Abstract
BackgroundThe clinical effectiveness of intensive lifestyle interventions in preventing or delaying diabetes in people at high risk has been established from randomised trials of structured, intensive interventions conducted in several countries over the past two decades. The challenge is to translate them into routine clinical settings. The objective of this review is to determine whether lifestyle interventions delivered to high-risk adult patients in routine clinical care settings are feasible and effective in achieving reductions in risk factors for diabetes.MethodsData sources: MEDLINE (PubMed), EMBASE, CINAHL, The Cochrane Library, Google Scholar, and grey literature were searched for English-language articles published from January 1990 to August 2009. The reference lists of all articles collected were checked to ensure that no relevant suitable studies were missed. Study selection: We included RCTs, before/after evaluations, cohort studies with or without a control group and interrupted time series analyses of lifestyle interventions with the stated aim of diabetes risk reduction or diabetes prevention, conducted in routine clinical settings and delivered by healthcare providers such as family physicians, practice nurses, allied health personnel, or other healthcare staff associated with a health service. Outcomes of interest were weight loss, reduction in waist circumference, improvement of impaired fasting glucose or oral glucose tolerance test (OGTT) results, improvements in fat and fibre intakes, increased level of engagement in physical activity and reduction in diabetes incidence.ResultsTwelve from 41 potentially relevant studies were included in the review. Four studies were suitable for meta-analysis. A significant positive effect of the interventions on weight was reported by all study types. The meta-analysis showed that lifestyle interventions achieved weight and waist circumference reductions after one year. However, no clear effects on biochemical or clinical parameters were observed, possibly due to short follow-up periods or lack of power of the studies meta-analysed. Changes in dietary parameters or physical activity were generally not reported. Most studies assessing feasibility were supportive of implementation of lifestyle interventions in routine clinical care.ConclusionLifestyle interventions for patients at high risk of diabetes, delivered by a variety of healthcare providers in routine clinical settings, are feasible but appear to be of limited clinical benefit one year after intervention. Despite convincing evidence from structured intensive trials, this systematic review showed that translation into routine practice has less effect on diabetes risk reduction.
Highlights
The clinical effectiveness of intensive lifestyle interventions in preventing or delaying diabetes in people at high risk has been established from randomised trials of structured, intensive interventions conducted in several countries over the past two decades
18 studies were excluded because: their replications of lifestyle interventions were conducted in non-routine clinical settings [52,53,54,55,56,57,58,59], or in a research setting [47,60,61,62,63,64,65]; or they did not include at least one of the outcomes of interest [66,67]
The systematic review of RCT results at 12-month follow-up showed: mean weight reduction was 1.82 Kg greater in treatment than control groups which was statistically significant; pooled mean waist measurement reductions in treatment exceeded control groups by 4.6 cm, and this was significant; fasting plasma glucose reduction was 0.19 mmol/l greater in treatment than controls but non-significant; and a non-significant greater increase in 2-hour oral glucose tolerance test result of 0.04 mmol/l (95%CI: -0.49 to +0.42 mmol/l)
Summary
The clinical effectiveness of intensive lifestyle interventions in preventing or delaying diabetes in people at high risk has been established from randomised trials of structured, intensive interventions conducted in several countries over the past two decades. The clinical effectiveness of intensive lifestyle interventions in preventing or delaying development of diabetes in people at high risk has been established from randomised controlled trials of structured, intensive interventions conducted over the past two decades in the USA [1,2], China [3], Finland [4,5], and India [6]. These interventions, promoting healthy eating and moderate physical activity, have shown that sustained weight loss of 3.5 kg or more can be achieved with lifestyle interventions, and that onset rates of diabetes can be reduced by as much as 58% in the first few years. Little systematic information exists on the feasibility or effectiveness of replications of these interventions (or less intensive and more generalisable settings for lifestyle intervention), and on achievement of expected associated benefits as part of routine clinical practice
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