Background:The Diabetes Prevention Program (DPP) lifestyle intervention reduced the incidence of type 2 diabetes mellitus (DM) among high-risk adults by 58%, with weight loss as the dominant predictor. However, it has not been adequately translated into primary care. Methods:We evaluated 2 adapted DPP lifestyle interventions among overweight or obese adults who were recruited from 1 primary care clinic and had pre-DM and/or metabolic syndrome. Participants were randomized to (1) a coach-led group intervention (n = 79), (2) a selfdirected DVD intervention (n = 81), or (3) usual care (n=81). During a 3-month intensive intervention phase, the DPP-based behavioral weight-loss curriculum was delivered by lifestyle coach-led small groups or homebased DVD. During the maintenance phase, participants in both interventions received lifestyle change coaching and support remotely-through secure email within an electronic health record system and the American Heart Association Heart360 website for weight and physical activity goal setting and self-monitoring. The primary outcome was change in body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) from baseline to 15 months.Results: At baseline, participants had a mean (SD) age of 52.9 (10.6) years and a mean BMI of 32.0 (5.4); 47% were female; 78%, non-Hispanic white; and 17%, Asian/ Pacific Islander. At month 15, the meanϮSE change in BMI from baseline was Ϫ2.2Ϯ0.3 in the coach-led group vs Ϫ0.9 Ϯ 0.3 in the usual care group (P Ͻ .001) and Ϫ1.6Ϯ0.3 in the self-directed group vs usual care (P=.02). The percentages of participants who achieved the 7% DPPbased weight-loss goal were 37.0% (P=.003) and 35.9% (P=.004) in the coach-led and self-directed groups, respectively, vs 14.4% in the usual care group. Both interventions also achieved greater net improvements in waist circumference and fasting plasma glucose level. Conclusion:Proven effective in a primary care setting, the 2 DPP-based lifestyle interventions are readily scalable and exportable with potential for substantial clinical and public health impact.
Background-Hyperglycemia on admission is associated with an increased mortality rate in patients with acute myocardial infarction. Whether metrics that incorporate multiple glucose assessments during acute myocardial infarction hospitalization are better predictors of mortality than admission glucose alone is not well defined. Methods and Results-We evaluated 16 871 acute myocardial infarction patients hospitalized from January 2000 to December 2005. Using logistic regression models and C indexes, 3 metrics of glucose control (mean glucose, time-averaged glucose, hyperglycemic index), each evaluated over 3 time windows (first 24 hours, 48 hours, entire hospitalization), were compared with admission glucose for their ability to discriminate hospitalization survivors from nonsurvivors. Models were then used to evaluate the relationship between mean glucose and in-hospital mortality. All average glucose metrics performed better than admission glucose. The ability of models to predict mortality improved as the time window increased (C indexes for admission, mean 24 hours, 48 hours, and hospitalization glucose were 0.62, 0.64, 0.66, 0.70; PϽ0.0001). Statistically significant but small differences in C indexes of mean glucose, time-averaged glucose, and hyperglycemic index were seen. Mortality rates increased with each 10-mg/dL rise in mean glucose Ն120 mg/dL (odds ratio, 1.8; Pϭ0.003 for glucose 120 to Ͻ130 mg/dL) and with incremental decline Ͻ70 mg/dL (odds ratio, 6.4; Pϭ0.01 versus glucose 100 to Ͻ110 mg/dL). The slope of these relationships was steeper in patients without diabetes. Conclusions-Measures of persistent hyperglycemia during acute myocardial infarction are better predictors of mortality than admission glucose. Mean hospitalization glucose appears to be the most practical metric of hyperglycemiaassociated risk. A J-shaped relationship exists between average glucose and mortality, with both persistent hyperglycemia and hypoglycemia associated with adverse prognosis.
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