A lifestyle intervention programme for the prevention of Type 2 diabetes mellitus among South Asian women with gestational diabetes mellitus [LIVING study]: protocol for a randomized trial.

AIM: This study aims to determine whether a resource- and culturally appropriate lifestyle intervention programme in South Asian countries, provided to women with gestational diabetes (GDM) after childbirth, will reduce the incidence of worsening of glycaemic status in a manner that is affordable, acceptable and scalable. METHODS: Women with GDM (diagnosed by oral glucose tolerance test using the International Association of the Diabetes and Pregnancy Study Groups criteria) will be recruited from 16 hospitals in India, Sri Lanka and Bangladesh. Participants will undergo a repeat oral glucose tolerance test at 6 ± 3 months postpartum and those without Type 2 diabetes, a total sample size of 1414, will be randomly allocated to the intervention or usual care. The intervention will consist of four group sessions, 84 SMS or voice messages and review phone calls over the first year. Participants requiring intensification of the intervention will receive two additional individual sessions over the latter half of the first year. Median follow-up will be 2 years. The primary outcome is the proportion of women with a change in glycaemic category, using the American Diabetes Association criteria: (i) normal glucose tolerance to impaired fasting glucose, or impaired glucose tolerance, or Type 2 diabetes; or (ii) impaired fasting glucose or impaired glucose tolerance to Type 2 diabetes. Process evaluation will explore barriers and facilitators of implementation of the intervention in each local context, while trial-based and modelled economic evaluations will assess cost-effectiveness. DISCUSSION: The study will generate important new evidence about a potential strategy to address the long-term sequelae of GDM, a major and growing problem among women in South Asia. (Clinical Trials Registry of India No: CTRI/2017/06/008744; Sri Lanka Clinical Trials Registry No: SLCTR/2017/001; and ClinicalTrials.gov Identifier No: NCT03305939).

Optimising the effectiveness of diabetes education in an East Asian population.

AIM: To explore the collective patterns of learning behaviours and preferences of Chinese people during diabetes education. The study was carried out across three countries and aimed to identify strategies that could be used to tailor diabetes education to Chinese people. METHODS: A case study approach was undertaken in three countries (Australia, China and Singapore) using participant observations and qualitative interviews. Purposive sampling was used to select field sites before a snowball technique was employed to identify relevant interviewees. Thematic analysis with pattern matching was used for data analysis. RESULTS: A total of 39 participant observations and 22 interviews were conducted. Chinese people with diabetes were observed seeking advice and recommendations from health professionals. When told clearly what to do, they strived for full compliance. They tended to be submissive during diabetes education and were not likely to raise concerns, negotiate or participate in making medical decisions. They appeared to prefer prescriptive concrete instructions rather than more flexible conceptual education and to believe that behavioural change should be achieved by individual willpower and determination, resulting in an 'all-or-nothing' approach. Regular repeated information sessions were reported to establish rapport and trust. CONCLUSIONS: For diabetes education to be culturally modified for Chinese people, there is a need to consider their unique philosophies and behaviours during education to support lifestyle changes. Building trust from the early stages of education was achieved by encouraging rapport through the provision of clear and precise instructions. This should be done before engaging in an open discussion of implementation strategies. Once the trust is built, healthy behaviour change may follow.

Evaluation of a large healthy lifestyle program: informing program implementation and scale-up in the prevention of obesity.

BACKGROUND: The Healthy Lifestyle Program for women (HeLP-her) is a low-intensity, self-management program which has demonstrated efficacy in preventing excess weight gain in women. However, little is known about the implementation, reach, and sustainability of low-intensity prevention programs in rural settings, where risk for obesity in women is higher than urban settings. We aimed to evaluate a low-intensity healthy lifestyle program delivered to women in a rural setting to inform development of effective community prevention programs. METHODS: A mixed method hybrid implementation and evaluation study, guided by the RE-AIM framework (addressing the Reach, Effectiveness, Adoption, Implementation, and Maintenance), was undertaken. Data collection tools included anthropometric measures, program checklists, questionnaires, and semi-structured interviews with participants and local stakeholders. The RE-AIM self-audit tool was applied to assess evaluation rigor. RESULTS: Six hundred and forty-nine women from 41 relatively socio-economic disadvantaged communities in Australia participated: mean age 39.6 years (±SD 6.7) and body mass index of 28.8 kg/m2 (±SD 6.9). A between-group weight difference of -0.92 kg (95% CI -1.67 to -0.16) showed program effectiveness. Reach was broad across 41 towns with 62% of participants reporting influencing some of the health behaviors of their families. Strong implementation fidelity was achieved with good retention rates at 1 year (76%) and high participant satisfaction (82% of participants willing to recommend this program). Over 300 multi-level community partnerships were established supporting high adoption. Stakeholders reported potential capacity to implement and sustain the prevention program in resource poor rural settings, due to the low-intensity design and minimal resources required. CONCLUSIONS: Our comprehensive RE-AIM evaluation demonstrates that an evidence-based obesity prevention program can be successfully implemented in real-world settings. The program achieved broad reach, effectiveness, and satisfaction at the community and stakeholder level, revealing potential for program sustainability. The evaluation addressed implementation knowledge gaps to support future obesity prevention program scale-up. TRIAL REGISTRATION: Australian and New Zealand Clinical Trial Registry ACTRN 12612000115831 [ http://www.anzctr.org.au/ ].

Weight satisfaction, management strategies and health beliefs in knee osteoarthritis patients attending an outpatient clinic.

BACKGROUND: Although weight control is important in managing knee osteoarthritis (OA), it is difficult to achieve. Understanding beliefs regarding weight management in people with knee OA may improve weight control. AIMS: To examine differences in bodyweight satisfaction, weight management strategies and weight-related health-beliefs in obese, overweight and normal weight people with knee OA. METHODS: The beliefs and attitudes to weight in 102 people with symptomatic knee OA were ascertained. Participants were classified as being obese, overweight or of normal weight. RESULTS: Although obese and overweight participants were less satisfied with their bodyweight, they were more likely to want to lose weight and to report dieting compared with normal weight participants(P < 0.001 for all) and also more likely to report weight gain in the past 6 months (P < 0.001). While most participants rated food intake to be a main determinant of health, this belief was more common in normal weight participants (P = 0.04). When asked about their own weight gain, obese participants more frequently believed genetic and metabolic factors to be important than normal and overweight participants (P = 0.01). While 51 (53%) believed that increasing activity was more important than dietary change to avoid weight gain, this was more commonly believed by obese and overweight participants (P < 0.05). CONCLUSIONS: Despite desiring and attempting to lose weight, obese people with symptomatic knee OA more commonly reported weight gain. Overweight and obese participants attributed weight gain to non-modifiable factors but believed physical activity is more important than dietary change in weight management. Thus, education regarding the importance of diet as compared with non-modifiable factors and physical activity may improve weight management in obese people with knee OA.

Acceptability of delivery modes for lifestyle advice in a large scale randomised controlled obesity prevention trial.

BACKGROUND: Preventing obesity is an international health priority and women living in rural communities are at an increased risk of weight gain. Lifestyle programs are needed as part of a comprehensive approach to prevent obesity. Evaluation provides a unique opportunity to investigate and inform improvements in lifestyle program implementation strategies. The Healthy Lifestyle Program for rural women (HeLP-her Rural) is a large scale, cluster randomized control trial, targeting the prevention of weight gain. This program utilises multiple delivery modes for simple lifestyle advice (group sessions, phone coaching, text messages, and an interactive program manual). Here, we describe the acceptability of these various delivery modes. METHODS: A mixed-method process evaluation was undertaken measuring program fidelity, recruitment strategies, dose delivered, program acceptability and contextual factors influencing program implementation. Data collection methodologies included qualitative semi-structured interviews for a sub-group of intervention participants [n = 28] via thematic analysis and quantitative methods (program checklists and questionnaires [n = 190]) analysed via chi square and t-tests. RESULTS: We recruited 649 women from 41 rural townships into the HeLP-her Rural program with high levels of program fidelity, dose delivered and acceptability. Participants were from low socioeconomic townships and no differences were detected between socioeconomic characteristics and the number of participants recruited across the towns (p = 0.15). A face-to-face group session was the most commonly reported preferred delivery mode for receiving lifestyle advice, followed by text messages and phone coaching. Multiple sub-themes emerged to support the value of group sessions which included: promoting of a sense of belonging, mutual support and a forum to share ideas. The value of various delivery modes was influenced by participant's various needs and learning styles. CONCLUSION: This comprehensive evaluation reveals strong implementation fidelity and high levels of dose delivery. We demonstrate reach to women from relatively low income rural townships and highlight the acceptability of low intensity healthy lifestyle programs with mixed face-to-face and remote delivery modes in this population. Group education sessions were the most highly valued component of the intervention, with at least one face-to-face session critical to successful program implementation. However, lifestyle advice via multiple delivery modes is recommended to optimise program acceptability and ultimately effectiveness. TRIAL REGISTRY: Australia & New Zealand Clinical Trial Registry. Trial number ACTRN12612000115831, date of registration 24/01/2012.

Risk stratification in early pregnancy for women at increased risk of gestational diabetes.

AIM: To evaluate the addition of fasting glucose and lipids to a simple, validated risk prediction tool for gestational diabetes (GDM) applied in early pregnancy. METHODS: Women at risk of developing GDM on a validated risk prediction tool were recruited in early pregnancy into a large randomised controlled trial. Outcome measures included fasting biochemical markers (glucose, lipids) at 12-15 weeks gestation and GDM diagnosis (28 weeks gestation). Multivariable logistic regression was used to identify additional predictive biochemical variables for GDM, with corresponding receiver operator characteristic (ROC) curves generated. Unadjusted and adjusted models were derived for both the Australasian Diabetes in Pregnancy (ADIPS) and the International Association for Diabetes in Pregnancy Study Group (IADPSG) GDM diagnostic criteria. RESULTS: 51 (23%) Women were diagnosed with GDM based on ADIPS criteria, with 60 (30%) diagnosed based on IADPSG criteria. In all four regression models, fasting glucose was the strongest predictor for GDM development with an odds ratio range of 4.7-6.3 (ADIPS) and 8.8-10 (IADPSG). ROC curves revealed an area under the curve of 0.79 (95% CI: 0.72-0.86) for ADIPS criteria and 0.83 (95% CI: 0.77-0.90) for IADPSG criteria for adjusted models. CONCLUSIONS: In a two-step approach, when applied with a validated risk prediction tool, fasting glucose in early pregnancy was predictive of GDM and incrementally improved risk identification, presenting potential for an early pregnancy, GDM risk screening strategy for streamlining of pregnancy care and opportunity for preventive intervention.

Understanding health behaviours in a cohort of pregnant women at risk of gestational diabetes mellitus: an observational study.

OBJECTIVE: To assess health behaviours, physical activity levels, weight gain and development of gestational diabetes mellitus (GDM) in high-risk women. DESIGN: An observational sub-study of a larger randomised controlled trial. SETTING: A large tertiary hospital in Australia. POPULATION: Ninety-seven women (mean age 31.7 ± 4.5 years; body mass index 30.3 ± 5.9 kg/m(2) ) at risk of developing GDM. METHODS: Women were identified as at risk of GDM based on a validated screening tool. Baseline measures were completed at 12-15 weeks of gestation and repeated at 26-28 weeks of gestation. MAIN OUTCOME MEASURES: Anthropometric (weight and height) and physical activity assessment (Yamax pedometer and International physical activity questionnaire), questionnaires (self-efficacy) and GDM screening. RESULTS: By 28 weeks of gestation, there was a high GDM prevalence of 26% using the recent International Association of Diabetes and Pregnancy Study Group criteria. Weight gain in overweight (body mass index 25-29.9 kg/m(2)) and obese (body mass index >30.0 kg/m(2)) women exceeded minimum total weight gain recommendations set by the Institute of Medicine (P < 0.01). Physical activity levels were low and declined during pregnancy (5437 ± 2951 steps/day to 4096 ± 2438 steps/day, respectively, P < 0.001). Despite reduced activity levels, increased weight gain and high GDM incidence many women did not accurately perceive GDM risk and were confident in their ability to control weight. A significant association with physical activity, weight and GDM outcome was not observed. CONCLUSIONS: Overweight and obese pregnant women at risk for developing GDM demonstrate excessive weight gain and a reduced level of physical activity observed from early pregnancy to 28 weeks of gestation. Results highlight the need for targeted intervention in women at risk for developing GDM.

What is the role of food in preventing depression and improving mood, performance and cognitive function?

Slow weight reduction in overweight women can help to elevate mood. Omega 3 polyunsaturated fatty acids may play a role in mental wellbeing. Eating breakfast regularly leads to improved mood, better memory, more energy and feelings of calmness. Eating regular meals and nutritious afternoon snacks may improve cognitive performance.