domingo, 14 de septiembre de 2014

The Community Guide - Summary - Diabetes: Combined Diet and Physical Activity Promotion Programs to Prevent Type 2 Diabetes Among People at Increased Risk

The Community Guide - Summary - Diabetes: Combined Diet and Physical Activity Promotion Programs to Prevent Type 2 Diabetes Among People at Increased Risk



Genomics & Health Impact Update

Diabetes Prevention: Family History & Genetics

a hand writing Diabletes with DNA in background
Recommendation from the Task Force on Community Preventive Services (2014) Diabetes Prevention and Control:External Web Site Icon Combined Diet and Physical Activity Promotion Programs to Prevent Type 2 Diabetes Among People at Increased Risk
CDC information: Prediabetes: Am I at risk?
Did you know? More than 3400 genes have been reported with risk of type 2 diabetes and its outcomes, including more than 160 genomewide association studies. To find out more, visit theHuGE NavigatorExternal Web Site Icon
The fight against type 2 diabetes: The promise of genomics,External Web Site Icon Sandra Adamson Fryhofer, Medscape podcast, July 11, 2014
Check out genetic disorders and tests associated with diabetes at the NIH Genetic Testing RegistryExternal Web Site Icon



Diabetes Prevention and Control: Combined Diet and Physical Activity Promotion Programs to Prevent Type 2 Diabetes Among People at Increased Risk

Task Force Finding

The Community Preventive Services Task Force recommends combined diet and physical activity promotion programs for people at increased risk of type 2 diabetes based on strong evidence of effectiveness in reducing new-onset diabetes. Combined diet and physical activity promotion programs also increase the likelihood of reverting to normoglycemia (normal blood sugar) and improve diabetes and cardiovascular disease risk factors, including overweight, high blood glucose, high blood pressure, and abnormal lipid profile.
Based on the evidence, combined diet and physical activity promotion programs are effective across a range of counseling intensities, settings, and implementers. Programs commonly include a weight loss goal, individual or group sessions (or both) about diet and exercise, meetings with a trained diet or exercise counselor (or both), and individually tailored diet or exercise plans (or both). Higher intensity programs lead to greater weight loss and reduction in new-onset diabetes.
Economic evidence indicates that combined diet and physical activity promotion programs to prevent type 2 diabetes among people at increased risk are cost-effective.
Read the full Task Force Finding and Rationale Statement for more detailed information on the finding, including implementation issues, potential benefits and harms, and evidence gaps.

Intervention Definition

Combined diet and physical activity promotion programs aim to prevent type 2 diabetes among people who are at increased risk of the disease. These programs actively encourage people to improve their diet and increase their physical activity using the following:
  • Trained providers in clinical or community settings who work directly with program participants for at least 3 months
  • Some combination of counseling, coaching, and extended support
  • Multiple sessions related to diet and physical activity, delivered in-person, or by other methods
Programs may also use one or more of the following:
  • Providers who are diet counselors of different specialties (for example, nutritionists, dietitians, diabetes educators), exercise counselors of different specialties (for example, physical educators, physiotherapists, trainers), physicians, nurses, trained laypeople, and others
  • A range of intensity in the counseling, with numerous or few sessions, longer or shorter duration sessions, and individual or group sessions
  • Individually tailored or generic diet or physical activity programs
  • Specific weight loss or exercise goals
  • A period of maintenance sessions following the primary core period of the program
Program participants may be considered at increased risk of type 2 diabetes if they have blood glucose levels that are abnormally elevated, but not high enough to be classified as type 2 diabetes.1 Participants may also be identified using diabetes risk assessment tools.

About the Systematic Review

The Task Force finding is based on evidence from a systematic review of 47 studies that described 60 programs (search period January 1991 - June 2014). The review was conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice and policy related to diabetes prevention and control.

Results

  • Among populations at increased risk of type 2 diabetes, combined diet and physical activity promotion programs led to improvements in health outcomes and risk factors for type 2 diabetes and cardiovascular disease compared with usual care.
    • The proportion of people who developed type 2 diabetes decreased by a median of 11 percentage points (interquartile interval [IQI]: 5 to 16; 14 studies).
    • The proportion of people who achieved normal blood sugar (normoglycemia) increased by a median of 12 percentage points (IQI: 6 to 14; 6 studies).
    • Body weight was reduced by an average of 2.4% (95% confidence interval [CI]: 1.2 to 3.6; 21 studies).
    • Fasting blood glucose was reduced (improved) by an average of 2.1 mg/dL (95% CI 0.5 to 3.8; 14 studies) and hemoglobin A1c (a measure of long-term glucose levels) was reduced (improved) by an average of 0.07 percentage points (95% CI 0.02 to 0.12; 8 studies).
    • Blood pressure (15 studies) and cholesterol levels (10 studies) also were improved.
  • The effect on mortality was unclear. Mortality was reduced by 2 to 10 percentage points (2 studies) or by 0.6 per 1000 person-years (1 study) over 3 to 23 years of follow-up. However, this benefit was statistically significant in only one study, and in that study only among women.
  • Regardless of program features, almost all programs led to weight loss, reduced risk of diabetes, or both. However, among 12 studies with direct comparisons, more intensive programs (based on features such as number of sessions, individual sessions, and additional personnel) resulted in greater weight loss and lower rates of diabetes than less intensive programs. Across all studies, more effective programs provided:
    • Individual (vs. group) diet sessions, or
    • Diet counselors
  • In studies of programs that used protocols outlined by the U.S. Diabetes Prevention Program (DPP) or Finnish Diabetes Prevention Study (DPS), or modifications of them, participants had a lower risk of developing diabetes (compared with people who did not participate in the programs) than those in programs not based on DPP or DPS (Relative Risk = 0.47 vs. 0.63; P<0.001).

Study Characteristics

  • Programs lasted between 3 months and 6 years, with a median of 12 months (IQI: 11.5 to 34.5 months).
    • The core period lasted between 2 months and 5 years, with a median of 6 months (IQI: 5 to 12 months).
    • Maintenance periods (in 27 programs) lasted between 4 and 68 months, with a median of 12 months (IQI: 7 to 26 months).
  • Programs provided between 3 and 72 sessions, with a median of 13.5 sessions (IQI: 8 to 24 sessions).
    • During the core period, there were between 3 and 72 sessions, with a median of 9 sessions (IQI: 6 to 16 sessions).
    • During the maintenance period, there were between 0 and 42 sessions, with a median of 4 sessions (IQI: 0.5 to 8.5 sessions). In some programs, the maintenance period contacts were by telephone or email only.
  • Programs used individual face-to-face meetings (37 programs included individual diet sessions, 38 programs included individual exercise sessions), group meetings (diet: 38 programs, exercise: 35 programs), or both (diet: 23 programs, exercise: 22 programs). Six programs were conducted via web-tools, social networking, email, text messaging, video (or a combination of these) with no in-person sessions.
  • Sessions were led by different combinations of trained diet counselors including dietitians, nutritionists, or others (35 programs); trained exercise counselors including physical trainers or others (25 programs); nurses (13 programs); physicians or psychologists (9 programs); and trained laypeople (10 programs).
  • Programs included specific weight loss goals (41 programs), diet goals (30 programs), and physical activity goals (28 programs).
  • Programs included individually tailored plans for diet (15 programs) and physical activity (22 programs).
  • Studies were conducted in the United States (19 studies), Western Europe (14 studies), and other countries.

Applicability

Based on results for programs in different settings and populations, findings are applicable to the following:
  • Adults at increased risk of type 2 diabetes
    • Older adults were shown to have greater benefits
  • Adolescents (based on two studies)
  • Women and men
  • All racial and ethnic groups
  • All socioeconomic levels
  • Urban and rural environments
  • Healthcare and community-based settings in the United States

Economic Evidence

An economic review of 26 studies (search period January 1985 - July 2014) shows that combined diet and physical activity promotion programs for people at increased risk for type 2 diabetes are cost-effective. All monetary values reported are in 2013 U.S. dollars.
Cost of the programs:
  • All programs: median $652 per participant (IQI: $383 to $1,160; 12 studies)
  • Group-based programs: median $407 per participant (IQI: $335 to $652; 7 studies)
  • Programs that translated the U.S. DPP into community or primary care settings: median $424 per participant (IQI: $340 to $793; 8 studies)
Cost-effectiveness of the program (from the health system perspective, which included only the direct medical costs of the programs and healthcare costs averted, based on either data collected in actual programs or estimates from simulation models):
  • Cost per quality-adjusted life year (QALY) saved:
    • All programs: median $13,367 (IQI: $2,302 to $23,327; 15 studies)
    • Group-based programs: median $1,819 (IQI: −$5,028 to $28,178; 5 studies)
    • Individual-based programs: median $15,846 (IQI: $7,979 to $136,122; 5 studies)
  • Cost per disability-adjusted life year (DALY) averted:
    • $21,195 or $50,707 (2 studies)
  • Cost per life year gained (LYG):
    • Median $2,684 (IQI: −$2,444 to $17,410; 6 studies)
The variation in program costs per participant is partly explained by the number of sessions, delivery mode of the core sessions (individual vs. group), setting (clinical trial vs. community or primary care), and type of personnel used (health professionals vs. trained laypeople). The variation in cost-effectiveness is partially explained by variation in cost and effectiveness of the programs, program delivery modes, patient follow-up times, and delivery settings.

Considerations for Implementation

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion. The Community Guide does not conduct systematic reviews of implementation.
  • In 2010, the U.S. Congress authorized CDC to establish the National Diabetes Prevention Program (National DPP), an alliance of public and private organizations (including insurers) managed by CDC to achieve wide-scale implementation and coordination of lifestyle change programs to prevent or delay type 2 diabetes. As of May 2014, more than 500 organizations in all states and the District of Columbia have applied for CDC recognition for their diabetes prevention programs. More information about the National DPP can be found at www.cdc.gov/diabetes/prevention External Web Site Icon.
  • Combined diet and physical activity promotion programs have been successfully implemented by several national and state-wide organizations, the majority of which are part of the National DPP.
  • Healthcare providers are usually the primary resource for individuals newly diagnosed with being at increased risk of type 2 diabetes. Providers need to be aware of the benefits of combined diet and physical activity promotion programs and of local programs, which may be offered by community centers, insurer-run programs, or non-profit or other private contractors among others.
  • Organizations implementing combined diet and physical activity promotion programs may want to address factors that make it difficult for some people to participate. Examples include limited ability to pay for program services; limited time to cook or exercise due to work schedules or childcare needs; limited access to inexpensive and healthful food, safe and convenient places to exercise and transportation there; and cognitive or physical disabilities.

1People are classified as being at increased risk of type 2 diabetes if their blood glucose levels are abnormally elevated but still below the threshold for the disease. People at increased risk of diabetes have hemoglobin levels between 5.7% and 6.4%, fasting plasma glucose between 100 and 125 mg/dL, or plasma glucose between 140 and 199 mg/dL after a 75 gram oral glucose tolerance test (American Diabetes Association, 2010).

Supporting Materials

Publication Status

Full peer-reviewed articles of this systematic review will be posted on the Community Guide website when published. Subscribe External Web Site Icon to be notified when we post these publications or other materials. See our library for previous Community Guide publications on this and other topics.

References

American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care2010;33 (Suppl 1):S62-9.


Disclaimer

The findings and conclusions on this page are those of the Community Preventive Services Task Force and do not necessarily represent those of CDC. Task Force evidence-based recommendations are not mandates for compliance or spending. Instead, they provide information and options for decision makers and stakeholders to consider when determining which programs, services, and policies best meet the needs, preferences, available resources, and constraints of their constituents.

Sample Citation

The content of publications of the Guide to Community Preventive Services is in the public domain. Citation as to source, however, is appreciated. Sample citation: Guide to Community Preventive Services. Diabetes prevention and control: combined diet and physical activity promotion programs to prevent type 2 diabetes among people at increased risk.www.thecommunityguide.org/diabetes/combineddietandpa.html. Last updated: MM/DD/YYYY.
Review completed: July 2014
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