[ Diabetes Type 2 ]

BMC Family Practice

Diabetes type 2 is one of the most prevalent causes of morbidity and mortality in developed countries (1). Obesity induced inflammation is an important contributor to the induction of insulin resistance. The study, published July 17 in Cell Metabolism, suggests that blocking this signal may protect against the development of metabolic disease, type 2 diabetes, and other disorders caused by obesity-linked inflammation. Free fatty acids (FFAs) in plasma are high (>1 mM) in prediabetic and diabetic ZDF rats; therefore, we cultured prediabetic islets in 1 mM FFA. Jeffrey S. Importantly, obesity antedates asthma. “When a person becomes obese, the fat cells in the adipose tissue accumulate fat.

Previous research has established that immune cells called macrophages infiltrate fat tissue and produce chemical mediators called cytokines which leads to inflammation responsible for the eventual insulin resistance,” explained Ganguly. Alterations of glucose metabolism are related with markers of systemic and intestinal inflammation [29]. Then she will assess mice from which AMPK has been genetically removed for their sensitivity to angiotensin II and aldosterone. Moreover, perhaps 10 percent of Type 2’s are not fat, and a certain number are even quite fit. In fact, the underlying causes of obesity can be associated with the limbic neural circuitry destruction of orbital frontal cortex [31]. Together with teams from the Paracelsus Private Medical University in Salzburg, they investigated tissue samples of overweight people and found: people with low HO-1 values very rarely developed secondary disease, while those with high levels were very often affected. Speaking Spanish was significantly related to HRQoL in complex ways.

As a result, insulin sensitivity and overall metabolism can be altered. However, they rated their children health better on physical health and family subscales. Also, it seemed that under healthy oral conditions, obesity per se does not promote pathologic periodontal alterations; however, in response to bacterial plaque accumulation, periodontal inflammation and destruction were more severe in obese animals.[4] Later on, the hypothesis of obesity as a risk factor for periodontal disease was supported by epidemiological studies. This suggests that Hispanic ethnicity does not directly determine poor physical health among children. However, because of small numbers the role of chance cannot be ruled out. At monthly intervals, the team examined bone and cartilage tissues in the knee joints for markers that would reveal signs of osteoarthritis. The results of our study suggest that efforts should be made to overcome language barriers that may face Spanish-speaking children or their parents.

Although we cannot infer causality because of the cross-sectional design of our study, it seems likely that hyperglycemia symptoms lead to poor HRQoL. The West Texas population is not typical of the U.S. population and thus results may not be generalizable. While most clinicians focus first on relieving depressive symptoms, Ganguli cautions against waiting too long to start discussing the person’s general health, including weight issues. The low response rate of approximately 55% can potentially result in self-selection bias if parents concerned with their child’s health were more likely to participate in the survey. In addition, weight and height were measured, and BMI calculated in every patient. Similarly, since this was a telephone survey, exclusion of subjects without telephone may induce a potential bias in the study.

This seems unlikely though since less than 5% of households in Texas are without telephone service [16]. In this study parents’/guardians acted as proxy for children and may not have reported their child’s health accurately. It is difficult to determine the direction of bias this may have caused in this cross-sectional study. The impact of hyperglycemic symptoms and language barriers on the health of children in the United States is potentially quite large. The increasing prevalence of childhood obesity has been recognized, but this fact understates the true magnitude of the problem. At least among rural and Spanish-speaking children, hyperglycemia symptoms are much more common and have more direct impact on health.

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[ Diabetes Solutions ]

BMC Family Practice

By looking into the back of your eye (the retina), eye doctors can see if there are changes in the blood vessels. The review did not report separate data for outreach screening or include outreach screening as a covariate in meta-analyses, so these conclusions should be viewed with caution. The earliest changes can be seen only with a special test called fluorescein angiography. In turn, these weak blood vessels leak fluid into your eye and blur your vision. Diabetic retinopathy can cause the blood vessels in the lining at the back of the eye (the retina) to leak or become blocked and damage your sight. Very rarely, allergic or even more severe reactions can occur. Control and moderate/severe NPDR cases comparison showed statistically significant differences in amplitude (Q(A)) and constriction velocity (Q(CV)) (Wilcoxon rank sum test P = 0.002, respectively).


Results time was insignificant (P = 0.122). Primary-care screening with retinal photographs through pharmacologically dilated pupils for diabetic retinopathy is an appropriate and cost-effective alternative to screening by an ophthalmologist in this setting. As there are no symptoms in the early stages of diabetic retinopathy, individuals with diabetes should have a comprehensive dilated exam once a year. (See table 1-3). In most Australian states, this relationship has increasingly included an educational element via the RACGP / RACO National GP Eye Skills Program. A GP screening model thus has the potential to provide a widely-available, holistic and extremely cost effective screening service on a population basis – providing general practitioner skills are adequate for the identification process. This will take about 10 minutes.

McCarty et al (13) identify lack of dilating drops in the practice, lack of confidence in detecting changes, concern re time taken and the fear of precipitation of angle-closure glaucoma as major barriers to GPs performing dilated ophthalmoscopy with their patients. Strategies to address all of these issues and perceptions were addressed as part of the “_How will this change my practice?” module in our educational intervention (Table 2). Follow up of a separate group of GPs taking this intervention as part of the national RACGP / RACO GP Eye Skills Workshop has demonstrated a sustained change in reported practice in this area [14]. There are no special risks from this test. In order to accommodate heterogeneity between studies and between tests within studies, a three-level random-intercepts logistic regression model (using 20 numerical quadrature points) was used to generate pooled estimates of sensitivity and specificity with 95% confidence intervals. The dye fluorescein is excreted from your body in your urine. This pilot aimed to assess the efficacy of this teaching program in raising the skills of those involved to the level of the current NHMRC guidelines for diabetic retinopathy screening.

These foods are: avocados; carrots; broccoli; eggs; spinach; kale; tomatoes; sunflower seeds; garlic; salmon. Following training, 94 % of the general practice study group reached this level within a two minute patient examination (both eyes). In addition, the specificity of the identification was such that it would not provide a gross referral overload to ophthalmologists for more accurate assessment and treatment. The time and effort required could be easily integrated into an annual review for patients with diabetes. The Royal Australian Colleges of General Practice and Ophthalmology have implemented this workshop across Queensland in 2000. This can cause severe blurring of vision. Clinicians, educators, bureaucrats and economists within our health system should be aware of this in framing future strategies in the area of diabetes.

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[ Diabetes Type 1 ]

BMC Family Practice

The cost of reports varies according to number of pages and postage address. We investigated whether use of antibiotics influences the risk of developing type 2 diabetes and whether the effect can be attributed to specific types of antibiotics. They may have diabetic complications, such as retinopathy, by the time they are diagnosed, or may suffer a heart attack, without warning. Managing the disease could cost up to two percent of the region’s gross domestic product. Associations were tested in subgroups representing different patient characteristics and study quality criteria. Among sansei, all adiposity measures were related to diabetes incidence, but, in adjusted models, only IAFA remained significantly associated with higher risk (2.7, 1.4-5.4, BMI-adjusted). Misak.

Perfecting pastries isn’t the only challenge to managing type 2 diabetes she faces in her career, Harris says. Women with diabetes and also women without diabetes experience a higher prevalence of depression than men. The many challenges of diabetes prevention and management resonate with patients and their families, and with health care providers, around the world. Uncontrolled levels of insulin in the body can have dire consequences. Although it must be said that Age and hereditary factors such as ethnic background and family history can also see increased risk. Let me further add, this book is not inclusive of all measurements available to date, but has a significant number of scales mentioned. The processes through which peer supporters were selected, trained and deemed appropriate for the intervention had two unforeseen consequences.

Firstly, the involvement of General Practice staff in selecting the peer supporters was significant. Although the effects shown were generally small, those that were present did appear to be relatively long-lasting. Another peer supporter was convinced to participate because he was told by the recruiting professional that she thought he ‘would be good at it’ because of his ‘life experience’. The first stage of selection would use risk factors, using data held on general practitioner computer systems, using the QDiabetes Risk Score, or by sending out questionnaires, using the Finnish Diabetes Risk Score (FINDRISC). Oman is an example of a country that instituted this approach in 1997, when management of high blood pressure and diabetes was integrated into the primary health care system across the country. For example, during one session observed by CB, a peer supporter suggested that ‘my doctor thinks I’m quite good at looking after myself, so I’m going to try and help you too’. A second peer supporter recruitment issue was identified during the process evaluation.

As described above, peer supporters were asked to complete a CRB check, occupational health check and to sign an honorary contract. The temptation of tasty desserts isn’t enough to sway Harris from the path of good health. For example, during the final peer supporter training session, at which the peer supporters completed this process by signing the honorary contract, a conversation was captured by CB in which a peer supporter declared ‘I never thought I’d be workin’ for the hospital – ‘I’ve gone up in the world!’ Such sentiments also appeared within some of the peer support sessions. Compared to their late-onset counterparts, patients with early-onset type 2 diabetes have worse risk factor control and are undertreated with life-saving drugs. In moments such as these, the formal ties the intervention provided to the institution were invoked by peer supporters as a means to stabilise their social role and construct a ‘working consensus’ with participants [33]. A study done in 2014 found that theory based interactive interventions had a positive influence on a patient’s physical activity, diet and their ability to control their blood glucose levels. Indeed, one peer supporter developed a technique for introducing the intervention and the role he was being asked to play: at the start of each session, he would say ‘I am just an ordinary person with diabetes, like you, who is here to help us all share experiences and information’.


In contrast to the examples above, this peer emphasised commonality and equality in peer support sessions, and left the institutional setting ‘backstage’ [33]. The second set of issues identified through the process evaluation relate to the training and education provided to peer supporters and participants. The decision to train peer supporters to deliver the intervention before they received the education session with other participants proved to be unpopular. The peer supporters made it clear during training sessions, meetings with the research nurse and interviews, that they felt that the basic diabetes education should precede peer support training. One peer commented during the first day of the training session that ‘we need to know more about diabetes if we’re to support people’, ‘specially if it’s [the treatment] different to ours’. The importance of diabetes knowledge and education to those involved in the study emerged subsequently in the results to the barriers survey. In addition to this, the peer supporters also suggested that the training relied too much on role play.

For example, one peer supporter noted that during the role plays another of the peers always looked uncomfortable and awkward and felt that he did not know how to ‘play act’. Another supporter suggested that the role play seemed to make the training ‘a bit too emotional’. During a focus group with the peer supporters, facilitated by the investigators, this issue was pursued further. A further peer supporter suggested that the role play was good, as it had helped them to think about how to introduce themselves to their peers. In low-income and middle-income countries, insufficient infrastructure, healthcare capacity, and lack of resources make quality improvement programs challenging. The final point identified here, relates to the framing of the education sessions. The content was well received by most patients, although some felt it contained too much information to absorb in a half day session.

However, observation and interview data suggest that not all participants understood how the education related to the peer support: some thought that it was the start of the peer support; others that it was a service provided by their GP practice. The final cluster of issues pinpointed in the process evaluation related to the role and perception of the peer supporters. The expert status claimed by some of the peer supporters, combined with the difficulty some had distinguishing the education and support components, also suggested a degree of confusion surrounding the function peer supporters were fulfilling. This was further confirmed by observations from two separate peer support sessions. In one group session, the peer supporter ran the meeting as if it were a committee in session: the group sat around a conference table, an agenda was circulated along with a bundle of information taken from the internet, relating to the low GI diet, blood glucose testing and different kinds of insulin and minutes were taken by another group member. Similarly, another peer was discovered to have requested that a 1:1 participant demand a blood glucose monitor from their diabetes specialist nurse. Such interactions created temporary moments of disagreement between peer supporters and participants predicated on contrasting perceptions of the purpose of peer support.

Whereas these two peer supporters understood their role to be one of information provision, quasi-expertise and practical involvement, the participants they worked with often saw such practices as ‘missing the point’, as one put it. However, such interactions were exceptional, and not observed or reported across the intervention. By contrast, most of the peer supporters provided support sessions that followed the intervention guidelines. One supporter, for example, centred his group sessions on the sharing of stories. In one, he listened as a participant told the group that he travels regularly with a snooker club to play in international tournaments, which he felt kept him fit. Later in the meeting, another participant told the group that she found it difficult to know what to do when eating out. The peer supporter returned to the travelling snooker player and asked him how he managed his diet when he takes trips.

Through such interactions, the peer supporter defined his role as one of facilitation and not leadership; acting to keep discussion moving and participants involved and not to impart instructions or knowledge. This was, as indicated above, the intent of the intervention design. That two of the peer supporters interpreted the role in a more directive manner suggests that the intervention procedures did not always convey and instil the relational, supportive practices in the manner intended. These examples also reveal a key difference between the dynamics of group and 1:1 sessions. In the group setting, peer supporters were able to draw on the experiences and narratives shared by others, as the case of the snooker player details above. By contrast, the 1:1 interactions often mimicked the patient-health care professional interaction or, in some cases, a counselling style. Although this was only a 2 month pilot, attendance data suggest better attendance at the 1:1 sessions (20/28, 71%, attending at least one session) than the group sessions (16/33, 48%, attending at least one session).

Arranging times when all peers could attend was often difficult.

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[ Diabetes Type 1 ]

BMC Family Practice

Some studies suggest individuals with schizophrenia have an increased risk of diabetes prior to antipsychotic use. Autoantibodies to the glutamic acid decarboxylase 65 isoform have been associated with chronic psychotic disorders and are found in neurons and pancreatic islets. Group differences were evaluated with analysis of variance and χ(2) test, and factors associated with antidiabetic treatment were evaluated with logistic regression. Data source: Local data collection. Sympathomimetic agents may cause adverse cardiovascular effects, particularly when used in high dosages and/or in susceptible patients. Although these metabolic effects can also be caused by the older antipsychotics, they have assumed greater importance as the incidence of premature mortality from preventable cardiovascular disease and diabetes has become increasingly evident. In the Psychoses in Finland study, we screened people with possible psychotic disorders from the Health 2000 study sample and interviewed them using the Research Version of the Structured Clinical Interview for DSM-IV (SCID-I) [20].

These effects can persist, even after the psychotic episode has subsided. Health and social care practitioners ensure that they carry out comprehensive physical health assessments in adults with psychosis or schizophrenia, and share the results (under shared care arrangements) when the service user is in the care of primary and secondary services. Some of these agents, particularly ephedra alkaloids (ephedrine, ma huang, phenylpropanolamine), may also predispose patients to hemorrhagic and ischemic stroke. The patient had presented multiple times over the past decade to gynaecologists, physiotherapists and surgeons with amenorrhoea, weight loss, arthralgia, abdominal pain and vomiting. These factors contribute to a life expectancy in adults with psychosis or schizophrenia that is 15–20 years lower than for the general population. Ensuring people who have a first episode of psychosis start treatment in an early intervention in psychosis service within 2 weeks of being referred. It is legally possible to restrain someone or prevent them leaving hospital if you have immediate concerns for their safety.

After diagnosis this was 0.89 (0.88-0.91) for cases and 0.84 (0.83-0.85) for matched controls.

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[ Diabetes Type 1 ]

BMC Family Practice

Depression is a severe mental illness characterised by a persistent low mood and loss of all interest and pleasure, usually accompanied by a range of symptoms such as appetite change, sleep disturbance and poor concentration. Decliners (56.1%) received time/attention matched care via diabetologist visits (attentional controls). In a double-blind placebo-controlled cross-over study, we examined hepatic and peripheral insulin action by the sequential hyperinsulinaemic-euglycaemic clamp technique with infusion of 3-[3H]-glucose in eight obese NIDDM patients and in eight obese non-diabetics, matched for age, sex and body mass index. Twenty three patients who scored 16 or above on the HDRS were included in the study and given the Short Form-36 (SF-36), and the Brief Disability Questionnaire (BDQ) and HbA1c levels were measured. Diabetic mice showed reduced cell proliferation. Do not take thioridazine (Mellaril®) with this medicine, and wait 5 weeks after stopping this medicine before you start taking thioridazine. There was also found loss of pain perception in diabetes rats which measured using hot plate and tail flick methods.

Maken de hoge glucosewaarden mensen kwetsbaar voor een depressie, of worden ze depressief van de ziektelast die diabetes met zich meebrengt? Subjects with a moderate to severe depression based on DSM-IV criteria were excluded as we considered it unethical to include more severely depressed patients because of the possibility of receiving placebo. Furthermore, subjects were excluded if they had glaucoma [14] and if they were using warfarin [15] because of possible adverse effects of paroxetine in these conditions. Furthermore, subjects with major complications due to diabetes (e.g. She was treated with subcutaneous insulin injections (daily glargine and three times a day lispro at a total dose of 0.5 units/kg/day) without any oral hypoglycemic agents. Our primary outcomes were improvement of GHbA1c and the SF-36 quality of life score. A mean difference between the treatment groups of 0.8 %-units in GHbA1c was considered to be clinically significant and power calculation, assuming an alpha error of 5 % and a beta error of 20 %, indicated that 19 patients per group were required to evidence this difference.

-0.07%, P = 0.13) were observed in the fluoxetine group. Fluoxetine should not be given to pregnant or lactating animals. While taking Prozac, you should see your physician regularly so that he/she can monitor your response to the drug and adjust the dosage accordingly. I asked her in the email if putting him back on fluoxetine would regulate his BG. I thought in the beginning, that I would be cured of my depression and anxiety, and go back to the happy person I was, then when I was ‘fixed’ I would stop taking it. For the sake of patient safety, healthcare professionals need to be aware of potential drug interactions that could lead to hypoglycemia[19]. Body mass index (kg/m2) was calculated using body weight measured to the nearest kg and height to the nearest cm.

At the same time points blood samples were drawn for the following analyses: serum glucose, GHbA1c, serum C-peptide and serum sex hormone binding globulin (SHBG). You’ll need to taper off the drug slowly to avoid withdrawal symptoms such as anxiety, sweating, nausea, and sleeping trouble. At baseline, at 1, 3 and 6 months adverse events were registered and the following safety blood tests were taken: blood count, serum sodium, serum potassium and liver enzymes. Subjects were to be removed from the study if any safety tests showed abnormal results. Further evidence for potential benefits in glycemic control came from a study by Ghaeli et al. Differences between the two treatment groups were assessed with analysis of covariance (ANCOVA), where baseline measurements were used as covariates. Changes from baseline were calculated with a paired samples t-test.

A 4 year, double blind, randomised, prospective trial of 3305 people with BMI ⩾30 kg/m2 who were randomised to lifestyle intervention plus either orlistat, 120 mg 3 times daily, or placebo showed that orlistat treatment combined with lifestyle changes reduced incident diabetes by 37%.1 It is uncertain if treatment with drugs, such as orlistat or sibutramine, is associated with weight cycling, which appears to adversely affect cardiovascular risk factors. Avoid lots of sun, sunlamps, and tanning beds.

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[ Herbal Remedies ]

BMC Family Practice

The growing burden of chronic illness has contributed to increasing healthcare costs in the past two decades. A formative study was done to evaluate the effectiveness of the CCCP compared to the normal polyclinic management of diabetes mellitus. We included randomized controlled trials involving adults with type 1 or 2 diabetes that evaluated the effect of disease-management programs on glycated hemoglobin (hemoglobin A1C) concentrations. Participants and nonparticipants were propensity-score matched. Quality scores in the DDMP sites were significantly better than in sites without the program. By interviewing patients and program staff members and analyzing program records, the McKinsey team identified several points along the patient treatment pathway where patients were likely to stop engaging in education programs. The pharmacist served as the primary care provider for the patients’ diabetes and comorbid conditions, hypertension, and hyperlipidemia.

During the prior year, 14 patients made 15 urgent care/emergency room visits and 5 patients incurred 6 hospitalizations. All participants envisioned a set of elements that could be integrated to this program. The estimated return on investment was $1.26 per $1.00 spent on DM services. The National Diabetes Prevention Program was actually modeled on its 2013 Y-USA initiative, reported the press release. Department of Health and Human Services, found that of employers with a wellness program, 77% offered a lifestyle management component and 56% offered a disease management component. On the other hand, the COACH programme by Allen et al. In addition, approximately 29,000 members with COPD, a group of diseases, including chronic bronchitis and emphysema, characterized by irreversible loss of lung capacity, participate in the COPD program.

We offer cross trainings for anyone wishing to offer the Diabetes Self-Management Program, the Positive Self-Management Program (HIV), the Chronic Pain Self-Management Program, the Cancer: Thriving and Surviving Program, the Tomando Control de su Salud program (Spanish CDSMP), or the Spanish Diabetes Program (Programa de Manejo Personal de la Diabetes) to those already trained as Master Trainers for the Chronic Disease Self-Management Program or Tomando Control de su Salud. In contrast to this study, the authors had only adapted the previous COACH studies as a patient support programme rather than a disease management programme due to severe resource limitation i.e. lack of trained nursing support resulting in resistance from local doctors to adopt a shared-care model on patient disease management counselling. As a result, the nurse educators in this study had no access to patient’s medical records and health education was reinforced using the health education booklet only. Evidence for the success of disease management programmes involving additional support from nurses or other disciplines is mixed. Our findings are comparable with some studies [14, 20] where reduction in blood cholesterol was similarly equivocal due to the Hawthorne effect among patients and healthcare providers, a change in people’s behaviour when being observed. In addition, the study may have heightened the awareness of disease management practices among family physicians involved.

However, studies published by Vale et al. [16] and Allen et al. [17] that utilised a similar programme, demonstrated significant improvement in LDL-C and TC change from baseline when patients with coronary heart diseases underwent the programme. These programs may rely less on financial incentives (other than lower or waived copays) but more on better practices. the study recruited CHD patients experiencing acute coronary syndrome who were more motivated to change; (2) difference in setting i.e. developed versus developing country; (3) difference in prescription behaviour i.e. higher proportion of patients prescribed with statin and with higher doses of atorvastatin in the Vale et al.

differences in compliance, nutrition or physical activity) may have led to the different BP values at baseline and to what extent these factors resulted in a greater decrease of systolic BP values in DMP patients during the time span of the study. Besides the 2 studies discussed above, there are also other studies that have had positive results with multi-disciplinary support [21–24]. The DISSEMINATE study had also revealed interesting findings with regards to HDL-C decrease over the 6 months duration. In addition, the prevalence of diabetes is expected to more than double from 5.6 to 12 percent of the U.S. Several theories are hypothesised for this outcome. First of all, there is some evidence that a low fat diet reduces not just LDL-C but also HDL-C [27–29]. Secondly, the COACH programme did not provide detailed nutritional education with information on how to reduce high dietary fat intake while substituting dietary fat with polyunsaturated fatty acids (PUFA) such as olive oil.

First, it enables identification of subgroups of patients for whom treatment is associated with the most positive effects. Several limitations to our study are identified. The evaluation results will be available by the end of 2010, but the National Insurance Fund has already announced that they will generalise this program to other regions and to other diseases (such as asthma and COPD) without waiting for the evaluation results. As discussed above, this had diluted the difference in interventional effects between control group and intervention group. For each statement in each question, 2 variables were built: 1 for  the Likert scale responses and 1 for ranking the statements that were marked “strongly agree.” Respondents were categorized into 3 groups: physicians, nurses, and others (paraprofessional and administrative personnel). And furthermore, our study has also shown that the task of personalised patient education does not have to be purely the domain of the physicians but can also be provided by trained nurses. The study might have elicited a more significant finding with addition of a third study arm assessing the lipid outcomes among patients who received “actual” standard care delivery by local physicians.

Though the primary outcome of the study was not achieved, an additional post-hoc analysis may be able to determine the proportion of uncontrolled dyslipidaemic patients who achieved cholesterol target at the end of the study follow-up. In the current analysis, the proportion of patients who achieved target cholesterol level is not known. A higher than expected attrition rate (initial sample size calculation only accounted for 10% loss to follow-up) could have also affected the final results of the study. Thus, patients with higher HbA1c values may have been less motivated and less compliant despite their greater potential for improvement. Continuous therapeutic behavioural change seems to be mandated to ensure long-term sustainable lipid control.

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[ Diabetes Solutions ]

BMC Family Practice

Purpose: To systematically review the effectiveness of lifestyle interventions on minimizing progression to diabetes in high-risk patients or progression to clinical outcomes (such as cardiovascular disease and death) in patients with type 2 diabetes. Patients were individually randomized into intervention (n = 103) and usual care group (n = 101). Trained community residents delivered the curricula in 5 group meetings aimed at improving dietary, physical activity, and diabetes self-care behaviors of study participants. In New Zealand, Professor Russell Scott of Christchurch Hospital and Professor Paul Drury of the Auckland Diabetes Centre were investigators in the trial. The A1C levels, diabetes knowledge, and diabetes health beliefs were measured 3 and 6 months postbaseline, and the mean change between the groups was analyzed. For many years, diabetes prevention had little success in reducing the rates of diabetes in Indian country. The health insurance system in Tuticorin does not cover diabetes, so it is of great importance to increase prevention and early care of the disease.

The program’s goal is to provide screening, education, and support services for patients at high risk for the development of type 2 diabetes and for those already diagnosed with the disease. The health belief scores decreased in both groups. Data were analyzed using SPSS (version 11.5; SPSS, Chicago, IL). Details of the theoretical framework of the APHRODITE intervention are described in Additional file 1 . Of 168 (30.4%) participants who withdrew from the trial, 83 were on placebo. During the process of behavior change, individuals progress from a motivational phase (planning change), via the motivation-action gap (initiating change) towards an action phase (achieving change). Progress through the different phases is limited by motivational and volitional barriers, which can be affected using lifestyle counseling.

After the admission interview with the GP [13], 11 consultations of 20 minutes were scheduled over 30 months with alternately the nurse practitioner and the GP (Additional file 2). Quinn. Moreover, intervention-group participants were invited for a 1-hour consultation with a dietician, in which a 3-day food record was discussed. Five project objectives were specified: weight reduction of at least 5% if overweight, physical exercise of moderate to high intensity for at least 30 minutes a day for at least five days a week, dietary fat intake less than 30% and saturated fat intake less than 10% of total energy intake and dietary fibre intake of at least 3.4 g per MJ. Men suffered more frequently from myocardial infarction, whereas women developed ECG criteria for IHD more frequently. The programme was free of charge for all participants. Providers received financial reimbursement for all consultations with their participants according to Dutch payment standards.


The intervention was registered with the Dutch Trial Register (NTR1082). An electronic health record serves as the registry system at intervention practices. All participants gave informed consent for participation. Before the start of the study, all GPs and nurse practitioners received a two-evening directive instruction on the theoretical framework of the intervention and its translation into practice (the content of this instruction is summarized in Additional file 1 and the mode of delivery in Additional file 3). Some researchers have suggested that health promotion programs have non-health benefits that are currently not measured, such as increased health literacy [28]. Moreover, as they intensively guided the behavior change process, all nurse practitioners received a five-evening course in motivational interviewing (MI) [16] (briefly summarized in Additional file 3). As a part of the course, active role-playing was performed and consultations with participants were audio-taped for feedback purposes.

During the study, regular return-meetings were organised with GPs (once a year) and nurse practitioners (every half a year). During the first 6 months, groups A and B received the clinic-based component, which included individual counseling visits at months 1, 2, 3, and 4. The nurse practitioner was visited only for measurements at baseline and after 6, 18 and 30 months. Apart from the admission interview participants did not have study-related encounters with the GP. Questionnaires were filled out after 18 months of intervention (Additional file 4). There were no significant baseline differences between the groups, except for the history of myocardial infarction. To reduce detection bias, individuals were not made aware of being in the intervention or the usual care group; they were only told to be in either of two groups with different contact frequency.

To gain more insight into perceived behavior change progress (Figure 1), participants were first asked whether they were planning to change a behavior or were already acting on it. When answering yes, they were asked whether they had initiated change. When answering yes, they were asked whether they had achieved change. For analysis, all participants who indicated to have planned, but not initiated change were called planners. All who reported to have initiated, but not achieved change were called initiators. Participants who indicated to have achieved change were called achievers. Motivational and volitional barriers for behavior change were inquired for all lifestyle objectives using open questions.

Motivational barriers were collected from non-planners with reporting rates ranging from 87% to 99% (intervention) and from 83% to 99% (usual care). Volitional barriers were collected from initiators and achievers, with reporting rates ranging from 81% to 88% (intervention) and from 80% to 94% (usual care). All barriers were coded by the main investigator and two research assistants; inconsistencies were checked by the main investigator. Categorization of the barriers was based on frameworks developed by Penn et al. [11] and Grol and Wensing [17]. Sample size calculation was based on the main outcome diabetes incidence. As implementation of lifestyle interventions in real life settings is challenging [9, 10], modest differences between groups were expected.

To detect small differences in diabetes incidence (Cohen’s conventional effect size of 0.1), with a power of 0.8, 393 individuals were needed in each arm. As in total 925 individuals could be included, this allowed for a dropout rate of approximately 15%, which was in line with others [4]. Post-hoc power analysis showed that the power to detect small differences between groups in the percentage of planners was 0,75 for all lifestyle objectives. For a difference in initiators, the power ranged between 0,63-0,68 and for a difference in achievers between 0,46-0,59.

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