Mastery of type 2 diabetes prevention and treatment knowledge by general practitioners in Shanghai: a cross-sectional study

Background To study the competency of general practitioners (GPs) in Shanghai, China on prevention and management of type 2 diabetes, also understand factors that may prohibit it. Methods A survey questionnaire with 25 questions was designed based on 2013 Chinese Type 2 Diabetes Prevention Guidelines and Chinese Type 2 Diabetes Prevention Guidelines (Grassroots Edition) and conducted among 789 GPs who work at 54 community healthcare centers (CHCs) within 16 districts at Shanghai, China. Excel 2016 and SPSS 24.0 were used for data analysis, and a difference of P < 0.05 was considered to be statistically significant. Results The GPs did poorly on three aspect of diabetes prevention and treatment: (1) treatment goals in elderly patients, (2) screening methods for high-risk population, and (3) aspirin contraindications. The statistical analysis data showed that GPs who finished standardized training had correct answer on 13.58 ± 3.31 questions out of total 25, with mean accuracy rate of 54.32%. Except the questions for high-risk population screening method and the diagnostic criteria for type 2 diabetes, there was no difference in the accuracy of other questions between GPs with or without standardized training (P < 0.05). However, sex, educational level, and subspecialty experience are affective factors on their competency in type 2 diabetes prevention and treatment knowledge. Conclusion The results indicated that communities should strengthen the training of GPs in diabetes management and bidirectional referral. Frequent continuing education and skills training should be provided among GPs at CHCs to ensure their competency of type 2 diabetes prevention and treatment knowledge after obtaining their GP license disregard of their standardized training. In addition, attention should be paid to GPs who had lower education background or non-clinical subspecialty experience to strengthen their clinical knowledge of type 2 diabetes.

Top-funded Companies Offering Digital Behavior Change Interventions for the Prevention and Management of Type-2 Diabetes: A Systematic Search on Venture Capital Databases and Content Analysis of Interventions (Preprint)

BACKGROUND Advancements in technology offer new opportunities for the prevention and management of type 2 diabetes. Venture capital companies have been investing in digital diabetes companies that offer digital behavior change interventions (DBCIs). However, little is known about the scientific evidence underpinning such interventions or the degree to which those interventions leverage novel technology-driven automated developments such as conversational agents (CAs) or just-in-time adaptive intervention (JITAI) approaches. OBJECTIVE Our objectives were to identify the top-funded companies offering DBCIs for type 2 diabetes management and prevention, review the level of scientific evidence underpinning the DBCIs, identify which DBCIs are recognized as evidence-based programs by quality assurance authorities, and examine the degree to which these DBCIs include novel automated approaches such as CAs and JITAI mechanisms. METHODS A systematic search was conducted using two venture capital databases (Crunchbase Pro and Pitchbook) to identify the top-funded companies in type 2 diabetes prevention and management. Scientific publications relating to the identified DBCIs were identified via PubMed, Google Scholar, and the DBCI’s website and data regarding intervention effectiveness were extracted. The US CDC’s Diabetes Prevention Recognition Program (DPRP) was used to identify recognition status. The DBCIs’ publications, websites, and mobile applications were reviewed with regards to the intervention characteristics. RESULTS The 16 most-funded companies offering DBCIs for type 2 diabetes received a total funding of 2.4 billion USD as of June 15, 2021. Only four out of 50 identified publications associated with these DBCIs were fully powered randomized controlled trials (RCTs). One of those four RCTs showed a significant difference in HbA1c outcomes between the intervention and control group. However, all of the studies reported HbA1c improvements ranging from 0.2-1.9% over the course of 12 months. Six interventions were fully recognized by the DPRP to deliver evidence-based programs, and two interventions had a pending recognition status. Health professionals were included in the majority of DBCIs (81%, 13/16), whereas only 10% (1/10) of accessible apps involved a CA as part of the intervention delivery. Self-reports represented most of the data sources (62%, 74/119) that could be used to tailor JITAIs. CONCLUSIONS Our findings suggest that the level of funding received by companies offering DBCIs for type 2 diabetes prevention and management does not coincide with the level of evidence on the intervention effectiveness. There a is large variation in the level of evidence underpinning the different DBCIs and an overall need for more rigorous effectiveness trials and transparent reporting by quality assurance authorities. Currently, very few DBCIs use automated approaches such as CAs and JITAIs, limiting the scalability and reach of these solutions. Finally, more research is needed to establish the effectiveness of fully automated DBCIs in comparison to those offering human support.

Effectiveness of two procedures for deploying a facilitated collaborative modeling implementation strategy—the PVS-PREDIAPS strategy—to optimize type 2 diabetes prevention in primary care: the PREDIAPS cluster randomized hybrid type II implementation trial

Background The most efficient procedures to engage and guide healthcare professionals in collaborative processes that seek to optimize practice are unknown. The PREDIAPS project aims to assess the effectiveness and feasibility of different procedures to perform a facilitated interprofessional collaborative process to optimize type 2 diabetes prevention in routine primary care. Methods A type II hybrid cluster randomized implementation trial was conducted in nine primary care centers of the Basque Health Service. All centers received training on effective healthy lifestyle promotion. Headed by a local leader and an external facilitator, centers conducted a collaborative structured process—the PVS-PREDIAPS implementation strategy—to adapt the intervention and its implementation to their specific context. The centers were randomly allocated to one of two groups: one group applied the implementation strategy globally, promoting the cooperation of all health professionals from the beginning, and the other performed it sequentially, centered first on nurses, who later sought the pragmatic cooperation of physicians. The following patients were eligible for inclusion: all those aged ≥ 30 years old with at least one known cardiovascular risk factor and an impaired fasting glucose level (≥ 110-125 mg/dl) but without diabetes who attended centers during the study period. The main outcome measures concerned changes in type 2 diabetes prevention practice indicators after 12 months. Results After 12 months, 3273 eligible patients at risk of type 2 diabetes had attended their family physician at least once, and of these, 490 (15%) have been addressed by assessing their healthy lifestyles in both comparison groups. The proportion of at-risk patients receiving a personalized prescription of lifestyle change was slightly higher (8.6%; range 13.5-5.9% vs 6.8%; range 7.2-5.8%) and 2.3 times more likely (95% CI for adjusted hazard ratio, 1.38-3.94) in the sequential than in the global centers, after 8 months of the intervention program implementation period. The probability of meeting the recommended levels of physical activity and fruit and vegetable intake were four- and threefold higher after the prescription of lifestyle change than only assessment and provision of advice. The procedure of engagement in and execution of the implementation strategy does not modify the effect of prescribing healthy habits (p interaction component of intervention by group, p > 0.05). Discussion Our results show that the PVS-PREDIAPS implementation strategy manages to integrate interventions with proven efficacy in the prevention of type 2 diabetes in clinical practice in primary care. Further, they suggest that implementation outcomes were somewhat better with a sequential facilitated collaborative process focused on enhancing the autonomy and responsibility of nurses who subsequently seek a pragmatic cooperation of GPs. Trial registration Clinicaltrials.gov identifier: NCT03254979. Registered 16 August 2017—retrospectively registered.

Trends in HbA1c Change Among Youth Referred to a Pediatric Type 2 Diabetes Prevention Clinic

Background: Pediatric type 2 diabetes (T2D) has increased in prevalence as childhood obesity rates climb. More youth are being referred to pediatric endocrinology due to the concern for developing T2D, yet prediction of which children will progress to overt T2D is challenging. We describe a single center experience with pediatric prediabetes referrals and trends in HbA1c change. Methods: Retrospective review of new patients seen at a Type 2 Diabetes Prevention (T2DP) Clinic July 2015 - December 2019. All children referred to T2DP Clinic have an elevated BMI and findings of insulin resistance/prediabetes/early T2D. They are evaluated by pediatric endocrinology providers and dieticians at each visit. The outcome of interest was categorical HbA1c change between patients’ initial and most recent T2DP Clinic visit. Only HbA1c measurements conducted at the study site were included to address inconsistencies in lab assays. HbA1c at the initial visit was categorized into 3 groups: 1) &lt; 5.7%; 2) 5.7 to &lt;6.5%; 3) 6.5% to &lt;8.5%. Final HbA1c was categorized similarly with the option to progress to a 4th HbA1c group of ≥8.5%. Patients were categorized as progressors, regressors, or stable depending on change in group (e.g., group 1 --&gt; group 2) between initial and most recent HbA1c. Comparisons between groups were made using ANOVA and Fisher’s exact tests. Results: Among 297 patients seen for an initial visit, mean BMI z-score was 2.3 and body fat percentage was 44%. High blood pressure occurred in 47%, high ALT in 24%, low HDL in 14%. Prevalence of initial HbA1c &lt; 5.7%, 5.7 to &lt; 6.5%, and 6.5% to &lt; 8.5% was 46%, 42%, and 12%, respectively. One-third (31%) were prescribed metformin at their initial visit. Only 63 patients (21%) had 2 or more visits in the T2DP Clinic with study site HbA1c data available. Of those 63 patients, mean age at initial visit was 12.5 years, BMI z-score 2.0, and body fat 46%. Most patients were female (68%) with public insurance (70%). Race/ethnicity was 35% black, 29% white, 30% Hispanic. Mean time between initial and most recent HbA1c was 11.9 months. Assessment of categorical HbA1c change showed 14% of patients with progression (n=9), 65% stable (n=41), and 21% with regression (n=13). Female sex, ALT elevation, HbA1c, fasting glucose were found to be statistically different between the groups at baseline (p &lt; 0.05). Age, race/ethnicity, BMI, body fat percentage, elevated blood pressure, lipid profile, 120-minute glucose on OGTT, and metformin use were not different between the groups. Conclusions. Only 14% of children who presented for follow up in our T2DP clinic demonstrated progression in HbA1c. Risk factors for those who progress include female sex and ALT elevation. Further development of predictive models to identify this high-risk population who will progress is necessary. Retaining consistent follow up in pediatric prediabetes clinics presents a challenge.

Type 2 Diabetes Prevention Focused on Normalization of Glycemia: A Two-Year Pilot Study

The purpose of this study is to assess the effects of an alternative approach to type 2 diabetes prevention. Ninety-six patients with prediabetes (age 52 (10) years; 80% female; BMI 39.2 (7.1) kg/m2) received a continuous remote care intervention focused on reducing hyperglycemia through carbohydrate restricted nutrition therapy for two years in a single arm, prospective, longitudinal pilot study. Two-year retention was 75% (72 of 96 participants). Fifty-one percent of participants (49 of 96) met carbohydrate restriction goals as assessed by blood beta-hydroxybutyrate concentrations for more than one-third of reported measurements. Estimated cumulative incidence of normoglycemia (HbA1c < 5.7% without medication) and type 2 diabetes (HbA1c ≥ 6.5% or <6.5% with medication other than metformin) at two years were 52.3% and 3%, respectively. Prevalence of metabolic syndrome, class II or greater obesity, and suspected hepatic steatosis significantly decreased at two years. These results demonstrate the potential utility of an alternate approach to type 2 diabetes prevention, carbohydrate restricted nutrition therapy delivered through a continuous remote care model, for normalization of glycemia and improvement in related comorbidities.