This document outlines several diabetes risk reduction programs: 1. A quality improvement program at community health centers that significantly improved processes of care for diabetes and asthma but not outcomes. 2. A lifestyle intervention program and metformin treatment that both reduced incidence of type 2 diabetes, with lifestyle changes proving more effective. 3. A study finding that increased colonic propionate reduced brain responses to high-calorie foods and led to less food appeal and calorie intake. 4. A nutrition education program tailored for low-literacy adults that significantly improved fat-related knowledge and behaviors over general nutrition classes. 5. An online health promotion program for older workers that significantly improved diet and exercise self-effic

1. DIABETES.
RISK REDUCTION PROGRAM.
Presented By: MPH(student) Gobinath P
Email: ponnusamig@aiias.edu
gopinathsteven@gmail.com

2. Out line of the presentation.
• Introduction.
• Different risk reduction program.
• Summary and conclusion.
• Recommendations.

3. Indroduction.
• Diabetes can strike anyone, from any walk of life.
• Worldwide, it afflicts more than 380 million people. And the World Health
Organization estimates that by 2030, that number of people living with
diabetes will more than double.
• Today, diabetes takes more lives than AIDS and breast cancer combined --
claiming the life of 1 American every 3 minutes. It is a leading cause of
blindness, kidney failure, amputations, heart failure and stroke.
• Living with diabetes places an enormous emotional, physical and financial
burden on the entire family. Annually, diabetes costs the American public
more than $245 billion.
(2016). Diabetes research institute.

4. • When you eat, your body turns food into sugars, or glucose. At that point,
your pancreas is supposed to release insulin.
• Several major things can go wrong – causing the onset of diabetes. Type 1
and type 2 diabetes are the most common forms of the disease, but there
are also other kinds, such as gestational diabetes, which occurs during
pregnancy, as well as other forms.
(2016). Diabetes research institute retrieved from http://www.diabetesresearch.org/what-is-diabetes.

5. DIFFERENT RISK REDUCTION PROGRAMS.

6. 1. Improving the Management of Chronic
Disease at Community Health Centers
PARTICIPANTS: We enrolled 9658 patients at 44 intervention centers that had participated in the
collaboratives and 20 centers that had not participated (external control centers).
METHODS: We performed a controlled preintervention and postintervention study of community health
centers participating in quality-improvement collaboratives (the Health Disparities Collaboratives
sponsored by the HRSA) for the care of patients with diabetes, asthma, or hypertension. Each
intervention center also served as an internal control for another condition. Quality measures were
abstracted from medical records at each health center. We created overall quality scores by standardizing
and averaging the scores from all of the applicable measures. Changes in quality were evaluated with the
use of hierarchical regression models that controlled for patient characteristics.

7. RESULTS: Overall, the intervention centers had considerably greater improvement than the external and
internal control centers in the composite measures of quality for the care of patients with asthma and
diabetes, but not for those with hypertension. As compared with the external control centers, the
intervention centers had significant improvements in the measures of prevention and screening, including
a 21% increase in foot examinations for patients with diabetes, and in disease treatment and monitoring,
including a 14% increase in the use of antiinflammatory medication for asthma and a 16% increase in the
assessment of glycated hemoglobin. There was no improvement, however, in any of the intermediate
outcomes assessed (urgent care or hospitalization for asthma, control of glycated hemoglobin levels for
diabetes, and control of blood pressure for hypertension).
CONCLUSIONS: The Health Disparities Collaboratives significantly improved the processes of care for
two of the three conditions studied. There was no improvement in the clinical outcomes studied.
Reference: http://www.nejm.org/doi/pdf/10.1056/NEJMsa062860

8. 2. Reduction in the Incidence of Type 2 Diabetes
with Lifestyle Intervention or Metformin
PARTICIPANTS: We randomly assigned 3234 nondiabetic persons with elevated fasting and
post-load plasma glucose
METHODS: concentrations to placebo, metformin (850 mg twice daily), or a lifestyle-
modification program with the goals of at least a 7 percent weight loss and at least 150 minutes
of physical activity per week. The mean age of the participants was 51 years, and the mean
body-mass index (the weight in kilograms divided by the square of the height in meters) was
34.0; 68 percent were women, and 45 percent were members of minority groups.

9. RESULTS: The average follow-up was 2.8 years. The incidence of diabetes
was 11.0, 7.8, and 4.8 cases per 100 person-years in the placebo, metformin,
and lifestyle groups, respectively. The lifestyle intervention reduced the
incidence by 58 percent (95 percent confidence interval, 48 to 66 percent) and
metformin by 31 percent (95 percent confidence interval, 17 to 43 percent), as
compared with placebo; the lifestyle intervention was significantly more
effective than metformin. To prevent one case of diabetes during a period of
three years, 6.9 persons would have to participate in the lifestyle-intervention
program, and 13.9 would have to receive metformin.
CONCLUSIONS: Lifestyle changes and treatment with metformin both
reduced the incidence of diabetes in persons at high risk. The lifestyle
intervention was more effective than metformin.
Reference : http://www.nejm.org/doi/full/10.1056/NEJMoa012512#t=abstract

10. 3. Increased colonic propionate reduces anticipatory
reward responses in the human striatum to high-
energy foods
Participants: 20 healthy non-obese men
Method: In a randomized crossover design, 20 healthy non-obese men completed a
functional magnetic resonance imaging (fMRI) food picture evaluation task after
consumption of control inulin or inulin-propionate ester, a unique dietary compound that
selectively augments colonic propionate production. The blood oxygen level–dependent
(BOLD) signal was measured in a priori brain regions involved in reward processing,
including the caudate, nucleus accumbens, amygdala, anterior insula, and orbitofrontal
cortex (n = 18 had analyzable fMRI data).
Reference: http://ajcn.nutrition.org/content/104/1/5.full.pdf+html

11. Results: Increasing colonic propionate production reduced BOLD signal during
food picture evaluation in the caudate and nucleus accumbens. In the caudate, the
reduction in BOLD signal was driven specifically by a lowering of the response to
high-energy food. These central effects were partnered with a decrease in subjective
appeal of high-energy food pictures and reduced energy intake during an ad libitum
meal. These observations were not related to changes in blood peptide YY (PYY),
glucagon-like peptide 1 (GLP-1), glucose, or insulin concentrations.
Conclusion: Our results suggest that colonic propionate production may play an
important role in attenuating reward-based eating behavior via striatal pathways,
independent of changes in plasma PYY and GLP-1.
Reference: http://ajcn.nutrition.org/content/104/1/5.full.pdf+html

12. 4. The Stanford Nutrition Action Program: a
dietary fat intervention for low-literacy adults.
PARTICIPANTS: 351 participants
METHODS: Twenty-four paired adult education classes (351 participants, 85% women, mean age =
31 years) were randomly assigned to receive a newly developed dietary fat curriculum (the Stanford
Nutrition Action Program) or an existing general nutrition curriculum. Food frequency and nutrition-
related data, body mass index, and capillary blood cholesterol were collected at baseline and at two
post-intervention follow-ups.

13. RESULTS: The Stanford Nutrition Action Program classes showed significantly greater
net improvements in nutrition knowledge (+7.7), attitudes (/0.2), and self-efficacy (-0.2)
than the general nutrition classes; they also showed significantly greater reductions in the
percentage of calories from total (-2.3%) and saturated (-0.9%) fat. There were no
significant differences in body mass index or blood cholesterol. All positive intervention
effects were maintained for 3 months post-intervention.
CONCLUSIONS: The Stanford Nutrition Action Program curriculum, tailored to the
cultural, economic, and learning needs of low-literacy, low-income adults, was
significantly more effective in achieving fat-related nutritional changes than the general
nutrition curriculum.
Reference: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1381239/

14. 5. A Web-Based Health Promotion Program for
Older Workers: Randomized Controlled Trial
Participants: workers aged 50 years and older who are at higher risk for chronic diseases.
Methods: The sample included 278 employees aged 50 to 68 who were recruited online and randomly
assigned to the Web-based HealthyPast50 program or to a wait-list control condition. Self-report
measures of diet, physical activity, stress, and tobacco use were collected online before and 3 months
after the program group was given access to the program. Use data included number of log-ins and
number of pages accessed. The primary analysis was multiple linear regression, following intent-to-
treat principles with multiple imputation using the Markov chain Monte Carlo (MCMC) approach for
nonmonotone missing data. Potential moderators from demographic characteristics and program dosage
effects were assessed using multiple linear regression models. Additional analyses were conducted on
complete (nonimputed) cases, excluding program participants who used the program for less than 30
minutes.

15. Results: Retention rates were good for both groups: 80.4% (111/138) for the program group and 94.3%
(132/140) for the control group. Program group participants spent a mean of 102.26 minutes in the program
(SD 148.32), logged in a mean of 4.33 times (SD 4.28), and viewed a mean of 11.04 pages (SD 20.08). In
the analysis of the imputed dataset, the program group performed significantly better than the control group
on diet behavioral change self-efficacy (estimated adjusted difference [Δ]=0.16, P=.048), planning healthy
eating (Δ=0.17, P=.03), and mild exercise (Δ=1.03, P=.01). Moderator and dosage analyses of the dataset
found no significant program effects. Analyses of the nonimputed dataset comparing program users with
controls found additional significant program effects on eating practices (Δ=0.09, P=.03), exercise self-
efficacy (Δ=0.12, P=.03), exercise planning (Δ=0.18, P=.03), and aging beliefs (Δ=0.17, P=.01).
Moderator analysis of this dataset also found significant moderator effects of gender on multiple measures
of exercise.
Conclusions: A Web-based health promotion program showed promise for making a significant
contribution to the short-term dietary and exercise practices of older working adults. Gender effects suggest
that the program effects on exercise are due mainly to improvements among women.
Reference: http://www.jmir.org/2015/3/e82/

16. 6. Cohort studies of Sugar Sweeten Beverage
(SSB)
Method: cohort studies of SSB intake and risk of metabolic syndrome and type 2
diabetes. We identified 11 studies (three for metabolic syndrome and eight for
type 2 diabetes) for inclusion in a random-effects meta-analysis comparing SSB
intake in the highest to lowest quantiles in relation to risk of metabolic syndrome
and type 2 diabetes.
Result: Based on data from these studies, including 310,819 participants and
15,043 cases of type 2 diabetes, individuals in the highest quantile of SSB intake
(most often 1–2 servings/day) had a 26% greater risk of developing type 2
diabetes than those in the lowest quantile (none or <1 serving/month) (relative
risk [RR] 1.26 [95% CI 1.12–1.41]). Among studies evaluating metabolic
syndrome, including 19,431 participants and 5,803 cases, the pooled RR was 1.20
[1.02–1.42].

17. CONCLUSIONS In addition to weight gain, higher consumption of
SSBs is associated with development of metabolic syndrome and type 2
diabetes. These data provide empirical evidence that intake of SSBs
should be limited to reduce obesity-related risk of chronic metabolic
diseases.
B, F. (2010). Sugar-Sweetened Beverages and Risk of Metabolic Syndrome and Type 2 Diabetes. American
Diabetes Association, 2477-2483.

18. 7. Reduction in Weight
Participants: 5,145 individuals with type 2 diabetes, aged 45-74 years
Method: A multi-centered randomized controlled trial of 5,145 individuals with type 2 diabetes,
aged 45-74 years, with body mass index >25 kg/m2 (>27 kg/m2if taking insulin). An Intensive
Lifestyle Intervention (ILI) involving group and individual meetings to achieve and maintain
weight loss through decreased caloric intake and increased physical activity was compared to a
Diabetes Support and Education (DSE) condition.
Result: Participants assigned to ILI lost an average 8.6% of their initial weight versus 0.7% in DSE
group (p<0.001). Mean fitness increased in ILI by 20.9% versus 5.8% in DSE (p<0.001). A greater
proportion of ILI participants had reductions in diabetes, hypertension, and lipid-lowering
medicines. Mean HbA1c dropped from 7.3% to 6.6% in ILI (p<0.001) versus from 7.3% to 7.2% in
DSE. Systolic and diastolic pressure, triglycerides, HDL-cholesterol, and urine albumin/creatinine
improved significantly more in ILI than DSE participants (all p<0.01).

19. Conclusions: At 1 year, ILI resulted in clinically significant weight loss in persons with type
2 diabetes. This was associated with improved diabetes control and CVD risk factors and
reduced medicine use in ILI versus DSE. Continued intervention and follow-up will
determine whether these changes are maintained and will reduce CVD risk.
Reference: Espeland, M. (2007, March). Reduction in Weight and Cardiovascular Disease Risk Factors in
Individuals With Type 2 Diabetes: One-Year Results of the Look AHEAD Trial. Diabetes care.

20. 8. Smoking cessation among diabetes patients: results of a pilot
randomized controlled trial in Kerala, India.
PARTICIPANTS: we selected 224 adult diabetes patients aged 18 years or older who smoked
in the last month, from two diabetes clinics in South India.
METHODS:
In our parallel-group randomized controlled trial, Using a computer generated random sequence
with block size four; the patients were randomized equally into intervention-1 and intervention-
2 groups. Patients in both groups were asked and advised to quit smoking by a doctor and
distributed diabetes specific education materials. The intervention-2 group received an
additional diabetes specific 30 minutes counseling session using the 5As (Ask, Advise, Assess,
Assist and Arrange), and 5 Rs (Relevance, Risks, Rewards, Roadblocks and Repetition) from a
non-doctor health professional. Follow up data were available for 87.5% of patients at six
months. The Quit Tobacco International Project is supported by a grant from the Fogarty
International Centre of the US National Institutes of Health (RO1TW005969-01).The primary
outcomes were quit rate (seven day smoking abstinence) and harm reduction (reduction of the
number of cigarettes / bidis smoked per day > 50% of baseline use) at six months.

21. RESULTS:
In the intention to treat analysis, the odds for quitting was 8.4 [95% confidence interval (CI):
4.1-17.1] for intervention-2 group compared to intervention-1 group. Even among high level
smokers the odds of quitting was similar. The odds of harm reduction was 1.9 (CI: 0.8-4.1)
for intervention-2 group compared to intervention-1 group.
CONCLUSIONS:
The value addition of culturally sensitive diabetic specific cessation counseling sessions
delivered by non-doctor health professional was an impressive and efficacious way of
preventing smoking related diabetic complications.
R, T. K. (2013, January 13). Smoking cessation among diabetes patients: results of a pilot randomized controlled
trial in Kerala, India. Pubmed. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23331722

22. 9. Specific Types of Alcoholic Beverage Consumption
and Risk of Type 2 Diabetes: A Systematic Review and Meta-
analysis.
PARTICIPANTS: 397296 study participants and 20641 cases of type 2 diabetes.
MATERIALS AND METHODS:
Search of PubMed, Embase and Cochrane Library databases from January 1966 to February 2016
was conducted for prospective cohort studies that assessed the effects of specific types of alcoholic
beverage on the risk of type 2 diabetes. The pooled relative risks (RRs) with 95% confidence
interval (CI) were calculated using random- or fixed-effect models when appropriate.

23. RESULTS:
13 prospective studies were included in this meta-analysis, with 397296 study participants and 20641 cases
of type 2 diabetes. Relative to no or rare alcohol consumption, wine consumption was associated with a
significant reduction of the risk of type 2 diabetes, with the pooled RRs of 0.85, while beer or spirits
consumption led to a slight trend of decreasing risk of type 2 diabetes (RR, 0.96, 0.95, respectively).
Further dose-response analysis displayed a U-shaped relationship between all three alcohol types and type
2 diabetes. Additionally, the peak risk reduction emerged at 20-30 g/day for wine and beer, at 7-15 g/day
for spirits, with a decrease of 20%, 9%, 5% respectively.
CONCLUSIONS:
Compared with beer or spirits, wine was associated with a more significant decreased risk of type
2 diabetes. This study indicated that wine may be more helpful for protection against type 2 diabetes than
beer or spirits. This article is protected by copyright. All rights reserved.
J, H. (2016, May 10). Alcoholic Beverage Consumption and Risk of Type 2 Diabetes: A Systematic Review and Meta-analysis.
Pubmed. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/27181845

24. 10. Mediterranean diet and mortality risk in
metabolically healthy obese and metabolically
unhealthy obese phenotypes
PARTICIPANTS: Data from 1739 adults aged 20-88 years
METHODS: Data from 1739 adults aged 20-88 years were analyzed from participants of the National
Health and Nutrition Examination Survey III, 1988-1994 followed up for deaths until December 31,
2011 in a prospective cohort analysis. Mediterranean Diet Scores (MDS) were created to assess the
adherence to Mediterranean diet. Participants were classified as metabolically healthy obese (MHO)
phenotype (0 or 1 metabolic abnormality) or metabolically unhealthy obese (MUO) phenotype (two or
more metabolic abnormalities), based on high glucose, insulin resistance, blood pressure, triglycerides,
C-reactive protein, and low high-density lipoprotein-cholesterol.

25. RESULTS:
The MHO phenotype (n=598) was observed in 34.8% (s.e., 1.7%) of those who were obese (mean body
mass index was 33.4 and 34.8 in MHO and MUO phenotypes, respectively). During a median follow-up of
18.5 years, there were 77 (12.9%) and 309 (27.1%) deaths in MHO and MUO individuals, respectively. In
MHO individuals, the multivariable-adjusted HR of all-cause mortality in the highest tertile compared to the
first tertile of MDS was 0.44 (95% CI, 0.26-0.75; P for trend <0.001), after adjustment for potential
confounders. The corresponding HR for cancer mortality was 0.23 (95% CI, 0.02-2.10; P trend=0.03). A
five-point (1 s.d.) increment in the adherence to MDS was associated with a 41%reduction in the risk of all-
cause mortality (HR, 0.59; 95% CI, 0.37-0.94). Similar findings were obtained when we restricted our
analyses to those with or without prevalent diabetes mellitus and hypertension. We did not observe
mortality risk reduction in either individuals with MUO phenotype or all obese participants combined.
CONCLUSIONS:
Adherence to a Mediterranean dietary pattern appears to reduce mortality in the MHO phenotype, but not
among the MUO phenotype in an obese population.International Journal of Obesity accepted article preview
online, 24 June 2016. doi:10.1038/ijo.2016.114.
Reference: Park Y.M, Zhang J. (2016, June 24). Mediterranean diet and mortality risk in metabolically healthy obese and metabolically
unhealthy obese phenotypes. Pubmed. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/27339604

26. SUMMARY
In the global perspective point of view everyone are not
excuse in all of the non-communicable diseases (NCDs)
around us especially Diabetes Mellitus (DM). Moreover
whether categorize in urban or rural areas, poor and rich
countries, young and old, and male or female. Though
biologically we acquire diabetes but still we have hope to
prevent it through our lifestyle practices.

27. CONCLUSION
Our group analyzed the following recommended healthy
preventive measures to lower the risk of Diabetes
Mellitus. It is a process in order an individual can change
their habits, attitude and lifestyle. The ten scientific
guiding principles of risk reduction program can be a
starting tools to help the people in our community and
society especially who are suffering from Diabetes
Mellitus.

28. RECOMMENDATIONS
 Build a healthier plate
 Shop Smart
 Eat Smart
 Regular exercise
 Drink at least 8-10 glasses of water a day.
 Get your rest
 Be social
 Be careful
 Get regular exams
 Avoid anything harmful
 Be grateful
 Be helpful
 Forgive others
 Be happy
And enjoy a full life!

29. References
http://www.nejm.org/doi/pdf/10.1056/NEJMsa062860
http://www.nejm.org/doi/full/10.1056/NEJMoa012512#t=abstract
http://ajcn.nutrition.org/content/104/1/5.full.pdf+html
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1381239
http://www.jmir.org/2015/3/e82/
B, F. (2010). Sugar-Sweetened Beverages and Risk of Metabolic Syndrome and Type 2 Diabetes.
American Diabetes Association, 2477-2483.
Espeland, M. (2007, March). Reduction in Weight and Cardiovascular Disease Risk Factors in
Individuals With Type 2 Diabetes: One-Year Results of the Look AHEAD Trial. Diabetes care.

30. R, T. K. (2013, January 13). Smoking cessation among diabetes patients: results
of a pilot randomized controlled trial in Kerala, India. Pubmed. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/23331722
J, H. (2016, May 10). Alcoholic Beverage Consumption and Risk of Type 2
Diabetes: A Systematic Review and Meta-analysis. Pubmed. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/27181845
Park Y.M, Zhang J. (2016, June 24). Mediterranean diet and mortality risk in
metabolically healthy obese and metabolically unhealthy obese phenotypes.
Pubmed. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/27339604