snack. CONCLUSIONS: The review provides evidence for the effectiveness of Ramadan-focused nutrition therapy among people with T2D and identifies key features of nutrition therapy that may provide favourable clinical outcomes. Additional data on dietary quality and adequacy during Ramadan fasting warrants further studies.

Comparison of Structured Nutrition Therapy for Ramadan with Standard Care in Type 2 Diabetes Patients.

(1) Background: Structured nutrition therapy (NT) is essential for the management of type 2 diabetes (T2D), but the optimal delivery during Ramadan fasting remains unclear. The present study aimed to evaluate the effect of structured NT program versus standard care in patients with T2D during Ramadan. (2) Methods: The present study was an 8-week, parallel, non-randomized study with patients' preference design involving 64 patients with T2D. The participants were asked to choose their preferred group, i.e., structured NT (Structured Ramadan NT, sRNT) or standard care (SC). The participants in the sRNT group received a Ramadan-focused nutrition plan, including a diabetes-specific formula throughout the study, whereas the patients in the SC group received standard nutrition care. Study outcomes included clinical outcomes and quality of life (QoL). Data was analyzed using two-way repeated-measures ANOVA and linear mixed-effects model. (3) Results: More than half of the participants (n = 38, 63%) chose sRNT as their preferred group. Both groups had comparable baseline characteristics. After 8-weeks of the respective intervention, participants in the sRNT group had lower levels of fasting plasma glucose (-0.9 ± 0.3 mmol/L vs. 0.2 ± 0.3 mmol/L, p < 0.05), triglycerides (-0.21 ± 0.08 mmol/L vs. 0.20 ± 0.17 mmol/L, p < 0.05), and self-monitoring glucose at pre-dawn (6.9 mmol/L vs. 7.8 mmol/L, p < 0.05) and pre-bedtime (7.6 mmol/L vs. 8.6 mmol/L, p < 0.05) than participants in the SC group. Although not different between groups, HbA1c levels decreased significantly in the sRNT (-0.72 ± 0.16%, p < 0.001) but not in the SC group (-0.35 ± 0.24%, p = 0.155). QoL and satisfaction scores improved significantly in sRNT group, but not in SC group. (4) Conclusions: The structured NT regimen for Ramadan is a feasible and beneficial program for T2D patients observing Ramadan fasting as it showed an improvement in clinical outcomes and QoL.

Factors associated with dietary glycemic index and glycemic load in pregnant women and risk for gestational diabetes mellitus.

The risk of gestational diabetes mellitus (GDM) increases during the second trimester of pregnancy. However, the role of dietary glycemic index (GI) and glycemic load (GL) on GDM risk is controversial. We aimed to determine the association of established risk factors of GDM with GI and GL among healthy pregnant women, and whether GI and GL were subsequently related to GDM risk. Dietary GI and GL were assessed in healthy pregnant women from the Seremban Cohort Study using a food frequency questionnaire. After adjusting for energy intake, high GI was significantly associated with lower household income, shorter stature, higher proportion of carbohydrate intake, lower sugar proportion and lower fibre intake. High GL was significantly associated with younger maternal age, higher carbohydrate proportion and lower fibre intake. GI and GL intakes were not significantly associated with GDM risk. However, they were associated with a few established risk factors of GDM.

Levels of Knowledge about the Glycemic Index Concept among Women with Gestational Diabetes Mellitus

@#Introduction: Low glycemic index (GI) diet is recommended as part of medical nutrition therapy for the management of gestational diabetes mellitus (GDM). While the clinical benefits are evident, data assessing knowledge of the GI concept among women with GDM are scarce. This was a needs assessment study to determine the level of knowledge about the GI concept among women with GDM. Methods: Using a cross-sectional design, we included 85 women with GDM (mean age: 30.6 ± 4.0, pre-pregnancy BMI: 24.8 ± 4.1 kg/m2, gestational age: 34.0 ± 4.0 weeks) from Hospital Serdang, Malaysia. Knowledge about the GI concept was assessed using a developed questionnaire. Additional questions on GDM were assessed using Gestational Diabetes Mellitus Knowledge Questionnaire (GDMKQ). Subjects with less than 50%, 51-74%, and more than 75% total score were categorized as having poor, fair, and good knowledge levels, respectively. Results: The mean knowledge score obtained by the subjects was 12.8 ± 3.5. More subjects scored correctly for GDM-related knowledge (68.2%). More than half (58.8%) had heard about the GI concept previously and 55.3% understood the definition of GI. The average knowledge score about the GI concept was 55.6%; subjects scored highest on the influence of different carbohydrates (teh tarik versus milk) on blood glucose level (87.1%). However, the majority of the subjects had fair knowledge level (62.4%). Conclusion: Women with GDM had moderate knowledge about the GI concept. Results of the needs assessment served as preliminary data for the development of a GI-based nutrition education program in Malaysia.

Dietary Characteristics of Women With Gestational Diabetes Mellitus

@#Introduction: The role of dietary intake on maternal glucose is uncertain. This study described the dietary characteristics of women with gestational diabetes mellitus (GDM) and examined the differences in dietary characteristics based on GDM diagnosis. Methods: This study recruited GDM women (n =45; age =31.1±5.1 years old) from health clinics in Seremban. Dietary intake, glycemic index (GI) and glycemic load (GL) were assessed using a semi-quantitative food frequency questionnaire (SFFQ) during first and second trimester of pregnancy. GDM diagnosis was made at 28 weeks gestation with the following cut-off for FPG ≥ 5.1 or 2hPG ≥ 7.8 mmol/L following oral glucose tolerance test. Results: Women with GDM had a reasonable intake of protein and fat but consumed high-carbohydrate at second trimester and high-sugar diet at both trimesters. Fibre, iron and calcium from the food sources did not meet the recommended nutrient intakes for pregnancy. About 75.6% (n = 34) GDM women had high 2hPG (9.3 ± 1.5 mmol/L) with a normal FPG (4.7 ± 0.7 mmol/L). While dietary characteristics were not significantly different, women with a higher 2hPG tended to take a higher proportion of protein at first trimester and a higher dietary GI, serving of rice, and sugars and creamer at second trimester than high FPG. Conclusion: Suboptimal maternal nutrition in women with GDM are of particular concern. Dietary characteristics of women with high fasting and 2-hour glucose were comparable but not optimal. The needs of tailored nutritional intervention are evident in women known to be at high risk of GDM.