Outcome of lifestyle intervention in relation to duration of pre-diabetes: the Pathobiology and Reversibility of Prediabetes in a Biracial Cohort (PROP-ABC) study.

INTRODUCTION: In studies that enrolled people with prevalent pre-diabetes of unknown duration, lifestyle intervention (LI) delayed progression to type 2 diabetes (T2D) but did not reverse pre-diabetes in most participants. Here, we assessed the effects of LI among individuals with pre-diabetes of known duration to determine whether outcomes are related to duration of pre-diabetes. RESEARCH DESIGN AND METHODS: The Pathobiology and Reversibility of Prediabetes in a Biracial Cohort study initiated LI in subjects with incident pre-diabetes during follow-up of initially normoglycemic African Americans and European Americans with parental T2D. Participants were stratified into those initiating LI after <3, 3-5, or >5 years of pre-diabetes diagnosis. Assessments included anthropometry, body fat, fasting and 2-hour plasma glucose (FPG, 2hPG), and insulin sensitivity and secretion. The outcomes were normal glucose regulation (NGR; ie, normal FPG and 2hPG), persistent pre-diabetes, or T2D. Participants who maintained normal FPG and normal 2hPG levels during follow-up served as the control. The control subjects did not receive lifestyle or other intervention to alter the course of glycemia or body weight. RESULTS: Of 223 participants (age 53.3±9.28 years, body mass index 30.6±6.70 kg/m2), 72 (control) maintained normoglycemia during follow-up and 138 subjects with incident pre-diabetes initiated LI after 4.08±2.02 years (range 3 months-8.3 years) of diagnosis. Compared with control, LI participants showed decrease in glucose, weight, and body fat; 42.8% reverted to NGR, 50% had persistent pre-diabetes, and 7.2% developed T2D after 5 years. These outcomes were similar across race and pre-diabetes duration strata, but greater glycemic decrease occurred when LI was initiated within 5 years of pre-diabetes diagnosis. CONCLUSIONS: Ninety-three per cent of adults with parental T2D who initiated LI within 3 months to 8.3 years of developing pre-diabetes did not progress to T2D; nearly half reverted to NGR.Trial registration number NCT02027571.

Pathobiology and Reversibility of Prediabetes in a Biracial Cohort (PROP-ABC) Study: design of lifestyle intervention.

INTRODUCTION: Intensive lifestyle intervention (ILI) prevents progression from prediabetes to type 2 diabetes (T2D) but reversal of prediabetes is less well studied. RESEARCH DESIGN AND METHODS: The overall objectives of the Pathobiology and Reversibility of Prediabetes in a Biracial Cohort (PROP-ABC) Study (ClinicalTrials.gov ID: NCT02027571) are to determine the natural history and reversibility of prediabetes. The study tests specific hypotheses on the patterns of progression to prediabetes among normoglycemic African-American (AA) and European-American (EA) offspring of parents with T2D; emergence of microvascular and macrovascular complications during transition from normal to impaired glucose regulation; significance of the 'metabolically healthy' obese phenotype; and effect of duration of the prediabetic state on its reversibility with lifestyle intervention. Participants who developed incident prediabetes were offered ILI and evaluated quarterly for 5 years. The primary outcome was restoration of normal glucose regulation (fasting plasma glucose <100 mg/dL and two-hour plasma glucose (2hrPG)<140 mg/dL). RESULTS: Of the 223 subjects enrolled in the PROP-ABC Study, 158 participants with incident prediabetes started ILI. The mean age was 53.3±9.28 years; body mass index 30.6±6.70 kg/m2; 70% were female, 52.4% AA and 47.6% EA. The ILI program used goal setting, weight-based calorie restriction, physical activity (180 min/week), self-monitoring, and meal replacement. Monthly face-to-face (F2F) counseling sessions during the initial 6 months, and quarterly visits thereafter, were supplemented with electronic and postal contacts. Attendance at F2F sessions was highly correlated with weight loss (r=0.98, p<0.0001). Meal replacement induced ~5 kg weight loss within 3 months in participants with recrudescent weight pattern. Self-reported exercise minutes correlated with pedometer step counts (r=0.47, p<0.0001). CONCLUSION: The PROP-ABC Study has demonstrated the feasibility of executing an ILI program designed to test reversibility of incident prediabetes in a biracial cohort.

Impact of intensive lifestyle intervention on depression and health-related quality of life in type 2 diabetes: the Look AHEAD Trial.

OBJECTIVE: We examined the effects of an intensive lifestyle intervention (ILI), compared with a diabetes support and education (DSE) control intervention, on long-term changes in depression symptoms, antidepressant medication (ADM) use, and health-related quality of life (HRQoL) in overweight/obese individuals with type 2 diabetes. RESEARCH DESIGN AND METHODS: Look AHEAD was a multisite randomized controlled trial of 5,145 overweight/obese participants assigned to ILI (designed to produce weight loss) or DSE and followed for a median of 9.6 years. The Beck Depression Inventory (BDI) was administered at baseline, annually at years 1-4, and again at year 8. Mean BDI scores and incidence of BDI scores ≥10, indicative of likely mild or greater depression, were examined. Annually through year 10, participants reported their ADM use and completed the Medical Outcomes Study Short Form 36 (SF-36) questionnaire, which yields physical component summary (PCS) and mental component summary (MCS) scores. RESULTS: ILI significantly reduced the incidence of mild or greater depression symptoms (BDI scores ≥10) compared with DSE (hazard ratio [HR] = 0.85; 95% CI 0.75-0.97; P = 0.0145). Although SF-36 PCS scores worsened over time in both groups, ILI participants reported better physical function than DSE throughout the first 8 years (all P values <0.01). There were no significant differences between treatment arms in the proportion of participants who used ADMs or in SF-36 MCS scores. CONCLUSIONS: ILI for overweight/obese patients with type 2 diabetes may reduce the risk of developing clinically significant symptoms of depression and preserve physical HRQoL. These findings should be considered when evaluating the potential benefits of ILIs.

The "shrinking" clerkship: characteristics and length of clerkships in psychiatry undergraduate education.

OBJECTIVE: The authors explored the time that is currently devoted to psychiatry clerkships to determine whether "shortened" clerkships differ in course director satisfaction and evaluation strategies. METHOD: An 18-item questionnaire was sent to 150 U.S. and Canadian clerkship directors. RESULTS: The return rate was 74% (111 questionnaires). Clerkship length ranged from 4 to 8 weeks, with 6 weeks being most common (49.5% of clerkships). Only 18.9% had clerkships lasting 8 full weeks. Shorter clerkships were more likely to rely on the NBME subject test, and less likely to rely on Objective Standardized Clinical Examinations (OSCEs) or oral examinations. Most clerkship directors (81.9%) felt their evaluation procedures reflected their clerkship objectives. Among those who did not or were not sure, a majority (77.7%) felt having too few weeks was among the causes, except for 8-week clerkship directors, who did not mention clerkship length as an issue. CONCLUSIONS: The number of clerkships having 2 full months devoted to psychiatry has decreased in recent years. Shorter clerkships rely heavily on the National Board of Medical Examiners (NBME) Subject Examination as an evaluation tool, testing for book knowledge rather than clinical skills.

Usage of the National Board of Medical Examiners Subject Test in Psychiatry by U.S. and Canadian clerkships.

OBJECTIVE: The authors explored psychiatry clerkship usage of the National Board of Medical Examiners (NBME) Subject Test. METHODS: U.S. and Canadian psychiatry clerkship directors (N=150) were sent an 18-item questionnaire surveying evaluation and remediation practices. RESULTS: Of 111 questionnaires (74%) returned, 76 (69%) reported using the NBME Subject Test. As part of the overall grade, the test was granted a mean weight of 31% and a median weight of 25%. Of 72 clerkship directors who use the test for grading, 42% convert the percentile score and 38% convert the subject score. Of 60 clerkship directors who use the test for passing, 72% convert the raw score (mean=58.3, median=58), and 28% convert the percentile score (mean=12.2(th), median=11(th) percentile). CONCLUSIONS: Most psychiatry clerkship directors use the NBME Subject Test, but no predominant method exists for weighing the test or converting it into a grade.