Search

Introduction Diabetes and obesity pose a significant burden for the U.S. military beneficiary population, creating a great need to provide evidence-based diabetes and obesity prevention services for military personnel, retirees, and their dependents. Despite increasing dissemination of the Diabetes Prevention Program (DPP) lifestyle intervention nationwide, formal evaluation of implementation of this highly successful program is limited in the military setting. The purpose of this study is to prospectively evaluate delivery of a direct adaptation of a 1-year DPP lifestyle intervention at a U.S. Air Force medical facility, Wright-Patterson Medical Center (WPMC), to determine the feasibility of delivery of the program in a group of at-risk active duty military, retirees, and family members, as well as assess effectiveness in improving weight and other risk factors for type 2 diabetes. Materials and Methods A pre/post study design was utilized to evaluate feasibility and effectiveness of the DPP Group Lifestyle Balance (GLB), an up-to-date, 22-session direct adaptation of the DPP curriculum, at WPMC. Participants chose to complete the 1-year program either in coach-led face-to-face groups or via DVD with weekly telephonic coach contact. The study was approved by the University of Pittsburgh and WPMC Institutional Review Boards. Results A total of 99 individuals enrolled in the study, with 83 (84%) and 77 (78%) completing 6- and 12-month follow-up assessments, respectively. The mean age of participants at baseline was 57 (range 20-85 years), with 63% being female. The group was comprised of individuals who were non-Hispanic White (73.7%), non-Hispanic Black (18.2%), and other race or Hispanic ethnicity (8.1%). Within this group, there were 10 active duty military, 37 retirees, and 52 family members. The DPP-GLB program was shown to be feasible to implement in this military healthcare setting as demonstrated by the high engagement over the course of the year-long program. Significant improvements were shown in the two main behavioral goals: mean weight (−12.8 lbs, −6.3%, P Conclusions These results demonstrate that the DPP-GLB program delivered via face-to-face groups or DVD was feasible and effective in improving weight, PA levels, and diabetes and cardiovascular risk factors in this group of active and retired military personnel and their family members. The program was well received by the program participants as well as the WPMC team. These findings offer a model for provision of the DPP-GLB program throughout the Military Health System.

Background Little is known about how adverse, midlife metabolic profiles affect future physical functioning. We hypothesized that a higher number of midlife metabolic syndrome (MetS) components are associated with poorer physical performance in early old age for multiethnic women. Methods MetS status from 1996 to 2011 (8 visits) and objective physical performance in 2015/2016 (Short Physical Performance Battery [SPPB; 0–12], 40-foot walk [meter/second], 4-meter gait speed [meter/second], chair stands [seconds], stair climb [seconds]) were assessed in the Study of Women’s Health Across the Nation (SWAN; n = 1722; age 65.4 ± 2.7 years; 26.9% African American, 10.1% Chinese, 9.8% Japanese, 5.5% Hispanic). Poisson latent class growth modeling identified MetS component trajectory groups: none (23.9%), 1 = low-MetS (28.7%), 2 = mid-MetS (30.9%), and ≥3 = high-MetS (16.5%). Adjusted linear regression related MetS groups to physical performance outcomes. Results High-MetS versus none had higher body mass index, pain, financial strain, and lower physical activity and self-reported health (p < .0001). Compared with White, African American and Hispanic women were more likely to be in the high-MetS groups and had worse physical functioning along with Chinese women (SPPB, chair stand, stair climb, and gait speed—not Hispanic). After adjustments, high-MetS versus none demonstrated significantly worse 40-ft walk (β: −0.08; 95% CI: −0.13, −0.03), gait speed (β: −0.09; 95% CI: −0.15, −0.02), SPPB (β: −0.79; 95% CI: −1.15, −0.44), and chair stands (β: 0.69; 95% CI: 0.09, 1.28), but no difference in stair climb. Conclusions Midlife MetS groups were related to poor physical performance in early old age multiethnic women. Midlife management of metabolic function may improve physical performance later in life.

Background Frailty is a geriatric syndrome of decreased physiologic reserve and resistance to stressors that results in increased vulnerability to adverse health outcomes with aging. Diabetes and hyperglycemia are established risk factors for frailty. We sought to examine whether the odds of frailty among individuals at high risk of diabetes randomized to treatment with intensive lifestyle (ILS), metformin, or placebo differed after long-term follow-up. Method The sample comprised participants in the Diabetes Prevention Program (DPP) clinical trial, who continued follow-up in the DPP Outcomes Study (DPPOS) and completed frailty assessments in DPPOS Years 8 (n = 2385) and 10 (n = 2289), approximately 12 and 14 years after DPP randomization. Frailty was classified using Fried Frailty Phenotype criteria. GEE models adjusting for visit year with repeated measures pooled for Years 8 and 10 were used to estimate pairwise odds ratios (ORs) between ILS, metformin, and placebo for the outcomes of frail and prefrail versus nonfrail. Results Frailty prevalence by treatment group was ILS = 3.0%, metformin = 5.4%, placebo = 5.7% at Year 8, and ILS = 3.6%, metformin = 5.3%, placebo = 5.4% at Year 10. Odds ratios (95% CI) estimated with GEE models were ILS versus placebo, 0.62 (0.42–0.93), p = .022; metformin versus placebo, 0.99 (0.69–1.42), p = .976; and ILS versus metformin, 0.63 (0.42–0.94), p = .022. Odds of being frail versus nonfrail were 37% lower for ILS compared to metformin and placebo. Conclusions Early ILS intervention, at an average age of about 50 years, in persons at high risk of diabetes may reduce frailty prevalence in later life. Metformin may be ineffective in reducing frailty prevalence. Clinical Trials Registration Numbers NCT00004992 (DPP) and NCT00038727 (DPPOS).

Background: The importance of leisure sedentary behavior (LSB) change in diabetes prevention efforts is not well known. This study examines the relationships between changes in self-reported LSB and the primary intervention goals (weight and moderate-intensity to vigorous-intensity physical activity [MVPA]) during a community-based translation of the Diabetes Prevention Program (the Group Lifestyle Balance Program). Methods: A total of 322 adults at risk for type 2 diabetes were recruited from 3 community centers, a worksite, and military site. Community and worksite participants were randomized to immediate or delayed-delivery (control) intervention. All military site participants (n = 99) received immediate intervention. Logistic and linear generalized estimating equations were used to determine associations between LSB changes and weight-related outcomes and MVPA. Results: Results were obtained for 259 (80.4%) participants. The LSB decreased after 6 and 12 months (mean [95% confidence interval]: −25.7 [−38.6 to −12.8] and −16.1 [−28.2 to −3.9] min/d; both P P = .042; adjusted model including MVPA), but LSB was not related to changes in reported MVPA minutes or MVPA goal achievement. Conclusion: Within the context of existing lifestyle intervention programs, reducing sedentary behavior has the potential to contribute to weight loss separately from reported MVPA improvement.

OBJECTIVE Across the Diabetes Prevention Program (DPP) follow-up, cumulative diabetes incidence remained lower in the lifestyle compared with the placebo and metformin randomized groups and could not be explained by weight. Collection of self-reported physical activity (PA) (yearly) with cross-sectional objective PA (in follow-up) allowed for examination of PA and its long-term impact on diabetes prevention. RESEARCH DESIGN AND METHODS Yearly self-reported PA and diabetes assessment and oral glucose tolerance test results (fasting glucose semiannually) were collected for 3,232 participants with one accelerometry assessment 11–13 years after randomization (n = 1,793). Mixed models determined PA differences across treatment groups. The association between PA and diabetes incidence was examined using Cox proportional hazards models. RESULTS There was a 6% decrease (Cox proportional hazard ratio 0.94 [95% CI 0.92, 0.96]; P < 0.001) in diabetes incidence per 6 MET-h/week increase in time-dependent PA for the entire cohort over an average of 12 years (controlled for age, sex, baseline PA, and weight). The effect of PA was greater (12% decrease) among participants less active at baseline ( CONCLUSIONS PA was inversely related to incident diabetes in the entire cohort across the study, with cross-sectional accelerometry results supporting these findings. This highlights the importance of PA within lifestyle intervention efforts designed to prevent diabetes and urges health care providers to consider both PA and weight when counseling high-risk patients.

To assess the relationship between walking for exercise and symptomatic and structural disease progression in individuals with knee osteoarthritis (OA).We assessed a nested cohort of participants age 50 years or older within the Osteoarthritis Initiative, a community-based observational study in which subjects were enrolled between 2004 and 2006. We focused on 4 dichotomous outcomes from baseline to the 48-month visit, involving determination of the frequency of knee pain and radiographic severity of knee OA on posteroanterior semiflexed knee radiographs. The outcomes assessed included 1) new frequent knee pain, 2) worsening of radiographic severity of knee OA based on the Kellgren/Lawrence grade, 3) progression of medial joint space narrowing, and 4) improved frequent knee pain. We used a modified version of the Historical Physical Activity Survey Instrument to ascertain those subjects who reported walking for exercise after age 50 years. The survey was administered at the 96-month visit (2012-2014).Of 1,212 participants with knee OA, 45% were male and 73% reported walking for exercise. The mean ± SD age was 63.2 ± 7.9 years, and the mean ± SD body mass index was 29.4 ± 4.6 kg/mIn individuals with knee OA who were age 50 years or older, walking for exercise was associated with less frequent development of knee pain. These findings support the notion that walking for exercise should be encouraged for people with knee OA. Furthermore, we offer a proof of concept that walking for exercise could be disease modifying, which warrants further study.

Highlights • The associations between metabolic syndrome and physical activity were compared between healthy middle-aged American men and Japanese men. • Higher total step counts/day had a protective effect on metabolic syndrome in both cohorts. • The effect of steps/day was greater than domain-specific moderate-vigorous physical activity captured by questionnaire. • Tools that capture total movement may be important to assess the effects of physical activity on metabolic syndrome., Background Metabolic syndrome (MetS) is a global health problem. Physical activity (PA) is a known modifiable risk factor for MetS and individual MetS components. However, the role of PA could differ between sub-populations due to differences in the variability of PA and other MetS risk factors. To examine these differences, multi-country studies with standardized outcome measurement methods across cohorts are needed. Methods Cross-sectional PA levels (total and domain specific) in healthy middle-aged (44–56 years) men in the Risk Factor Assessment among Japanese and U.S. Men in the Post-World War II Birth Cohort (ERA-JUMP) Study (n = 730; American: n = 417; Japanese: n = 313; from population-representative samples in Pittsburgh, Pennsylvania, USA, and Kusatsu, Shiga, Japan) were compared. The relationships between PA levels and MetS (overall and specific components) in/across the American and Japanese sub-cohorts (adjusting for age, smoking, and alcohol consumption) were also assessed using the same instruments (pedometer and validated questionnaire) to measure PA in both cohorts. Results A total of 510 individuals provided complete data on PA (American: n = 265; Japanese: n = 245). The American cohort had significantly lower mean ± SD steps/day (7878 ± 3399 steps/day) vs. the Japanese cohort (9055 ± 3797 steps/day) (p < 0.001) but had significantly higher self-reported moderate-vigorous leisure PA (American: 15.9 (7.4–30.3) metabolic task equivalent hours per week (MET-h/week) vs. Japanese: 4.0 (0–11.3) MET-h/week, p < 0.0001). In both sub-cohorts, each 1000 steps/day increase was associated with lower odds of having MetS (American: OR = 0.90, 95%CI: 0.83–0.98; Japanese: OR = 0.87, 95%CI: 0.79–0.95) and the individual MetS component of high waist circumference (American: OR = 0.86, 95%CI: 0.79–0.94; Japanese: OR = 0.87, 95%CI: 0.80–0.95). In the American cohort only, higher self-reported leisure PA (Met-h/week) was associated with lower odds of MetS and high waist circumference (OR = 0.98, 95%CI: 0.97–0.99 for MetS and waist circumference, respectively). Conclusion Higher total step counts/day had an important protective effect on MetS prevalence in both the Japanese and American cohorts, despite differences in PA levels and other MetS risk factors. The effect of steps/day (across all intensity levels) was much greater than domain-specific moderate-vigorous PA captured by questionnaire, suggesting the need for measurement tools that can best capture total movement when examining the effects of PA on MetS development., Graphical abstract Image, graphical abstract

Obesity is a key risk factor for Type 2 diabetes (T2D). Alarmingly, 87% of US adults have overweight or obesity, with non-Hispanic black adults having higher obesity and T2D prevalence than non-Hispanic white. The Diabetes Prevention Program (DPP) demonstrated the clinical benefits of lifestyle intervention (LI). While the DPP LI is effective, some participants don't achieve clinically significant weight loss in the current group-based translation paradigm. Black adults have the lowest adjusted weight loss (3.2%) among all racial/ethnic groups. Early intervention nonresponse defined as ≤1% weight loss at intervention week 4 is linked to lower probability of achieving weight loss goals. This paper describes the design and methods of a cluster randomized controlled trial among black weight loss nonresponders nested in 20 community sites (primarily churches). Descriptions of the adaptations made to transition the program to virtual format during the COVID-19 pandemic are also included. Trained community health workers deliver a group-based, 6-month long DPP over 18 sessions via Zoom. Additionally, nonresponders in the enhanced group receive weekly telephone support to provide individual-level intervention to help overcome weight loss barriers. Outcomes include weight, physical activity level, blood pressure, and dietary behaviors; these are compared between nonresponders in the enhanced intervention group and nonresponders in the active control group. Cost, mediators, and moderators are explored. If found to efficacious, these enhanced strategies could be standardized as a supplement for use with DPP nonresponders.

Background The Diabetes Prevention Program (DPP) behavioral lifestyle intervention was effective among a diverse sample of adults with prediabetes. Demonstrated effectiveness in translated versions of the DPP lifestyle intervention (such as Group Lifestyle Balance, DPP-GLB) led to widescale usage with national program oversight and reimbursement. However, little is known about the success of these DPP-translation programs across subgroups of sociodemographic factors. This current effort investigated potential disparities in DPP-translation program primary goal achievement (physical activity and weight) by key sociodemographic factors. Methods Data were combined from two 12-month community-based DPP-GLB trials among overweight/obese individuals with prediabetes and/or metabolic syndrome. We evaluated change in weight (kilograms and percent) and activity (MET-hrs/week) and goal achievement (yes/no; ≥5% weight loss and 150 min per week activity) after 6 and 12 months of intervention within and across subgroups of race/ethnicity (non-Hispanic white, non-Hispanic black), employment status, education, income, and gender. Results Among 240 participants (85%) with complete data, most sociodemographic subgroups demonstrated significant weight loss. However, non-Hispanic white lost more weight at both 6 and 12 months compared to non-Hispanic black participants [median weight loss (IQR), 6 months: 5.7% (2.7–9.0) vs. 1.5% (1.2–7.5) p = .01 and 12 months: 4.8% (1.1–9.6) vs. 1.1% (− 2.0–3.7) p = .01, respectively]. In addition, a larger percentage of non-Hispanic white demonstrated a 5% weight loss at 6 and 12 months. Employment was significantly related to 12-month weight loss, with retired participants being the most successful. Men, participants with graduate degrees, and those with higher income were most likely to meet the activity goal at baseline and 12 months. Differences in physical activity goal achievement across gender, education, and income groups were significant at baseline, attenuated after 6 months, then re-emerged at 12 months. Conclusions The DPP-GLB was effective in promoting weight loss and helped to alleviate disparities in physical activity levels after 6 months. Despite overall program success, differences in weight loss achievement by race/ethnicity were found and disparities in activity re-emerged after 12 months of intervention. These results support the need for intervention modification providing more tailored approaches to marginalized groups to maximize the achievement and maintenance of DPP-GLB behavioral goals. Trial registration NCT01050205, NCT02467881.

BACKGROUND: Self-efficacy, or the perceived capability to engage in a behavior, has been shown to play an important role in adhering to weight loss treatment. Given that adherence is extremely important for successful weight loss outcomes and that sleep and self-efficacy are modifiable factors in this relationship, we examined the association between sleep and self-efficacy for adhering to the daily plan. Investigators examined whether various dimensions of sleep were associated with self-efficacy for adhering to the daily recommended lifestyle plan among participants (N=150) in a 12-month weight loss study. METHODS: This study was a secondary analysis of data from a 12-month prospective observational study that included a standard behavioral weight loss intervention. Daily assessments at the beginning of day (BOD) of self-efficacy and the previous night’s sleep were collected in real-time using ecological momentary assessment. RESULTS: The analysis included 44,613 BOD assessments. On average, participants reported sleeping for 6.93±1.28 hours, reported 1.56±3.54 awakenings, and gave low ratings for trouble sleeping (3.11±2.58;0: no trouble; 10: a lot of trouble) and mid-high ratings for sleep quality (6.45±2.09;0: poor; 10: excellent). Participants woke up feeling tired 41.7% of the time. Using linear mixed effects modeling, a better rating in each sleep dimension was associated with higher self-efficacy the following day (all p values

Purpose The purpose of this study was to examine how maintenance session attendance and 6-month weight loss (WL) goal achievement impacted 12-month 5% WL success in older adults participating in a community-based Diabetes Prevention Program (DPP) lifestyle intervention. Methods Data were combined from 2 community trials that delivered the 12-month DPP-based Group Lifestyle Balance (GLB) to overweight/obese adults (mean age = 62 years, 76% women) with prediabetes and/or metabolic syndrome. Included participants (n = 238) attended ≥4 core sessions (months 0-6) and had complete data on maintenance attendance (≥4 of 6 sessions during months 7-12) and 6- and 12-month WL (5% WL goal, yes/no). Multivariate logistic regression was used to estimate the odds of 12-month 5% WL associated with maintenance attendance and 6-month WL. Associations between age (Medicare-eligible ≥65 vs Results Both attending ≥4 maintenance sessions and meeting the 6-month 5% WL goal increased the odds of meeting the 12-month 5% WL goal. For those not meeting the 6-month WL goal, maintenance session attendance did not improve odds of 12-month WL success. Medicare-eligible adults ≥65 years were more likely to meet the 12-month WL goal (odds ratio = 3.03, 95% CI, 1.58-5.81) versus Conclusions The results of this study provide important information regarding participant attendance and WL for providers offering DPP-based lifestyle intervention programs across the country who are seeking Medicare reimbursement. Understanding Medicare reimbursement-defined success will allow these providers to focus on and develop strategies to enhance program effectiveness and sustainability.

INTRODUCTION: Lifestyle interventions promoting weight loss and physical activity are important elements of prevention efforts with the evaluation of program impact typically limited to weight loss. Unfortunately, diabetes/cardiovascular disease risk factors and activity are infrequently reported and inconsistent in findings when examined. This inconsistency may partially be due to a lack of consideration for ceiling effects because of broad risk profile inclusion criteria in community translation efforts. To demonstrate this, change in each individual cardiometabolic risk factor limited to those who, at baseline, had a clinically defined abnormal value for that risk factor was examined in 2 cohorts using identical community translations of the Diabetes Prevention Program lifestyle intervention. METHODS: For both studies (2010–2014, 2014–2019), adults with prediabetes and/or metabolic syndrome were recruited through community centers. Outcome measures collected at baseline and 6 months included BMI, activity, blood pressure, lipids, and fasting glucose. Data analyses examined pre–post change in each variable after 6 months of intervention and change within randomized groups at 6 months. RESULTS: Change results were examined for the entire cohort and separately for participants with baseline values outside the recommended range for that risk factor. Whether assessing the pre–post intervention change or change within the randomized groups at 6 months, often the risk factor–specific approach demonstrated a greater effect size for that variable and sometimes newly reached statistical significance. CONCLUSIONS: When examining the effectiveness of community translation efforts, consideration of the individual’s baseline profile with risk factor–specific analysis is suggested to understand the full extent of the impact of the intervention.

Subclinical markers of atherosclerosis, including CAC, are less favorable in adults with IGT. In previous adult studies, higher PA has been associated with lower CAC with findings varying by age and sex. PA and CAC were examined by age and sex in the diverse Diabetes Prevention Program Outcomes Study (DPPOS) cohort with IGT who were randomized at baseline to lifestyle intervention, metformin, or placebo groups for a mean of 3.2 years, and subsequently observed in DPPOS for follow-up. PA was measured via questionnaire (annually); accelerometry once at 11-13yrs and CAC Agatston score (AS) using chest computed tomography at 13-15 yrs from randomization. The relationship between PA and CAC was examined using Tobit regression models in 1434 participants with valid PA and CAC data (mean age 63±9.5 yrs; 70% female; 54% with diabetes) adjusted for treatment group, age, sex, race/ethnicity, lipid medication use, diabetes status, and cumulative metformin exposure; pairwise and three-way interactions were examined. Accelerometry-assessed median (IQR) daily step counts and moderate+ PA (MVPA) minutes were 5302 (3576, 7104) and 21 (9, 41), respectively. Median (IQR) AS was 9 (0, 151). In fully adjusted models, each 1000 steps /day was associated with lower CAC (p=0.024). Results were examined by sex and age subgroups (0.05). Similarly, significant inverse associations between MVPA minutes and CAC AS were found in women ( Suggested sex differences in the PA-CAC association in adults with initial glucose intolerance was found and should be investigated in other studies. Disclosure B. Rockette-wagner: None. E. Horton: None. M. A. Hoskin: None. U. N. Ibebuogu: None. M. Schlögl: None. R. B. Goldberg: None. D. Research group: None. A. Kriska: None. N. Younes: None. S. Edelstein: None. T. J. Orchard: None. M. Armstrong: None. A. L. Brown: Research Support; Self; Medtronic, National Heart, Lung, and Blood Institute, National Institute of Diabetes and Digestive and Kidney Diseases. D. Dabelea: None. K. M. Gadde: Other Relationship; Self; AstraZeneca, Research Support; Self; BioKier, National Institute of Diabetes and Digestive and Kidney Diseases. Funding National Institute of Diabetes and Digestive and Kidney Diseases (U01DK048489)

AIMS: Dietary intake provides a potential intervention target to reduce the high risk for coronary artery disease (CAD) in type 1 diabetes. This effort aimed to identify patterns of nutrient intake in young/middle-aged adults with type 1 diabetes and to examine associations between those patterns and development of CAD. METHODS: Principal component analysis was used to derive nutrient intake patterns among 514 individuals with childhood-onset (

Background Depressive symptoms often manifest in adolescence and predict worsening insulin sensitivity, a key precursor in the path to β-cell failure and type 2 diabetes (T2D). Objective To assess the efficacy of a six-week cognitive-behavioral group versus six-week health education group for improving insulin sensitivity and preserving β-cell function in adolescent girls at-risk for T2D with depressive symptoms and evaluate mechanisms underlying the association between depression and insulin dynamics. Design Randomized controlled trial of N = 150 12–17-year-old girls with overweight/obesity (body mass index [BMI; kg/m2] ≥85th percentile), elevated depressive symptoms (Center for Epidemiologic Studies-Depression Scale [CES-D] total score > 20), and diabetes family history. Methods Girls at-risk for T2D with elevated depressive symptoms are recruited from the Denver-metropolitan area and randomized to participate in one of two six-week interventions. The cognitive-behavioral group is a depression prevention program involving psycho-education, restructuring negative thoughts, and behavioral activation. The health education group is a didactic control that provides knowledge about healthy living. Participants are assessed at baseline, immediate post-intervention, and one-year follow-up. Primary outcomes are insulin sensitivity and β-cell function from oral glucose tolerance tests. Secondary outcomes are disinhibited eating, physical activity, sleep, and cortisol. Summary Results from this adequately powered randomized controlled trial will determine whether decreasing depressive symptoms with a behavioral health program preventatively alters insulin sensitivity and β-cell function trajectories in adolescents at-risk for T2D. Results from the MIND Project will add to knowledge of the contribution of depressive symptoms to T2D risk.

Background Many studies have used the internet to promote physical activity (PA) in several settings, including the home environment, but few have been tailored for African Americans (AAs). To address this research gap, we conducted focus groups with AAs to inform the development of a web-based intervention, Physical Activity for The Heart (PATH), that leverages openly accessible platforms, such as YouTube, to promote PA in any setting. Purpose To describe the rationale and design of a pilot randomized clinical trial (RCT), that examines the feasibility and acceptability of the PATH intervention among 30 AA adults aged 40‐–70 years without history of cardiovascular disease. Methods A 12-week, single-site, wait-listed RCT with subjects randomized 1:1 to either: 1) treatment group - participants receive the PATH intervention, including the online portal and twice a month phone calls from a PA coach, or 2) attention control group - participants receive a self-help PA handout and twice a month general health newsletter. All participants self-monitor step count using actigraphy. The primary outcomes of this 12-week, pilot RCT are recruitment, retention, and adherence to self-monitoring (Actigraph wear time) and the intervention protocol (PATH utilization). The secondary outcomes include changes in PA (step count, moderate-to-vigorous PA, exercise self-efficacy), and cardiometabolic risk (HbA1C, HDL, LDL, total cholesterol, type 2 diabetes risk score, percent body fat, weight, and waist circumference) from baseline to 12 weeks. Conclusions This study will provide PATH intervention feasibility and acceptability data among inactive AA adults and will inform a future, full-scale RCT testing efficacy.

Objective: Across the DPP follow-up, cumulative diabetes incidence remained lower in the lifestyle compared to placebo and metformin randomized groups and could not be explained by weight. Collection of self-reported PA (yearly) with cross-sectional objective PA (in follow-up) allowed for examination of PA and its long-term impact on diabetes prevention. Research Design and Methods: Yearly self-reported PA and diabetes assessment, OGTT, (fasting glucose semi-annually) was collected for 3232 participants with one accelerometry assessment 11-13 years after randomization (n=1,793). Mixed models determined PA differences across treatment groups. The association between PA and diabetes incidence was examined using Cox proportional hazards models. Results: There was a 6% decrease (Cox proportional HR 0.94 [0.92, 0.96]; P< 0.001) in diabetes incidence per 6 MET-hrs/week increase in time-dependent PA for the entire cohort over an average 12 years (controlled for age, sex, baseline PA and weight). The effect of PA was greater (12% decrease) among participants less active at baseline ( Conclusions: PA was inversely related to incident diabetes in the entire cohort across the study with cross-sectional accelerometry results supporting these findings. This highlights the importance of PA within lifestyle intervention efforts designed to prevent diabetes and urge health-care providers to consider both PA and weight when counseling high-risk patients.

Background To date, there have not been any epidemiologic studies that have evaluated the association between swimming over a lifetime and knee health. Objective The study aimed to evaluate the relationship of a history of swimming with knee pain, radiographic knee OA (ROA), and symptomatic knee OA (SOA). Design Cross-sectional retrospective study. Setting Four academic centers in the United States. Participants Respondents to the historical physical activity survey within the Osteoarthritis Initiative with knee radiographs and symptom assessments. Methods In this retrospective study nested within the Osteoarthritis Initiative, researchers performed logistic regression with the predictor being swimming over a lifetime and over particular age ranges. Main outcome measurements Person-based definitions of frequent knee pain, ROA, and SOA. Results A total of 2637 participants were included, with a mean age of 64.3 years (SD 8.9), body mass index of 28.4 kg/m2 (SD 4.9), and 44.2% male. Over a lifetime, the adjusted prevalence measures for frequent knee pain, ROA, and SOA for any versus no history of swimming were 36.4% (33.4% - 39.5%) v. 39.9% (37.4% - 42.5%), 54.3% (51.0% - 57.6%) v. 61.1% (58.4% - 63.7%), and 21.9% (19.4% - 24.7%) v. 27.0% (24.7% - 29.4%) respectively. Conclusions This is the first epidemiologic study to indicate that swimming is potentially beneficial toward knee health, particularly when performed earlier in life (before age 35). Future prospective studies are needed to confirm these findings and to better scrutinize the associations in older age groups.

The DPP lifestyle intervention showed that meeting weight loss (WL) and activity goals can prevent/delay T2D. The success of community translated versions of it (e.g., Group Lifestyle Balance, DPP-GLB) has led to Medicare reimbursement based on session attendance (at 6 and 12 months) and participant success at meeting a 5% WL goal at 12 months. Although attendance has been suggested to be related to WL success, the impact of the 6 monthly maintenance sessions (mos 7-12) after the more frequent 16 core sessions (mos 0-6) on one-year WL is not known. This effort examines how maintenance session attendance and WL goal status at 6 months in DPP-GLB affects achievement of the 12-month 5% WL goal. Data were combined from two identical intervention trials that delivered the 12-month DPP-GLB in a community setting to overweight/obese adults (mean age 62 years, 76% women) with prediabetes and/or metabolic syndrome. Participants who attended ≥4 core sessions during the first 6 months and had complete data on maintenance attendance and WL were included (n=238). Meeting the 6-month WL goal was associated with greater odds of meeting the 12-month WL goal (p Disclosure J. Napoleone: None. R.G. Miller: None. S. Devaraj: None. B. Rockette-Wagner: None. V.C. Arena: None. E.M. Venditti: None. K. Kramer: None. A. Kriska: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (R18DK100933, R18DK081323)

AIMS/HYPOTHESIS: Type 1 diabetes increases CHD risk. We examined the use of the American Heart Association’s cardiovascular health metrics (blood pressure, total cholesterol, glucose/HbA(1c), BMI, physical activity, diet, smoking) to predict incidence of CHD among individuals with type 1 diabetes, with the hypothesis that a better American Heart Association health metric profile would be associated with lower incident CHD. METHODS: Prevalence of the seven cardiovascular health metrics was determined using first and second visits from adult participants (mean age 28.6 years) in the Epidemiology of Diabetes Complications prospective cohort study of childhood-onset type 1 diabetes. An ideal metric score (0–7) was defined as the sum of all metrics within the ideal range, and a total metric score (0–14) was calculated based on poor, intermediate and ideal categories for each metric. Incident CHD development (medical record-confirmed CHD death, myocardial infarction, revascularisation, ischaemic electrocardiogram changes or Epidemiology of Diabetes Complications physician-determined angina) over 25 years of follow-up was examined by metric scores. RESULTS: Among 435 participants, BMI, blood pressure, total cholesterol and smoking demonstrated the highest prevalence within the ideal range, while diet and HbA(1c) demonstrated the lowest. During 25 years of follow-up, 177 participants developed CHD. In Cox models, each additional metric within the ideal range was associated with a 19% lower risk (p=0.01), and each unit increase in total metric score was associated with a 17% lower risk (p

The Diabetes Prevention Program (DPP) and its translational adaptations have been shown to be effective. However, individual-level economic impacts, such as the out-of-pocket costs borne by participants due to involvement in these programs have not been consistently and thoroughly evaluated. As cost is an important consideration that will impact the willingness of individuals to participate in such programs, this study examined direct monetary costs to participants in the Group Lifestyle Balance (GLB) DPP. Older adults (n = 134, mean age 62.8 years) with body mass index (BMI) ≥24 kg/m2 and prediabetes and/or metabolic syndrome participated in this GLB intervention, with two-thirds randomized to begin the intervention immediately and one-third functioning as a control for 6 months before receiving the entire intervention. Food and activity time and costs borne by participants were measured by self-report at baseline and after 6 months. Significant improvements in clinical metabolic measures, weight, and physical activity levels were achieved after 6 months in the intervention group compared both with baseline and the controls. Food costs did not increase among intervention participants. Costs related to physical activity did not change consistently over the course of the intervention. This DPP–GLB lifestyle intervention was effective in reducing risk factors for Type 2 diabetes mellitus among a diverse group of older participants without significantly increasing their out-of-pocket costs for food or physical activity over the course of the intervention. These results should help reduce concerns of individuals who are hesitant to participate in similar programs due to costs. The clinical trial registration number of this study is NCT01050205.

BACKGROUND Most adults are not achieving recommended levels of physical activity (150 minutes/week, moderate-to-vigorous intensity). Inadequate activity levels are associated with numerous poor health outcomes, and clinical recommendations endorse physical activity in the front-line treatment of obesity, diabetes, dyslipidemia, and hypertension. A framework for physical activity prescription and referral has been developed, but has not been widely implemented. This may be due, in part, to the lack of feasible and effective physical activity intervention programs designed to coordinate with clinical care delivery. OBJECTIVE This manuscript describes the protocol for a pilot randomized controlled trial (RCT) that tests the efficacy of a 13-week online intervention for increasing physical activity in adult primary care patients (aged 21-70 years) reporting inadequate activity levels. The feasibility of implementing specific components of a physical activity clinical referral program, including screening for low activity levels and reporting patient program success to referring physicians, will also be examined. Analyses will include participant perspectives on maintaining physical activity. METHODS This pilot study includes a 3-month wait-listed control RCT (1:1 ratio within age strata 21-54 and 55-70 years). After the RCT primary end point at 3 months, wait-listed participants are offered the full intervention and all participants are followed to 6 months after starting the intervention program. Primary RCT outcomes include differences across randomized groups in average step count, moderate-to-vigorous physical activity, and sedentary behavior (minutes/day) derived from accelerometers. Maintenance of physical activity changes will be examined for all participants at 6 months after the intervention start. RESULTS Recruitment took place between October 2018 and May 2019 (79 participants were randomized). Data collection was completed in February 2020. Primary data analyses are ongoing. CONCLUSIONS The results of this study will inform the development of a clinical referral program for physical activity improvement that combines an online intervention with clinical screening for low activity levels, support for postintervention behavior maintenance, and feedback to the referring physician. CLINICALTRIAL ClinicalTrials.gov NCT03695016; https://clinicaltrials.gov/ct2/show/NCT03695016. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/18891

Introduction Male youth in the United States commonly participate in gridiron (American) football. There are little data substantiating current popular opinion that it is associated with knee pain or osteoarthritis (OA) later in life. We aimed to evaluate the relationship of football with these outcomes in the Osteoarthritis Initiative (OAI). Methods This is a study of male OAI participants with knee x-ray readings, symptom assessments, and completed surveys on lifetime physical activity. The OAI is a multicenter, observational cohort recruited from the community not based on football participation status. A history of exposure to American football was ascertained via self-report. Knee radiographs were scored for Kellgren-Lawrence grade (0-4). Radiographic OA (ROA) was defined as Kellgren-Lawrence ≥ 2 in at least one knee. Frequent knee pain meant at least one knee with frequent knee pain. Symptomatic ROA required at least one knee with both ROA and frequent knee pain. Results A total of 1166 men had a mean age of 63.7 (SD, 9.2) yr and body mass index of 28.6 (SD, 4.2) kg·m. Thirty-one percent (365/1166) played football at some point in their lives, 95% of whom participated from ages 12 to 18 yr. The ORs for symptomatic ROA from the lowest to highest football participation were 1.2, 1.5, and 2.2, respectively (P for trend = 0.004). Findings were similar for football from ages 12 to 18 yr and for outcomes of knee pain and ROA. Conclusion This is the first large epidemiologic study to suggest that football participation, including in the teen years, may be detrimental toward knee health. Prospective studies evaluating football players are warranted.

Introduction: The AHA created “Life’s Simple Seven” metrics to measure progress toward the goal of improving the cardiovascular (CV) health of all Americans, classifying each metric as “ideal”, “intermediate,” or “poor”. Few studies have examined the impact of behavioral lifestyle interventions on CV health metrics. We evaluated changes in CV health metrics during the course of a CDC recognized Diabetes Prevention Program-based lifestyle intervention known as Group Lifestyle Balance (DPP-GLB). Hypothesis: DPP-GLB will be associated with improvements in CV health metrics after 6 months of intervention and maintenance of these improvements at 12 months post-baseline. Methods: We used combined data from two similar intervention trials (occurring 6 years apart) offering a 12 month DPP-GLB program in the community setting to overweight/obese individuals with prediabetes and/or metabolic syndrome. Changes in individual CV health metrics (BMI, blood pressure, total cholesterol, fasting blood glucose, physical activity; measures of smoking and diet were not available) and total metric score (sum of metric profile where ideal=2, intermediate=1 and poor=0 for each metric, possible “total “range of 0-10) were considered after 6 and 12 months of intervention. Results: Among 222 participants (76%) with complete data for all 5 metrics at intervention baseline, 6 and 12 month follow up, there was a significant beneficial shift from baseline to 6 and 12 months in the proportion of participants within CV health metric categories for BMI, physical activity and blood pressure (Figure 1). Total metric score also improved significantly (p Conclusions: The DPP-GLB intervention was successful in improving CV health metrics at both 6 and 12 months, demonstrating the potential of this program to decrease CVD risk.

Purpose The purpose of this study is to evaluate the feasibility and effectiveness of an adapted Diabetes Prevention Program (DPP) lifestyle program, DPP Group Lifestyle Balance (GLB), delivered in 3 economically diverse senior/community centers. Methods The DPP-GLB was implemented in 3 senior/community centers in Allegheny County, PA. A 6-month delayed control intervention design was used. Participants were randomized to begin the DPP-GLB immediately (immediate) or after a 6-month delay (delayed). Adults (n = 134; mean age = 62.8 years) with BMI ≥24 kg/m2 and prediabetes and/or the metabolic syndrome took part. Weight, physical activity (PA), and diabetes and cardiovascular disease (CVD) risk factors were assessed at 6, 12, and 18 months from baseline. Results At 6 months, the immediate group demonstrated greater mean weight loss than the delayed control group as well as significantly greater improvements in PA, A1C, fasting insulin, and waist circumference. In pre-post analyses, both randomized groups showed similar success that was maintained at 18 months. Conclusions The DPP-GLB delivered in economically diverse community centers was effective in this group of older adults. These findings support provision of coverage for prevention programs in older adults at risk for diabetes/CVD, which is important considering the large number of individuals who will be Medicare eligible in the near future.

Objective To assess the association of proxies of behavioral adherence to the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY) lifestyle program with changes in glycemic control and obesity in a multi-ethnic sample of youth with type 2 diabetes. Methods The TODAY clinical trial included an intensive lifestyle intervention to promote weight reduction. Adherence was assessed with measures of attendance at intervention sessions and rates of self-monitoring of diet and physical activity by participants and their caregivers. The relation between participant characteristics and consistency of proxies of adherence were examined across 3 phases of intervention. Results A total of 234 TODAY youth were randomized to the lifestyle program. Overall rate of session attendance was approximately 60% of planned sessions. Participants with an adequate dose of session attendance (≥75% attended) did not differ from those who attended

The U.S. Diabetes Prevention Program (DPP) showed that lifestyle participants who achieved ≥7% weight loss and ≥150 min/week physical activity experienced the greatest reduction in type 2 diabetes incidence. Demographic, clinical, and program factors that are related to achieving both these lifestyle goals have seldom been explored in community-delivered DPP programs. The purpose of this investigation is to examine factors associated with concurrent achievement of weight loss and physical activity goals in a 12-month community DPP lifestyle intervention. Adults [n = 223; age = 58.4 (SD = 11.5); BMI = 33.8 (SD = 6.0)] with glucose or HbA1c values in the pre-diabetes range and/or metabolic syndrome risk factors enrolled from one worksite and three community centers in the Pittsburgh, PA metropolitan area between January 2011 and January 2014. Logistic regression analyses determined the demographic, clinical and program adherence factors related to goal achievement at 6, 12, and 18 months. Participants achieving both intervention goals at 6 months (n = 57) were more likely to attend sessions [Adjusted Odds Ratio (AOR) =1.48], self-weigh (AOR = 1.19), and self-monitor behaviors (AOR = 1.18) than those meeting neither goal (n = 35; all p

Background Little is known about the feasibility and impact of lifestyle intervention, determined by change in diet and cardiovascular fitness (CRF), on glycemic control in youth who are overweight with type 2 diabetes. This was examined in the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY) clinical trial cohort from across 15 US centers. Subjects TODAY enrolled 699 youth aged 10 to 17 years with type 2 diabetes

Introduction This study aims to determine if evidence exists for a lasting effect of the Diabetes Prevention Program (DPP) lifestyle intervention on activity levels by comparing objectively collected activity data between the DPP Outcome Study (DPPOS) cohort and adults from the National Health and Nutrition Examination Survey (NHANES; 2003–2006). Methods Average minutes/day of light and moderate to vigorous physical activity (MVPA) and sedentary behavior from ActiGraph accelerometers (collected 2010–2012) were examined (2013–2014) for comparable DPPOS and NHANES subgroups by age, sex, and diabetes status. Longitudinal questionnaire data on leisure activity, collected yearly from DPP baseline to the time of accelerometer measurement (1996–2010; 11.9-year mean follow-up), were also examined to provide support for a long-term intervention effect. Results Average minutes/day of accelerometer-derived MVPA was higher in all DPPOS subgroups versus NHANES subgroups of similar age/sex/diabetes status; with values as much as twice as high in some DPPOS subgroups. Longitudinal questionnaire data from DPP/DPPOS showed a maintained increase of 1.24 MET hours/week ( p =0.026) of leisure activity in DPPOS participants from all original study arms between DPP baseline and accelerometer recording. There were no consistent differences between comparable DPPOS and NHANES subgroups for accelerometer-derived sedentary or light-intensity activity minutes/day. Conclusions More than 10 years after the start of DPP, DPPOS participants performed more accelerometer-measured MVPA than similar adults from NHANES. Longitudinal questionnaire data support the accelerometer-based findings by suggesting that leisure activity levels at the time of accelerometer recording remained higher than DPP baseline levels.

Objective Regular physical activity, including running, is recommended based on known cardiovascular and mortality benefits. However, controversy exists regarding whether running can be harmful to knees. The purpose of this study is to evaluate the relationship of running with knee pain, radiographic osteoarthritis (OA), and symptomatic OA. Methods This was a retrospective cross-sectional study of Osteoarthritis Initiative participants (2004–2014) with knee radiograph readings, symptom assessments, and completed lifetime physical activity surveys. Using logistic regression, we evaluated the association of history of leisure running with the outcomes of frequent knee pain, radiographic OA, and symptomatic OA. Symptomatic OA required at least 1 knee with both radiographic OA and pain. Results Of 2,637 participants, 55.8% were female, the mean ± SD age was 64.3 ± 8.9 years, and the mean ± SD body mass index was 28.5 ± 4.9 kg/m2; 29.5% of these participants ran at some time in their lives. Unadjusted odds ratios of pain, radiographic OA, and symptomatic OA for those prior runners and current runners compared to those who never ran were 0.83 and 0.71 (P for trend = 0.002), 0.83 and 0.78 (P for trend = 0.01), and 0.81 and 0.64 (P for trend = 0.0006), respectively. Adjusted models were similar, except radiographic OA results were attenuated. Conclusion There is no increased risk of symptomatic knee OA among self-selected runners compared with nonrunners in a cohort recruited from the community. In those without OA, running does not appear to be detrimental to the knees.

Introduction: Sleep duration is commonly associated with cardiovascular disease risk. Surprisingly, though, relatively few studies have examined the association between sleep duration and arterial stiffness, an early marker of cardiovascular risk. The available evidence remains equivocal, and few studies have examined whether sleep quality confounds the association between sleep duration and arterial stiffness. Purpose: The purpose of these analyses was to examine the association between sleep duration, sleep quality, and arterial stiffness in a sample of young- and middle-aged adults. Methods: The present analyses utilized baseline data from a sample of adults enrolled in a lifestyle intervention (N=324; 37.8±6.2 y, body mass index [BMI]: 32.8±3.9 kg/m 2 , resting systolic blood pressure [SBP]: 113.5±10.4 mmHg, 77.2% female, 80.6% white). Sleep was assessed with the Pittsburgh Sleep Quality Index (PSQI); sleep duration and sleep quality were each assessed with single PSQI items; duration was classified into three categories (< 6 h, ≥ 6 to < 7 h, ≥ 7 h) and quality was dichotomized into good (very good/fairly good) and poor (very bad/fairly bad). Risk for sleep apnea was assessed with the Berlin Questionnaire. Arterial stiffness was assessed with carotid-femoral pulse wave velocity; values were log-transformed prior to analysis. Analysis of covariance models were used to examine the associations between sleep duration and quality with arterial stiffness. All models adjusted for age, sex, race, BMI, SBP, and sleep apnea risk. Results: Approximately 13%, 34%, and 53% of participants reported < 6 h, ≥ 6 but < 7 h, or ≥ 7 h sleep duration, respectively; 18% of participants reported poor sleep quality. Arterial stiffness significantly differed across categories of sleep duration (η p 2 =.02; P=.03); adults reporting < 6 h sleep duration had significantly greater arterial stiffness than adults reporting either ≥ 6 but < 7 h (P=.02) or ≥ 7 h (P=.01). In contrast, arterial stiffness did not differ according to sleep quality (η p 2 =.00; P=.75). When included in the same model, sleep duration remained a significant predictor of arterial stiffness (η p 2 =.02; P=.03), while sleep quality remained nonsignificant (η p 2 =.00; P=.66). Conclusion: In a sample of young- to middle-aged adults with overweight or obesity, short sleep duration was associated with greater arterial stiffness independently of sleep quality. Whether increasing sleep duration can improve arterial stiffness deserves further exploration.

Background: Weighted hula-hoops have gained popularity, but whether they indeed reshape the trunk or have beneficial metabolic effects in overweight subjects is unknown. Objectives: To determine effects of hula-hooping and walking matched for energy expenditure on android fat %, trunk muscle mass, and metabolic parameters in a randomized cross-over study. Design: We recruited 55 overweight nondiabetic subjects, who were randomized to hula-hooping (HULA) for 6 weeks using a 1.5-kg weighted hula-hoop followed by walking (WALK) for another 6 weeks or vice versa. The increments in energy expenditure were similar by HULA and WALK. Body composition (dual-energy X-ray absorptiometry) and metabolic parameters were measured at baseline and after HULA and WALK. The primary endpoint was the change in fat % in the android region. Results: A total of 53subjects (waist 92 ± 1 cm, body mass index 28 ± 1 kg/m2) completed the study. Body weight changed similarly (–0.6 ± 0.2 vs. –0.5 ± 0.2 kg, nonsignificant; HULA vs. WALK). During the intervention the subjects hula-hooped on average 12.8 ± 0.5 min/day and walked 9,986 ± 376 steps/day. The % fat in the android region decreased significantly by HULA but not by WALK (between-group change p < 0.001). Trunk muscle mass increased more by HULA than by WALK (p < 0.05). Waist circumference decreased more by HULA than by WALK (–3.1 ± 0.3 cm vs. –0.7 ± 0.4 cm, p < 0.001; HULA vs. WALK). WALK but not HULA significantly lowered systolic blood pressure and increased HDL cholesterol while HULA significantly decreased LDL cholesterol. Conclusions: Hula-hooping with a weighted hula-hoop can be used to decrease abdominal fat % and increase trunk muscle mass in overweight subjects. Its LDL lowering effect resembles that described for resistance training.

Since 2010, the American Diabetes Association has endorsed both HbA1C (A1C) and fasting plasma glucose (FPG) to determine diabetes risk. Given the discordance between classifications based on FPG and A1C and higher A1C levels among African Americans (AAs) than whites, we sought to examine the prevalence of normoglycemia, prediabetes, and diabetes among a community sample of adult AAs (n=704) screened for enrollment in a randomized Diabetes Prevention Program (DPP). We conducted a retrospective analysis to estimate the degree of discordance between risk categories based on FPG and A1C and examine the risk factors that predicted A1C and FPG levels. To determine differential effects on risk categories defined using FPG and A1C, we examined the effects of the program on the measures at 12 weeks post-intervention among the intervention arm participants.

Behavioral lifestyle interventions in the community setting are effective in reducing the risk and burden of chronic diseases. The promotion and implementation of physical activity plays a key role in these community-based lifestyle programs. New guidelines on preparticipation screening for cardiovascular disease prior to physical activity have been released which include substantive modifications. These updated recommendations represent a substantial paradigm shift toward a more liberal approach that results in fewer individuals needing to seek medical clearance before starting a physical activity program. This shift has significant implications for those promoting physical activity within the community setting. The objectives of this commentary are to review the updated recommendations within the context of community-based lifestyle intervention programs such as those currently being offered throughout the United States for the primary purpose of diabetes prevention and to discuss the implications for those providers developing and implementing such programs.

Introduction The American Heart Association created “Life’s Simple Seven” metrics to estimate progress toward improving US cardiovascular health in a standardized manner. Given the widespread use of federally funded Diabetes Prevention Program (DPP)-based lifestyle interventions such as the Group Lifestyle Balance (DPP-GLB), evaluation of change in health metrics within such a program is of national interest. This study examined change in cardiovascular health metric scores during the course of a yearlong DPP-GLB intervention. Methods Data were combined from 2 similar randomized trials offering a community based DPP-GLB lifestyle intervention to overweight/obese individuals with prediabetes and/or metabolic syndrome. Pre/post lifestyle intervention participation changes in 5 of the 7 cardiovascular health metrics were examined at 6 and 12 months (BMI, blood pressure, total cholesterol, fasting plasma glucose, physical activity). Smoking was rare and diet was not measured. Results Among 305 participants with complete data (81.8% of 373 eligible adults), significant improvements were demonstrated in all 5 risk factors measured continuously at 6 and 12 months. There were significant positive shifts in the “ideal” and “total” metric scores at both time points. Also noted were beneficial shifts in the proportion of participants across categories for BMI, activity, and blood pressure. Conclusion AHA-metrics could have clinical utility in estimating an individual’s cardiovascular health status and in capturing improvement in cardiometabolic/behavioral risk factors resulting from participation in a community-based translation of the DPP lifestyle intervention.

The Diabetes Prevention Program (DPP) lifestyle intervention demonstrated that meeting the weight loss (WL) and activity goals prevents/delays type 2 diabetes. Older DPP participants, 60-85 years, reduced the risk of developing diabetes by 71% versus 58% in those

Background Most adults are not achieving recommended levels of physical activity (150 minutes/week, moderate-to-vigorous intensity). Inadequate activity levels are associated with numerous poor health outcomes, and clinical recommendations endorse physical activity in the front-line treatment of obesity, diabetes, dyslipidemia, and hypertension. A framework for physical activity prescription and referral has been developed, but has not been widely implemented. This may be due, in part, to the lack of feasible and effective physical activity intervention programs designed to coordinate with clinical care delivery. Objective This manuscript describes the protocol for a pilot randomized controlled trial (RCT) that tests the efficacy of a 13-week online intervention for increasing physical activity in adult primary care patients (aged 21-70 years) reporting inadequate activity levels. The feasibility of implementing specific components of a physical activity clinical referral program, including screening for low activity levels and reporting patient program success to referring physicians, will also be examined. Analyses will include participant perspectives on maintaining physical activity. Methods This pilot study includes a 3-month wait-listed control RCT (1:1 ratio within age strata 21-54 and 55-70 years). After the RCT primary end point at 3 months, wait-listed participants are offered the full intervention and all participants are followed to 6 months after starting the intervention program. Primary RCT outcomes include differences across randomized groups in average step count, moderate-to-vigorous physical activity, and sedentary behavior (minutes/day) derived from accelerometers. Maintenance of physical activity changes will be examined for all participants at 6 months after the intervention start. Results Recruitment took place between October 2018 and May 2019 (79 participants were randomized). Data collection was completed in February 2020. Primary data analyses are ongoing. Conclusions The results of this study will inform the development of a clinical referral program for physical activity improvement that combines an online intervention with clinical screening for low activity levels, support for postintervention behavior maintenance, and feedback to the referring physician. Trial Registration ClinicalTrials.gov NCT03695016; https://clinicaltrials.gov/ct2/show/NCT03695016. International Registered Report Identifier (IRRID) DERR1-10.2196/18891

The presence of risk factors for type 2 diabetes and cardiovascular disease, or the conditions themselves, contributes to lower health-related quality of life (HRQoL) among adults. Although community-based lifestyle intervention programs have been shown to be effective for improving risk factors for these diseases, the impact of these interventions on HRQoL has rarely been described. To examine changes in HRQoL following participation in the Group Lifestyle Balance program, a community translation of the Diabetes Prevention Program lifestyle intervention for adults with prediabetes and/or the metabolic syndrome. Participants enrolled in the 12-month, 22-session intervention program (N = 223) completed the EuroQol Health Questionnaire (EQ-5D-3L) at baseline, 6, and 12 months. Linear mixed-effects regression models determined change in EQ-5D-visual analog scale (VAS) and Index scores post-intervention. Mean EQ-5D-VAS was improved by +7.38 (SE = 1.03) at 6 months and by +6.73 (SE = 1.06) at 12 months post-intervention (both; p

Introduction Short sleep duration and poor sleep quality have each been associated with obesity and weight gain. However, less is known regarding how sleep may impact attempted weight loss. The purpose of this study was to investigate the associations between sleep duration and sleep quality, both independently and in combination, with weight loss in a 12-month behavioral weight loss intervention. Methods Young to middle-aged adults who were overweight or obese (N=296) completed a 12-month behavioral weight loss intervention, with weight assessed at baseline, 6 and 12 months. Sleep duration and quality were derived from the Pittsburgh Sleep Quality Index. Analyses examined the change in sleep over time and the association between baseline sleep and changes in sleep with 6- and 12-month weight loss following adjustment for relevant covariates including age, gender, race, education, baseline body mass index, and baseline risk for sleep apnea. Results Participants (with an average baseline weight of 97.0±1.0 kg) lost 6.6±1.1 kg (6.8%) and 6.7±1.2 kg (6.9%) at 6 and 12 months relative to baseline, respectively. Global sleep quality significantly improved over the 12-month intervention (P=.03), but average sleep duration and the prevalence of short sleep duration ( Conclusion Our findings highlight the importance of both sleep duration and sleep quality as predictors of behavioral weight loss and suggest that screening for sleep disturbance may be useful to determine who may benefit from additional counseling and resources. Support R01HL077525, K23HL118318

Walking difficulty is a common and costly problem in older adults. A potentially important yet unaddressed strategy to enhance walking ability through exercise intervention is to add a timing and coordination component in gait training (i.e. task specific timing and coordination exercise intervention) to the usual strength, endurance, and flexibility training. We describe the methods and rationale of a randomized single-blind, physical therapist supervised, exercise intervention trial to compare the effects of a standard strength, endurance, and flexibility program to a standard plus timing and coordination program in community-dwelling older adults walking slower than the desired gait speed of 1.2 m/s. Exercise sessions are twice weekly for 12 weeks. Participants are assessed at baseline, 12 weeks (post intervention), 24 weeks and 36 weeks. The primary outcome is gait speed, secondary outcomes represent components of the interventions (strength, endurance, flexibility, timing and coordination), and tertiary outcomes are measure of activity and participation (Late Life Function and Disability Instrument and physical activity). The findings of this trial will (1) establish if a standard-plus task specific timing and coordination program is superior to a standard strength and endurance program in improving mobility, activity and participation and (2) determine if the improvements are sustained over time. The information derived from this project will provide valuable insight into the prevention and management of walking difficulty, which is so common in older Americans.

Randomization to lifestyle intervention (ILS) or metformin (MET) in the Diabetes Prevention Program (DPP) resulted in weight loss and reduced progression to diabetes. The long term effects of these interventions on bone mineral density (BMD) and falls, both associated with weight loss, are not known. We determined if ILS or MET was associated with prevalence of osteoporosis, osteopenia or history of falls in the DPP Outcome Study (DPPOS). During DPP, 3234 participants at high risk for diabetes were randomized to ILS, MET or PLB; 2779 continued in DPPOS and were offered modified group ILS. During DPPOS, ILS was offered additional lifestyle reinforcement semi-annually and MET received unmasked metformin. This analysis includes 1384 DPPOS participants who had dual-energy X-ray absorptiometry hip scans at year 12 (Y12). Osteoporosis was defined as femoral neck BMD T-score ≤-2.5 and osteopenia as -2.5 Mean age at Y12 was 66.5 (±9.5) years. Mean time since DPP baseline was 15.6 (±0.7) years. Weight loss (DPP baseline to DPPOS Y12) did not differ across treatment groups (-4.4 kg ILS; -3.5 kg MET; -3.1 kg PLB; p=0.114). There were no differences across groups in the prevalence of osteoporosis in men (1.4% ILS, 1.3% MET, 0.7% PLB; p=0.836) or women (2.9% ILS, 2.9% MET, 3.1% PLB; p=0.983). Prevalence of osteopenia was also similar across groups. Prevalence of history of falls was similar across groups in men (16.0% ILS, 16.4% MET, 16.0% PLB; p=0.995) and women (25.7% ILS, 21.3% MET, 21.6% PLB; p=0.342). Prevalence of osteoporosis, osteopenia or history of falls did not differ between ILS or MET and PLB in men or women. In a cohort at high risk of diabetes, lifestyle intervention or metformin did not have long-term effects on bone density or falls. Disclosure A.V. Schwartz: None. Q. Pan: None. V. Aroda: Consultant; Self; Novo Nordisk Inc.. Research Support; Self; Novo Nordisk Inc., AstraZeneca, Calibra Medical, Eisai Inc., Sanofi. Consultant; Self; Sanofi. Research Support; Self; Theracos, Inc.. Employee; Spouse/Partner; Merck & Co., Inc.. Other Relationship; Self; American Diabetes Association. Consultant; Self; ADOCIA. J.P. Crandall: None. A. Kriska: None. C.S. Piromalli: None. M. Temprosa: Other Relationship; Self; Merck KGaA. H. Florez: Advisory Panel; Self; Sanofi. D. Research Group: None.

Weight loss prevents progression to diabetes but long term effects on lean mass are unknown. We determined if intensive lifestyle modification (ILS), metformin (MET) or placebo (PLB) treatment in the Diabetes Prevention Program (DPP) had differential effects on appendicular lean mass (ALM) and sarcopenic-obesity (SO) ∼16 years after DPP randomization in the DPP Outcome Study (DPPOS). During DPP, 3234 participants at high risk for diabetes were randomized to ILS, MET or PLB; 2779 continued in DPPOS and were offered modified group ILS. During DPPOS, ILS was offered additional lifestyle reinforcement semi-annually and MET received unmasked metformin. This analysis includes 1374 DPPOS participants who had dual-energy X-ray absorptiometry scans at year 12 for ALM (sum of lean mass in arms and legs). Low ALM was defined as ALM/BMI 30. Prevalence of low ALM and SO was compared across the 3 groups using Pearson’s chi-squared test. Logistic regression models determined the associations between treatment and low ALM or SO and between weight loss and low ALM or SO. Mean age at Y12 was 66.5 (±9.5) years. Mean time since DPP baseline was 15.6 (±0.7) years. Weight loss (DPP baseline to DPPOS Y12) did not differ by group (-4.4 kg ILS; -3.5 kg MET; -3.1 kg PLB; p=0.114). Prevalence of low ALM differed by group in men (35.7% ILS, 28.3% MET, 22.5% PLB; p=0.049) but not women (20.9% ILS, 24.8% MET, 24.1% PLB; p=0.482). In men, low ALM prevalence was higher in ILS compared with PLB (P=0.024) but not in MET vs. PLB. Prevalence of SO did not differ across groups in men (23.1% ISL, 22.0% MET, 14.1% PLB; p=0.112) or women (17.3% ILS, 20.9% MET, 20.3% PLB; p=0.492). SO prevalence was not different in ILS vs. PLB or in MET vs. PLB in men or women. More weight loss was associated with higher risk of low ALM and SO in women and men (p Disclosure A.V. Schwartz: None. Q. Pan: None. H.P. Hazuda: None. E. Horton: Advisory Panel; Self; PTS Diagnostics, Merck & Co., Inc., Theracos, Inc.. M.A. Hoskin: None. R. Rastogi Kalyani: None. W.C. Knowler: None. A. Kriska: None. M. Schlögl: None. H. Florez: Advisory Panel; Self; Sanofi. D. Research Group: None.

Objective: To examine whether odds of frailty differ by DPP intervention arms (intensive lifestyle intervention [ILS], metformin [MET], placebo [PLB] after long-term follow-up in the DPPOS. Methods: DPP, a randomized trial of individuals at high risk of diabetes, lasted 2.8 years, after which there was a 13-month bridge period in which 16 sessions of group ILS was offered to all participants. During DPPOS, ILS was offered lifestyle reinforcement semi-annually and MET received unmasked metformin. Frailty was measured initially in DPPOS Year 8 in 2385 participants and repeated in 2264 of these in Year 10 (12 and 14 years after randomization). Using Fried criteria, presence of 3 of 5 characteristics (slow walking speed, weak grip strength, unintentional weight loss, low physical activity, and exhaustion) was classified as frail, 1 or 2 pre-frail, and 0 non-frail.: GEE models adjusting for visit year were employed with repeated measures pooled from Years 8 and 10 to estimate pairwise odds ratios between ILS, MET and PLB for the outcomes of frail and pre-frail vs. non-frail. Results: Odds of frailty vs. non-frailty were 37% lower in ILS compared to PLB (Table) and MET (OR=0.629, CI= 0.420-0.942, p=0.024). There were no significant treatment group differences in odds of pre-frailty. Conclusion: ILS intervention in persons at high risk of diabetes may reduce frailty in later life.12 years Post-randomization14 years post-randomizationOdds of Frailty vs. Non-Frailty Pooled over both examsTreatment GroupPrevalencePrevalence OR (95% CI) compared with placeboP-valuePre-FrailtyFrailtyPre-FrailtyFrailtyPlacebo42.8%5.7%43.7%5.4%1 (referent)n/aMetformin45.8%5.4%42.5%5.3%0.994 (0.694-1.424)0.976Lifestyle46.8%3.0%46.3%3.6%0.625 (0.419-0.934)0.022 Disclosure H.P. Hazuda: None. Q. Pan: None. J.P. Crandall: None. H. Florez: Advisory Panel; Self; Sanofi. J.A. Luchsinger: None. E.M. Venditti: None. A. Kriska: None. S. Golden: None. G. Bray: Advisory Panel; Self; Herbalife International of America, Inc., Novo Nordisk A/S. D. Research Group: None.

Objective: Parents of overweight and obese children often underestimate the severity of their child’s weight problem, which may influence the parent’s anticipated need for weight loss treatment and parent’s concern for future weight problems in their child. The purpose of this study is to examine the influence of individuals who have expressed concern for their child’s weight on: 1) parental perception of their child’s weight; 2) parental concern for future weight problems in their child (C-FWP). Methods: Forty-eight parent-child dyads completed questionnaires reporting individuals who have expressed concern for their child’s weight, parental perception of their child’s weight, and parental C-FWP. Child subjects were 6-12 years old and were overweight or obese (≥85th percentile for BMI). Results: Parents were more likely to accurately perceive their child as overweight if concern was expressed by a primary care pediatrician (PCP) (p=0.0001), family member (p=0.013), grandparent (p=0.042), or spouse/other parent (p=0.013). There was no influence on parent perception of child weight if weight concern was expressed by a school nurse (p=0.302), teacher (p=0.165), or the child’s coach (p=0.392). Expressed concern had no influence C-FWP. Conclusion: PCP’s, family members, grandparents, or spouse/other parents have a significant impact on parent perception of child weight. Accurate parent perception of child weight may help parents recognize the need for lifestyle modifications and to promote healthy weight in their child. PCP’s should anchor parents to the child’s weight status and express concern to the parent when a child is overweight or obese.