Lifestyle Interventions Help Prevent Diabetes CME

News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd

Complete author affiliations and disclosures, and other CME information, are available at the end of this activity.

Release Date: December 3, 2003; Valid for credit through December 3, 2004

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Dec. 3, 2003 — Intensive lifestyle interventions can help prevent diabetes, according to three-year results of the Finnish Diabetes Prevention Study (DPS) study published in the December issue of Diabetes Care.

"It is evident that lifestyle intervention can prevent or at least postpone type 2 diabetes and should therefore be implemented in primary health care," write Jaana Lindström, MSC, from the National Public Health Institute in Helsinki, Finland, and colleagues. "However, the lifestyle interventions used have been either insufficiently described or not intended as conventional treatment of high-risk individuals."

In the DPS, 522 middle-aged, overweight subjects with impaired glucose tolerance were randomized to receive either usual care or intensive lifestyle intervention aimed at reducing body weight and dietary and saturated fat and increasing physical activity and dietary fiber.

Both groups received general dietary and exercise advice at baseline and had an annual physical examination. In the intervention group, subjects also received additional individualized dietary counseling from a nutritionist, were offered circuit-type resistance training sessions, and were advised to increase overall physical activity. These interventions were most intensive during the first year.

The intervention group fared significantly better than the control group in each intervention goal, including weight reduction after one year (4.5 kg vs. 1.0 kg), weight reduction after three years (3.5 kg vs. 0.9 kg), and measures of glycemia and lipemia.

Study limitations include possible underreporting of dietary intake and recollection bias.

"The intensive lifestyle intervention produced long-term beneficial changes in diet, physical activity, and clinical and biochemical parameters and reduced diabetes risk," the authors write. "This type of intervention is a feasible option to prevent type 2 diabetes and should be implemented in the primary health care system.... In the long run, a lifestyle-intervention approach to weight control rather than a weight-reduction diet might be a more cost-efficient way to manage overweight in individuals at high risk for diabetes."

The Finnish Academy, the Ministry of Education, the Novo Nordisk Foundation, Yrjö Jahnsson Foundation, Juho Vainio Foundation, and the Finnish Diabetes Research Foundation supported the DPS study.

Diabetes Care. 2003;26:3230-3236

Learning Objectives

Upon completion of this activity, participants will be able to:

  • Evaluate the long-term benefits of intensive lifestyle intervention compared with usual care in the management of weight loss, diabetes prevention, and lipid outcomes.
  • Define the important characteristics of primary health care intervention in intensive lifestyle modification.

Clinical Context

The DPS has previously shown a reduction in incidence of diabetes by 58% with lifestyle intervention compared with a usual-care group, according to a study by Tuomilehto and colleagues published in the May 3, 2001, issue of the New England Journal of Medicine. This finding was replicated by the Diabetes Prevention Program (DPP), in which a more expensive, customized model of intensive lifestyle intervention was associated with a 58% risk reduction in diabetes compared with metformin treatment, as reported in the Feb. 7, 2002, issue of the New England Journal of Medicine by the DPP Research Group.

This randomized, longitudinal prospective study conducted at five Finnish participating centers employed a physician, study nurse, and nutritionist (with MSc in nutrition) and hired or paid for the services of an exercise physiologist or physiotherapist for exercise counseling at each center. Patients were followed for one to three years to assess the efficacy of maintenance of changes. The authors hypothesized that long-term lifestyle modification may be more cost-effective for weight management of individuals at high risk for diabetes than short-term weight-reduction diets.

Study Highlights

  • 522 middle-aged, overweight subjects with impaired glucose tolerance defined by the World Health Organization criteria were recruited via local advertising or screening relatives of patients with type 2 diabetes.
  • 265 subjects were randomized to the intervention group and 257 to the control group between 1993 and 1998. They were stratified by center, sex, and 2-hour plasma glucose results. Dropout rate was similar between groups.
  • The study was prematurely terminated in March 2000 because the incidence of diabetes was found to be significantly lower in the intervention group compared with the control group. However, follow-up of participating subjects continued to year 3.
  • Lifestyle intervention goals were 5% weight reduction (recommended weight loss rate, 0.5-1.0 kg/week), moderate-intensity physical activity (PA) of 30 min/day, dietary fat of 30% or less of total daily energy intake, saturated fat of 10% or less of daily intake, and fiber intake of 15 g/1,000 kcal or more.
  • Intervention group subjects received 7 individualized face-to-face, 30-minute sessions with the study nutritionist in year 1, and 4 sessions per year thereafter. A subgroup of 48 subjects participated in a very-low-calorie diet for 2 to 5 weeks after 6 months. All subjects regularly measured and recorded weight and physical activity.
  • Control group subjects were given the same general goals and information in a single group session with printed materials, but there was no individualized counseling.
  • Annual measurements included oral glucose tolerance testing, medical history and physical examination, height, weight, waist circumference, and complete lipid profile.
  • Patients assessed their dietary intake with a 3-day food record before every visit using a standardized book, and a dietary analysis program was used to calculate caloric intake. Subjects were similar in baseline characteristics of mean age (55 years), sex (50%-55% male), first-degree relative with diabetes (one third), education level, occupation, mean weight at entry (86 kg), body mass index (BMI) of 31 kg/m2 (55% had BMI of 30 kg/m2), waist circumference (101 cm), fasting plasma glucose (6.1 mmol/L), HbA1C (5.6%), cholesterol profile, total LTPA per week (mean of 160 min/week with one third of subjects defined as sedentary) and caloric intake of micro- and macronutrients per day.
  • PA was significantly higher at years 1 and 3 for the intervention group (30% and 29%, respectively) compared with the control group (14% and 17%, respectively). Comparisons were significant at year 1 (P < .0001) and year 3 (P = .0028). Moderate-to-vigorous physical activity increased in the intervention group compared with the control group.
  • The intervention group had a significantly better weight loss at year 1 of 4.5 kg compared with 1.0 kg weight loss in the control group. In addition, 46% attained the 5% weight loss goal compared with 14% in the control group (P < .0001). At year 3, mean weight reduction was 3.5 kg in the intervention group compared with 0.9 kg in the control group.
  • Dietary fat intake goal was reached by 37% vs. 20%, respectively (P < .0001), saturated fat goal was reached by 21% vs. 9%, respectively (P < .0001), and fiber intake goal was reached by 37% vs. 23%, respectively (P < .0006).
  • Fasting plasma glucose and 2-hour glucose values were improved in the intervention group compared with the control group in year 1 (-0.2 mmol/L vs. 0.0 mmol/L; P < .0001), and this difference persisted in year 3 (P = .002). Lipid measures were more improved in the intervention group compared with the control group.

Pearls for Practice

  • Intensive lifestyle modification using an individualized approach and a team of skilled healthcare professionals produces positive outcomes of weight reduction, increased physical activity, and glucose and lipid metabolism improvement over three years compared to simple one-time group counseling.
  • Lifestyle intervention can prevent or postpone the onset of type 2 diabetes in susceptible individuals.

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Target Audience

This article is intended for primary care physicians, endocrinologists, and other specialists who care for patients with or at risk of diabetes.


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Authors and Disclosures

This article may discuss investigational products or unapproved uses of products regulated by the U.S. Food and Drug Administration.

News Author

Laurie Barclay, MD
Writer for Medscape Medical News

Disclosure: Dr. Barclay has reported no significant financial interests.

CME Author

Désirée Lie, MD, MSEd
Associate Clinical Professor of Family Medicine and Director, Division of International Faculty Development, Irvine Medical Center, University of California, Irvine

Disclosure: Dr. Lie has reported no significant financial interests.

News CME Staff

Deborah Flapan
Assistant Managing Editor, Medscape Medical News

Disclosure: Ms. Flapan has reported no significant financial interests.

Gary Vogin, MD
Clinical Reviewer and Senior Medical Editor, Medscape

Disclosure: Dr. Vogin has reported no significant financial interests.

About News CME

News CME is designed to keep physicians abreast of current research and related clinical developments that are likely to affect practice, as reported by the Medscape Medical News group. Medscape Medical News is edited by Deborah Flapan. Clinical review is provided by Gary Vogin, MD. Send comments or questions about this program to

Medscape Medical News 2003. © 2003 Medscape

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