Month: February 2023

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Columbiaville Elementary School sees results from ‘WIN Time’ program

Columbiaville Elementary School sees results from ‘WIN Time’ program
Fourth-grade students Bryce Burrows, Logan Arredondo and Brooklynn Fosdick play a match game designed to help with phonics. Photos by Nicholas Pugliese

Fourth-grade students Bryce Burrows, Logan Arredondo and Brooklynn Fosdick engage in a match sport created to support with phonics. Photos by Nicholas Pugliese

COLUMBIAVILLE — At Columbiaville Elementary University, it’s all about “WIN”-ning.

Commencing this calendar year, all college students in the college have observed part of their working day devoted to Win Time, or “What I Have to have.” It is a time period throughout which just about every college student receives concentrated instruction on an area of learning discovered as in want, and educators are currently seeing outcomes.

Each individual day, looking through and math intervention teachers Annette Thueme, Amy Harris and Kim Riley are joined by a variety of other educators and directors to run split-out compact teams of college students based on studying areas. Each individual of the school’s 387 K-4 pupils be a part of 3 lecturers, three interventionists and 5 paraprofessionals for sport-centered learning.

The concept’s dependent on the e book “Win Time: Fearlessly Transforming Your School” by Morris Lyon and Stephanie McConnell. “It will take a great deal of info, a whole lot of screening,” said Thueme, but the final results are now revealing them selves.

Intervention teacher Annette Thueme helps out fourth-grade students Sophia Carter and Connor Napora during a WIN Time session on Monday.

Intervention trainer Annette Thueme helps out fourth-quality students Sophia Carter and Connor Napora in the course of a Acquire Time session on Monday.

Just about every team is based on the individual needs of just about every university student. For the to start with yr, claimed Thueme, it was resolved throughout preliminary meetings to “really work” on reading through instruction prior to branching into math in the long term. “It actually lets us drill down on distinct competencies,” she reported. “Whichever ability they seriously require.”

Pupils get targeted instruction in quite a few spots, together with rhyming, suffixes, segmenting and a lot more.

Roughly 90{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of Columbiaville’s learners on an Specific Examining Advancement System (IRIP) have previously met their original intention and are already making progress towards their subsequent one. Details also demonstrates advancements in a range of looking through locations, together with letter recognition amongst kindergarteners as effectively as vowel competencies in fourth graders.

Unlike other approaches that crack out students centered on normal overall performance, Win Time’s precise concentrating on of competencies is concentrated on possibly what extra help students might will need, or provide enrichment or an more obstacle. Gain Time replaces traditional intervention that may well eat into regular tutorial time. “It seriously works on both equally ends of the spectrum, so given that everyone’s doing it, no unique group is singled out,” explained Thueme. “It’s incredibly centered time — all organization.”

Kindergartener Morgan Mulholland uses learned skills to solve a puzzle during WIN Time.

Kindergartener Morgan Mulholland utilizes discovered skills to address a puzzle in the course of Get Time.

In an academic earth that is continue to coping with the lingering outcomes of the COVID-19 pandemic and affiliated on the net understanding, educators in Columbiaville are observing Acquire Time as a way to “catch up” students. “There’s a good deal of COVID stuff, when we experienced blanket lessons where every person was executing this or that,” reported Thueme. “You really do not realize how a lot they select up on from just being in the classroom.”

And at the finish of the working day, 1 of the most critical features of Gain Time for the students concerned is that it is simply just entertaining. “Kids like it, and it comes about extremely almost never that little ones are saying ‘please train me,’” claimed Thueme. “Maybe we’re on the correct observe.”

The games-based learning of WIN Time has been a hit with kindergarteners like Radley Moore, all the way up to fourth grade.

The online games-primarily based studying of Earn Time has been a hit with kindergarteners like Radley Moore, all the way up to fourth quality.

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Are our educational institutions becoming export-oriented units?

Are our educational institutions becoming export-oriented units?

In the name of academic freedom, if Western professors begin denigrating and launching vituperative attacks on Indians, their beliefs, traditions and values, then it gets to be required to teach them about the financial worthy of of each Indian scholar.

An invitation to produce an anti-prescription drugs awareness discuss in a prestigious faculty turned out to be a excellent eye-opener. The welcome speech and introduction by the principal, threw light on an insidious difficulty that is nonetheless to be publicly debated. The principal enthusiastically remarked that this is an elite establishment, meant for the monetarily well-off segment or much more correctly the nouveau riche, and proceeded to inform that all the students were entirely focused on going abroad by way of higher experiments and thereafter having up citizenship in Western nations around the world. As if to prove her terms, she requested the scholar-aspirants seeking to go overseas to raise their arms. Without the need of exception the around 200-solid learners of Courses X, XI and XII raised their hands with no hesitation. A worrisome pattern of trafficking in clever learners to the West has been likely on uninterruptedly for the previous 10 years or so. Outstanding youngsters of industrialists, bureaucrats, intellectuals, scholars, and professionals in assorted fields, are quietly flocking to Western nations as also to Australia and New Zealand.
Non-public instructional establishments, supported by an effective staff of educational consultants, representatives of American and Western universities, job steerage and academic steerage professionals, immigration professionals, offer conclude to conclude schooling expert services ranging from intercontinental education and learning counseling, admission, visa, guidance to scholarship, overseas schooling loans, forex trading, flight ticketing and lodging products and services. Students are extensively groomed and prepared to deal with any examination, be it IELTS, TOEFL, PTE, OET, ACT, GRE, GMAT, or SAT. There are rigid minimum amount slice-off marks that want to be attained in order to obtain entry to prestigious Ivy League universities and other effectively-recognized universities. There are no mark relaxations of any type for any local community or creed. Only the good are welcome.
The US embassy in India issued a file-breaking 82,000 college student visas until September 2022. Indian students gained much more US scholar visas than any other country. The British Substantial Fee granted 1.27 lakh student visas to Indians in the 12 months ending September 2022. For the duration of this time period, Australia gave all-around 9,000 scholar visas, when Canada been given close to 123,500 analyze permit programs in just the initially five months of 2022. Several modest European nations around the world, with no terrific keep track of file for good quality training, like Estonia, Georgia, Moldova, Malta, and quite a few extra have opened up to seize a piece of the pie.
High quality learners are currently being sent absolutely free of expense at the doorsteps of Western universities. The Indian pupils shell out for every little thing, ranging from language capability assessment costs, issue proficiency tests service fees, college processing service fees, visa expenses, consultancy costs, airline ticket prices, scholar hostel service fees, and 1st semester service fees. Each and every and each and every fee is exorbitant. The relocating of amazing students in Western international locations is currently being exploited to the hilt by biased Western organizations. With definitely zero financial investment, Western universities get the most excellent of Indian college students delivered at their doorsteps.
The price tag for these pricey education and learning is fulfilled by availing lender loans, mortgaging residence, providing jewellery, and other borrowings. The amazing just want to go away the country, no matter what be the price tag. There is a agency perception that there is no spot for merit in India. The outcomes of this frame of mind can have significantly reaching repercussions.
These days, numerous American universities have develop into a fertile floor for anti-India propaganda. Intelligence organizations, NGOs, media barons have cultivated the staff members and students to indulge in hostile propaganda towards their motherland. Focused fake propaganda is directed in opposition to India, and Hinduism in certain, apart from the typical vitriol about harassment by Indian stability forces in Kashmir. The intent of the “Dismantling Worldwide Hindutva” conference, which was phase-managed in a handful of American universities was to paint Hinduism black. Though the organisers of this celebration remained anonymous, they took good pains to portray Hindus as purveyors of extremism Hindu philosophy, assumed and social methods have been denounced as diabolical. An on the net conference, “Dismantling International Hindutva: Multidisciplinary Perspectives” was held on 10-12 September 2021. It was organised and co-sponsored by quite a few history, South Asian studies, human rights, political science, spiritual reports and other multi-disciplinary departments and centers at many US, European and Canadian universities, which includes Harvard, Princeton, Stanford, University of California at Berkeley, and University of Toronto. These universities depend on Indian pupils for their pretty survival and the employees for their bread and butter. The common tuition cost for the 2022-2023 academic calendar year at Harvard is $52,659, with no any financial support home and board and other charges provide the total cost tag to a whopping $76,763. Most of the Ivy League universities boast of comparable hefty cost tags.
The significant existence of Indian college students on American campuses need to suggest that they are dealt with with respect and dignity. In the name of educational freedom, if professors and the supporting instructing workers, begin denigrating and launching vituperative attacks on Indians, their beliefs, traditions and values, then it gets necessary to educate them about the monetary value of each Indian university student.
For this goal, the Government wants to make it obligatory for all overseas universities intending to recruit Indian pupils to sign-up with the Ministry of Schooling. Eligibility for student education and learning financial loans will be only for studies in these registered universities. These universities will need to have to guarantee that all college students will be addressed with regard and dignity, and that their campuses will not be used for any kind of anti-India packages, seminars and events. In the function of violation of this condition, Indian banking companies can be recommended not to entertain any financial loan software for analyze in that university. It will be curtains down for people rouge universities that persuade their premises for anti-India functions.
Nevertheless, the phenomenon of outstanding pupils leaving their motherland and relocating to Western nations is India’s unique issue. There is chat of “food security”, “energy security”, but hardly any one talks about “intellectual security”. If the brightest and smart youthful minds transfer absent from their motherland, can the country in long run be run by the mediocre? Can the country’s civil solutions, defence expert services, overall health products and services be entrusted to people of lower calibre? How do we make sure and safeguard the intellectual safety of the country? This wants a countrywide discussion and correct laws, for mental safety is an essential precondition for sustainable advancement. Purpose Variety 4 of the 17 Sustainable Growth Ambitions of the United Nations is about good quality training. Intellectual trafficking and talent trafficking on an annual basis are a grave impediment for the country’s upcoming growth. Fantastic young minds are regretably confident at a very tender age that a whole evaluation of their skills, creativeness and skills is not attainable in this country, thanks to a wide range of social, political and economic challenges. The authorities should really convene a meeting of educationists, directors, bankers and industrialists to find a way out of this impasse. Maybe a number of oases of brilliance will need to be set up, devoted for nurturing only intellectual giants, who can guideline and guide the country by the coming many years.

Dr G. Shreekumar Menon, IRS (Retd), PhD (Narcotics) is previous Director Common, Countrywide Academy of Customs, Oblique Taxes & Narcotics.

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Behind Portland’s decision to shut down Online Learning Academy

Behind Portland’s decision to shut down Online Learning Academy

In Portland Public Schools’ adopted spending budget for this faculty yr, continuing the On-line Mastering Academy was highlighted as one particular of the district’s initiatives to “increase finding out opportunities for every college student.”

The state’s major district opened the On the web Finding out Academy, or OLA, in 2021 to provide students in kindergarten by means of twelfth quality who required to proceed university on the internet. Some households flocked to the plan for well being factors as most learners in Oregon have been returning to in-man or woman college entire-time during the pandemic.

The exterior doors to a school building are plastered in signs. One shows two drawings of people, with a line between them showing they are 6 feet apart. Another shows a person wearing a mask. Others are difficult to read.

FILE: Signs market protection safety measures to restrict the spread of COVID-19 at Sabin Elementary College in January 2021. As thousands of learners returned to educational institutions throughout Oregon, a lot of family members with well being worries opted to have their small children continuing to discover on line.

Rob Manning / OPB

Sara Kemper observed OLA as a safe faculty selection for her two youngsters in portion simply because their residence included an immunocompromised family members member. She also saw the on the internet software as a possible enhancement for her daughter, who gets exclusive training solutions. Soon after yrs of battling to uncover the ideal in good shape in just the district’s educational institutions and applications, Kemper’s daughter thrived in the virtual ecosystem.

“We did not know that it was likely to fulfill all of my child’s ‘sped’ [special education] demands,” Kemper claimed.

Kemper’s daughter is in center faculty and is regarded “twice extraordinary,” a time period for college students who qualify as talented and gifted and have a understanding disability. Kemper’s daughter has autism and ADHD.

Kemper explained the lodging demanded under her daughter’s individualized training strategy weren’t important and typically “fell away” in the on the web atmosphere.

“She’s observed by her academics in a new way. They genuinely are in a position to meet her learning demands,” Kemper explained of OLA.

“She doesn’t have to have earphones, she does not have to have timeouts, she’s not clearing school rooms — this is a little one that would throw desks when activated and upset. She’s not suicidal,” Kemper stated. “There’s so numerous matters that are becoming fulfilled for her academically and socially in this article that simply cannot be fulfilled in an in-particular person natural environment.”

Tuesday evening, Kemper gained a textual content that the method was closing at the stop of this college 12 months. Just after two many years she described as “peaceful,” she felt blindsided by the reduction of a “huge resource”.

“This was a gem, and I really don’t even know what else is out there,” she reported.

Related: Students with disabilities facial area tutorial setbacks and basic safety pitfalls in Oregon schools

District officers cited very low enrollment and finances challenges in ending the software, a final decision created by executive management. In an interview with OPB, district officials mentioned the software was a short term one particular and that in a complicated finances environment, the district has to make difficult phone calls.

“We are making the complicated decisions that will sustain us in the long-time period,” PPS chief of staff Jonathan Garcia mentioned.

District leaders say the on the web plan was funded with momentary federal bucks that schools have to expend by September 2024.

“It was a short-term software that was only opened a couple of several years in the past for a specific objective,” stated Cheryl Proctor, PPS’ deputy superintendent of instruction and university communities.

District officers opened the Online Studying Academy for “students who could not show up at in-particular person owing to overall health explanations.”

Garcia admitted the district did not use the expression “short-term” to explain the plan.

“Was the phrase ‘short-term’ made use of? I really do not consider so,” Garcia said. “Could we have been clearer? Probably.”

District officers also cited “low participation” and large charge as motives for the closure.

Portland Public Schools district headquarters, Portland, Ore., Dec. 15, 2018.

FILE: Portland Public Colleges district headquarters, Portland, Ore., Dec. 15, 2018.

Bradley W. Parks / OPB

In accordance to the district’s proposed budget for 2022-23, OLA’s spending budget was pretty much $5 million — about $12,186 for each college student. Only 18 of the district’s more than 80 universities have a higher per-scholar charge than the on-line system.

Demographic info in that document for the 2021-22 college 12 months shows a scholar population that provided 21{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} college students with disabilities, 15{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} Black learners and 20{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} Latino pupils.

Currently, 236 learners attend, an enhance of 11 students from October enrollment studies.

Proctor said the district will sit down with each and every OLA household to discuss possibilities for following calendar year, like the district’s other digital offerings. People solutions include things like Virtual Scholars and Night Scholars, applications generally available to learners in large faculty. At this time, the district does not have any elementary or middle faculty virtual solutions other than OLA.

As not long ago as this wintertime, PPS director of specific schooling Michelle Murer talked about OLA as an selection for serving students with disabilities in a method wherever learners and people are having difficulties to get what they need to have.

Proctor claimed there will be solutions for OLA pupils receiving unique training products and services.

“We are guaranteeing that we are having discussions with each and every relatives, including our learners with disabilities, and guaranteeing that every solution that we have available to meet up with their needs inside of PPS and within just our programming, we will … make individuals applications out there in accordance to what is in the [individualized education plan],” Proctor claimed.

Proctor and Garcia did not specify when family members would be contacted for people conversations.

Associated: Households of Oregon college students with disabilities lookup for options

Kemper claimed if she would’ve recognised her children’s schooling approach was in risk of closing, she would’ve advocated. She’s completed it in advance of, when Portland was moving Accessibility, an option plan for proficient and gifted college students.

“Why weren’t we instructed nearly anything prior to? Why was not there a board meeting? I would’ve revealed up,” she stated.

Because the method is not technically a “school,” district officers explained the move to near it did not bring about the district’s school closure plan, which demands a community approach involving the faculty board and the superintendent.

Kemper reported she’s wanting into other on the web digital educational facilities.

“We can not and will not go back again to in-human being,” she mentioned.

This is one particular of the first conclusions built as the district prepares to present a finances for next university 12 months to the university board at the close of April. District officials have introduced other financial measures they’re arranging to get, together with a freeze on selecting at the central place of work.

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Ohio officials are investigating pro-Nazi home-schoolers

Ohio officials are investigating pro-Nazi home-schoolers

Remark

Ohio’s schooling department claimed it would examine the apparent use of fascist resources by a dwelling-education community after stories that the pro-Nazi team is run by a couple residing in the condition. The study course materials denigrate the intelligence of African People and rejoice Adolf Hitler.

An formal with the state’s schooling agency reported the division is informed of the reports and “is actively examining compliance with statutory and regulatory prerequisites.”

But there’s likely very little the point out can do since although the condition mandates that particular topics be taught, it does not govern particulars of what home faculty can and simply cannot include things like.

Previous week, the Anonymous Comrades Collective, a team of anti-fascism scientists, reported that an firm named Dissident Homeschool was distributing pro-Nazi curriculum by way of a Telegram channel that has extra than 2,300 subscribers.

The group’s leaders connect with on their own Mr. and Mrs. Saxon, but the Nameless Comrades analysis staff determined them as Katja and Logan Lawrence of Higher Sandusky, Ohio. HuffPost verified their identities in a subsequent report.

The Lawrences could not be attained for remark.

How Christian dwelling-schoolers laid the groundwork for ‘parental rights’

The messages and classes distributed by the household-schooling community are loaded with Nazi, white supremacist and racist classes, according to excerpts posted by the Nameless Comrades Collective. When the network achieved its 1,000th subscriber, leaders celebrated with a image of boys offering a Nazi salute. “Mrs. Saxon” wrote, “It fills my coronary heart with joy to know there is these kinds of a solid base of house-schoolers and homeschool-fascinated nationwide socialists. Hail Victory.”

She informed a podcast termed “Achtung! Amerikaner” that she commenced the network simply because she was acquiring issues locating “Nazi accredited college material for my household-schooled young children.”

She also said: “We are so deeply invested into generating absolutely sure that that baby gets a great Nazi.”

A single lesson dispersed by the community teaches learners that Black folks have lower IQs than White people do. The lessons venerate Confederate Gen. Robert E. Lee and denigrate the Rev. Martin Luther King Jr. “Mrs. Saxon” also talks of celebrating Hitler’s birthday with favourite German foods, bragging about producing a “swastika apple pie.”

In a lesson noted by HuffPost, young children are taught handwriting by copying a quotation about “the habits of the blacks” that begins: “A leopard does not adjust his places just due to the fact you convey him in from the jungle and check out to housebreak him and switch him into a pet.”

Nazis murdered 6 million Jews for the duration of the Holocaust. In current many years, the United States and other nations around the world have observed a rise in antisemitism, together with responses from high-profile figures such as the rapper Ye greater acceptance of stereotypes and tropes and growing incidents of antisemitic graffiti and other incidents.

In Ohio, mom and dad who want to house-faculty their little ones ought to notify the area school district and present 900 hrs of instruction per year on a vary of topics including language, examining, geography, math and science. They also must give an evaluation of pupil perform.

In a assertion, Stephanie K. Siddens, Ohio’s interim superintendent of general public instruction, condemned the Nazi residence-schoolers but said absolutely nothing about how they may possibly be stopped.

Dwelling schooling exploded among Black, Asian and Latino students. But it was not just the pandemic.

“I am outraged and saddened,” she stated. “There is totally no put for detest-crammed, divisive and hurtful instruction in Ohio’s educational facilities, including our state’s house-education community. I emphatically and categorically denounce the racist, antisemitic and fascist ideology and elements remaining circulated as noted in modern media stories.”

The superintendent of the Upper Sandusky Exempted Village Faculties, Eric Landversicht, also responded to the reporting with a letter to the local community. He stated he could not explore distinct learners and explained there was nothing at all he could do to halt this teaching. He also said the district vigorously enforces a ban on discrimination in official courses and actions, and he offered counseling guidance for students who want it.

“The allegations are egregious, and the District vehemently condemns any this sort of resources,” he wrote.

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Healthy lifestyle behaviors, mediating biomarkers, and risk of microvascular complications among individuals with type 2 diabetes: A cohort study

Healthy lifestyle behaviors, mediating biomarkers, and risk of microvascular complications among individuals with type 2 diabetes: A cohort study

Abstract

Methods and findings

This retrospective cohort study included 15,104 patients with T2D free of macro- and microvascular complications at baseline (2006 to 2010) from the UK Biobank. Healthy lifestyle behaviors included noncurrent smoking, recommended waist circumference, regular physical activity, healthy diet, and moderate alcohol drinking. Outcomes were ascertained using electronic health records. Over a median of 8.1 years of follow-up, 1,296 cases of the composite microvascular complications occurred, including 558 diabetic retinopathy, 625 diabetic kidney disease, and 315 diabetic neuropathy, with some patients having 2 or 3 microvascular complications simultaneously. After multivariable adjustment for sociodemographic characteristics, history of hypertension, glycemic control, and medication histories, the hazard ratios (95{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} confidence intervals (CIs)) for the participants adhering 4 to 5 low-risk lifestyle behaviors versus 0 to 1 were 0.65 (0.46, 0.91) for diabetic retinopathy, 0.43 (0.30, 0.61) for diabetic kidney disease, 0.46 (0.29, 0.74) for diabetic neuropathy, and 0.54 (0.43, 0.68) for the composite outcome (all Ps-trend ≤0.01). Further, the population-attributable fraction (95{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} CIs) of diabetic microvascular complications for poor adherence to the overall healthy lifestyle (<4 low-risk factors) ranged from 25.3{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} (10.0{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}, 39.4{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) to 39.0{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} (17.7{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}, 56.8{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}). In addition, albumin, HDL-C, triglycerides, apolipoprotein A, C-reactive protein, and HbA1c collectively explained 23.20{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} (12.70{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}, 38.50{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) of the associations between overall lifestyle behaviors and total diabetic microvascular complications. The key limitation of the current analysis was the potential underreporting of microvascular complications because the cases were identified via electronic health records.

Author summary

Citation: Geng T, Zhu K, Lu Q, Wan Z, Chen X, Liu L, et al. (2023) Healthy lifestyle behaviors, mediating biomarkers, and risk of microvascular complications among individuals with type 2 diabetes: A cohort study. PLoS Med 20(1):
e1004135.

https://doi.org/10.1371/journal.pmed.1004135

Academic Editor: Weiping Jia, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, CHINA

Received: June 8, 2022; Accepted: October 26, 2022; Published: January 10, 2023

Copyright: © 2023 Geng et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The UK Biobank data are available on application to the UK Biobank (www.ukbiobank.ac.uk/). This research has been conducted using the UK Biobank Resource under Application Number 68307.

Funding: GL is supported by grants from National Nature Science Foundation of China (82073554), the Hubei Province Science Fund for Distinguished Young Scholars (2021CFA048), and the Fundamental Research Funds for the Central Universities (2021GCRC076). AP is supported by grants from National Nature Science Foundation of China (81930124, 82021005, and 82192902), and the Fundamental Research Funds for the Central Universities (2021GCRC075). The Funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Competing interests: The authors have declared that no competing interests exist.

Abbreviations:
ALP,
alkaline phosphatase; ALT,
alanine aminotransferase; AST,
aspartate aminotransferase; BMI,
body mass index; CI,
confidence interval; CRIC,
Chronic Renal Insufficiency Cohort; CRP,
C-reactive protein; CVD,
cardiovascular disease; DBP,
diastolic blood pressure; DIY,
do-it-yourself; eGFR,
estimated glomerular filtration rate; GGT,
gamma glutamyltransferase; HDL-C,
high-density lipoprotein cholesterol; HR,
hazard ratio; LDL-C,
low-density lipoprotein cholesterol; MET,
metabolic equivalent of task; ONTARGET,
Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial; PAF,
population-attributable fraction; SBP,
systolic blood pressure; TC,
total cholesterol; T2D,
type 2 diabetes; WC,
waist circumference

Introduction

Diabetes is a global public health crisis affecting greater than 0.5 billion adults worldwide [1]. Diabetic microvascular complications including diabetic retinopathy, diabetic neuropathy, and diabetic kidney disease have placed a significant health and economic burden borne by individuals, families, and health systems [2,3]. For example, diabetic retinopathy, the leading cause of vision loss, is present in nearly 30{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of patients with diabetes [4]. Furthermore, both diabetic kidney disease and diabetic neuropathy may develop in approximately 50{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of patients with diabetes [5,6]. Therefore, it is paramount to identify cost-effective strategies to prevent and delay the development of microvascular complications in patients with diabetes.

Beyond the glucose control by medications, the American Diabetes Association guideline has highlighted that both caregivers and patients should focus on how to optimize lifestyle behaviors to improve diabetes care [7]. Although lifestyle behaviors that are generally recommended, e.g., normal weight, no smoking, moderate alcohol drinking, healthy diet, and physically active, have been associated with lower risks of microvascular complications [8–14], to our best knowledge, the magnitudes of the joint association of multiple lifestyle factors with the development of microvascular complications in diabetes have not yet been quantified, which may have substantial public health implications on translating epidemiological findings to meaningful public health actions. In addition, several studies have linked lifestyle behaviors with a range of intermediate variables including lipid profile [15,16], liver function biomarkers [15,17–19], renal function biomarkers [20,21], blood pressure indices [22], glucose metabolism measures [23], and systemic inflammatory factors [15,16]; however, whether and the extent to which these metabolic biomarkers could mediate the association between lifestyle behaviors and diabetic microvascular complications remains unclear.

To shed light on the potential favorable association of overall lifestyle behaviors on microvascular complications in patients with diabetes, we examined the joint association of multiple lifestyle behaviors, including waist circumference (WC), smoking status, habitual diet, physical activity, and alcohol intake with risks of total microvascular complications, diabetic retinopathy, diabetic neuropathy, and diabetic kidney disease among patients with type 2 diabetes (T2D) who participated in the UK Biobank study. In addition, we also comprehensively evaluated the effect of a series of blood biomarkers on mediating the relationship between lifestyle behaviors and diabetic microvascular complications.

Methods

Study population

The UK Biobank is a large community-based prospective cohort study for common diseases of middle and older adults including over 500,000 participants aged 37 to 73 years from 22 sites across England, Scotland, and Wales between March 2006 and October 2010. Extensive data were obtained through touchscreen questionnaires, physical measurements, and biological samples at recruitment. Specific methods of data collection have been described previously [24,25].

Our sample of 15,104 was generated by including patients with T2D identified by using the algorithms method developed by the UK Biobank study [26] and excluding participants with prevalent macro- or microvascular complication cases, had incomplete information on lifestyle behaviors, or withdrawal from the study. The flowchart of patients included in the current study is present in S1 Fig.

The study was approved by the North West Multi-Centre Research Ethics Committee, the National Information Governance Board for Health and Social Care in England and Wales, and the Community Health Index Advisory Group in Scotland. All participants provided written informed consent. In the current analysis, we employed the UK Biobank study to test a priori hypothesis; we did not publish an analysis plan before conducting analyses between January 2022 and March 2022. The associations between lifestyle factors and the risk of microvascular complications in participants without excluding those with macrovascular complications and stratified analysis by preexisting cardiovascular disease (CVD) status were performed in response to peer review in July 2022. This study is reported as per the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline (S1 Checklist).

Measurements of lifestyle behaviors

Five lifestyle behaviors, namely, WC, smoking status, physical activity, habitual diet, and alcohol intake, were evaluated in the current analysis. We used WC instead of body mass index (BMI) to avoid the potential obesity paradox [27,28] as evidence found an obesity paradox when obesity was measured by BMI but not when measured by WC in patients with diabetes [29]. WC was measured using the Wessex nonstretchable sprung tape measurement, and low-risk WC was defined as <80 cm for women and <94 cm for men [30,31]. Data on smoking status were self-reported, and noncurrent smoking was defined as low-risk behavior. The frequency of all types of alcohol intake was reported using 6 predefined categories, between never to daily or almost daily. For participants who reported to drink alcohol, data on the average monthly or weekly alcohol intake from 6 types of alcohol beverages were collected. We calculated the average units of alcohol intake using the abovementioned information and defined low-risk drinking as moderate drinking (1 to 14 g/day for women or 1 to 28 g/day for men). Data on the type and duration of physical activity were derived from the questionnaire. Leisure-time physical activity score based on the 5 activities undertaken in the last 4 weeks was computed by multiplying the metabolic equivalent of task [MET] score of each activity by the minutes performed [32,33]. Light DIY (do-it-yourself), walking for pleasure, other exercises (e.g., swimming, cycling, keep fit, bowling), heavy DIY, and strenuous sports were given 1.5, 3.5, 4.0, 5.5, and 8.0 METs, respectively [34]. The midpoints of the frequency and duration of physical activities were used to calculate the time spent on each activity. We then classified the top third of the physical activity score as the low-risk group. In addition, we generated a dietary score to reflect the overall diet quality including 10 components, namely, fruits, vegetables, whole grains, fish, dairy, vegetable oils, refined grains, processed meat, unprocessed meat, and sugar-sweetened beverages. Low-risk diet was defined as meeting 5 or more ideal diet components [35]. Participants with each low-risk behavior were assigned 1 point; otherwise, 0 points. The overall healthy lifestyle score was the sum of individual score of the 5 lifestyle behaviors, ranging from 0 to 5, with higher score indicating healthier lifestyle.

Assessment of the circulating biomarkers

Blood samples were collected from consenting participants at recruitment, separated by components and stored at UK Biobank (−80°C and LN2) until analysis. Blood biomarkers were externally validated with stringent quality control in the UK Biobank; full details on assay performance have been given elsewhere [36]. We selected the potential biological biomarkers mediating the association between lifestyle factors and microvascular complications based on knowledge of potential pathways, including glycemic control determined by glycated hemoglobin (HbA1c), lipid profile (total cholesterol [TC], high-density lipoprotein cholesterol [HDL-C], low-density lipoprotein cholesterol [LDL-C], triglycerides, apolipoprotein A, apolipoprotein B, and lipoprotein A), liver function (alanine aminotransferase [ALT], alkaline phosphatase [ALP], aspartate aminotransferase [AST], gamma glutamyltransferase [GGT], total bilirubin, total protein, and albumin), renal function (cystatin C, creatinine, urate, and urea), inflammation (C-reactive protein [CRP], and white blood cell count), and blood pressure indices (systolic blood pressure [SBP] and diastolic blood pressure [DBP]).

Statistical analysis

Comparisons of baseline characteristics across the categories of the overall healthy lifestyle score were made using ANOVA or chi-squared test. We also compared the differences between patients included in the current analysis and those who were excluded due to missing values. Person-years were calculated from the date of recruitment to the date of death, first endpoint, lost to follow-up, or the end of follow-up, whichever came first. The lost to follow-up variable in the UK Biobank has been created by amalgamating data from 5 possible sources: (1) Death reported to UK Biobank by a relative; (2) NHS records indicate they are lost to follow-up; (3) NHS records indicate they have left the UK; (4) UK Biobank sources report they have left the UK; (5) Participant has withdrawn consent for future linkage. The end of follow-up dates were 1 April 2017, 17 September 2016, and 1 November 2016, for centers in England, Wales, and Scotland, respectively. Cox proportional hazards regression models were used to calculated hazard ratios (HRs) and 95{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} confidence intervals (CIs) for the associations of individual lifestyle behaviors and overall healthy lifestyle score with risks of total and individual microvascular complications in patients with T2D. We imputed the missing values of covariates (≤7{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) using multiple imputations by chained equations with 5 imputations (SAS PROC MI with a fully conditional specification method and PROC MIANALYZE). Linear regression model and logistic regression model with all the covariates in the fully adjusted model were used to impute continuous variables and categorical variables, respectively. The percentage of missing values are present in S1 Table.

Three models were built. In Model 1, we adjusted for age (continuous, years), sex (male, female), Townsend Deprivation Index (continuous), and race/ethnicity (White, others). In Model 2, we further adjusted for education attainment (college or university degree, A/AS levels or equivalent or O levels/GCSEs, NVQ or HND or HNC or equivalent or other professional qualifications, none of the above), sleep duration (<6, 6 to 8, or ≥9 hours/day), family history of CVD (yes, no), family history of hypertension (yes, no), and prevalence of hypertension (yes, no). Finally, in Model 3, diabetes duration (continuous, years), HbA1c (continuous, mmol/mol), use of diabetes medication (none, only oral medicine, insulin, and others), use of antihypertensive medication (yes, no), use of lipid-lowing medication (yes, no), and use of aspirin (yes, no) were additionally adjusted. Further, restricted cubic spline analysis was applied to test dose–response relationships between the healthy lifestyle score and risks of outcomes. We also calculated the population-attributable fractions (PAFs) using the {e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}par SAS Macro (https://www.hsph.harvard.edu/donna-spiegelman/software/par/) to estimate the proportion of microvascular complications that could theoretically be avoided if all participants adhered to 4 or more low-risk lifestyle behaviors.

Mediation effects of biomarkers on the associations of overall lifestyle score with risks of total and individual microvascular complications were evaluated using mediation package in R. Indirect, direct, and total effects for each mediator were computed via combining the mediator and outcome models with the adjustment of all the covariates in Model 3. Nonparametric bootstrap resampling was used to compute the CIs of the proportions of mediations. We selected the available biomarkers from the UK Biobank for the mediation analyses based on knowledge of potential causal pathways to predisposing to microvascular complications or mortality [19,37–40]. The selected biomarkers were considered as potential mediators following two-step analysis. First, we assessed the associations of all biomarkers with the overall lifestyle score using the multivariable-adjusted linear regression models. Second, we evaluated the associations of biomarkers that were significantly associated with the overall lifestyle score, with risks of all the outcomes using the multivariable-adjusted Cox regression model. We then chose the biomarkers significantly associated with each outcome for the mediation analysis accordingly.

In addition, stratified analyses were conducted by age (≤60, >60 years), sex (female, male), education (less than college, college, or above), diabetes duration (≤3, >3 years), use of diabetes medication (yes, no), and HbA1c (≤53, >53 mmol/mol). Interactions between the overall healthy lifestyle score and stratified factors on the risk of outcomes were examined using the likelihood ratio test by adding product terms in the multivariable-adjusted Cox models. Further, we examined the associations of different combinations of low-risk lifestyle behaviors with outcomes.

Several sensitivity analyses were conducted to test the robustness of our results. First, to minimize the potential reverse causation, we performed the analysis among patients with T2D after excluding the cases that occurred within 2 years of follow-up. Second, we generated the overall lifestyle score using low-risk drinking defined as moderate alcohol drinking and never drinking and repeated the main analysis using the new lifestyle score. Third, we constructed the healthy lifestyle score using BMI or waist-to-hip ratio instead of WC. Fourth, we generated a weighted healthy lifestyle score and examined the associations of the weighted healthy lifestyle score with risks of outcomes. Fifth, we investigated the association between the overall lifestyle score and risk of diabetic kidney disease, and mediation analysis for diabetic kidney disease with additional adjustment for kidney function biomarkers. Sixth, we performed the analysis via including the patients with CVD (n = 3,397) at baseline and stratified the associations by preexisting CVD status. Finally, given the potential competing risk of death highlighted during the peer review process, we assessed the associations of healthy lifestyle score with risks of microvascular complications using both the cause-specific hazard model and Fine and Gray subdistribution methods.

We used SAS V.9.4 and R software version 4.0.2 (R Foundation for Statistical Computing) for all statistical analyses. A two-tailed P < 0.05 was considered to be statistically significant.

Results

Baseline characteristics

Among 15,104 participants with T2D (60.3{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} male; mean age, 59.3 years), there were 3,406 (22.6{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}), 6,080 (40.3{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}), 4,062 (26.9{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}), 1,556 (10.3{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) having 0 or 1, 2, 3, and 4 or 5 low-risk lifestyle behaviors, respectively. The baseline characteristics are shown in Table 1. Participants with more low-risk lifestyle behaviors were more likely to be men, White, less deprived, highly educated, sleep recommended hours, have a lower level of HbA1c, and have a lower prevalence of hypertension. They were less likely to use aspirins and medications for diabetes, dyslipidemia, and hypertension. In addition, compared the participants who were excluded due to missing values, those included in the current analysis were more likely to be men, White, less deprived, highly educated, noncurrent smokers, physically active, moderate alcohol drinkers, and eat healthier (S2 Table).

Lifestyle behaviors and outcomes

During 117,445 person-years of follow-up (median 8.1 years; interquartile range 7.3 to 8.8 years; maximum 11.9 years), there occurred 1,639 (10.9{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) deaths and 1,296 (8.6{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) composite microvascular complications cases, including 558 (3.7{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) diabetic retinopathy, 625 (4.1{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) diabetic kidney disease, and 315 (2.1{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) diabetic neuropathy. Among all the cases, one case of diabetic kidney disease was uniquely identified from death records. S3 Table shows the associations between individual lifestyle behaviors and all the outcomes. Being physically active, with lower WC, and moderate alcohol intake were associated with a lower risk of microvascular complications, while noncurrent smoking and healthy diet were not. The overall healthy lifestyle score was associated with lower risks of all the outcomes in a dose–response manner (all Ps for linear trend ≤0.01; Table 2 and Figs 1 and S2). Compared with participants with 0 to 1 low-risk lifestyle behavior, participants with 4 to 5 low-risk lifestyle behaviors had HRs (95{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} CIs) of 0.65 (0.46, 0.91) for diabetic retinopathy, 0.43 (0.30, 0.61) for diabetic kidney disease, 0.46 (0.29, 0.74) for diabetic neuropathy, and 0.54 (0.43, 0.68) for the composite microvascular complications, respectively. For each number increment in low-risk lifestyle behavior, there was a 13{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} lower risk of diabetic retinopathy (HR, 0.87; 95{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} CI: 0.80, 0.95), 22{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} lower risk of diabetic kidney disease (HR, 0.78; 95{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} CI: 0.72, 0.85), 27{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} lower risk of diabetic neuropathy (HR, 0.73; 95{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} CI: 0.65, 0.83), and a 18{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} lower risk of the composite microvascular complications (HR, 0.82; 95{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} CI: 0.77, 0.87).

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Fig 1. Dose–response relationship of the healthy lifestyle score with risk of microvascular complications among individuals with T2D.

X-axis showed the numbers of low-risk lifestyle behaviors, and y-axis showed the HRs of the composite microvascular complications (A), diabetic retinopathy (B), diabetic kidney disease (C), and diabetic neuropathy (D). Black curves were HRs, and grey zones were 95{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} CIs. Multivariable-adjusted models were adjusted for age (continuous, years), sex (male, female), ethnicity (White, others), education attainment (college or university degree, A/AS levels or equivalent or O levels/GCSEs or equivalent or other professional qualifications, or none of the above), Townsend Deprivation Index (continuous), sleep duration (<6, 6–8, or ≥9 hours/day), family history of CVD (yes, no), family history of hypertension (yes, no), prevalence of hypertension (yes, no), diabetes duration (continuous, years), HbA1c (continuous, mmol/mol), use of diabetes medication (none, only oral medication pills, or insulin or others), use of antihypertensive medication (yes, no), use of lipid-lowing medication (yes, no), and use of aspirin (yes, no). All P-nonlinearity were ≥0.09 and all P for overall association were <0.001 (except for diabetic retinopathy: P for overall association = 0.008). CI, confidence interval; CVD, cardiovascular disease; HR, hazard ratio; T2D, type 2 diabetes.


https://doi.org/10.1371/journal.pmed.1004135.g001

In addition, the estimated PAFs of nonadherence to 4 or more low-risk lifestyle factors were 39.0{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} (17.7{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}, 56.8{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) for diabetic kidney disease and 25.3{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} (10.0{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}, 39.4{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}) for the composite microvascular complications (Table 2).

Mediation analysis

All the biomarkers were significantly associated with the overall lifestyle score except for total protein, lipoprotein A, and SBP (S4 Table). The associations between the selected biomarkers and all outcomes are shown in S5 Table. Six significant mediators were detected on the associations of lifestyle score with risk of the composite microvascular complications and diabetic kidney disease, namely, albumin, HDL-C, triglycerides, apolipoprotein A, CRP, and HbA1c. The relationship between the lifestyle behaviors and risk of diabetic neuropathy was mediated by cystatin C, GGT, total bilirubin, albumin, HDL-C, triglycerides, apolipoprotein A, CRP, and HbA1c with the proportion of mediation effect ranging from 3.22{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} to 11.35{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}. Collectively, the mediators explained 23.20{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}, 24.40{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}, and 31.90{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of the associations of overall lifestyle behaviors with composite microvascular complications, diabetic kidney disease, and diabetic neuropathy, respectively. In addition, our data showed that among all the potential biomarkers, only HbA1c was a significant mediator that explained 15.26{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of the relationship between the overall lifestyle score and risk of diabetic retinopathy (Table 3).

Secondary analysis and sensitivity analysis

Consistent results were observed when analyses were stratified by age, sex, education, diabetes duration, use of hypoglycemic medication, and HbA1c level. No significant interaction was observed between the healthy lifestyle score and the stratified factors on the outcomes considering multiple comparisons (S3 Fig). Further, the results of different combinations of low-risk lifestyle factors showed that the increased numbers of low-risk lifestyle factors were associated with graded lower risks of diabetic retinopathy, diabetic kidney disease, diabetic neuropathy, and the composite microvascular complications (S6 Table).

In the sensitivity analyses, the results were generally robust when excluding patients with events that occurred within the first 2 years of follow-up, defining low-risk alcohol intake as moderate drinking and nondrinking, generating the lifestyle score using BMI or waist-to-hip ratio instead of WC, or generating the overall lifestyle score as a weighted score (S7–S10 Tables). The association between overall lifestyle behaviors and risk of diabetic kidney disease was slightly attenuated when estimated glomerular filtration rate (eGFR) was additionally adjusted, and the results of mediation analysis for diabetic kidney disease were largely unchanged with the additional adjustment of eGFR (S11 and S12 Tables). Further, we observed similar results when patients with preexisting CVD were included and in patients with preexisting CVD, although diabetic retinopathy did not reach statistical significance in patients with preexisting CVD probably due to the insufficient power (S13 and S14 Tables). Finally, consistent results were demonstrated when we used 2 competing risk models accounting for the death (S15 Table).

Discussion

In this retrospective cohort study of patients with T2D, adherence to a greater number of healthy lifestyle behaviors, including recommended WC, noncurrent smoking, physically active, healthy diet, and moderate alcohol drinking, was inversely associated with lower risks of diabetic retinopathy, diabetic kidney disease, diabetic neuropathy, and the composite microvascular complications. For each number increment in low-risk lifestyle behavior, there was an 18{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} lower risk of developing diabetic microvascular complications. Moreover, the results of PAFs suggested that 25.3{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of the diabetic microvascular complications could have been avoided if the patients with T2D had 4 or more healthy lifestyle behaviors. In addition, the mediators collectively explained 23.20{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of the associations between the overall healthy lifestyle score and diabetic microvascular complications. Specifically, CRP, albumin, HbA1c, and lipids profile (HDL-C, triglycerides, and apolipoprotein A) could explain 4.44{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} to 10.69{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of the association between overall lifestyle behaviors and the total diabetic microvascular complications.

Our study contributes to the literature regarding the influence of combined healthy lifestyle behaviors on the risk of diabetic microvascular complications. To date, many studies have been performed to evaluate the relationship between individual lifestyle behaviors and risk of diabetic microvascular complications; however, the joint association of multiple lifestyle behaviors with microvascular complications remains unknown. For example, the Irish Longitudinal Study showed that a history of smoking was associated with a higher risk of developing microvascular complications [8]. The Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial (ONTARGET) studies demonstrated that adherence to a healthy dietary pattern (the Alternate Healthy Eating Index) [9], being physically active, and moderate alcohol consumption [12] were associated with a lower risk of incident chronic kidney disease among patients with T2D. Furthermore, general obesity and abdominal obesity were associated with higher risks of diabetic kidney disease [41], diabetic retinopathy [13], and diabetic neuropathy [42].

However, the results of lifestyle interventions on microvascular complications among patients with diabetes or impaired glucose tolerance in clinical trials were inconsistent. The Steno-2 randomized trial including 160 patients with T2D and persistent microalbuminuria showed pharmacological therapies in combination with lifestyle behavior modifications, including adopting a healthy diet, engaging regular physical activity, and participating in smoking cessation courses, significantly reduced the risk of diabetic nephropathy, retinopathy, and neuropathy [43]. Further, the China Da Qing Diabetes Prevention Study including 577 participants with impaired glucose tolerance reported that healthy diet and exercise interventions in combination resulted in a 47{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} reduction in the diabetic retinopathy incidence, but no beneficial effects were observed for diabetic nephropathy or neuropathy [44]. In addition, the Look AHEAD trial consisting of 5,145 overweight or obese patients with T2D, which focused on weight management through increased energy deficit and physical activity, resulted in a significant decrease in chronic kidney disease [45], but not diabetic neuropathy measured by physical examinations [46]. Notably, microvascular complications were not predefined primary outcomes in these trials and small numbers of cases might partially explained the heterogeneities in these findings (e.g., 296 cases of very-high-risk chronic kidney disease in the Look AHEAD trial). Further trials with proper designs are needed to corroborate our findings in the future.

Our mediation analyses contribute to better understanding the lower risk of microvascular complications associated with lifestyle behaviors. Our data showed that the associations of overall lifestyle behaviors with diabetic kidney disease, diabetic neuropathy, and total microvascular complications may be explained by the improvement in glycemic control, liver function, lipid profile, and systemic inflammation, with lifestyle behaviors related lower risk of diabetic neuropathy might be additionally explained by kidney function amelioration. However, our data showed that the association between lifestyle and diabetic retinopathy was mainly through the glycemic control rather than other pathways. Our results corroborate prior findings from the observational studies. For example, intensive lifestyle intervention including physical activity and healthy diet recommendations could benefit glycemic control [47]. Adherence to a combined healthy lifestyle score including healthy diet, physically active, nonsmoking, healthy sleep, and social support were associated with lower concentrations of inflammatory markers [48]. Chronic Renal Insufficiency Cohort (CRIC) Study showed that combined healthy lifestyle characterized as physically active, nonsmoking, and BMI ≥25 kg/m2 were associated with lower risks of atherosclerotic events and kidney function decline among patients with chronic kidney disease [20]. Furthermore, lifestyle modifications including promoting healthy diet, physical activity, and weight loss could significantly improve liver function, renal function, lipid profile, endothelial dysfunction, and reduce systemic inflammation in interventional studies [49–54].

The current study is among the first to investigate the relationship between the overall lifestyle behaviors and diabetic microvascular complications. The strengths of this study included the large sample size, long period of follow-up, and extensive collection of data on clinical biomarkers, which allowed us to comprehensively evaluate the potential mechanisms underlying the observed associations. Despite the strengths, this study should be interpreted in the light of its potential limitations. First, as the microvascular complications were identified via hospital inpatient records and death registries, there might be underreporting of the cases, for example, primary care data were not completely available currently. Second, the self-reported and one-time assessment of lifestyle behaviors data are susceptible to measurement errors. In addition, information on lifestyle behaviors was collected at recruitment and the behaviors may change over time; hence, the observed associations might be attenuated due to nondifferential misclassification bias. Third, mediation analysis assumes causality between lifestyles behaviors and biological biomarkers, although both the lifestyle behaviors and biological mediators were assessed at the same time in the UK Biobank. Future studies with repeatedly measured data are required to replicate our findings. Fourth, our study is limited in terms of ethnic diversity (>85{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} Whites); our results may not be directly generalized to other ethnic groups. Fifth, our study was based on a retrospective sampling from the UK Biobank study; hence, the causality should be interpreted with caution. Sixth, the UK Biobank is not representative of the general population of the UK, particularly relating to socioeconomic deprivation, lifestyles, and noncommunicable disease, with evidence of the healthy volunteer selection bias. Finally, residual or unknown confounding could not be excluded due to the observational study design, although we have in our effort to adjust for the potential confounding factors.

Supporting information

S2 Fig. Dose–response relationship of the healthy lifestyle score with risk of microvascular complications among individuals with T2D (unadjusted model).

X-axis showed the numbers of low-risk lifestyle behaviors, and y-axis showed the HRs of the composite microvascular complications (A), diabetic retinopathy (B), diabetic kidney disease (C), and diabetic neuropathy (D). Black curves were HRs, and grey zones were 95{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} CIs. All P-nonlinearity were ≥0.10, and all P for overall association were <0.001 (except for diabetic retinopathy: P for overall association = 0.005). CI, confidence interval; HR, hazard ratio; T2D, type 2 diabetes.

https://doi.org/10.1371/journal.pmed.1004135.s003

(TIF)

S3 Fig. Stratified analyses of the associations of overall healthy lifestyle score with microvascular complications.

Model 1: unadjusted model. Model 2: age (continuous, years), sex (male, female), race (White, others), education attainment (college or university degree, A/AS levels or equivalent or O levels/GCSEs or equivalent or other professional qualifications, or none of the above), Townsend Deprivation Index (continuous), sleep duration (<6, 6–8, or ≥9 hours/day), family history of CVD (yes, no), family history of hypertension (yes, no), prevalence of hypertension (yes, no), diabetes duration (continuous, years), use of diabetes medication (none, only oral medication pills, or insulin or others), HbA1c (continuous, mmol/mol), use of antihypertensive medication (yes, no), use of lipid-lowing medication (yes, no), and use of aspirin (yes, no), with exception of stratifying factors. Interactions were tested based on Model 2.

https://doi.org/10.1371/journal.pmed.1004135.s004

(TIF)

S7 Table. HRs (95{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} CIs) of microvascular complications according to the overall lifestyle score among individuals with T2D after excluding the cases that occurred within first 2 years of follow-up.

CI, confidence interval; HR, hazard ratio; T2D, type 2 diabetes.

https://doi.org/10.1371/journal.pmed.1004135.s011

(DOCX)

S8 Table. HRs (95{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} CIs) of microvascular complications according to the healthy lifestyle score using moderate drinking and nondrinking as the low-risk behavior in individuals with T2D.

CI, confidence interval; HR, hazard ratio; T2D, type 2 diabetes.

https://doi.org/10.1371/journal.pmed.1004135.s012

(DOCX)

S9 Table. HRs (95{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} CIs) of microvascular complications according to the healthy lifestyle score using optimal BMI or optimal WHR as the low-risk behavior in individuals with T2D.

BMI, body mass index; CI, confidence interval; HR, hazard ratio; T2D, type 2 diabetes; WHR, waist-to-hip ratio.

https://doi.org/10.1371/journal.pmed.1004135.s013

(DOCX)

S11 Table. HRs (95{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} CIs) of diabetic kidney disease according to the healthy lifestyle score among individuals with T2D with additional adjustment for eGFR.

CI, confidence interval; eGFR, estimated glomerular filtration rate; HR, hazard ratio; T2D, type 2 diabetes.

https://doi.org/10.1371/journal.pmed.1004135.s015

(DOCX)

S12 Table. Possible mediators of the associations between the healthy lifestyle score and diabetic kidney disease among individuals with T2D with additional adjustment for eGFR.

eGFR, estimated glomerular filtration rate; T2D, type 2 diabetes.

https://doi.org/10.1371/journal.pmed.1004135.s016

(DOCX)

S13 Table. HRs (95{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} CIs) of microvascular complications according to the healthy lifestyle score in 18,501 individuals with T2D including patients with preexisting macrovascular disease.

CI, confidence interval; HR, hazard ratio; T2D, type 2 diabetes.

https://doi.org/10.1371/journal.pmed.1004135.s017

(DOCX)

Acknowledgments

We are grateful to all the participants of UK Biobank and all the people involved in building the UK Biobank study.

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Clovis Unified to name new elementary school

Clovis Unified to name new elementary school

A new school board in Clovis, California inherits major issues that could take years to resolve, including unionization efforts, teacher pay disputes. (Bee file photo)

A new school board in Clovis, California inherits major issues that could take years to resolve, including unionization efforts, teacher pay disputes. (Bee file photo)


JOHN WALKER

Fresno Bee file

By March, Clovis Unified School District will name its newest elementary school based on community input.

So far, of nearly 300 people surveyed, most believe the school should be named after a local landmark or feature, such as a mountain or something related to agriculture. Many had mixed feelings about naming the school after a person.

Across the country and as close as Central Unified, school districts have changed school names because of a namesake’s views or actions.

“I have some strong feelings on how important it is to honor people who’ve done wonderful things for our school district with school names,” Trustee Steven Fogg said at a Jan. 18 meeting on the topic. “There’s also people who feel that naming schools after people — they’re imperfect.”

Along with the survey of families in the Clovis East area, CUSD will continue garnering input throughout February, district spokesperson Kelly Avants said.

Set to open in August 2024 to prevent overcrowding, the school will be the district’s 35th elementary school, located near Fowler and McKinley avenues in the southeast area of the city.

McKinleyFowlerElementary.jpg
Clovis Unified School District is opening its 35th elementary school at Fowler and McKinley avenues in the southeast area of the city to prevent overcrowding. Pictured is a site drawing of the new school. Courtesy of Clovis Unified School District

Options for names: Person, place or thing

The parent/student committee formed to recommend school name options have been examining the family survey results and previous suggestions for school names.

Laura Reynolds, the new school’s principal, conducted the informal survey of Clovis East families, those from Boris, Reagan, Freedom, Miramonte, Temperance-Kutner, Fancher Creek and Young elementary schools.

From the survey, 52{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of 273 people said the school should be named after a local feature; 22.4{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} chose a person of historical significance, either in the Central Valley or the nation; 13.2{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} prefer a person of “great character” that either works or previously worked in Clovis Unified; and 5.5{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} said an important historical moment.

If the school is named after a local feature, common themes include agriculture, foothills or mountains, blossoms, orchards or the rodeo.

Students at schools with similar names such as Mountain View Elementary and Valley Oak Elementary don’t know the significance of their school name, Fogg said.

“I still feel strongly that we should look at those who have served our community and consider their names though it may be safer to name it after an object,” he said in January.

If the school is named after a person, important characteristics to survey respondents included diversity, veterans, commitment to service in the Valley, honesty or integrity.

If the district were to name the school after an important historical event, survey takers said it should be something related to equality or be meaningful to diversity, shows patriotism, be historically important to CUSD or be related to independence or the revolution.

School names that have been suggested in the past, according to Clovis Unified, are:

  • Carol Putnam, a former principal and district-level administrator

  • Carlo Prandini, a former deputy superintendent

  • Earl and Muriel Smittcamp, longtime Clovis residents and district supporters

  • Einer Cook, a Clovis High graduate and founding board member

  • Gary Prentice, a former Clovis High counselor

  • Jackie Robinson, the first African American to play major league baseball

  • Wanda Rogers, a longtime Clovis resident and district supporter

  • Walt Buster, former superintendent

  • Ralph Lynn, a longtime board member who helped found the Foundation for Clovis Schools

  • Stan King, a former mayor

  • Dan Kaiser, a former deputy superintendent

  • Lloyd Harline, former principal

  • May Case, who established Clovis Independent in 1919 and was the oldest-working journalist who worked until her death at age 93

  • Peg Bos, the first female city council member and former Clovis mayor

  • Jerry Cook, of Cook Land Company, who is still active in the community

Using that information as well as feedback the district continues to gather, the committee will recommend either a person, place or theme, which is outlined in board policy.

What’s next?

The board is expected to vote on the school name at its March 1 meeting as well as the school attendance boundary at its Feb. 15 meeting, the board agenda details. Avants on Friday said the board decided during a subcommittee meeting to name the school in March.

Parents can still access information on the new school, including the boundary study, school location, school site drawings, frequently asked questions and a form to submit feedback online.

A study of school enrollment showed that elementary schools will be overcrowded with over 1,000 students at the Clovis East area elementary schools within 10 years.

Most of the Clovis East area schools’ capacity are at either 750 or 800 students.

The study examined student enrollment for the last 15 years, including student transfers to the district, and accounted for the number of students who’d most likely transfer to Clovis Unified over the next decade.

After the school naming, the principal will lead the effort to pick school mascot and colors.

The Education Lab is a local journalism initiative that highlights education issues critical to the advancement of the San Joaquin Valley. It is funded by donors. Learn about The Bee’s Education Lab at its website.

This story was originally published February 3, 2023 5:30 AM.

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Lasherica Thornton is the Engagement Reporter for The Fresno Bee’s Education Lab in Fresno. She was previously the Education Reporter at The Jackson Sun, a Gannett and USA Today Network paper in Jackson, TN for more than three years.