Hypothetical Midlife Interventions in Women and Risk of Type 2 Diabetes Prevention of type 2 diabetes - where is the evidence? Rotating night shift work and adherence to unhealthy lifestyle in predicting risk of type 2 diabetes: results from two large US cohorts of female nurses Globalization of Diabetes Lifestyle Factors and Risk for New-Onset Diabetes Adherence to healthy lifestyle factors and risk of death in men with diabetes mellitus: The Physicians' Health Study. The Diabetes Prevention Program. Design and methods for a clinical trial in the prevention of type 2 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 The Sydney Diabetes Prevention Program: A community-based translational study Physical Activity/Exercise and Type 2 Diabetes Birth weight and later life adherence to unhealthy lifestyles in predicting type 2 diabetes: prospective cohort study Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients With Diabetes Mellitus. Combined effect of alcohol consumption and lifestyle behaviors on risk of type 2 diabetes. Healthy Living Partnerships to Prevent Diabetes (HELP PD): design and methods. A risk table to assist health practitioners assess and prevent the onset of depression in later life. Adherence to healthy lifestyle and risk of gestational diabetes mellitus: prospective cohort study The epidemic of obesity and diabetes: trends and treatments. Combined effect of low-risk dietary and lifestyle behaviors in primary prevention of myocardial infarction in women. Multiple health behaviors in an ethnically diverse sample of adults with risk factors for cardiovascular disease. An Online Intervention Comparing a Very Low-Carbohydrate Ketogenic Diet and Lifestyle Recommendations Versus a Plate Method Diet in Overweight Individuals With Type 2 Diabetes: A Randomized Controlled Trial The Lifestyle Intervention for the Treatment of Diabetes study (LIFT Diabetes): Design and baseline characteristics for a randomized translational trial to improve control of cardiovascular disease risk factors. Look AHEAD (Action for Health in Diabetes): design and methods for a clinical trial of weight loss for the prevention of cardiovascular disease in type 2 diabetes. Lifestyle factors and mortality risk in individuals with diabetes mellitus: are the associations different from those in individuals without diabetes?
Background : R and omized trials have examined short-term effects of lifestyle interventions for diabetes prevention only among high-risk individuals . Prospect i ve studies have examined the associations between lifestyle factors and diabetes in healthy population s but have not characterized the intervention . We estimated the long-term effects of hypothetical lifestyle interventions on diabetes in a prospect i ve study of healthy women , using the parametric g-formula . Methods : Using data from the Nurses ’ Health Study , we followed 76,402 women from 1984 to 2008 . We estimated the risk of type 2 diabetes under eight hypothetical interventions : quitting smoking , losing weight by 5 % every 2 years if overweight/obese , exercising at least 30 minutes a day , eating less than three servings a week of red meat , eating at least two servings a day of whole grain , drinking two or more cups of coffee a day , drinking five or more grams of alcohol a day , and drinking less than one serving of soda a week . Results : The 24-year risk of diabetes was 9.6 % under no intervention and 4.3 % when all interventions were imposed ( 55 % lower risk [ 95 % confidence interval = 47 to 63 % ] ) . The most effective interventions were weight loss ( 24 % lower risk ) , physical activity ( 19 % ) , and moderate alcohol use ( 19 % ) . Overweight/obese women would benefit the most , with 10.8 percentage point reduction in 24-year risk of diabetes . The validity of these estimates relies on the absence of unmeasured confounding , measurement error , and model misspecification . Conclusion : A combination of dietary and nondietary lifestyle modifications , begun in midlife or later in relatively healthy women , could have prevented at least half of the cases of type 2 diabetes in this cohort of U.S. women 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 Abstract Objectives To prospect ively evaluate the joint association of duration of rotating night shift work and lifestyle factors with risk of type 2 diabetes risk , and to quantitatively decompose this joint association to rotating night shift work only , to lifestyle only , and to their interaction . Design Prospect i ve cohort study . Setting Nurses ’ Health Study ( 1988 - 2012 ) and Nurses ’ Health Study II ( 1991 - 2013 ) . Participants 143 410 women without type 2 diabetes , cardiovascular disease , or cancer at baseline . Exposures Rotating night shift work was defined as at least three night shifts per month in addition to day and evening shifts in that month . Unhealthy lifestyles included current smoking , physical activity levels below 30 minutes per day at moderate to vigorous intensity , diet in the bottom three fifths of the Alternate Healthy Eating Index score , and body mass index of 25 or above . Main outcome measures Incident cases of type 2 diabetes were identified through self report and vali date d by a supplementary question naire . Results During 22 - 24 years of follow-up , 10 915 cases of incident type 2 diabetes occurred . The multivariable adjusted hazard ratios for type 2 diabetes were 1.31 ( 95 % confidence interval 1.19 to 1.44 ) per five year increment of duration of rotating night shift work and 2.30 ( 1.88 to 2.83 ) per unhealthy lifestyle factor ( ever smoking , low diet quality , low physical activity , and overweight or obesity ) . For the joint association of per five year increment rotating night shift work and per unhealthy lifestyle factor with type 2 diabetes , the hazard ratio was 2.83 ( 2.15 to 3.73 ) with a significant additive interaction ( P for interaction < 0.001 ) . The proportions of the joint association were 17.1 % ( 14.0 % to 20.8 % ) for rotating night shift work alone , 71.2 % ( 66.9 % to 75.8 % ) for unhealthy lifestyle alone , and 11.3 % ( 7.3 % to 17.3 % ) for their additive interaction . Conclusions Among female nurses , both rotating night shift work and unhealthy lifestyle were associated with a higher risk of type 2 diabetes . The excess risk of rotating night shift work combined with unhealthy lifestyle was higher than the addition of risk associated with each individual factor . These findings suggest that most cases of type 2 diabetes could be prevented by adhering to a healthy lifestyle , and the benefits could be greater in rotating night shift workers 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 BACKGROUND Epidemiologic data on the combined influence of several lifestyle factors on diabetes risk are rare , particularly among older adults . OBJECTIVE To examine how combinations of lifestyle risk factors relate to the 11-year risk for incident diabetes . DESIGN Population -based prospect i ve cohort study . SETTING National Institutes of Health (NIH)-AARP Diet and Health Study . PARTICIPANTS 114,996 men and 92,483 women , aged 50 to 71 years in 1995 to 1996 , without evidence of heart disease , cancer , or diabetes . MEASUREMENTS A comprehensive survey of demographic characteristics and lifestyle factors  , including dietary intake , body weight and height , physical activity , smoking , and alcohol consumption  at baseline ( 1995 to 1996 ) . Low-risk groups were formed by dichotomizing each lifestyle factor . Incident self-reported , physician-diagnosed diabetes was identified with a follow-up survey in 2004 to 2006 . RESULTS 11,031 men ( 9.6 % ) and 6969 women ( 7.5 % ) developed new-onset diabetes . For each additional lifestyle factor in the low-risk group , the odds for diabetes were 31 % lower ( odds ratio [ OR ] , 0.69 [ 95 % CI , 0.68 to 0.71 ] ) among men and 39 % lower ( OR , 0.61 [ CI , 0.60 to 0.63 ] ) among women . Men and women whose diet score , physical activity level , smoking status , and alcohol use were all in the low-risk group had ORs for diabetes of 0.61 ( CI , 0.56 to 0.66 ) and 0.43 ( CI , 0.34 to 0.55 ) , respectively . When absence of overweight or obesity was added , the respective ORs were 0.28 ( CI , 0.23 to 0.34 ) and 0.16 ( CI , 0.10 to 0.24 ) for men and women . Results did not differ by family history of diabetes or level of adiposity . LIMITATION The study was observational , with potential for residual confounding . CONCLUSION Lifestyle factors , when considered in combination , are associated with a substantial reduction in risk for diabetes . PRIMARY FUNDING SOURCE The NIH-AARP Diet and Health Study was supported by the Intramural Research Program of the NIH BACKGROUND & AIMS The relationship between healthy lifestyle factors and mortality in people with type 2 diabetes is unclear . The purpose of this study was to examine whether healthy lifestyle factors are associated with mortality in people with type 2 diabetes . METHODS We prospect ively studied 1163 men with type 2 diabetes from the Physicians ' Health Study . Lifestyle factors consisted of currently not smoking , moderate drinking ( 1 - 2 drinks/day ) , vigorous exercise ( 1+/week ) , BMI < 25 kg/m2 , and being in the top 2 quintiles of the alternate healthy eating index-2010 ( AHEI-2010 ) . Multivariate Cox regression models were used to estimate hazard ratios ( 95 % confidence intervals ) of mortality . RESULTS At baseline , average age was 69 years and mean follow up was 9 years . About 22 % of study participants had ≤1 healthy lifestyle factor , 37 % had two , 29 % had three , and 12 % had four or more healthy lifestyle factors . An inverse relationship was found between the number of lifestyle factors and total mortality . Compared with participants who had ≤1 healthy lifestyle factor , the risk of death was 42 % ( 95 % CI ; 19%-58 % ) lower for those with two healthy lifestyle factors , 41 % ( 95 % CI ; 18%-58 % ) lower for those with three , and 44 % ( 95 % CI ; 12%-64 % ) lower for those with 4 or more healthy lifestyle factors . CONCLUSION Adherence to modifiable healthy lifestyle factors is associated with a lower risk of death among adult men with type 2 diabetes . Our study emphasizes the importance of educating individuals with diabetes to adhere to healthy lifestyle factors The Diabetes Prevention Program is a r and omized clinical trial testing strategies to prevent or delay the development of type 2 diabetes in high-risk individuals with elevated fasting plasma glucose concentrations and impaired glucose tolerance . The 27 clinical centers in the U.S. are recruiting at least 3,000 participants of both sexes , approximately 50 % of whom are minority patients and 20 % of whom are > or = 65 years old , to be assigned at r and om to one of three intervention groups : an intensive lifestyle intervention focusing on a healthy diet and exercise and two masked medication treatment groups -- metformin or placebo -- combined with st and ard diet and exercise recommendations .  Participants are being recruited during a 2 2/3-year period , and all will be followed for an additional 3 1/3 to 5 years after the close of recruitment to a common closing date in 2002 . The primary outcome is the development of diabetes , diagnosed by fasting or post-challenge plasma glucose concentrations meeting the 1997 American Diabetes Association criteria . The 3,000 participants will provide 90 % power to detect a 33 % reduction in an expected diabetes incidence rate of at least 6.5 % per year in the placebo group . Secondary outcomes include cardiovascular disease and its risk factors ; changes in glycemia , beta-cell function , insulin sensitivity , obesity , diet , physical activity , and health-related quality of life ; and occurrence of adverse events . A fourth treatment group -- troglitazone combined with st and ard diet and exercise recommendations --was included initially but discontinued because of the liver toxicity of the drug . This r and omized clinical trial will test the possibility of preventing or delaying the onset of type 2 diabetes in individuals at high risk 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 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 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 Objectives To prospect ively assess the joint association of birth weight and established lifestyle risk factors in adulthood with incident type 2 diabetes and to quantitatively decompose the attributing effects to birth weight only , to adulthood lifestyle only , and to their interaction . Design Prospect i ve cohort study . Setting Health Professionals Follow-up Study ( 1986 - 2010 ) , Nurses ’ Health Study ( 1980 - 2010 ) , and Nurses ’ Health Study II ( 1991 - 2011 ) . Participants 149 794 men and women without diabetes , cardiovascular disease , or cancer at baseline . Main outcome measure Incident cases of type 2 diabetes , identified through self report and vali date d by a supplementary question naire . Unhealthy lifestyle was defined on the basis of body mass index , smoking , physical activity , alcohol consumption , and the alternate healthy eating index . Results During 20 - 30 years of follow-up , 11 709 new cases of type 2 diabetes were documented . The multivariate adjusted relative risk of type 2 diabetes was 1.45 ( 95 % confidence interval 1.32 to 1.59 ) per kg lower birth weight and 2.10 ( 1.71 to 2.58 ) per unhealthy lifestyle factor . The relative risk of type 2 diabetes associated with a combination of per kg lower birth weight and per unhealthy lifestyle factor was 2.86 ( 2.26 to 3.63 ) , which was more than the addition of the risk associated with each individual factor , indicating a significant interaction on an additive scale ( P for interaction<0.001 ) . The attributable proportions of joint effect were 22 % ( 95 % confidence interval 18.3 % to 26.4 % ) to lower birth weight alone , 59 % ( 57.1 % to 61.5 % ) to unhealthy lifestyle alone , and 18 % ( 13.9 % to 21.3 % ) to their interaction . Conclusion Most cases of type 2 diabetes could be prevented by the adoption of a healthier lifestyle , but simultaneous improvement of both prenatal and postnatal factors could further prevent additional cases BACKGROUND Evidence is limited regarding the impact of healthy lifestyle practice s on the risk of subsequent cardiovascular events among patients with diabetes . OBJECTIVES The purpose of this study was to examine the associations of an overall healthy lifestyle , defined by eating a high- quality diet ( top two-fifths of Alternative Healthy Eating Index ) , nonsmoking , engaging in moderate- to vigorous-intensity physical activity ( ≥150 min/week ) , and drinking alcohol in moderation ( 5 to 15 g/day for women and 5 to 30 g/day for men ) , with the risk of developing cardiovascular disease ( CVD ) and CVD mortality among adults with type 2 diabetes ( T2D ) . METHODS This prospect i ve analysis included 11,527 participants with T2D diagnosed during follow-up ( 8,970 women from the Nurses ' Health Study and 2,557 men from the Health Professionals Follow-Up Study ) , who were free of CVD and cancer at the time of diabetes diagnosis .  Diet and lifestyle factors before and after T2D diagnosis were repeatedly assessed every 2 to 4 years . RESULTS There were 2,311 incident CVD cases and 858 CVD deaths during an average of 13.3 years of follow-up . After multivariate adjustment of covariates , the low-risk lifestyle factors after diabetes diagnosis were each associated with a lower risk of CVD incidence and CVD mortality . The multivariate-adjusted hazard ratios for participants with 3 or more low-risk lifestyle factors compared with 0 were 0.48 ( 95 % confidence interval [ CI ] : 0.40 to 0.59 ) for total CVD incidence , 0.53 ( 95 % CI : 0.42 to 0.66 ) for incidence of coronary heart disease , 0.33 ( 95 % CI : 0.21 to 0.51 ) for stroke incidence , and 0.32 ( 95 % CI : 0.22 to 0.47 ) for CVD mortality ( all p trend < 0.001 ) . The population -attributable risk for poor adherence to the overall healthy lifestyle ( <3 low-risk factors ) was 40.9 % ( 95 % CI : 28.5 % to 52.0 % ) for CVD mortality . In addition , greater improvements in healthy lifestyle factors from pre-diabetes to post-diabetes diagnosis were also significantly associated with a lower risk of CVD incidence and CVD mortality . For each number increment in low-risk lifestyle factors there was a 14 % lower risk of incident total CVD , a 12 % lower risk of coronary heart disease , a 21 % lower risk of stroke , and a 27 % lower risk of CVD mortality ( all p < 0.001 ) . Similar results were observed when analyses were stratified by diabetes duration , sex/cohort , body mass index at diabetes diagnosis , smoking status , and lifestyle factors before diabetes diagnosis . CONCLUSIONS Greater adherence to an overall healthy lifestyle is associated with a substantially lower risk of CVD incidence and CVD mortality  among adults with T2D . These findings further support the tremendous benefits of adopting a healthy lifestyle in reducing the subsequent burden of cardiovascular complications in patients with T2D 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 Although the Diabetes Prevention Program ( DPP ) developed a lifestyle weight loss intervention that has been demonstrated to prevent type 2 diabetes in high-risk individuals , it has yet to be widely adopted at the community level . The Healthy Living Partnership to Prevent Diabetes study ( HELP PD ) was design ed to translate the DPP approach for use in community setting s as a cost-effective intervention led by Community Health Workers ( CHW 's ) and administered through a Diabetes Care Center ( DCC ) . Approximately 300 overweight and obese ( BMI 25 - 40 kg/m(2 ) ) individuals with prediabetes ( fasting blood glucose 95 - 124 mg/dl ) were r and omly assigned to either a lifestyle weight loss intervention ( LW ) or an enhanced usual care comparison condition ( UC ) . The goal of LW is > or=7 % weight loss achieved through increases in physical activity ( 180 min/wk ) and decreases in caloric intake ( approximately 1500 kcal/day ) . The intervention consists of CHW-led group-mediated cognitive behavioral meetings that occur weekly for 6 months and monthly thereafter for 18 months . UC consists of 2 individual meetings with a registered dietitian and a monthly newsletter . The primary outcome is change in fasting blood glucose . Secondary outcomes include cardiovascular risk factors , health-related quality of life , and social cognitive variables . Outcomes are masked and are collected every 6 months . The cost-effectiveness of the program will also be assessed . A community-based program that is administered through local DCC 's and that harnesses the experience of community members ( CHW 's ) may be a promising strategy for the widespread dissemination of interventions effective at preventing type 2 diabetes in high risk individuals OBJECTIVE This study aim ed to develop a simple risk table of modifiable factors prospect ively associated with  depression in later life that could be used to guide the assessment , management and introduction of preventive strategies in clinical practice . METHODS This retrospective cohort study included 4636 men aged 65 to 83 years living in the community who denied history of past diagnosis or treatment for depression . They self-reported information about their physical activity , weight and height , smoking history , alcohol consumption and dietary habits , as well as history of hypertension , diabetes , coronary heart disease and stroke . We calculated the body mass index ( BMI ) in kg/m(2 ) . Three to 8 years later they were assessed with the Geriatric Depression Scale 15 ( GDS-15 ) and those with a total score of 7 or greater were considered to display clinical ly significant symptoms of depression . We used binomial exponentiated log-linked general linear models to estimate the risk ratio ( RR ) and 95 % confidence interval ( 95 % CI ) of incident depression after adjusting for age , education , marital status and prevalent medical illnesses . We calculated the probability of depression for each individual combination of risk factors and displayed the results in a risk table . RESULTS Two hundred and twenty-nine men ( 4.5 % ) showed evidence of incident depression 5.7±0.9 ( mean±st and ard deviation ) years later . Measured dietary factors showed no association with incident depression . The probability of depression was the highest for older men who were underweight , overweight or obese , physically inactive , risk drinkers and smokers ( 12.0 % , 95 % CI=7.0 % , 17.1 % ) , and the lowest for those who had all 4 healthy lifestyle markers : physically active , normal body mass , non-risk drinking and non-smoking ( 1.6 % , 95 % CI=0.6 % , 2.5 % ) . The probability of incident depression fell between these two extremes for different combinations of lifestyle practice s. CONCLUSION Four modifiable lifestyle factors can be used in combination to produce a risk table that predicts the probability of incident depression over a period of 3 to 8 years . The risk table is simple , informative and can be easily incorporated into clinical practice to guide assessment and risk reduction interventions Objective To quantify the association between a combination of healthy lifestyle factors before pregnancy ( healthy body weight , healthy diet , regular exercise , and not smoking ) and the risk of gestational diabetes . Design Prospect i ve cohort study . Setting Nurses ’ Health Study II , United States . Participants 20 136 singleton live births in 14 437 women without chronic disease . Main outcome measure Self reported incident gestational diabetes diagnosed by a physician , vali date d by medical records in a previous study . Results Incident first time gestational diabetes was reported in 823 pregnancies . Each lifestyle factor measured was independently and significantly associated with risk of gestational diabetes . The combination of three low risk factors ( non-smoker , ≥150 minutes a week of moderate to vigorous physical activity , and healthy eating ( top two fifths of Alternate Healthy Eating Index-2010 adherence score ) ) was associated with a 41 % lower risk of gestational diabetes compared with all other pregnancies ( relative risk 0.59 , 95 % confidence interval 0.48 to 0.71 ) . Addition of body mass index ( BMI ) < 25 before pregnancy ( giving a combination of four low risk factors ) was associated with a 52 % lower risk of gestational diabetes compared with all other pregnancies ( relative risk 0.48 , 0.38 to 0.61 ) . Compared with pregnancies in women who did not meet any of the low risk lifestyle factors , those meeting all four criteria had an 83 % lower risk of gestational diabetes ( relative risk 0.17 , 0.12 to 0.25 ) . The population attributable risk percentage of the four risk factors in combination ( smoking , inactivity , overweight , and poor diet ) was 47.5 % ( 95 % confidence interval 35.6 % to 56.6 % ) . A similar population attributable risk percentage ( 49.2 % ) was observed when the distributions of the four low risk factors from the US National Health and Nutrition Examination Survey ( 2007 - 10 ) data were applied to the calculation . Conclusions Adherence to a low risk lifestyle before pregnancy is associated with a low risk of gestational diabetes and could be an effective strategy for the prevention of gestational diabetes Cardiovascular disease remains the leading cause of death in women . Both obesity and diabetes mellitus are important independent risk factors for the development of cardiovascular disease . Obesity is the leading risk factor for type 2 diabetes . The Centers for Disease Control and Prevention report that 32 % of white and 53 % of black women are obese . Women with a body mass index ( BMI ) of 30 kg/m2 have a 28 times greater risk of developing diabetes than do women of normal weight . The risk of diabetes is 93 times greater if the BMI is 35 kg/m2.1 The presence of diabetes can increase a woman 's risk of heart disease 2-fold . In addition , the presence of diabetes overshadows the protective effects of the premenopausal state . In 2007 , 11.5 million of all women over the age of 20 ( 10.2 % ) had diabetes , and rates were slightly higher in ethnic minority groups : 10.4 % in Hispanic women and 11.8 % in non-Hispanic black women.2 The national prevalence rates of diabetes have increased in parallel with the rates of obesity ( Fig. 1 ) . Fig. 1 Age-adjusted percentage of U.S. adults who were obese or who had a diagnosis of diabetes mellitus . Screening Screening for obesity and diabetes is the 1st step to treatment and often reveals individuals who are at risk for but do not yet have overt disease . The United States Preventive Services Task Force ( USPSTF ) recommends that all adults be screened for obesity . Obesity signifies excess adipose tissue . The most widely used method for screening is determination of the BMI . The BMI is weight in kilograms divided by height in meters squared ( BMI = kg/m2 ) ( Table I ) . Most electronic medical records automatically calculate BMI if height and weight are entered . There are also many smart-phone applications and online calculators that can calculate BMI ( for example , http://www.nhlbisupport.com/ bmi ) . Other screening tools include  waist circumference and the waist-to-hip ratio . In women , a waist circumference > 35 in ( 88 cm ) or a waist-to-hip ratio > 0.7 indicates excess visceral fat and increased risk for disease . TABLE I. Body Mass Index ( BMI ) Classification Recommendations for screening for diabetes vary by guideline author . The USPSTF recommends screening asymptomatic patients who have  blood pressures > 135/80 mmHg  . The American Diabetes Association ( ADA ) recommends that individuals who are ≥18 years of age and have a BMI ≥25 kg/m2 and 1 additional risk factor for diabetes should be screened annually ( Table II).3 Individuals over the age of 45 without risk factors should be screened every 3 years . In January 2010 , the ADA released new recommendations for the use of hemoglobin A1C as a screening tool . An A1C greater than 6.5 % indicates diabetes . In addition , the results of screening tests for diabetes can identify individuals with “ prediabetes ” who have a markedly increased risk of developing overt disease.3 TABLE II . American Diabetes Association Recommendations on Screening for Type 2 Diabetes3 Non-Pharmaceutical Treatment Lifestyle-treatment options for diabetes mellitus and excess weight are similar , and 2 recent studies 4,5 have demonstrated the critical components for treating pre-diabetes and diabetes through weight loss , using caloric restriction and physical activity . The 1st study was the Diabetes Prevention Program.4 The purpose of the study was to identify individuals who were at risk for developing diabetes because of elevated fasting plasma glucose or impaired glucose tolerance levels that were not yet in the diagnostic range , in order to determine if metformin or an intensive lifestyle intervention could delay or prevent the onset of diabetes . More than 3,000 individuals with prediabetes were r and omized to receive placebo , metformin , or a 16-session lifestyle-modification program . The intensive lifestyle program set a goal of 7 % weight loss and 150 min/wk of moderate physical activity . Fifty percent of the lifestyle-intervention group lost 7 % of their body weight . The 3-year incidence of diabetes in the metformin group was 31 % lower than that in the placebo group . The incidence was 58 % lower in the lifestyle group than in the placebo group.4 The clinical implication s of this study are that we should 1 ) identify individuals with pre-diabetes and 2 ) recommend lifestyle modifications that result in a 7 % weight loss and include 150 min/wk of moderate physical activity . The 2nd study that examined lifestyle treatment of diabetes and obesity is the Look AHEAD Trial . The purpose of the study was to determine the effect of intentional weight loss on cardiovascular risk factors in individuals with diabetes . Approximately 5,100 individuals with type 2 diabetes and an elevated BMI were r and omized . Study conditions specified a 36-session intensive lifestyle intervention with the option of using partial meal replacements for caloric restriction or 4 sessions of st and ard diabetes support and education ( DSE ) . At 1 year , 55 % of the intensive-lifestyle-intervention group achieved 7 % weight loss . Hemoglobin A1C , systolic and diastolic blood pressure , and lipids improved significantly more in the intensive-lifestyle group than in the DSE group.5 The clinical implication of this study is that intentional weight loss of at least 7 % can improve the cardiovascular risk profile of patients with type 2 diabetes . Conclusions Excess weight affects two thirds of the U.S. adult population and increases risk for cardiovascular disease and diabetes . All patients should be screened for obesity and most should be screened for pre-diabetes and diabetes . The best treatment for diabetes is prevention . Prevention of diabetes can be accomplished through a 7 % weight loss through intensive lifestyle interventions that include caloric reduction and approximately 30 min of daily moderate physical activity . Practitioners will have access to these evidence -based programs soon . The Centers for Disease Control and Prevention are promoting community-based diabetes prevention programs throughout the country BACKGROUND Limited data are available on the benefit of combining healthy dietary and lifestyle behaviors in the prevention of  myocardial infa rct ion ( MI ) in women . METHODS We used factor analysis to identify a low-risk behavior-based dietary pattern in 24 444 postmenopausal women from the population -based prospect i ve Swedish Mammography Cohort who were free of diagnosed cancer , cardiovascular disease , and diabetes mellitus at baseline ( September 15 , 1997 ) . We also defined 3 low-risk lifestyle factors : nonsmoking , waist-hip ratio less than the 75th percentile ( < 0.85 ) , and being physically active ( at least 40 minutes of daily walking or bicycling and 1 hour of weekly exercise ) . RESULTS During 6.2 years ( 151 434 person-years ) of follow-up , we ascertained 308 cases of primary MI . Two major identified dietary patterns , " healthy " and " alcohol , " were significantly associated with decreased risk of MI . The low-risk  diet  ( high scores for the healthy dietary pattern ) characterized by a high intake of vegetables , fruit , whole grains , fish , and legumes , in combination with moderate alcohol consumption ( > /= 5 g of alcohol per day ) , along with the 3 low-risk lifestyle behaviors , was associated with 92 % decreased risk ( 95 % confidence interval , 72%-98 % ) compared with findings in women without any low-risk diet and lifestyle factors . This combination of healthy behaviors , present in 5 % , may prevent 77 % of MIs in the study population . CONCLUSION Most MIs in women may be preventable by consuming a healthy diet and moderate amounts of alcohol , being physically active , not smoking , and maintaining a healthy weight BACKGROUND Health behaviors of adults living with cardiovascular disease ( CVD ) risk factors affect additional risk , where lifestyle behavioral choices become even more important in controlling disease and preventing additional negative health outcomes . In addition , both lifestyle behaviors and CVD risk factor prevalence can vary by ethnicity . OBJECTIVE We compared multiple health behaviors of adults with diabetes , hypertension , high cholesterol , and obesity to the behaviors of adults without those conditions in a diverse ethnic sample to determine if significant differences existed between groups . METHODS Data were obtained from  30-minute r and om-digit-dial telephone surveys in 2007 ( n = 3607 ) . All data were self-reports . Healthy behaviors  included meeting recommendations for intake of fruits and vegetables ; consuming low or very low amounts of dietary fat ; eating breakfast six or seven days per week ; having a healthy diet ; and meeting recommendations for walking , moderate , and vigorous physical activity . Unhealthy behaviors included  frequent consumption of soda and fast food , smoking , binge drinking ,  and high stress .  RESULTS More than 6 % of respondents had diabetes , 15.9 % had hypertension , 16.4 % had high cholesterol , and 18.5 % were obese . Significantly fewer healthy and more unhealthy behaviors were reported for those who had CVD risk factors than were reported by those who did not have such conditions . Ethnic differences in CVD risk factor prevalence and health behaviors existed as well ( p < 0.001 ) . Logistic regression models indicated that not eating a healthy diet ( odds ratio [ OR ] = 1.82 ) was a significant predictor for diabetes ; not eating a healthy diet ( OR = 1.52 ) and not doing vigorous physical activity ( OR = 1.79 ) were significant predictors for hypertension ; consumption of high amounts of dietary fat ( OR = 1.70 ) and of fast food ( OR = 1.51 ) were significant predictors for high cholesterol levels ; and not eating a healthy diet ( OR = 1.52 ) , high consumption of dietary fat ( OR = 2.20 ) , not eating breakfast ( OR = 1.33 ) and not performing vigorous physical activity ( OR = 1.63 ) , but less consumption of fast food ( OR = 0.64 ) were significant predictors for obesity . CONCLUSIONS Specifically tailored and culturally sensitive interventions that address multiple health behaviors may be necessary for these high-risk population Background Type 2 diabetes is a prevalent , chronic disease for which diet is an integral aspect of treatment . In our previous trial , we found that recommendations to follow a very low-carbohydrate ketogenic diet and to change lifestyle factors ( physical activity , sleep , positive affect , mindfulness ) helped overweight people with type 2 diabetes or prediabetes  improve glycemic control and lose weight . This was an in-person intervention , which could be a barrier for people without the time , flexibility , transportation , social support , and /or financial re sources to attend . Objective The aim was to determine whether an online intervention based on our previous recommendations ( an ad libitum very low-carbohydrate ketogenic diet with lifestyle factors ; “ intervention ” ) or an online diet program based on the American Diabetes Associations ’ “ Create Your Plate ” diet ( “ control ” ) would improve glycemic control and other health outcomes among overweight individuals with type 2 diabetes . Methods In this pilot feasibility study , we r and omized overweight adults ( body mass index ≥25 ) with type 2 diabetes ( glycated hemoglobin [ HbA1c ] 6.5%-9.0 % ) to a 32-week online intervention based on our previous recommendations ( n=12 ) or an online diet program based around a plate method diet ( n=13 ) to assess the impact of each intervention on glycemic control and other health outcomes . Primary and secondary outcomes were analyzed by mixed-effects linear regression to compare outcomes by group . Results At 32 weeks , participants in the intervention group reduced their HbA1c levels more ( estimated marginal mean [ EMM ] –0.8 % , 95 % CI –1.1 % to –0.6 % ) than participants in the control group ( EMM –0.3 % , 95 % CI –0.6 % to 0.0 % ; P=.002 ) . More than half of the participants in the intervention group ( 6/11 , 55 % ) lowered their HbA1c to less than 6.5 % versus 0 % ( 0/8 ) in the control group ( P=.02 ) . Participants in the intervention group lost more weight ( EMM –12.7 kg , 95 % CI –16.1 to –9.2 kg ) than participants in the control group ( EMM –3.0 kg , 95 % CI –7.3 to 1.3 kg ; P<.001 ) . A greater percentage of participants lost at least 5 % of their body weight in the intervention ( 10/11 , 90 % ) versus the control group ( 2/8 , 29 % ; P=.01 ) . Participants in the intervention group lowered their triglyceride levels ( EMM –60.1 mg/dL , 95 % CI –91.3 to –28.9 mg/dL ) more than participants in the control group ( EMM –6.2 mg/dL , 95 % CI –46.0 to 33.6 mg/dL ; P=.01 ) . Dropout was 8 % ( 1/12 ) and 46 % ( 6/13 ) for the intervention and control groups , respectively ( P=.07 ) . Conclusions Individuals with type 2 diabetes improved their glycemic control and lost more weight after being r and omized to a very low-carbohydrate ketogenic diet and lifestyle online program rather than a conventional , low-fat diabetes diet online program . Thus , the online delivery of these very low-carbohydrate ketogenic diet and lifestyle recommendations may allow them to have a wider reach in the successful self-management of type 2 diabetes . Trial Registration Clinical Trials.gov NCT01967992 ; https:// clinical trials.gov/ct2/show/NCT01967992 ( Archived by WebCite at http://www.webcitation.org/6o0fI9Mkq The prevalence of type 2 diabetes continues to increase in minority and underserved patients , who are also more likely to have poorer control of diabetes and related risk factors for complications . Although the Look AHEAD trial has demonstrated improved risk factor control among overweight or obese diabetes patients who received an intensive lifestyle intervention  , translating such findings into accessible programs is a major public health challenge . The purpose of this paper is to report the design and baseline characteristics of the Lifestyle Interventions for the Treatment of Diabetes study ( LIFT Diabetes ) . The overall goal is to test the impact of a community-based lifestyle weight loss ( LWL ) intervention adapted from Look AHEAD on cardiovascular disease risk at 12-months and 24-months among minority and lower income diabetes patients . Secondary outcomes include body weight , physical activity , medication use , cost , re source utilization , and safety . The primary hypothesis being tested is that the  LWL  will result in 10 % relative reduction in CVD risk compared to the DSM . We have r and omized 260 overweight or obese adults with diabetes one of two 12-month interventions : a LWL condition delivered by community health workers or a diabetes self-management ( DSM ) education condition . The baseline demographic characteristics indicate that our sample is predominantly female , obese , low income , and ethnic minority . Translating evidence -based , lifestyle strategies , and targeting minority and underserved patients , will yield , if successful , a model for addressing the burden of diabetes and may favorably impact health disparities Overweight and obesity are major contributors to both type 2 diabetes and cardiovascular disease ( CVD ) . Moreover , individuals with type 2 diabetes who are overweight or obese are at particularly high risk for CVD morbidity and mortality . Although short-term weight loss has been shown to ameliorate obesity-related metabolic abnormalities and CVD risk factors , the long-term consequences of intentional weight loss in overweight or obese individuals with type 2 diabetes have not been adequately examined . The primary objective of the Look AHEAD clinical trial is to assess the long-term effects ( up to 11.5 years ) of an intensive weight loss program delivered over 4 years in overweight and obese individuals with type 2 diabetes . Approximately 5000 male and female participants who have type 2 diabetes , are 45 - 74 years of age , and have a body mass index > or=25 kg/m(2 ) will be r and omized to one of the two groups . The intensive lifestyle intervention is design ed to achieve and maintain weight loss through decreased caloric intake and increased physical activity . This program is compared to a control condition given diabetes support and education . The primary study outcome is time to incidence of a major CVD event . The study is design ed to provide a 0.90 probability of detecting an 18 % difference in major CVD event rates between the two groups . Other outcomes include components of CVD risk , cost and cost-effectiveness , diabetes control and complications , hospitalizations , intervention processes , and quality of life Aims /hypothesisThus far , it is unclear whether lifestyle recommendations for people with diabetes should be different from those for the general public . We investigated whether the associations between lifestyle factors and mortality risk differ between individuals with and without diabetes . Methods Within the European Prospect i ve Investigation into Cancer and Nutrition ( EPIC ) , a cohort was formed of 6,384 persons with diabetes and 258,911 EPIC participants without known diabetes . Joint Cox proportional hazard regression models of people with and without diabetes were built for the following lifestyle factors in relation to overall mortality risk : BMI , waist/height ratio , 26 food groups , alcohol consumption , leisure-time physical activity , smoking . Likelihood ratio tests for heterogeneity assessed statistical differences in regression coefficients . Results Multivariable adjusted mortality risk among individuals with diabetes compared with those without was increased , with an HR of 1.62 ( 95 % CI 1.51 , 1.75 ) . Intake of fruit , legumes , nuts , seeds , pasta , poultry and vegetable oil was related to a lower mortality risk , and intake of butter and margarine was related to an increased mortality risk . These associations were significantly different in magnitude from those in diabetes-free individuals , but directions were similar . No differences between people with and without diabetes were detected for the other lifestyle factors . Conclusions /interpretationDiabetes status did not substantially influence the associations between lifestyle and mortality risk .  People with diabetes may benefit more from a healthy diet , but the directions of association were similar . Thus , our study suggests that lifestyle advice with respect to mortality for patients with diabetes should not differ from recommendations for the general population
The associations were largely consistent and significant among individuals from different socioeconomic background s and baseline characteristics .
Conclusions /interpretationAdoption of a healthy lifestyle is associated with substantial risk reduction in type 2 diabetes and long-term adverse outcomes among diabetic individuals .
Aims /hypothesisA healthy lifestyle has been widely recommended for the prevention and management of type 2 diabetes .
However , no systematic review has summarised the relationship between combined lifestyle factors ( including , but not limited to , smoking , alcohol drinking , physical activity , diet and being overweight or obese ) and  incident type 2 diabetes and risk of health outcomes among diabetic individuals .