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A dietary pattern can be defined as the quantities, proportions, variety, or combination of foods and drinks typically consumed. The dietary pattern approach aims to place emphasis on the total diet as a long-term health determinant, instead of focussing on separate foods and nutrients, which may interact or confound each other. This scoping review describes the totality of evidence for the role of dietary patterns for health-related outcomes as a basis for setting and updating food-based dietary guidelines in the Nordic Nutrition Recommendations 2023 (NNR2023). We used evidence from 10 qualified systematic reviews identified by the NNR2023 project. No additional literature search was conducted. Strong or moderate evidence linked dietary patterns high in vegetables, fruits, whole grains, fish, low-fat dairy and legumes, and low in red and processed meats, sugar-sweetened beverages, sugary foods- and refined grains with beneficial health outcomes, such as reduced risk of cardiovascular disease (CVD), type 2 diabetes, obesity, cancer, bone health, and premature death. We also found limited evidence suggesting a relationship with the described dietary patterns in childhood and decreased risk of obesity and hypertension later in life. Most studies have been conducted among adult populations, and thus, there is a need for studies in certain subgroups, such as children and adolescents as well as the elderly.

Effect of Lifestyle Intervention on the Occurrence of Metabolic Syndrome and its Components in the Finnish Diabetes Prevention Study Pirjo Ilanne-Parikka , MD 1 2 , Johan G. Eriksson , MD, PHD 3 4 , Jaana Lindström , PHD 3 , Markku Peltonen , PHD 3 , Sirkka Aunola , PHD 5 , Helena Hämäläinen , MD, PHD 6 , Sirkka Keinänen-Kiukaanniemi , MD, PHD 7 8 9 , Mauri Laakso , MD 7 8 10 , Timo T. Valle , MD 3 , Jorma Lahtela , MD, PHD 11 , Matti Uusitupa , MD, PHD 12 , Jaakko Tuomilehto , MD, PHD 3 4 and on behalf of the Finnish Diabetes Prevention Study Group 1 Diabetes Center, Finnish Diabetes Association, Tampere, Finland 2 Department of Research Administration, Pirkanmaa Hospital District, Tampere, Finland 3 Diabetes Unit, Department of Health Promotion and Chronic Disease Prevention, National Public Health Institute, Helsinki, Finland 4 Department of Public Health, University of Helsinki, Helsinki, Finland 5 Department of Health and Functional Capacity, Laboratory for Population Research, National Public Health Institute, Turku, Finland 6 Research Department, Social Insurance Institution, Turku, Finland 7 Department of Public Health Science and General Practice, University of Oulu, Oulu, Finland 8 Department of Sport Medicine, Oulu Deaconess Institute, Oulu, Finland 9 Oulu Health Centre, Oulu, Finland 10 Unit of General Practice, Oulu University Hospital, Oulu, Finland 11 Department of Internal Medicine, Tampere University Hospital, Tampere, Finland 12 Department of Public Health and Clinical Nutrition, University of Kuopio, Kuopio, Finland Address correspondence and reprint requests to Pirjo Ilanne-Parikka, Matinkatu 6, FIN 33900 Tampere, Finland. E-mail: pirjo.ilanneparikka{at}diabetes.fi Abstract OBJECTIVE —The aim of this secondary analysis of the Finnish Diabetes Prevention Study was to assess the effects of lifestyle intervention on metabolic syndrome and its components. RESEARCH DESIGN AND METHODS —A total of 522 middle-aged overweight men and women with impaired glucose tolerance were randomized into an individualized lifestyle intervention group or a standard care control group. National Cholesterol Education Program criteria were used for the definition of metabolic syndrome. RESULTS —At the end of the study, with a mean follow-up of 3.9 years, we found a significant reduction in the prevalence of metabolic syndrome in the intervention group compared with the control group (odds ratio [OR] 0.62 [95% CI 0.40–0.95]) and in the prevalence of abdominal obesity (0.48 [0.28–0.81]). CONCLUSIONS —The results suggest that lifestyle intervention may also reduce risk of cardiovascular disease in the long run. DPS, Finnish Diabetes Prevention Study IGT, impaired glucose tolerance Footnotes Published ahead of print at http://care.diabetesjournals.org on 9 January 2008. DOI: 10.2337/dc07-1117. Clinical trial reg. no. NCT00518167, clinicaltrials.gov. The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. Accepted December 24, 2007. Received August 15, 2007. DIABETES CARE

Determinants for the Effectiveness of Lifestyle Intervention in the Finnish Diabetes Prevention Study Jaana Lindström , PHD 1 2 , Markku Peltonen , PHD 1 , Johan G. Eriksson , MD, PHD 1 2 , Sirkka Aunola , PHD 3 , Helena Hämäläinen , MD, PHD 4 , Pirjo Ilanne-Parikka , MD 5 , Sirkka Keinänen-Kiukaanniemi , MD, PHD 6 , Matti Uusitupa , MD, PHD 7 , Jaakko Tuomilehto , MD, MPH, PHD 1 2 and for the Finnish Diabetes Prevention Study (DPS) Group * 1 Diabetes Unit, Department of Health Promotion and Chronic Disease Prevention, National Public Health Institute, Helsinki, Finland 2 Department of Public Health, University of Helsinki, Helsinki, Finland 3 Laboratory for Population Research, Department of Health and Functional Capacity, National Public Health Institute, Turku, Finland 4 Research Department, Social Insurance Institution, Turku, Finland 5 Research Unit of Tampere University Hospital and the Diabetes Center, Finnish Diabetes Association, Tampere, Finland 6 Institute of Health Sciences (General Practice), University of Oulu, Unit of General Practice, Oulu University Hospital and Health Centre of Oulu, Oulu, Finland 7 School of Public Health and Clinical Nutrition, Department of Clinical Nutrition, University of Kuopio, Kuopio, Finland Corresponding author: Jaana Lindström, National Public Health Institute, Mannerheimintie 166, 00300 Helsinki, Finland. E-mail: jaana.lindstrom{at}ktl.fi Abstract OBJECTIVE —Intensive lifestyle intervention significantly reduced diabetes incidence among the participants in the Finnish Diabetes Prevention Study. We investigated whether and to what extent risk factors for type 2 diabetes and other baseline characteristics of the study participants modified the effectiveness of the lifestyle intervention. RESEARCH DESIGN AND METHODS —Overweight, middle-aged volunteers with impaired glucose tolerance were randomly assigned to intensive lifestyle intervention ( n = 265) or to a control group ( n = 257) for a median of 4 years. Diabetes status was ascertained annually with repeated oral glucose tolerance testing. Incidence rates of diabetes and hazard ratios (HRs) comparing the intervention group with the control group were calculated by sex and baseline tertiles of age, BMI, waist circumference, plasma glucose concentration at fasting and 2 h after a glucose load, fasting serum insulin and insulin resistance index, and categories of composite baseline Finnish Diabetes Risk Score (FINDRISC). Interactions between the intervention assignment and baseline risk factors on diabetes risk were analyzed. RESULTS —The intervention was most effective among the oldest individuals (HRs 0.77, 0.49, and 0.36 by increasing age tertiles, respectively; P interaction = 0.0130) and those with a high baseline FINDRISC (HRs 1.09, 0.84, 0.34, and 0.22 by increasing risk score category, respectively; P interaction = 0.0400). The effect of the intervention on diabetes risk was not modified by other baseline characteristics or risk factors. CONCLUSIONS —The FINDRISC may be useful in identifying high-risk groups most likely to benefit from intensive lifestyle intervention to prevent type 2 diabetes. DPS, the Finnish Diabetes Prevention Study FINDRISC, the Finnish Diabetes Risk Score HOMA-IR, homeostasis model assessment of insulin resistance IGT, impaired glucose tolerance NNT, number needed to treat OGTT, oral glucose tolerance test Footnotes Published ahead of print at http://care.diabetesjournals.org on 5 February 2008. DOI: 10.2337/dc07-2162. Clinical trial reg. no. NCT00518167, clinicaltrials.gov. * ↵ * A complete list of the members of the Finnish Diabetes Prevention Study Group can be found in the appendix . The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C Section 1734 solely to indicate this fact. Accepted January 21, 2008. Received November 12, 2007. DIABETES CARE

Lifestyle interventions can prevent the deterioration of impaired glucose tolerance to manifest type 2 diabetes, at least as long as the intervention continues. In the extended follow-up of the Finnish Diabetes Prevention Study, we assessed the extent to which the originally-achieved lifestyle changes and risk reduction remain after discontinuation of active counselling. Overweight, middle-aged men (n=172) and women (n=350) with impaired glucose tolerance were randomly assigned to intensive lifestyle intervention or control group. After a median of 4 years of active intervention period, participants who were still free of diabetes were further followed up for a median of 3 years, with median total follow-up of 7 years. Diabetes incidence, bodyweight, physical activity, and dietary intakes of fat, saturated fat, and fibre were measured. During the total follow-up, the incidence of type 2 diabetes was 4·3 and 7·4 per 100 person-years in the intervention and control group, respectively (log-rank test p=0·0001), indicating 43% reduction in relative risk. The risk reduction was related to the success in achieving the intervention goals of weight loss, reduced intake of total and saturated fat and increased intake of dietary fibre, and increased physical activity. Beneficial lifestyle changes achieved by participants in the intervention group were maintained after the discontinuation of the intervention, and the corresponding incidence rates during the post-intervention follow-up were 4·6 and 7·2 (p=0·0401), indicating 36% reduction in relative risk. Lifestyle intervention in people at high risk for type 2 diabetes resulted in sustained lifestyle changes and a reduction in diabetes incidence, which remained after the individual lifestyle counselling was stopped.

Objectives In a prospective study among workers in an airline company, we explored whether change in work stress symptoms or night shifts was associated with nutrient intake. Methods Participants in a workplace type 2 diabetes (T2D) prevention study completed a questionnaire on lifestyle, work stress symptoms, work schedule, and food intake at baseline and after 2.4-years follow-up (211 men and 155 women, 93% with increased risk for T2D). Multiple linear regression models with covariates were used to explore the associations between change in work stress symptoms or night shifts and change in nutrient intake during the follow-up. Results Among men, an increase in stress and a decrease in perceived workability was associated with a higher proportion of energy (E%) from fat [β 0.6, 95% confidence interval (CI) 0.07-1.11, β 1.3, 95% CI 0.57-2.05] and saturated fat (β 0.3, 95% CI 0.02-0.58, β 0.5, 95% CI 0.14-0.90), respectively. Furthermore, a decrease in workability was associated with lower vitamin C intake (β-9.2, 95% CI -16.56- -1.84) and an increase in sleepiness with higher E% from saturated fat (β 0.7, 95% CI 0.00-0.15). Among women, an increase in work-related fatigue was associated with higher alcohol intake (β 7.5, 95% CI 1.25-13.74) and an increase of night shifts was associated with higher E% from fat (β 0.24, 95% CI 0.00-0.47) and saturated fat (β 0.17, 95% CI 0.04-0.29). Conclusions Work stress symptoms were associated with a reduction in diet quality especially among men. The possible impact of work stress symptoms on workers' dietary habits should be acknowledged and the assessment of dietary habits should consequently be incorporated into occupational health examinations.

Type 2 diabetes can be prevented by lifestyle intervention. We aimed to identify metabolites that associate with glucose metabolism and respond to lifestyle intervention with evidence-based targets for nutrition and physical activity in individuals at high risk of type 2 diabetes. Standard oral glucose tolerance test (OGTT) was used to categorize 624 participants into those having normal glucose tolerance (NGT), isolated impaired glucose tolerance (IGT), IGT with increased fasting glucose (IGT + IFG), and type 2 diabetes. Plasma LC-MS metabolomics was performed to reveal metabolic signatures. The baseline group differences were analysed with the Kruskal–Wallis test and the effect of intervention with a linear mixed-effects model. Significant differences in the metabolite signature were observed between the baseline groups, particularly in amino acids, acylcarnitines, and phospholipids. Fatty acid amides, phospholipids, amino acids, dimethylguanidinovaleric acid, and 5-aminovaleric acid betaine responded most to the lifestyle intervention. Lysophosphatidylcholines containing odd-chain fatty acids showed associations with improved glucose metabolism. Twenty-five metabolites differed between the baseline groups, responded to the intervention, and were associated with changes in glucose metabolism. The findings suggest a metabolite panel could be used in distinguishing individuals with varying degrees of glucose metabolism and in predicting response to lifestyle interventions.

The Finnish Diabetes Prevention Study (DPS) Lifestyle intervention and 3-year results on diet and physical activity Jaana Lindström , MSC 1 , Anne Louheranta , PHD 2 , Marjo Mannelin , MSC 3 , Merja Rastas , MSC 4 , Virpi Salminen , MSC 5 , Johan Eriksson , MD, PHD 1 , Matti Uusitupa , MD, PHD 2 , Jaakko Tuomilehto , MD, PHD 1 6 and for the Finnish Diabetes Prevention Study Group 1 Diabetes and Genetic Epidemiology Unit, Department of Epidemiology and Health Promotion, National Public Health Institute, Helsinki, Finland 2 Department of Clinical Nutrition, University of Kuopio, Kuopio, Finland 3 Department of Sport Medicine, Oulu Deaconess Institute, Oulu, Finland 4 Research and Development Centre, Social Insurance Institution, Turku, Finland 5 Institute of Nursing and Health Care, Tampere, Finland 6 Department of Public Health, University of Helsinki, Helsinki, Finland Address correspondence and reprint requests to Jaana Lindström, National Public Health Institute, Mannerheimintie 166, 00300 Helsinki, Finland. E-mail: jaana.lindstrom{at}ktl.fi Abstract OBJECTIVE —To describe the 1 ) lifestyle intervention used in the Finnish Diabetes Prevention Study, 2 ) short- and long-term changes in diet and exercise behavior, and 3 ) effect of the intervention on glucose and lipid metabolism. RESEARCH DESIGN AND METHODS —There were 522 middle-aged, overweight subjects with impaired glucose tolerance who were randomized to either a usual care control group or an intensive lifestyle intervention group. The control group received general dietary and exercise advice at baseline and had an annual physician’s examination. The subjects in the intervention group received additional individualized dietary counseling from a nutritionist. They were also offered circuit-type resistance training sessions and advised to increase overall physical activity. The intervention was the most intensive during the first year, followed by a maintenance period. The intervention goals were to reduce body weight, reduce dietary and saturated fat, and increase physical activity and dietary fiber. RESULTS —The intervention group showed significantly greater improvement in each intervention goal. After 1 and 3 years, weight reductions were 4.5 and 3.5 kg in the intervention group and 1.0 and 0.9 kg in the control group, respectively. Measures of glycemia and lipemia improved more in the intervention group. CONCLUSIONS —The intensive lifestyle intervention produced long-term beneficial changes in diet, physical activity, and clinical and biochemical parameters and reduced diabetes risk. This type of intervention is a feasible option to prevent type 2 diabetes and should be implemented in the primary health care system. DPP, Diabetes Prevention Program DPS, Diabetes Prevention Study E%, proportion of total energy OGTT, oral glucose tolerance test LTPA, leisure-time physical activity VLCD, very-low-calorie diet Footnotes Additional information for this article can be found in an online appendix at http://care.diabetesjournals.org . A table elsewhere in this issue shows conventional and Systéme International (SI) units and conversion factors for many substances. Accepted September 4, 2003. Received July 17, 2003. DIABETES CARE

Digital health interventions may offer a scalable way to prevent type 2 diabetes (T2D) with minimal burden on health care systems by providing early support for healthy behaviors among adults at increased risk for T2D. However, ensuring continued engagement with digital solutions is a challenge impacting the expected effectiveness. We aimed to investigate the longitudinal usage patterns of a digital healthy habit formation intervention, BitHabit, and the associations with changes in T2D risk factors. This is a secondary analysis of the StopDia (Stop Diabetes) study, an unblinded parallel 1-year randomized controlled trial evaluating the effectiveness of the BitHabit app alone or together with face-to-face group coaching in comparison with routine care in Finland in 2017-2019 among community-dwelling adults (aged 18 to 74 years) at an increased risk of T2D. We used longitudinal data on usage from 1926 participants randomized to the digital intervention arms. Latent class growth models were applied to identify user engagement trajectories with the app during the study. Predictors for trajectory membership were examined with multinomial logistic regression models. Analysis of covariance was used to investigate the association between trajectories and 12-month changes in T2D risk factors. More than half (1022/1926, 53.1%) of the participants continued to use the app throughout the 12-month intervention. The following 4 user engagement trajectories were identified: terminated usage (904/1926, 46.9%), weekly usage (731/1926, 38.0%), twice weekly usage (208/1926, 10.8%), and daily usage (83/1926, 4.3%). Active app use during the first month, higher net promoter score after the first 1 to 2 months of use, older age, and better quality of diet at baseline increased the odds of belonging to the continued usage trajectories. Compared with other trajectories, daily usage was associated with a higher increase in diet quality and a more pronounced decrease in BMI and waist circumference at 12 months. Distinct long-term usage trajectories of the BitHabit app were identified, and individual predictors for belonging to different trajectory groups were found. These findings highlight the need for being able to identify individuals likely to disengage from interventions early on, and could be used to inform the development of future adaptive interventions. ClinicalTrials.gov NCT03156478; https://clinicaltrials.gov/ct2/show/NCT03156478. RR2-10.1186/s12889-019-6574-y.

Several challenging barriers for diabetes prevention exist in real-world clinical practice, making it necessary to focus on identifying efficient intervention methods and delivery mechanisms. In this Review, the authors discuss these mechanisms and consider the implications for public-health strategy and policy. During the past decade, improved understanding of the pathophysiological mechanisms of diabetes development has resulted in advances in therapeutic concepts, but has also supported the potential for diabetes prevention through nonpharmacological means. At the beginning of the century, we experienced a shift in paradigm, as landmark studies have shown that diabetes mellitus is preventable with lifestyle intervention; moderate changes in diet and physical activity produce a substantial and sustained reduction in the incidence of type 2 diabetes mellitus (T2DM) for individuals with impaired glucose tolerance. This evidence must now be translated into clinical and public-health practice, but translational studies have varied in their ability to replicate the results of clinical trials. This variation reflects a number of challenging barriers for diabetes prevention in real-world clinical practice, which makes it necessary to focus on identifying efficient intervention methods and delivery mechanisms. Research is now focusing on these mechanisms, as well as on developing efficient screening and risk-identification strategies and realistic scenarios for public-health policy to implement diabetes prevention programs. In this Review, we will discuss these mechanisms and will consider the implications of diabetes prevention for public-health strategy and policy. Key Points Type 2 diabetes mellitus (T2DM) is a highly preventable disease; however, prevention programs need to systematically identify people at high risk and address the pathophysiological, behavioural and public-health determinants of diabetes development Evidence-based recommendations for clinical practice are available and provide a solid basis for the development and implemention of T2DM prevention programs Increased physical activity and a healthy diet (high fibre, low saturated fat, appropriate energy intake), ideally resulting in weight loss, are important and effective interventions that can prevent the development of T2DM To identify individuals at increased risk of T2DM, a multi-stage approach is recommended, starting with a noninvasive risk score, followed by a diagnostic test to confirm glycaemic status if necessary Implementing evidence-based strategies to initiate and support behaviour change should help to achieve sustained lifestyle changes in preventive intervention programs Population-based implementation of primary diabetes prevention programs requires active partnerships across all different levels of public health, including local and national government and community-level organisations and services

Background Early identification of people at elevated risk of type 2 diabetes (T2D) is an important step in preventing or delaying its onset. Pharmacies can serve as a significant channel to reach these people. This study aimed to assess the potential health economic impact of screening and recruitment services in pharmacies in referring people to preventive interventions. Methods A decision analytic model was constructed to perform a cost-utility analysis of the expected national health economic consequences (in terms of costs and quality-adjusted life years, QALYs) of a hypothetical pharmacy-based service where people screened and recruited through pharmacies would participate in a digital lifestyle program. Cost-effectiveness was considered in terms of net monetary benefit (NMB). In addition, social return on investment (SROI) was calculated as the ratio of the intervention and recruitment costs and the net present value of expected savings. Payback time was the time taken to reach the break-even point in savings. In the base scenario, a 20-year time horizon was applied. Probabilistic and deterministic sensitivity analyses were applied to study robustness of the results. Results In the base scenario, the expected savings from the pharmacy-based screening and recruitment among the reached target cohort were 255.3 m€ (95% CI − 185.2 m€ to 717.2 m€) in pharmacy visiting population meaning 1412€ (95% CI − 1024€ to 3967€) expected savings per person. Additionally, 7032 QALYs (95% CI − 1344 to 16,143) were gained on the population level. The intervention had an NMB of 3358€ (95% CI − 1397€ to 8431€) using a cost-effectiveness threshold of 50,000 €/QALY. The initial costs were 122.2 m€ with an SROI of 2.09€ (95% CI − 1.52€ to 5.88€). The expected payback time was 10 and 8 years for women and men, respectively. Results were most sensitive for changes in effectiveness of the intervention and selected discount rate. Conclusions T2D screening and recruitment to prevention programs conducted via pharmacies was a dominant option providing both cost savings and QALY gains. The highest savings can be potentially reached by targeting recruitment at men at elevated risk of T2D.