The Impact of Physical Activity on the Prevention of Type 2 Diabetes: Evidence and Lessons Learned From the Diabetes Prevention Program, a Long-Standing Clinical Trial Incorporating Subjective and Objective Activity Measures
Authors: Kriska Andrea M. , Rockette-Wagner Bonny , Edelstein Sharon L. , Bray George A. , Delahanty Linda M. , Hoskin Mary A. , Horton Edward S. , Venditti Elizabeth M. , Knowler William C. ,   DPP Research Group, Bray George A. , Gadde Kishore , Culbert Iris W. , Arceneaux Jennifer , Chatellier Annie , Dragg Amber , Champagne Catherine M. , Duncan Crystal , Eberhardt Barbara , Greenway Frank , Guillory Fonda G. , Herbert April A. , Jeffirs Michael L. , Kennedy Betty M. , Levy Erma , Lockett Monica , Lovejoy Jennifer C. , Morris Laura H. , Melancon Lee E. , Ryan Donna H. , Sanford Deborah A. , Smith Kenneth G. , Smith Lisa L. , St. Amant Julia A. , Tulley Richard T. , Vicknair Paula C. , Williamson Donald , Zachwieja Jeffery J. , Polonsky Kenneth S. , Tobian Janet , Ehrmann David A. , Matulik Margaret J. , Clark Bart , Czech Kirsten , DeSandre Catherine , Hilbrich Ruthanne , McNabb Wylie , Semenske Ann R. , Caro Jose F. , Furlong Kevin , Goldstein Barry J. , Watson Pamela G. , Smith Kellie A. , Mendoza Jewel , Wildman Wendi , Liberoni Renee , Spandorfer John , Pepe Constance , Donahue Richard P. , Goldberg Ronald B. , Prineas Ronald , Calles Jeanette , Ojito Juliet , Rowe Patricia , Cassanova-Romero Paul , Castillo-Florez Sumaya , Florez Hermes J. , Giannella Anna , Kirby Lascelles , Larreal Carmen , Lara Olga , McLymont Valerie , Mendez Jadell , Perry Arlette , Saab Patrice , Veciana Beth , Haffner Steven M. , Hazuda Helen P. , Montez Maria G. , Hattaway Kathy , Lorenzo Carlos , Martinez Arlene , Walker Tatiana , Dabelea Dana , Hamman Richard F. , Nash Patricia V. , Steinke Sheila C. , Testaverde Lisa , Anderson Denise R. , Ballonoff Larry B. , Bouffard Alexis , Bucca Brian , Calonge B. Ned , Delve Lynne , Farago Martha , Hill James O. , Hoyer Shelley R. , Jenkins Tonya , Jortberg Bonnie T. , Lenz Dione , Miller Marsha , Perreault Leigh , Price David W. , Regensteiner Judith G. , Seagle Helen , Smith Carissa M. , VanDorsten Brent , Horton Edward S. , Lawton Kathleen E. , Poirier Catherine S. , Swift Kati , Arky Ronald A. , Bryant Marybeth , Burke Jacqueline P. , Caballero Enrique , Callaphan Karen M. , Fargnoli Barbara , Franklin Therese , Ganda Om P. , Guidi Ashley , Guido Mathew , Jackson Sharon D. , Jacobsen Alan M. , Lambert Lori , Ledbury Sarah , Kocal Margaret , Kula Lyn M. , Malloy Maureen A. , Nicosia Maryanne , Oldmixon Cathryn F. , Pan Jocelyn , Quitingon Marizel , Rubtchinsky Stacy , Sansoucy Jessica , Schweizer Dana , Seely Ellen W. , Simonson Donald , Smith Fannie , Solomon Caren G. , Spellman Jeanne , Warram James , Kahn Steven E. , Montgomery Brenda K. , Fujimoto Wilfred , Knopp Robert H. , Lipkin Edward W. , Marr Michelle , Morgan-Taggart Ivy , Murillo Anne , Trence Dace , Taylor Lonnese , Thomas April , Tsai Elaine C. , Dagogo-Jack Samuel , Kitabchi Abbas E. , Murphy Mary E. , Taylor Laura , Dolgoff Jennifer , Applegate William B. , Bryer-Ash Michael , Clark Debra , Frieson Sandra L. , Ibebuogu Uzoma , Imseis Raed , Lambeth Helen , Lichtermann Lynne C. , Oktaei Hooman , Ricks Harriet , Rutledge Lily K. , Sherman Amy R. , Smith Clara M. , Soberman Judith E. , Williams-Cleaves Beverly , Metzger Boyd E. , Molitch Mark E. , Johnson Mariana K. , Adelman Daphne T. , Behrends Catherine , Cook Michelle , Fitzgibbon Marian , Giles Mimi M. , Heard Deloris , Johnson Cheryl H. , Larsen Diane , Lowe Anne , Lyman Megan , McPherson David , Penn Samsam C. , Pitts Thomas , Reinhart Renee , Roston Susan , Schinleber Pamela A. , Nathan David M. , McKitrick Charles , Turgeon Heather , Larkin Mary , Abbott Kathy , Anderson Ellen , Bissett Laurie , Bondi Kristy , Cagliero Enrico , Florez Jose C. , D’Anna Kali , Delahanty Linda , Goldman Valerie , Lou Peter , Poulos Alexandra , Raymond Elyse , Stevens Christine , Tseng Beverly , Olefsky Jerrold M. , Barrett-Connor Elizabeth , Carrion-Petersen Mary Lou , Beltran Madeline , Claravall Lauren N. , Dowden Jonalle M. , Edelman Steven V. , Henry Robert R. , Horne Javiva , Lamkin Marycie , Szerdi Janesch Simona , Leos Diana , Mudaliar Sunder , Polonsky William , Smith Jean , Torio-Hurley Jennifer , Vejvoda Karen , Pi-Sunyer F. Xavier , Lee Jane E. , Allison David B. , Agharanya Nnenna , Aronoff Nancy J. , Baldo Maria , Crandall Jill P. , Foo Sandra T. , Hagamen Susan , Luchsinger Jose A. , Pal Carmen , Parkes Kathy , Pena Mary Beth , Rooney Ellen S. , VanWye Gretchen H. , Viscovich Kristine A. , Marrero David G. , Mather Kieren J. , Prince Melvin J. , Kelly Susie M. , Jackson Marcia A. , McAtee Gina , Putenney Paula , Ackermann Ronald T. , Cantrell Carolyn M. , Dotson Yolanda F. , Fineberg Edwin S. , Fultz Megan , Guare John C. , Hadden Angela , Ignaut James M. , Kirkman Marion S. , O’Kelly Phillips Erin , Porter Beverly D. , Roach Paris J. , Rowland Nancy D. , Wheeler Madelyn L. , Aroda Vanita , Ratner Robert E. , Youssef Gretchen , Shapiro Sue , Bavido-Arrage Catherine , Boggs Geraldine , Bronsord Marjorie , Brown Ernestine , Cheatham Wayman W. , Cola Susan , Evans Cindy , Gibbs Peggy , Kellum Tracy , Wiggins Renee , Lagarda Milvia , Leon Lilia , Levatan Claresa , Lindsay Milajurine , Nair Asha K. , Passaro Maureen , Silverman Angela , Uwaifo Gabriel , Wells-Thayer Debra , Saad Mohammed F. , Watson Karol , Budget Maria , Jinagouda Sujata , Botrous Medhat , Akbar Khan , Conzues Claudia , Magpuri Perpetua , Ngo Kathy , Rassam Amer , Waters Debra , Xapthalamous Kathy , Santiago Julio V. , Dagogo-Jack Samuel , White Neil H. , Brown Angela L. , Das Samia , Khare-Ranade Prajakta , Stich Tamara , Santiago Ana , Fisher Edwin , Hurt Emma , Jones Tracy , Kerr Michelle , Ryder Lucy , Wernimont Cormarie , Hill Golden Sherita , Saudek Christopher D. , Bradley Vanessa , Sullivan Emily , Whittington Tracy , Abbas Caroline , Allen Adrienne , Brancati Frederick L. , Cappelli Sharon , Clark Jeanne M. , Charleston Jeanne B. , Freel Janice , Horak Katherine , Greene Alicia , Jiggetts Dawn , Johnson Deloris , Joseph Hope , Loman Kimberly , Mosley Henry , Reusing John , Rubin Richard R. , Samuels Alafia , Shields Thomas , Stephens Shawne , Stewart Kerry J. , Thomas Lee Lana , Utsey Evonne , Williamson Paula , Schade David S. , Adams Karwyn S. , Canady Janene L. , Johannes Carolyn , Hemphill Claire , Hyde Penny , Atler Leslie F. , Boyle Patrick J. , Burge Mark R. , Chai Lisa , Colleran Kathleen , Gonzales Ysela , Hernandez-McGinnis Doris A. , Katz Patricia , King Carolyn , Rassam Amer , Rubinchik Sofya , Senter Willette , Waters Debra , Crandall Jill , Shamoon Harry , Brown Janet O. , Trandafirescu Gilda , Adorno Elsie , Cox Liane , Duffy Helena , Engel Samuel , Friedler Allison , Goldstein Angela , Howard-Century Crystal J. , Lukin Jennifer , Kloiber Stacey , Longchamp Nadege , Martinez Helen , Pompi Dorothy , Scheindlin Jonathan , Violino Elissa , Walker Elizabeth A. , Wylie-Rosett Judith , Zimmerman Elise , Zonszein Joel , Orchard Trevor , Wing Rena R. , Jeffries Susan , Koenning Gaye , Kramer M. Kaye , Smith Marie , Barr Susan , Benchoff Catherine , Boraz Miriam , Clifford Lisa , Culyba Rebecca , Frazier Marlene , Gilligan Ryan , Guimond Stephanie , Harrier Susan , Harris Louann , Kriska Andrea , Manjoo Qurashia , Mullen Monica , Noel Alicia , Otto Amy , Pettigrew Jessica , Rubinstein Debra , Semler Linda , Smith Cheryl F. , Venditti Elizabeth , Weinzierl Valarie , Williams Katherine V. , Wilson Tara , Arakaki Richard F. , Latimer Renee W. , Baker-Ladao Narleen K. , Isonaga Mae K. , Beddow Ralph , Bermudez Nina E. , Dias Lorna , Inouye Jillian , Mau Marjorie K. , Melish John S. , Mikami Kathy , Mohideen Pharis , Odom Sharon K. , Perry Raynette U. , Yamamoto Robin E. , Knowler William C. , Cooeyate Norman , Hoskin Mary A. , Percy Carol A. , Enote Alvera , Natewa Camille , Acton Kelly J. , Andre Vickie L. , Barber Rosalyn , Begay Shandiin , Bennett Peter H. , Beth Benson Mary , Bird Evelyn C. , Broussard Brenda A. , Bucca Brian C. , Chavez Marcella , Cook Sherron , Curtis Jeff , Dacawyma Tara , Doughty Matthew S. , Duncan Roberta , Dodge Charlotte , Edgerton Cyndy , Ghahate Jacqueline M. , Glass Justin , Glass Martia , Gohdes Dorothy , Grant Wendy , Hanson Robert L. , Horse Ellie , Ingraham Louise E. , Jackson Merry , Jay Priscilla , Kaskalla Roylen S. , Kessler David , Kobus Kathleen M. , Krakoff Jonathan , Kurland Jason , Manus Catherine , McCabe Cherie , Michaels Sara , Morgan Tina , Nashboo Yolanda , Nelson Julie A. , Poirier Steven , Polczynski Evette , Piromalli Christopher , Reidy Mike , Roumain Jeanine , Rowse Debra , Roy Robert J. , Sangster Sandra , Sewenemewa Janet , Smart Miranda , Tonemah Darryl , Williams Rachel , Wilson Charlton , Yazzie Michelle , Bain Raymond , Fowler Sarah , Temprosa Marinella , Larsen Michael D. , Brenneman Tina , Edelstein Sharon L. , Abebe Solome , Bamdad Julie , Barkalow Melanie , Bethepu Joel , Bezabeh Tsedenia , Butler Nicole , Callaghan Jackie , Carter Caitlin E. , Christophi Costas , Dwyer Gregory M. , Foulkes Mary , Gao Yuping , Gooding Robert , Gottlieb Adrienne , Grimes Kristina L. , Grover-Fairchild Nisha , Haffner Lori , Hoffman Heather , Jablonski Kathleen , Jones Steve , Jones Tara L. , Katz Richard , Kolinjivadi Preethy , Lachin John M. , Ma Yong , Mucik Pamela , Orlosky Robert , Pan Qing , Reamer Susan , Rochon James , Sapozhnikova Alla , Sherif Hanna , Stimpson Charlotte , Hogan Tjaden Ashley , Walker-Murray Fredricka , Venditti Elizabeth M. , Kriska Andrea M. , Semler Linda , Marcovina Santica , Harting Jessica , Aldrich F. Alan , Albers John , Strylewicz Greg , Eastman R. , Fradkin Judith , Garfield Sanford , Lee Christine , Gregg Edward , Zhang Ping , O’Leary Dan , Evans Gregory , Budoff Matthew , Dailing Chris , Stamm Elizabeth , Schwartz Ann , Navy Caroline , Palermo Lisa , Rautaharju Pentti , Prineas Ronald J. , Alexander Teresa , Campbell Charles , Hall Sharon , Li Yabing , Mills Margaret , Pemberton Nancy , Rautaharju Farida , Zhang Zhuming , Soliman Elsayed Z. , Huc Julie , Hensley Susan , Keasler Lisa , Taylor Tonya , Danis Ronald , Davis Matthew , Hubbard Larry , Endres Ryan , Elsas Deborah , Johnson Samantha , Gama Vonnie , Goulding Anne , Luchsinger Jose A. , Manly Jennifer , Mayer-Davis Elizabeth , Moran Robert R. , Ganiats Ted , David Kristin , Sarkin Andrew J. , Groessl Erik , Katzir Naomi , Herman William H. , Brändle Michael , Brown Morton B. , Florez Jose C. , Altshuler David , Billings Liana K. , Chen Ling , Harden Maegan , Hanson Robert L. , Knowler William C. , Pollin Toni I. , Shuldiner Alan R. , Jablonski Kathleen , Franks Paul W. , Hivert Marie-France 
Published: November 2020

OBJECTIVE
Across the Diabetes Prevention Program (DPP) follow-up, cumulative diabetes incidence remained lower in the lifestyle compared with the placebo and metformin randomized groups and could not be explained by weight. Collection of self-reported physical activity (PA) (yearly) with cross-sectional objective PA (in follow-up) allowed for examination of PA and its long-term impact on diabetes prevention.

RESEARCH DESIGN AND METHODS
Yearly self-reported PA and diabetes assessment and oral glucose tolerance test results (fasting glucose semiannually) were collected for 3,232 participants with one accelerometry assessment 11–13 years after randomization (n = 1,793). Mixed models determined PA differences across treatment groups. The association between PA and diabetes incidence was examined using Cox proportional hazards models.

RESULTS
There was a 6% decrease (Cox proportional hazard ratio 0.94 [95% CI 0.92, 0.96]; P &lt; 0.001) in diabetes incidence per 6 MET-h/week increase in time-dependent PA for the entire cohort over an average of 12 years (controlled for age, sex, baseline PA, and weight). The effect of PA was greater (12% decrease) among participants less active at baseline (&lt;7.5 MET-h/week) (n = 1,338) (0.88 [0.83, 0.93]; P &lt; 0.0001), with stronger findings for lifestyle participants. Lifestyle had higher cumulative PA compared with metformin or placebo (P &lt; 0.0001) and higher accelerometry total minutes per day measured during follow-up (P = 0.001 and 0.047). All associations remained significant with the addition of weight in the models.

CONCLUSIONS
PA was inversely related to incident diabetes in the entire cohort across the study, with cross-sectional accelerometry results supporting these findings. This highlights the importance of PA within lifestyle intervention efforts designed to prevent diabetes and urges health care providers to consider both PA and weight when counseling high-risk patients.