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Article by Dr. Sheri Colberg, Phd, FACSM


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The New England Journal of Medicine

Type 2 diabetes is well known for its effects on immune function and for infections that can be recurring or more difficult to treat. It is also a condition that has very clear negative effects upon immunity, energy metabolism, and repair functions. In a landmark study published in the New England Journal of Medicine, doctors divided patients into two groups of eighty people each, one group receiving conventional drug therapy and the other group receiving “multifactorial intervention,” also referred to as “intensive therapy,” which involved exercise, lifestyle modification, dietary recommendations, and a vitamin and mineral supplement that included  [i]
vitamin C 250 mg,
vitamin E 100 mg (d-alpha-tocopherol),
folic acid 400 mcg, and
chromium picolinate, 100 mcg.

This study was also noteworthy because it was carried out over the course of almost eight years. Doctors measured the rate of key complications of diabetes including nephropathy (kidney complications), retinopathy (eye complications), cardiovascular events, neuropathy (peripheral nerve complications), and autonomic neuropathy.

Those in the supplementation (intensive therapy group) experienced an almost 50 percent reduction in nearly all of the above complications of diabetes (except neuropathy, which was comparable in each group). While the trial lasted almost eight years, favorable outcomes were similar after only four years. This is really quite extraordinary.

While immune parameters, infections, and antibiotic use were not examined in this trial, the study has an important message related to our discussion. As noted, diabetes is a condition of altered immunity, altered energy regulation, and diminished repair capability. The finding that several of the major complications associated with diabetes were reduced by almost 50 percent with an intensive therapy that included supplementation of nutrients, suggests that nutritional intervention as a component of a chronic illness treatment can have a dramatic impact on energy and repair functions.

The supplementation strategy used in this trial was limited to modest doses of only a small number of key nutrients. It is interesting to speculate on the possible outcomes were a larger number of nutrients used or where nutrient supplementation was tailored to the individual based on blood analysis of nutrient status. 

Autonomic neuropathy is not a disease, but a set of symptoms that involve damage to nerves that control digestion, heart rate, blood pressure, bladder function, skin, muscles, internal organs, blood vessels, and many others. Symptoms include, but are not limited to diarrhea, constipation, nausea after eating, heat intolerance, difficulty beginning to urinate, urinary incontinence, and abnormal sweating.

Gaude P, Vedel P, Larsen N, Jensen GVH, Parving H, Pedersen O: Multifactorial interventions and cardiovascular disease in patients with type 2 diabetes. N Engl J Med 348:383–393, 2003.

Lifestyle Changes Can Keep Diabetes at Bay for 14 Years

Among people at high risk, healthy eating and exercise can delay disease, researchers say

By Steven Reinberg
HealthDay Reporter

THURSDAY, May 22, 2008 (HealthDay News) -- Diet and exercise programs for people at high risk for developing diabetes, when followed for six years, can actually delay the development of diabetes for 14 years after the programs end, a new report finds.

The report is published in the May 24 special diabetes issue of The Lancet.

In another study in the same journal issue, Chinese researchers found that intensive therapy with insulin in patients with newly diagnosed type 2 diabetes can help restore the cells in the body that produce insulin, and thereby restore blood sugar balance.

"Early intensive insulin therapy in patients with newly diagnosed type 2 diabetes has favorable outcomes on recovery and maintenance of B-cell function and prolonged glycemic remission compared with treatment with oral hypoglycemic agents," the researchers concluded.

In terms of the lifestyle study a series of trials around the world have shown lifestyle changes in diet and exercise can reduce cases of diabetes in people with high blood sugar levels.

"When you do lifestyle interventions in communities, it seems to have durability beyond the life of the intervention itself, which is very encouraging," said co-author Edward Gregg, branch chief of the Epidemiology and Statistical Branch in the Division of Diabetes Translation at the U.S. Centers for Disease Control and Prevention.

In the trial, called the China Da Qing Diabetes Prevention Outcome Study, 577 adults with high blood sugar levels, at risk for developing diabetes, from 33 clinics in China, were randomly assigned to one of three lifestyle intervention groups. One group relied on diet, a second group on exercise and a third on a combination of diet and exercise. In addition, there was a group that did not participate in any diet or exercise program.

People were counseled to reduce the amount of food they ate and to cut down on sugar and alcohol, Gregg said. "People were encouraged to eat more vegetables and increase their levels of physical activity," he added.

The study began in 1986, and these groups continued their diet and/or exercise programs until 1992. In 2006, the people in the study were seen again to determine the long-term effect of diet and exercise.

Gregg's team found lifestyle interventions reduced the incidence of diabetes by 51 percent over the six years of the program.

Moreover, over the whole 20-year period, the incidence of diabetes was reduced by 43 percent in those people who had been in diet and exercise programs.

On average, the incidence of newly diagnosed diabetes was 7 percent for people who had participated in diet and exercise programs, compared with 11 percent for people who hadn't, the researchers reported.

By the 20th year, 80 percent of those who had participated in a diet and exercise program had developed diabetes, compared with 93 percent of the people who did not participate in such a program. People who had been in a diet and exercise program, spent 3.6 fewer years with diabetes than people who hadn't, Gregg's team found.

Gregg believes that similar programs could be effective in the United States. "Interventions used in this study are similar to interventions that have been used in the United States and do work," he said.

One expert says that despite these impressive results, the study does have a couple of important limitations.

"The majority of study participants in both intervention and control groups went on to develop diabetes eventually," said Dr. David Katz, director of the Prevention Research Center at Yale University School of Medicine. "Moreover, the study is unable to prove that the intervention conferred a survival benefit."

Another limitation is how these results from lifestyle changes can be translated into the real world, Katz said.

"Despite these limitations and the challenges that lay ahead, the finding that we can teach people to eat well and be active, and thereby provide them meaningful defense against diabetes that lasts for decades, is of extraordinary significance," Katz said.

In a third study, Finnish researchers found that incidence of type 1 diabetes has more than doubled among Finnish children in the past 25 years. The incidence of type 1 diabetes rose from 31.4 children per 100,000 children in 1980 to 64.2 children per 100,000 children in 2005.

The increase is expected to continue. This dramatic increase in type 1 diabetes appears to be a combination of genetic and lifestyle factors, the researchers say. For example, obesity among Finnish children has risen from 9.5 percent in the mid-1980s to 20 percent currently.

Steven Reinberg, HealthDay News, US News and World Report, May 23, 2008 

Telephone versus print delivery of an individualized motivationally tailored physical activity intervention: Project STRIDE.

Marcus BH, Napolitano MA, King AC, Lewis BA, Whiteley JA, Albrecht A, Parisi A, Bock B, Pinto B, Sciamanna C, Jakicic J, Papandonatos GD.
Miriam Hospital and Brown Medical Centers for Behavioral and Preventive Medicine, Providence, RI 02903, USA.

OBJECTIVE: Given that only 25% of Americans meet physical activity recommendations, there is a need to develop and disseminate effective, evidence-based interventions to promote physical activity. The authors tested 2 delivery channels, telephone and print, to determine whether one was more effective in promoting physical activity.

DESIGN: The authors randomly assigned 239 healthy, sedentary adults to (a) telephone-based individualized feedback, (b) print-based individualized feedback, or (c) contact control. Both intervention arms were guided by a motivationally tailored, theoretically driven computer expert system.

MAIN OUTCOME MEASURES: Physical activity as measured by the 7-day Physical Activity Recall interview.

RESULTS: At 6 months, both telephone and print arms significantly increased in minutes of moderate intensity physical activity compared with control, with no differences between the intervention arms. At 12 months, print participants reported a significantly greater number of moderate intensity minutes than both telephone and control participants, who did not differ.

CONCLUSION: Results suggest that both telephone and print enhance the adoption of physical activity among sedentary adults; however, print interventions may be particularly effective in maintaining physical activity in the longer term.

Ongoing physical activity advice by humans versus computers: the Community Health Advice by Telephone (CHAT) trial.

King AC, Friedman R, Marcus B, Castro C, Napolitano M, Ahn D, Baker L.
Division of Epidemiology, Department of Health Research and Policy, Prevention Research Center, Stanford University School of Medicine, 211 Quarry Road, Stanford, CA 94305, USA.

PURPOSE: Given the prevalence of physical inactivity among American adults, convenient, low-cost interventions are strongly indicated. This study determined the 6- and 12-month effectiveness of telephone interventions delivered by health educators or by an automated computer system in promoting physical activity.

DESIGN: Initially inactive men and women age 55 years and older (N = 218) in stable health participated. Participants were randomly assigned to human advice, automated advice, or health education control.

MEASURES: The validated 7-day physical activity recall interview was used to estimate minutes of moderate to vigorous physical activity. Physical activity differences by experimental arm were verified on a random subsample via accelerometry.

RESULTS: Using intention-to-treat analysis, at 6 months, participants in both interventions, although not differing from one another, showed significant improvements in weekly physical activity compared with controls. These differences were generally maintained at 12 months, with both intervention arms remaining above the target of 150 min per week of moderate to vigorous physical activity on average.

CONCLUSION: Automated telephone-linked delivery systems represent an effective alternative for delivering physical activity advice to inactive older adults.

The extent and breadth of benefits from participating in chronic disease self-management courses: a national patient-reported outcomes survey.

Nolte S, Elsworth GR, Sinclair AJ, Osborne RH.
AFV Centre for Rheumatic Diseases, Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, Vic. 3050, Australia.

OBJECTIVE: To quantify the benefits that people receive from participating in self-management courses and identify subgroups that benefit most.

METHODS: People with a wide range of chronic conditions attending self-management courses (N = 1341 individuals) were administered the Health Education Impact Questionnaire (heiQ). Baseline and follow-up data were collected resulting in 842 complete responses. Outcomes were categorized as substantial improvement (effect size, ES > or = 0.5), minimal/no change (ES -0.49 to 0.49) and substantial decline (ES < or = -0.5).

RESULTS: On average, one third of participants reported substantial benefits at the end of a course and this ranged from 49% in the heiQ subscale Skill and technique acquisition to 27% in the heiQ subscale Health service navigation. Stratification by gender, age and education showed that younger participants were more likely to benefit, particularly young women. No further subgroup differences were observed.

CONCLUSION: While the well-being of people with chronic diseases tends to decline, about one third of participants from a wide range of backgrounds show substantial improvements in a range of skills that enable them to self-manage.

PRACTICE IMPLICATIONS: These data support the application of self-management courses indicating that they are a useful adjunct to usual care for a modest proportion of attendees.


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