Lifestyle management : preventing Type 2 diabetes and cardiovascular complications

For individuals with Type 2 diabetes, cardiovascular disease is the principle cause of morbidity and mortality. Lifestyle management is recognized as being an essential part of diabetes and cardiovascular disease prevention. Meta-analyses demonstrate that lifestyle interventions, including diet and physical activity, led to a 63% reduction in diabetes incidence in those at high risk. ‘Real-world’ lifestyle modification programs have demonstrated encouraging improvement in risk factors for diabetes; however, the effect on diabetes incidence has not been reported. It has been demonstrated that lifestyle interventions reduce cardiovascular risk factors; however, data on long-term cardiovascular outcomes is lacking. The aim of this review is to discuss the current evidence of lifestyle interventions in the prevention of diabetes and cardiovascular disease.

Lifestyle management of unipolar depression

Objective To be used in conjunction with ‘Pharmacological management of unipolar depression’ [Malhi et al. Acta Psychiatr Scand 2013;127(Suppl. 443):6–23] and ‘Psychological management of unipolar depression’ [Lampe et al. Acta Psychiatr Scand 2013;127(Suppl. 443):24–37]. To provide clinically relevant recommendations for lifestyle modifications in depression, derived from a literature review.

Method A search of pertinent literature was conducted up to August 2012 in the area of lifestyle factors and depression. A narrative review was then conducted.

Results There is evidence that level of physical activity plays a role in the risk of depression, and there is a large and validated evidence base for exercise as a therapeutic modality. Smoking and alcohol and substance misuse appear to be independent risk factors for depression, while the new epidemiological evidence supports the contention that diet is a risk factor for depression; good quality diets appear protective and poor diets increase risk.

Conclusion Lifestyle modification, with a focus on exercise, diet, smoking and alcohol, may be of substantial value in reducing the burden of depression in individuals and the community.

Description and preliminary results from a structured specialist behavioural weight management group intervention:Specialist Lifestyle Management (SLiM) programme

Background -  Specialist Lifestyle Management (SLiM) is a structured patient education and self-management group weight management programme. Each session is run monthly over a 6-month period providing a less intensive long-term approach. The groups are patient-centred incorporating educational, motivational, behavioural and cognitive elements. The theoretical background, programme structure and preliminary results of SLiM are presented. Subjects/methods - The study was a pragmatic service evaluation of obese patients with a body mass index (BMI) ≥35 kg/m2 with comorbidity or ≥40 kg/m2 without comorbidity referred to a specialist weight management service in the West Midlands, UK. 828 patients were enrolled within SLiM over a 48-month period. Trained facilitators delivered the programme. Preliminary anonymised data were analysed using the intention-to-treat principle. The primary outcome measure was weight loss at 3 and 6 months with comparisons between completers and non-completers performed. The last observation carried forward was used for missing data. Results - Of the 828 enrolled within SLiM, 464 completed the programme (56%). The mean baseline weight was 135 kg (BMI=49.1 kg/m2) with 87.2% of patients having a BMI≥40 kg/m2 and 12.4% with BMI≥60 kg/m2. The mean weight change of all patients enrolled was −4.1 kg (95% CI −3.6 to −4.6 kg, p=0.0001) at the end of SLiM, with completers (n=464) achieving −5.5 kg (95% CI −4.2 to −6.2 kg, p=0.0001) and non-completers achieving −2.3 kg (p=0.0001). The majority (78.6%) who attended the 6-month programme achieved weight loss with 32.3% achieving a ≥5% weight loss. Conclusions - The SLiM programme is an effective group intervention for the management of severe and complex obesity.

Psychological health and lifestyle management preconception and in pregnancy

Healthful lifestyles before and during pregnancy are important to facilitate healthy outcomes for mother and baby. For example, behaviors such as a sedentary lifestyle and consuming an energy-dense/nutrient-poor diet increase the risk of overweight/obesity before pregnancy and excessive weight gain during pregnancy, leading to adverse maternal and child health outcomes. Maternal psychopathology may be implicated in the development of suboptimal maternal lifestyle behaviors before and during pregnancy, perhaps through impacts on motivation. This article explores this notion using maternal obesity and excessive gestational weight gain as examples of the health impacts of psychological states. We suggest that factors such as psychological well-being, individual motivation for behavior change, and broader environmental influences that affect both individual and system-wide determinants all play important roles in promoting healthy lifestyles periconception and are key modifiable aspects for intervention designers to consider when trying to improve dietary behaviors and increase physical activity before and during pregnancy. In addition, implementing system-wide changes that impact positively on individual and environmental barriers to behavior change that are sustainable, measureable, and effective is required.

Next steps in the logic of consumer-led self-management : translating chronic condition self-management programmes (CCSM) into lifestyle management programmes for young people

The techniques applied in chronic condition self-management programmes (CCSM) to support patients with chronic conditions are basic counselling and communication strategies that would benefit people at all stages of life and wellness. The question being explored here is why, as a society, we wait until people develop essentially preventable chronic conditions before helping them to develop the life skills they need to manage their lives and their human interactions better rather than working to avoid or prevent many chronic conditions that develop as a result of people lacking such skills? If we were to teach coping and managing skills to everyone in a supportive and structured way, using the peer-led teaching and learning strategies and basic counselling and education processes that have been shown to be successful for other older groups with chronic illness, the overall population impact would be more significant. Therefore why wait until people have chronic conditions before empowering them with basic life management techniques? Do people need to be sick before they can be motivated to live more effective lives? Is sickness the main stimulus for triggering health-related behaviour change or can other factors in people’s lives serve to inform and motivate lifestyle change?

Translating chronic condition self-management programmes (CCSM) into lifestyle management programmes for young people

The techniques applied in chronic condition self-management programmes (CCSM) to support patients with chronic conditions are basic counselling and communication strategies that would benefit people at all stages of life and wellness. The question being explored here is why, as a society, we wait until people develop essentially preventable chronic conditions before helping them to develop the life skills they need to manage their lives and their human interactions better rather than working to avoid or prevent many chronic conditions that develop as a result of people lacking such skills? If we were to teach coping and managing skills to everyone in a supportive and structured way, using the peer-led teaching and learning strategies and basic counselling and education processes that have been shown to be successful for other older groups with chronic illness, the overall population impact would be more significant. Therefore why wait until people have chronic conditions before empowering them with basic life management techniques? Do people need to be sick before they can be motivated to live more effective lives? Is sickness the main stimulus for triggering health-related behaviour change or can other factors in people's lives serve to inform and motivate lifestyle change.

Pharmacological management of unipolar depression

Objective : To be used in conjunction with ‘Psychological management of unipolar depression’ [Lampe et al. Acta Psychiatr Scand 2013;127(Suppl. 443):24–37] and ‘Lifestyle management of unipolar depression’ [Berk et al. Acta Psychiatr Scand 2013;127(Suppl. 443):38–54]. To provide clinically relevant recommendations for the use of pharmacological treatments in depression derived from a literature review.

Method : Using our previous Clinical Practice Guidelines [Malhi et al. Clinical practice recommendations for bipolar disorder. Acta Psychiatr Scand 2009;119(Suppl. 439):27–46] as a foundation, these clinician guidelines target key practical considerations when prescribing pharmacotherapy. A comprehensive review of the literature was conducted using electronic database searches (PubMed, MEDLINE), and the findings have been synthesized and integrated alongside clinical experience.

Results : The pharmacotherapy of depression is an iterative process that often results in partial and non-response. Beyond the initiation of antidepressants, the options within widely used strategies, such as combining agents and switching between agents, are difficult to proscribe because of the paucity of pertinent research. However, there is some evidence for second-line strategies, and a non-prescriptive algorithm can be derived that is based broadly on principles rather than specific steps.

Conclusion : Depression is by its very nature a heterogeneous illness that is consequently difficult to treat. Invariably, situation-specific factors often play a significant role and must be considered, especially in the case of partial and non-response. Consulting with colleagues and trialling alternate treatment paradigms are essential strategies in the management of depression.

Psychological management of unipolar depression

Objective: To be used in conjunction with 'Pharmacological management of unipolar depression' [Malhi et al. Acta Psychiatr Scand 2013;127(Suppl. 443):6-23] and 'Lifestyle management of unipolar depression' [Berk et al. Acta Psychiatr Scand 2013;127(Suppl. 443):38-54]. To provide clinically relevant recommendations for the use of psychological treatments in depression derived from a literature review. Method: Medical databases including MEDLINE and PubMed were searched for pertinent literature, with an emphasis on recent publications. Results: Structured psychological treatments such as cognitive behaviour therapy and interpersonal therapy (IPT) have a robust evidence base for efficacy in treating depression, even in severe cases of depression. However, they may not offer benefit as quickly as antidepressants, and maximal efficacy requires well-trained and experienced therapists. These therapies are effective across the lifespan and may be preferred where it is desired to avoid pharmacotherapy. In some instances, combination with pharmacotherapy may enhance outcome. Psychological therapy may have more enduring protective effects than medication and be effective in relapse prevention. Newer structured psychological therapies such as mindfulness-based cognitive therapy and acceptance and commitment therapy lack an extensive outcome literature, but the few published studies yielding positive outcomes suggest they should be considered options for treatment. Conclusion: Cognitive behaviour therapy and IPT can be effective in alleviating acute depression for all levels of severity and in maintaining improvement. Psychological treatments for depression have demonstrated efficacy across the lifespan and may present a preferred treatment option in some groups, for example, children and adolescents and women who are pregnant or postnatal. © 2013 John Wiley & Sons A/S. Published by Blackwell Publishing Ltd.

Relationships among epilepsy self-management, health outcomes, and socioeconomic status

The purpose of this study was to investigate the association between epilepsy self-management and disease control and socio-economic status. Study participants were adult patients at two epilepsy specialty clinics in Houston, Texas that serve demographically and socioeconomically diverse populations. Self-management behaviors- medication, information, safety, seizure, and lifestyle management were tested against emergency room visits, hospitalizations, and seizure occurrence. Overall self-management score was associated with a greater likelihood of hospitalizations over a prior twelve month time frame, but not for three months, and was not associated with seizure occurrence or emergency room visits, at all. Scores on specific self-management behaviors varied in their relationships to the different disease control indicators, over time. Contrary to expectations based on the findings of previous research, higher information management scores were associated with greater likelihood of emergency room visits and hospitalizations, over the study's twelve months. Higher lifestyle management scores were associated with lower likelihood of any emergency room visits, over the preceding twelve months and emergency room visits for the last three months. The positive associations between overall self-management scores and information management behaviors and disease control are contrary to published research. These findings may indicate that those with worse disease control in a prior period employ stronger self-management efforts to better control their epilepsy. Further research is needed to investigate this hypothesis.^

Comparison of weight loss outcomes between obese patients with and without Type 2 diabetes attending a weight management focused structured educational group

Aims: Specialist lifestyle management (SLiM) is a medically supported dietetically led structured group education and self-management programme focusing on weight management. Obese patients with Type 2 diabetes are perceived to find it more difficult to lose weight compared with those without diabetes. We aimed to compare the weight loss achieved by obese patients with or without Type 2 diabetes completing the SLiM programme. Methods: A prospective analysis of patients attending SLiM between 2009 and 2013 was conducted. Results: There were 454 obese patients (mean age 49.1 ± 11.6years, women 72.5%, body mass index 49.8 ± 9.3kg/m2, weight137.3 ± 28kg). 152/454 patients (33%) had Type 2 diabetes of which 31 (20.4%) were insulin treated. Patients with Type 2diabetes were older (52.4 ± 11.3 vs 47.5 ± 11.4 years, p < 0.001). SLiM resulted in significant weight loss in patients with (136.5 ± 27 vs 130.2 ± 25.3, p < 0.001) or without (137.6 ± 29 vs 132.6 ± 28.4, p < 0.001) Type 2 diabetes. Weight loss was comparable between patients with and without Type 2 diabetes (6.1 ± 7.9 vs5.1 ± 7kg, p = 0.2). The proportion of patients achieving ≥ 10%weight loss was similar between patients with and without Type 2diabetes (10.5% vs 9.9%, p = 0.4). Insulin-treated patients lost similar weight to those not treated with insulin (6.3 ± 9.4 vs 6.1 ± 7.6kg, p = 0.9). After adjustment for age, sex, referral weight and medications, Type 2 diabetes did not predict weight change during the SLiM programme (b = 0.3, p = 0.5). Conclusions: Attending the SLiM groups produces a significant weight loss in patients with Type 2 diabetes which is comparable to those without Type 2 diabetes. Insulin-treated patients lost similar weight to those not on insulin. Weight gain with Type 2 diabetes and insulin treatment is not ‘unavoidable’ if patients receive the appropriate support and education.

Genetics and hyperlipidaemia

Hannah is a 30 year old single mother with two young children. She is of Chinese descent and moved to the UK six years ago; she has a good level of English. Recently her mother suffered a heart attack, which prompted Hannah’s first visit to the general practitioner (GP). Meanwhile Hannah performed a predictive genetic test independently through an online company, which showed an increased risk of developing cardiovascular disease (CVD); she has the ɛ4 variant of the APOE gene. The company has recommended a daily supplement and dietary changes. Blood tests showed raised blood lipids and her GP referred Hannah to a dietitian for lifestyle management. Hannah is very concerned and anxious about her health.

Effects of high-intensity progressive resistance training on self-reported health status in older persons with type 2 diabetes

Purpose: To evaluate the influence of high-intensity progressive resistance training (PRT) on self-reported physical and mental health in older persons with type 2 diabetes.

Methods: We performed a 12-month RCT with 36 overweight men and women with type 2 diabetes (aged 60-80 years) who were randomly assigned to a moderate weight-loss diet plus PRT (PRT&WL) or a moderate weight-loss diet plus a control (stretching) program (WL). Gymnasium-based training for 6 months was followed by an additional 6 months of home-based training. The SF-36 (v1) questionnaire was used to obtain physical (PCS) and mental (MCS) health component summary scores at baseline, 6 and 12 months.

Results: Subject retention was 81% and 72% after 6 and 12 months respectively. Exercise adherence during gymnasium- and home-based training was 88% and 73% for the PRT&WL group, and 85% and 78.1% for the WL group respectively. In a regression model adjusted for age and sex, PCS improved in the PRT&WL group compared to the WL group after 6 months of gymnasium-based training (2.3 versus -2.0, p = 0.05), which persisted after 12 months training (0.7 versus -4.1, p = 0.03). There were no between-group differences at 6 or 12 months for the MCS.

Conclusion: High-intensity PRT was effective in improving self-reported physical health, but not mental health. PRT provides an effective exercise alternative in lifestyle management for older adults with type 2 diabetes.

The effects of progressive resistance training combined with a whey-protein drink and vitamin D supplementation on glycaemic control, body composition and cardiometabolic risk factors in older adults with type 2 diabetes: study protocol for a randomized c

While physical activity, energy restriction and weight loss are the cornerstone of type 2 diabetes management, less emphasis is placed on optimizing skeletal muscle mass. As muscle is the largest mass of insulin-sensitive tissue and the predominant reservoir for glucose disposal, there is a need to develop safe and effective evidence-based, lifestyle management strategies that optimize muscle mass as well as improve glycaemic control and cardiometabolic risk factors in people with this disease, particularly older adults who experience accelerated muscle loss.

Deployed military women: A second look at gender-specific infections

This descriptive, cross-sectional study addressed the relationship between variables of deployed military women and prevalence of gender-specific infections. The analysis of secondary data will look at the last deployment experience of 880 randomly selected U.S. military women who completed a mailed questionnaire (Deployed Female Health Practice Questionnaire (FHPQ)) in June 1998. The questionnaire contained 191 items with 80 data elements and one page for the subject's written comments. The broad categories of the questionnaire included: health practices, health promotion, disease prevention and treatment, reproduction, lifestyle management, military characteristics and demographics. The research questions are: (1) What is the prevalence of sexually transmitted diseases (STD), urinary tract infections (UTI) and vaginal infections (VI) related to demographic data, military characteristics, behavioral risk factors and health practices of military women during their last deployment? and (2) What are the differences between STD, UTI and VI related to the demographic data, military characteristics, behavioral risk factors and health practices of military women during their last deployment. The results showed that (1) STDs were found to be significantly associated with age and rank but not location of deployment or military branch; (2) UTI were found to be significantly associated with intrauterine device (IUD) use, prior UTI and type of items used for menses management, but not education or age; and (3) VI were significantly associated with age, rank and deployment location but not ethnicity or education. Although quantitative research exploring hygiene needs of deployed women continues, qualitative studies may uncover further “hidden” issues of importance. It cannot be said that the military has not made proactive changes for women, however, continued efforts to hone these changes are still encouraged. Mandatory debriefings of “seasoned” deployed women soldiers and their experiences would benefit leadership and newly deployed female soldiers with valuable “lessons learned.” Tailored hygiene education material, prevention education classes, easy access website with self-care algorithms, pre-deployment physicals, revision of military protocols for health care providers related to screening, diagnosing and treatment of gender-specific infections and process changes in military supply network of hygiene items for women are offered as recommendations. ^

Treatment with metformin

Metformin is an anti-hyperglycaemic agent widely used in the treatment of type 2 diabetes. It counters insulin resistance through insulin-dependent and -independent effects on cellular nutrient and energy metabolism, improving glycaemic control without weight gain and without increasing the risk of hypoglycaemia. Metformin can also benefit several risk factors for vascular disease independently of glycaemic control. In subjects with metabolic syndrome, metformin improves prognosis. It decreases progression of impaired glucose tolerance to type 2 diabetes, assists weight reduction especially in conjunction with lifestyle management and exerts other potentially favourable cardiovascular effects. For example, metformin can modestly improve the lipid profile in some dyslipidaemic individuals, reduce pro-inflammatory cytokines and monocyte adhesion molecules and decrease advanced glycation end products. Metformin can also improve parameters of endothelial function in the macro- and micro-vasculature, indicating lower athero-thrombotic risk, but it does not appear to reduce blood pressure. In normoglycaemic individuals with risk factors for diabetes and in women with polycystic ovary syndrome there is evidence that metformin can defer or prevent the development of diabetes. Thus, metformin offers beneficial effects to delay the onset and reverse or reduce the progression of many of the metabolic features and cardiovascular risk factors associated with metabolic syndrome.