Physical Activity/Exercise and Type 2 Diabetes Improved lifestyle and decreased diabetes risk over 13 years: long-term follow-up of the randomised Finnish Diabetes Prevention Study (DPS) A 3-Year Randomized Trial of Lifestyle Intervention for Cardiovascular Risk Reduction in the Primary Care Setting: The Swedish Björknäs Study The Sydney Diabetes Prevention Program: A community-based translational study Prevention of type 2 diabetes - where is the evidence? Motivational interviewing and problem solving treatment to reduce type 2 diabetes and cardiovascular disease risk in real life: a randomized controlled trial The epidemiology of Type 2 diabetes mellitus in Greek adults: the ATTICA study. Prevention of Diabetes With Mediterranean Diets Combined effect of alcohol consumption and lifestyle behaviors on risk of type 2 diabetes. A randomized trial of lifestyle intervention in primary healthcare for the modification of cardiovascular risk factors The Björknäs study Long-term (1- and 2-year) effects of lifestyle intervention in type 2 diabetes relatives. Outcomes of a multifaceted physical activity regimen as part of a diabetes self-management intervention Effects of an intensive diet and physical activity modification program on the health risks of adults. Short and long term effects of a lifestyle intervention for construction workers at risk for cardiovascular disease: a randomized controlled trial Lifestyle modification improves risk factors in type 2 diabetes relatives. The PULSE (Prevention Using LifeStyle Education) trial protocol: a randomised controlled trial of a Type 2 Diabetes Prevention programme for men. Therapeutic education among adults with type 2 diabetes: effects of a three-day intervention on perceived competence, self-management behaviours and glycaemic control Physical activity, cardiovascular health, quality of life and blood pressure control in hypertensive subjects: randomized clinical trial Maintenance of lifestyle changes: 3-year results of the Groningen Overweight and Lifestyle study. Globalization of Diabetes The effect of weight management interventions that include a diet component on weight‐related outcomes in pregnant and postpartum women: a systematic review protocol Does a population-based multifactorial lifestyle intervention increase social inequality in physical activity? The Inter99 study Estudio Parto: postpartum diabetes prevention program for hispanic women with abnormal glucose tolerance in pregnancy: a randomised controlled trial – study protocol
For decades , exercise has been considered a cornerstone of diabetes management , along with diet and medication . However , high- quality evidence on the importance of exercise and fitness in diabetes was lacking until recent years . The present document summarizes the most clinical ly relevant recent advances related to people with type 2 diabetes and the recommendations that follow from these . Our recently published technical review on physical activity/exercise and type 2 diabetes ( 1 ) includes greater detail on individual studies , on prevention of diabetes , and on the physiology of exercise . The present statement focuses on type 2 diabetes . Issues primarily germane to type 1 diabetes will be covered in a subsequent technical review and ADA Statement . The levels of evidence used are defined by the ADA in ref . 2 . Two r and omized trials each found that lifestyle interventions including ∼150 min/week of physical activity and  diet-induced weight loss of 5–7 % reduced the risk of progression from impaired glucose tolerance ( IGT ) to type 2 diabetes by 58 % ( 3,4 ) . A cluster-r and omized trial found that diet alone , exercise alone , and combined diet and exercise were equally effective in reducting the progression from IGT to diabetes ( 5 ) . Therefore , there is firm and consistent evidence that programs of increased physical activity  and modest weight loss reduce the incidence of type 2 diabetes in individuals with IGT . Boule et al. ( 6 ) undertook a systematic review and meta- analysis on the effects of structured exercise interventions in clinical trials of ≥8 weeks duration on HbA1c ( A1C ) and body mass in people with type 2 diabetes . Postintervention A1C was significantly lower in exercise than control groups ( 7.65 vs. 8.31 % , weighted mean difference −0.66 % ; P < 0.001 ) . In contrast , postintervention body weight did not differ between the exercise and control groups . Meta-regression confirmed that the beneficial effect of exercise on A1C Aims /hypothesisThis study aim ed to determine whether lifestyle intervention lasting for 4 years affected diabetes incidence , body weight , glycaemia or lifestyle over 13 years among individuals at high risk of type 2 diabetes . Methods Overweight , middle-aged men ( n = 172 ) and women ( n = 350 ) with impaired glucose tolerance were r and omised in 1993–1998 to an  intensive lifestyle intervention group ( n = 265 ) , aim ing at weight reduction , dietary modification and increased physical activity , or to a control group ( n  = 257  )  that received general lifestyle information . The primary outcome was a diagnosis of diabetes based on annual OGTTs . Secondary outcomes included changes in body weight , glycaemia , physical activity and diet . After active intervention ( median 4 years , range 1–6 years ) , participants still free of diabetes and willing to continue their participation ( 200 in the intervention group and 166 in the control group ) were further followed until diabetes diagnosis , dropout or the end of 2009 , with a median total follow-up of 9 years and a time span of 13 years from baseline . Results During the total follow-up the adjusted HR for diabetes ( intervention group vs control group ) was 0.614 ( 95 % CI 0.478 , 0.789 ; p < 0.001 ) . The corresponding HR during the post-intervention follow-up was 0.672 ( 95 % CI 0.477 , 0.947 ; p = 0.023 ) . The former intervention group participants sustained lower absolute levels of body weight , fasting and 2 h plasma glucose and a healthier diet . Adherence to lifestyle changes during the intervention period predicted greater risk reduction during the total follow-up . Conclusions /interpretationLifestyle intervention in people at high risk of type 2 diabetes induces sustaining lifestyle change and results in long-term prevention of progression to type 2 diabetes . Trial registration Clinical Trials.gov NCT00518167 Funding The DPS study has been financially supported by the Academy of Finl and ( 128315 , 129330 ) , Ministry of Education , Novo Nordisk Foundation , Yrjö Jahnsson Foundation , Juho Vainio Foundation , Finnish Diabetes Research Foundation , Finnish Foundation for Cardiovascular Research , Unilever , and Competitive Research Funding from Tampere , Kuopio and Oulu University Hospitals . The study sponsors had no role in the design and conduct of the study ; the collection , analysis and interpretation of the data ; or the preparation , review or approval of the manuscript Background Successfully transferring the findings of expensive and tightly controlled programmes of intensive lifestyle modification to the primary care setting is necessary if such knowledge is to be of clinical utility . The objective of this study was to test whether intensive lifestyle modification , shown previously in tightly-controlled clinical trials to be efficacious for diabetes risk-reduction among high-risk individuals , can reduce cardiovascular risk factor levels in the primary care setting . Methodology / Principal Findings The Swedish Björknäs study was a r and omized controlled trial conducted from 2003 to 2006 with follow-up on cardiovascular risk factors at 3 , 12 , 24 and 36 months . A total of 151 middle-aged men and women at moderate- to high-risk of cardiovascular disease from northern Sweden were r and omly assigned to either an intensive lifestyle intervention ( n = 75 ) or control ( n = 76 ) group . The intervention was based broadly on the protocol of the Diabetes Prevention Program . The three-month intervention period was administered in the primary care setting and consisted of supervised exercise sessions and diet counselling , followed by regular group meetings during three years . The control group was given general advice about diet and exercise and received st and ard clinical care . Outcomes were changes in anthropometrics , aerobic fitness , self-reported physical activity , blood pressure , and metabolic traits . At 36 months post-r and omisation , intensive lifestyle modification  reduced waist circumference ( −2.2 cm : p = 0.001 ) , waist-hip ratio ( −0.02 : p<0.0001 ) , systolic blood pressure ( −4.9 mmHg : p = 0.036 ) , and diastolic blood pressure ( −1.6 mmHg : p = 0.005 ) , and improved aerobic fitness ( 5 % ; p = 0.038 ) . Changes in lipid or glucose values did not differ statistically between groups . At 36 months , self-reported time spent exercising and total physical activity had increased more in the intervention group than in the control group ( p<0.001 ) . Conclusion / Significance A program of intensive lifestyle modification undertaken in the primary health care setting can favourably influence cardiovascular risk-factor profiles in high-risk individuals . Trial Registration Clinical Trials.gov Background Type 2 diabetes is a major public health problem in Australia with prevalence increasing in parallel with increasing obesity . Prevention is an essential component of strategies to reduce the diabetes burden . There is strong and consistent evidence from r and omised controlled trials that type 2 diabetes can be prevented or delayed through lifestyle modification which improves diet , increases physical activity and achieves weight loss in at risk people . The current challenge is to translate this evidence into routine community setting s , determine feasible and effective ways of delivering the intervention and providing on-going support to sustain successful behavioural changes . Methods / Design The Sydney Diabetes Prevention Program ( SDPP ) is a translational study which will be conducted in 1,550 participants aged 50 - 65 years ( including 100 indigenous people aged 18 years and older ) at high risk of future development of diabetes . Participants will be identified through a screening and recruitment program delivered through primary care and will be offered a community-based lifestyle modification intervention . The intervention comprises an initial individual session and three group sessions based on behaviour change principles and focuses on five goals : 5 % weight loss , 210 min/week physical activity ( aerobic and strength training exercise ) , limit dietary fat and saturated fat to less than 30 % and 10 % of energy intake respectively , and at least 15 g/1000 kcal dietary fibre . This is followed by 3-monthly contact with participants to review progress and offer ongoing lifestyle advice for 12 months . The effectiveness and costs of the program on diabetes-related risk factors will be evaluated . Main outcomes include changes in weight , physical activity , and dietary changes ( fat , saturated fat and fibre intake ) . Secondary outcomes include changes in waist circumference , fasting plasma glucose , blood pressure , lipids , quality of life , psychological well being , medication use and health service utilization . Discussion This translational study will ascertain the reach , feasibility , effectiveness and cost-effectiveness of a lifestyle modification program delivered in a community setting through primary health care . If demonstrated to be effective , it will result in recommendations for policy change and practical methods for a wider community program for preventing or delaying the onset of type 2 diabetes in high risk people Diabetes is an “ old disease ” . The first description of diabetes written on papyrus about 3500 years ago is found in the Ebers papyrus  , which was discovered in Egypt in 1873 by the German archeologist Georg Ebers . Humans , like most mammals , may develop diabetes , if sufficient environmental exposure to physical inactivity , unhealthy diet and obesity are present . Genetic effects are important for the individual risk of type 2 diabetes ( T2D ) but twin studies have shown that the genetic effects combined explain less than 50 % of the risk of T2D ( 1 ) . Today we know almost 100 susceptibility genes associated with T2D but the relative importance of each of these genes is low ( 2 ) , and together they explain only a small part of the disease risk . Thus , genetic screening can not be used for the prediction of T2D for individuals . On the other h and , healthy lifestyle can also prevent T2D in people who are genetically at high risk , e.g. those with positive family history ( 3 ) . Thus , the importance of lifestyle factors for the development and prevention of T2D is overwhelming . The strongest evidence in medicine is considered to come from r and omized controlled trials ( RCTs ) . They are also important in providing the link to causal inference that in most observational studies can not be derived . At the same time , observational studies are necessary for the identification of factors associated with an increased or decreased risk of a disease , and for generation of hypotheses on potential means for prevention based on modifiable risk factors . Observational studies have by now identified a large number of factors that are associated with the development of T2D or with the protection against it . Most of them are related to physical activity , diet and obesity . It has also been shown unequivocally that exposures ( poor nutrition , infections , smoking , etc . ) during fetal life and early infancy result ing in insufficient development ( often shown as low birth weight ) also predict T2D later in life ( 4 ) . Traditionally , T2D has been considered to be a disease of the elderly . However , with increasing obesity and sedentary lifestyle in children , there are increasing numbers of cases of T2D already occurring at a young age in many population s ( 5 ) . In the past two decades several innovative RCTs have repeatedly shown that interventions on modifiable risk factors can reduce the incidence of diabetes in high-risk groups . The evidence has been summarized in several systematic review s and meta-analyses ( 6,7 ) . There is compelling scientific evidence from RCTs that T2D can be prevented or its onset delayed . The key for prevention is a multimodal package of lifestyle changes that is a sum outcome of dietary and physical activity behaviours . The power of lifestyle was dramatically illustrated by the Finnish Diabetes Prevention Study ( DPS ) that explicitly showed that when the study participants with impaired glucose tolerance reached all five modest lifestyle intervention targets , none of them progressed to T2D ( 8) . Importantly , lifestyle intervention lasting for 3–6 years has been shown to have a carry-over effect on T2D incidence that lasts for several years ; up to 15 in the Finnish Diabetes Prevention Study ( 9 ) and 20 years in the China Da Qing Diabetes Prevention Study ( 10 ) . The observed sustained risk reduction seems to be a result of sustained lifestyle changes , but the legacy effect of improved glycaemia during the early intervention may also have contributed to the long-term effect . The follow-up data from the Chinese study indicate moreover that vascular risks are also reduced by lifestyle management . Several prognostic question naires exist for detecting people at risk of T2D ( 11 ) . One of the screening tools with an adequately high sensitivity and specificity is the Finnish Diabetes Risk Score ( FINDRISC ) developed in Finl and ( 12 ) . The FINDRISC has been successfully implemented in the Finnish primary health care system and used also in many other countries . The FINDRISC was also tested in the Omani population and as a result a slightly modified Omani Diabetes Risk Score was developed ( 13 ) which may be a suitable screening tool for the Arab population s in the Middle East . Lifestyle interventions aim ing at translating evidence from efficacy RCTs on T2D prevention into “ real world ” intervention programmes have also been carried out in various population s. Such data were recently combined in a meta- analysis considering the relationship between intervention effectiveness and adherence to guidelines ( 14 ) . The primary meta- analysis included 22 studies with outcome data for weight loss at 12 months . The pooled result of the direct pairwise meta- analysis shows that Background Intensive lifestyle interventions in well-controlled setting s are effective in lowering the risk of chronic diseases such as type 2 diabetes ( T2DM ) and cardiovascular diseases ( CVD ) , but there are still no effective lifestyle interventions for everyday practice . In the Hoorn Prevention Study we aim ed to assess the effectiveness of a primary care based lifestyle intervention to reduce the estimated risk of developing T2DM and for CVD mortality , and to motivate changes in lifestyle behaviors . Methods The Hoorn Prevention Study is a parallel group r and omized controlled trial , implemented in the region of West-Friesl and , the Netherl and s. 622 adults with ≥10 % estimated risk of T2DM and /or CVD mortality were r and omly assigned and monitored over a period of 12 months . The intervention group ( n=314 ) received a theory-based lifestyle intervention based on an innovative combination of motivational interviewing and problem solving treatment , provided by trained practice nurses in 12 general practice s. The control group ( n=308 ) received existing health brochures . Primary outcomes was the estimated diabetes risk according to the formula of the Atherosclerosis Risk In Communities ( ARIC ) Study , and the estimated risk for CVD mortality according to the Systematic COronary Risk Evaluation ( SCORE ) formula . Secondary outcomes included lifestyle behavior ( diet , physical activity and smoking ) . The research assistants , the principal investigator and the general practitioners were blinded to group assignment . Linear and logistic regression analysis was applied to examine the between-group differences in each outcome measure , adjusted for baseline values . Results 536 ( 86.2 % ) of the 622 participants ( age 43.5 years ) completed the 6-month follow-up , and 502 ( 81.2 % ) completed the 12-month follow-up . The mean baseline T2DM risk was 18.9 % ( SD 8.2 ) and the mean CVD mortality risk was 3.8 % ( SD 3.0 ) . The intervention group participated in a median of 2 sessions . Intention-to-treat analyses showed no significant differences in outcomes between the two groups at 6 or 12-months follow-up . Conclusions The lifestyle intervention was not more effective than health brochures in reducing risk scores for T2DM and CVD or improving lifestyle behavior in an at-risk population .Trial registration Current Controlled Trials : IS RCT AIMS Individuals with Type 2 diabetes are at high risk for coronary heart disease , and may benefit from aggressive lifestyle modification . We evaluated the prevalence of Type 2 diabetes , in a Greek adult population , in relation to physical activity and dietary habits . METHODS From May 2001 to December 2002 , we r and omly enrolled 1514 men and 1528 women , with no evidence of cardiovascular or any other chronic disease . The sampling was stratified by the age and gender distribution of the general population in the greater area of Athens ( census 2001 ) . Diabetes was defined according to the established American Diabetes Association criteria .  Dietary habits  were assessed through a vali date d food frequency question naire and a diet score  was developed , in which higher values suggest greater adherence to the Mediterranean diet . Weekly energy expenditure  was assessed by considering frequency , duration and intensity of sports-related physical activity during a usual week . RESULTS After age adjustment for the Greek adult population ( 2001 census ) , the projected prevalence of Type 2 diabetes was 7.6 % in men and 5.9 % in women . A significant proportion of diabetic subjects ( 24 % of men and 30 % of women ) were unaware of their condition . Moreover , a 10-unit increase in the diet score was associated with 21 % lower odds of diabetes ( P < 0.05 ) , while individuals taking light physical activity were at 35 % lower odds ratio of diabetes compared with sedentary individuals ( P < 0.05 ) . CONCLUSIONS Diabetes mellitus is common in our population , with approximately 1 in 5 individuals with Type 2 diabetes being unaware of their condition . The lifestyle approach described here may contribute significantly to the reduction in the prevalence of diabetes , at a population level Context Can changes in diet prevent diabetes in older adults ? Contribution This subgroup analysis of a multicenter trial involved older adults with high risk for heart disease who were r and omly assigned to a Mediterranean diet supplemented with either extra-virgin olive oil or mixed nuts or to a low-fat control diet . Neither energy restriction nor increased physical activity was advised . After 4 years of follow-up , fewer persons in the Mediterranean diet groups developed diabetes than in the control group . Implication Changes in dietary patterns that do not necessarily lead to weight loss or include energy restrictions could help prevent diabetes in some older adults . The Editors Type 2 diabetes mellitus represents a major health problem because worldwide prevalence has more than doubled in the past 3 decades , with nearly 347 million persons with diabetes in 2010 ( 1 ) , and is a potent risk factor for cardiovascular disease ( CVD ) , blindness , renal failure , and lower limb amputation ( 2 ) . Compelling evidence shows that diabetes can be prevented with lifestyle changes . Intensive lifestyle modification promoting weight loss through energy-restricted diets together with increased physical activity can decrease incident diabetes to as low as 50 % ( 3 ) . Indeed , lifestyle modification has performed better than pharmacologic approaches ( such as metformin or rosiglitazone ) in diabetes prevention ( 46 ) . Of interest , the benefit of lifestyle changes in decreasing diabetes risk seems to extend beyond the termination of active intervention ( 68 ) . However , there is little information on whether changes in the overall dietary pattern , without energy restriction , increased physical activity , and ensuing weight loss , may also be effective to prevent diabetes . Prospect i ve epidemiologic studies strongly suggest that dietary patterns characterized by high consumption of fruit , vegetables , whole grains , and fish and reduced consumption of red and processed meat , sugar-sweetened beverages , and starchy foods delay diabetes onset ( 9 ) . In the last 6 years , the traditional Mediterranean diet has emerged as a healthy dietary pattern that is also associated with a decreased risk for diabetes ( 1012 ) . The Mediterranean diet is moderately rich in fat ( 35 % to 40 % of energy ) , especially from vegetable sources ( rich in olive oil and nuts ) , and relatively low in dairy products . Moderate consumption of alcohol , mostly wine , and frequent use of sauces with tomato , onions , garlic , and spices for meal preparation are also typical . Preliminary data from the PREDIMED ( Prevencin con Dieta Mediterrnea ) study ( 1317 ) showed that traditional Mediterranean diets enriched with high-fat foods of vegetable origin decreased the incidence of diabetes ( 18 ) . However , that report studied participants only from 1 of the 11 PREDIMED recruiting centers . In this analysis , we provide the final results on diabetes incidence in the whole multicenter trial after a median follow-up of 4.1 years . Methods Design Overview The PREDIMED study is a parallel-group , r and omized , primary cardiovascular prevention trial done in Spain in persons at high risk but without CVD at baseline . The protocol , design , objectives , and methods have been reported in detail elsewhere ( 13 , 14 ) . Briefly , participants were r and omly assigned in a 1:1:1 ratio to 1 of 3 nutrition interventions : Mediterranean diet supplemented with extra-virgin olive oil ( EVOO ) , Mediterranean diet supplemented with mixed nuts , or a control diet consisting of advice to reduce intake of all types of fat . A complete list of PREDIMED study investigators is available in Supplement 1 . The local institutional review boards approved the protocol at each study location , and all participants provided written informed consent . Supplement . Original Version ( PDF ) Supplement 1 . List of Prevencin con Dieta Mediterrnea Study Investigators Setting and Participants Eligible participants were community-dwelling men ( aged 55 to 80 years ) and women ( aged 60 to 80 years ) without CVD at baseline who had either type 2 diabetes or at least 3 or more cardiovascular risk factors , namely current smoking , hypertension , hypercholesterolemia , low high-density lipoprotein cholesterol levels , overweight or obesity , and family history of premature CVD . Exclusion criteria have previously been reported ( 13 ) . R and omization and Intervention From October 2003 to June 2009 , 7447 suitable c and i date s were enrolled in the trial . The study nurse from each recruiting center r and omly assigned each participant to the corresponding intervention group following computer-generated r and om numbers for allocation contained in sealed envelopes , which were central ly prepared for each center by the coordinating unit . Four strata of r and omization were built by sex and age ( cutoff , 70 years ) but not by baseline diabetes status . The primary care physicians did not participate in the r and omization process . The study nurses were independent of the nursing staff of the primary care health centers . Therefore , they were not involved in the usual clinical care of participants , and their exclusive role was to collect data for the trial . Given the nature of the interventions ( nutritional advice and provision of foods ) , only investigators assessing outcomes were blinded with respect to intervention assignment . This was done by providing them with coded data sets and medical records blinded with respect to the personal identity of the participant and without any information on treatment allocation . Because our main objective was to determine the effect of the 3 interventions on diabetes incidence , this report includes data only on participants who did not have diabetes at baseline and for whom we could ascertain the incidence of diabetes during follow-up ( n= 3541 ) ( Figure 1 ) . Figure 1 . Study flow diagram . EVOO = extra-virgin olive oil ; MedDiet = Mediterranean diet . A behavioral intervention promoting the Mediterranean diet was implemented in the corresponding groups of the trial , as described ( 13 ) . Dietitians gave personalized advice to participants about the amount and use of EVOO for cooking and dressing ; weekly intake of nuts ; increased consumption of vegetables , fruits , legumes , and fish ; recommended intake of white meat instead of red or processed meat ; avoidance of butter , fast food , sweets , pastries , or sugar-sweetened beverages ; and the dressing of dishes with sofrito sauce ( using tomato , garlic , onion , and spices simmered in olive oil ) . Reduction of alcoholic beverages other than wine was advised to all participants . Wine with meals was recommended with moderation only to habitual drinkers . At baseline and quarterly thereafter , dietitians conducted individual and group dietary training sessions to provide information on typical Mediterranean foods , seasonal shopping lists , meal plans , and recipes for each group . In each session , a 14-item question naire was used to assess adherence to the Mediterranean diet ( 13 , 14 ) so that personalized advice could be provided to up grade participants adherence . The same question naire was assessed yearly in the control group . Participants assigned to the 2 Mediterranean diet groups received allotments of either EVOO ( 50 mL/d ) or mixed nuts ( 30 g/d : 15 g of walnuts , 7.5 g of almonds , and 7.5 g of hazelnuts ) at no cost . Participants assigned to the control diet received recommendations to reduce intake of all types of fat ( from both animal and vegetable sources ) and received nonfood gifts ( kitchenware , tableware , aprons , or shopping bags ) . Through October 2006 , participants in the control group received only a leaflet describing the low-fat diet . Thereafter , participants assigned to the control diet also received personalized advice and were invited to group sessions with the same frequency and intensity as those in the Mediterranean diet groups . A separate 9-item dietary question naire ( 14 ) was used to assess adherence to the low-fat diet . Neither energy restriction nor increased physical activity was advised for any intervention group . At baseline examination and yearly during follow-up , we administered a 137-item vali date d semiquantitative food-frequency question naire ( 19 ) ; the vali date d Spanish version of the Minnesota Leisure-time Physical Activity Question naire ( 20 ) ; and a 47-item question naire about education , lifestyle , medical history , and medication use . At baseline , trained personnel performed  electrocardiography and anthropometric and blood pressure measurements . Blood pressure  was measured in triplicate by using a vali date d semiautomatic oscillometer with a 5-minute interval between measurements and the participant in a sitting position ( Omron HEM-705CP , Omron , Hoofddorp , the Netherl and s ) . Fasting blood and spot urine were sample d at baseline and follow-up years 1 , 3 , 5 , and 7 . After an overnight fast , tubes for EDTA plasma , citrate plasma , and serum and urine sample s were collected and aliquots were coded and stored at 80C in the central laboratory until analysis . Serum glucose , cholesterol , and triglyceride levels were measured using st and ard enzymatic methods . High-density lipoprotein cholesterol was measured after precipitation with phosphotungstic acid and magnesium chloride . Biomarkers of adherence to the supplemental foods , including urine hydroxytyrosol levels and plasma -linolenic acid proportions , which are reliable biomarkers of EVOO and walnut intake , respectively , were measured in r and om sub sample s of participants during the first 5 years of follow-up ( by gas chromatographymass spectrometry and by gas chromatography , respectively ) . Laboratory technicians were blinded to intervention group . Outcomes and Follow-up Diabetes was a prespecified secondary outcome of the PREDIMED trial . IT was considered to be present at baseline by clinical diagnosis or use of antidiabetic medication . New-onset diabetes during follow-up was diagnosed using the American Diabetes Association criteria , namely fasting plasma glucose levels of 7.0 mmol/L or BACKGROUND It has been suggested that the inverse association between alcohol and type 2 diabetes could be explained by moderate drinkers ' healthier lifestyles . OBJECTIVE We studied whether moderate alcohol consumption is associated with a lower risk of type 2 diabetes in adults with combined low-risk lifestyle behaviors . DESIGN We prospect ively examined 35,625 adults of the Dutch European Prospect i ve Investigation into Cancer and Nutrition ( EPIC-NL ) cohort aged 20 - 70 y , who were free of diabetes , cardiovascular disease , and cancer at baseline ( 1993 - 1997 ) . In addition to moderate alcohol consumption ( women : 5.0 - 14.9 g/d ; men : 5.0 - 29.9 g/d ) , we defined low-risk categories of 4 lifestyle behaviors : optimal weight [ body mass index ( in kg/m(2 ) ) < 25 ] , physically active ( > or = 30 min of physical activity/d ) , current nonsmoker , and a healthy diet [ upper 2 quintiles of the Dietary Approaches to Stop Hypertension ( DASH ) diet ] . RESULTS During a median of 10.3 y , we identified 796 incident cases of type 2 diabetes . Compared with teetotalers , hazard ratios of moderate alcohol consumers for risk of type 2 diabetes in low-risk lifestyle strata after multivariable adjustments were 0.35 ( 95 % CI : 0.17 , 0.72 ) when of a normal weight , 0.65 ( 95 % CI : 0.46 , 0.91 ) when physically active , 0.54 ( 95 % CI : 0.41 , 0.71 ) when nonsmoking , and 0.57 ( 95 % CI : 0.39 , 0.84 ) when consuming a healthy diet . When > or =3 low-risk lifestyle behaviors were combined , the hazard ratio for incidence of type 2 diabetes in moderate alcohol consumers after multivariable adjustments was 0.56 ( 95 % CI : 0.32 , 1.00 ) . CONCLUSION In subjects already at lower risk of type 2 diabetes on the basis of multiple low-risk lifestyle behaviors , moderate alcohol consumption was associated with an approximately 40 % lower risk compared with abstention Aims : To evaluate the effects of a lifestyle intervention programme in primary healthcare , targeted to patients with moderate to high risk of cardiovascular disease in terms of cardiovascular risk factors , physical activity , and quality of life . Method : R and omized controlled trial with one-year follow-up , carried out in a primary healthcare centre in Northern Sweden . A total of 151 middle-aged men and women , with hypertension , dyslipidemia , type 2 diabetes , or obesity were enrolled . The subjects were r and omized to either the intervention ( n=75 ) or the control group ( n=76 ) . A total of 123 subjects completed the one-year follow-up . Interventions : Exercise : supervised endurance and circuit training in groups three times a week for three months . Diet : five group sessions of diet counselling with a dietitian . Follow- up meetings with a physiotherapist were conducted monthly thereafter . Primary outcomes were changes in anthropometry , maximal oxygen uptake , health-related quality of life , and self-reported physical activity . The secondary outcomes were changes in blood pressure and metabolic variables . Results : After one year the intervention group significantly increased maximal oxygen uptake , physical activity , and quality of life and significantly decreased body weight , waist and hip circumference , body mass index , waist — hip ratio , systolic and diastolic blood pressure , triglycerides , and glycosylated haemoglobin . There were significant differences between groups , mean changes ( and their 95 % confidence intervals , CI ) in waist circumference -1.9 cm ( -2.80 to -0.90 ; p<0.001 ) , in waist — hip ratio -0.01 ( -.02 to -0.004 ; p<0.01 ) and in diastolic blood pressure -2.3 mmHg ( -4.04 to -0.51 ; p<0.05 ) . Conclusion : A prevention programme in primary healthcare with a focus on physical activity and diet counselling followed by structured follow-up meetings can favourably influence several risk factors for cardiovascular diseases and quality of life in high-risk subjects for at least one year AIMS To study the long-term ( 1- and 2-year ) effect of a lifestyle intervention on non-diabetic first-degree relatives of type 2 diabetic patients , i.e. , the 1-year effect of diet versus diet and exercise in relation to a control group and the 2-year sustainability of these treatment effects . METHOD Seventy-seven healthy first-degree relatives ( men and women ) between the ages of 25 and 55 were allocated to one of three groups : diet group ( D ) , diet and exercise group ( DE ) and control group ( C ) . For ethical reasons , after 1 year the control group began the intervention and were followed for another 2 years . Diet and physical activity counselling was based on current nutrition recommendations , including increased intake of fatty fish and low glycaemic index foods . The fatty acid composition of the erythrocyte membrane was studied as an objective measure of dietary change . Assessment s included fasting insulin , 2-h insulin , oral glucose tolerance test ( OGTT ) , anthropometry and blood lipid measurements . Groups D and DE received intensive follow-up through unannounced telephone interviews during the first 4 months . RESULTS Dietary changes were significant at 1 year , and to a large degree sustained at 2 years . Adherence to advice regarding fat quality was confirmed through changes in the fatty acid composition of the erythrocyte membrane . The least active subjects in DE increased their physical activity ( PA ) . At 1 year , group D showed a reduction in the ratio of LDL to HDL cholesterol ( p=0.028 ) while group DE decreased their body weight by 2.7 % ( p<0.029 ) and increased HDL ( p<0.037 ) versus controls . At 2 years , cholesterol levels ( total , LDL and the ratio LDL/HDL ) were reduced within group D and when compared to DE ( p=0.022 , 0.009 , 0.035 , respectively ) . Fasting insulin was reduced within group DE and when compared to group D ( p=0.025 ) . CONCLUSIONS Positive changes in lifestyle , blood lipids and fasting insulin can be achieved and maintained in a non-diabetic population at risk of type 2 diabetes after 2 years Background :  Physical activity ( PA )  is important for management of diabetes , yet practical interventions that achieve sustained behavior change are rare . Purpose : The goals of this research were to evaluate the effectiveness of a multifaceted PA intervention for people with type 2 diabetes that emphasized participant choice in activity selection . Baseline activity patterns were examined to determine whether they predicted changes in PA at 2 months . Methods : Three hundred thirty-five participants were recruited from 42 primary care physicians and then r and omized to either a computer-assisted , tailored self-management intervention ( N = 174 ) or health risk appraisal with feedback control ( N = 161 ) . Primary outcome measures included the Community Healthy Activities Model Program for Seniors Question naire , diet , and psychosocial assessment s at baseline and 2 months . Results : For 301 participants who completed the 2-month follow-up , the intervention significantly improved all PA ( p < .01 ) and moderate PA ( metabolic equivalents > 3.0 , p < .01 ) relative to controls . Baseline cluster analyses grouped participant activity patterns into three categories . At 2 months , cluster assignment differentially predicted change in calories expended in moderate , rote , sport , and lifestyle PA . Conclusions : A computer-assisted , multifaceted approach to PA demonstrated improvement after 2 months . The results suggest that individuals are capable of adjusting their activity patterns to maximize their PA BACKGROUND This study assessed the clinical impact of lifestyle change education on chronic disease risk factors within a community . DESIGN R and omized clinical trial . SETTING / PARTICIPANTS Participants included 337 volunteers age 43 to 81 years from the Rockford , IL , metropolitan area . INTERVENTION The intervention group attended a 40-hour educational course delivered over a 4-week period . Participants learned the importance of making healthful lifestyle choices and how to make improvements in nutrition and physical activity . MAIN OUTCOME MEASURES Changes in health knowledge , nutrition , and physical activity behavior , and several chronic disease risk factors were assessed at baseline and 6 weeks . RESULTS Beneficial mean changes in scores tended to be significant for the intervention group but not for the control group . Variables with improved scores included health knowledge , percent body fat , total steps per week , and most nutrition variables . Clinical improvements were seen in resting heart rate , total cholesterol , low-density lipoprotein cholesterol , and systolic and diastolic blood pressure . The control group experienced comparatively small but significant improvements in health knowledge , systolic and diastolic blood pressure , glucose , and in some nutrition variables . For almost all variables , the intervention group showed significantly greater improvements . CONCLUSIONS This lifestyle modification program is an efficacious nutrition and physical activity intervention in the short term and has the potential to dramatically reduce the risks associated with common chronic diseases in the long term Background The prevalence of overweight and elevated cardiovascular disease ( CVD ) risk among workers in the construction industry is relatively high . Improving lifestyle lowers CVD risk and may have work-related benefits . The purpose of the study was to evaluate the effects on physical activity ( PA ) , diet , and smoking  of a lifestyle intervention consisting of individual counseling among male workers in the construction industry with an elevated risk of cardiovascular disease ( CVD ) . Methods In a r and omized controlled trial including 816 male blue- and white-collar workers in the construction industry with an elevated risk of CVD , usual care was compared to a 6-month lifestyle intervention . The intervention consisted of individual counseling using motivational interviewing techniques , and was delivered by an occupational physician or occupational nurse . In three face to face and four telephone contacts , the participant 's risk profile , personal determinants , and barriers for behavior change were discussed , and personal goals were set . Participants chose to aim at either  diet and PA  , or smoking . Data were collected at baseline and after six and 12 months , by means of a question naire . To analyse the data , linear and logistic regression analyses were performed . Results The intervention had a statistically significant beneficial effect on snack intake ( β-1.9 , 95%CI -3.7 ; -0.02 ) and fruit intake ( β 1.7 , 95%CI 0.6 ; 2.9 ) at 6 months . The effect on snack intake was sustained until 12 months ; 6 months after the intervention had ended ( β -1.9 , 95%CI -3.6 ; -0.2 ) . The intervention effects on leisure time PA and metabolic equivalent-minutes were not statistically significant . The beneficial effect on smoking was statistically significant at 6 ( OR smoking 0.3 , 95%CI 0.1;0.7 ) , but not at 12 months ( OR 0.8 , 95%CI 0.4 ; 1.6 ) . Conclusions Beneficial effects on smoking , fruit , and snack intake can be achieved by an individual-based lifestyle intervention among male construction workers with an elevated risk of CVD . Future research should be done on strategies to improve leisure time PA and on determinants of maintenance of changed behavior . Considering the rising prevalence of unhealthy lifestyle and CVD , especially in the aging population , implementation of this intervention in the occupational health care setting is recommended . Trial registration Current Controlled Trials IS RCT AIMS To investigate the short-term ( 16 weeks ) effect of lifestyle intervention on insulin sensitivity , anthropometric and metabolic variables in non-diabetic first-degree relatives of type 2 diabetic patients ( FDR ) . METHODS Seventy-seven ( 49 male , 28 female ) FDR were allocated to one of three groups , diet ( D-group ; n = 25 ) , diet and exercise ( DE-group ; n = 30 ) or control group ( C-group ; n = 22 ) . Lifestyle counselling was based on current nutrition recommendations , including increased intake of fatty fish and low glycaemic index foods . Group counselling was given on two occasions with follow-up through telephone interviews every 10 days . Assessment s included insulin sensitivity index ( Si ) , anthropometry , lipid parameters , circulating leptin and adiponectin levels . RESULTS The D-group reduced total cholesterol ( -0.31 mmol/l , P = 0.024 ) , LDL cholesterol ( -0.22 mmol/l , P = 0.021 ) and apolipoprotein B ( -9.5 mg/dl , P = 0.009 ) levels , whereas the DE-group decreased body weight ( -2.1 % , P = 0.030 ) and waist circumference ( -3.0 cm , P < 0.001 ) versus controls . A 13 % reduction in fasting insulin was observed in the DE-group , but no significant improvement in Si in D-group or DE-group was observed . A subgroup , adherent to diet and who increased exercise , significantly improved Si and lipid profile . CONCLUSIONS The improved metabolic risk profile in FDR suggests that lifestyle changes can be effective in individuals at high risk to develop type 2 diabetes and cardiovascular disease BACKGROUND Intensive lifestyle interventions have been successful in reducing  type 2 diabetes  incidence . Whether intensive programmes requiring face-to-face contact , trained staff and access to facilities are feasible , on a larger scale , has been debated . OBJECTIVES The aim of this study is to determine the feasibility and efficacy of a lifestyle intervention for type 2 diabetes prevention in men using an assessor-blinded , parallel-group , r and omised controlled trial . The ' Type 2 Diabetes PULSE ( Prevention Using LifeStyle Education ) Programme for Men ' is a 6-month , self-administered , gender-tailored lifestyle intervention , with a multicomponent approach ( weight loss , dietary modification , aerobic exercise and resistance training ) . Eligible men were aged 18 - 65 years , overweight/obese ( BMI 25 - 40 kg·m(-2 ) ) and at high-risk for type 2 diabetes ( score ≥ 12 , Australian diabetes risk tool ) . Men with diagnosed prediabetes were eligible , but those with type 1 and 2 diabetes were ineligible . R and omisation was stratified by age ( < 50 or ≥ 50 years ) and BMI category ( kg·m(-2 ) : 25 - 29.9 ; 30 - 34.9 ; 35 - 40 ) to the intervention or wait-list control group . Data are collected at study entry ( baseline ) , 3 and 6 months . The primary outcome is weight change at 6 months . Secondary outcomes include : fasting plasma glucose , HbA1C , waist circumference , body composition , blood pressure , diet quality , aerobic fitness , muscular fitness and physical activity . Generalised linear mixed models ( intention-to-treat ) will assess outcomes for treatment ( intervention vs. control ) , time ( baseline , 3 and 6-months ) and the treatment-by-time interaction . CONCLUSION The results will determine the efficacy of a type 2 diabetes prevention programme for men with potential for wide reach and dissemination . TRIAL REGISTRATION Australian New Zeal and Clinical Trials Registry ( ACTRN12612000721808 ) The purpose of this study was to evaluate the impact of a three-day therapeutic education programme on perceived competence , self-management behaviours ( i.e. physical activity , diet and medication ) and glycaemic control among adults with type 2 diabetes . A total of 120 participants were included in this r and omized , wait list control group trial . The results confirm that therapeutic education may be a powerful healthcare intervention to improve lifestyle and health status of people with type 2 diabetes . We observed that the education programme used in this study generated positive changes in glycaemic control and adherence to physical activity and diet after three months follow-up . Furthermore , the intervention positively impacted participants ’ perceived competence towards physical activity and diet . The latter finding is of particular importance , given that perceived competence has been found to be involved in long-term adherence to self-management behaviours Background Physical activity ( PA ) promotes cardiovascular health and health related quality of life ( HRQoL ) , although the effect of that on blood pressure ( BP ) control has rarely been studied in hypertensive subjects . Our aim was to evaluate the effectiveness of a PA intervention programme on cardiovascular disease ( CVD ) risk , HRQoL and BP control  in hypertensive subjects . Methods A r and omized clinical trial , with a PA intervention programme of 9 months duration , comprising a walking group of 120 min/week , supervised , and with socio-cultural activities .  Participants were 207 hypertensive subjects ( 68.2 years , 76.8 % women ) .  PA ( IPAQ-s ) , diet , CVD risk , BP , BMI , smoking , and HRQoL ( SF-36 ) were assessed at baseline and at the end of the intervention . Changes in CVD risk and in HRQoL during the intervention was calculated ( end-baseline score ) . Multivariate models were applied . Results In multivariate models , the PA intervention programme , with no modification of the diet , decreased CVD risk ( − 1.19 points ) and the systolic BP ( − 8.68 mmHg ) , and increased some areas of HRQoL ( 4.45 to 14.62 points ) . An increase in the percentage of subjects with controlled BP was observed by the PA programme itself ( OR 5.395 to 5.785 according to multivariate models ) , and by the changes during the intervention in the decrease in CVD risk ( OR 0.609 ) and in the increase in the HRQoL in physical component summary ( OR 1.041 ) , role physical ( OR 1.010 ) , and bodily pain ( OR 1.014 ) , independently of controlled BP at baseline . Conclusions This PA intervention programme  improved cardiovascular health and HRQoL , and favoured BP control in primary care users with hypertension . Trial registration Clinical trials.gov ID NCT02767739 ; Trial registered on May 5th , 2016 . Retrospectively registered OBJECTIVE This study aims to evaluate the three-year effect of lifestyle counseling by a nurse practitioner ( NP ) on  physical activity ( PA ) and dietary intake compared with usual care by a general practitioner ( GP ) . METHODS At baseline , subjects were r and omly allocated to the NP group ( n = 225 ) or to the GP group ( n = 232 ) . The NP group received a low-intensive lifestyle intervention for three years by the NP and the GP group received one consultation by the GP and thereafter usual care . PA and dietary intake  were assessed with question naires at baseline , 1 year follow-up and 3 year follow-up . RESULTS After three years , leisure-time activity increased and favorable improvements towards a healthy diet were made for both groups . These three-year changes in PA and diet did not differ significantly between groups . Changes in PA and dietary habits after one year were practically maintained after 3 years , because only small relapses were found . CONCLUSION After three years , subjects were more physically active and had a healthier diet compared to baseline . Lifestyle counseling by NP result ed in similar lifestyle changes compared to GP consultation . PRACTICE IMPLICATION S NPs could also advice patients at cardiovascular risk by lifestyle counseling , to possibly reduce GP barriers Type 2 diabetes is a global public health crisis that threatens the economies of all nations , particularly developing countries . Fueled by rapid urbanization , nutrition transition , and increasingly sedentary lifestyles , the epidemic has grown in parallel with the worldwide rise in obesity . Asia 's large population and rapid economic development have made it an epicenter of the epidemic . Asian population s tend to develop diabetes at younger ages and lower BMI levels than Caucasians . Several factors contribute to accelerated diabetes epidemic in Asians , including the “ normal-weight metabolically obese ” phenotype ; high prevalence of smoking and heavy alcohol use ; high intake of refined carbohydrates ( e.g. , white rice ) ; and dramatically decreased physical activity levels . Poor nutrition in utero and in early life combined with overnutrition in later life may also play a role in Asia 's diabetes epidemic . Recent advances in genome-wide association studies have contributed substantially to our underst and ing of diabetes pathophysiology , but currently identified genetic loci are insufficient to explain ethnic differences in diabetes risk . Nonetheless , interactions between Westernized diet and lifestyle and genetic background may accelerate the growth of diabetes in the context of rapid nutrition transition . Epidemiologic studies and r and omized clinical trials show that type 2 diabetes is largely preventable through diet and lifestyle modifications . Translating these findings into practice , however , requires fundamental changes in public policies , the food and built environments , and health systems . To curb the escalating diabetes epidemic , primary prevention through promotion of a healthy diet and lifestyle should be a global public policy priority Review question / objective What are the effects of weight management interventions that include a diet component on weight‐related outcomes in pregnant and postpartum women ? The primary objective of this systematic review is to evaluate the effectiveness of weight management interventions which include a diet component and are aim ed at limiting gestational weight gain and postpartum weight retention in women . The second objective of this systematic review is to investigate included intervention components with respect to effect on weight‐related outcomes . This may include , but is not limited to : length of intervention , use of face‐to‐face counselling , group or individual consultations , use of other interventions components including exercise , use of goals and use of support tools like food diaries , coaching , including email or text message support . Background Around half of all women of reproductive age are either overweight or obese,1,2,3 with women aged 25‐34 years having a greater risk of substantial weight gain compared with men of all ages.1,4 Excessive gestational weight gain ( GWG ) and postpartum weight retention ( PPWR ) may play a significant role in long term obesity . Having one child doubles the five‐ and 10‐year obesity incidence for women , with many women who gain excessive weight during pregnancy remaining obese permanently.5 Excessive GWG and /or PPWR can also significantly contribute to short‐ and long‐term adverse health outcomes for mother , baby and future pregnancies.6,7 Maternal obesity increases the risk of pregnancy related complications such as pre‐eclampsia , gestational diabetes mellitus , stillbirth and the rate of caesarean section.8 Childhood obesity is a further long term complication of maternal obesity for offspring , which may persist in to adulthood.9 Excess GWG is also a risk factor for PPWR both in the short and long‐term.10,11 Nehring et al. conducted a meta‐ analysis with over 65,000 women showing that , compared to women who gained weight within recommendations during pregnancy , women with GWG above Institute of Medicine weight gain recommendations , 12 retained an additional 3.1 kg and 4.7 kg after three and greater than or equal to 15 years postpartum , respectively.13 The health risk associated with PPWR is highlighted in a study of 151,025 Swedish women followed between 1992 and 2001.The study identified the risk of adverse pregnancy outcomes for those who gained three or more units of Body Mass Index ( kg/m2 ) between consecutive pregnancies ( an average of two years ) was much higher compared with women whose BMI changed from ‐1.0 and 0.9 units.14 Long‐term chronic disease risk may also be affected by PPWR as weight retention at the end of the first year post‐partum has been found to be a predictor of maternal overweight 15 years later.15With around 14‐20 % of women retaining 5 kg or more 12 months postpartum,16,5 the risk of developing conditions like diabetes , metabolic syndrome and cardiovascular disease may be increased.17 It becomes evident that interventions which aim to support attainment of healthy weight both in the antenatal and postpartum periods are key health priorities for women during this life stage . Lifestyle factors of overweight , having poor diet quality , and not undertaking enough moderate‐to‐vigorous physical activity are amongst the top five predictors of mortality in women.18 Additionally it is noted that , for many women , pregnancy and the postpartum period are associated with a reduction in physical activity.19 It is known that a combination of poor dietary choices , an increase in sedentary time and reduction in physical activity are all contributors to the development of overweight and obesity . With this in mind , current research has focused on lifestyle interventions to limit GWG and PPWR . Thangaratinam et al. review ed 44 r and omized controlled trials ( 7278 women ) where interventions including diet , physical activity or both were evaluated for their influence on maternal weight during  pregnancy.20 Results indicate that all were significantly effective in reducing GWG compared with the control group . More specifically , dietary interventions were the most effective in reducing weight gain , with a mean weight loss of ‐3.84 kg compared with ‐0.72 kg and ‐1.06 kg for physical activity and the mixed ( diet plus physical activity ) approach , respectively.20 This finding is supported by Hill and colleagues ' recent systematic review of theory based interventions to limit GWG.21 Included studies in this review reported an underpinning theory base and were classified as adopting a dietary , physical activity or mixed approach . Hill et al. concluded that studies which included a diet intervention were significantly more effective at limiting GWG.21 In 2011 Tanentsapf et al. review ed the effect of dietary interventions alone for reducing GWG in normal weight , overweight and obese pregnant women.22 This review analysed 13 r and omized controlled trials and quasi‐r and omized controlled trials with a dietary intervention to prevent excessive GWG in women . The review concluded that dietary interventions during pregnancy were effective in reducing GWG with an effect of ‐1.92 kg ( n=1434 ) compared with the control group.22 Tanentsapf et al. identified that trials differed in the conduct of the interventions with various diet and non‐diet related components utilised . Dietary approaches were highly variable with some trials focusing only on calorie restriction and others included additional target macronutrient distribution for intake . Some trials further provided feedback based on maternal weight gain guidelines .12 Interventions also varied in delivery method with a variety of modes used , including face‐to‐face , individual or group consultations and /or written correspondence . The frequency of communication , despite the type or mix , also changed from trial to trial with additional methods via telephone , posted material s , feedback or food diaries utilised . The inclusion of physical activity in addition to diet intervention was also common . Whilst the recent review by Tanentsapf et al.22 identified that dietary interventions are effective in reducing GWG , the review did not investigate the impact that different intervention components , delivery methods or dietary counselling approaches had on gestational weight management . It remains unclear as to which intervention components optimize GWG in women . The impact of lifestyle interventions has also been investigated in the postpartum period . The recent systematic review from van der Pligt et al. reported seven of 11 studies review ed were successful in limiting PPWR.23 As with studies aim ed at limiting GWG , interventions included in van der Pligt et al. 's review differed greatly in their conduct . Six of these seven studies included both dietary and physical activity components for the intervention , with the final successful study including a diet only intervention . Five of the successful studies recruited overweight or obese women only . Intervention time varied considerably in successful studies with some running for as little at ten days , and others up to six months . Bertz et al. demonstrated that their 12‐week behavior modification intervention which targeted diet alone or diet and exercise , including two individual sessions with a dietitian and physical therapist , provision of scales for weight self‐monitoring and bi‐weekly text messages was successful in achieving significant weight loss following the intervention , and sustained at one year.24 The diet intervention and the diet and exercise intervention  yielded significant weight loss compared to the control . Following 12 weeks a reduction of ‐8.3 + /‐ 4.2 kg for diet intervention and ‐6.9 + /‐ 3.0 kg for diet and exercise was observed . Additionally after one year , the diet intervention showed ‐10.2 + /‐ 5.7 kg reduction and ‐7.3 + /‐ 6.3 kg for the diet and exercise intervention (p<0.001).24 Colleran et al. also found significant weight change results by implementing a 16‐week intervention which consisted of weekly individual sessions with a dietitian regarding calorie restriction , two additional home visits regarding exercise , weekly food diary completion and email support.25 The intervention group had greater weight loss compared to the control group ( ‐5.8 kg + /‐ 3.5 kg vs ‐1.6 kg + /‐ 5.4 kg ) . It can be seen that various methods have been utilized in investigating the impact of diet and physical activity interventions on PPWR . The review by van der Pligt et al.23 highlights the impact successful lifestyle interventions can have on postpartum weight change . However , this review did not investigate the different intervention strategies utilized . It remains unclear as to the optimal setting , delivery method , diet strategy , contact frequency or intervention length to limit PPWR . Previous systematic review s for both GWG and PPWR have focused on the effectiveness of lifestyle interventions as a whole for weight management in pregnant and postpartum women.20,23 And despite Tanentsapf et al. 's focus on dietary interventions for GWG,22 much is still unknown about the effectiveness of differing diet interventions over the antenatal and postpartum period . Specifically , the impact of differing diet intervention strategies on maternal weight gain is not known . Firstly , this systematic review will focus on whether  weight management interventions which include a dietary component  are effective in pregnant and postpartum women . In addition to this , this review will investigate the different intervention strategies utilized and their effectiveness in maternal weight management . A search of systematic review protocol data bases has shown that there is no current review underway for this topic Aim To examine the effect of a multifactorial lifestyle intervention on 5-year change in physical activity ( PA ) and to explore whether length of education had an impact on the effect of the intervention . Methods Two r and om sample s ( high intervention group A , n=11 708 ; low intervention group B , n=1308 ) were invited for a health examination , assessment of absolute risk of ischemic heart disease and individual lifestyle counselling . The participation rate was 52.5 % . High-risk individuals in group A were also offered group-based counselling on diet and PA and /or smoking cessation .  High-risk individuals in group B were referred to usual care . All high-risk individuals were reinvited for examination and counselling after 1 and 3 years , and all participants were reexamined after 5 years . The control group ( group C , n=5264 , response rate 61.1 % ) answered a mailed question naire . Change in self-reported PA from baseline to 5-year follow-up was the main outcome . Level of education was classified as no vocational training , ≤4 years and > 4 years . Data were analysed using longitudinal linear regression models with r and om intercepts . Results In men , the high-intensity intervention had a beneficial effect on PA level after 5 years . The age- or time-related decrease in PA was approximately 30 min/week less compared to men in the control group ( p<0.0001 ) . Level of education had no significant impact on the effect of the intervention neither in men ( p=0.39 ) nor in women ( p=0.32 ) . Conclusion A population -based multifactorial lifestyle intervention did not influence social ine quality in PA . Keywords Lifestyle , Exercise , R and omised Intervention Study , Ischemic Heart Disease , Socioeconomic Position Background Diabetes and obesity have reached epidemic proportions in the U.S. with rates consistently higher among Hispanics as compared to non-Hispanic whites . Among Hispanic women diagnosed with gestational diabetes mellitus ( GDM ) , 50 % will go on to develop type 2 diabetes within 5 years of the index pregnancy . Although r and omised controlled trials among adults with impaired glucose tolerance have shown that diet and physical activity reduce the risk of type 2 diabetes , such programs have not been tested in high-risk postpartum women . The overall goal of this r and omised controlled trial is to test the efficacy of a culturally and linguistically modified , individually-tailored lifestyle intervention to reduce risk factors for type 2 diabetes and cardiovascular disease among postpartum Hispanic women with a history of abnormal glucose tolerance during pregnancy . Methods / Design Hispanic pregnant women who screen positive for GDM will be recruited and r and omly assigned to a Lifestyle Intervention ( n = 150 ) or a Health & Wellness ( control ) Intervention ( n = 150 ) . Multimodal contacts ( i.e. , in-person , telephone , and mailed material s ) will be used to deliver the intervention from late pregnancy ( 29 weeks gestation ) to 12 months postpartum . Targets of the intervention are to achieve Institute of Medicine Guidelines for postpartum weight loss ; American Congress of Obstetrician and Gynecologist guidelines for physical activity ; and American Diabetes Association guidelines for diet . The intervention draws from Social Cognitive Theory and the Transtheoretical Model and addresses the specific cultural and environmental challenges faced by low-income Hispanic women . Assessment s will be conducted at enrollment , and at 6-weeks , 6-months , and 12-months postpartum by trained bicultural and bilingual personnel blinded to the intervention arm . Efficacy will be assessed via postpartum weight loss and biomarkers of insulin resistance and cardiovascular risk . Changes in physical activity and diet will be measured via 7-day actigraph data and three unannounced 24-hour dietary recalls at each assessment time period . Discussion Hispanic women are the fastest growing minority group in the U.S. and have the highest rates of sedentary behavior and postpartum diabetes after a diagnosis of GDM . This r and omised trial uses a high-reach , low-cost strategy that can readily be translated into clinical practice in underserved and minority population s . Trial registration
Results reveal no significant difference between the groups , with respect to BMI , while PA and DIET yielded a greater reduction in HbA1c .
Significant reduction in both systolic and diastolic pressures in the DIET group , and diastolic pressure in the PA group , was observed .
HDL-c in the DIET group was significantly higher than the control group , while no change in LDL-c levels , was seen in all three intervention subtypes .
There was no difference between the EDU vs. the control group in terms of HbA1c , blood pressure or HDL-c and LDL-c .
CONCLUSION DIET intervention showed an improvement in HbA1c , systolic/diastolic blood pressure and HDL-c , with an exception of LDL-c and BMI , suggesting that nutritional intervention had a significant impact on the quality of life by reducing the cardiovascular risk in type 2 diabetes patients
BACKGROUND The current meta- analysis evaluated the outcomes of various lifestyle interventions , including diet modifications ( DIET ) , physical activity ( PA ) , and patient education ( EDU ) in reducing the risk of cardiovascular disease in patients with type 2 diabetes .