| Diabetes has become a major public health problem and a global problem in this century.China has 141 million diabetes patients,the largest number of countries in the world.Diabetes and its complications pose a serious threat to the physical and mental health and life safety of patients.There is no effective radical treatment for diabetes at present,lifelong diabetes treatment or management must be undertaken for patients,which brings heavy economic burden to the government,society,and individuals.How to rationally use health resources to effectively prevent and treat diabetes is an important issue that needs to be solved urgently.Clinical practice has found that good dietary adherence is an important means to prevent and treat diabetes,which plays an important role in improving lipid metabolism and maintaining blood glucose levels in patients.However,many studies at home and abroad have shown that the overall level of dietary adherence among T2DM patients is low,and there is no effective intervention measure at present.Therefore,it has become a research hotspot and difficulty in the field of diabetes care to further clarify the influencing factors of dietary adherence of T2DM patients,explore effective intervention methods,help T2DM patients improve dietary adherence and the effectiveness of blood glucose control,reduce or delay the occurrence and development of complications,and improve the quality of life.Inhibitory control,an important factor in the regulation of dietary behavior,has attracted more and more attention in recent years.However,studies have mainly focused on healthy people,people with eating disorders,overweight or obese patients,and restrictive dieters,but less on chronic diseases such as diabetes that require long-term strict dietary management.In addition,many studies at home and abroad have shown that inhibitory control training can effectively improve the healthy dietary behavior of individuals,but whether it can improve the dietary control behavior among T2DM patients is still unclear.Therefore,the current study introduced inhibitory control into the research scope,explored the relationship between inhibitory control and dietary adherence,and empirically studied the effect of inhibitory control training on improving dietary adherence among T2DM patients,so as to provide new ideas and new ways for effectively improving dietary adherence of T2DM patients.Objectives1 To clarify the relationship between inhibitory control and dietary adherence in patients with T2DM.2 To understand the neural mechanism of inhibitory control on dietary adherence in T2DM patients.3 To explore the effect of inhibitory control training on improving the dietary adherence of patients with T2DM.Methods1 Based on subjective perspective,a cross-sectional study design was adopted.The Behavioral Rating Scale for Executive Function-Adult version（BRIEF-A）,the BRIEF Barratt Impulsivity Scale（BIS-Brief）and the Dietary Behavior Compliance Scale for Type2 Diabetes Mellitus were used as measurement tools.The data of inhibitory control,impulsivity and dietary adherence were collected from 393 T2DM patients hospitalized in the Department of Endocrinology of three tertiary hospitals in Xi’an from March to July2022.IBM SPSS 23.0 statistical software was used for data analysis.We performed descriptive statistical analyses,independent sample t test,one-way analysis of variance,Pearson correlation analysis,multiple regression analysis and mediating effect analysis,etc.,to explore the current status and influencing factors of inhibitory control,impulsivity and dietary adherence in T2DM patients,and to further clarify the relationship between inhibitory control,impulsivity and dietary adherence.2 Based on the objective perspective,a cross-sectional study design was adopted.The classic Go/No go task and Stroop task were used as research paradigms,combined with the dietary behavior compliance scale for type 2 diabetes patients.The data of general response inhibitory control（n=105）,general conflict control（n=101）and dietary adherence were collected among T2DM patients hospitalized in the Department of Endocrinology,the Second Affiliated Hospital of Air Force Medical University from April to September 2022.IBM SPSS 23.0 statistical software was used for data analysis.We performed descriptive analysis,independent sample t test,one-way analysis of variance,Pearson correlation analysis,and multiple regression analysis,etc.,to understand the current situation and influencing factors of general response inhibition and general conflict control among T2DM patients,and to further explore the relationship between general response inhibition,general conflict control and dietary adherence.3 A mixed study design of 2（group:dietary adherence qualified group and unqualified group）×2（stimulus:high-calorie and low-calorie food pictures）was used.Group was an inter-subject variable,and stimulus was an intra-subject variable.Using high-calorie and low-calorie food pictures as stimulus materials,the Go/No go task and Stroop task were adapted,combined with ERP technology,and the behavioral data of food specific response inhibition and conflict control and electroencephalogram data of T2DM patients hospitalized in the Department of Endocrinology of the Second Affiliated Hospital of Air Force Medical University from September,2022 to January,2023 were collected（n=61）.Independent sample t test,chi-square test,repeated measures analysis of variance and mixed design analysis of variance were used to explore the behavioral and electrophysiological characteristics of food specific response inhibition and conflict control in T2DM patients with different dietary adherence.4 A total of 62 patients with T2DM hospitalized in the Department of Endocrinology,the Second Affiliated Hospital of Air Force Medical University from October 2022 to January 2023 were randomly divided into two groups,with 31 cases in each group.The intervention group received inhibitory control training,and the control group read popular science articles related to self-control.Behavioral data and clinical indicators such as explicit attitude to food,implicit attitude to food,dietary adherence,fasting blood glucose and postprandial blood glucose,response inhibition and conflict control were collected before and after the intervention.The ERP data of the subjects were collected.The dietary adherence and blood glucose levels of the subjects were tracked and measured 1 week and4 weeks after the intervention.Independent sample t test,chi-square test,repeated measures analysis of variance and mixed design analysis of variance were used to explore the effects of inhibitory control training on dietary adherence of T2DM patients from the aspects of behavioral and neural mechanisms.Results1 Effect of inhibitory control on dietary adherence in patients with T2DM from subjective perspectiveOf the 418 questionnaires distributed,393 were valid questionnaires,with an effective recovery rate of 94.02%.1.1 The correlation between inhibitory control,impulsivity and dietary adherence in patients with T2DMThe inhibitory control score,the total score of impulsivity and the scores of each dimension were negatively correlated with the total score and the scores of each dimension of dietary adherence（p<0.05）.The inhibitory control score was positively correlated with the total score and the scores of all dimensions of impulsivity（p<0.05）.1.2 Multiple linear stepwise regression analysis of influencing factors of dietary adherence in T2DM patientsInhibitory control,poor self-control,BMI,gender and medical expenses had predictive effects on diet adherence of T2DM patients,which could explain 21.2%of the total variation.1.3 Analysis of the mediating effect of poor self-control between inhibitory control and dietary adherencePoor self-control played a partial mediating role between inhibitory control and dietary adherence（mediating effect=-0.066,p=0.043）,and the mediating effect accounted for17.11%of the total effect.2 Effects of inhibitory control on dietary adherence in patients with T2DM from objective perspectiveA total of 114 subjects were recruited in this study,105 cases of response inhibition and 101 cases of conflict inhibition were finally included in the analysis.2.1 The correlation between performance of Stroop task and dietary adherence in patients with T2DMThe Stroop effect and conflict scores were negatively correlated with the compliance behavior of carbohydrate and fat（p<0.05）.2.2 Regression analysis of conflict score on compliance behavior of carbohydrate and fat in T2DM patientsConflict score,medical expenses,family per capita monthly income,and whether hypoglycemia occurred in the past year had a predictive effect on the compliance behavior of carbohydrate and fat in T2DM patients,which could explain 25.7%of the total variation.3 The neural mechanism of inhibitory control on dietary adherence in T2DM patients based on ERP studyA total of 65 subjects were recruited in this study,4 cases dropped out,and 61 cases were finally included in the statistical analysis.3.1 Comparison of the performance in Go/No go task among T2DM patients with different dietary adherenceRepeated measures ANOVA was performed with GoRT and No go correct rates as dependent variables,respectively.The analysis of GoRT found a significant stimulus main effect,F（1,59）=4.39,p=0.041,and the reaction time of patients to high-calorie food was significantly longer than that to low-calorie food.The analysis of the correct rate of No go also found a significant stimulus main effect,F（1,59）=4.20,p=0.045.The correct rate of low-calorie food was significantly higher than that of high-calorie food.3.2 The electrophysiological characteristics in Go/No go task among T2DM patients with different dietary adherenceThe difference amplitude of P2,N2 and P3（No go minus Go condition）was used as the dependent variable to conduct a mixed-design analysis of variance.The analysis of P2difference amplitude showed a significant main effect of brain region,F（2,118）=179.05,p<0.001;The interaction between group（qualified/unqualified）and brain regions（frontal lobe,central brain region,parietal brain region）was significant,F（2,118）=5.29,p=0.007.Further simple effect analysis showed that in the frontal lobe,patients with qualified dietary adherence caused a larger P2 difference amplitude than patients with unqualified dietary adherence,p=0.019.In the central brain region,the qualified diet compliance group caused a larger P2 difference amplitude than the unqualified dietary adherence group,p=0.011.In the parietal region,the difference amplitude margin of P2 in patients with different dietary adherence was significant,p=0.087.The analysis of N2 difference amplitude found a significant brain region main effect,F（2,118）=4.62,p=0.012;The interaction of three factors was significant,F（2,118）=4.27,p=0.017.Further simple effect analysis showed that the difference amplitude of N2 in the central brain region of patients in the qualified group was larger than that in the unqualified group,and the difference margin was significant,p=0.064.The analysis of the difference amplitude of P3 found a significant main effect of brain region,F（2,118）=17.21,p<0.001;The main effect of group was significant,F（2,118）=17.21,p=0.015,and the amplitude of P3 difference induced by qualified dietary adherence was larger than that of unqualified dietary adherence.3.3 Comparison of the performance in Stroop task among T2DM patients with different dietary adherenceRepeated measures ANOVA was performed with Stroop effect and conflict score as dependent variables,respectively.The analysis of Stroop effect found a significant stimulus main effect,F（1,59）=24.08,p<0.001.The Stroop effect of high-calorie food was significantly greater than that of low-calorie food.The analysis of conflict score also found a significant stimulus main effect,F（1,59）=22.38,p<0.001,and the conflict score of patients for high-calorie food was significantly higher than that for low-calorie food.3.4 Electrophysiological characteristics in Stroop task among T2DM patients with different dietary adherenceThe amplitude of P2,N2 and P3 under inconsistent condition were used as dependent variables to conduct a mixed-design analysis of variance.The analysis of P2 amplitude showed a significant main effect of brain region,F（2,118）=10.68,p<0.001;The interaction of three factors was significant,F（2,118）=4.44,p=0.015.Simple effect analysis showed that the P2 amplitude induced by high-calorie and low-calorie food pictures in the T2DM patients with qualified dietary adherence was significantly larger than that in the patients with unqualified dietary adherence,p=0.010 and p=0.025,respectively.When the dietary adherence group was stimulated by low-calorie food pictures,the P2 amplitude in the parietal brain region evoked by the qualified dietary adherence group was larger than that of the unqualified dietary adherence group,and the difference margin was significant,p=0.057.The P2 amplitude in the central brain region evoked by low-calorie food picture stimulation in the qualified dietary adherence group was significantly higher than that in the unqualified dietary adherence group,p=0.026.The analysis of N2 amplitude showed a significant regional main effect,F（2,118）=10.78,p<0.001.Further analysis showed that the amplitude of N2 amplitude in frontal lobe was larger than that in parietal lobe,p=0.001.The amplitudes in the central brain regions were larger than those in the parietal brain regions,p=0.001.The analysis of P3 amplitude showed that the main effect of brain region was significant,F（2,118）=5.78,p=0.004.Further analysis showed that the amplitude of parietal lobe was larger than that of frontal lobe,p=0.014.The amplitudes in the parietal regions were larger than those in the central regions,p=0.009.4 Behavioral study on the effect of inhibitory control training on dietary adherence of patients with T2DMA total of 62 subjects were recruited in this study,9 cases dropped out,and 53 cases were finally included in the statistical analysis.4.1 Changes in the score of food picture evaluation in T2DM patients before and after interventionThe interaction between time and group on craving for high-calorie food was significant F（1,51）=7.10,p=0.011.After the intervention,the craving for high-calorie food in the intervention group was significantly lower than that before the intervention,F（1,51）=4.44,p=0.041.4.2 Changes of food implicit effect in T2DM patients before and after interventionThe interaction between time and group of implicit preference for low-calorie food in the two groups was significant,F（1,51）=4.80,p=0.033.After the intervention,the implicit preference for low-calorie food in the control group was significantly lower than that before the intervention,F（1,51）=7.65,p=0.008.And the D score of the control group was negative（-0.003±0.66）after intervention.4.3 Changes of inhibitory control task performance in T2DM patients before and after interventionThe interaction between time and group of Stroop effect on high-calorie food was significant in the two groups,F（1,51）=6.58,p=0.013.After intervention,the Stroop effect on high-calorie food in the intervention group was significantly reduced,F（1,51）=8.76,p=0.005.5 The neural mechanism of inhibitory control training on dietary adherence in patients with T2DM based on ERP studyA total of 62 subjects were recruited,1 case dropped out,and 61 cases were finally included in the statistical analysis.5.1 The changes of Electrophysiological indexes in Go/No go task before and after interventionThe difference amplitudes of P2,N2 and P3 in the frontal lobe were used as the dependent variable to conduct a mixed-design analysis of variance.The analysis of P2difference amplitude showed that the main effect of pictures was significant,F（1,59）=5.02,p=0.030.Low-calorie food pictures caused larger P2 difference amplitude than high-calorie food pictures.The interaction between time and group was significant,F（1,59）=5.59,p=0.023.Further simple effect analysis showed that,after intervention the intervention group caused smaller P2 difference amplitude than before intervention,p=0.020;In the control group,there was no significant difference in P2 amplitude before and after intervention,p=0.403.The analysis of N2 difference amplitude showed that the main effect of time was significant,F（1,59）=11.17,p=0.002,and the difference amplitude of N2 after intervention was larger than that before intervention.The main effect of pictures was significant,F（1,59）=4.65,p=0.037.High-calorie food pictures caused a larger N2 difference amplitude than low-calorie food pictures.The interaction between time and group was significant,F（1,59）=4.97,p=0.031.Further simple effect analysis showed that,after the intervention the intervention group caused a larger N2 difference amplitude than before the intervention,p=0.001;In the control group,there was no significant difference in the amplitude of N2difference before and after intervention,p=0.409.The analysis of the difference amplitude of P3 showed that the main effect of time was significant,F（1,59）=10.15,p=0.003,and the difference amplitude of P3 after the intervention was larger than that before the intervention.5.2 The changes of Electrophysiological indexes in Stroop task before and after interventionThe amplitude of P2,N2 and P3 in the frontal lobe was used as the dependent variable to conduct a mixed-design analysis of variance.The analysis of P2 amplitude showed that the interaction between time and group was significant,F（1,59）=4.39,p=0.043.Further simple effect analysis showed that after intervention the intervention group caused a smaller P2 amplitude trend than before intervention,p=0.140;In contrast,In the control group,after intervention caused a trend of greater P2 amplitude than before intervention,p=0.151.The analysis of N2 amplitude showed that the main effect edge of time was significant,and the N2 amplitude after intervention was larger than that before intervention,F（1,59）=3.82,p=0.057.The interaction margin between time and group was significant,F（1,59）=3.82,p=0.057.Simple effect analysis showed that the intervention group the N2 amplitude was larger after intervention than before intervention,p=0.011;In the control group,there was no significant difference in N2 amplitude before and after intervention,p=0.926.The analysis of P3 amplitude showed that the main effect of time was significant,F（1,59）=7.02,p=0.011,and the post-intervention elicited a larger P3 amplitude than the pre-intervention.Conclusion1 Inhibitory control has a positive predictive effect on dietary adherence in T2DM patients.The stronger the inhibitory control ability,the better the dietary adherence.2 There are significant differences in the characteristics of neuroelectrophysiological activities in T2DM patients with different dietary adherence.The higher the dietary adherence,the larger the P2 and P3 amplitude,indicating the stronger the attentional bias andinhibitory control ability to food.3 Inhibitory control training can effectively reduce the degree of craving for high-calorie food in T2DM patients,and strengthen their implicit preference for low-calorie food;In addition,the intervention significantly improved patients’conflict control ability to food.4 Larger N2 amplitude and smaller P2 amplitude were induced after inhibitory control training,indicating that inhibitory control training enhanced patients’inhibitory control ability to food and reduced their attentional bias to food. |
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