Lifestyle Interventions Help Prevent Diabetes
CME
News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd
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Release
Date: December 3, 2003; Valid for credit through December 3, 2004
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Surgeons,
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
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
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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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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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.
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