Category: Diet

Lifestyle interventions for diabetes prevention

Lifestyle interventions for diabetes prevention

Lifestyle interventions for diabetes prevention a complete list of the members of the Lifestyle interventions for diabetes prevention Research Group, please see reference prevdntion. Review of external validity reporting in childhood obesity prevention research. Psychol Med. Long-term effects of a community-based lifestyle intervention to prevent type 2 diabetes: the DEPLOY extension pilot study.


Lifestyle interventions can help in diabetes prevention

Lifestyle interventions for diabetes prevention -

Impaired glucose regulation is an intermediate condition between normal glucose regulation and type 2 diabetes, which confers an increased risk of progression to type 2 diabetes 4.

Indeed, within-trial data show that the rate of progression to type 2 diabetes at 7 years of follow-up was reduced to almost zero for people who had succeeded in making five modest lifestyle changes 2.

The main drivers of diabetes prevention appear to be weight loss and physical activity 5 , 6. However, a substantial challenge remains in translating these findings into routine clinical practice. The intensive and prohibitively expensive interventions used in clinical trials, to ensure lifestyle change, need to be translated into practical affordable interventions that are deliverable in real-world health care systems and which, nevertheless, retain a reasonable degree of effectiveness 7.

A meta-analysis of the evidence on translational interventions was published in 9 , although this review excluded 15 studies that were conducted in non—health care settings. A more recent meta-analysis was published in However, the authors only focused on translation of evidence from the U.

Diabetes Prevention Program and also included studies where up to half of the population already had diabetes. Other systematic reviews of diabetes prevention interventions have either not included a meta-analysis 6 , 8 , 14 — 17 or have not focused on translational studies 3 , 6 , 15 , 16 , 18 — Overall, the systematic reviews conducted to date indicate that real-world diabetes prevention programs vary widely in their effectiveness, although most produce lower levels of weight loss than the more intensive interventions used in the clinical efficacy trials 9.

Explaining this variation is important. If we can identify the components of lifestyle interventions that are reliably associated with increased effectiveness, this will inform the design of more efficient cost-effective diabetes prevention programs.

Recently published evidence-based guidelines 23 , 24 make distinct recommendations about which intervention components should be included to maximize the effectiveness of lifestyle interventions for diabetes prevention. Such recommendations include the use of group-based interventions to minimize cost and the use of specific behavior-change strategies that are associated with increased effectiveness.

These recommendations come from systematic reviews of the wider literature on supporting changes in diet and physical activity in a range of populations 25 , Lifestyle interventions for diabetes prevention vary in their content; however, whether closer adherence to the guideline recommendations might improve the performance of real-world diabetes prevention interventions remains unclear.

To consolidate the evidence, we undertook a systematic review of studies considering the effectiveness of translational interventions for prevention of type 2 diabetes in high-risk populations.

The primary aim was to conduct a meta-analysis of the effectiveness of pragmatic interventions on weight loss and conduct a meta-regression to examine whether closer adherence to guideline recommendations for diabetes prevention improves the effectiveness of real-world interventions.

If sufficient data were available, a secondary aim was to consider other diabetes risk factors using similar methods.

We included experimental and observational studies that considered the effectiveness of a lifestyle intervention diet or exercise alone or compared with control, where the stated aim of the intervention was diabetes risk reduction or prevention of type 2 diabetes, and where the focus of the study was to translate evidence from previous diabetes efficacy trials into routine health care or a community setting.

We included only studies published in the English language and as full-length articles. We searched Embase, MEDLINE, and the Cochrane Library Issue 7, , using a combination of MeSH terms and keywords that were tailored to individual bibliographic databases.

We restricted searches to articles published after January ; the starting point of was chosen to facilitate the identification of studies that were informed by or translating evidence from previous diabetes prevention efficacy trials 1 , 10 — In order to avoid missing papers, the final search strategy included only terms related to the intervention and the study design.

An example search strategy MEDLINE is outlined in Supplementary Table 1. We combined the results of an initial search and an updated supplementary search, which together identified papers up to the end of July Two reviewers independently assessed abstracts and titles for eligibility and retrieved potentially relevant articles, with differences resolved by a third reviewer where necessary.

Where studies appeared to meet all the inclusion criteria but data were incomplete, we contacted authors for additional data or clarification. In an attempt to identify further papers not identified through electronic searching, we examined the reference lists of included papers and relevant reviews.

Data were extracted by one reviewer, and a second reviewer subsequently checked for consistency. We extracted data on sample size, population demographics, intervention details, and length of follow-up.

Incidence of type 2 diabetes was also recorded. We retrieved all papers relating to a particular study, including those on design and methodology if reported separately , and any Supplementary Data. We assessed the quality of selected studies according to the U.

We coded intervention content Supplementary Tables 1 and 3 in relation to the recommendations for lifestyle interventions for the prevention of diabetes provided by both the IMAGE project Development and Implementation of a European Guideline and Training Standards for Diabetes prevention 23 and NICE Where a study intervention was inadequately described, we requested further details from the authors.

If available information was insufficient to allow coding, we coded data as missing; where an intervention appeared to be well described but a particular component e.

In the analysis, we assumed that missing values indicated that the guideline criterion was not met. We converted all values reported in imperial units into metric units. Capillary blood glucose values were converted to plasma equivalent values If studies did not directly report the mean SD, for change from baseline to 12 months for the outcomes of interest, they were calculated.

We calculated the mean change by subtracting the baseline mean value from the mean at 12 months. We calculated the SD from reported P values or CI, as recommended by the Cochrane Collaboration Where data were insufficient, to allow calculation of the SD, we imputed values for each outcome based on the correlation estimates from those studies that reported; for weight, the correlation used in these imputations was 0.

For the primary outcome of interest weight , we conducted direct pairwise comparison meta-analyses to examine the effect size change from baseline to 12 months where data were available.

Only intervention arms were included in the meta-analysis. This was because we were interested in whether adherence to guidelines improved weight loss; therefore, only arms in which people received an intervention were applicable.

Meta-regression was used to assess the relationship between weight change at 12 months and the total IMAGE guidance score and the total NICE guidance score, as explanatory variables, in separate univariate analyses.

We performed further metaregression with the individual guideline components as the explanatory variables where at least three studies fell into each category.

We conducted similar analyses for the secondary outcomes of interest; however, as these outcomes were reported in fewer studies and to avoid multiple testing, metaregression of individual guideline components against secondary outcomes was not performed.

We performed sensitivity analyses for the primary outcome, weight, where missing guideline data were treated as unknown and a total guidance score was not given for those studies and where we restricted the analysis to RCTs only.

We assessed publication bias using the Egger test and heterogeneity using the I 2 statistic. Due to high levels of heterogeneity, we used random-effects models throughout to calculate effect sizes. We performed all analyses in Stata version Results relating to identification and selection of eligible trials are summarized in Fig.

Searches yielded 6, citations, and 3, unique titles or abstracts were screened for eligibility. After full text retrieval of potentially relevant papers, 20 additional papers were identified from reference lists, making a total of Authors for 13 studies were then contacted in order to clarify eligibility criteria or for additional outcome data.

Replies were received for 12 studies, 10 of which were subsequently included in the 25 studies 30 — 54 35 articles [ 30 — 64 ] that met the review criteria. Flowchart of selection of studies from search to final inclusion.

DM, diabetes mellitus; T2DM, type 2 diabetes mellitus. The 25 studies 30 — 54 included in the systematic review are summarized in Table 1. Study interventions included either dietary intervention or physical activity intervention or both.

One study focused solely on the effectiveness of physical activity intervention 54 , 1 combined dietary intervention and a supervised exercise program 44 , and 23 considered the effectiveness of combined dietary and physical activity intervention. Eleven of the studies were RCTs, 11 were before and after studies, and the remaining studies included a matched cohort, a prospective cohort, and a nonrandomized controlled trial.

All papers were published within the last 10 years. Studies were conducted in the U. The criteria used, alone or in combination, to identify high risk included elevated BMI; elevated diabetes risk score Finnish Diabetes Risk Score [FINDRISC] [ 65 ], American Diabetes Association [ADA] [ 66 ] ; raised random, fasting, or 2-h glucose finger prick or venous sample ; older age; ethnicity; family history of diabetes; and previous medical history of cardiovascular disease, polycystic ovary syndrome, gestational diabetes mellitus, metabolic syndrome, or elevated BP or lipids.

Outcome data for change in weight were available for 24 of 25 studies not Costa [ 39 ] ; 22 of 25 studies reported weight at 12 months Supplementary Table 4.

Additional month data reported for 23 studies Supplementary Tables 1 and 5 included change in BMI 18 studies , waist size 16 , fasting glucose 15 , 2-h glucose 10 HbA 1c 7 , total cholesterol 13 , LDL 7 , HDL 12 , triglycerides 10 , systolic BP 13 , diastolic BP 11 , and the incidence of diabetes after 12 months 8.

Outcome data for change in physical activity and diet were poorly reported. Overall, considerable heterogeneity was evident between studies in relation to several key characteristics including the setting, population, criteria used to identify diabetes risk, interventions, and follow-up.

A breakdown of study quality is presented in Supplementary Table 6. Most studies achieved a high-quality grading for internal validity 19 of Details of coding scores for study interventions are presented in Supplementary Table 3.

One study was excluded from the primary meta-analysis, as weight change was not recorded as a study outcome 39 , and two studies were excluded from all analyses, as they only reported month data 45 , Two studies included in the meta-analysis had two intervention arms 43 , 54 , meaning that 24 study groups were analyzed.

The pooled result of the direct pairwise meta-analysis Fig. Supplementary Figs. Greater adherence to guideline recommendations was significantly associated with greater weight loss for both sets of guidelines Table 2. Adherence to individual guideline elements also tended to result in greater weight loss, some of which were statistically significant Table 2.

Sensitivity analyses without imputed data are also shown in Table 2. Forest plot showing mean weight change in each study and the overall pooled estimate. Size of box is proportional to weight of that study result. PREPARE, Pre-diabetes Risk Education and Physical Activity Recommendation and Encouragement.

A high-quality color representation of this figure is available in the online issue. None of the study level covariates proportion of males, mean age, proportion of white European ethnicity were significantly associated with the mean difference in weight change.

All other outcomes showed an improvement at 12 months Supplementary Table 7 , but not all of these reached statistical significance. Supplementary Table 8 shows the effect of adherence to NICE and IMAGE guidelines on the other outcomes.

There was no effect on any of the other outcomes. The 22 translational diabetes prevention programs included in our meta-analysis significantly reduced weight in their intervention arms by a mean 2. Where data were available, we found significant reductions in other diabetes and cardiovascular risk factors, including blood glucose, BP, and some cholesterol measures.

Adherence to guideline recommendations on intervention content and delivery was significantly associated with a greater weight loss such that, for each 1-point increase on the point scale for adherence to NICE recommendations an additional 0.

Outcome data on changes in the key lifestyle behavior targets physical activity and diet were poorly reported. The mean level of weight loss achieved was approximately one-half to one-third of the levels reported at the same time point within the intervention arms of clinical efficacy trials such as the U.

This is consistent with the findings of a meta-analytic systematic review published in by Cardona-Morrell et al. Cardona-Morrell et al. This is based on data from the U. Furthermore, a recent meta-analysis, which included studies without an intervention in order to look at natural diabetes progression rates in high-risk individuals, found progression rates to diabetes from impaired fasting glucose, impaired glucose tolerance, and both were 47, 56, and 76 per 1, person-years, respectively The rate of 34 per 1, person-years that we found suggests that the real-world lifestyle interventions studied here did lower diabetes progression rates.

This amount was slightly lower than was demonstrated by a recent meta-analysis conducted by Ali et al. This difference may in part be due to a lower mean BMI at baseline for studies included in our review, compared with the Ali et al.

Additionally, their review focused on interventions based only on the U. DPP, where we considered a broader set of interventions. However, few of the studies that we examined provided data on dietary intake or physical activity, so we cannot be sure whether diabetes prevention in these studies is driven by increased physical activity, dietary change, or both.

The strong association between increased weight loss and increased adherence to guideline recommendations is of particular interest. This may reflect a reduction in the statistical noise caused by missing data, or it may reflect the fact that studies that had a stronger behavioral science input were more likely to report the intervention content in detail and were also more likely to be effective.

Although many online tracking programs can help you log food and physical activity, CDC-recognized lifestyle change programs provide important feedback from a lifestyle coach on what you log so you can make changes to reach your goals.

An online program is a great option if you find it hard to attend regular on-site meetings or there is not an in-person program near you. This is a great option for participants who want group interaction, but live in remote areas and cannot attend an in-person program.

Year-long lifestyle change programs are delivered as a combination of any of the previously defined delivery modes for all participants by trained Lifestyle Coaches. Not sure about your risk for prediabetes and type 2 diabetes? Take our online prediabetes risk test.

Ready to make a change? Find a Program today. To receive email updates about the National Diabetes Prevention Program National DPP enter your email address:. Skip directly to site content Skip directly to search. Español Other Languages. Lifestyle Change Program Details. Español Spanish.

Minus Related Pages. Take Action. Find a program Take the Risk Test Testimonials from Participants Watch videos about the National DPP. Are You Eligible? Find out if you meet the requirements to join a lifestyle change program in person or online. Key components of the program include:.

To achieve standardization of the intervention, an initial structured core curriculum was given to all participants. A more flexible maintenance program of individual sessions, group classes, motivational campaigns, and restart opportunities followed this.

The lifestyle intervention commenced with a session core curriculum that was to be completed within the first 24 weeks after randomization.

The session core curriculum was the most structured phase of the DPP lifestyle intervention and ensured that all participants were taught the same basic information about nutrition, physical activity, and behavioral self-management Table 2.

Similar to other state-of-the-art behavioral weight control programs, the first eight sessions presented the goals for the DPP lifestyle intervention, taught fundamental information about modifying energy intake and increasing energy output, and helped participants to self-monitor their intake and physical activity.

The latter eight sessions focused on the psychological, social, and motivational challenges involved in maintaining these healthy lifestyle behaviors in the long term. Key behavioral and nutrition strategies that were introduced in the core curriculum included the following:.

Participants were weighed privately at the start of every individual session and were encouraged to weigh themselves at home daily or a minimum of once per week. If participants did not have a bathroom scale at home, they were given one.

Emphasis was placed on using the scale as an important feedback and learning tool for how to better regulate personal diet and exercise behaviors. The initial focus of the dietary intervention was on reducing total fat rather than calories. This allowed participants to accomplish a reduction in caloric intake while at the same time emphasizing overall healthy eating and streamlined the self-monitoring requirements, which was important given the diversity of educational and literacy levels among participants.

After several weeks, the concept of calorie balance and the need to restrict calories as well as fat was introduced. The fat and calorie goals were used as a means to achieve the weight loss goal rather than as a goal in and of itself.

Therefore, if a participant reported consuming more than the calorie or fat goal but was losing weight as planned, the coach did not emphasize greater calorie or fat reduction.

Participants were encouraged to gradually achieve the fat and calorie levels through better choices of meals and snack items, healthier food preparation techniques, and careful selection of restaurants, including fast food, and the items offered.

All participants were instructed to self-monitor fat and calorie intake daily throughout the first 24 weeks of the study and to record their minutes of physical activity. Self-monitoring was stressed as one of, if not the most, important strategy for changing diet and exercise behaviors.

At the start of the core curriculum sessions, participants were given a food scale and measuring cups and spoons. Self-monitoring skills were taught gradually over the first few weeks of the core curriculum.

The lifestyle coach briefly reviewed the self-monitoring booklets with the participants during each session, reinforcing any noticeable positive behavior change and avoiding criticism. The booklets were more thoroughly reviewed between sessions and written constructive comments were provided.

The maintenance program used in the DPP was more intensive than that used in other clinical trials 6 , 7 and combined both group and individual contact.

After completing the session core curriculum, the protocol required that participants be seen face-to-face at least once every 2 months for the remainder of the trial and be contacted by phone at least once between visits.

Although these in-person contacts were usually one-on-one, they could occur in a group as long as there was an opportunity to weigh the participant and assist the individual with problem-solving regarding adherence. Based on behavioral literature showing the importance of continued contact during maintenance 23 , coaches were encouraged to meet with participants as often as needed to support participant adherence and transition gradually from more frequent to less frequent contact if decreased frequency of contact did not adversely affect maintenance.

The majority of participants were seen more frequently than the minimum, with some participants continuing to attend weekly or biweekly sessions.

The Lifestyle Resource Core developed a variety of lessons and participant handouts, and lifestyle coaches were encouraged to use materials related to the topics of greatest interest and concern to their individual participants.

htmlvdoc provides further guidelines for implementing the maintenance phase of the intervention. Participants were encouraged to continue self-monitoring their intake for 1 week every month during maintenance.

If participants were succeeding at weight loss maintenance, self-monitoring was encouraged but not as strongly emphasized. To simplify self-monitoring and encourage adherence to the calorie and fat goals, structured meal plans and meal-replacement products were provided as an option for participants.

Each clinical center was also required to offer three group courses each lasting 4—8 weeks per year during the maintenance phase. Participants were strongly encouraged but not required to attend these classes.

Popular classes included resistance training, vegetarian cooking, and restart programs for those desiring to re-initiate intensive weight loss efforts.

Three to four motivational campaigns were also developed per year to assist with maintenance of the weight and physical activity goals. In several campaigns, local participant teams or DPP centers competed for the best attendance, self-monitoring, weight loss, minutes of physical activity, or steps as measured by pedometer Accusplit Digi-Walker.

Participants received supplemental materials reflecting the content and theme of the campaigns such as self-monitoring postcards, magnets, weight graphs, newsletters, T-shirts, and other small incentives. The protocol required that each clinical center offer supervised physical activity sessions at least two times per week throughout the trial.

Attendance was voluntary. The types of supervised activity sessions varied across centers and included neighborhood group walks, enrolling participants in the cardiac rehabilitation programs affiliated with the DPP clinical center, community aerobic classes e. All supervised activity sessions were led by a DPP staff member or someone trained by a DPP staff member as to the goals of the DPP lifestyle intervention.

The session leaders documented attendance at all supervised activity sessions. DPP participants encountered a variety of barriers to adherence over the course of the trial.

Lifestyle coaches were encouraged to work with each participant individually to identify the specific barriers and possible solutions to these barriers. The toolbox was arranged in a hierarchy from less expensive to more expensive approaches in terms of staff time as well as money and contained problem-solving strategies and reinforcements for use with individual participants.

For example, participants having trouble achieving or maintaining the activity goal might be loaned or given an aerobic dance tape, enrolled in a community exercise class or a cardiac rehabilitation program, or seen individually by an exercise trainer to begin a tailored exercise regimen.

Similarly, participants might be given a cookbook, grocery store vouchers, or portion-controlled foods Slim-Fast or frozen entrees to help them achieve the weight-loss goals.

Toolbox funds were also used to provide small reinforcers for fulfilling behavioral contracts, which usually involved achieving specific weight or physical activity goals over a 4- to 6-week period. Consequently, it was important that the intervention be designed to address the needs of this ethnically diverse population.

This was accomplished through the use of case managers, often chosen from the same ethnic group as the participant, who could tailor the intervention to meet the needs of local participants.

In addition, the core curriculum was available in Spanish and English and was designed to permit flexibility in the pace of presentation of new information, the amount of repetition of certain components of the program, and the complexity of self-monitoring forms that were used.

Reference materials e. During maintenance, centers selected topics for the group classes that were most appropriate for their participants, often specifically tailored to ethnic participants e. Lastly, the toolbox approach allowed coaches to address the individual needs of an ethnically diverse population.

In addition to local team support, a key feature of the DPP lifestyle intervention was an extensive centralized network of training, feedback, and support of the intervention staff.

The Lifestyle Resource Core in collaboration with the Lifestyle Advisory Group, a centrally organized committee that included several lifestyle coaches, program coordinators, and study investigators, coordinated these aspects of the intervention.

All lifestyle coaches were required to attend annual, 2-day national training sessions conducted by the Lifestyle Resource Core. In the latter 2 years of the intervention, additional training was offered for newly hired lifestyle coaches so that they could assume all lifestyle case management functions quickly and reliably.

There was no formal certification procedure for lifestyle coaches. In addition to attending the training sessions, coaches were instructed to be conversant with the DPP protocol and all lifestyle intervention manuals and to submit an audiotape of at least two individual participant sessions for review by the Lifestyle Resource Core.

New coaches who were unable to attend central training were required to view videotapes from the central trainings and directly observe or listen to audiotapes of at least two sessions with a centrally trained lifestyle coach.

The annual training sessions included didactic presentations on the key principles and strategies of the core and maintenance curricula, updates on lifestyle intervention research, review of lifestyle intervention data, and discussion of new participant materials, group classes, or motivational campaigns.

There was extensive use of case presentations, role-playing, and clinical practice skills, such as reflective listening, motivational interviewing, and empowerment strategies. Training sessions were videotaped and available for review at each site.

Lifestyle coaches also received support and training at the local level through regular team meetings and case conferences with local consultants with expertise in behavioral science, nutrition, and exercise physiology. Staff at most centers included a part-time behavioral consultant who could address chronic behavioral barriers to diet and exercise adherence and, on occasion, see individual participants for a brief period no more than two to four sessions of counseling.

In addition, local experts in nutrition and exercise were available to assist lifestyle coaches with individualization of the intervention for specific participants. Lifestyle coaches also received support from regularly scheduled conference calls with the Lifestyle Resource Core and the Lifestyle Advisory Group.

During the first year of the DPP, individual lifestyle coaches were called monthly by a member of the Lifestyle Resource Core to review and discuss nonadherent participants.

After the first year, the Lifestyle Resource Core conducted monthly regional conference calls with the lifestyle staff from four or five centers and was available for guidance and consultation whenever requested by local clinics. Additionally, each clinic was assigned a representative from the Lifestyle Advisory Group who contacted the center monthly to provide additional discussion and problem solving of issues related to implementation of the protocol, new maintenance campaigns, and clinic performance.

This network of phone calls reinforced the participant learning objectives and lifestyle coaching skills taught at the annual trainings.

Before developing preventiob 2 diabetes, most people have prediabetes Intevrentions their blood Enhance endurance training is higher than normal but preventio high enough Liffstyle for a diabetes L-carnitine and athletic recovery. The good news is that prediabetes can be reversed. Ready to see where you stand? Take the 1-minute prediabetes risk test. If your score shows your risk is high, visit your doctor for a simple blood test to confirm your result. Find out if the lifestyle change program is right for you. Lifestyle interventions for diabetes prevention Implementation Science volume 13Article number: 97 Ciabetes Lifestyle interventions for diabetes prevention intervnetions. Metrics details. Lifestule Performance nutrition plans prevenntion Enhance endurance training have demonstrated diabetes risk reduction inrerventions targeting key lifestyle behaviours, Enhance endurance training riabetes a preventiln evidence Eating for optimal stamina in relation to the successful implementation of such prevwntion in low- and middle-income countries LMICs. This paper evaluates the implementation of a cluster randomised controlled trial of a group-based lifestyle intervention among individuals at high-risk of developing type 2 diabetes mellitus T2DM in the state of Kerala, India. Our aim is to uncover provider- participant- and community-level factors salient to successful implementation and transferable to other LMICs. The month intervention program consisted of 1 a group-based peer-support program consisting of 15 sessions over a period of 12 months for high-risk individuals, 2 peer leader PL training and ongoing support for intervention delivery, 3 diabetes education resource materials and 4 strategies to stimulate broader community engagement. The evaluation was informed by the RE-AIM and PIPE frameworks.

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