Karla I. Galaviz

Long-term Sustainability of Diabetes Prevention Approaches: A Systematic Review and Meta-analysis of Randomized Clinical Trials

Importance Diabetes prevention is imperative to slow worldwide growth of diabetes-related morbidity and mortality. Yet the long-term efficacy of prevention strategies remains unknown. Objective To estimate aggregate long-term effects of different diabetes prevention strategies on diabetes incidence. Data Sources Systematic searches of MEDLINE, EMBASE, Cochrane Library, and Web of Science databases. The initial search was conducted on January 14, 2014, and was updated on February 20, 2015. Search terms included prediabetes, primary prevention, and risk reduction. Study Selection Eligible randomized clinical trials evaluated lifestyle modification (LSM) and medication interventions (>6 months) for diabetes prevention in adults (age ≥18 years) at risk for diabetes, reporting between-group differences in diabetes incidence, published between January 1, 1990, and January 1, 2015. Studies testing alternative therapies and bariatric surgery, as well as those involving participants with gestational diabetes, type 1 or 2 diabetes, and metabolic syndrome, were excluded. Data Extraction and Synthesis Reviewers extracted the number of diabetes cases at the end of active intervention in treatment and control groups. Random-effects meta-analyses were used to obtain pooled relative risks (RRs), and reported incidence rates were used to compute pooled risk differences (RDs). Main Outcomes and Measures The main outcome was aggregate RRs of diabetes in treatment vs control participants. Treatment subtypes (ie, LSM components, medication classes) were stratified. To estimate sustainability, post-washout and follow-up RRs for medications and LSM interventions, respectively, were examined. Results Forty-three studies were included and pooled in meta-analysis (49 029 participants; mean [SD] age, 57.3 [8.7] years; 48.0% [n = 23 549] men): 19 tested medications; 19 evaluated LSM, and 5 tested combined medications and LSM. At the end of the active intervention (range, 0.5-6.3 years), LSM was associated with an RR reduction of 39% (RR, 0.61; 95% CI, 0.54-0.68), and medications were associated with an RR reduction of 36% (RR, 0.64; 95% CI, 0.54-0.76). The observed RD for LSM and medication studies was 4.0 (95% CI, 1.8-6.3) cases per 100 person-years or a number-needed-to-treat of 25. At the end of the washout or follow-up periods, LSM studies (mean follow-up, 7.2 years; range, 5.7-9.4 years) achieved an RR reduction of 28% (RR, 0.72; 95% CI, 0.60-0.86); medication studies (mean follow-up, 17 weeks; range, 2-52 weeks) showed no sustained RR reduction (RR, 0.95; 95% CI, 0.79-1.14). Conclusions and Relevance In adults at risk for diabetes, LSM and medications (weight loss and insulin-sensitizing agents) successfully reduced diabetes incidence. Medication effects were short lived. The LSM interventions were sustained for several years; however, their effects declined with time, suggesting that interventions to preserve effects are needed.

Evaluating the Theoretical Content of Online Physical Activity Information for People with Multiple Sclerosis

BACKGROUND Physical activity can aid people with multiple sclerosis (MS) in managing symptoms and maintaining functional abilities. The Internet is a preferred source of physical activity information for people with MS and, therefore, a method for the dissemination of behavior change techniques. The purpose of this study was to examine the coverage and quality of physical activity behavior change techniques delivered on the Internet for adults with MS using Abraham and Michies taxonomy of behavior change techniques. METHODS Using the taxonomy, 20 websites were coded for quality (ie, accuracy of information) and coverage (ie, completeness of information) of theoretical behavior change techniques. RESULTS RESULTS indicated that most websites covered a mean of 8.05 (SD 3.86, range 3-16) techniques out of a possible 20. Only one of the techniques, provide information on behavior-health link and consequences, was delivered on all websites. The websites demonstrated low mean coverage and quality across all behavior change techniques, with means of 0.64 (SD 0.67) and 0.62 (SD 0.37) on a scale of 0 to 2, respectively. However, coverage and quality improved when websites were examined solely for the techniques that they covered, as opposed to all 20 techniques. CONCLUSIONS This study, which examined quality and coverage of physical activity behavior change techniques described online for people with MS, illustrated that the dissemination of these techniques requires improvement.

A Pragmatic Application of the RE-AIM Framework for Evaluating the Implementation of Physical Activity as a Standard of Care in Health Systems

Introduction Exercise is Medicine (EIM) is an initiative that seeks to integrate physical activity assessment, prescription, and patient referral as a standard in patient care. Methods to assess this integration have lagged behind its implementation. Purpose and Objectives The purpose of this work is to provide a pragmatic framework to guide health care systems in assessing the implementation and impact of EIM. Evaluation Methods A working group of experts from health care, public health, and implementation science convened to develop an evaluation model based on the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. The working group aimed to provide pragmatic guidance on operationalizing EIM across the different RE-AIM dimensions based on data typically available in health care settings. Results The Reach of EIM can be determined by the number and proportion of patients that were screened for physical inactivity, received brief counseling and/or a physical activity prescription, and were referred to physical activity resources. Effectiveness can be assessed through self-reported changes in physical activity, cardiometabolic biometric factors, incidence/burden of chronic disease, as well as health care utilization and costs. Adoption includes assessing the number and representativeness of health care settings that adopt any component of EIM, and Implementation involves assessing the extent to which health care teams implement EIM in their clinic. Finally, Maintenance involves assessing the long-term effectiveness (patient level) and sustained implementation (clinic level) of EIM in a given health care setting. Implications for Public Health The availability of a standardized, pragmatic, evaluation framework is critical in determining the impact of implementing EIM as a standard of care across health care systems.

Global Diabetes Prevention Interventions: A Systematic Review and Network Meta-analysis of the Real-World Impact on Incidence, Weight, and Glucose

OBJECTIVE Understanding the real-world impacts of lifestyle modification (LSM) for diabetes prevention is imperative to inform resource allocation. The purpose of this study was to synthetize global evidence on the impact of LSM strategies on diabetes incidence and risk factors in one parsimonious model. RESEARCH DESIGN AND METHODS PubMed, Embase, Cochrane Library, and ClinicalTrials.gov were searched for studies published between January 1990 and April 2015. Effectiveness/translation studies of any design testing LSM strategies, targeting high-risk populations (with prediabetes or diabetes risk factors), and reporting diabetes incidence, weight, or glucose outcomes were included. We extracted number of diabetes cases/incidence rates and mean changes in weight (kg), fasting blood glucose (FBG, mmol/L), 2-h postload glucose (mmol/L), and hemoglobin A1c (%). Pairwise random-effects and frequentist random-effects network meta-analyses were used to obtain pooled effects. RESULTS Sixty-three studies were pooled in the meta-analysis (n = 17,272, mean age 49.7 years, 28.8% male, 60.8% white/European). In analyses restricted to controlled studies (n = 7), diabetes cumulative incidence was 9% among intervention participants and 12% among control participants (absolute risk reduction 3%; relative risk 0.71 [95% CI 0.58, 0.88]). In analyses combining controlled and uncontrolled studies (n = 14), participants receiving group education by health care professionals had 33% lower diabetes odds than control participants (odds ratio 0.67 [0.49, 0.92]). Intervention participants lost 1.5 kg more weight [−2.2, −0.8] and achieved a 0.09 mmol/L greater FBG decrease [−0.15, −0.03] than control participants. Every additional kilogram lost by participants was associated with 43% lower diabetes odds (β = 0.57 [0.41, 0.78]). CONCLUSIONS Real-world LSM strategies can reduce diabetes risk, even with small weight reductions.

Lifestyle and the Prevention of Type 2 Diabetes: A Status Report:

Diabetes is a costly disease affecting 387 million individuals globally and 28 million in the United States. Its precursor, prediabetes, affects 316 and 86 million individuals globally and in the United States, respectively. People living with elevated blood glucose levels are at high risk for all-cause mortality and numerous cardiometabolic ailments. Fortunately, diabetes can be prevented or delayed by maintaining a healthy lifestyle and a healthy body weight. In this review, we summarize the literature around lifestyle diabetes prevention programs and provide recommendations for introducing prevention strategies in clinical practice. Overall, evidence supports the efficacy and effectiveness of lifestyle diabetes prevention interventions across clinical and community settings, delivery formats (eg, individual-, group-, or technology-based), and implementers (eg, clinicians, community members). Evidence-based diabetes prevention strategies that can be implemented in clinical practice include brief behavior change counseling, group-based education, community referrals, and health information technologies. These strategies represent opportunities where practitioners, communities, and health care systems can work together to provide individuals with education, support and opportunities to maintain healthy, diabetes-free lifestyles.

The Public Health Leadership and Implementation Academy (PH-LEADER) for Non-Communicable Diseases

Abstract Low- and middle-income countries (LMICs) are experiencing a growing burden of non-communicable diseases (NCDs) and confront challenges of leadership, lack of local data and evidence, and gaps in implementation of successful interventions. To address these challenges, we designed an interdisciplinary training program, the Public Health Leadership and Implementation Academy (PH-LEADER) for NCDs. The year-long program has three components; a two-month preparation period; a three-week, in-person summer short course; and an in-country mentored project phase. The training was directed at mid-career, high-potential public health professionals from LMICs who are involved in NCDs prevention and control. We collected demographic data and information about achievements and products attained from participation in the program among trainees. Over four and a half years (2012–2016), 67 NCDs professionals (mean age 38.7 years; 58% male) from 11 countries have been trained. The training program has promoted the design and implementation of 49 projects focused on implementation of programs and policies addressing NCDs; 20 manuscripts submitted for publication; and four abstracts submitted for conference presentations. The PH-LEADER program promotes the design and implementation of evidence-based strategies to address NCDs in LMICs. Impact on trainee implementation research capacity and leadership skills and ultimately on NDCs prevention and control is yet to be assessed.

Room for Improvement: The HIV-Diabetes Care Continuum Over 15 Years in the Women's Interagency HIV Study

Abstract Background Gains in life expectancy through optimal control of HIV infection with antiretroviral therapy (ART) may be threatened if other comorbidities, such as diabetes, are not optimally managed. Methods We analyzed cross-sectional data of the Women’s Interagency HIV Study (WIHS) from 2001, 2006, and 2015. We estimated the proportions of HIV-positive and HIV-negative women with diabetes who were engaged in care and achieved treatment goals (hemoglobin A1c [A1c] <7.0%, blood pressure [BP] <140/90 mmHg, low-density lipoprotein [LDL] cholesterol <100 mg/dL, not smoking) and viral suppression. Repeated-measures models were used to estimate the adjusted prevalence of achieving each diabetes treatment goal at each time point, by HIV status. Results We included 486 HIV-positive and 258 HIV-negative women with diabetes. In 2001, 91.8% visited a health care provider, 60.7% achieved the A1c target, 70.5% achieved the BP target, 38.5% achieved the LDL cholesterol target, 49.2% were nonsmokers, 23.3% achieved combined ABC targets (A1c, BP, and cholesterol), and 10.9% met combined ABC targets and did not smoke. There were no differences by HIV status, and patterns were similar in 2006 and 2015. Among HIV-positive women, viral suppression increased from 41% in 2001 to 87% in 2015 compared with 8% and 13% achieving the ABC goals and not smoking. Viral suppression was not associated with achievement of diabetes care goals. Conclusions Successful management of HIV is outpacing that of diabetes. Future studies are needed to identify factors associated with gaps in the HIV–diabetes care continuum and design interventions to better integrate effective diabetes management into HIV care.

Cardiometabolic Risk Reduction Through Recreational Group Sport Interventions in Adults: A Systematic Review and Meta-analysis

Objective: To estimate the pooled effects of community‐based, recreational‐level group sports on cardiometabolic risk factors and fitness parameters among adults. Participants and Methods: We systematically searched PubMed, EMBASE, PsychINFO, CINAHL, and Web of Science electronic databases for English‐language articles reporting the effectiveness of recreational‐level group sports published between January 1, 1965, and January 17, 2017. We extracted baseline and end of intervention means for cardiometabolic and fitness parameters. Random‐ or fixed‐effects meta‐analyses were used to obtain pooled before and after change in outcome means within intervention participants and between groups. Results: From 2491 screened titles, 23 publications were included (902 participants; mean ± SD age, 46.6±11.7 years), comprising 21 soccer and 2 rugby interventions. Intervention participants achieved larger improvements (mean [95% CI]) compared with control subjects in weight (−1.44 kg [−1.79 to −1.08 kg]), body mass index (−0.88 kg/m2 [−1.73 to −0.03 kg/m2]), waist circumference (−0.77 cm [−1.21 to −0.33 cm]), body fat (−1.8% [−3.12% to −0.49%]), total cholesterol level (−0.33 mmol/L [−0.53 to −0.13 mmol/L]), low‐density lipoprotein cholesterol level (−0.35 mmol/L [−0.54 to −0.15 mmol/L]), systolic blood pressure (−5.71 mm Hg [−7.98 to −3.44 mm Hg]), diastolic blood pressure (−3.36 mm Hg [−4.93 to −1.78 mm Hg]), maximum oxygen consumption (3.93 mL/min per kg [2.96‐4.91 mL/min]), and resting heart rate (−5.51 beats/min [−7.37 to −3.66 beats/min]). Most studies (16) were classified as high quality, and we found no evidence of publication bias. Conclusion: We found significant cardiometabolic and fitness improvements following group sport participation, primarily recreational soccer. These findings suggest that group sport interventions are promising strategies for reducing cardiometabolic risk in adults.