Long-term follow-up on patient-reported outcomes after supervised exercise training in individuals at risk of complications to type 2 diabetes.

AIMS: We investigated long-term changes of patient-reported outcomes after a supervised exercise intervention in individuals with type 2 diabetes (T2D). METHODS: In an intervention study without a control group, follow-up assessments were performed 12 months after initiating 12 weeks of physical exercise in individuals with T2D at intermediate or high risk of complications. Primary outcomes were health-related quality of life assessed with EQ-5D-5L, empowerment with Diabetes Empowerment Scale-Short Form, and self-reported physical activity with the Physical Activity Scale. Secondary outcomes were physical function (30-s chair-stand test) and working capacity (Aastrand or Graded Cycling Test). RESULTS: 153 participants completed follow-up (35% women, age (mean ± SD) 67 ± 11 years, body mass index 33.1 ± 5.9 kg/m2, glycated haemoglobin A1c 7.8 ± 3.7%). No changes were reported in health-related quality of life (index score p = 0.444, visual analogue scale p = 0.270), empowerment (p = 0.232), and moderate intensity physical activity (p = 0.917). Vigorous intensity physical activity decreased (mean (95% CI) -25.5 (-37.14; -13.94) min/day, p < 0.001). Physical function increased (p < 0.001) and working capacity decreased (Aastrand p = 0.002, Graded Cycling Test p = 0.039). CONCLUSIONS: Health-related quality of life, empowerment, and self-reported moderate intensity physical activity time remained elevated at the long-term follow-up after a supervised exercise intervention.

Copenhagen Diabetes Consensus (CODIAC) 2021: User involvement in diabetes care, prevention and research.

AIMS: User involvement is pivotal for health development, but there are significant gaps in our understanding of the concept. The Copenhagen Diabetes Consensus on User Involvement in Diabetes Care, Prevention and Research (CODIAC) was established to address these gaps, share knowledge and develop best practices. METHODS: A literature review of user involvement was undertaken in diabetes care, prevention and research. Moreover, a Group Concept Mapping (GCM) survey synthesized the knowledge and opinions of researchers, healthcare professionals and people with diabetes and their carers to identify gaps between what is important for user involvement and what is being done in practice. Finally, a consensus conference discussed the main gaps in knowledge and practice while developing plans to address the shortcomings. RESULTS: The literature review demonstrated that user involvement is an effective strategy for diabetes care, prevention and research, given the right support and conditions, but gaps and key challenges regarding the value and impact of user involvement approaches were found. The GCM process identified 11 major gaps, where important issues were not being sufficiently practised. The conference considered these gaps and opportunities to develop new collaborative initiatives under eight overall themes. CONCLUSIONS: User involvement is effective and adds value to diabetes care, prevention and research when used under the right circumstances. CODIAC developed new learning about the way in which academic and research knowledge can be transferred to more practice-oriented knowledge and concrete collaborative initiatives. This approach may be a potential new framework for initiatives in which coherence of process can lead to coherent outputs.

Designing a Co-created Intervention to Promote Motivation and Maintenance of Time-Restricted Eating in Individuals With Overweight and Type 2 Diabetes.

OBJECTIVE: To design an appealing time-restricted eating (TRE) intervention by exploring behavioral and social mechanisms to improve TRE adoption and maintenance among people with type 2 diabetes (T2D) and overweight. Time-restricted eating is an intermittent fasting regimen suggested to improve glycemic control and body weight. METHODS: Intervention development combined coherence theory and empirical data (workshops and semistructured interviews with the target group, their relatives, and health care professionals [HCPs]). Abductive analysis was applied. RESULTS: The analysis suggested designing the TRE intervention in 2 phases: a short period with strict TRE, followed by a longer period focusing on adapting TRE to individual needs with support from HCPs, relatives, and peers. To reinforce TRE motivation and maintenance, HCPs should adopt a whole-person approach that focuses on participants' previous experiences. CONCLUSIONS AND IMPLICATIONS: Important intervention elements to promote TRE adoption and maintenance are suggested to include a 2-phase design and support from professionals, family, and peers.

Feasibility of time-restricted eating in individuals with overweight, obesity, prediabetes, or type 2 diabetes: A systematic scoping review.

OBJECTIVE: This systematic scoping review aimed to map and synthesize research on feasibility of time-restricted eating (TRE) in individuals with overweight, obesity, prediabetes, or type 2 diabetes, including recruitment rate, retention rate, safety, adherence, and participants' attitudes, experiences, and perspectives. METHODS: The authors searched MEDLINE, Embase, and Cumulative Index to Nursing and Allied Health Literature from inception to November 22, 2022, supplemented by backward and forward citation search. RESULTS: From 4219 identified records, 28 studies were included. In general, recruitment was easy and median retention rate was 95% among studies with <12 weeks duration and 89% among studies ≥12 weeks. Median (range) adherence to the target eating window for studies <12 and ≥12 weeks was 89% (75%-98%) and 81% (47%-93%), respectively. Variation in adherence among participants and studies was considerable, indicating that following TRE was difficult for some people and that intervention conditions influenced adherence. These findings were supported by qualitative data synthetized from seven studies, and determinants of adherence included calorie-free beverages outside the eating window, provision of support, and influence on the eating window. No serious adverse events were reported. CONCLUSIONS: TRE is implementable, acceptable, and safe in populations with overweight, obesity, prediabetes, or type 2 diabetes, but it should be accompanied by support and options for individual adjustments.

Transforming Motivation for Exercise in a Safe and Kind Environment-A Qualitative Study of Experiences among Individuals with Type 2 Diabetes.

Exercise is a cornerstone in diabetes care; however, adherence is low and sustaining physical activity remains a challenge. Patient-centered diabetes self-management education and support are recommended; however, sparse literature exists on how to design exercise interventions that improve self-management in individuals with complications of type 2 diabetes mellitus (T2D). We aimed to gain insights into needs, barriers, and motivation based on experiences with exercise participation among individuals with T2D and complications to adjust and develop new types of tailored, supervised exercise classes in specialized care at three hospitals in Denmark. In keeping with a constructivist research paradigm, a qualitative hermeneutic approach using focus group interviews was applied to explore perspectives among different participants in terms of disease severity. Seven interviews with 30 participants (aged 49-88) representing seven different exercise classes, were conducted over three years. Reflective thematic analysis was used. Four themes were generated: People like us, Getting started with exercise, Game changers, and Moving forward. An overarching theme 'The transformation of motivation when exercising in a safe and kind environment' links the themes together, resembling the participants' development of physical literacy encompassing motivation, confidence, physical competence as well as an ability to value physical activity. Supportive patient-centered exercise classes promoted a transformation of motivation grounded in the development of physical literacy among participants in specialized diabetes care. However, participants were concerned with continuing to exercise on their own after the intervention, as they experienced a lack of continuous, supervised exercise opportunities in local communities.

Caught between good intentions and rigid structures: A qualitative description of professionals' experiences with health promotion in mental health services.

BACKGROUND AND AIM: Compared with the general population, people with mental illness are at higher risk of developing type 2 diabetes due to poor diet, medication and inactive lifestyle. People with mental illness and members of the general population are equally interested in health behaviour change, but those with mental illness experience communication barriers with professionals. The study aimed to explore philosophies that social care and healthcare professionals apply to health promotion activities targeting people with mental illness and challenges they face in applying these philosophies across multiple settings. METHODS: Qualitative interviews were conducted with 18 social and healthcare professionals in a range of settings in 2016-2019. Descriptive qualitative analysis was applied to interview data. RESULTS: Interviewees faced many structural challenges in the organisation of their work, which did not coincide with their philosophy or intentions in relation to health promotion. Three philosophical categories were identified: (a) health promotion approach, (b) elements of care and (c) social relations. Many interviewees intended to apply philosophies of broadly defined health, dialogue-based health education, and incremental approaches to health behaviour change. They wanted to provide holistic and flexible care and they valued peer-to-peer activities, family and friend involvement in care and a trusting relationship between the professional and the person with mental illness. However, rigid structures determining the organisation of health promotion challenged professionals' ability to follow their philosophical intentions. CONCLUSION: Interviewees aspired to a collaborative, empowering and person-centred approach, but practical and structural factors made this difficult to achieve in practice. Major changes are required at the organisational level, implemented with the active involvement of professionals and people with mental illness.

The process of health behaviour change following participation in a randomised controlled trial targeting prediabetes: A qualitative study.

AIM: To explore how participating in a randomised controlled trial affected motivation, barriers and strategies in the process of health behaviour change among individuals with prediabetes. METHODS: An extension to the PRE-D trial, a qualitative study investigated the efficacy of glucose-lowering interventions (metformin, dapagliflozin or exercise) compared with a control group among individuals with prediabetes and overweight/obesity. Data were collected through separate focus group interviews with participants using semi-structured interview guides inspired by health behaviour change theories. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis with an inductive-deductive approach. RESULTS: Four interrelated themes were generated from interviews: (1) 'self-construction of prediabetes', on how participants understood the term 'prediabetes', (2) 'altered health image', on how participants' health perceptions were affected, (3) 'personal strategies for health behaviour change', on different ways to attempt to implement behaviour changes and (4) 'the process of health behaviour change', on how participants progressed and relapsed while trying to change behaviour. Themes relate to the health belief model, self-determination theory, self-efficacy and the trans-theoretical model of change. Participants shared their experiences and thoughts during interviews and inspired each other, which led some participants to develop a new perspective on prediabetes severity and increased their motivation for behaviour change. CONCLUSIONS: How participants perceived and accepted, rejected or neglected prediabetes appeared to affect their health images and whether they realised a need for behaviour change. Their achievements during interventions, health literacy, self-efficacy and perceived support from their social networks, professionals and technological aids influenced the maintenance of health behaviour changes.

Tingbjerg Changing Diabetes: a protocol for a long-term Supersetting initiative to promote health and prevent type 2 diabetes among people living in an ethnically and socioeconomically diverse neighbourhood in Copenhagen, Denmark.

INTRODUCTION: Type 2 diabetes is an escalating public health problem closely related to socioeconomic position. There is increased risk of type 2 diabetes in disadvantaged neighbourhoods where education, occupation and income levels are low. Meanwhile, studies show positive health outcomes of participatory community interventions pointing towards the need for increased health promotion and prevention of type 2 diabetes in local communities. This study protocol describes Tingbjerg Changing Diabetes (TCD), a community-based health promotion and type 2 diabetes prevention initiative in Tingbjerg, a disadvantaged neighbourhood in Copenhagen, Denmark. METHODS AND ANALYSIS: TCD is a long-term, complex intervention, implemented in three phases from 2014 to 2032, focusing on partnership formation (phase 1, 2014-2019), developing and implementing action for health (phase 2, 2019-2030) and diffusion of knowledge (phase 3, 2022-2032). The Supersetting principles act as guidelines for development and implementation of all intervention activities of TCD, involving several population groups in a variety of everyday life settings. The implementation of TCD draws on Community Action Research design and methodologies. TCD's evaluation and research strategy is interdisciplinary, pragmatic and multimethod, unfolding at three levels of operation: (A) evaluating activities, (B) researching cross-cutting topics, and (C) researching methods and approaches. ETHICS AND DISSEMINATION: TCD has been approved by the Danish Data Protection Agency. Accordingly, the initiative is carried out in adherence to rules and regulations of the Danish Data Protection Agency. As data contain no personal identifiable or sensitive data, no clearance from the Danish National Ethical Review Board can be obtained according to Danish regulations. Citizen, local agents and stakeholders are engaged in the design and execution of TCD to ensure usefulness, reflexive interpretation of data, relevance and iterative progression of interventions. Results will be published in international peer-reviewed scientific journals, presented at conferences and through public media including TCD home page, podcasts and videos.

Supporting Positive Parenting and Promoting Healthy Living through Family Cooking Classes.

BACKGROUND: The family is an important setting in the promotion of child health. The parent-child relationship affects the social and health development of children, and children's healthy behaviors are associated with positive parenting strategies. The parent-child relationship is bi-directional and the connection between parenting and child health is complex. However, few parenting interventions work with parents and children together, and more knowledge is needed on how to develop and implement interventions promoting healthy parent-child relationships. Focusing on a family cooking class program, this study addresses how community initiatives engaging parents and children together can contribute to integrating parenting support with local health promotion. METHODS: Participant-driven photo-elicited interviews (nine families), focus group evaluations (nine parents/14 children) and observations during cooking classes (10 classes) were applied to analyze the tools and mechanisms that can support positive parenting. RESULTS: The study found that visual, practical and sensory learning techniques, applied in a context-sensitive learning environment that ensured guidance, safety and a friendly social atmosphere, contributed to positive parent-child interaction and bonding. CONCLUSION: The cooking program facilitated parenting practices that support child involvement and autonomy. Thus, the program constituted an effective intervention to strengthen parent-child relationships and positive parenting.

Determinants of glycaemic control among patients with type 2 diabetes: testing a process model based on self-determination theory.

AIMS: To investigate a hypothesised process model based on self-determination theory (SDT) in a population of people with type 2 diabetes. The model suggests that autonomy support from healthcare professionals is an important determinant of autonomous motivation and perceived competence in diabetes, which correlate positively in turn with wellbeing and negatively with HbA1c. METHODS: This cross-sectional study used baseline questionnaire data and HbA1c levels from a randomised controlled trial investigating the effects of a person-centred consultation program. The questionnaire used validated scales and items assessing autonomy support, wellbeing, motivation, self-care activities, diabetes distress and perceived competence. Pearson correlations were calculated, and mediation analysis was conducted by multivariate linear regression analysis. RESULTS: 116 participants completed the questionnaire. Autonomy support was significantly correlated with perceived competence and controlled motivation. Perceived competence correlated negatively with diabetes distress and positively with self-care activities. Diabetes distress correlated negatively with wellbeing. Controlled motivation correlated positively with autonomous motivation, which correlated positively with both wellbeing and self-care activities. Self-care activities correlated negatively with HbA1c. CONCLUSION: As suggested by the hypothesised SDT process model, autonomy support, autonomous motivation and perceived competence are associated with better wellbeing and improved HbA1c.

Improving empowerment, motivation, and medical adherence in patients with poorly controlled type 2 diabetes: A randomized controlled trial of a patient-centered intervention.

OBJECTIVE: To test whether an intervention consisting of four patient-centered consultations improves glycemic control and self-management skills in patients with poorly regulated type 2 diabetes (T2DM), compared to a control group receiving usual care. METHODS: Unblinded parallel randomized controlled trial including 97 adults diagnosed with T2DM ≥ 1 year and hemoglobin A1c (HbA1c) levels ≥ 8.0% (64 mmol/mol). Consultations incorporated tools supporting self-reflection, learning processes, and goal setting. Primary outcome was HbA1c. Secondary outcomes were autonomy support, motivation, self-management skills, and well-being. RESULTS: Average HbA1c decreased slightly in both groups. Autonomy support and frequency of healthy eating were significantly higher in the intervention group. Most participants in the intervention group chose to set goals related to diet and physical exercise. Implementation of the intervention was inconsistent. CONCLUSION: Despite increased autonomy support and individual goal-setting, the intervention was not superior to usual care in terms of glycemic control. More research is needed on how individual preferences and goals can be supported in practice to achieve sustainable behavior changes. PRACTICE IMPLICATIONS: The intervention promoted participant engagement and supported exploration of participants' challenges and preferences. Further exploration of more flexible use of tools adapted to individual contexts is recommended.

Targeting "hardly reached" people with chronic illness: a feasibility study of a person-centered self-management education approach.

BACKGROUND: Self-management education is critical to the development of successful health behavior changes related to chronic illness. However, people in high-risk groups attend less frequently or benefit less from patient education programs than do people with more socioeconomic advantages. AIM: The aim was to test the feasibility of a participatory person-centered education approach and tool-kit targeting self-management of chronic illness in hardly reached people. METHODS: After participating in a training program, educators (n=77) tested the approach in practice. Data collection included online questionnaires for educators (n=65), observations of education sessions (n=7), and interviews with educators (n=11) and participants (n=22). Descriptive statistics were calculated. Transcripts of interviews and observations were analyzed using systematic text condensation. Feasibility was examined in terms of practicality, integration, suitability, and efficacy. RESULTS: Educators had a positive response to the approach and found that the tools supported involving participants in education and support. Participant satisfaction varied, depending on the ability of educators to integrate the tools into programs in a meaningful way. The tools provided time for reflection in the education process that benefited participants and educators alike. Educators found it challenging to allow participants to help set the agenda and to exchange experiences without educator control. Barriers to use reported by educators included lack of time for both training and preparation. LIMITATIONS: The testing included varied groups of participants, some groups included members of hardly reached populations and others did not. Also, some tools were only tried in practice by a few educators. CONCLUSION: The approach was feasible in terms of practicality, integration, acceptability, and efficacy and perceived by educators as suitable for both hardly reached participants and those who are less disadvantaged. Implementation of the approach requires time for training and preparation.

Involvement of family members in life with type 2 diabetes: Six interconnected problem domains of significance for family health identity and healthcare authenticity.

OBJECTIVES: Family involvement plays a key role in diabetes management. Problems and challenges related to type 2-diabetes often affect the whole family, and relatives are at increased risk of developing diabetes themselves. We highlight these issues in our objectives: (1) to uncover specific family problems associated with mutual involvement in life with type 2-diabetes and (2) to analytically look at ways of approaching these problems in healthcare settings. METHODS: Qualitative data were gathered in participatory problem assessment workshops. The data were analysed in three rounds using radical hermeneutics. RESULTS: Problems were categorized in six domains: knowledge, communication, support, everyday life, roles and worries. The final cross-analysis focusing on the link between family identity and healthcare authenticity provided information on how the six domains can be approached in healthcare settings. CONCLUSION: The study generated important knowledge about problems associated with family involvement in life with type 2 diabetes and about how family involvement can be supported in healthcare practice.

Simplicity, flexibility, and respect: preferences related to patient education in hardly reached people with type 2 diabetes.

Individuals with lower income and less education are two to four times more likely to develop diabetes than more advantaged individuals. In response to this, there is a need for developing health promotion activities targeting hardly reached populations. The aim of this study was to examine the perspectives of hardly reached people with type 2 diabetes on patient education, focusing on their wishes and needs regarding format and approach. Data were collected through qualitative interviews with nine individuals with type 2 diabetes with little or no education and characterized as hardly reached patients by health professionals. Interviews were transcribed verbatim and analyzed according to systematic text condensation. We identified four main categories of preferences for patient education: 1) flexibility related to start time, duration, and intensity; 2) simple and concrete education tools, with regard to design and extent; 3) being together, related to meeting people in a similar situation; and 4) respectful educators, related to constructive patient-educator relationships. Insights into the preferences of hardly reached people with diabetes can contribute to the development of appropriately tailored patient education for this patient group.

Empowerment, motivation, and medical adherence (EMMA): the feasibility of a program for patient-centered consultations to support medication adherence and blood glucose control in adults with type 2 diabetes.

PURPOSE: To explore the feasibility of a research-based program for patient-centered consultations to improve medical adherence and blood glucose control in patients with type 2 diabetes. PATIENTS AND METHODS: The patient-centered empowerment, motivation, and medical adherence (EMMA) consultation program consisted of three individual consultations and one phone call with a single health care professional (HCP). Nineteen patients with type 2 diabetes completed the feasibility study. Feasibility was assessed by a questionnaire-based interview with patients 2 months after the final consultation and interviews with HCPs. Patient participation was measured by 10-second event coding based on digital recordings and observations of the consultations. RESULTS: HCPs reported that EMMA supported patient-centered consultations by facilitating dialogue, reflection, and patient activity. Patients reported that they experienced valuable learning during the consultations, felt understood, and listened to and felt a trusting relationship with HCPs. Consultations became more person-specific, which helped patients and HCPs to discover inadequate diabetes self-management through shared decision-making. Compared with routine consultations, HCPs talked less and patients talked more. Seven of ten dialogue tools were used by all patients. It was difficult to complete the EMMA consultations within the scheduled time. CONCLUSION: The EMMA program was feasible, usable, and acceptable to patients and HCPs. The use of tools elicited patients' perspectives and facilitated patient participation and shared decision-making.

Addressing challenges and needs in patient education targeting hardly reached patients with chronic diseases.

Some patients do not benefit from participation in patient education due to reasons related to disease burden, literacy, and socioeconomic challenges. In this communication, we address more specifically both the challenges that these hardly reached patients face in relation to patient education programs and the challenges educators face when conducting patient education with hardly reached patients. We define principles for the format and content of dialogue tools to better support this patient group within the population of individuals with diabetes.

A stereochemical anomaly: the cyclised (R)-AMPA analogue (R)-3-hydroxy-4,5,6,7-tetrahydroisoxazolo[5,4-c]pyridine-5-carboxylic acid [(R)-5-HPCA] resembles (S)-AMPA at glutamate receptors.

(RS)-3-Hydroxy-4,5,6,7-tetrahydroisoxazolo[5,4-c]pyridine-5-carboxylic acid (5-HPCA)(), which is a conformationally constrained cyclised analogue of AMPA has previously been described as causing glutamate receptor mediated excitations of spontaneously firing cat spinal interneurons in a similar fashion to AMPA. We have now prepared the enantiomers of through chiral chromatographic resolution of (RS)-3-(carboxymethoxy)-4,5,6,7-tetrahydroisoxazolo[5,4-c]pyridine-5-carboxylic acid () followed by a stereoconservative hydrolysis resulting in the enantiomers of with high enantiomeric excess (% ee [greater-than-or-equal] 99). The absolute configurations indicated by an X-ray analysis of (-)- monohydrate were confirmed by comparing observed and ab initio calculated electronic circular dichroism spectra and by stereoconservative synthesis of (S)- from (S)-AMPA, the pharmacologically active form of AMPA. The pharmacological effects at native and cloned (GluR1-4) AMPA receptors were shown to reside exclusively with (R)-(+)-, in striking contrast to the usual stereoselectivity trend among AMPA receptor agonists. The reasons for this anomalous behaviour became clear upon docking both enantiomers of to the agonist binding site of GluR2.