The Sydney Diabetes Prevention Program: A community-based translational study A Community-Based Diabetes Prevention Program Prevention of type 2 diabetes - where is the evidence? A cluster-randomized controlled trial to study the effectiveness of a protocol-based lifestyle program to prevent type 2 diabetes in people with impaired fasting glucose SLIMMER: a randomised controlled trial of diabetes prevention in Dutch primary health care: design and methods for process, effect, and economic evaluation Let’s prevent diabetes: study protocol for a cluster randomised controlled trial of an educational intervention in a multi-ethnic UK population with screen detected impaired glucose regulation A large-scale diabetes prevention program in real-life settings in Qingdao of China (2006-2012). Implementation of a lifestyle intervention for type 2 diabetes prevention in Dutch primary care: opportunities for intervention delivery Cluster randomised controlled trial of a peer-led lifestyle intervention program: study protocol for the Kerala diabetes prevention program Slowing Down the Progression of Type 2 Diabetes: We Need Fair, Innovative, and Disruptive Action on Environmental and Policy Levels! Increasing efficacy of primary care-based counseling for diabetes prevention: Rationale and design of the ADAPT (Avoiding Diabetes Thru Action Plan Targeting) trial Walking away from type 2 diabetes: trial protocol of a cluster randomised controlled trial evaluating a structured education programme in those at high risk of developing type 2 diabetes A community based primary prevention programme for type 2 diabetes integrating identification and lifestyle intervention for prevention: the Let's Prevent Diabetes cluster randomised controlled trial. Preventing type 2 diabetes after gestational diabetes: women's experiences and implications for diabetes prevention interventions. A Comprehensive Lifestyle Intervention to Prevent Type 2 Diabetes and Cardiovascular Diseases: the German CHIP Trial A lifestyle intervention to reduce Type 2 diabetes risk in Dutch primary care: 2.5-year results of a randomized controlled trial. Reasons for participation and non-participation in a diabetes prevention trial among women with prior gestational diabetes mellitus (GDM) Delaying progression to type 2 diabetes among high-risk Spanish individuals is feasible in real-life primary healthcare settings using intensive lifestyle intervention Lifestyle INtervention for Diabetes prevention After pregnancy (LINDA-Brasil): study protocol for a multicenter randomized controlled trial Globalization of Diabetes Translating the Diabetes Prevention Program to Primary Care: A Pilot Study A Randomized-Controlled, Pilot Intervention on Diabetes Prevention and Healthy Lifestyles in the New York City Korean Community A model of translational research for diabetes prevention in low and middle-income countries: The Diabetes Community Lifestyle Improvement Program (D-CLIP) trial.
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 Purpose With growing numbers of people at risk for diabetes and cardiovascular disease , diabetes educators report increasing referrals for intervention in prevention of these conditions . Diabetes educators have expertise in diabetes self-management education ; however , they are generally not prepared for delivery of chronic disease primary prevention . The purpose of this project was to determine if individuals at risk for diabetes who participate in an intervention delivered by trained diabetes educators in existing diabetes self-management education community-based programs can reduce risk factors for diabetes and cardiovascular disease . Methods Diabetes educators in 3 outpatient-hospital programs ( urban , suburban , and rural ) received training and support for implementation of the Group Lifestyle Balance program , an adaptation of the Diabetes Prevention Program lifestyle intervention , from the Diabetes Prevention Support Center of the University of Pittsburgh . Adults with prediabetes and /or the metabolic syndrome were eligible to enroll in the program with physician referral . With use of existing diabetes educator networks , recruitment was completed via on-site physician in-services , informative letters , and e-mail contact as well as participant-directed newspaper advertisement . Results Eighty-one participants enrolled in the study ( 71 women , 10 men ) .  Mean overall weight loss was 11.3 lb ( 5.1 % , P < .001 ) ; in addition , significant decreases were noted in fasting plasma glucose , low-density lipoprotein cholesterol , triglycerides , and blood pressure . Conclusions These results suggest that the Group Lifestyle Balance program delivered by diabetes educators was successful in reducing risk for diabetes and cardiovascular disease in high-risk individuals . Furthermore , diabetes educators , already integrated within the existing health care system , provide yet another re source for delivery of primary prevention programs in the community 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 Effective diabetes prevention strategies that can be implemented in daily practice , without huge amounts of money and a lot of personnel are needed . The Dutch Diabetes Federation developed a protocol for coaching people with impaired fasting glucose ( IFG ; according to WHO criteria : 6.1 to 6.9 mmol/l ) to a sustainable healthy lifestyle change : ‘ the road map towards diabetes prevention ’ ( abbreviated : Road Map : RM ) . This protocol is applied within a primary health care setting by a general practitioner and a practice nurse . The feasibility and ( cost- ) effectiveness of care provided according to the RM protocol will be evaluated . Methods / Design A cluster r and omised clinical trial is performed , with r and omisation at the level of the general practice s. Both opportunistic screening and active case finding took place among clients with high risk factors for diabetes . After IFG is diagnosed , motivated people in the intervention practice s receive 3–4 consultations by the practice nurse within one year . During these consultations they are coached to increase the level of physical activity and healthy dietary habits . If necessary , participants are referred to a dietician , physiotherapist , lifestyle programs and /or local sports activities . The control group receives care as usual . The primary outcome measure in this study is change in Body Mass Index ( BMI ) . Secondary outcome measures are waist circumference , physical activity , total and saturated fat intake , systolic blood pressure , blood glucose , total cholesterol , HDL cholesterol , triglycerides and behaviour determinants like risk perception , perceived knowledge and motivation . Based on a sample size calculation 120 people in each group are needed . Measurements are performed at baseline , and after one ( post-intervention ) and two years follow up . Anthropometrics and biochemical parameters are assessed in the practice s and physical activity , food intake and their determinants by a vali date d question naire . The cost-effectiveness is estimated by using the Chronic Disease Model ( CDM ) . Feasibility will be tested by interviews among health care professionals . Discussion The results of the study will provide valuable information for both health care professionals and policy makers . If this study shows the RM to be both effective and cost-effective the protocol can be implemented on a large scale . Trial registration IS RCT N41209683 . Ethical approval number : NL31342.075.10 Background Implementation of interventions in real-life setting s requires a comprehensive evaluation approach . The aim of this article is to describe the evaluation design of the SLIMMER diabetes prevention intervention in a Dutch real-life setting . Methods / Design The SLIMMER study is a r and omised , controlled intervention study including subjects aged 40 through 70 years with impaired fasting glucose or high risk of diabetes . The 10-month SLIMMER intervention involves a dietary and physical activity intervention , including case management and a maintenance programme . The control group receives usual health care and written information about a healthy lifestyle . A logic model of change is composed to link intervention activities with intervention outcomes in a logical order . Primary outcome is fasting insulin . Measurements are performed at baseline and after 12 and 18 months and cover quality of life , cardio-metabolic risk factors ( e.g. glucose tolerance , serum lipids , body fatness , and blood pressure ) , eating and physical activity behaviour , and behavioural determinants . A process evaluation gives insight in how the intervention was delivered and received by participants and health care professionals . The economic evaluation consists of a cost-effectiveness analysis and a cost-utility analysis . Costs are assessed from both a societal and health care perspective . Discussion This study is expected to provide insight in the effectiveness , including its cost-effectiveness , and delivery of the SLIMMER diabetes prevention intervention conducted in Dutch primary health care . Results of this study provide valuable information for primary health care professionals , research ers , and policy makers . Trial registration The SLIMMER study is registered with Clinical Trials.gov ( NCT02094911 ) since March 19 , 2014 Background The prevention of type 2 diabetes is a globally recognised health care priority , but there is a lack of rigorous research investigating optimal methods of translating diabetes prevention programmes , based on the promotion of a healthy lifestyle , into routine primary care . The aim of the study is to establish whether a pragmatic structured education programme targeting lifestyle and behaviour change in conjunction with motivational maintenance via the telephone can reduce the incidence of type 2 diabetes in people with impaired glucose regulation ( a composite of impaired glucose tolerance and /or impaired fasting glucose ) identified through a vali date d risk score screening programme in primary care . Design Cluster r and omised controlled trial undertaken at the level of primary care practice s. Follow-up will be conducted at 12 , 24 and 36 months . The primary outcome is the incidence of type 2 diabetes . Secondary outcomes include changes in HbA1c , blood glucose levels , cardiovascular risk , the presence of the Metabolic Syndrome and the cost-effectiveness of the intervention . Methods The study consists of screening and intervention phases within 44 general practice s coordinated from a single academic research centre . Those at high risk of impaired glucose regulation or type 2 diabetes are identified using a risk score and invited for screening using a 75 g-oral glucose tolerance test . Those with screen detected impaired glucose regulation will be invited to take part in the trial . Practice s will be r and omised to st and ard care or the intensive arm . Participants from intensive arm practice s will receive a structured education programme with motivational maintenance via the telephone and annual refresher sessions . The study will run from 2009–2014 . Discussion This study will provide new evidence surrounding the long-term effectiveness of a diabetes prevention programme conducted within routine primary care in the United Kingdom . Trial registration Clinical trials.gov AIMS Qingdao Diabetes Prevention Program aims to translate the trial experience to real-life setting s with goals to : ( 1 ) raise the public awareness of diabetes and diabetes risk factors , and promote healthy diet and physical activity ; ( 2 ) reduce the number of high-risk people developing diabetes through lifestyle counselling ; ( 3 ) early diagnosis of diabetes ; ( 4 ) evaluate the effectiveness , cost-effectiveness , feasibility , acceptability and sustainability of the programs . PROGRAM DESIGN The project 's first phase ( 2006 - 2009 ) was focused on health promotion targeting at the entire population of 1.94 million , and training of professionals ; and the second phase ( 2009 - 2012 ) on  lifestyle counselling targeting at individuals with a diabetes risk score of > or=14 . The effectiveness of the intervention and the cost-effectiveness of the program between the intervention arm ( n=8000 ) and the control arm ( n=4000 ) who are r and omly selected from the project targeting and not-targeting areas will be evaluated with the diabetes incidence as the primary outcome . Milestone achieved from 2006 to 2009 : 3993 health professionals finished training courses ; 724,130 educational booklets were distributed to families and 318,284 high-risk individuals recorded and 130,164 underwent at least one follow-up counselling session Background As in clinical practice re sources may be limited compared to experimental setting s , translation of evidence -based lifestyle interventions into daily life setting s is challenging . In this study we therefore evaluated the implementation of the APHRODITE lifestyle intervention for the prevention of type 2 diabetes in Dutch primary care . Based on this evaluation we discuss opportunities for refining intervention delivery . Methods A 2.5-year intervention was performed in 14 general practice s in the Netherl and s among individuals at high risk for type 2 diabetes ( FINDRISC-score ≥ 13 ) ( n = 479 ) and was compared to usual care ( n = 446 ) . Intervention consisted of individual lifestyle counselling by nurse practitioners ( n = 24 ) and GPs ( n = 48 ) and group-consultations .  Drop-out and attendance were registered during the programme . After the intervention , satisfaction with the programme and perceived implementation barriers were assessed with question naires . Results Drop-out was modest ( intervention : 14.6 % ; usual care : 13.2 % ) and attendance at individual consultations was high ( intervention : 80 - 97 % ; usual care : 86 - 94 % ) . Providers were confident about diabetes prevention by lifestyle intervention in primary care . Participants were more satisfied with counselling from nurse practitioners than from GPs . A major part of the GPs reported low self-efficacy regarding dietary guidance . Lack of counselling time ( 60 % ) , participant motivation ( 12 % ) , and financial reimbursement ( 11 % ) were regarded by providers as important barriers for intervention implementation . Conclusions High participant compliance and a positive attitude of providers make primary care a suitable setting for diabetes prevention by lifestyle counselling . Results support a role for the nurse practitioner as the key player in guiding lifestyle modification . Further research is needed on strategies that could increase cost-effectiveness , such as more stringent criteria for participant inclusion , group-counselling , more tailor-made counselling and integration of screening and / or interventions for different disorders Background India currently has more than 60 million people with Type 2 Diabetes Mellitus ( T2DM ) and this is predicted to increase by nearly two-thirds by 2030 . While management of those with T2DM is important , preventing or delaying the onset of the disease , especially in those individuals at ‘ high risk ’ of developing T2DM , is urgently needed , particularly in re source -constrained setting s. This paper describes the protocol for a cluster r and omised controlled trial of a peer-led lifestyle intervention program to prevent diabetes in Kerala , India . Methods / design A total of 60 polling booths are r and omised to the intervention arm or control arm in rural Kerala , India . Data collection is conducted in two steps . Step 1 ( Home screening ) : Participants aged 30–60 years are administered a screening question naire . Those having no history of T2DM and other chronic illnesses with an Indian Diabetes Risk Score value of ≥60 are invited to attend a mobile clinic ( Step 2 ) . At the mobile clinic , participants complete question naires , undergo physical measurements , and provide blood sample s for biochemical analysis . Participants identified with T2DM at Step 2 are excluded from further study participation . Participants in the control arm are provided with a health education booklet containing information on symptoms , complications , and risk factors of T2DM with the recommended levels for primary prevention . Participants in the intervention arm receive : ( 1 ) eleven peer-led small group sessions to motivate , guide and support in planning , initiation and maintenance of lifestyle changes ; ( 2 ) two diabetes prevention education sessions led by experts to raise awareness on T2DM risk factors , prevention and management ; ( 3 ) a participant h and book containing information primarily on peer support and its role in assisting with lifestyle modification ; ( 4 ) a participant workbook to guide self-monitoring of lifestyle behaviours , goal setting and goal review ; ( 5 ) the health education booklet that is given to the control arm . Follow-up assessment s are conducted at 12 and 24 months . The primary outcome is incidence of T2DM . Secondary outcomes include behavioural , psychosocial , clinical , and biochemical measures . An economic evaluation is planned . Discussion Results from this trial will contribute to improved policy and practice regarding lifestyle intervention programs to prevent diabetes in India and other re source -constrained setting s . Trial registration Australia and New Zeal and Clinical Trials Registry : ACTRN12611000262909 Over the past decades , we have observed an increase of prevalence of diabetes  in many countries along with significant differences in prevalence trends between countries worldwide ( 1 ) . In Europe and other Western countries , the prevalence rate reaches a plateau or has slowed down on the level of ∼8–10 % . In Asia , a continuous rise in prevalence has been monitored , similar to that in Africa , and an explosion of diabetes prevalence can be observed in the Arabic region . Surprisingly , in each of the countries , there is a significant number of people who do not develop  diabetes  during their lives despite living unhealthy lifestyles in similar environments — in Europe , an estimated 10 % of the population ( 2 ) . These people might be the secret answer to successful individual diabetes prevention , but we still do not underst and the detailed mechanisms of why some people develop diabetes— and why others do not . What we can do is observe individual lifestyle and environment as determinants for the development or prevention of diabetes and the respective risk factors including genetic susceptibility . The interplay between these determinants , influencing the probability of the individual staying healthy or how a person learns or chooses a healthy lifestyle , will define success in diabetes prevention ( 3 ) . Innovative actions are needed to slow down the progression of type 2 diabetes . The purpose of this article is to offer innovative policy and environmental strategic activities design ed to enable sustainable diabetes prevention with scalability on national level . # # # Why Do We Need Environmental and Policy Changes in Diabetes Prevention ? Diabetes prevention is a success story , but it generates new challenges . Throughout the past 15 years , a number of r and omized controlled trials have sought to test various interventions to prevent diabetes ( 4 ) . The results are overwhelmingly positive on an individual level , with a significant relative diabetes risk reduction attributed to lifestyle and pharmacological intervention ( 5 Background Studies have shown that lifestyle  behavior changes are most effective to prevent onset of diabetes in high-risk patients . Primary care providers are charged with encouraging behavior change among their patients at risk for diabetes , yet the practice environment and training in primary care often do not support effective provider counseling . The goal of this study is to develop an electronic health record-embedded tool to facilitate shared patient-provider goal setting to promote behavioral change and prevent diabetes . Methods The ADAPT ( Avoiding Diabetes Thru Action Plan Targeting ) trial leverages an innovative system that integrates evidence -based interventions for behavioral change with already-existing technology to enhance primary care providers ' effectiveness to counsel about lifestyle behavior changes . Using principles of behavior change theory , the multidisciplinary design team utilized in-depth interviews and in vivo usability testing to produce a prototype diabetes prevention counseling system embedded in the electronic health record . Results The core element of the tool is a streamlined , shared goal - setting module within the electronic health record system . The team then conducted a series of innovative , " near-live " usability testing simulations to refine the tool and enhance workflow integration . The system also incorporates a pre-encounter survey to elicit patients ' behavior-change goals to help tailor patient-provider goal setting during the clinical encounter and to encourage shared decision making . Lastly , the patients interact with a website that collects their longitudinal behavior data and allows them to visualize their progress over time and compare their progress with other study members . The finalized ADAPT system is now being piloted in a small r and omized control trial of providers using the system with prediabetes patients over a six-month period . Conclusions The ADAPT system combines the influential powers of shared goal setting and feedback , tailoring , modeling , contracting , reminders , and social comparisons to integrate evidence -based behavior-change principles into the electronic health record to maximize provider counseling efficacy during routine primary care clinical encounters . If successful , the ADAPT system may represent an adaptable and scalable technology-enabled behavior-change tool for all primary care providers . Trial Registration Clinical Trials.gov Identifier Background The prevention of  type 2 diabetes  is a recognised health care priority globally . Within the United Kingdom , there is a lack of research investigating optimal methods of translating diabetes prevention programmes , based on the promotion of a healthy lifestyle , into routine primary care . This study aims to establish the behavioural and clinical effectiveness of a structured educational programme design ed to target perceptions and knowledge of diabetes risk and promote a healthily lifestyle , particularly increased walking activity , in a multi-ethnic population at a high risk of developing type 2 diabetes . Design Cluster r and omised controlled trial undertaken at the level of primary care practice s. Follow-up will be conducted at 12 , 24 and 36 months . The primary outcome is change in objective ly measured ambulatory activity . Secondary outcomes include progression to type 2 diabetes , biochemical variables ( including fasting glucose , 2-h glucose , HbA1c and lipids ) , anthropometric variables , quality of life and depression . Methods 10 primary care practice s will be recruited to the study ( 5 intervention , 5 control ) . Within each practice , individuals at high risk of impaired glucose regulation will be identified using an automated version of the Leicester Risk Assessment tool . Individuals scoring within the 90th percentile in each practice will be invited to take part in the study . Practice s will be assigned to either the control group ( advice leaflet ) or the intervention group , in which participants will be invited to attend a 3 hour structured educational programme design ed to promote physical activity and a healthy lifestyle . Participants in the intervention practice s will also be invited to attend annual group-based maintenance workshops and will receive telephone contact halfway between annual sessions . The study will run from 2010–2014 . Discussion This study will provide new evidence surrounding the long-term effectiveness of a diabetes prevention programme run within routine primary care in the United Kingdom . Trial Registration Clinical Trials . Gov identifier : OBJECTIVES Prevention of type 2 diabetes ( T2DM ) is a priority in healthcare , but there is a lack of evidence investigating how to effectively translate prevention research into a UK primary care setting . We assessed whether a structured education programme targeting lifestyle and behaviour change was effective at preventing progression to T2DM  in people with pre-diabetes . MATERIAL S AND METHODS Forty-four general practice s were r and omised to receive either st and ard care or a 6hour group structured education programme with an annual refresher course , and regular phone contact . Participants were followed up for 3years . The primary outcome was progression to T2DM . RESULTS Eight hundred and eighty participants were included ( 36 % female , mean age 64years , 16 % ethnic minority group ) ; 131 participants developed T2DM . There was a non-significant 26 % reduced risk of developing T2DM in the intervention arm compared to st and ard care ( HR 0.74 , 95 % CI 0.48 , 1.14 , p=0.18 ) . The reduction in T2DM risk when excluding those who did not attend the initial education session was also non-significant ( HR 0.65 , 0.41 , 1.03 , p=0.07 ) . There were statistically significant improvements in HbA1c ( -0.06 , -0.11 , -0.01 ) , LDL cholesterol ( -0.08 , -0.15 , -0.01 ) , sedentary time ( -26.29 , -45.26 , -7.32 ) and step count ( 498.15 , 162.10 , 834.20 ) when data were analysed across all time points . CONCLUSIONS This study suggests that a relatively low re source , pragmatic diabetes prevention programme result ed in modest benefits to biomedical , lifestyle and psychosocial outcomes , however the reduction to the risk of T2DM did not reach significance . The findings have important implication s for future research and primary care AIMS To explore factors influencing post-natal health behaviours following the experience of gestational diabetes , and to elicit women 's views about the feasibility of lifestyle intervention to prevent diabetes during the first 2 years after childbirth . METHODS Qualitative study using semi-structured interviews with women who had gestational diabetes . In phase 1 ( 31 women ) , interviews explored the experience of gestational diabetes , ideas about future risk of diabetes and factors influencing post-natal health-related behaviours . Statements were developed summarizing women 's views of lifestyle change to prevent diabetes . In phase 2 ( 14 women ) , interviews explored how the passage of time had contributed to changes in health behaviour , and the statements were used to develop views about diabetes interventions . RESULTS Women were aware of their risk of developing diabetes , but did not always act on such knowledge . Pregnancy motivated behaviour changes to benefit the unborn child , but after delivery these changes were often not maintained . Tiredness , maternal attachment and childcare dem and s were prominent barriers in the early post-natal months . Later , work , family and child development became more significant barriers . Many women became more receptive to healthy eating messages around the time of weaning . Women were positive about long-term support for self-management to reduce their diabetes risk . CONCLUSIONS There is potential to reduce the risk of Type 2 diabetes post-natally among women with gestational diabetes . Interventions need to be developed that take into account context ual factors and competing dem and s , are flexible and respond to women 's individual circumstances . R and omized trials of such interventions are warranted The prevalence of type 2 diabetes is continuously increasing . This chronic metabolic disorder is difficult to treat and imposes a considerable economic burden on the healthcare system . In view of the fact that type 2 diabetes is primarily caused by behavioral factors , effective preventive strategies are urgently needed . We examined the effects of a holistic lifestyle intervention on clinical and laboratory parameters as well as on the long-term diabetes risk in patients at risk to develop diabetes . We conducted a r and omized controlled trial in a primary care setting in Hannover , Germany , with 83 patients diagnosed as (pre)diabetic or at risk for diabetes . CHIP Germany is a 40-hour coaching lifestyle intervention program for the primary and secondary prevention of type 2 diabetes and cardiovascular diseases . The intervention included a comprehensive nutrition and health educational program based on the American CHIP approach . The primary outcome parameter was the body mass index ( BMI ) . Secondary outcome parameters included body weight , blood pressure , fasting glucose , HbA1c , blood lipids , and the FINDRISK score , which assesses long-term diabetes risk . At the final measurement after 12 months , in the intervention group the BMI was reduced by 1.4 versus 0.2 kg/m2 in controls ( p = .119 ) . The mean sustained weight loss after 12 months was −4.1 kg in the intervention group versus −0.8 kg in controls . Furthermore , we found a trend toward a stronger reduction in blood pressure , fasting glucose , and HbA1c as well as an improved FINDRISK score in the intervention group , compared to controls . Although failing to reach statistical significance at the final assessment , this comprehensive lifestyle intervention showed a noticeable reduction in several cardiometabolic risk factors which may facilitate the prevention of diabetes AIMS To determine the effectiveness of a 2.5-year lifestyle intervention for Type 2 diabetes prevention in Dutch general practice compared with usual care . METHODS A r and omized controlled trial of 925 individuals at high risk for Type 2 diabetes ( FINDRISC-score ≥ 13 ) in 14 general practice s in the Netherl and s. Intervention consisted of lifestyle counselling from the nurse practitioner and the general practitioner . Usual care consisted of oral and written information at the start of the study . Study groups were compared over 2.5 years regarding changes in clinical and lifestyle measures . RESULTS Both groups showed modest changes in body weight , glucose concentrations , physical activity and dietary intake [ weight : intervention group , -0.8 ( 5.1 ) kg , usual care group , -0.4 ( 4.7 ) kg , ( P=0.69 ) ; fasting plasma glucose : intervention group , -0.17 ( 0.4 ) mmol/l , usual care group , -0.10 ( 0.5 ) mmol/l , ( P=0.10 ) ] . Differences between groups were significant only for total physical activity and fibre intake . In the intervention group , self-efficacy was significantly higher in individuals successful at losing weight compared with unsuccessful individuals . No significant differences in participant weight loss were found between general practitioners and nurse practitioners with different levels of motivation or self-efficacy . CONCLUSIONS Diabetes risk factors could significantly be reduced by lifestyle counselling in Dutch primary care . However , intervention effects above the effects attributable to usual care were modest . Higher participant self-efficacy seemed to facilitate weight loss . Lack of motivation or self-efficacy of professionals did not negatively influence participant guidance Background Gestational diabetes mellitus ( GDM ) is a risk factor for the development of type 2 diabetes . Lifestyle intervention can prevent progression to type 2 diabetes in high risk population s. We design ed a r and omised controlled trial ( RCT ) to evaluate the effectiveness of an established lifestyle intervention compared to st and ard care for delaying diabetes onset in European women with recent GDM . Recruitment into the RCT was more challenging than anticipated with only 89 of 410 ( 22 % ) women agreeing to participate . This paper identifies factors that could enhance participation of the target population in future interventions . Methods We hypothesised that women who agreed to participate would have higher diabetes risk profiles than those who declined , and secondly that it would be possible to predict participation on the bases of those risk factors . To test our hypothesis , we identified the subset of women for whom we had comprehensive data on diabetes risks factors 3 - 5 years following GDM , reducing the sample to 43 participants and 73 decliners . We considered established diabetes risk factors : smoking , daily fruit and vegetable intake , participation in exercise , family history of diabetes , glucose values and BMI scores on post-partum re-screens , use of insulin during pregnancy , and age at delivery . We also analysed narrative data from 156 decliners to further underst and barriers to and facilitators of participation . Results Two factors differentiated participants and decliners : age at delivery ( with women older than 34 years being more likely to participate ) and insulin use during pregnancy ( with women requiring the use of insulin in pregnancy less likely to participate ) . Binary logistic regression confirmed that insulin use negatively affected the odds of participation . The most significant barriers to participation included the accessibility , affordability and practicality of the intervention . Conclusions Women with recent GDM face multiple barriers to lifestyle change . Intervention design ers should consider : ( i ) the practicalities of participation for this population , ( ii ) research design s that capitalise on motivational differences between participants , ( iii ) alleviating concerns about long-term diabetes management . We hope this work will support future research ers in developing interventions that are more relevant , effective and successful in recruiting the desired population .Trial registration Current Controlled Trials IS RCT Aims /hypothesisTo assess the feasibility and effectiveness of an active real-life primary care lifestyle intervention in preventing  type 2 diabetes within a high-risk Mediterranean population . Methods A prospect i ve cohort study was performed in the setting of Spanish primary care . White-European individuals without diabetes aged 45–75 years ( n = 2,054 ) were screened using the Finnish Diabetes Risk Score ( FINDRISC ) and a subsequent 2 h OGTT . Where feasible , high-risk individuals who were identified were allocated sequentially to st and ard care , a group-based or an individual level intervention ( intensive reinforced DE-PLAN [ Diabetes in Europe — Prevention using Lifestyle , Physical Activity and Nutritional ] intervention ) . The primary outcome was the development of diabetes according to WHO criteria . Analyses after 4-year follow-up were performed based on the intention-to-treat principle with comparison of st and ard care and the combined intervention groups . Results The st and ard care ( n = 219 ) and intensive intervention ( n = 333 ) groups were comparable in age ( 62.0/62.2 years ) , sex ( 64.4/68.2 % women ) , BMI ( 31.3/31.2 kg/m2 ) , FINDRISC score ( 16.2/15.8 points ) , fasting ( 5.3/5.2 mmol/l ) , 2 h plasma glucose ( 7.1/6.9 mmol/l ) and self-reported interest to make lifestyle changes at baseline . Diabetes was diagnosed in 124 individuals : 63 ( 28.8 % ) in the st and ard care group and 61 ( 18.3 % ) in the intensive intervention group . During a 4.2-year median follow-up , the incidences of diabetes were 7.2 and 4.6 cases per 100 person-years , respectively ( 36.5 % relative risk reduction , p < 0.005 ) . The number of participants needed to be treated by intensive intervention for 4 years to reduce one case of diabetes was 9.5 . Conclusions /interpretationIntensive lifestyle intervention is feasible in a primary care setting and substantially reduces diabetes incidence among high-risk individuals . Clinical trial registration : Clinical Trial.gov NCT01519505 Funding : Commission of the European Communities , Institute of Health Carlos III , Spanish Ministry of Health and Department of Health , Generalitat de Catalunya Background Gestational diabetes mellitus ( GDM ) , a hyperglycemic state detected during pregnancy , is an established risk factor for diabetes . However , treatment during pregnancy in and of itself is not able to eliminate this risk , and a considerable fraction of women with GDM will develop frank diabetes in the decade following pregnancy . Our aim is to conduct a multicenter r and omized controlled trial to investigate the effectiveness of a lifestyle intervention program implemented after a pregnancy complicated by GDM in delaying or preventing the development of type 2 diabetes . Methods Women aged 18 or older identified as having recent GDM are recruited and followed by telephone to assess eligibility for the trial . To be eligible , women must have used insulin during pregnancy or present intermediate hyperglycemia postpartum . Women are encouraged to enter the trial as early as 10 weeks , and are permitted to do so up to 2 years after a pregnancy with GDM . An estimated 740 women will be r and omized to either conventional care or to coach-based interventions focused on breastfeeding , weight loss , healthy eating , and increased physical activity , and predominantly delivered by telephone . Women are followed annually to detect new onset diabetes , the primary outcome , and additional secondary outcomes which include reversion to normoglycemia , weight loss , physical activity and fitness , and insulin resistance . Discussion Though previous studies have demonstrated that type 2 diabetes can be delayed or prevented , no study has yet demonstrated the feasibility and effectiveness of similar interventions implemented in the postpartum period for women with recent GDM . If shown to be successful , this approach could become an important means of preventing diabetes in primary care setting s . Trial registration Clinical Trials.gov Identifier : NCT02327286 ; Registered 23 December 2014 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 : Research on the translation of efficacious lifestyle change programs to prevent type 2 diabetes into community or clinical setting s is needed . Objective : The objective of this study was to examine the reach , implementation , and efficacy of a 6-month lifestyle program implemented in primary care by nurse practitioners ( NPs ) for adults at risk of type 2 diabetes . Methods : The NP sites ( n = 4 ) were r and omized to an enhanced st and ard care program ( one  NP  and one  nutrition session ) or a lifestyle program ( enhanced st and ard care and six NP sessions ) . These NPs recruited adults at risk of diabetes from their practice ( n = 58 ) , with an acceptance rate of 70 % . Results : The program reached a diverse , obese , and moderately low income sample . The NPs were able to successfully implement the protocol s. The average length of the program was 9.3 months . Attendance was high ( 98 % ) , and attrition was low ( 12 % ) . The NPs were able to adopt the educational , behavioral , and psychosocial strategies of the intervention easily . Motivational interviewing was more difficult for NPs . Mixed-model repeated- measures analysis indicated significant trends or improvement in both groups for nutrition and exercise behavior . Participants of the lifestyle program demonstrated trends for better high-density lipoprotein ( HDL ) and exercise behavior compared with the enhanced st and ard care participants . Twenty-five percent of lifestyle participants met treatment goals of 5 % weight loss compared with 11 % of st and ard care participants . Discussion : A lifestyle program can be implemented in primary care by NPs , reach the targeted population , and be modestly successful . Further research is indicated Asian Americans experience diabetes at a higher rate than non-Hispanic whites . Diabetes prevention programs using lifestyle interventions have been shown to produce beneficial results , yet there have been no culturally-tailored programs for diabetes prevention in the Korean community . We explore the impact and feasibility of a pilot Community Health Worker ( CHW ) intervention to improve health behaviors and promote diabetes prevention  among Korean Americans using a r and omized controlled trial . Between 2011 and 2012 , a total of 48 Korean Americans at risk for diabetes living in New York City ( NYC ) participated in the intervention . Participants were allocated to treatment or control groups . A community-based participatory research approach guided development of the intervention , which consisted of 6 workshops held by CHWs on diabetes prevention , nutrition , physical activity , diabetes complications , stress and family support , and access to health care . Changes over 6 months were examined for clinical measurements ( weight , BMI , waist circumference , blood pressure , glucose , and cholesterol ) ; health behaviors ( physical activity , nutrition , food behaviors , diabetes knowledge , self-efficacy , and mental health ) ; and health access ( insurance and self-reported health ) . In this small pilot study , changes were seen in weight , waist circumference , diastolic blood pressure , physical activity nutrition , diabetes knowledge , and mental health . Qualitative findings provide additional context ual information that inform ways in which CHWs may influence health outcomes . These findings demonstrate that a diabetes prevention program can be successful among a Korean American population in NYC , and important insight is provided for ways that programs can be tailored to meet the needs of vulnerable population AIMS The Diabetes Community Lifestyle Improvement Program ( D-CLIP ) aims to implement and evaluate in a controlled , r and omized trial the effectiveness , cost-effectiveness , and sustainability of a culturally appropriate , low-cost , and sustainable lifestyle intervention for the prevention of type 2 diabetes mellitus in India . METHODS D-CLIP , a translational research project adapted from the methods and curriculum developed and tested for efficacy in the Diabetes Prevention Program , utilizes innovated methods ( a step-wise model of diabetes prevention with lifestyle and metformin added when needed ; inclusion of individuals with isolated glucose tolerance , impaired fasting glucose , and both ; classes team-taught by professionals and trained community educators ) with the goals of increasing diabetes prevention , community acceptability , and long-term dissemination and sustainability of the program . The study outcomes are : diabetes incidence ( primary measure of effectiveness ) , cost-effectiveness , changes in anthropometric measures , plasma lipids , blood pressure , blood glucose , and HbA(1c , ) Program acceptability and sustainability will be assessed using a mixed methods approach . CONCLUSION D-CLIP , a low-cost , community-based , research program , addresses the key components of translational research and can be used as a model for prevention of chronic diseases in other low and middle-income country setting
This review also found mixed views on the value of preventative services within primary care .
The third theme was centred on professional factors impacting on diabetes prevention which included workload , time constraints , re sources , self-efficacy and knowledge as well as professionals ' perception of patient motivations towards change .
BACKGROUND Type 2 diabetes is impacting millions of people globally ; however , many future cases can be prevented through lifestyle changes and interventions .
Primary care is an important setting for diabetes prevention , for at-risk population s , because it is a patient 's primary point of contact with the health care system and professionals can provide lifestyle counselling and support , as well as monitoring health outcomes .
These are all essential elements for diabetes prevention for at-risk adults .
AIM To underst and the factors related to the delivery and uptake of type 2 diabetes prevention interventions within primary care in higher income countries .
CONCLUSION This review explored the factors influencing diabetes prevention in primary care , and identified the context of prevention , as well as patient and professional factors related to preventative services being offered in primary care .