Diabetes Management: Intensive Lifestyle Interventions for Patients with Type 2 Diabetes

The CPSTF uses recently published systematic reviews to conduct accelerated assessments of interventions that could provide program planners and decision-makers with additional, effective options. The following published review was selected and evaluated by a team of specialists in systematic review methods, and in research, practice, and policy related to diabetes management

Huang XL, Pan JH, Chen D, Chen J, Hu TT. Efficacy of lifestyle interventions in patients with type 2 diabetes: A systematic review and meta-analysis. European Journal of Internal Medicine 2016;27;37-47.

The systematic review and meta-analysis included 17 studies (Huang et al., 2016; search period through July 15, 2014). The CPSTF finding is based on results from a subset of 7 studies that evaluated intensive physical activity programs (5 studies) and intensive dietary programs (3 studies) in addition to expert input from team members and the CPSTF. The largest and longest study (Look AHEAD trial) evaluated both intensive dietary and physical activity programs.

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

The systematic review included 7 studies. The largest and longest study (Look AHEAD trial) evaluated both intensive dietary and physical activity programs.

• Dietary Programs (3 studies)
  • Intensive dietary programs led to favorable changes in reported outcomes.
    • Body Mass Index: non-significant decrease
    • Blood glucose (A1c): significant decrease
    • Systolic blood pressure: significant decrease
    • Diastolic blood pressure: significant decrease
    • LDL cholesterol: non-significant decrease
    • HDL cholesterol: significant increase
• Physical Activity Programs (5 studies)
  • Intensive physical activity programs led to favorable changes in reported outcomes.
    • Body Mass Index: non-significant decrease
    • Blood glucose (A1c): significant decrease
    • Systolic blood pressure: non-significant decrease
    • Diastolic blood pressure: significant decrease
    • LDL cholesterol: non-significant decrease
    • HDL cholesterol: non-significant increase

Huang et al. did not consider evidence or information on the economic benefits of these interventions. An economic evaluation of the Look AHEAD trial reported lower health-care costs over 10 years.

Based on evidence from the review, the CPSTF finding is applicable to interventions offered to adults with type 2 diabetes through healthcare settings in the United States.

The 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 effectiveness vary between specific programs in different populations (e.g., by race, SES, educational attainment, age, cognitive or physical disabilities)?
• How effective are programs delivered through the internet, email, apps, or social networking?
• What is the relative effectiveness of individual and group sessions?
• What structures and systems are needed to maintain program effectiveness and help participants continue their improvements to diet and physical activity following program completion?
• What are long-term effects on participants’ glycemic control, weight loss, cardiovascular disease risk factors, morbidity, and mortality?
• What are program attrition rates? Why do participants drop out, and how can they be retained?
• Are these interventions effective with children and adolescents?

• All included studies were randomized controlled trials.
• Evaluated interventions provided a median of 11 sessions that were individual (3 studies) or a combination of individual and group sessions (4 studies).
• Studies evaluated interventions that provided patients specific, tailored instruction on lifestyle changes through multiple interactions over extended periods of time.
• Four of the programs provided additional, extended telephone contact and 2 of the programs had frequent, ongoing contact with patients through regular exercise sessions.
• The median intervention duration was 12 months. All 7 studies established clear goals for patients’ dietary changes (3 studies), physical activity levels (5 studies), or weight loss (2 studies).

No content is available for this section.

A summary evidence table for this Community Guide review is not available because the CPSTF finding is based on the following published systematic review:

Huang XL, Pan JH, Chen D, Chen J, Hu TT. Efficacy of lifestyle interventions in patients with type 2 diabetes: A systematic review and meta-analysis. European Journal of Internal Medicine 2016;27;37-47.

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

Studies from Huang et al. (2016) Included in this Review

Ali M, Schifano F, Robinson P, Phillips G, Doherty L, Melnick P, et al. Impact of community pharmacy diabetes monitoring and education programme on diabetes management: a randomized controlled study. Diabet Med 2012;29(9):e326 33.

Balducci S, Zanuso S, Nicolucci A, De Feo P, Cavallo S, Cardelli P, et al. Effect of an intensive exercise intervention strategy on modifiable cardiovascular risk factors in subjects with type 2 diabetes mellitus: a randomized controlled trial: the Italian Diabetes and Exercise Study (IDES). Arch Intern Med 2010;170:1794 803.

Chan CW, Siu SC, Wong CK, Lee VW. A pharmacist care program: positive impact on cardiac risk in patients with type 2 diabetes. J Cardiovasc Pharmacol Ther 2012;17:57 64.

Coppell KJ, KataokaM, Williams SM, Chisholm AW, Vorgers SM, Mann JI. Nutritional intervention in patients with type 2 diabetes who are hyperglycaemic despite optimised drug treatment Lifestyle Over and Above Drugs in Diabetes (LOADD) study: randomised controlled trial. BMJ 2010;341:c3337.

Crasto W, Jarvis J, Khunti K, Skinner TC, Gray LJ, Brela J, et al. Multifactorial intervention in individuals with type 2 diabetes and microalbuminuria: the Microalbuminuria Education and Medication Optimisation (MEMO) study. Diabetes Res Clin Pract 2011;93: 328 36.

Dobrosielski DA, Gibbs BB, Ouyang P, Bonekamp S, Clark JM,Wang NY, et al. Effect of exercise on blood pressure in type 2 diabetes: a randomized controlled trial. J Gen Intern Med 2012;27:1453 9.

Ko GT, Li JK, Kan EC, LoMK. Effects of a structured health education programme by a diabetic education nurse on cardiovascular risk factors in Chinese type 2 diabetic patients: a 1-year prospective randomized study. Diabet Med 2004;21:1274 9.

Kirk A, Mutrie N, MacIntyre P, Fisher M. Effects of a 12-month physical activity counselling intervention on glycaemic control and on the status of cardiovascular risk factors in people with type 2 diabetes. Diabetologia 2004;47:821 32.

Krein SL, Klamerus ML, Vijan S, Lee JL, Fitzgerald JT, Pawlow A, et al. Case management for patients with poorly controlled diabetes: a randomized trial. Am J Med 2004;116:732 9.

Look ARG, Wing RR. Long-term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus: four-year results of the Look AHEAD trial. Arch Intern Med 2010;170:1566 75.

Mohamed H, Al-Lenjawi B, Amuna P, Zotor F, Elmahdi H. Culturally sensitive patient-centred educational programme for self-management of type 2 diabetes: a randomized controlled trial. Prim Care Diabetes 2013;7:199 206.

Salinero-Fort MA, Carrillo-de Santa Pau E, Arrieta-Blanco FJ, Abanades-Herranz JC, Martin-Madrazo C, Rodes-Soldevila B, et al. Effectiveness of PRECEDE model for health education on changes and level of control of HbA1c, blood pressure, lipids, and body mass index in patients with type 2 diabetes mellitus. BMC Public Health 2011;11:267.

Sevick MA, Korytkowski M, Stone RA, Piraino B, Ren D, Sereika S, et al. Biophysiologic outcomes of the Enhancing Adherence in Type 2 Diabetes (ENHANCE) trial. J Acad Nutr Diet 2012;112:1147 57.

Sone H, Tanaka S, Iimuro S, Tanaka S, Oida K, Yamasaki Y, et al. Long-term lifestyle intervention lowers the incidence of stroke in Japanese patients with type 2 diabetes: a nationwide multicentre randomised controlled trial (the Japan Diabetes Complications Study). Diabetologia 2010;53:419 28.

Trento M, Passera P, Bajardi M, Tomalino M, Grassi G, Borgo E, et al. Lifestyle intervention by group care prevents deterioration of type II diabetes: a 4-year randomized controlled clinical trial. Diabetologia 2002;45:1231 9.

Uusitupa M, Laitinen J, Siitonen O, Vanninen E, Pyorala K. The maintenance of improved metabolic control after intensified diet therapy in recent type 2 diabetes. Diabetes Res Clin Pract 1993;19:227 38.

Wisse W, Boer Rookhuizen M, de Kruif MD, van Rossum J, Jordans I, ten Cate H, et al. Prescription of physical activity is not sufficient to change sedentary behavior and improve glycemic control in type 2 diabetes patients. Diabetes Res Clin Pract 2010;88:e10 3.

Refer to the existing systematic review for information about the search strategy:

Huang XL, Pan JH, Chen D, Chen J, Hu TT. Efficacy of lifestyle interventions in patients with type 2 diabetes: A systematic review and meta-analysis. European Journal of Internal Medicine 2016;27;37-47.

Huang XL, Pan JH, Chen D, Chen J, Hu TT. Efficacy of lifestyle interventions in patients with type 2 diabetes: A systematic review and meta-analysis. European Journal of Internal Medicine 2016;27;37-47.

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

The U.S. Preventive Services Task Force (USPSTF) issued the following in 2015:

The U.S. Preventive Services Task Force recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 years who are overweight or obese. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity. (B recommendation: October 2015)

• This recommendation will likely increase demand for early intervention to support patients in making lifestyle changes and adopting long-term self-management behaviors.
• Close coordination between healthcare systems, healthcare providers, and community-based programs will likely be an essential element of sustainable community-based services.
  • Healthcare coverage for preventive services recommended by the USPSTF will likely be an important source of funding for community-based programs once barriers to billing and reimbursement are addressed.
  • Patients with, or at increased risk for, cardiovascular disease may need pre-intervention assessments before initiating changes in physical activity, diet, and weight management.
  • Patients will need regular, ongoing diabetes care and medication management, which may require adjustment as lifestyle changes are adopted.
  • Participants may be at increased risk for injuries associated with changes in physical activity. This risk can be reduced if walking is emphasized as the primary mode of physical activity with gradually increasing activity levels added as tolerated.

Healthy People 2030

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

• Reduce the proportion of adults with diabetes who have an A1c value above 9 percent — D-03
• Increase the proportion of people with diabetes who get formal diabetes education — D-06