Carnosine supplementation improves glucose control in adults with pre-diabetes and type 2 diabetes: A randomised controlled trial.

BACKGROUND AND AIMS: Type 2 diabetes (T2DM) is a major cause of morbidity and mortality globally. Carnosine, a naturally occurring dipeptide, has anti-inflammatory, antioxidant, and anti-glycating effects, with preliminary evidence suggesting it may improve important chronic disease risk factors in adults with cardiometabolic conditions. METHODS AND RESULTS: In this randomised controlled trial, 43 adults (30%F) living with prediabetes or T2DM consumed carnosine (2 g) or a matching placebo daily for 14 weeks to evaluate its effect on glucose metabolism assessed via a 2-h 75 g oral glucose tolerance test. Secondary outcomes included body composition analysis by dual energy x-ray absorptiometry (DEXA), calf muscle density by pQCT, and anthropometry. Carnosine supplementation decreased blood glucose at 90 min (-1.31 mmol/L; p = 0.02) and 120 min (-1.60 mmol/L, p = 0.02) and total glucose area under the curve (-3.30 mmol/L; p = 0.04) following an oral glucose tolerance test. There were no additional changes in secondary outcomes. The carnosine group results remained significant before and after adjustment for age, sex, and change in weight (all>0.05), and in further sensitivity analyses accounting for missing data. There were no significant changes in insulin levels. CONCLUSION: This study provides preliminary support for larger trials evaluating carnosine as a potential treatment for prediabetes and the initial stages of T2DM. Likely mechanisms may include changes to hepatic glucose output explaining the observed reduction in blood glucose without changes in insulin secretion following carnosine supplementation.

Disrupting future discounting: a commentary on an underutilised psychological approach for improving adherence to diet and physical activity interventions.

Non-communicable diseases (NCD) such as CVD and type 2 diabetes mellitus are major contributors to the burden of disease. NCD are largely driven by modifiable lifestyle factors including poor diet and insufficient physical activity, and consequently, prevention is a public health priority. Although diet and physical activity levels can be improved via lifestyle interventions, long-term adherence to such interventions remains low, which limits their effectiveness. Thus, it is critical to identify the underlying mechanisms that challenge uptake and adherence to such interventions. The current commentary discusses an important, but underexplored, psychological driver of poor adherence to lifestyle interventions, namely, future discounting, which describes the tendency to prefer smaller, short-term rewards over larger, long-term rewards. For example, in the nutrition domain, future discounting refers to valuing the immediate reward of excessive intake of energy-dense, nutrient-poor, discretionary foods high in salt, sugar, and saturated fat, and insufficient intake of low-energy, nutrient-dense, whole foods such as vegetables. Prominent theoretical models propose that excessive future discounting is a major contributor to the development of unhealthy lifestyle behaviours. Furthermore, a vast body of evidence suggests that future discounting plays a key role in risk of NCD. Thus, the evidence to date supports the idea that future discounting is an important multi-behaviour target for supporting lifestyle behaviour change; however, this approach has been largely neglected in preventive health efforts. Furthermore, this commentary discusses promising techniques (e.g. Episodic Future Thinking) for disrupting future discounting to promote improved adherence to lifestyle interventions aimed at reducing NCD risk.

Barriers and enablers associated with participation in a home-based pragmatic exercise snacking program in older adults delivered and monitored by Amazon Alexa: a qualitative study.

BACKGROUND: 'Exercise snacking', which is characterised by shorter and more frequent exercise bouts compared with traditional exercise guidelines, may be an acceptable strategy for increasing physical activity and reducing sedentary behaviour in older adults. AIM: The aim of this study was to evaluate the enablers and barriers for older adults associated with participation in a home-based exercise snacking program delivered and monitored using an Amazon Echo Show 5 device (Alexa). METHODS: This study used an interpretive description qualitative design to conduct semi-structured interviews following a 12-week pilot study in 15 adults aged 60-89 years with at least one chronic condition. All participants were prescribed a home based, individualised, lower limb focussed 'exercise snacking' program (involving ≤ 10 min of bodyweight exercises 2-4 times per day) delivered and monitored by an Alexa. Qualitative interview data were analysed using thematic analysis. RESULTS: All 15 participants (mean age 70.3 years) attended the semi-structured interview. Themes including time efficiency, flexibility, perceived health benefits, and motivation were enablers for participation in the 'exercise snacking' program. A lack of upper body exercises and omission of exercise equipment in the program, as well as a lack of time and motivation for performing exercise snacks three or more times per day, were barriers to participation. CONCLUSION: While 'exercise snacking' is acceptable for older adults, future trials should provide equipment (e.g. adjustable dumbbells, exercise bands), prescribe whole-body exercise programs, and establish strategies to support participation in more than three exercise snacks per day.

Client and Clinician Experiences and Perspectives of Exercise Physiology Services During the COVID-19 Pandemic: Qualitative Study.

BACKGROUND: The COVID-19 pandemic led to changes in the delivery of exercise physiology services. The lived experience of those who continued to provide or receive exercise physiology services during the heightened public health restrictions of the inaugural year of the COVID-19 pandemic has received little attention to date. Acquiring this knowledge will be fundamental in addressing whether telehealth is a viable option for service delivery in exercise care, research, and policy. This is especially pertinent in the wake of the COVID-19 pandemic and subsequent global interest in digital health delivery of health care services. OBJECTIVE: This study aims to explore the clinician and client experiences and perspectives of exercise physiology services delivered in person or via telehealth during the inaugural year of the COVID-19 pandemic (after January 25, 2020; the date of the first confirmed case in Australia). METHODS: Eligible participants for this study were adult (aged 18 years or older; capable of understanding and writing in English) clients who received and clinicians who delivered 1 or more exercise physiology sessions in Australia during the first year of the COVID-19 pandemic (June 2020 to June 2021). The data collection period spanned from January 20, 2021, to September 24, 2021. A total of 18 semistructured individual interviews were conducted with accredited exercise physiologists (n=7) and clients (n=11) who engaged with exercise physiology services during this period. All interviews were digitally recorded and transcribed verbatim. Thematic analysis was conducted with themes and subthemes derived using deductive and inductive approaches. RESULTS: A total of 3 dominant themes, each with 2 subthemes, were identified. The first theme was that telehealth enables access to services but limits the use of some clinical tools. Remote access to services was valued by both clinicians and clients, but the exercise clinical environment could not be replicated over telehealth. This was especially true regarding access to exercise equipment. Second, engagement and the "relational space" are limited by telehealth. Perceived challenges regarding social interactions and a sense of community were a limitation for clients, and difficulties fostering clinician-client report were noted by clinicians. Finally, technological challenges are pervasive in the telehealth delivery of exercise services. Both clinicians and clients noted that systems necessary to facilitate telehealth frequently disrupted delivery, and client-based technical issues were influenced by digital health literacy. CONCLUSIONS: Shared client and accredited exercise physiologist experiences highlight key considerations for the ongoing implementation of telehealth to facilitate the uptake and effectiveness of exercise physiology services. These findings imply that the co-design of solutions to client-perceived limitations of telehealth delivery is warranted.

Feasibility and acceptability of a remotely delivered, home-based, pragmatic resistance 'exercise snacking' intervention in community-dwelling older adults: a pilot randomised controlled trial.

BACKGROUND: Very few older adults meet current muscle strengthening exercise guidelines, and several barriers exist to supervised, community-based resistance exercise programs. Older adults therefore require access to feasible resistance exercise modalities that may be performed remotely. This pilot study assessed the feasibility and acceptability of undertaking a four-week home-based resistance 'exercise snacking' intervention (performed either once, twice, or thrice daily) when delivered and monitored remotely in older adults. METHODS: Thirty-eight community-dwelling older adults [mean ± SD age 69.8 ± 3.8 y, 63% female] were randomised to complete resistance 'exercise snacks' (9-minute sessions) either once (n = 9), twice (n = 10), or thrice (n = 9) daily, or allocated to usual-activity control (n = 10). Exercise adherence and adverse events were assessed using an exercise diary, and acceptability of the intervention was explored using an online questionnaire. Physical function [balance, 5-times sit-to-stand (STS), and 30-second STS tests] was assessed remotely at baseline and follow-up using videoconferencing. RESULTS: The intervention was feasible and safe, with 100% participant retention, high adherence (97, 82, and 81% for once, twice, and thrice daily, respectively), and only two adverse events from a total of 1317 'exercise snacking' sessions. The exercise intervention was rated as enjoyable (75% reported their enjoyment as ≥4 on a 5-point Likert scale), easy to perform, and most (82%) planned to continue similar exercise at home. We also found it was feasible to assess measures of physical function via videoconferencing, although effect sizes for 4-week changes in both 5-STS (d range, 0.4-1.4) and 30-STS (d range, 0.7-0.9) following the exercise intervention were similar to controls (d = 1.1 and 1.0 for 5-STS and 30-STS, respectively). CONCLUSIONS: Resistance 'exercise snacking' may be a feasible strategy for engaging older adults in home-based resistance exercise when delivered and monitored remotely. The findings of this pilot feasibility trial support the need for longer-term studies in larger cohorts to determine the effectiveness of resistance 'exercise snacking' approaches for improving physical function in older adults. TRIAL REGISTRATION: The trial was retrospectively registered on 10/11/2021 with the Australian New Zealand Clinical Trials Registry (ANZCTR) ( ACTRN12621001538831 ).

Barriers and enablers for older adults participating in a home-based pragmatic exercise program delivered and monitored by Amazon Alexa: a qualitative study.

BACKGROUND: The remote delivery and monitoring of individually-tailored exercise programs using voice-controlled intelligent personal assistants (VIPAs) that support conversation-based interactions may be an acceptable alternative model of digital health delivery for older adults. The aim of this study was to evaluate the enablers and barriers for older adults participating in a home-based exercise program delivered and monitored by VIPAs. METHOD: This qualitative study used videoconferencing to conduct semi-structured interviews following a 12-week, prospective single-arm pilot study in 15 adults aged 60 to 89 years living alone in the community. All participants were prescribed an individualized, brief (10 min, 2-4 times per day), home-based muscle strengthening and balance exercise program delivered and monitored using an Amazon Echo Show 5 device (Alexa). Qualitative interview data were analysed using inductive thematic analysis. RESULTS: All 15 participants (aged 70.3 ± 4.3 years, mean ± SD) attended the semi-structured interview. Themes including enjoyability and ease of use, social engagement and motivation were enablers for participation in the exercise program. Errors in voice recognition, lack of feedback, and preference for other existing digital health modes of exercise delivery were barriers associated with the Alexa technology. CONCLUSIONS: This qualitative study identified enablers and barriers associated with using an Alexa device to deliver and monitor an individualized, home-based exercise program in older adults living alone. Future interventions using VIPAs should focus on reducing technical errors, providing regular exercise feedback, and comparing participants' experiences of exercise programs delivered by VIPAs to programs delivered via other digital health tools.

Interventions to achieve ongoing exercise adherence for adults with chronic health conditions who have completed a supervised exercise program: systematic review and meta-analysis.

OBJECTIVE: To determine which exercise adherence interventions are most effective for achieving ongoing exercise adherence in adults with chronic health conditions who had already completed a supervised short-term program. METHOD: Search of MEDLINE (Ovid Medline 1946 to April 8th, 2016), EMBASE (1980 to April 8th, 2016), CINAHL (1982-April 8th 2016) and the Cochrane Central Register of Controlled Trials was conducted. The chronic health conditions search terms as per the Chronic Disease and Participation in Work AIHW Report, 2008. Included were randomised (or quasi-randomised) trials and observational studies evaluating interventions that aimed to improve exercise adherence in adults with chronic health conditions that had completed a supervised exercise program. Random-effects meta-analyses and random-effects logistic meta-regression were used to examine relationships between exercise adherence strategy and adherence. RESULTS: Eleven studies were included with a total of 1231 participants with Chronic Obstructive Pulmonary Disease, Diabetes, Cardiovascular disease or Osteoarthritis. Methods used for maintaining adherence were categorized post hoc as: centre based programs; home exercise programs with telephone follow-up; home exercise programs with no follow-up; and weaning programs that transitioned patients to an independent, off-site exercise program. There was no difference in the proportion of participants who were fully adherent to an exercise program 12 months between the centre-based follow-up (pooled proportion fully adherent=0.34) and telephone follow-up (pooled proportion fully adherent=0.30, difference p-value=0.75). CONCLUSION: Interventions such as centre-based exercise programs or home exercise programs (with or without telephone follow-up) do not differentially impact exercise adherence for people who have completed a short-term supervised program.

Engagement With Conversational Agent-Enabled Interventions in Cardiometabolic Disease Management: Protocol for a Systematic Review.

BACKGROUND: Cardiometabolic diseases (CMDs) are a group of interrelated conditions, including heart failure and diabetes, that increase the risk of cardiovascular and metabolic complications. The rising number of Australians with CMDs has necessitated new strategies for those managing these conditions, such as digital health interventions. The effectiveness of digital health interventions in supporting people with CMDs is dependent on the extent to which users engage with the tools. Augmenting digital health interventions with conversational agents, technologies that interact with people using natural language, may enhance engagement because of their human-like attributes. To date, no systematic review has compiled evidence on how design features influence the engagement of conversational agent-enabled interventions supporting people with CMDs. This review seeks to address this gap, thereby guiding developers in creating more engaging and effective tools for CMD management. OBJECTIVE: The aim of this systematic review is to synthesize evidence pertaining to conversational agent-enabled intervention design features and their impacts on the engagement of people managing CMD. METHODS: The review is conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions and reported in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Searches will be conducted in the Ovid (Medline), Web of Science, and Scopus databases, which will be run again prior to manuscript submission. Inclusion criteria will consist of primary research studies reporting on conversational agent-enabled interventions, including measures of engagement, in adults with CMD. Data extraction will seek to capture the perspectives of people with CMD on the use of conversational agent-enabled interventions. Joanna Briggs Institute critical appraisal tools will be used to evaluate the overall quality of evidence collected. RESULTS: This review was initiated in May 2023 and was registered with the International Prospective Register of Systematic Reviews (PROSPERO) in June 2023, prior to title and abstract screening. Full-text screening of articles was completed in July 2023 and data extraction began August 2023. Final searches were conducted in April 2024 prior to finalizing the review and the manuscript was submitted for peer review in July 2024. CONCLUSIONS: This review will synthesize diverse observations pertaining to conversational agent-enabled intervention design features and their impacts on engagement among people with CMDs. These observations can be used to guide the development of more engaging conversational agent-enabled interventions, thereby increasing the likelihood of regular intervention use and improved CMD health outcomes. Additionally, this review will identify gaps in the literature in terms of how engagement is reported, thereby highlighting areas for future exploration and supporting researchers in advancing the understanding of conversational agent-enabled interventions. TRIAL REGISTRATION: PROSPERO CRD42023431579; https://tinyurl.com/55cxkm26. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/52973.

Exploring the Feasibility of Digital Voice Assistants for Delivery of a Home-Based Exercise Intervention in Older Adults With Obesity and Type 2 Diabetes Mellitus: Randomized Controlled Trial.

BACKGROUND: Current clinical guidelines for the management of type 2 diabetes mellitus (T2DM) in older adults recommend the use of antihyperglycemic medications, monitoring of blood glucose levels, regular exercise, and a healthy diet to improve glycemic control and reduce associated comorbidities. However, adherence to traditional exercise programs is poor (<35%). Common barriers to adherence include fear of hypoglycemia and the need for blood glucose level monitoring before exercise. Digital health strategies offer great promise for managing T2DM as they facilitate patient-practitioner communication, support self-management, and improve access to health care services for underserved populations. We have developed a novel web-based software program allowing practitioners to create tailored interventions and deliver them to patients via digital voice assistants (DVAs) in their own homes. OBJECTIVE: We aim to evaluate the feasibility of a 12-week, home-based, personalized lifestyle intervention delivered and monitored by DVAs for older adults with obesity and T2DM. METHODS: In total, 50 older adults with obesity aged 50-75 years with oral hypoglycemic agent-treated T2DM were randomized to the intervention (DVA, n=25) or a control group (n=25). Participants allocated to the DVA group were prescribed a home-based muscle strengthening exercise program (~20- to 30-min sessions) and healthy eating intervention, delivered via DVAs (Alexa Echo Show 8; Amazon) using newly developed software ("Buddy Link"; Great Australian Pty Ltd). Control group participants received generalized physical activity information via email. Outcomes were feasibility, DVA usability (System Usability Scale), and objectively assessed physical activity and sedentary time (wrist-worn accelerometers). RESULTS: In total, 45 (90%) out of 50 participants completed this study. Mean adherence to prescribed exercise was 85% (SD 43%) with no intervention-related adverse events. System usability was rated above average (70.4, SD 16.9 out of 100). Compared with controls, the DVA group significantly decreased sedentary time (mean difference -67, SD 23; 95% CI -113 to -21 min/d), which was represented by a medium to large effect size (d=-0.6). CONCLUSIONS: A home-based lifestyle intervention delivered and monitored by health professionals using DVAs was feasible for reducing sedentary behavior and increasing moderate-intensity activity in older adults with obesity and T2DM. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12621000307808; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=381364&isReview=true.

Type 2 Diabetes Mellitus and Sarcopenia as Comorbid Chronic Diseases in Older Adults: Established and Emerging Treatments and Therapies.

Type 2 diabetes mellitus (T2DM) and sarcopenia (low skeletal muscle mass and function) share a bidirectional relationship. The prevalence of these diseases increases with age and they share common risk factors. Skeletal muscle fat infiltration, commonly referred to as myosteatosis, may be a major contributor to both T2DM and sarcopenia in older adults via independent effects on insulin resistance and muscle health. Many strategies to manage T2DM result in energy restriction and subsequent weight loss, and this can lead to significant declines in muscle mass in the absence of resistance exercise, which is also a first-line treatment for sarcopenia. In this review, we highlight recent evidence on established treatments and emerging therapies targeting weight loss and muscle mass and function improvements in older adults with, or at risk of, T2DM and/or sarcopenia. This includes dietary, physical activity and exercise interventions, new generation incretin-based agonists and myostatin-based antagonists, and endoscopic bariatric therapies. We also highlight how digital health technologies and health literacy interventions can increase uptake of, and adherence to, established and emerging treatments and therapies in older adults with T2DM and/or sarcopenia.