Behavioral strategies in diabetes prevention programs: A systematic review of randomized controlled trials

doi:10.1016/j.diabres.2010.06.030

Diabetes Research and Clinical Practice

Volume 91, Issue 1, January 2011, Pages 1-12

https://doi.org/10.1016/j.diabres.2010.06.030 Get rights and content

Abstract

The worldwide epidemic of type 2 diabetes (T2D) emphasizes the need for guidelines regarding community implementation of lifestyle modification prevention programs. An understanding of effective behavioral strategies is needed if evidence translation is to be realized. The aim of this paper is to systematically review the behavioral change strategies for lifestyle T2D prevention programs.

Methods

Randomized controlled trials (RCTs) of lifestyle interventions for the prevention of T2D were reviewed with a systematic literature search. Data relating to the behavioral strategies and trial outcomes were extracted.

Results

Overall, lifestyle interventions were successful in reducing the incidence of T2D. The behavioral strategies utilized in these interventions were drawn from a variety of theoretical backgrounds. All RCTs utilized intensive modes of delivery and were associated with low dropout rates of 5.5–13.4%.

Conclusions

The available evidence shows that a robust behavioral change strategy is an essential part of an effective lifestyle modification program, as the absence of intensive individualized advice or “information only” more closely resembles the control group interventions used in these RCTs.

Section snippets

Design

Randomized controlled trials, published in full in English were considered.

Subjects

Studies that involved adults at-risk of T2D were included, defined as being dysmetabolic or having IGT according to World Health Organization (WHO) criteria, at the time of the trial. Studies with participants already diagnosed with T2D were not included.

Interventions

Studies were included if they incorporated exercise training/physical activity and/or nutritional intervention as a means of diabetes prevention.

Outcome

Incidence of diagnosis

Study inclusion/exclusion

The process of study inclusion/exclusion at each step is presented in Fig. 1. Seven separate RCTs with prevention of type 2 diabetes as their primary outcome were identified. Trial results were generally published in multiple papers, all of which were included in the data extraction process, in contrast to previous systematic reviews which have used only one or a small number of papers as source documents for each trial.

• Diabetes Prevention Program (DPP), U.S.A.	– 41 publications
• Diabetes

Discussion

Clinical guidelines are needed for the optimal community implementation of evidence-based diabetes prevention programs. Successful translation of RCT evidence into public health practice requires an understanding of the most effective behavioral strategies. Thus, we reviewed all available evidence regarding behavioral strategies used in RCTs of lifestyle interventions for preventing T2D in at-risk individuals. Overall, lifestyle interventions targeting multiple physical activity and nutritional

Conclusion

The results of this paper may be clinically relevant when considering the implementation of T2D prevention programs in a community setting. The available evidence shows that a robust behavioral change strategy is a critical part of such a prevention program. The absence of an intensive individualized delivery with the provision of advice or information only more closely resembles the control group interventions used by the RCTs, and cannot be considered optimally effective.

Conflicts of interest

There are no conflicts of interest.

Acknowledgement

Sources of funding: nil.

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Cited by (113)

Identification of Intervention Characteristics Within Diabetes Prevention Programs Using the Template for Intervention Description and Replication: A Scoping Review
2024, Canadian Journal of Diabetes
Diabetes prevention programs (DPPs) targeting dietary and physical activity behaviour change have been shown to decrease the incidence of type 2 diabetes; however, a more thorough reporting of intervention characteristics is needed to expedite the translation of such programs into different communities. In this scoping review we aim to synthesize how DPPs are being reported and implemented.
A scoping review using Arkey and O’Malley methods was conducted in accordance with the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analysis. MEDLINE, CINAHL, PsycINFO, EMBASE, and SPORTDiscus were searched for studies relating to diabetes prevention, and diet/exercise interventions. Only studies delivering a diet/exercise intervention for adults identified as “at risk” for developing type 2 diabetes were included. The Template for Intervention Description and Replication (TIDieR) was used to guide data extraction, and each DPP was scored on a scale from 0 to 2 for how thoroughly it reported each of the items (0 = did not report, 2 = reported in full; total score out of 26).
Of the 25,110 publications screened, 351 (based on 220 programs) met the inclusion criteria and were included for data extraction. No studies comprehensively reported on all TIDieR domains (mean TIDieR score: 15.7 of 26; range 7 to 25). Reporting was particularly poor among domains related to “modifications,” “tailoring,” and “how well (planned/actual).” "How well (planned)" assesses the intended delivery of an intervention, detailing the initial strategies and components as per the original design, whereas "how well (actual)" evaluates the extent to which the intervention was executed as planned during the study, including any deviations or modifications made in practice.
Although there is evidence to suggest that DPPs are efficacious, a more thorough reporting of program content and delivery is needed to improve the ability for effective programs to be implemented or translated into different communities.
Il a été démontré que les programmes de prévention du diabète (PPD) axés sur les changements de comportement en matière d’alimentation et d’activité physique permettent de diminuer l’incidence du diabète de type 2. Toutefois, des comptes rendus exhaustifs sur les caractéristiques de l’intervention sont nécessaires pour accélérer la transposition de ces programmes au sein des diverses collectivités. La présente étude de portée vise à faire la synthèse sur la façon dont les programmes de prévention du diabète ont été traités et mis en œuvre.
Une étude de portée selon les méthodes proposées par Arkey et O’Malley a été réalisée conformément aux lignes directrices PRISMA. Nous avons effectué des recherches dans les bases de données Medline, CINAHL, PsycINFO, EMBASE et SPORTDiscus pour trouver des études sur la prévention du diabète et les interventions portant sur le régime alimentaire/l’exercice physique. Seules les études qui proposaient une intervention sur le régime alimentaire/l’exercice physique aux adultes considérés comme exposés au risque d’avoir le diabète de type 2 ont été incluses. Nous avons utilisé le Template for Intervention Description and Replication (TIDieR, c’est-à-dire le Modèle pour la description et la réplication des interventions) aux fins de l’extraction des données, et avons noté chaque PPD sur une échelle de 0 à 2 selon la façon dont chacun des items était traité en profondeur (0 = non traité; 2 = traités en entier; score total/26).
Parmi les 25 110 publications sélectionnées, 351 publications (qui représentent 220 programmes) ont rempli les critères d’inclusion et ont été incluses pour l’extraction des données. Aucune étude n’a rendu compte en détail de tous les domaines du TIDieR (score moyen au TIDieR = 15,7/26; étendue de 7 à 25). Les informations entre les domaines liés aux « modifications », à l’« adaptation » et à la « façon dont les interventions étaient… » (planifiées/actuelles) » étaient particulièrement mauvaises. « La façon dont les interventions étaient… (planifiées) » permet d’évaluer la prestation escomptée d’une intervention, en détaillant les stratégies initiales et les volets conformément à la conception, alors que « la façon dont les interventions (actuelles) » permet d’évaluer la mesure dans laquelle l’intervention a été exécutée comme prévu durant l’étude, y compris tout écart ou toute modification faite dans la pratique.
Alors qu’il existe des données probantes qui suggèrent que les programmes de prévention du diabète sont efficaces, des comptes rendus exhaustifs sur le contenu et la prestation des programmes sont nécessaires pour améliorer la capacité de mettre en œuvre ou de transposer les programmes efficaces dans diverses collectivités.
Preventing diabetes in Latino families: A protocol for a randomized control trial
2023, Contemporary Clinical Trials
Latino families are disproportionately affected by type 2 diabetes (T2D) and lifestyle intervention is the first-line approach for preventing T2D. The purpose of this study is to test the efficacy of a culturally-grounded lifestyle intervention that prioritizes health promotion and diabetes prevention for Latino families. The intervention is guided by a novel Family Diabetes Prevention Model, leveraging the family processes of engagement, empowerment, resilience, and cohesion to orient the family system towards health.
Latino families (N = 132) will be recruited and assessed for glucose tolerance as measured by an Oral Glucose Tolerance Test (OGTT) and General and Weight-Specific Quality of Life (QoL) at baseline, four months, and 12 months. All members of the household age 10 and over will be invited to participate. Families will be randomized to the intervention group or a control group (2:1). The 16-week intervention includes weekly nutrition and wellness classes delivered by bilingual, bicultural Registered Dietitians and community health educators at a local YMCA along with two days/week of supervised physical activity classes and a third day of unsupervised physical activity. Control families will meet with a physician and a Registered Dietitian to discuss the results of their metabolic testing and recommend lifestyle changes. We will test the efficacy of a family-focused diabetes prevention intervention for improving glucose tolerance and increasing QoL and test for mediators and moderators of long-term changes.
This study will provide much needed data on the efficacy of a family-focused Diabetes Prevention Program among high-risk Latino families.
A Systematic Review of Behavioral Interventions on Children at Risk for Diabetes
2023, American Journal of Preventive Medicine
In adults, behavioral-based interventions support prevention of Type 2 diabetes; less is known in children. The aim of this systematic review was to examine the impact of behavioral-based interventions on cardiometabolic outcomes among children at risk for diabetes.
PubMed, CINAHL Plus with Full Text, PsycINFO, and Web of Science were searched between September 2011 and September 2021. RCTs in children aged 6−12 years at risk for Type 2 diabetes that implemented a behavioral-based intervention and included ≥1 cardiometabolic outcome were eligible. If reported, dietary quality data were extracted. Risk of bias was assessed using the revised Cochrane risk-of-bias tool.
Of the 2,386 records identified, 4 met the inclusion criteria. Study length ranged from 10 weeks to 24 months, with sample sizes ranging from 53 to 113 participants. Among the 4 studies, there were 5 behavioral-based arms. All studies included weight status outcomes, with 3 finding significant between-group differences. Four studies assessed fasting glucose, and 3 assessed HbA1c; none found significant changes between groups. Of the 4 studies reporting blood pressure outcomes, 1 found a significant between-group difference for systolic blood pressure. Three studies assessed cholesterol and found no changes. No studies reported measures of dietary quality. All studies had some concerns about risk of bias.
Behavioral-based interventions improved weight status and supported the maintenance of cardiometabolic parameters. Stronger consideration of the most important risk factors in children along with intermediate outcomes (e.g., diet quality) may help to elucidate the relationship between behavioral-based interventions and cardiometabolic outcomes.
Two decades of diabetes prevention efforts: A call to innovate and revitalize our approach to lifestyle change
2023, Diabetes Research and Clinical Practice
The impact of global diabetes prevention efforts has been modest despite the promise of landmark diabetes prevention trials nearly twenty years ago. While national and regional initiatives show potential, challenges remain to adapt large-scale strategies in the real-world that fits individuals and their communities. Additionally, the sedentary lifestyle changes during the COVID-19 pandemic and guidelines that now call for earlier screening (e.g., US Preventative Task Force) will increase the pool of eligible adults worldwide. Thus, a more adaptable, person-centered approach that expands the current toolkit is urgently needed to innovate and revitalize our approach to diabetes prevention.
This review identifies key priorities to optimize the population-level delivery of diabetes prevention based on a consensus-based evaluation of the current evidence among experts in global translational programs; key priorities identified include (1) participant eligibility, (2) intervention intensity, (3) delivery components, (4) behavioral economics, (5) technology, and (6) the role of pharmacotherapy. We offer a conceptual framework for a broader, person-centered approach to better address an individual’s risk, readiness, barriers, and digital competency.
Effects of a lifestyle intervention on cardiovascular risk among high-risk individuals for diabetes in a low- and middle-income setting: Secondary analysis of the Kerala Diabetes Prevention Program
2020, Preventive Medicine
We aimed to examine whether a lifestyle intervention was effective in reducing cardiovascular disease (CVD) risk in individuals at high-risk of developing diabetes in a low- and middle-income setting. The Kerala Diabetes Prevention Program was evaluated by a cluster-randomized controlled trial (2013–2016) of 1007 individuals (aged 30–60 years) at high-risk for diabetes (Indian Diabetes Risk Score ≥ 60 and without diabetes) in Kerala state, India. Sixty polling areas in Kerala were randomized to intervention or control groups by an independent statistician using a computer-generated randomization sequence. Participants from 30 intervention communities received a 12-month structured peer-support lifestyle intervention program involving 15 group sessions and linked community activities, aimed at supporting and maintaining lifestyle change. The primary outcome for this analysis was the predicted 10-year CVD risk at two years, assessed using the Framingham Risk Score. The mean age at baseline was 46.0 (SD: 7.5) years, and 47.2% were women. Baseline 10-year CVD risk was similar between study groups. The follow-up rate at two years was 95.7%. The absolute risk reduction in predicted 10-year CVD risk between study groups was 0.69% (95% CI: 0.09% to 1.29%, p=0.024) at one year and 0.69% (95% CI: 0.10% to 1.29%, p=0.023) at two years. The favorable change in CVD risk with the intervention condition was mainly due to the reduction in tobacco use (change index: −0.25, 95% CI: −0.42 to −0.09). Our findings suggest that a community-based peer-support lifestyle intervention could reduce CVD risk in individuals at high-risk of developing diabetes in India.
Australia and New Zealand Clinical Trials Registry ACTRN12611000262909.
A systematic review of recruitment strategies and behaviour change techniques in group-based diabetes prevention programmes focusing on uptake and retention
2020, Diabetes Research and Clinical Practice
Many countries worldwide have developed diabetes prevention programmes (DPPs) that involve lifestyle modification. Research has shown that uptake and retention of DPPs are important and by exploring recruitment strategies and behaviour change techniques (BCTs) used, factors that are most effective in promoting uptake and retention can be identified. Objectives: This review aims to identify recruitment strategies of group-based DPPs that are associated with high uptake and common BCTs associated with high retention. Methods: Papers were identified with a systematic literature search. Programmes that were predominantly group-based and involved lifestyle modification and in which uptake and/or retention could be determined, were included. Intervention details were extracted, recruitment strategies and BCTs identified, and response, uptake and retention rates were calculated. Results: A range of recruitment strategies were used making it difficult to discern associations with uptake rates. For BCTs, all programmes used a credible source, 81% used instruction on how to perform a behaviour and 71% used goal setting (behaviour). BCTs more commonly found in high retention programmes included problem-solving, demonstrating the behaviour, using behavioural practice and reducing negative emotions. Conclusions: Recommendations include that DPPs incorporate BCTs like problem-solving and demonstrating the behaviour to maximise retention.

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Review articleBehavioral strategies in diabetes prevention programs: A systematic review of randomized controlled trials

Abstract

Methods

Results

Conclusions

Section snippets

Design

Subjects

Interventions

Outcome

Study inclusion/exclusion

Discussion

Conclusion

Conflicts of interest

Acknowledgement

J Clin Epidemiol

Diabetes Res Clin Pract

Lancet

Aust J Physiother

Lancet

Am J Prevent Med

Diabetes Res Clin Pract

Global prevalence of diabetes: estimates for the year 2000 and projections for 2030

Diabetes Care

Diabetes: Australian facts

Physical activity in the prevention of type 2 diabetes: the finnish diabetes prevention study

Diabetes

Lifestyle strategies for weight control: experience from the finnish diabetes prevention study

Proc Nutr Soc

Pharmacological and lifestyle interventions to prevent or delay type 2 diabetes in people with impaired glucose tolerance: systematic review and meta-analysis

BMJ (Clin Res Ed)

Exercise or exercise and diet for preventing type 2 diabetes mellitus

Cochrane Database Syst Rev (Online)

Home-based resistance training is not sufficient to maintain improved glycemic control following supervised training in older individuals with type 2 diabetes

Diabetes Care

Community center-based resistance training for the maintenance of glycemic control in adults with type 2 diabetes

Diabetes Care

Statistical significant change versus relevant or important change in (quasi) experimental design: some conceptual and methodological problems in estimating magnitude of intervention-related change in health services research

Int J Integr Care

Determining the magnitude of treatment effects in strength training research through the use of the effect size

J Strength Cond Res

The diabetes prevention program (dpp): description of lifestyle intervention

Diabetes Care

The finnish diabetes prevention study (dps): lifestyle intervention and 3-year results on diet and physical activity

Diabetes Care

A randomized lifestyle intervention with 5-year follow-up in subjects with impaired glucose tolerance: pronounced short-term impact but long-term adherence problems

Scand J Public Health

Effects of diet and exercise in preventing niddm in people with impaired glucose tolerance. The da qing igt and diabetes study

Diabetes Care

Impaired glucose tolerance and its relationship to ecg-indicated coronary heart disease and risk factors among Chinese. Da qing igt and diabetes study

Diabetes Care

Effectiveness of a lifestyle intervention on metabolic syndrome. A randomized controlled trial

J Gen Intern Med

Health psychological theory in promoting population health in paijat-hame, finland: First steps toward a type 2 diabetes prevention study

J Health Psychol

Review article
Behavioral strategies in diabetes prevention programs: A systematic review of randomized controlled trials