Diabetes: Combined Diet and Physical Activity Promotion Programs to Prevent Type 2 Diabetes Among People at Increased Risk

The CPSTF finding is based on evidence from a systematic review of 53 studies that described 66 programs (search period January 1991 – February 2015).

The review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice and policy related to diabetes prevention and control.

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

The systematic review included 53 studies that described 66 programs.

• Among populations at increased risk of type 2 diabetes, combined diet and physical activity promotion programs led to improvements in health outcomes and risk factors for type 2 diabetes and cardiovascular disease compared with usual care.
  • The proportion of people who developed type 2 diabetes decreased by a median of 11 percentage points (16 studies).
  • The proportion of people who achieved normal blood sugar (normoglycemia) increased by a median of 12 percentage points (6 studies).
  • Body weight was reduced by an average of 2.2% (24 studies).
  • Fasting blood glucose was reduced (improved) by an average of 2.2 mg/dL (17 studies) and hemoglobin A1c (a measure of long-term glucose levels) was reduced (improved) by an average of 0.08 percentage points (8 studies).
  • Blood pressure (17 studies) and cholesterol levels (13 studies) also were improved.
• The effect on mortality was unclear. Mortality was reduced by 2 to 10 percentage points (2 studies) or by 0.6 per 1000 person-years (1 study) over 3 to 23 years of follow-up. However, this benefit was statistically significant in only one study, and in that study, only among women.
• Regardless of program features, almost all programs led to weight loss, reduced risk of diabetes, or both. However, among 12 studies with direct comparisons, more intensive programs (based on features such as number of sessions, individual sessions, and additional personnel) resulted in greater weight loss and lower rates of diabetes than less intensive programs. Across studies, more effective programs provided:
  • Individual (vs. group) exercise sessions,
  • Individual (vs. group) diet sessions, or
  • Diet counselors
• In studies of programs that used protocols outlined by the U.S. Diabetes Prevention Program (DPP) study or Finnish Diabetes Prevention Study (DPS), or modifications of them, participants lost more weight (3% of initial body weight) than participants in programs not based on DPP or DPS (1.6% of initial body weight). Reductions in risk of developing diabetes were similar between studies of different programs.

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

An economic review of 28 studies (search period January 1985 – April 2015) shows that combined diet and physical activity promotion programs for people at increased risk for type 2 diabetes are cost-effective. All monetary values reported are in 2013 U.S. dollars.

Cost of programs:

• All programs: median $653 per participant (12 studies)
• Group-based programs: median $417 per participant (8 studies)
• Programs that translated the U.S. DPP into community or primary care settings: median $424 per participant (8 studies)

Cost-effectiveness of the program (from the health system perspective, which included only the direct medical costs of the programs and healthcare costs averted, based on either data collected in actual programs or estimates from simulation models):

• Cost per quality-adjusted life year (QALY) saved:
  • All programs: median $13,761 (16 studies)
  • Group-based programs: median $1,819 (5 studies)
  • Individual-based programs: median $15,846 (5 studies)
• Cost per disability-adjusted life year (DALY) averted:
  • $21,195 and $50,707 (2 studies)
• Cost per life year gained (LYG):
  • Median $2,684 (6 studies)

The variation in program costs per participant is partly explained by the number of sessions, delivery mode of the core sessions (individual vs. group), setting (clinical trial vs. community or primary care), and type of personnel used (health professionals vs. trained laypeople).

The variation in cost-effectiveness is partially explained by variation in cost and effectiveness of the programs, program delivery modes, patient follow-up times, and delivery settings.

The CPSTF finding is applicable to men and women in the United States who are at increased risk for type 2 diabetes, regardless of race/ethnicity, socioeconomic level, setting (urban or rural). The finding applies to programs offered through healthcare and community-based settings.

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

• How does program effectiveness vary by population demographics (e.g., race/ethnicity, SES, educational attainment, age, cognitive or physical disabilities)?
• How effective are programs delivered via the Internet, email, apps, or social networking?
• What is the relative effectiveness of individual and group sessions?
• What are effective structures for the maintenance phase of these programs to help participants continue their improvements to diet and physical activity following completion of the core phase?
• What are long-term effects of community-based programs on diabetes incidence, weight loss, other diabetes risk factors, morbidity, and mortality?
• What are recruitment and attrition rates? Why don’t all referred clients follow-up and why do some participants drop out? What are effective strategies to recruit and retain clients?
• What are the economic costs and benefits of programs implemented in community and primary care settings? Evaluations should include group-based programs delivered by trained laypeople.
• What are the costs of identifying and recruiting eligible individuals to participate?
• What are the costs associated with program implementation in community or primary care settings, and how can they be lowered? Costs include start-up costs, costs of program delivery (by program duration and setting), and costs to different stakeholders and society as a whole.
• What are long-term economic benefits of a program? What are actual heath care expenditures averted in total, by expenditure category? Ideally, an assessment would follow an intervention cohort and its comparison group for a long period of time.

• Programs lasted from three months to six years (median 12 months).
  • The core period lasted between one month and five years (median 6 months).
  • Maintenance periods (in 28 programs) lasted between four and 68 months, with a median of 12 months.
• Programs provided between 0 (virtual sessions only) and 72 sessions, with a median of 15 sessions.
  • During the core period, there were between 0 (virtual only) and 72 sessions, with a median of 10 sessions.
  • During the maintenance period (in 28 programs), there were between 0 (virtual only) and 24 sessions, with a median of 6 sessions. In some programs, the maintenance period contacts were by telephone or email only.
• Programs used individual face-to-face meetings (40 programs included individual diet sessions, 41 programs included individual exercise sessions), group meetings (diet: 41 programs, exercise: 39 programs), or both (diet: 24 programs, exercise: 24 programs). Five programs were conducted via web-tools, social networking, email, text messaging, video, or a combination of these, with no in-person sessions.
• Sessions were led by different combinations of trained diet counselors including dietitians, nutritionists, or others (37 programs); trained exercise counselors including physical trainers or others (26 programs); nurses (15 programs); physicians or psychologists (8 programs); and trained laypeople (13 programs).
• Programs included specific weight loss goals (42 programs), diet goals (19 programs), and physical activity goals (32 programs).
• Programs included individually tailored plans for diet (16 programs) and physical activity (23 programs).
• Studies were conducted in the United States (21 studies), Europe (17 studies), and other countries.

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

• Study Characteristics
• Patient Characteristics
• Intervention Characteristics
  • Combined Diet & Physical Activity vs. Control
  • More vs. Less Intensive Combined Diet & Physical Activity
  • Before-After Combined Diet & Physical Activity Studies
  • Studies Using Trainers or Dieticians
• Results of Studies
  • Combined Diet & Physical Activity vs. Control
  • More vs. Less Intensive Combined Diet & Physical Activity
  • Before-After Combined Diet & Physical Activity Studies
  • Quality Assessment of Studies

Economic Review

Summary Evidence Table – Economic Review

The Community Preventive Services Task Force recommendation on combined diet and physical activity promotion programs to prevent type 2 diabetes among people at increased risk is based on evidence from 53 studies (in 104 articles) that met eligibility criteria, published between 1991 and February 2015 (one study that was identified was excluded because of limited quality of execution).

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Absetz P, Valve R, Oldenburg B, et al. Type 2 diabetes prevention in the “real world”: one-year results of the GOAL Implementation Trial. Diabetes Care 2007;30:2465-70. PMID: 17586741.

Ackermann RT, Finch EA, Brizendine E, Zhou H, Marrero DG. Translating the Diabetes Prevention Program into the community. The DEPLOY Pilot Study. Am J Prev Med 2008;35:357-63. PMID: 18779029.

Ackermann RT, Sandy LG, Beauregard T, Coblitz M, Norton KL, Vojta D. A randomized comparative effectiveness trial of using cable television to deliver diabetes prevention programming. Obesity 2014;22:1601-7. PMID: 24740868

Admiraal WM, Vlaar EM, Nierkens V, et al. Intensive lifestyle intervention in general practice to prevent type 2 diabetes among 18 to 60-year-old South Asians: 1-year effects on the weight status and metabolic profile of participants in a randomized controlled trial. PLoS ONE 2013;8:e68605. PMID: 23894322.

Bhopal RS, Douglas A, Wallia S, et al. Effect of a lifestyle intervention on weight change in south Asian individuals in the UK at high risk of type 2 diabetes: a family-cluster randomised controlled trial. Lancet Diabetes Endocrinol 2014;2:218-27. PMID: 24622752.

Cezaretto A, Siqueira-Catania A, de Barros CR, Salvador EP, Ferreira SR. Benefits on quality of life concomitant to metabolic improvement in intervention program for prevention of diabetes mellitus. Qual Life Res 2012;21:105-13. PMID: 21538199.

Cole RE, Boyer KM, Spanbauer SM, Sprague D, Bingham M. Effectiveness of prediabetes nutrition shared medical appointments: prevention of diabetes. Diabetes Educ 2013;39:344-53. PMID: 23589326.

Costa B, Barrio F, Cabr JJ, et al. Delaying progression to type 2 diabetes among high-risk Spanish individuals is feasible in real-life primary healthcare settings using intensive lifestyle intervention. Diabetologia 2012;55:1319-28. PMID: 22322921.

De la Rosa A, Tahsin B, Sanghani R, et al. Detecting and managing metabolic syndrome: a feasibility study in a general medicine clinic. Ethn Dis 2008;S16-8.

Dunbar JA, Hernan A, Janus ED, et al. Implementation salvage experiences from the Melbourne diabetes prevention study. BMC Public Health 2012;12:806.

Eriksson KF, Lindg rde F. Prevention of type 2 (non-insulin-dependent) diabetes mellitus by diet and physical exercise. The 6-year Malmo feasibility study. Diabetologia 1991;34:891-8. PMID: 1778354.

Gagnon C, Brown C, Couture C, et al. A cost-effective moderate-intensity interdisciplinary weight-management programme for individuals with prediabetes. Diab Metab 2011;37:410-8. PMID: 21489843.

Gilis-Januszewska A, Szybinski Z, Kissimova-Skarbek K, et al. A. Prevention of type 2 diabetes by lifestyle intervention in primary health care setting in Poland: Diabetes in Europe Prevention using Lifestyle, physical Activity and Nutritional intervention (DE-PLAN) project. Br J Diab Vasc Dis 2011;11:198-203.

Gillison F, Stathi A, Reddy P, et al. Processes of behavior change and weight loss in a theory-based weight loss intervention program: a test of the process model for lifestyle behavior change. Int J Behav Nutr Phys Act 2015;12:2. PMID: 25592314.

Iqbal Hydrie MZ, Basit A, Shera AS, Hussain A. Effect of intervention in subjects with high risk of diabetes mellitus in Pakistan. J Nutr Metab 2012:867604. PMID: 22888411.

Islam NS, Zanowiak JM, Wyatt LC, et al. Diabetes prevention in the New York City Sikh Asian Indian community: a pilot study. Int J Environ Res Public Health 2014;11:5462-86. PMID: 24852392.

Janus ED, Best JD, vis-Lameloise N, Philpot B, Hernan A, Bennett CM, O’Reilly S, Carter R, Vartiainen E, Dunbar JA, Melbourne Diabetes Prevention Study research group. Scaling-up from an implementation trial to state-wide coverage: results from the preliminary Melbourne Diabetes Prevention Study. Trials 2012;13:152. PMID: 22929458.

Jiang L, Manson SM, Beals J, Henderson WG, Huang H, Acton KJ, Roubideaux Y, Special Diabetes Program for Indians Diabetes Prevention Demonstration Project. Translating the Diabetes Prevention Program into American Indian and Alaska Native communities: results from the Special Diabetes Program for Indians Diabetes Prevention demonstration project. Diabetes Care 2013;36:2027-34. PMID: 23275375.

Kanaya AM, Santoyo-Olsson J, Gregorich S, Grossman M, Moore T, Stewart AL. The Live Well, Be Well study: a community-based, translational lifestyle program to lower diabetes risk factors in ethnic minority and lower-socioeconomic status adults. Am J Public Health 2012;102:1551-8. PMID: 22698027.

Katula JA, Vitolins MZ, Morgan TM, Lawlor MS, Blackwell CS, Isom SP, Pedley CF, Goff DC, Jr. The Healthy Living Partnerships to Prevent Diabetes study: 2-year outcomes of a randomized controlled trial. Am J Prev Med 2013;44:Suppl-32. PMID: 23498294.

Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, Nathan DM, Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393-403. PMID: 11832527.

Knowler WC, Fowler SE, Hamman RF, Christophi CA, Hoffman HJ, Brenneman AT, Brown-Friday JO, Goldberg R, Venditti E, Nathan DM. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. [Erratum appears in Lancet 2009;374(9707):2054]. Lancet 2009;374:1677-86. PMID: 19878986.

Kosaka K, Noda M, Kuzuya T. Prevention of type 2 diabetes by lifestyle intervention: a Japanese trial in IGT males. Diab Res Clin Pract 2005;67:152-62. PMID: 15649575.

Kulzer B, Hermanns N, Gorges D, Schwarz P, Haak T. Prevention of diabetes self-management program (PREDIAS): effects on weight, metabolic risk factors, and behavioral outcomes. Diabetes Care 2009;32:1143-6. PMID: 19509014.

Kyrios M, Moore SM, Hackworth N, Buzwell SA, Crafti N, Critchley C, Hardie E. The influence of depression and anxiety on outcomes after an intervention for prediabetes. Med J Aust 2009;190:Suppl-5. PMID: 19351299.

Laatikainen T, Dunbar JA, Chapman A, Kilkkinen A, Vartiainen E, Heistaro S, Philpot B, Absetz P, Bunker S, O’Neil A, Reddy P, Best JD, Janus ED. Prevention of type 2 diabetes by lifestyle intervention in an Australian primary health care setting: Greater Green Triangle (GGT) Diabetes Prevention Project. BMC Public Health 2007;7:249. PMID: 17877832.

Liao D, Asberry PJ, Shofer JB, Callahan H, Matthys C, Boyko EJ, Leonetti D, Kahn SE, Austin M, Newell L, Schwartz RS, Fujimoto WY. Improvement of BMI, body composition, and body fat distribution with lifestyle modification in Japanese Americans with impaired glucose tolerance. Diabetes Care 2002;25:1504-10. PMID: 12196418.

Ma J, Yank V, Xiao L, et al. Translating the Diabetes Prevention Program lifestyle intervention for weight loss into primary care: a randomized trial. JAMA Intern Med 2013;173:113-21. PMID: 23229846.

Makrilakis K, Liatis S, Grammatikou S, Perrea D, Katsilambros N. Implementation and effectiveness of the first community lifestyle intervention programme to prevent Type 2 diabetes in Greece. The DE-PLAN study. Diabet Med 2010;27:459-65. PMID: 20536519.

Moore SM, Hardie EA, Hackworth NJ, Critchley CR, Kyrios M, Buzwell SA, Crafti NA. Can the onset of type 2 diabetes be delayed by a group-based lifestyle intervention? A randomised control trial. Psych Health 2011;26:485-99. PMID: 20945253.

Nilsen V, Bakke PS, Gallefoss F. Effects of lifestyle intervention in persons at risk for type 2 diabetes mellitus – results from a randomised, controlled trial. BMC Public Health 2011;11:893. PMID: 22117618.

Ockene IS, Tellez TL, Rosal MC, Reed GW, Mordes J, Merriam PA, Olendzki BC, Handelman G, Nicolosi R, Ma Y. Outcomes of a Latino community-based intervention for the prevention of diabetes: the Lawrence Latino Diabetes Prevention Project. Am J Publ Health 2012;102:336-42. PMID: 22390448.

Oldroyd JC, Unwin NC, White M, Mathers JC, Alberti KG. Randomised controlled trial evaluating lifestyle interventions in people with impaired glucose tolerance. Diab Res Clin Pract 2006;72:117-27. PMID: 16297488.

Pan XR, Li GW, Hu YH, Wang JX, Yang WY, An ZX, Hu ZX, Lin J, Xiao JZ, Cao HB, Liu PA, Jiang XG, Jiang YY, Wang JP, Zheng H, Zhang H, Bennett PH, Howard BV. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study. Diabetes Care 1997;20:537-44. PMID: 9096977.

Patrick K, Norman GJ, Davila EP et al. Outcomes of a 12-month technology-based intervention to promote weight loss in adolescents at risk for type 2 diabetes. J Diab Sci Tech 2013;7:759-70. PMID: 23759410.

Penn L, Ryan V, White M. Feasibility, acceptability and outcomes at a 12-month follow-up of a novel community-based intervention to prevent type 2 diabetes in adults at high risk: mixed methods pilot study. BMJ Open 2013;3:e003585. PMID: 24227871.

Penn L, White M, Oldroyd J, Walker M, Alberti KG, Mathers JC. Prevention of type 2 diabetes in adults with impaired glucose tolerance: the European Diabetes Prevention RCT in Newcastle upon Tyne, UK. BMC Public Health 2009;9:342. PMID: 19758428.

Ramachandran A, Snehalatha C, Mary S, Mukesh B, Bhaskar AD, Vijay V, Indian Diabetes Prevention Program. The Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1). Diabetologia 2006;49:289-97. PMID: 16391903.

Ramachandran A, Snehalatha C, Mary S, Selvam S, Kumar CK, Seeli AC, Shetty AS. Pioglitazone does not enhance the effectiveness of lifestyle modification in preventing conversion of impaired glucose tolerance to diabetes in Asian Indians: results of the Indian Diabetes Prevention Programme-2 (IDPP-2). Diabetologia 2009;52:1019-26. PMID: 19277602.

Ramachandran A, Snehalatha C, Ram J, et al. Effectiveness of mobile phone messaging in prevention of type 2 diabetes by lifestyle modification in men in India: a prospective, parallel-group, randomised controlled trial. Lancet Diabetes Endocrinol 2013;1:191-8. PMID: 24622367.

Rautio N, Jokelainen J, Oksa H, et al. FIN-D2D Study Group. Socioeconomic position and effectiveness of lifestyle intervention in prevention of type 2 diabetes: one-year follow-up of the FIN-D2D project. Scand J Public Health 2011;39:561-70. PMID: 21622677.

Roumen C, Corpeleijn E, Feskens EJ, Mensink M, Saris WH, Blaak EE. Impact of 3-year lifestyle intervention on postprandial glucose metabolism: the SLIM study. Diabet Med 2008;25:597-605. PMID: 18445174.

Saito T, Watanabe M, Nishida J, Izumi T, Omura M, Takagi T, Fukunaga R, Bandai Y, Tajima N, Nakamura Y, Ito M, Zensharen Study for Prevention of Lifestyle Diseases Group. Lifestyle modification and prevention of type 2 diabetes in overweight Japanese with impaired fasting glucose levels: a randomized controlled trial. Arch Intern Med 2011;171:1352-60. PMID: 21824948.

Sakane N, Sato J, Tsushita K, Tsujii S, Kotani K, Tsuzaki K, Tominaga M, Kawazu S, Sato Y, Usui T, Kamae I, Yoshida T, Kiyohara Y, Sato S, Kuzuya H, Japan Diabetes Prevention Program (JDPP) Research Group. Prevention of type 2 diabetes in a primary healthcare setting: three-year results of lifestyle intervention in Japanese subjects with impaired glucose tolerance. BMC Public Health 2011;11:40. PMID: 21235825.

Savoye M, Caprio S, Dziura J, et al. Reversal of early abnormalities in glucose metabolism in obese youth: results of an intensive lifestyle randomized controlled trial. Diab Care 2014;37:317-24. PMID: 24062325.

Sepah SC, Jiang L, Peters AL. Translating the Diabetes Prevention Program into an Online Social Network: Validation against CDC Standards. Diab Educ 2014;40:435-43. PMID: 24723130.

Swanson CM, Bersoux S, Larson MH, et al. An outpatient-based clinical program for diabetes prevention: an update. Endo Pract 2012;18:200-8. PMID: 22068253.

Tate DF, Jackvony EH, Wing RR. Effects of Internet behavioral counseling on weight loss in adults at risk for type 2 diabetes: a randomized trial. JAMA 2003;289:1833-6. PMID: 12684363.

Tuomilehto J, Lindstr m J, Eriksson JG, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001;344:1343-50. PMID: 11333990.

Vanderwood KK, Hall TO, Harwell TS, Butcher MK, Helgerson SD, Montana Cardiovascular Disease and Diabetes Prevention Program Workgroup. Implementing a state-based cardiovascular disease and diabetes prevention program. Diab Care 2010;33:2543-5. PMID: 20805260.

Vermunt PW, Milder IE, Wielaard F, de Vries JH, van Oers HA, Westert GP. Lifestyle counseling for type 2 diabetes risk reduction in Dutch primary care: results of the APHRODITE study after 0.5 and 1.5 years. Diab Care 2011;34:1919-25. PMID: 21775759.

Vojta D, Koehler TB, Longjohn M, Lever JA, Caputo NF. A coordinated national model for diabetes prevention: linking health systems to an evidence-based community program. Am J Prev Med 2013;44:Suppl-6. PMID: 23498291.

Weinstock RS, Trief PM, Cibula D, Morin PC, Delahanty LM. Weight loss success in metabolic syndrome by telephone interventions: results from the SHINE Study. J Gen Intern Med 2013;28:1620-8. PMID: 23843020.

Additional References Linked to Included Studies

The articles are listed in order of the primary studies indicated in square brackets.

[Absetz 2007] Absetz P, Oldenburg B, Hankonen N, Valve R, Heinonen H, Nissinen A, et al. Type 2 diabetes prevention in the real world: three-year results of the GOAL lifestyle implementation trial. Diabetes Care 2009;32:1418-20. PMID: 19401442.

[Admiraal 2013] Hosper K, Deutekom M, Stronks K. The effectiveness of “Exercise on Prescription” in stimulating physical activity among women in ethnic minority groups in the Netherlands: protocol for a randomized controlled trial. BMC Public Health 2008;8:406. PMID: 19077190.

[Admiraal 2013] Vlaar EM, van Valkengoed IG, Nierkens V, Nicolaou M, Middelkoop BJ, Stronks K. Feasibility and effectiveness of a targeted diabetes prevention program for 18 to 60-year-old South Asian migrants: design and methods of the DH!AAN study. BMC Public Health 2012;12:371. PMID: 22621376.

[Eriksson 1991] Eriksson KF, Lindg rde F. No excess 12-year mortality in men with impaired glucose tolerance who participated in the Malm Preventive Trial with diet and exercise. Diabetologia 1998;41:1010-6. PMID: 9754818.

[Gagnon 2011] Bouchard DR, Baillargeon JP, Gagnon C, Brown C, Langlois MF. Impact of health professionals’ contact frequency on response to a lifestyle intervention with individuals at high risk for diabetes. Diabetes Res Clin Pract 2012;96:129-34. PMID: 22245692.

[Katula 2011] Katula JA, Vitolins MZ, Morgan TM, Lawlor MS, Blackwell CS, Isom SP, et al. The Healthy Living Partnerships to Prevent Diabetes study: 2-year outcomes of a randomized controlled trial. Am J Prev Med 2013;44:S324-32. PMID: 23498294.

[Knowler 2002] Crandall J, Schade D, Ma Y, Fujimoto WY, Barrett-Connor E, Fowler S, et al; Diabetes Prevention Program Research Group. The influence of age on the effects of lifestyle modification and metformin in prevention of diabetes. J Gerontol A Biol Sci Med Sci 2006;61:1075-81. PMID: 17077202.

[Knowler 2002] Delahanty LM, Peyrot M, Shrader PJ, Williamson DA, Meigs JB, Nathan DM; DPP Research Group. Pretreatment, psychological, and behavioral predictors of weight outcomes among lifestyle intervention participants in the Diabetes Prevention Program (DPP). Diabetes Care 2013;36:34-40. PMID: 23129133.

[Knowler 2002] Haffner S, Temprosa M, Crandall J, Fowler S, Goldberg R, Horton E, et al; Diabetes Prevention Program Research Group. Intensive lifestyle intervention or metformin on inflammation and coagulation in participants with impaired glucose tolerance. Diabetes 2005;54:1566-72. PMID: 15855347.

[Knowler 2002] Perreault L, Kahn SE, Christophi CA, Knowler WC, Hamman RF; Diabetes Prevention Program Research Group. Regression from pre-diabetes to normal glucose regulation in the diabetes prevention program. Diabetes Care 2009;32:1583-8. PMID: 19587364.

[Knowler 2002] Perreault L, Ma Y, Dagogo-Jack S, Horton E, Marrero D, Crandall J, et al; Diabetes Prevention Program. Sex differences in diabetes risk and the effect of intensive lifestyle modification in the Diabetes Prevention Program. Diabetes Care 2008;31:1416-21. PMID: 18356403.

[Knowler 2002] Ratner R, Goldberg R, Haffner S, Marcovina S, Orchard T, Fowler S, et al; Diabetes Prevention Program Research Group. Impact of intensive lifestyle and metformin therapy on cardiovascular disease risk factors in the diabetes prevention program. Diabetes Care 2005;28:888-94. PMID: 15793191.

[Knowler 2002] The Diabetes Prevention Program. Design and methods for a clinical trial in the prevention of type 2 diabetes. Diabetes Care 1999;22:623-34. PMID: 10189543.

[Knowler 2002] West DS, Elaine Prewitt T, Bursac Z, Felix HC. Weight loss of black, white, and Hispanic men and women in the Diabetes Prevention Program. Obesity (Silver Spring) 2008;16:1413-20. PMID: 18421273.

[Knowler 2002] Wing RR, Hamman RF, Bray GA, Delahanty L, Edelstein SL, Hill JO, et al; Diabetes Prevention Program Research Group. Achieving weight and activity goals among diabetes prevention program lifestyle participants. Obes Res 2004;12:1426-34. PMID: 15483207.

[Knowler 2009] Diabetes Prevention Program Research Group. HbA1c as a predictor of diabetes and as an outcome in the Diabetes Prevention Program: a randomized clinical trial. Diabetes Care 2015;38:51-8. PMID: 25336746.

[Knowler 2009] Orchard TJ, Temprosa M, Barrett-Connor E, Fowler SE, Goldberg RB, Mather KJ, et al; Diabetes Prevention Program Outcomes Study Research Group. Long-term effects of the Diabetes Prevention Program interventions on cardiovascular risk factors: a report from the DPP Outcomes Study. Diabet Med 2013;30:46-55. PMID: 22812594.

[Knowler 2009] Perreault L, Pan Q, Mather KJ, Watson KE, Hamman RF, Kahn SE; Diabetes Prevention Program Research Group. Effect of regression from prediabetes to normal glucose regulation on long-term reduction in diabetes risk: results from the Diabetes Prevention Program Outcomes Study. Lancet 2012;379:2243-51. PMID: 22683134.

[Liao 2002] Carr DB, Utzschneider KM, Boyko EJ, Asberry PJ, Hull RL, Kodama K, et al. A reduced-fat diet and aerobic exercise in Japanese Americans with impaired glucose tolerance decreases intra-abdominal fat and improves insulin sensitivity but not beta-cell function. Diabetes 2005;54:340-7. PMID: 15677490.

[Ma 2013] Azar KM, Xiao L, Ma J. Baseline obesity status modifies effectiveness of adapted diabetes prevention program lifestyle interventions for weight management in primary care. Biomed Res Int 2013;2013:191209. PMID: 24369008.

[Ma 2013] Xiao L, Yank V, Wilson SR, Lavori PW, Ma J. Two-year weight-loss maintenance in primary care-based Diabetes Prevention Program lifestyle interventions. Nutr Diabetes 2013;3:e76. PMID: 23797383.

[Makrilakis 2010] Makrilakis K, Grammatikou S, Liatis S, Kontogianni M, Perrea D, Dimosthenopoulos C, et al. The effect of a non-intensive community-based lifestyle intervention on the prevalence of metabolic syndrome. The DEPLAN study in Greece. Hormones (Athens) 2012;11:316-24. PMID: 22908064.

[Moore 2011] Critchley CR, Hardie EA, Moore SM. Examining the psychological pathways to behavior change in a group-based lifestyle program to prevent type 2 diabetes. Diabetes Care 2012;35:699-705. PMID: 22338102.

[Ockene 2012] Merriam PA, Tellez TL, Rosal MC, Olendzki BC, Ma Y, Pagoto SL, et al. Methodology of a diabetes prevention translational research project utilizing a community-academic partnership for implementation in an underserved Latino community. BMC Med Res Methodol 2009;9:20. PMID: 19284663.

[Oldroyd 2006] Oldroyd JC, Unwin NC, White M, Imrie K, Mathers JC, Alberti KG. Randomised controlled trial evaluating the effectiveness of behavioural interventions to modify cardiovascular risk factors in men and women with impaired glucose tolerance: outcomes at 6 months. Diabetes Res Clin Pract 2001;52:29-43. PMID: 11182214.

[Pan 1997] Gong Q, Gregg EW, Wang J, An Y, Zhang P, Yang W, et al. Long-term effects of a randomised trial of a 6-year lifestyle intervention in impaired glucose tolerance on diabetes-related microvascular complications: the China Da Qing Diabetes Prevention Outcome Study. Diabetologia 2011;54:300-7. PMID: 21046360.

[Pan 1997] Li G, Zhang P, Wang J, An Y, Gong Q, Gregg EW, et al. Cardiovascular mortality, all-cause mortality, and diabetes incidence after lifestyle intervention for people with impaired glucose tolerance in the Da Qing Diabetes Prevention Study: a 23-year follow-up study. Lancet Diabetes Endocrinol 2014;2:474-80. PMID: 24731674.

[Pan 1997] Li G, Zhang P, Wang J, Gregg EW, Yang W, Gong Q, et al. The long-term effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a 20-year follow-up study. Lancet 2008;371:1783-9. PMID: 18502303.

[Penn 2009] Penn L, White M, Lindstr m J, den Boer AT, Blaak E, Eriksson JG, et al. Importance of weight loss maintenance and risk prediction in the prevention of type 2 diabetes: analysis of European Diabetes Prevention Study RCT. PLoS One 2013;8:e57143. PMID: 23451166.

[Ramachandran 2006] Ramachandran A, Arun N, Shetty AS, Snehalatha C. Efficacy of primary prevention interventions when fasting and postglucose dysglycemia coexist: analysis of the Indian Diabetes Prevention Programmes (IDPP-1 and IDPP-2). Diabetes Care 2010;33:2164-8. PMID: 20519663.

[Ramachandran 2006] Snehalatha C, Mary S, Selvam S, Sathish Kumar CK, Shetty SB, Nanditha A, et al. Changes in insulin secretion and insulin sensitivity in relation to the glycemic outcomes in subjects with impaired glucose tolerance in the Indian Diabetes Prevention Programme-1 (IDPP-1). Diabetes Care 2009;32:1796-801. PMID: 19587369.

[Rautio 2011] Rautio N, Jokelainen J, Oksa H, Saaristo T, Moilanen L, Vanhala M, et al. Do depressive symptoms have an impact on the effectiveness of lifestyle counseling in prevention of type 2 diabetes? One-year follow-up of FIN-D2D. Prim Care Diabetes 2014;8:43-7. PMID: 24238822.

[Rautio 2011] Rautio N, Jokelainen J, Oksa H, Saaristo T, Peltonen M, Niskanen L, et al. Participation, socioeconomic status and group or individual counselling intervention in individuals at high risk for type 2 diabetes: one-year follow-up study of the FIN-D2D-project. Prim Care Diabetes 2012;6:277-83. PMID: 22868007.

[Rautio 2011] Rautio N, Jokelainen J, Oksa H, Saaristo T, Peltonen M, Puolijoki H, et al. Family history of diabetes and effectiveness of lifestyle counselling on the cardio-metabolic risk profile in individuals at high risk of type 2 diabetes: 1-year follow-up of the FIN-D2D project. Diabet Med 2012;29:207-11. PMID: 21781153.

[Rautio 2011] Rautio N, Jokelainen J, Saaristo T, Oksa H, Kein nen-Kiukaanniemi S, Peltonen M, et al; FIN-D2D Writing Group. Predictors of success of a lifestyle intervention in relation to weight loss and improvement in glucose tolerance among individuals at high risk for type 2 diabetes: the FIN-D2D project. J Prim Care Community Health 2013;4:59-66. PMID: 23799691.

[Rautio 2011] Saaristo T, Moilanen L, Korpi-Hy v lti E, Vanhala M, Saltevo J, Niskanen L, et al. Lifestyle intervention for prevention of type 2 diabetes in primary health care: one-year follow-up of the Finnish National Diabetes Prevention Program (FIN-D2D). Diabetes Care 2010;33:2146-51. PMID: 20664020.

[Roumen 2008] den Boer AT, Herraets IJ, Stegen J, Roumen C, Corpeleijn E, Schaper NC, et al. Prevention of the metabolic syndrome in IGT subjects in a lifestyle intervention: results from the SLIM study. Nutr Metab Cardiovasc Dis 2013;23:1147-53. PMID: 23462149.

[Roumen 2008] Roumen C, Feskens EJ, Corpeleijn E, Mensink M, Saris WH, Blaak EE. Predictors of lifestyle intervention outcome and dropout: the SLIM study. Eur J Clin Nutr 2011;65:1141-7. PMID: 21587283.

[Sakane 2011] Sakane N, Sato J, Tsushita K, Tsujii S, Kotani K, Tominaga M, et al; Japan Diabetes Prevention Program (JDPP) Research Group. Effect of baseline HbA1c level on the development of diabetes by lifestyle intervention in primary healthcare settings: insights from subanalysis of the Japan Diabetes Prevention Program. BMJ Open Diabetes Res Care 2014;2:e000003. PMID: 25452854.

[Tuomilehto 2001] Eriksson J, Lindstr m J, Valle T, Aunola S, H m l inen H, Ilanne-Parikka P, et al. Prevention of type II diabetes in subjects with impaired glucose tolerance: the Diabetes Prevention Study (DPS) in Finland. Study design and 1-year interim report on the feasibility of the lifestyle intervention programme. Diabetologia 1999;42:793-801. PMID: 10440120.

[Tuomilehto 2001] Ilanne-Parikka P, Eriksson JG, Lindstr m J, Peltonen M, Aunola S, H m l inen H, et al; Finnish Diabetes Prevention Study Group. Effect of lifestyle intervention on the occurrence of metabolic syndrome and its components in the Finnish Diabetes Prevention Study. Diabetes Care 2008;31:805-7. PMID: 18184907.

[Tuomilehto 2001] Lindstr m J, Eriksson JG, Valle TT, Aunola S, Cepaitis Z, Hakum ki M, et al. Prevention of diabetes mellitus in subjects with impaired glucose tolerance in the Finnish Diabetes Prevention Study: results from a randomized clinical trial. J Am Soc Nephrol 2003;14:S108-13. PMID: 12819313.

[Tuomilehto 2001] Lindstr m J, Ilanne-Parikka P, Peltonen M, Aunola S, Eriksson JG, Hemi K, et al; Finnish Diabetes Prevention Study Group. Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. Lancet 2006;368:1673-9. PMID: 17098085.

[Tuomilehto 2001] Lindstr m J, Louheranta A, Mannelin M, Rastas M, Salminen V, Eriksson J, et al; Finnish Diabetes Prevention Study Group. The Finnish Diabetes Prevention Study (DPS): lifestyle intervention and 3-year results on diet and physical activity. Diabetes Care 2003;26:3230-6. PMID: 14633807.

[Tuomilehto 2001] Lindstr m J, Peltonen M, Eriksson JG, Aunola S, H m l inen H, Ilanne-Parikka P, et al; Finnish Diabetes Prevention Study (DPS) Group. Determinants for the effectiveness of lifestyle intervention in the Finnish Diabetes Prevention Study. Diabetes Care 2008;31:857-62. PMID: 18252900.

[Tuomilehto 2001] Lindstr m J, Peltonen M, Eriksson JG, Ilanne-Parikka P, Aunola S, Kein nen-Kiukaanniemi S, et al; Finnish Diabetes Prevention Study (DPS). Improved lifestyle and decreased diabetes risk over 13 years: long-term follow-up of the randomised Finnish Diabetes Prevention Study (DPS). Diabetologia 2013;56:284-93. PMID: 23093136.

[Tuomilehto 2001] Uusitupa M, Peltonen M, Lindstr m J, Aunola S, Ilanne-Parikka P, Kein nen-Kiukaanniemi S, et al; Finnish Diabetes Prevention Study Group. Ten-year mortality and cardiovascular morbidity in the Finnish Diabetes Prevention Study secondary analysis of the randomized trial. PLoS One 2009;4:e5656. PMID: 19479072.

[Tuomilehto 2001] Uusitupa MI, Stanc kov A, Peltonen M, Eriksson JG, Lindstr m J, Aunola S, et al. Impact of positive family history and genetic risk variants on the incidence of diabetes: the Finnish Diabetes Prevention Study. Diabetes Care 2011;34:418-23. PMID: 20980412.

[Tuomilehto 2001] Wikstr m K, Peltonen M, Eriksson JG, Aunola S, Ilanne-Parikka P, Kein nen-Kiukaanniemi S, et al. Educational attainment and effectiveness of lifestyle intervention in the Finnish Diabetes Prevention Study. Diabetes Res Clin Pract 2009;86:e1-5. PMID: 19592125.

[Vermunt 2011] Vermunt PW, Milder IE, Wielaard F, de Vries JH, Baan CA, van Oers JA, et al. A lifestyle intervention to reduce type 2 diabetes risk in Dutch primary care: 2.5-year results of a randomized controlled trial. Diabet Med 2012;29:e223-31. PMID: 22416789.

[Weinstock 2013] Trief PM, Cibula D, Delahanty LM, Weinstock RS. Depression, stress, and weight loss in individuals with metabolic syndrome in SHINE, a DPP translation study. Obesity (Silver Spring) 2014;22:2532-8. PMID: 25251749.

Study Excluded Due to Limited Quality of Execution (1 study)

Alibasic E, Ramic E, Alic A. Prevention of diabetes in family medicine. Materia Sociomedica 2013;25:80-2. PMID: 24082827.

Economic Review

Studies Providing Information on Program Costs Only

Kramer MK, Kriska AM, Venditti EM, Miller RG, Brooks MM, Burke LE, Siminerio LM, Solano FX, Orchard TJ. Translating the Diabetes Prevention Program: a comprehensive model for preventing training and program delivery. Am J Prev Med 2009;37(6):505-11.

Kramer MK, McWilliams JR, Chen HY, Siminerio LM. A community-based diabetes prevention program: evaluation of the group lifestyle balance program delivered by diabetes educators. Diabetes Educ 2011;37(5):659-68.

Krukowski RA, Pope RA, Love S, Lensing S, Felix HC, Prewitt TE, West D. Examination of costs for a lay health educator-delivered translation of the Diabetes Prevention Program in senior centers. Prev Med 2013;57(4):400-2.

Lawlor MS, Blackwell CS, Isom SP, Katula JA, Vitolins MZ, Morgan TM, Goff DC Jr. Cost of a group translation of the Diabetes Prevention Program: Healthy Living Partnerships to Prevent Diabetes. Am J Prev Med 2013;44(4 Suppl 4):S381-9.

Ockene IS, Tellez TL, Rosal MC, Reed GW, Mordes J, Merriam PA, Olendzki BC, Handelman G, Nicolosi R, Ma Y. Outcomes of a Latino community-based intervention for the prevention of diabetes: the Lawrence Latino Diabetes Prevention Project. Am J Public Health 2012;102(2):336-42.

Vadheim LM, Brewer KA, Kassner DR, Vanderwood KK, Hall TO, Butcher MK, Helgerson SD, Harwell TS. Effectiveness of a lifestyle intervention program among persons at high risk for cardiovascular disease and diabetes in a rural community. J Rural Health 2010;26(3):266-72.

Studies Providing Assessments of Cost-Effectiveness

Studies Evaluating Economic Outcomes Based on Within-Trial Data

Diabetes Prevention Program Research Group. Within-trial cost-effectiveness of lifestyle intervention or metformin for the primary prevention of type 2 diabetes. Diabetes Care 2003;26(9):2518-23.

Diabetes Prevention Program Research Group. The 10-year cost-effectiveness of lifestyle intervention or metformin for the primary prevention: an intent-to-treat analysis of the DPP/DPPOS. Diabetes 2012;35(4):723-30.

Irvine L, Barton GR, Gasper AV, Murray N, Clark A, Scarpello T, Sampson M. Cost-effectiveness of a lifestyle intervention in preventing Type 2 diabetes. Int J Technol Assess Health Care 2011;27(4):275-82.

Sagarra R, Costa B, Cabre JJ, Sola-Morales O, Barrio F, Grp Invest D-P-CP. Lifestyle interventions for diabetes mellitus type 2 prevention. Revista Clinica Espanola 2014;214(2):59-68.

Studies Modeling Long-Term Economic Outcomes Based on Trial Data

Ackermann RT, Marrero DG, Hicks KA, Hoerger TJ, Sorensen S, Zhang P, Engelgau MM, Ratner RE, Herman WH. An evaluation of cost sharing to finance a diet and physical activity intervention to prevent diabetes. Diabetes Care 2006;29(6):1237-41.

Bertram MY, Lim SS, Barendregt JJ, Vos T. Assessing the cost-effectiveness of drug and lifestyle intervention following opportunistic screening for pre-diabetes in primary care. Diabetologia 2010;53(5):875-81.

Caro JJ, Getsios D, Caro I, Klittich WS, O’Brien JA. Economic evaluation of therapeutic interventions to prevent Type 2 diabetes in Canada. Diabet Med 2004;21(11):1229-36.

Eddy DM, Schlessinger L, Kahn R. Clinical outcomes and cost-effectiveness of strategies for managing people at high risk for diabetes. Ann Intern Med 2005;143(4):251-64.

Feldman I, Hellstr m L, Johansson P. Heterogeneity in cost-effectiveness of lifestyle counseling for metabolic syndrome risk groups -primary care patients in Sweden. Cost Eff Resour Alloc 2013;11(1):19.

Gillies CL, Lambert PC, Abrams KR, Sutton AJ, Cooper NJ, Hsu RT, Davies MJ, Khunti K. Different strategies for screening and prevention of type 2 diabetes in adults: cost effectiveness analysis. BMJ 2008;336(7654):1180-5.

Herman WH, Hoerger TJ, Brandle M, Hicks K, Sorensen S, Zhang P, Hamman RF, Ackermann RT, Engelgau MM, Ratner RE; Diabetes Prevention Program Research Group. The cost-effectiveness of lifestyle modification or metformin in preventing type 2 diabetes in adults with impaired glucose tolerance [see comment]. Ann Intern Med 2005;142(5):323-32.

Hoerger TJ, Hicks KA, Sorensen SW, Herman WH, Ratner RE, Ackermann RT, Zhang P, Engelgau MM. Cost-effectiveness of screening for pre-diabetes among overweight and obese U.S. adults. Diabetes Care 2007;30(11):2874-9. [Epub 2007 Aug 13]

Jacobs-van der Bruggen MA, Bos G, Bemelmans WJ, Hoogenveen RT, Vijgen SM, Baan CA. Lifestyle interventions are cost-effective in people with different levels of diabetes risk: results from a modeling study. Diabetes Care 2007;30(1):128-34.

Lindgren P, Lindstr m J, Tuomilehto J, Uusitupa M, Peltonen M, J nsson B, de Faire U, Hell nius ML; DPS Study Group. Lifestyle intervention to prevent diabetes in men and women with impaired glucose tolerance is cost-effective. Int J Technol Assess Health Care 2007;23(2):177-83.

Neumann A, Schwarz P, Lindholm L. Estimating the cost-effectiveness of lifestyle intervention programmes to prevent diabetes based on an example from Germany: Markov modelling. Cost Eff Resour Alloc. 2011;9(1):17.

Palmer AJ, Roze S, Valentine WJ, Spinas GA, Shaw JE, Zimmet PZ. Intensive lifestyle changes or metformin in patients with impaired glucose tolerance: modeling the long-term health economic implications of the diabetes prevention program in Australia, France, Germany, Switzerland, and the United Kingdom. Clin Ther 2004;26(2):304-21.

Palmer AJ, Tucker DM. Cost and clinical implications of diabetes prevention in an Australian setting: a long-term modeling analysis. Prim Care Diabetes 2012;6(2):109-21.

Png ME, Yoong JS. Evaluating the cost-effectiveness of lifestyle modification versus metformin therapy for the prevention of diabetes in Singapore. PLoS One. 2014;9(9):e107225.

Segal L, Dalton AC, Richardson J. Cost-effectiveness of the primary prevention of non-insulin dependent diabetes mellitus. Health Promotion International 1998;13(3):197-209.

Smith KJ, Hsu HE, Roberts MS, Kramer MK, Orchard TJ, Piatt GA, Seidel MC, Zgibor JC, Bryce CL. Cost-effectiveness analysis of efforts to reduce risk of type 2 diabetes and cardiovascular disease in southwestern Pennsylvania, 2005-2007. Prev Chronic Dis 2010;7(5):A109. [Epub 2010 Aug 15]

Studies Modeling Economic Effects of Community-Based Programs Nation-Wide

Colagiuri S, Walker AE. Using an economic model of diabetes to evaluate prevention and care strategies in Australia. Health Aff (Millwood) 2008;27(1):256-68.

Zhuo X, Zhang P, Gregg EW, Barker L, Hoerger TJ, Tony Pearson-Clarke, Albright A. A nationwide community-based lifestyle program could delay or prevent type 2 diabetes cases and save $5.7 billion in 25 years. Health Aff (Millwood) 2012;31(1):50-60.

The CPSTF finding is based on evidence from a systematic review (search period 1991 February 27, 2015). The following databases were searched: Ovid Medline, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, CAB Abstracts, Global Health, and Ovid HealthStar. Reference lists of review and systematic review articles were screened and experts were solicited for additional articles.

Effectiveness Review

Search Terms

Combined database search (OVID)

1. (“pre-diabetes” or pre-diabet* or prediabet*).af.
2. exp prediabetic state/
3. (impaired and (fasting glucose or glucose tolerance)).af.
4. (impaired and fasting blood sugar).af.
5. (“diabetes risk” or (risk adj6 diabetes)).af.
6. or/1-5
7. (((behaviour or behavior) and modification) or behavior therapy or lifestyle or lifestyle intervention or healthy eating or diet or weight loss or physical activity or resistance training or exercise or life style or healthy-living).af.
8. exp diet/ or diet therapy.sh. or exp exercise/ or exp exercise therapy/ or exp lifestyle/ or exp weight loss/ or exp behavior therapy/
9. *”Diabetes Mellitus”/pc [Prevention & Control]
10. or/7-9
11. (diabetes prevention program* or diabetes prevention study*).af.
12. randomized controlled trial.pt.
13. controlled clinical trial.pt.
14. randomized controlled trials/
15. Random Allocation/
16. Double-blind Method/
17. Single-Blind Method/
18. clinical trial.pt.
19. Clinical Trials.mp. or exp Clinical Trials/
20. (clinic$ adj25 trial$).tw.
21. ((singl$ or doubl$ or trebl$ or tripl$) adj (mask$ or blind$)).tw.
22. Placebos/
23. placebo$.tw.
24. random$.tw.
25. trial$.tw.
26. (randomized control trial or clinical control trial).sd. or program evaluation.af.
27. (latin adj square).tw.
28. Comparative Study.tw. or Comparative Study.pt.
29. exp Evaluation studies/
30. Follow-Up Studies/
31. Prospective Studies/
32. (control$ or prospectiv$ or volunteer$).tw.
33. Cross-Over Studies/
34. or/12-33
35. exp cohort studies/ or exp prospective studies/ or exp retrospective studies/ or exp epidemiologic studies/ or exp case-control studies/
36. (cohort or retrospective or prospective or longitudinal or observational or follow-up or followup or registry).af.
37. case-control.af. or (case adj10 control).tw.
38. ep.fs.
39. or/35-38
40. ((6 and 10) or 11) and (34 or 39)
41. (((Non-alcoholic or nonalcoholic) and Fatty Liver Disease) or hepatitis).af.
42. 40 not 41
43. remove duplicates from 42
44. meta-analysis.pt.
45. systematic$ review$.mp. [mp=ti, ab, ot, nm, hw, ps, rs, ui, tx, kw, ct]
46. (systematic$ adj9 overview$).mp.
47. (meta-analys$ or meta analys$ or metaanalys$).mp. [mp=ti, ab, ot, nm, hw, ps, rs, ui, tx, kw, ct]
48. evidence review$.mp. [mp=ti, ab, ot, nm, hw, ps, rs, ui, tx, kw, ct]
49. or/44-48
50. “pre-diabetes”.af.
51. prediabetes.af.
52. impaired glucose tolerance.af.
53. impaired fasting glucose.af.
54. insulin resistance.af.
55. or/7-11
56. 6 and 12
57. remove duplicates from 13
58. 43 or 57

$=truncation symbol

Economic Review

The economic review is based on evidence from the Community Guide search for effectiveness evidence (search period January 1991-February 2015) and a separate focused search for economic evidence (search period January 1985-April 2015).

The focused economics search examined eight bibliographic databases: Cochrane, EMBASE, MEDLINE, PsycInfo, SocAbstracts, Web of Science, Econlit, CINAHL. In addition, reference lists of included studies were screened and subject matter experts were solicited for additional articles.

Search terms and strategies were adjusted to each database, based on controlled and uncontrolled vocabularies and search software.

Terms Defining Diabetes

1. exp diabetes mellitus/
2. diabet$.tw.
3. IDDM.tw.
4. NIDDM.tw.
5. MODY.tw.
6. (late onset adj diabet$).tw.
7. (maturity onset adj diabet$).tw.
8. (juvenil adj diabet$).tw.
9. (syndrome X and diabet$).tw.
10. hyperinsulin$.tw.
11. insulin sensitiv$.tw.
12. insulin$ secret$ dysfunc$.tw.
13. impaired glucose toleran$.tw.
14. exp glucose intolerance/
15. glucose intoleran$.tw.
16. exp insulin resistance/
17. insulin$ resist$.tw.
18. (non insulin$ depend$ or noninsulin$ depend$ or non insulin?depend$ or noninsulin?depend$).tw.
19. (insulin$ depend$ or insulin?depend$).tw.
20. metabolic$ syndrom$.tw.
21. (pluri metabolic$ syndrom$ or plurimetabolic$ syndrom$).tw.
22. ((typ$ 1 or typ$ 2) and diabet$).tw.
23. ((typ I or typ$ II) and diabet$).tw.
24. or/1-23
25. exp diabetes insipidus/
26. diabet$ insipidus.tw.
27. 25 or 26
28. 24 not 27

Terms Defining Cost

29. exp “costs and cost analysis”/
30. exp health care costs/
31. exp “cost of illness”/
32. *ECONOMICS/
33. or/29-32

Terms Defining Benefit

34. benefit.mp.
35. (cost$ or expenditure$).mp.
36. Life years.mp.
37. exp Quality-Adjusted Life Years/
38. Disability adjusted life years.mp.
39. effectiveness.mp.
40. or/34-39

Terms Defining Both Cost and Benefit

41. 33 and 40

Additional Terms Defining Cost Effectiveness Analysis or Cost-Benefit Analysis

42. exp COST-BENEFIT ANALYSIS/
43. cost-effectiveness analysis.mp.
44. Cost-utility analysis.mp.
45. Economic evaluation.mp.
46. or/42-45
47. 28 and (41 or 46)

Terms Defining Lifestyle Interventions Preventing Diabetes

48. primary prevention/
49. primary prevention.tw.
50. (reduc* adj3 risk).tw.
51. risk reduction behavior/
52. (prevent* adj3 diabet*).tw.
53. health promotion.mp.
54. diabetes mellitus/pc
55. life style/
56. lifestyle*.tw.
57. life style*.tw.
58. prediabet*.mp.
59. weight loss/
60. health education/
61. health educator*.mp.
62. patient education as topic/
63. diet/
64. exp exercise/
65. motor activity/
66. physical activity.tw.
67. walking.mp.
68. or/48-67
69. 47 and 68

Defining Searching Time Period

70. limit 69 to yr=”1985 -Current”

Deduplication of Study Results

71. remove duplicates from 70

Searches were done between January 1985 and April 2015. Last run: April 7, 2015.

American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2010;33 (Suppl 1):S62-9.

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

• In 2010, the U.S. Congress authorized CDC to establish the National Diabetes Prevention Program (National DPP), an alliance of public and private organizations (including insurers) managed by CDC to achieve wide-scale implementation and coordination of lifestyle change programs to prevent or delay type 2 diabetes. As of May 2014, more than 500 organizations in all states and the District of Columbia have applied for CDC recognition for their diabetes prevention programs. More information about the National DPP can be found at www.cdc.gov/diabetes/prevention.
• Combined diet and physical activity promotion programs have been successfully implemented by several national and state-wide organizations, the majority of which are part of the National DPP.
• Healthcare providers are usually the primary resource for individuals newly diagnosed as being at increased risk of type 2 diabetes. Providers need to know the benefits of combined diet and physical activity promotion programs and be aware of local programs, which may be offered by community centers, insurer-run programs, or non-profit or other private contractors among others.
• Organizations implementing combined diet and physical activity promotion programs may want to address factors that make it difficult for some people to participate. Examples include limited ability to pay for program services; limited time to cook or exercise due to work schedules or childcare needs; limited access to inexpensive and healthful food, safe and convenient places to exercise and transportation there; and cognitive or physical disabilities.

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Reduce the number of diabetes cases diagnosed yearly — D-01
• Increase the proportion of adults who get recommended evidence-based preventive health care — AHS-08