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Unhealthy lifestyle behaviors such as poor diets and physical inactivity account for most of the cardiometabolic disease (CMD) burden, including type 2 diabetes and cardiovascular diseases. Much of this burden is mediated by the effects of unhealthy lifestyle behaviors on overweight and obesity, and disproportionally impacts certain population groups-including those from disadvantaged socioeconomic backgrounds. Combined lifestyle interventions (CLIs), which target multiple behaviors, have the potential to prevent CMD, but their implementation, reach and effectiveness in routine practice are often limited. Considering the increasing availability of effective but expensive pharmaceutical options for weight loss, we review the short-term and long-term benefits and cost-effectiveness of CLIs on overweight, obesity and associated CMDs, in controlled studies and in routine care. Against the backdrop of changing living environments, we discuss the effective components of CLIs and the many challenges associated with implementing them. Finally, we outline future directions for research and implications for policy and practice to improve lifestyle behaviors and cardiometabolic health at the population level., Competing Interests: Competing interests: S.G. reports receiving honoraria from Astra Zeneca and Eli Lilly for contributing to postgraduate educational sessions. The remaining authors have no conflicts of interest to disclose., (© 2024. Springer Nature America, Inc.)

In this observational cross-sectional study, we investigated the relationship between combined obesogenic neighbourhood characteristics and various cardiovascular disease risk factors in adults, including BMI, systolic blood pressure, and blood lipids, as well as the prevalence of overweight/obesity, hypertension, and dyslipidaemia. We conducted a large-scale pooled analysis, comprising data from five Dutch cohort studies (n = 183,871). Neighbourhood obesogenicity was defined according to the Obesogenic Built-environmental CharacterisTics (OBCT) index. The index was calculated for 1000m circular buffers around participants' home addresses. For each cohort, the association between the OBCT index and prevalence of overweight/obesity, hypertension and dyslipidaemia was analysed using robust Poisson regression models. Associations with continuous measures of BMI, systolic blood pressure, LDL-cholesterol, HDL-cholesterol, and triglycerides were analysed using linear regression. All models were adjusted for age, sex, education level and area-level socio-economic status. Cohort-specific estimates were pooled using random-effects meta-analyses. The pooled results show that a 10 point higher OBCT index score was significantly associated with a 0.17 higher BMI (95%CI: 0.10 to 0.24), a 0.01 higher LDL-cholesterol (95% CI: 0.01 to 0.02), a 0.01 lower HDL cholesterol (95% CI: -0.02 to -0.01), and non-significantly associated with a 0.36 mmHg higher systolic blood pressure (95%CI: -0.14 to 0.65). A 10 point higher OBCT index score was also associated with a higher prevalence of overweight/obesity (PR = 1.03; 95% CI: 1.02 to 1.05), obesity (PR = 1.04; 95% CI: 1.01 to 1.08) and hypertension (PR = 1.02; 95% CI: 1.00 to 1.04), but not with dyslipidaemia. This large-scale pooled analysis of five Dutch cohort studies shows that higher neighbourhood obesogenicity, as measured by the OBCT index, was associated with higher BMI, higher prevalence of overweight/obesity, obesity, and hypertension. These findings highlight the importance of considering the obesogenic environment as a potential determinant of cardiovascular health., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Paul Meijer reports financial support was provided by Dutch Research Council. Thao Minh Lam reports financial support was provided by Dutch Research Council. Nicolette R den Braver reports financial support was provided by Dutch Research Council. Jeroen Lakerveld reports financial support was provided by Dutch Research Council., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: This study aimed to investigate cross-sectional associations of total, animal, and plant-based protein intake and depressive symptoms in Dutch adults with type 2 diabetes (T2D)., Methods: We included 1137 individuals with T2D (aged 68.6 ± 9.0) from the Hoorn Diabetes Care System cohort. Energy-adjusted protein intake was assessed using a validated Food Frequency Questionnaire. The nine-item Patient Health Questionnaire (PHQ-9) was used to assess the prevalence of depressive symptoms (PHQ-9 ≥ 10 and/or anti-depressant use) and the severity of depressive symptoms (continuous PHQ-9 score). Associations between total, animal, and plant-based protein (quartiles) with depressive symptoms were assessed using multiple logistic and linear regression., Results: Highest intake of total, animal, and plant-based protein was not associated with the prevalence of depressive symptoms, compared to lowest intake (e.g., total protein, ORQ4vsQ1:0.75, 95%CI 0.42;1.32). For the severity of depressive symptoms, highest total protein intake was significantly associated with lower PHQ-9 scores (ORQ4vsQ1:0.87, 95%CI 0.75;1.00), compared to lowest intake. Animal protein was not associated with the severity of depressive symptoms (β ∼ 1), while the association for plant-based protein was marginally non-significant (βQ4vsQ1:0.88, 95%CI 0.76;1.02)., Conclusion: In individuals with T2D, higher total protein intake was associated with reduced severity of depressive symptoms, but not with the prevalence of depressive symptoms. Further prospective research with a larger sample size is needed to confirm these associations., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier Inc.)

Background: Obesity is a key risk factor for major chronic diseases such as type 2 diabetes and cardiovascular diseases. To extensively characterise the obesogenic built environment, we recently developed a novel Obesogenic Built environment CharacterisTics (OBCT) index, consisting of 17 components that capture both food and physical activity (PA) environments., Objectives: We aimed to assess the association between the OBCT index and body mass index (BMI) in a nationwide health monitor. Furthermore, we explored possible ways to improve the index using unsupervised and supervised methods., Methods: The OBCT index was constructed for 12,821 Dutch administrative neighbourhoods and linked to residential addresses of eligible adult participants in the 2016 Public Health Monitor. We split the data randomly into a training (two-thirds; n = 255,187) and a testing subset (one-third; n = 127,428). In the training set, we used non-parametric restricted cubic regression spline to assess index's association with BMI, adjusted for individual demographic characteristics. Effect modification by age, sex, socioeconomic status (SES) and urbanicity was examined. As improvement, we (1) adjusted the food environment for address density, (2) added housing price to the index and (3) adopted three weighting strategies, two methods were supervised by BMI (variable selection and random forest) in the training set. We compared these methods in the testing set by examining their model fit with BMI as outcome., Results: The OBCT index had a significant non-linear association with BMI in a fully-adjusted model (p<0.05), which was modified by age, sex, SES and urbanicity. However, variance in BMI explained by the index was low (<0.05%). Supervised methods increased this explained variance more than non-supervised methods, though overall improvements were limited as highest explained variance remained <0.5%., Discussion: The index, despite its potential to highlight disparity in obesogenic environments, had limited association with BMI. Complex improvements are not necessarily beneficial, and the components should be re-operationalised., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Overweight and obesity impose a considerable individual and social burden, and the urban environments might encompass factors that contribute to obesity. Nevertheless, there is a scarcity of research that takes into account the simultaneous interaction of multiple environmental factors., Objectives: Our objective was to perform an exposome-wide association study of body mass index (BMI) in a multicohort setting of 15 studies., Methods: Studies were affiliated with the Dutch Geoscience and Health Cohort Consortium (GECCO), had different population sizes (688-141,825), and covered the entire Netherlands. Ten studies contained general population samples, others focused on specific populations including people with diabetes or impaired hearing. BMI was calculated from self-reported or measured height and weight. Associations with 69 residential neighborhood environmental factors (air pollution, noise, temperature, neighborhood socioeconomic and demographic factors, food environment, drivability, and walkability) were explored. Random forest (RF) regression addressed potential nonlinear and nonadditive associations. In the absence of formal methods for multimodel inference for RF, a rank aggregation-based meta-analytic strategy was used to summarize the results across the studies., Results: Six exposures were associated with BMI: five indicating neighborhood economic or social environments (average home values, percentage of high-income residents, average income, livability score, share of single residents) and one indicating the physical activity environment (walkability in 5 -km buffer area). Living in high-income neighborhoods and neighborhoods with higher livability scores was associated with lower BMI. Nonlinear associations were observed with neighborhood home values in all studies. Lower neighborhood home values were associated with higher BMI scores but only for values up to € 300,000 . The directions of associations were less consistent for walkability and share of single residents., Discussion: Rank aggregation made it possible to flexibly combine the results from various studies, although between-study heterogeneity could not be estimated quantitatively based on RF models. Neighborhood social, economic, and physical environments had the strongest associations with BMI. https://doi.org/10.1289/EHP13393.

Objectives: Type 2 diabetes mellitus (T2DM) is a chronic disease associated with overweight and obesity. Evidence suggests that 24-hour movement behaviors (24 h-MBs) play a crucial role in cardiometabolic health. However, it is not yet known if 24 h-MBs differ between weight status groups among people with T2DM (PwT2DM) and how 24 h-MBs are associated with their cardiometabolic health., Design: Cross-sectional study., Methods: Cardiometabolic variables (i.e. Body Mass Index (BMI), waist circumference (WC), HbA1c, fasting glucose, triglycerides, total-cholesterol, HDL-cholesterol, LDL-cholesterol, blood pressure) and 24 h-MBs (accelerometry and sleep-diary) of 1001 PwT2DM were collected. Regression models using compositional data analysis explored differences in 24 h-MBs between weight status groups and analyzed associations with cardiometabolic variables., Results: The 24 h-MBs of PwT2DM being obese consisted of less sleep, light physical activity (LPA) and moderate to vigorous physical activity (MVPA) and more sedentary time (ST) per day as compared to PwT2DM being overweight or normal weight (p < 0.001). Regardless of weight status, the largest associations were found when reallocating 20 min a day from ST into MVPA for BMI (-0.32 kg/m 2 ; [-0.55; -0.09], -1.09 %), WC (-1.44 cm, [-2.26; -0.62], -1.35 %) and HDL-cholesterol (0.02 mmol/l, [0.01, 0.02], +1.59 %), as well as from ST into LPA for triglycerides (-0.04 mmol/l, [-0.05; -0.03], -2.3 %). Moreover, these associations were different when stratifying people by short-to-average (7.7 h/night) versus long sleep (9.3 h/night) period., Conclusions: This study highlights the importance of 24 h-MBs in the cardiometabolic health of PwT2DM. Shifting time from ST and/or sleep toward LPA or MVPA might theoretically benefit cardiometabolic health among relatively inactive PwT2DM, irrespective of weight status., Competing Interests: Declaration of interest statement The authors declare that they have no competing interests., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Current evidence on neighborhood walkability and active commuting focuses on residential rather than workplace environment. This cross-sectional study investigated whether higher workplace walkability (WW) was associated with commute walking, both independently and together with residential walkability, using data from 6769 respondents of the 2017 Dutch national travel survey. In a fully adjusted logistic regression model, 10% increase in WW was associated with 32% higher odds of commute walking (Odds ratio (OR): 1.31, 95% Confidence Interval (CI: 1.27-1.36). The estimates were stronger in rural dwellers than urban residents, (OR rural 1.49, 95%CI: 1.34-1.64 vs OR highly . urban 1.19, 95%CI: 1.13-1.26). In participants with both high residential walkability and WW, we observed 215% higher odds (OR 3.15, 95% CI: 2.48-3.99) of commute walking compared to those with low walkability in both. Our study indicated the importance and complementary nature of walkable residence and workplace in contribution to physical activity of working individuals through active commuting., (© 2023 The Authors. Published by Elsevier Ltd.)

A food-abundant environment is associated with unhealthy food intake, but not everyone is affected to the same degree. Mindful eating, which is eating with attention and awareness, has been associated with less external eating and less food cravings, and could act as a protective factor against influences from the food environment. The current study aimed to investigate whether the association between exposure to fast-food around the home and unhealthy food intake was moderated by mindful eating. The study was conducted in 1086 Dutch adults of 55 years and older of the Longitudinal Aging Study Amsterdam study. The mindful eating domains (Mindful Eating Behavior Scale) were tested as moderating variables in the linear regression models with absolute and relative density of fast-food outlets in the neighbourhood (400, 800 and 1600m) as independent variables and unhealthy food intake (snacks (g/d)) and saturated fat as a percentage of total energy intake (en%)) as dependent variable. Bootstrapping with 5000 samples using the pick-a-point approach showed that after adjustments, only two out of 48 interactions terms were statistically significant: Eating with Awareness (EwA) and Eating without Distraction (EwD) moderated the positive association between the relative density of fast-food outlets and saturated fat (en%) respectively in a buffer of 800m (interaction EwA: B = -0.84, 95% CI [-1.46; -0.22]) and in a buffer of 1600m (interaction EwD: B = -0.82, 95% CI [-1.61; -0.04]). The results of the current study indicate that mindful eating cannot buffer against the influence of the fast-food abundant environment on unhealthy food intake. Future research is needed to confirm these findings, for example in younger populations., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: Car dependency contributes to physical inactivity and, consequently, may increase the likelihood of diabetes. We investigated whether neighborhoods that are highly conducive to driving confer a greater risk of developing diabetes and, if so, whether this differs by age., Research Design and Methods: We used administrative health care data to identify all working-age Canadian adults (20-64 years) who were living in Toronto on 1 April 2011 without diabetes (type 1 or 2). Neighborhood drivability scores were assigned using a novel, validated index that predicts driving patterns based on built environment features divided into quintiles. Cox regression was used to examine the association between neighborhood drivability and 7-year risk of diabetes onset, overall and by age-group, adjusting for baseline characteristics and comorbidities., Results: Overall, there were 1,473,994 adults in the cohort (mean age 40.9 ± 12.2 years), among whom 77,835 developed diabetes during follow-up. Those living in the most drivable neighborhoods (quintile 5) had a 41% higher risk of developing diabetes compared with those in the least drivable neighborhoods (adjusted hazard ratio 1.41, 95% CI 1.37-1.44), with the strongest associations in younger adults aged 20-34 years (1.57, 95% CI 1.47-1.68, P < 0.001 for interaction). The same comparison in older adults (55-64 years) yielded smaller differences (1.31, 95% CI 1.26-1.36). Associations appeared to be strongest in middle-income neighborhoods for younger residents (middle income 1.96, 95% CI 1.64-2.33) and older residents (1.46, 95% CI 1.32-1.62)., Conclusions: High neighborhood drivability is a risk factor for diabetes, particularly in younger adults. This finding has important implications for future urban design policies., (© 2023 by the American Diabetes Association.)

Objective: Social jet lag, i.e., the discordance among social and biological rhythms, is associated with poor metabolic control. This study aimed to assess cross-sectional and longitudinal associations among social jet lag and glycemic and metabolic control in people with type 2 diabetes., Methods: In a prospective cohort (N = 990) with type 2 diabetes, social jet lag was measured at baseline using daily diaries and was categorized (high, moderate, or low). Metabolic outcomes were assessed at baseline and at 1 and 2 years of follow-up. Associations among social jet lag and glycemic and metabolic control were analyzed using linear regression and linear mixed models adjusted for confounding factors. Analyses were stratified for work status (retired vs. working; p value for interaction = 0.007 for glycated hemoglobin [HbA1c])., Results: In working people, a cross-sectional association between high social jet lag and HbA1c (1.87 mmol/mol [95% CI: 0.75 to 2.99]) and blood pressure (5.81 mm Hg [95% CI: 4.04 to 7.59]) was observed. For retired people, high social jet lag was negatively associated with HbA1c (-1.58 mmol/mol [95% CI: -2.54 to -0.62]), glucose (-0.19 mmoL/L [95% CI:-0.36 to -0.01]), and blood pressure (-3.70 mm Hg [95% CI: -5.36 to -2.04]), and the association with BMI was positive (1.12 kg/m 2 [95% CI: 0.74 to 1.51]). Prospective associations had the same direction as cross-sectional findings but were nonsignificant for working or retired people., Conclusions: Social jet lag was cross-sectionally, but not prospectively, associated with glycemic and metabolic markers. Interaction with work status was present, and directions of the associations were generally detrimental in the working population, whereas higher social jet lag was associated with improved glycemic and metabolic control for retired people., (© 2023 The Authors. Obesity published by Wiley Periodicals LLC on behalf of The Obesity Society.)

Study Objectives: We investigated the prevalence of self-reported insomnia symptoms in people with type 2 diabetes and assessed the association with metabolic outcomes and the mediating role of lifestyle factors., Methods: In a prospective cohort of 1,272 participants with type 2 diabetes (63.4% male, age 68.7 ± 9 years) we measured insomnia symptoms using the Insomnia Severity Index and metabolic outcomes as hemoglobin A1c, glucose, lipids, and body mass index at baseline and at 1 year follow-up. Linear regression analyses assessed the association between insomnia symptoms and metabolic outcomes, corrected for demographic factors, comorbidities, and body mass index. Mediation analyses were conducted for lifestyle factors., Results: The prevalence of mild and severe insomnia symptoms was 23.0% and 10.7%, respectively. When adjusted for demographic factors and comorbidities, cross-sectionally severe insomnia symptoms were associated with higher body mass index (β = 0.97 kg/m 2 ; 95% confidence interval 0.04: 1.89) compared to no insomnia symptoms. Cross-sectionally, no associations were observed for the other metabolic outcomes. Additionally, no prospective associations were observed with any of the outcomes. Finally, physical activity mediated the association between severe insomnia symptoms and body mass index by 29.3%., Conclusions: About a third of people with type 2 diabetes experience self-reported insomnia symptoms, but insomnia symptoms were not associated with metabolic outcomes in people with type 2 diabetes., Citation: Groeneveld L, den Braver NR, Beulens JWJ, et al. The prevalence of self-reported insomnia symptoms and association with metabolic outcomes in people with type 2 diabetes: the Hoorn Diabetes Care System cohort. J Clin Sleep Med . 2023;19(3):539-548., (© 2023 American Academy of Sleep Medicine.)

Objective: Environmental factors that drive obesity are often studied individually, whereas obesogenic environments are likely to consist of multiple factors from food and physical activity (PA) environments. This study aimed to compose and describe a comprehensive, theory-based, expert-informed index to quantify obesogenicity for all neighborhoods in the Netherlands., Methods: The Obesogenic Built Environment CharacterisTics (OBCT) index consists of 17 components. The index was calculated as an average of componential scores across both food and PA environments and was scaled from 0 to 100. The index was visualized and summarized with sensitivity analysis for weighting methods., Results: The OBCT index for all 12,821 neighborhoods was right-skewed, with a median of 44.6 (IQR = 10.1). Obesogenicity was lower in more urbanized neighborhoods except for the extremely urbanized neighborhoods (>2500 addresses/km 2 ), where obesogenicity was highest. The overall OBCT index score was moderately correlated with the food environment (Spearman ρ = 0.55, p <0.05) and with the PA environment (ρ = 0.38, p <0.05). Hierarchical weighting increased index correlations with the PA environment but decreased correlations with the food environment., Conclusions: The novel OBCT index and its comprehensive environmental scores are potentially useful tools to quantify obesogenicity of neighborhoods., (© 2022 The Authors. Obesity published by Wiley Periodicals LLC on behalf of The Obesity Society.)

Background: This review of reviews aimed to: (1) summarize the evidence from published reviews on the effectiveness of mass-media campaigns to promote physical activity (PA) or PA-related determinants (intermediate psychological and proximal outcomes) and (2) to identify policy-relevant recommendations related to successful PA campaigns., Methods: An extensive literature search was performed on 1 March 2021. Reviews that evaluated the impact of campaigns on distal (e.g. PA) and/or proximal outcomes of PA (awareness, knowledge, etc.) and that targeted the general population or subsets were included. Quality of reviews was assessed using the AMSTAR-2 tool. Policy-relevant recommendations were systematically derived and synthesized and formulated as good practice statements. A protocol was registered beforehand (ID: CRD42021249184)., Results: A total of 1915 studies were identified, of which 22 reviews were included. The most consistent evidence was found for the effectiveness of mass-media campaigns on proximal outcomes, while the evidence for distal outcomes was mixed. Good practice statements were derived: (1) to achieve behaviour change, mass-media is an important component of larger, multilevel and multicomponent strategies; (2) mass-media strategies should be coordinated and aligned at local- and national-level and be sustained, monitored and resourced at these levels and (3) media should be tailored to reduce socioeconomic inequalities., Conclusions: Mass-media can play an important role in the promotion of PA. In general, evidence was more inconsistent for effectiveness on distal outcomes than for proximal outcomes. Policy-relevant recommendations include that mass-media strategies should be resourced, coordinated, aligned, sustained, monitored and evaluated on the local and national level., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Public Health Association.)

Background: A multifaceted response, including government action, is essential to improve population levels of physical activity (PA). This article describes the development process of the 'Physical Activity Environment Policy Index' (PA-EPI) monitoring framework, a tool to assess government policies and actions for creating a healthy PA environment., Methods: An iterative process was undertaken. This involved a review of policy documents from authoritative organizations, a PA policy audit of four European countries, and a systematic review of scientific literature. This was followed by an online consultation with academic experts (N = 101; 20 countries, 72% response rate), and policymakers (N = 40, 4 EU countries). During this process, consensus workshops were conducted, where quantitative and qualitative data, alongside theoretical and pragmatic considerations, were used to inform PA-EPI development., Results: The PA-EPI is conceptualized as a two-component 'policy' and 'infrastructure support' framework. The two-components comprise eight policy and seven infrastructure support domains. The policy domains are education, transport, urban design, healthcare, public education (including mass media), sport-for-all, workplaces and community. The infrastructure support domains are leadership, governance, monitoring and intelligence, funding and resources, platforms for interaction, workforce development and health-in-all-policies. Forty-five 'good practice statements' or indicators of ideal good practice within each domain conclude the PA-EPI. A potential eight-step process for conducting the PA-EPI is described., Conclusions: Once pre-tested and piloted in several countries of various sizes and income levels, the PA-EPI good practice statements will evolve into benchmarks established by governments at the forefront of creating and implementing policies to address inactivity., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Public Health Association.)

Purpose: This review presents a general overview of the state of evidence on the relationships between neighborhood built environments and cardiovascular health outcomes among adults. We also summarize relevant literature on the associations of built environments with active living behaviors (physical activity [PA] and sedentary behavior), as they are considered as key behavioral pathways., Review Methods: We identified recently published systematic reviews assessing associations of built environment attributes with cardiovascular health outcomes or active living behaviors. We summarized findings of the key systematic reviews and presented findings of pertinent empirical studies, where appropriate., Summary: Increasing evidence suggests that living in a place supportive of engaging in PA for transportation (eg, walkability features) and recreation (eg, parks) can be protective against cardiovascular disease (CVD) risk. Places conducive to higher levels of sedentary travel (ie, prolonged sitting in cars) may have adverse effects on cardiovascular health. The built environment of where people live can affect how active they are and subsequently their cardiovascular health. Clinical professionals are encouraged to consider the built environment features of where their patients live in counseling, as this may assist them to understand potential opportunities or barriers to active living and to propose a suitable CVD prevention strategy., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: We aimed to study the mediating role of diet quality, physical activity, smoking, and alcohol intake in the association of stressful life events with visceral obesity over a seven-year period and assessed effect modification by sex and SES., Methods: In total, 2416 participants with a mean age of 56.1 (±7.3) years, of which 51.4% were women, and 12.5% had a lower educational level from the Hoorn studies were followed for seven years. Stress was measured with a 'Serious Life Events' questionnaire, which was summed into a total score (range zero to ten events) and stratified to account for nonlinearity. Changes in visceral obesity were assessed by changes in BMI (kg/m 2 ) and waist circumference (cm) in seven years. We used the product of coefficient approach to assess mediation of the following lifestyle factors: diet, physical activity, smoking, and alcohol intake. We analyzed associations between stressful life events and change in BMI and waist circumference with linear regression models., Results: Within the low education group, we observed a significant association between ≥3 stressful life events and a change in BMI (0.60 kg/m 2 (CI: 0.05, 1.14)) and waist circumference (2.23 cm (CI: 0.19, 4.48)), compared to experiencing no events. For both BMI and waist circumference, no significant associations were observed when experiencing 1 or 2 events. In the moderate to high education group, we observed only statistically significant associations for waist circumference when experiencing ≥3 stressful life events (0.86 cm (CI: 0.05, 1.41)) and not for the other event groups. Our mediation analyses showed that the proportion mediated by smoking was 13.2%, while the other lifestyle factors showed no mediating effect., Conclusions: Multiple stressful life events are associated with an increase in waist circumference and BMI in those with lower education. Smoking might play a mediating role in this association., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

Purpose: To investigate whether adherence to the Dutch Healthy Diet index 2015 (DHD15-index) is associated with change in glycemic control and cardio-metabolic markers over two-year follow-up in people with type 2 diabetes (T2D)., Methods: This prospective cohort study included 1202 individuals with T2D (mean age 68.7 ± 9.0 years; 62.5% male; mean HbA1c 53.8 ± 11.7 mmol/mol) from the Diabetes Care System cohort. Baseline dietary intake was assessed using a validated food frequency questionnaire, and adherence to the DHD15-index was estimated (range 0-130). HbA1c, fasting glucose, blood lipids (HDL and LDL cholesterol, cholesterol ratio), blood pressure, estimated glomerular filtration rate (eGFR), and BMI were measured at baseline, and after one- and two-year follow-up. Linear mixed model analyses were conducted to examine the associations between adherence to the DHD15-index and glycemic control and the cardio-metabolic outcomes, adjusting for energy intake, sociodemographic and lifestyle characteristics, and medication., Results: Highest adherence (T3) to the DHD15-index was not associated with change in HbA1c, compared to lowest adherence (T1) [β T3vsT1 : 0.62 mmol/mol (- 0.94; 2.19), P trend  = 0.44]. There was a non-linear association with fasting glucose, where moderate adherence (T2) was associated with a decrease in fasting glucose [β T2vsT1 : - 0.29 mmol/L (- 0.55; - 0.03), P trend  = 0.30]. Higher adherence to the DHD15-index was associated with a decrease in BMI [β 10point : - 0.41 kg/m 2 (- 0.60; - 0.21), P trend  < 0.001], but not with blood lipids, blood pressure or kidney function., Conclusion: In this well-controlled population of people with T2D, adherence to the DHD15-index was associated with a decrease in BMI, but not with change in glycemic control or other cardio-metabolic parameters., (© 2022. The Author(s).)

Insufficient physical activity (PA) is one of major risk factors for serious diseases and premature mortality worldwide. Public policies to enhance PA across society are recognized as an effective tool against the problem. This paper presents the results of a comprehensive assessment of national-level PA policy approach in Poland. A standardized survey of Word Health Organization named the Health-Enhancing Physical Activity Policy Audit Tool (HEPA PAT) was used for data collection. Content analysis and strengths, weaknesses, opportunities, and threats analysis (SWOT) were used to characterize various PA policy aspects, to appraise the current situation, and accommodate organizational and environmental factors that it is influenced by. The results show that the national PA policy approach has been constantly developing in Poland, but there is room for improvement in a number of areas. The most important weaknesses are the lack of clear leadership, no mechanisms in place to coordinate efforts undertaken at different levels, and lack of collaboration across different levels of government and across different sectors of economy. Providing an umbrella covering all PA promotion policies and activities is, therefore, a key issue to be addressed. The country should seize the opportunity coming from an increasing awareness of a healthy lifestyle among Polish society.

Background: Walkability indices have been developed and linked to behavioural and health outcomes elsewhere in the world, but not comprehensively for Europe. We aimed to 1) develop a theory-based and evidence-informed Dutch walkability index, 2) examine its cross-sectional associations with total and purpose-specific walking behaviours of adults across socioeconomic (SES) and urbanisation strata, 3) explore which walkability components drive these associations., Methods: Components of the index included: population density, retail and service density, land use mix, street connectivity, green space, sidewalk density and public transport density. Each of the seven components was calculated for three Euclidean buffers: 150 m, 500 m and 1000 m around every 6-digit postal code location and for every administrative neighbourhood in GIS. Componential z-scores were averaged, and final indices normalized between 0 and 100. Data on self-reported demographic characteristics and walking behaviours of 16,055 adult respondents (aged 18-65) were extracted from the Dutch National Travel Survey 2017. Using Tobit regression modelling adjusted for individual- and household-level confounders, we assessed the associations between walkability and minutes walking in total, for non-discretionary and discretionary purposes. By assessing the attenuation in associations between partial indices and walking outcomes, we identified which of the seven components drive these associations. We also tested for effect modification by urbanization degree, SES, age and sex., Results: In fully adjusted models, a 10% increase in walkability was associated with a maximum increase of 8.5 min of total walking per day (95%CI: 7.1-9.9). This association was consistent across buffer sizes and purposes of walking. Public transport density was driving the index's association with walking outcomes. Stratified results showed that associations with minutes of non-discretionary walking were stronger in rural compared to very urban areas, in neighbourhoods with low SES compared to high SES, and in middle-aged (36-49 years) compared to young (18-35 years old) and older adults (50-65 years old)., Conclusions: The walkability index was cross-sectionally associated with Dutch adult's walking behaviours, indicating its validity for further use in research., (© 2022. The Author(s).)

Background: Car driving is a form of passive transport that is associated with an increase in physical inactivity, obesity, air pollution and noise. Built environment characteristics may influence transport mode choice, but comprehensive indices for built environment characteristics that drive car use are still lacking, while such an index could provide tangible policy entry points., Objective: We developed and validated a neighbourhood drivability index, capturing combined dimensions of the neighbourhood environment in the City of Toronto, and investigated its association with transportation choices (car, public transit or active transport), overall, by trip length, and combined for residential neighbourhood and workplace drivability., Methods: We used exploratory factor analysis to derive distinct factors (clusters of one or more environmental characteristics) that reflect the degree of car dependency in each neighbourhood, drawing from candidate variables that capture density, diversity, design, destination accessibility, distance to transit, and demand management. Area-level factor scores were then combined into a single composite score, reflecting neighbourhood drivability. Negative binomial generalized estimating equations were used to test the association between driveability quintiles (Q) and primary travel mode (>50% of trips by car, public transit, or walking/cycling) in a population-based sample of 63,766 Toronto residents enrolled in the Transportation Tomorrow Survey (TTS) wave 2016, adjusting for individual and household characteristics, and accounting for clustering of respondents within households., Results: The drivability index consisted of three factors: Urban sprawl, pedestrian facilities and parking availability. Relative to those living in the least drivable neighbourhoods (Q1), those in high drivability areas (Q5) had a significantly higher rate of car travel (adjusted Risk Ratio (RR): 1.80, 95%CI: 1.77-1.88), and lower rate of public transit use (RR: 0.90, 95%CI: 0.85-0.94) and walking/cycling (RR: 0.22, 95%CI: 0.19-0.25). Associations were strongest for short trips (<3 km) (RR: 2.72, 95%CI: 2.48-2.92), and in analyses where both residential and workplace drivability was considered (RR for car use in high/high vs. low/low residential/workplace drivability: 2.18, 95%CI: 2.08-2.29)., Conclusion: This novel neighbourhood drivability index predicted whether local residents drive or use active modes of transportation and can be used to investigate the association between drivability, physical activity, and chronic disease risk., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: Our aim was to investigate prospective associations of consumption of total dairy and dairy types with incident prediabetes in a Dutch population-based study., Methods: Two enrolment waves of the Hoorn Studies were harmonized, resulting in an analytic sample of 2262 participants without (pre-) diabetes at enrolment (mean age 56 ± 7.3 years; 50% male). Baseline dietary intake was assessed by validated food frequency questionnaires. Relative risks (RRs) were calculated between dairy, fermented dairy, milk, yogurt (all total/high/low fat), cream and ice cream and prediabetes. Additionally, substituting one serving/day of dairy types associated with prediabetes with alternative dairy types was analysed., Results: During a mean 6.4 ± 0.7 years of follow-up, 810 participants (35.9%) developed prediabetes. High fat fermented dairy, cheese and high fat cheese were associated with a 17% (RR 0.83, 95% CI 0.69-0.99, p trend  = 0.04), 14% (RR 0.86, 95% CI 0.73-1.02, p trend  = 0.04) and 21% (RR 0.79, 95% CI 0.66-0.94, p trend  = 0.01) lower risk of incident prediabetes, respectively, in top compared to bottom quartiles, after adjustment for confounders. High fat cheese consumption was continuously associated with lower prediabetes risk (RR servings/day 0.94, 95% CI 0.88-1.00, p = 0.04). Total dairy and other dairy types were not associated with prediabetes risk in adjusted models, irrespective of fat content (RR ~ 1). Replacing high fat cheese with alternative dairy types was not associated with prediabetes risk., Conclusion: The highest intake of high fat fermented dairy, cheese and high fat cheese were associated with a lower risk of prediabetes, whereas other dairy types were not associated. Cheese seems to be inversely associated with type 2 diabetes risk, despite high levels of saturated fatty acids and sodium., (© 2021. The Author(s).)

Type 2 diabetes is one of the major chronic diseases accounting for a substantial proportion of disease burden in Western countries. The majority of the burden of type 2 diabetes is attributed to environmental risks and modifiable risk factors such as lifestyle. The environment we live in, and changes to it, can thus contribute substantially to the prevention of type 2 diabetes at a population level. The 'exposome' represents the (measurable) totality of environmental, i.e. nongenetic, drivers of health and disease. The external exposome comprises aspects of the built environment, the social environment, the physico-chemical environment and the lifestyle/food environment. The internal exposome comprises measurements at the epigenetic, transcript, proteome, microbiome or metabolome level to study either the exposures directly, the imprints these exposures leave in the biological system, the potential of the body to combat environmental insults and/or the biology itself. In this review, we describe the evidence for environmental risk factors of type 2 diabetes, focusing on both the general external exposome and imprints of this on the internal exposome. Studies provided established associations of air pollution, residential noise and area-level socioeconomic deprivation with an increased risk of type 2 diabetes, while neighbourhood walkability and green space are consistently associated with a reduced risk of type 2 diabetes. There is little or inconsistent evidence on the contribution of the food environment, other aspects of the social environment and outdoor temperature. These environmental factors are thought to affect type 2 diabetes risk mainly through mechanisms incorporating lifestyle factors such as physical activity or diet, the microbiome, inflammation or chronic stress. To further assess causality of these associations, future studies should focus on investigating the longitudinal effects of our environment (and changes to it) in relation to type 2 diabetes risk and whether these associations are explained by these proposed mechanisms., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: In this study, we investigated the association between adherence to the Dutch Healthy Diet index 2015 (DHD15-index) and incidence of prediabetes (preT2D) and Type 2 Diabetes (T2D) in a representative sample for the general Dutch population., Methods: Two prospective cohort studies, The Hoorn and The New Hoorn Study, were used for data analyses. In total, data from 2951 participants without diabetes at baseline (mean age 56.5 ± 7.5 years; 49.6% male) were harmonized. Baseline dietary intake was assessed with validated Food Frequency Questionnaires and adherence to the DHD15-index was calculated (range 0-130). PreT2D and T2D were classified according to the WHO criteria 2011. Poisson regression was used to estimate prevalence ratios between participant scores on the DHD15-index and preT2D and T2D, adjusted for follow-up duration, energy intake, socio-demographic, and lifestyle factors. Change in fasting plasma glucose levels (mmol/L) over follow-up was analysed using linear regression analyses, additionally adjusted for baseline value., Results: During a mean follow-up of 6.3 ± 0.7 years, 837 participants developed preT2D and 321 participants developed T2D. The highest adherence to the DHD15-index was significantly associated with lower T2D incidence [model 3, PR T3vsT1 : 0.70 (0.53; 0.92), p trend  = 0.01]. The highest adherence to the DHD15-index pointed towards a lower incidence of preT2D [PR T3vsT1 : 0.87 (0.74; 1.03), p trend  = 0.11]. Higher adherence to the DHD15-index was not associated with change in fasting plasma glucose levels [β 10point : - 0.012 (- 0.034; 0.009)mmol/L]., Conclusion: The present study showed that the highest compared to the lowest adherence to the DHD15-index was associated with a lower T2D incidence, and pointed towards a lower incidence of preT2D. These results support the benefits of adhering to the guidelines in T2D prevention.

Aim: To investigate the relative contribution of phenotypic and lifestyle factors to HbA1c, independent of fasting plasma glucose (FPG) and 2h post-load glucose (2hPG), in the general population., Methods: The study populations included 2309 participants without known diabetes from the first wave of the Hoorn Study (1989) and 2619 from the second wave (2006). Multivariate linear regression models were used to analyze the relationship between potential determinants and HbA1c in addition to FPG and 2hPG. The multivariate model was derived in the first wave of the Hoorn Study, and replicated in the second wave., Results: In both cohorts, independent of FPG and 2hPG, higher age, female sex, larger waist circumference, and smoking were associated with a higher HbA1c level. Larger hip circumference, higher BMI, higher alcohol consumption and vitamin C intake were associated with a lower HbA1c level. FPG and 2hPG together explained 41.0% (first wave) and 53.0% (second wave) of the total variance in HbA1c. The combination of phenotypic and lifestyle determinants additionally explained 5.7% (first wave) and 3.9% (second wave)., Conclusions: This study suggests that, independent of glucose, phenotypic and lifestyle factors are associated with HbA1c, but the contribution is relatively small. These findings contribute to a better understanding of the low correlation between glucose levels and HbA1c in the general population., Competing Interests: The authors have read the journal’s policy and have the following competing interests: At the time this article was written, MA was a paid employee of Unilever, which manufactures and sells consumer food products. This does not alter our adherence to PLOS ONE policies on sharing data and materials. There are no patents, products in development or marketed products associated with this research to declare. All other authors declare that they have no potential conflict of interests relevant to this article.

Background: Obesogenic food environments may influence dietary behaviours and contribute to obesity. Few countries quantified changes in their foodscape. We explored how the availability of different types of food retailers has changed in the Netherlands across levels of neighbourhood socioeconomic status (SES) and urbanisation., Methods: This longitudinal ecological study conducted in the Netherlands had as unit of analysis administrative neighbourhoods. From 2004 to 2018, the geographic location and type of each food retailer were objectively assessed by a commercial company. Food retailers were categorised as local food shops, fast food restaurants, food delivery, restaurants, supermarkets, and convenience stores. Information on neighbourhood SES and urbanisation was obtained from Central Bureau of Statistics (CBS). To test the change in the counts of food retailers we used negative binomial generalized estimating equations (GEE), with neighbourhoods as the group variable, time as the independent variable and the counts of each type of food retailer as outcome. To account for changes in population density, analyses were adjusted for the number of inhabitants per neighbourhood. We tested effect modification by adding an interaction term for neighbourhood SES and urbanisation to the models., Results: In Dutch neighbourhoods between 2004 and 2018, a 120 and 35% increase was found in the count of food delivery outlets and restaurants, respectively, and a 24% decrease in count of local food shops. Stratified analyses showed an increase in the availability of supermarkets and convenience stores in the more urbanised and lower SES neighbourhoods, while a decrease was observed in the less urbanised and higher SES neighbourhoods., Conclusions: We observed considerable changes in the Dutch foodscape. Over a 14 years period, the foodscape changed towards a higher availability of food retailers offering convenience and ready-to-eat foods. These findings can help policy makers aiming to promote a healthier food environment and obesity prevention.

Background: Car driving is a form of passive transportation associated with higher sedentary behaviour, which is associated with morbidity. The decision to drive a car is likely to be influenced by the 'drivability' of the built environment, but there is lack of scientific evidence regarding the relative contribution of environmental characteristics of car driving in Europe, compared to individual characteristics. This study aimed to determine which neighbourhood- and individual-level characteristics were associated with car driving in adults of five urban areas across Europe. Second, the study aimed to determine the percentage of variance in car driving explained by individual- and neighbourhood-level characteristics., Methods: Neighbourhood environment characteristics potentially related to car use were identified from the literature. These characteristics were subsequently assessed using a Google Street View audit and available GIS databases, in 59 administrative residential neighbourhoods in five European urban areas. Car driving (min/week) and individual level characteristics were self-reported by study participants (analytic sample n = 4258). We used linear multilevel regression analyses to assess cross-sectional associations of individual and neighbourhood-level characteristics with weekly minutes of car driving, and assessed explained variance at each level and for the total model., Results: Higher residential density (β:-2.61, 95%CI: - 4.99; -0.22) and higher land-use mix (β:-3.73, 95%CI: - 5.61; -1.86) were significantly associated with fewer weekly minutes of car driving. At the individual level, higher age (β: 1.47, 95%CI: 0.60; 2.33), male sex (β: 43.2, 95%CI:24.7; 61.7), being employed (β:80.1, 95%CI: 53.6; 106.5) and ≥ 3 person household composition (β: 47.4, 95%CI: 20.6; 74.2) were associated with higher weekly minutes of car driving. Individual and neighbourhood characteristics contributed about equally to explained variance in minutes of weekly car driving, with 2 and 3% respectively, but total explained variance remained low., Conclusions: Residential density and land-use mix were neighbourhood characteristics consistently associated with minutes of weekly car driving, besides age, sex, employment and household composition. Although total explained variance was low, both individual- and neighbourhood-level characteristics were similarly important in their associations with car use in five European urban areas. This study suggests that more, higher quality, and longitudinal data are needed to increase our understanding of car use and its effects on determinants of health.

Background: In low and middle-income countries (LMIC), the total and LDL cholesterol and triglyceride levels of residents of urban areas are reported to be higher than those of rural areas. This may be due to differences in lifestyle behaviors between residents of urban areas and rural areas in LMIC. In this study, our aims were to (1) examine whether or not LDL cholesterol, total/HDL ratios and triglyceride levels of individuals in densely populated areas are higher than those of individuals living in less-densely populated areas in a high-income country (HIC) and (2) investigate the potential mediating roles of physical activity and sedentary behavior., Methods: We used cross-sectional data from 2547 Dutch blood donors that participated in Donor InSight-III. Linear regression was used to analyze the association between population density and LDL cholesterol, total/HDL cholesterol ratio and HDL cholesterol. The mediating roles of moderate-to-vigorous physical activity (MVPA) and sedentary behavior were investigated in a subsample (n = 740) for which objectively measured MVPA/sedentary behavior data was available. Multiple mediation with linear regression analyses were performed and the product-of-coefficients method was used to calculate direct and indirect effects., Results: Mean LDL cholesterol and median total cholesterol/HDL cholesterol ratio and triglyceride levels were 2.89, 3.43 and 1.29 mmol/L, respectively. Population density was not associated with LDL cholesterol [β 0.00 (- 0.01; 0.01)], log transformed total/HDL cholesterol ratio [β 1.00 (1.00; 1.00)] and triglyceride levels [β 1.00 (0.99; 1.00)]. No statistically significant direct or indirect effects were found., Conclusion: Contrary to previous findings in LMIC, no evidence was found that population density is associated with blood lipid levels in blood donors in the Netherlands or that MVPA and sedentary behavior mediate this association. This may be the result of socioeconomic differences and, in part, may be due to the good health of the study population and the relatively high population density in the Netherlands. Also, compared to LMIC, differences in physical activity levels in more versus less populated areas may be less pronounced in HIC.

Diabetes risk factors outside the individual are receiving increasing attention. In this issue of Diabetologia, Nielsen et al (DOI: https://doi.org/10.1007/s00125-018-4587-1 ) demonstrate that an individual's obesity level is associated with incident type 2 diabetes in their spouse. This is in line with studies providing evidence for spousal and peer similarities in lifestyle behaviours and obesity. Non-random mating and convergence over time are two explanations for this phenomenon, but shared exposure to more upstream drivers of diabetes may also play a role. From a systems-science perspective, these mechanisms are likely to occur simultaneously and interactively as part of a complex system. In this commentary, we provide an overview of the wider system-level factors that contribute to type 2 diabetes.

Background: The built environment influences behaviour, like physical activity, diet and sleep, which affects the risk of type 2 diabetes mellitus (T2DM). This study systematically reviewed and meta-analysed evidence on the association between built environmental characteristics related to lifestyle behaviour and T2DM risk/prevalence, worldwide., Methods: We systematically searched PubMed, EMBASE.com and Web of Science from their inception to 6 June 2017. Studies were included with adult populations (>18 years), T2DM or glycaemic markers as outcomes, and physical activity and/or food environment and/or residential noise as independent variables. We excluded studies of specific subsamples of the population, that focused on built environmental characteristics that directly affect the cardiovascular system, that performed prediction analyses and that do not report original research. Data appraisal and extraction were based on published reports (PROSPERO-ID: CRD42016035663)., Results: From 11,279 studies, 109 were eligible and 40 were meta-analysed. Living in an urban residence was associated with higher T2DM risk/prevalence (n = 19, odds ratio (OR) = 1.40; 95% CI, 1.2-1.6; I 2  = 83%) compared to living in a rural residence. Higher neighbourhood walkability was associated with lower T2DM risk/prevalence (n = 8, OR = 0.79; 95% CI, 0.7-0.9; I 2  = 92%) and more green space tended to be associated with lower T2DM risk/prevalence (n = 6, OR = 0.90; 95% CI, 0.8-1.0; I 2  = 95%). No convincing evidence was found of an association between food environment with T2DM risk/prevalence., Conclusions: An important strength of the study was the comprehensive overview of the literature, but our study was limited by the conclusion of mainly cross-sectional studies. In addition to other positive consequences of walkability and access to green space, these environmental characteristics may also contribute to T2DM prevention. These results may be relevant for infrastructure planning.

Background & Aims: Vitamin K has been associated with various health outcomes, including non-fatal cardiovascular diseases (CVD) and cancer. However, little is known about the association between vitamin K intake and all-cause and cause specific mortality. This study aims to investigate the association between vitamin K intake and all-cause and cause-specific mortality., Methods: This prospective cohort study included 33,289 participants from the EPIC-NL cohort, aged 20-70 years at baseline and recruited between 1993 and 1997. Dietary intake was assessed at baseline with a validated food frequency questionnaire and intakes of phylloquinone, and total, short chain and long chain menaquinones were calculated. Information on vital status and causes of death was obtained through linkage to several registries. The association between the different forms of vitamin K intake and mortality was assessed with Cox proportional hazards, adjusted for risk factors for chronic diseases and nutrient intake., Results: During a mean follow-up of 16.8 years, 2863 deaths occurred, including 625 from CVD (256 from coronary heart disease (CHD)), 1346 from cancer and 892 from other causes. After multivariable adjustment, phylloquinone and menaquinones were not associated with all-cause mortality with hazard ratios for the upper vs. the lowest quartile of intake of 1.04 (0.92;1.17) and 0.94 (0.82;1.07) respectively. Neither phylloquinone intake nor menaquinone intake was associated with risk of CVD mortality. Higher intake of long chain menaquinones was borderline significantly associated (p trend  = 0.06) with lower CHD mortality with a HR 10μg of 0.86 (0.74;1.00). None of the forms of vitamin K intake were associated with cancer mortality or mortality from other causes., Conclusions: Vitamin K intake was not associated with all-cause mortality, cancer mortality and mortality from other causes., (Copyright © 2016. Published by Elsevier Ltd.)

Background: Although there are many effective lifestyle interventions for type 2 diabetes (T2DM) prevention, insight into effective intervention pathways, especially of long-term interventions, is often lacking. This study aims to provide insight into the effective intervention pathways of the SLIMMER diabetes prevention intervention using mediation analyses., Methods: In total, 240 participants at increased risk of T2DM were included in the analyses over 18 months. The intervention was a combined lifestyle intervention with a dietary and a physical activity (PA) component. The primary and secondary outcomes were change in fasting insulin (pmol/L) and change in body weight (kg) after 18 months, respectively. Firstly, in a multiple mediator model, we investigated whether significant changes in these outcomes were mediated by changes in dietary and PA behavior. Secondly, in multiple single mediator models, we investigated whether changes in dietary and PA behavior were mediated by changes in behavioral determinants and the participants' psychological profile. The mediation analyses used linear regression models, where significance of indirect effects was calculated with bootstrapping., Results: The effect of the intervention on decreased fasting insulin was 40% mediated by change in dietary and PA behavior, where dietary behavior was an independent mediator of the association (34%). The effect of the intervention on decreased body weight was 20% mediated by change in dietary and PA behavior, where PA behavior was an independent mediator (17%). The intervention significantly changed intake of fruit, fat from bread spread, and fiber from bread. Change in fruit intake was mediated by change in action control (combination of consciousness, self-control, and effort), motivation, self-efficacy, intention, and skills. Change in fat intake was mediated by change in action control and psychological profile. No mediators could be identified for change in fiber intake. The change in PA behavior was mediated by change in action control, motivation, and psychological profile., Conclusion: The effect of the SLIMMER intervention on fasting insulin and body weight was mediated by changes in dietary and PA behavior, in distinct ways. These results indicate that changing dietary as well as PA behavior is important in T2DM prevention.

Purpose: Low muscle mass is present in approximately 40% of patients with metastatic colorectal cancer (mCRC) and may be associated with poor outcome. We studied change in skeletal muscle during palliative chemotherapy in patients with mCRC and its association with treatment modifications and overall survival., Patients and Methods: In 67 patients with mCRC (mean age ± standard deviation, 66.4 ± 10.6 years; 63% male), muscle area (square centimeters) was assessed using computed tomography scans of the third lumbar vertebra before and during palliative chemotherapy. Treatment modifications resulting from toxicity were evaluated, including delay, dose reduction, or termination of chemotherapy. Multiple regression analyses were performed for the association between change in muscle area and treatment modification and secondly overall survival., Results: Muscle area of patients with mCRC decreased significantly during 3 months of chemotherapy by 6.1% (95% CI, -8.4 to -3.8; P < .001). Change in muscle area was not associated with treatment modifications. However, patients with muscle loss during treatment of 9% or more (lowest tertile) had significantly lower survival rates than patients with muscle loss of less than 9% (at 6 months, 33% v 69% of patients alive; at 1 year, 17% v 49% of patients alive; log-rank P = .001). Muscle loss of 9% or more remained independently associated with survival when adjusted for sex, age, baseline lactate dehydrogenase concentration, comorbidity, mono-organ or multiorgan metastases, treatment line, and tumor progression at first evaluation by computed tomography scan (hazard ratio, 4.47; 95% CI, 2.21 to 9.05; P < .001)., Conclusion: Muscle area decreased significantly during chemotherapy and was independently associated with survival in patients with mCRC. Further clinical evaluation is required to determine whether nutritional interventions and exercise training may preserve muscle area and thereby improve outcome., (© 2016 by American Society of Clinical Oncology.)