Clare Y England

Diet or diet plus physical activity versus usual care in patients with newly diagnosed type 2 diabetes: the Early ACTID randomised controlled trial

BACKGROUND Lifestyle changes soon after diagnosis might improve outcomes in patients with type 2 diabetes mellitus, but no large trials have compared interventions. We investigated the effects of diet and physical activity on blood pressure and glucose concentrations. METHODS We did a randomised, controlled trial in southwest England in adults aged 30-80 years in whom type 2 diabetes had been diagnosed 5-8 months previously. Participants were assigned usual care (initial dietary consultation and follow-up every 6 months; control group), an intensive diet intervention (dietary consultation every 3 months with monthly nurse support), or the latter plus a pedometer-based activity programme, in a 2:5:5 ratio. The primary endpoint was improvement in glycated haemoglobin A(1c)(HbA(1c)) concentration and blood pressure at 6 months. Analysis was done by intention to treat. This study is registered, number ISRCTN92162869. FINDINGS Of 593 eligible individuals, 99 were assigned usual care, 248 the diet regimen, and 246 diet plus activity. Outcome data were available for 587 (99%) and 579 (98%) participants at 6 and 12 months, respectively. At 6 months, glycaemic control had worsened in the control group (mean baseline HbA(1c) percentage 6·72, SD 1·02, and at 6 months 6·86, 1·02) but improved in the diet group (baseline-adjusted difference in percentage of HbA(1c) -0·28%, 95% CI -0·46 to -0·10; p=0·005) and diet plus activity group (-0·33%, -0·51 to -0·14; p<0·001). These differences persisted to 12 months, despite less use of diabetes drugs. Improvements were also seen in bodyweight and insulin resistance between the intervention and control groups. Blood pressure was similar in all groups. INTERPRETATION An intensive diet intervention soon after diagnosis can improve glycaemic control. The addition of an activity intervention conferred no additional benefit. FUNDING Diabetes UK and the UK Department of Health.

A systematic review of brief dietary questionnaires suitable for clinical use in the prevention and management of obesity, cardiovascular disease and type 2 diabetes

The aim of this systematic review was to identify and describe brief dietary assessment tools suitable for use in clinical practice in the management of obesity, cardiovascular disease and type 2 diabetes. Papers describing development of brief (<35 items) dietary assessment questionnaires, that were accessible, simple to score and assessed aspects of the diet of relevance to the conditions of interest were identified from electronic databases. The development of 35 tools was described in 47 papers. Ten tools assessed healthy eating or healthy dietary patterns, 2 assessed adherence to the Mediterranean diet, 18 assessed dietary fat intake, and 5 assessed vegetable and/or fruit intake. Twenty tools were developed in North America. Test-retest reliability was conducted on 18 tools; correlation coefficients for total scores ranged from 0.59 to 0.95. Relative validation was conducted on 34 tools. The most common reference variable was percentage energy from fat (15 tools) and correlation coefficients ranged from 0.24, P<0.001 to 0.79, P<0.002. Tools that have been evaluated for reliability and/or relative validity are suitable for guiding clinicians when providing dietary advice. Variation in study design, settings and populations makes it difficult to recommend one tool over another, although future developers can enhance the understanding and use of tools by giving clear guidance as to the strengths and limitations of the study design. When selecting a tool, clinicians should consider whether their patient population is similar in characteristics to the evaluation sample.

The effect of macronutrients on glycaemic control: a systematic review of dietary randomised controlled trials in overweight and obese adults with type 2 diabetes in which there was no difference in weight loss between treatment groups

Weight loss is crucial for treating type 2 diabetes mellitus (T2DM). It remains unclear which dietary intervention is best for optimising glycaemic control, or whether weight loss itself is the main reason behind observed improvements. The objective of this study was to assess the effects of various dietary interventions on glycaemic control in overweight and obese adults with T2DM when controlling for weight loss between dietary interventions. A systematic review of randomised controlled trials (RCT) was conducted. Electronic searches of Medline, Embase, Cinahl and Web of Science databases were conducted. Inclusion criteria included RCT with minimum 6 months duration, with participants having BMI≥25·0 kg/m2, a diagnosis of T2DM using HbA1c, and no statistically significant difference in mean weight loss at the end point of intervention between dietary arms. Results showed that eleven studies met the inclusion criteria. Only four RCT indicated the benefit of a particular dietary intervention over another in improving HbA1c levels, including the Mediterranean, vegan and low glycaemic index (GI) diets. However the findings from one of the four studies showing a significant benefit are questionable because of failure to control for diabetes medications and poor adherence to the prescribed diets. In conclusion there is currently insufficient evidence to suggest that any particular diet is superior in treating overweight and obese patients with T2DM. Although the Mediterranean, vegan and low-GI diets appear to be promising, further research that controls for weight loss and the effects of diabetes medications in larger samples is needed.

Development of a brief, reliable and valid diet assessment tool for impaired glucose tolerance and diabetes: the UK Diabetes and Diet Questionnaire

Objective Dietary advice is fundamental in the prevention and management of type 2 diabetes (T2DM). Advice is improved by individual assessment but existing methods are time-consuming and require expertise. We developed a twenty-five-item questionnaire, the UK Diabetes and Diet Questionnaire (UKDDQ), for quick assessment of an individual’s diet. The present study examined the UKDDQ’s repeatability and relative validity compared with 4 d food diaries. Design The UKDDQ was completed twice with a median 3 d gap (interquartile range=1–7 d) between tests. A 4 d food diary was completed after the second UKDDQ. Diaries were analysed and food groups were mapped on to the UKDDQ. Absolute agreement between total scores was examined using intra-class correlation (ICC). Agreement for individual items was tested with Cohen’s weighted kappa (κ w). Setting South West of England. Subjects Adults (n 177, 50·3 % women) with, or at high risk for, T2DM; mean age 55·8 (sd 8·6) years, mean BMI 34·4 (sd 7·3) kg/m2; participants were 91 % White British. Results The UKDDQ showed excellent repeatability (ICC=0·90 (0·82, 0·94)). For individual items, κ w ranged from 0·43 (‘savoury pastries’) to 0·87 (‘vegetables’). Total scores from the UKDDQ and food diaries compared well (ICC=0·54 (0·27, 0·70)). Agreement for individual items varied and was good for ‘alcohol’ (κ w=0·71) and ‘breakfast cereals’ (κ w=0·70), with no agreement for ‘vegetables’ (κ w=0·08) or ‘savoury pastries’ (κ w=0·09). Conclusions The UKDDQ is a new British dietary questionnaire with excellent repeatability. Comparisons with food diaries found agreements similar to those for international dietary questionnaires currently in use. It targets foods and habits important in diabetes prevention and management.

Changes in reported food intake in adults with type 2 diabetes in response to a nonprescriptive dietary intervention

OBJECTIVES There is a lack of published data about the food intake of patients with type 2 diabetes and the changes that they make in response to patient-centred dietary advice. The present study describes the changes reported in response to a nonprescriptive dietary intervention based upon UK dietary guidelines. METHODS Two hundred and sixty-two patients (87 women and 175 men) from the Early ACTivity in Diabetes (ACTID) trial who received the dietary intervention returned 4 days food diaries at baseline and 6 months. Nonparametric tests were used to examine changes in meal patterns, total energy intake and energy from food groups between baseline and 6 months. RESULTS Mean (SD) number of reported meals day(-1) was 3.0 (0.3) and mean (SD) number of snacks was 1.1 (0.6) at both baseline and 6 months for men and women. Men reported decreasing energy intake by a mean (SD) of 912 (1389) KJ/day [218 (332) kcal day(-1) ] (P < 0.001) and women by 515 (1130) KJ/day [123 (270) kcal day(-1) ] (P < 0.001). Men reported reducing energy from alcoholic drinks [-234 (527) KJ day(-1) ; P < 0.001], white bread [-113 (402) KJ day(-1) ; P = 0.001], biscuits [i.e. cookies -67 (205) KJ day(-1) ; P < 0.001] and cakes [-50 (410) KJ day(-1) ; P = 0.0012]. Women reported reducing energy from mixed main meals [-134 (456) KJ day(-1) ; P = 0.036], pasta and rice [-79 (326) KJ day(-1) ; P = 0.019], high-energy drinks [-59 (159) KJ day(-1) ; P = 0.001] and white bread [-59 (368) KJ day(-1) ; P = 0.042]. CONCLUSIONS Men and women in the Early ACTID study reported small changes in higher-energy and lower-fibre foods and drinks in response to patient-centred dietary advice.

Dietary changes and associations with metabolic improvements in adults with type 2 diabetes during a patient-centred dietary intervention: an exploratory analysis

Objectives Describe dietary intake of participants enrolled in a non-prescriptive dietary intervention and dietary changes at 6 months and explore whether these changes had a role in observed improvements in glycated haemoglobin (HbA1c), weight, lipids and blood pressure. Design Secondary analysis of data from the Early ACTivity in Diabetes randomised controlled trial. Participants 262 patients with newly diagnosed type 2 diabetes randomised to the dietary intervention. Outcomes and analysis Changes in energy intake, macronutrients, fibre and alcohol and in weight, waist circumference, lipids, HbA1c and blood pressure at baseline and 6 months. Multivariate models were used to examine associations between dietary changes and metabolic variables. Results Men reported reducing mean energy intake from 1903±462 kcal to 1685 kcal±439 kcal (p<0.001), increasing carbohydrate intake from 42.4±6.6% to 43.8±6.6% (p=0.002) and reducing median alcohol intake from 13 (0–27) g to 5 (0–18) g (p<0.001). Women reported reducing mean energy intake from 1582±379 kcal to 1459±326 kcal (p<0.001) with no change to macronutrient distribution and alcohol. Fibre intake was maintained. In men (n=148), weak and clinically insignificant associations were found between increased carbohydrates and reduction in HbA1c (β=−0.003 (−0.006, −0.001); p=0.009), increased fibre and reduction in total cholesterol (β=−0.023 (−0.044, −0.002); p=0.033), decreased total fat and reduction in low-density lipoprotein (LDL)-cholesterol (β=0.024 (0.006, 0.001); p=0.011), and decreased alcohol and reduction in diastolic blood pressure (β=0.276 (0.055, 0.497); p=0.015). In women (n=75), associations were found between a decrease in transfats and reductions in waist circumference (β=−0.029 (0.006, 0.052); p=0.015), total cholesterol (β=0.399 (0.028, 0.770); p=0.036) and LDL cholesterol (β=0.365 (0.042, 0.668); p=0.028). Conclusions Clinically important metabolic improvements observed in a patient-centred dietary intervention were not explained by changes in macronutrients. However, a non-prescriptive approach may promote a reduction in total energy intake while maintaining fibre consumption. Trial registration number The Early ACTID trial number ISRCTN92162869.

The potential of electric bicycles to improve the health of people with type 2 diabetes: a feasibility study

To explore in a feasibility study whether ‘e‐cycling’ was acceptable to, and could potentially improve the health of, people with Type 2 diabetes.

Dietary intake and factors influencing eating behaviours in overweight and obese South Asian men living in the UK: mixed method study

Objective It is widely recognised that South Asian men living in the UK are more likely to develop type 2 diabetes mellitus (T2DM) than their white British counterparts. Despite this, limited data have been published quantifying current dietary intake patterns and qualitatively exploring eating behaviours in this population. The objectives of this study were to (1) assess diet, (2) explore perceptions of T2DM, (3) investigate factors influencing eating behaviours in overweight/obese South Asian men and (4) determine the suitability of the UK Diet and Diabetes Questionnaire (UKDDQ) for use in this population. Setting Community-based setting in the Greater London, UK area. Participants South Asian men aged 18–64 years, with a body mass index of over 23.0 kg/m2, not previously diagnosed with T2DM. Methods A cross-sectional mixed-methods design, including assessment of dietary intake using UKDDQ (n=63), followed by semistructured interviews in a purposive sample (n=36). Results UKDDQ scores indicated 54% of participants had a ‘healthy’ diet with a mean sample score of 3.44±0.43 out of a maximum of 5. Oily fish consumption was low (1.84±1.85). Body weight was positively associated with a high-added sugar subscore (r=0.253, p=0.047), with 69.8% of the men having ‘unhealthy’ intakes of sugar-sweetened beverages. Cultural commitments (eg, extended family and faith events), motivation and time were identified as key barriers to dietary change, with family support an important facilitator to making healthy dietary changes. Participants stated that UKDDQ was suitable for assessing diets of South Asians and made suggestions for tailoring questions related to rice consumption, providing examples of Indian sweets, and including ghee as a fat source. Conclusion Many of the areas of dietary improvement and factors affecting eating behaviours identified in this study are similar to those observed in the general UK population. Consumption of sugar-sweetened beverages in particular was high; given the association between their consumption and the risk of T2DM, this should be an area of primary focus for healthcare professionals. Nevertheless, there are sociocultural factors unique to this population that need to be considered when designing culturally specific programs to reduce the development of T2DM in this high-risk population.

Validation of the English Version of the 14-Item Mediterranean Diet Adherence Screener of the PREDIMED Study, in People at High Cardiovascular Risk in the UK

The aim of this study was to examine the validity of the English version of the PREvencion con DIetaMEDiterranea (PREDIMED) 14-item Mediterranean Diet Adherence Screener (MEDAS), a brief questionnaire assessing adherence to the Mediterranean diet (MedDiet), which was used in the PREDIMED trial for assessment and immediate feedback. This instrument (MEDAS) was administered to 96 adults with a high cardiovascular risk (66% women, mean age 68.3 ± 6.0 years), recruited from general practices in Bristol, UK. Participants then completed a 3-day estimated food record, and the MEDAS was administered again one month later. A MedDiet score (range = 0–14) was calculated from the MEDAS’ administrations and food record to assess concurrent validity and test-retest reliability. Predictive validity was assessed by examining the association of the MEDAS-derived score with cardiometabolic risk factors and dietary intakes derived from the food records. The MEDAS-derived MedDiet score was higher by 1.47 points compared to food records (5.47 vs.4.00, p < 0.001), correlated moderately with the record-derived score (r = 0.50, p < 0.001; ICC = 0.53, p < 0.001) and there was borderline fair agreement between the two methods (κ = 0.19, 95% CI 0.07–0.31, p = 0.002; 95% limits of agreement −2.2, 5.1). Exact agreement within score categories and gross misclassificationwere 45.8% and 21.9%, respectively. The distribution of dietary intakes, reported on the food records by the MEDAS-derived total MedDiet score, was in the expected direction, but no association was observed with cardiometabolic risk factors. The two administrations of the MEDAS produced similar mean total MedDiet scores (5.5 vs. 5.4, p = 0.706), which were correlated (r and ICC = 0.69, p < 0.001) and agreed fairly (κ = 0.38, 95% CI 0.24–0.52, p < 0.001; 95% limits of agreement −3.1, 3.2). The English version of the MEDAS has acceptable accuracy and reliability for assessing MedDiet adherence among individuals with a high cardiovascular risk, in the UK, and can be used to rank individuals according to MedDiet adherence in research and practice.