In the present randomized controlled clinical trial, the effect of an anti-inflammatory diet alone or in combination with acupuncture on mental health, anthropometric indices, and metabolic status were examined in diabetic patients with depression.
Eligibility criteria: Inclusion criteria were as follows: (i) both genders, (ii) aged 20–75 years old, (iii) suffering from T2DM for more than 6 months, (iv) taking oral anti-diabetic medications, and (v) suffering from mild-to-moderate depression. Patients were excluded if they injected insulin or liraglutide, take medicinal herbs or herbal medicine, antibiotics, antioxidant supplements (multivitamins & minerals, vitamin E, vitamin C, Zinc), suffer from severe depression, have heart-vascular diseases, chronic liver and kidney disease, untreated thyroid and any other diabetes complications leads to inflammatory and oxidative conditions, other types of diabetes and taking psychiatry medications. Pregnancy and lactation were also considered as exclusion criteria.
Intervention
Eligible patients were selected randomly from those referred to a Diabetic clinic affiliated with Tehran University of Medical Sciences. Before starting the trial, the study was explained to eligible individuals and if they volunteered to participate, they would sign the written informed consent.
Eligible individuals received either: (i) an individualized anti-inflammatory diet with acupuncture therapy, (ii) an individualized anti-inflammatory diet, or (iii) common treatment and dietary recommendations (control group). Notably, all three groups received common treatment (medications, weight-loss diet in overweight and obese subjects, and healthy dietary recommendations) throughout the study. Patients were asked to report any changes in the type and dosage of medications throughout the study.
Diet
For each participant, an individualized diet considering the participants’ characteristics was designed by a nutritionist. Mifflin formula (29) was used for the calculation of resting metabolic rate. Of the total calculated calories, 50%, 20%, and 30% were dedicated to carbohydrate, protein and fat, respectively. If participants were overweight or obese, 500 kcal/day was subtracted from the total calculated calorie.
To reduce the inflammatory potential of an individual's overall diet, 45 food items [21], with pro-inflammatory, anti-inflammatory characteristics, applied for the calculation of dietary inflammatory factors (DII) were considered. To reduce dietary inflammation, food and components with lower DII were taken into account as well as this pro-inflammatory dietary component was restricted.
In general, considering pro- and anti-inflammatory food parameters, food sources, and participants’ characteristics, an individualized anti-inflammatory diet was designed for both intervention groups.
Acupuncture: Acupuncture was performed for two sessions (30 minutes in each session) per week for a period of 8 weeks. Acupoints were selected based on WHO standard acupuncture point locations in the Western Pacific regions and needle manipulation techniques were based on an acupuncture textbook in China. The main acupuncture points (n = 22) were as follows: DU20, LV3 (Bilateral), SP6 (Bilateral), ST36 (Bilateral), ST25 (Bilateral), SP15 (Bilateral), PC6 (Bilateral), HT7 (Bilateral), Sishencong (EX-HN 1), Yintang (EX-HN 3), Ren4, Ren6.
Our designed protocol for "Diabetic patients with Depression" emphasized treating different dimensions, etiologies, and symptoms of depression, and we avoided points that were proven to have blood sugar-increasing effects.
Sample size
In the present clinical trial with 3 study groups, type 2 diabetic patients with depression (mild to moderate) were examined and our primary outcome was depression. The sample size was calculated using the G*Power analysis program. The true difference between the mean was assumed to be 5 scores in depression. Considering ANOVA as a statistical test, the number of groups = 3, alpha error 0.05, power 80%, and effect size f = 0.33, 30 subjects are needed for each study group.
Outcomes
In the present study, depression was our primary outcome, and biochemical parameters (FBS, HbA1c, TC, TG, LDL-C, HDL-C, hs-CRP), anxiety, and anthropometric indices (body weight, body mass index, waist circumference) and dietary intake were as our secondary outcomes.
Recruitment
At the beginning of the study, eligible individuals were examined using the
Montgomery–Åsberg Depression Rating Scale (MADRS) questionnaire via a face-to-face interview. Based on the score obtained, individuals judged to be suffering from mild-to-moderate depression (a score of 7–34) were not included patients with severe depression were referred to a psychologist. Notably, all patients received common treatment and no changes in dosage and the type of medications occurred throughout the study. In addition, participants were asked not to change their physical activity during the study. As patients with mild-to-moderate depression usually do not receive anti-depressant drugs, we included only these patients.
Eligible patients were selected randomly from those referred to Diabetic clinics affiliated with Tehran University of Medical Sciences. Before starting the trial, the study was explained to eligible individuals and if they wanted to participate, they would sign the written informed consent. Randomization: Before the intervention, all eligible subjects entered the two-week run-in period. After a 2-week run-in period, volunteers were randomly allocated (1:1:1) to one of the three following groups: (i) receiving an individualized anti-inflammatory diet with acupuncture therapy (n = 30), (ii) receiving only an individualized anti-inflammatory diet, and (iii) receiving a common diet with dietary recommendations (control group) (n = 30).
Notably, volunteers were randomized and allocated to each group based on the severity of depression (mild, moderate). The randomization was carried out using an online system (https://www.sealedenvelope.com/). Once the randomization has been made, each patient is given a code with which she/he was identified throughout the study. The randomization numbers were assigned consecutively. Randomization was not exposed to those conducting the study and was provided in sealed opaque envelopes with successive numbers. The envelope was opened after signing the informed consent form and complying with the eligibility criteria by the patients. Blinding: Due to the type of intervention in this study, complete blindness is not possible. Only statistical analysis was blinded.
Data collection
Participants were followed for 8 weeks to examine any changes in mental health (depression, anxiety), metabolic parameters (FBS, HbA1c, TC, TG, LDL-C, HDL-C, hs-CRP), anthropometric indices (body weight, body mass index, waist circumference and body composition) and dietary intake following the intervention. At the beginning and the end of the first and second month of the study, three 24-hour dietary recalls (2 work days, 1 weekend), a physical activity questionnaire, and anthropometric measurements with standard methods were obtained. In addition, at the beginning and the end of the study, depression and biochemical parameters were assessed. Visit descriptions are provided in Table 1.
The assessments of mental health: Depression and anxiety will be examined using MADRS and the Beck questionnaire, respectively. Physical activity information was obtained through the International Physical Activity Questionnaire (IPAQ) (36) at baseline and at the end of the study via a face-to-face interview. To examine depression, the MADRS questionnaire was used. In the present study, we applied the Persian form of MADRS including 10 questions that its validity and reliability were evaluated earlier [22]. Usual cutoff points are as follows: 0 to 6: normal, 7 to 19: mild depression, 20 to 34: moderate depression, > 34: severe depression. Accordingly, only patients with a score between 7 and 34 were included.
To assess anxiety, the Beck questionnaire (21 items) was used. Individuals with a score of 0–7 were considered as having the least anxiety and those with a score of 26–63 were considered as people with severe anxiety.
Anthropometric indices measurements: A digital weighing scale (Seca 725 GmbH & Co., Hamburg, Germany) was used for body weight measurement to the nearest 0.1 kg. Body weight and height (precision measurement: 0.5 cm) were measured using standard methods. BMI was computed by dividing the weight (kg) by the square of height 11 (m). Waist circumference (WC) was measured to the nearest 0.5 cm at the midpoint between the lower border of the rib cage and the iliac crest using a flexible tape (cm).
Biochemical measurement
At the beginning and the end of the study, after 12–14 hours of fasting, 10 cc of blood was collected from the left arm arterial of study participants. Blood was taken in a sitting posture. The serum was separated by centrifugation and stored in the freezer at -70°C until the measurement of the biochemical indicators. Notably, FBS and serum lipid levels were immediately measured after blood sampling. All biochemical variables were examined by commercial biochemical kits according to the manufacturer’s protocol.
Ethical and confidential issues: All participants provided written informed consent at the beginning of the study. All participant information is kept in a password-protected file with restricted access. To maintain participant confidence, a code identification number is used to identify data collection and forms. This research was conducted following the principles of the Declaration of Helsinki and was registered in the National Institute for Medical Research Development (NIMAD) with the Ethic code of IR.NIMAD.REC.1398.340. The protocol was registered in the Iranian Registry of Clinical trial (IRCTID: IRCT20110314006065N3).
Statistical Methods
Descriptive information was presented by mean ± Standard deviation (SD) or number (Percent), and was compared using Mann-Whitney U and Pearson Chi-Square tests between the study groups. Shapiro-Wilk test was also applied to assess the normality assumption within the groups. Furthermore, the Generalized Estimating Equations (GEE) model Adjusted for age, duration of diabetes, and total energy was performed to evaluate the between and within groups differences in terms of fat and anthropometric indices. In addition, Generalized Linear Models (GLM) Adjusted for age, weight, duration of diabetes, total energy, and the outcome baseline value were used to compare the groups in terms of depression, anxiety, biomarkers, and nutritional parameters. Both models were followed by the least significant difference (LSD) post-hoc test for pairwise comparisons between or within groups. All analyses were performed through IBM SPSS version 24 and P-values less than 0.05 were considered as statistically significant.