title: Prevention of type 2 diabetes in adults with impaired glucose tolerance: the European Diabetes Prevention RCT in Newcastle upon Tyne, UK The appraisal of public health interventions: the use of theory. A Pregnancy and Postpartum Lifestyle Intervention in Women With Gestational Diabetes Mellitus Reduces Diabetes Risk Factors A yoga intervention for type 2 diabetes risk reduction: a pilot randomized controlled trial The Healthy Living Partnerships to Prevent Diabetes study: 2-year outcomes of a randomized controlled trial. Effects of lifestyle intervention and meal replacement on glycaemic and body-weight control in Chinese subjects with impaired glucose regulation: a 1-year randomised controlled trial. eulerAPE: Drawing Area-Proportional 3-Venn Diagrams Using Ellipses Low glycaemic index diets improve glucose tolerance and body weight in women with previous history of gestational diabetes: a six months randomized trial Preventing type 2 diabetes after gestational diabetes: women's experiences and implications for diabetes prevention interventions. Prevention of type 2 diabetes by lifestyle intervention: a Japanese trial in IGT males. The Comparative Effectiveness of Diabetes Prevention Strategies to Reduce Postpartum Weight Retention in Women With Gestational Diabetes Mellitus: The Gestational Diabetes’ Effects on Moms (GEM) Cluster Randomized Controlled Trial A web-based pedometer programme in women with a recent history of gestational diabetes. Patient freedom to choose a weight loss diet in the treatment of overweight and obesity: a randomized dietary intervention in type 2 diabetes and pre-diabetes Challenges of diabetes prevention in the real world: results and lessons from the Melbourne Diabetes Prevention Study Reduction in Weight and Cardiovascular Disease Risk Factors in Individuals With Type 2 Diabetes Outcome of intensive integrated intervention in participants with impaired glucose regulation in China Reach and Effectiveness of a Weight Loss Intervention in Patients With Prediabetes in Colorado Effect of community-based yoga intervention on oxidative stress and glycemic parameters in prediabetes: a randomized controlled trial. A1C Cut Points to Define Various Glucose Intolerance Groups in Asian Indians Effects of telephone-delivered lifestyle support on the development of diabetes in participants at high risk of type 2 diabetes: J-DOIT1, a pragmatic cluster randomised trial Prevention of type 2 diabetes in a primary healthcare setting: Three-year results of lifestyle intervention in Japanese subjects with impaired glucose tolerance Effectiveness of a Pragmatic Education Program Designed to Promote Walking Activity in Individuals With Impaired Glucose Tolerance A Randomized Pilot Trial of a Moderate Carbohydrate Diet Compared to a Very Low Carbohydrate Diet in Overweight or Obese Individuals with Type 2 Diabetes Mellitus or Prediabetes Ten-Year Mortality and Cardiovascular Morbidity in the Finnish Diabetes Prevention Study—Secondary Analysis of the Randomized Trial 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. Supervised Exercise in Patients with Impaired Fasting Glucose: Impact on Exercise Capacity The single most important intervention to tackle obesity… Accuracy of glycated haemoglobin in screening for pre-diabetes in Asian Indians--a community survey: the Chandigarh Urban Diabetes Study (CUDS). Effect of metformin on patients with impaired glucose tolerance. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. Breast-feeding is associated with reduced postpartum maternal glucose intolerance after gestational diabetes. 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) Sensitivity and specificity of glycated hemoglobin as a diagnostic test for diabetes and prediabetes in Arabs. Short-term effectiveness of an individual counseling program for impaired fasting glucose and mild type 2 diabetes in Japan: a multi-center randomized control trial. A randomized lifestyle intervention with 5-year follow-up in subjects with impaired glucose tolerance: Pronounced short-term impact but long-term adherence problems Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study Enhanced fitness: a randomized controlled trial of the effects of home-based physical activity counseling on glycemic control in older adults with prediabetes mellitus. Can the onset of type 2 diabetes be delayed by a group-based lifestyle intervention? A randomised control trial Optimal hemoglobin A1C Cutoff Value for Diagnosing type 2 diabetes mellitus in Korean adults. Can life-styles of subjects with impaired glucose tolerance be changed? A feasibility study. Effects of Diet and Exercise in Preventing NIDDM in People With Impaired Glucose Tolerance: The Da Qing IGT and Diabetes Study The long-term effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a 20-year follow-up study Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. lmplementing lifestyle change through phone-based motivational interviewing in rural-based women with previous gestational diabetes mellitus. 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. Impact of health professionals' contact frequency on response to a lifestyle intervention with individuals at high risk for diabetes. Tianjin Gestational Diabetes Mellitus Prevention Program: study design, methods, and 1-year interim report on the feasibility of lifestyle intervention program. Prevention of type 2 diabetes - where is the evidence? Randomised controlled trial evaluating lifestyle interventions in people with impaired glucose tolerance. Lifestyle modification and prevention of type 2 diabetes in overweight Japanese with impaired fasting glucose levels: a randomized controlled trial. Diabetes mellitus and abnormal glucose tolerance development after gestational diabetes: A three-year, prospective, randomized, clinical-based, Mediterranean lifestyle interventional study with parallel groups. Effect of a continuous diabetes lifestyle intervention program on male workers in Korea.
abstract: Abstract Background Diabetes prevalence is increasing . The Finnish Diabetes Prevention Study ( DPS ) showed a 58 % reduction in Type 2 Diabetes ( T2D ) incidence in adults with impaired glucose tolerance ( IGT ) . The European Diabetes Prevention Study ( EDIPS ) extends the DPS to different European population s , using the same study design . In the Newcastle arm of this study ( EDIPS-Newcastle ) , we tested the hypothesis that T2D can be prevented by lifestyle intervention and explored secondary outcomes in relation to diabetes incidence . Methods We recruited 102 participants ( 42 men and 60 women , mean age 57 years , mean BMI 34 kgm-2 ) with IGT to EDIPS-Newcastle and r and omised to Intervention and usual care Control groups .  The intervention included individual motivational interviewing aim ed at : weight reduction , increase in physical activity , fibre and carbohydrate intake and reduction of fat intake ( secondary outcomes ) . The primary outcome was diagnosis of T2D . Results Mean duration of follow-up was 3.1 years . T2D was diagnosed in 16 participants ( I = 5 , C = 11 ) . Absolute incidence of T2D was 32.7 per 1000 person-years in the Intervention-group and 67.1 per 1000 person-years in the Control-group . The overall incidence of diabetes was reduced by 55 % in the Intervention-group , compared with the Control-group : RR 0.45 ( 95%CI 0.2 to 1.2).Explanatory survival analysis of secondary outcomes showed that those who sustained beneficial changes for two or more years reduced their risk of developing T2D . Conclusion Our results are consistent with other diabetes prevention trials . This study was design ed as part of a larger study and although the sample size limits statistical significance , the results contribute to the evidence that T2D can be prevented by lifestyle changes in adults with IGT . In explanatory analysis small sustained beneficial changes in weight , physical activity or dietary factors were associated with reduction in T2D incidence . Trial Registration International St and ard R and omised Controlled Trial Number registry ( IS RCT N)Registry number : IS RCT N 15670600 http://www.controlled-trials.com/is rct n/ search .html?srch=15670600%26sort=3%26dir = BACKGROUND Public health decision-making is hampered by inappropriate adherence to underpowered r and omized controlled trials ( RCTs ) which give inconclusive results and lead to decision-makers being loath to recommend interventions with strong theoretical and observational support . METHODS We outline situations in which robust decisions about health interventions can be made without trial evidence . We present a new approach in which theory , causal models and past observations are given proper regard in the decision-making process . RESULTS Using our approach , we provide examples where the use of causal theories and observations in areas , such as salt reduction , smoking cessation and gardening to improve mental health , is sufficient for deciding that such interventions are effective for improving health without needing the support of underpowered RCTs . Particularly where RCT evidence is inconclusive , our approach may provide similar aggregate health outcomes for society for vastly lower cost . CONCLUSIONS When knowledge and theoretical underst and ing are unable sufficiently to reduce doubt about the direction of effect from an intervention , decisions should be made using evidence -based medicine approaches . There are , however , many cases where the combination of robust theory , causal underst and ing and observation are able to provide sufficient evidence of the direction of effect from an intervention that current practice should be altered OBJECTIVE To pilot , among women with gestational diabetes mellitus ( GDM ) , the feasibility of a prenatal/postpartum intervention to modify diet and physical activity similar to the Diabetes Prevention Program . The intervention was delivered by telephone , and support for breastfeeding was addressed . RESEARCH DESIGN AND METHODS The goal was to help women return to their prepregnancy weight , if it was normal , or achieve a 5 % reduction from prepregnancy weight if overweight . Eligible participants were identified shortly after a GDM diagnosis ; 83.8 % consented to be r and omly assigned to intervention or usual medical care ( 96 and 101 women , respectively ) . The retention was 85.2 % at 12 months postpartum . RESULTS The proportion of women who reached the postpartum weight goal was higher , although not statistically significant , in the intervention condition than among usual care ( 37.5 vs. 21.4 % , absolute difference 16.1 % , P = 0.07 ) . The intervention was more effective among women who did not exceed the recommended gestational weight gain ( difference in the proportion of women meeting the weight goals : 22.5 % , P = 0.04 ) . The intervention condition decreased dietary fat intake more than the usual care ( condition difference in the mean change in percent of calories from fat : −3.6 % , P = 0.002 ) and increased breastfeeding , although not significantly ( condition difference in proportion : 15.0 % , P = 0.09 ) . No differences in postpartum physical activity were observed between conditions . CONCLUSIONS This study suggests that a lifestyle intervention that starts during pregnancy and continues postpartum is feasible and may prevent pregnancy weight retention and help overweight women lose weight . Strategies to help postpartum women overcome barriers to increasing physical activity are needed Background Type 2 diabetes is a major health problem in many countries including India .  Yoga may be an effective type 2 diabetes prevention strategy in India , particularly given its cultural familiarity . Methods This was a parallel , r and omized controlled pilot study to collect feasibility and preliminary efficacy data on yoga for diabetes risk factors among people at high risk of diabetes . Primary outcomes included : changes in BMI , waist circumference , fasting blood glucose , postpr and ial blood glucose , insulin , insulin resistance , blood pressure , and cholesterol . We also looked at measures of psychological well-being including changes in depression , anxiety , positive and negative affect and perceived stress . Forty-one participants with elevated fasting blood glucose in Bangalore , India were r and omized to either  yoga  ( n = 21 ) or a walking control ( n = 20 ) . Participants were asked to either attend yoga classes or complete monitored walking 3–6 days per week for eight weeks . R and omization and allocation was performed using computer-generated r and om numbers and group assignments delivered in sealed , opaque envelopes generated by off-site study staff . Data were analyzed based on intention to treat . Results This study was feasible in terms of recruitment , retention and adherence . In addition , yoga participants had significantly greater reductions in weight , waist circumference and BMI versus control ( weight −0.8 ± 2.1 vs. 1.4 ± 3.6 , p = 0.02 ; waist circumference −4.2 ± 4.8 vs. 0.7 ± 4.2 , p < 0.01 ; BMI −0.2 ± 0.8 vs. 0.6 ± 1.6 , p = 0.05 ) . There were no between group differences in fasting blood glucose , postpr and ial blood glucose , insulin resistance or any other factors related to diabetes risk or psychological well-being . There were significant reductions in systolic and diastolic blood pressure , total cholesterol , anxiety , depression , negative affect and perceived stress in both the yoga intervention and walking control over the course of the study . Conclusion Among Indians with elevated fasting blood glucose , we found that participation in an 8-week yoga intervention was feasible and result ed in greater weight loss and reduction in waist circumference when compared to a walking control . Yoga offers a promising lifestyle intervention for decreasing weight-related type 2 diabetes risk factors and potentially increasing psychological well-being . Trial registration Clinical Trials.gov Identified NCT00090506 BACKGROUND Since the Diabetes Prevention Project ( DPP ) demonstrated that lifestyle weight-loss interventions can reduce the incidence of diabetes by 58 % , several studies have translated the DPP methods to public health-friendly context s. Although these studies have demonstrated short-term effects , no study to date has examined the impact of a translated DPP intervention on blood glucose and adiposity beyond 12 months of follow-up . PURPOSE To examine the impact of a 24-month , community-based diabetes prevention program on fasting blood glucose , insulin , insulin resistance as well as body weight , waist circumference , and BMI in the second year of follow-up . DESIGN An RCT comparing a 24-month lifestyle weight-loss program ( LWL ) to an enhanced usual care condition ( UCC ) in participants with prediabetes ( fasting blood glucose=95 - 125 mg/dL ) . Data were collected in 2007 - 2011 ; analyses were conducted in 2011 - 2012 . SETTING / PARTICIPANTS 301 participants with prediabetes were r and omized ; 261 completed the study . The intervention was held in community-based sites . INTERVENTION The LWL program was led by community health workers and sought to induce 7 % weight loss at 6 months that would be maintained over time through decreased caloric intake and increased physical activity . The UCC received two visits with a registered dietitian and a monthly newsletter . MAIN OUTCOME MEASURES The main measures were fasting blood glucose , insulin , insulin resistance , body weight , waist circumference , and BMI . RESULTS Intent-to-treat analyses of between-group differences in the average of 18- and 24-month measures of outcomes ( controlling for baseline values ) revealed that the LWL participants experienced greater decreases in fasting glucose ( -4.35 mg/dL ) ; insulin ( -3.01 μU/ml ) ; insulin resistance ( -0.97 ) ; body weight ( -4.19 kg ) ; waist circumference ( -3.23 cm ) ; and BMI ( -1.40 ) , all p-values < 0.01 . CONCLUSIONS A diabetes prevention program administered through an existing community-based system and delivered by community health workers is effective at inducing significant long-term reductions in metabolic indicators and adiposity The purpose of the present study was to evaluate the impact of a lifestyle intervention programme , combined with a daily low-glycaemic index meal replacement , on body-weight and glycaemic control in subjects with impaired glucose regulation ( IGR ) . Subjects with IGR were r and omly assigned to an intervention group ( n 46 ) and a control group ( n 42 ) . Both groups received health counselling at baseline . The intervention group also received a daily meal replacement and intensive lifestyle intervention to promote healthy eating habits during the first 3 months of the study , and follow-up visits performed monthly until the end of the 1-year study . Outcome measurements included changes in plasma glucose , glycated Hb ( HbA1c ) , plasma lipids , body weight , blood pressure and body composition ( such as body fat mass and visceral fat area ) . The results showed that body-weight loss after 1 year was significant in the intervention group compared with the control group ( -1·8 ( SEM 0·35 ) v. -0·6 ( SEM 0·40 ) 2·5 kg , P<0·05 ) . The 2 h plasma glucose concentration decreased 1·24 mmol/l in the intervention group and increased 0·85 mmol/l in the control group ( P<0·05 ) compared with their baseline , respectively . A 5 kg body-weight loss at 1 year was associated with a decrease of 1·49 mmol/l in 2 h plasma glucose ( P<0·01 ) . The incidence of normal glucose regulation ( NGR ) in the two groups was significantly different ( P=0·001 ) . In conclusion , the combination of regular contact , lifestyle advice and meal replacement is beneficial in promoting IGR to NGR Venn  diagrams with three curves are used extensively in various medical and scientific disciplines to visualize relationships between data sets and facilitate data analysis . The area of the regions formed by the overlapping curves is often directly proportional to the cardinality of the depicted set relation or any other related quantitative data . Drawing these diagrams manually is difficult and current automatic drawing methods do not always produce appropriate diagrams . Most methods depict the data sets as circles , as they perceptually pop out as complete distinct objects due to their smoothness and regularity . However , circles can not draw accurate diagrams for most 3-set data and so the generated diagrams often have misleading region areas . Other methods use polygons to draw accurate diagrams . However , polygons are non-smooth and non-symmetric , so the curves are not easily distinguishable and the diagrams are difficult to comprehend . Ellipses are more flexible than circles and are similarly smooth , but none of the current automatic drawing methods use ellipses . We present eulerAPE as the first method and software that uses ellipses for automatically drawing accurate area-proportional Venn diagrams  for 3-set data . We describe the drawing method adopted by eulerAPE and we discuss our evaluation of the effectiveness of  eulerAPE and ellipses for drawing r and om 3-set data . We compare eulerAPE and various other methods that are currently available and we discuss differences between their generated diagrams in terms of accuracy and ease of underst and ing for real world data Background Gestational Diabetes Mellitus ( GDM ) increases risks for type 2 diabetes and weight management is recommended to reduce the risk . Conventional dietary recommendations ( energy-restricted , low fat ) have limited success in women with previous GDM . The effect of lowering Glycaemic Index ( GI ) in managing glycaemic variables and body weight in women post-GDM is unknown . Objective To evaluate the effects of conventional dietary recommendations administered with and without additional low-GI education , in the management of glucose tolerance and body weight in Asian women with previous GDM . MethodS eventy seven Asian , non-diabetic women with previous GDM , between 20- 40y were r and omised into Conventional healthy dietary recommendation ( CHDR )  and  low GI  ( LGI ) groups . CHDR received conventional dietary recommendations only ( energy restricted , low in fat and refined sugars , high-fibre ) . LGI group received advice on lowering GI in addition . Fasting and 2-h post-load blood glucose after 75 g oral glucose tolerance test ( 2HPP ) were measured at baseline and 6 months after intervention . Anthropometry and dietary intake were assessed at baseline , three and six months after intervention . The study is registered at the Malaysian National Medical Research Register ( NMRR ) with Research ID : 5183 . Results After 6 months , significant reductions in body weight , BMI and waist-to-hip ratio were observed only in LGI group ( P<0.05 ) . Mean BMI changes were significantly different between groups ( LGI vs. CHDR : -0.6 vs. 0 kg/m2 , P= 0.03 ) . More subjects achieved weight loss ≥5 % in LGI compared to CHDR group ( 33 % vs. 8 % , P=0.01 ) . Changes in 2HPP were significantly different between groups ( LGI vs. CHDR : median ( IQR ) : -0.2(2.8 ) vs. + 0.8 ( 2.0 ) mmol/L , P=0.025 ) . Subjects with baseline fasting insulin≥2 μIU/ml had greater 2HPP reductions in LGI group compared to those in the CHDR group ( −1.9±0.42 vs. + 1.31±1.4 mmol/L , P<0.001 ) . After 6 months , LGI group diets showed significantly lower GI ( 57±5 vs. 64±6 , P<0.001 ) , GL ( 122±33 vs. 142±35 , P=0.04 ) and higher fibre content ( 17±4 vs.13±4 g , P<0.001 ) . Caloric intakes were comparable between groups . Conclusion In women post-GDM , lowering GI of healthy diets result ed in significant improvements in glucose tolerance and body weight reduction as compared to conventional low-fat diets with similar energy prescription 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 Prevention of type 2 diabetes by intensive lifestyle intervention design ed to achieve and maintain ideal body weight was assessed in subjects with impaired glucose tolerance ( IGT ) . Male subjects with IGT recruited from health-screening examinees were r and omly assigned in a 4:1 ratio to a st and ard intervention group ( control group ) and intensive intervention group ( intervention group ) . The final numbers of subjects were 356 and 102 , respectively . The subjects in the control group and in the intervention group were advised to maintain body mass index ( BMI ) of < 24.0 kg/m2 and of < 22.0 kg/m2 , respectively , by diet and exercise . In the intervention group , detailed instructions on lifestyle were repeated every 3 - 4 months during hospital visits . Diabetes was judged to have developed when two or more consecutive fasting plasma glucose ( FPG ) values exceeded 140 mg/dl . A 100 g oral glucose tolerance test was performed every 6 months to detect improvement of glucose tolerance . The subjects were seen in an ordinary outpatient clinic . The cumulative 4-year incidence of diabetes was 9.3 % in the control group , versus 3.0 % in the intervention group , and the reduction in risk of diabetes was 67.4 % ( P < 0.001 ) . Body weight decreased by 0.39 kg in the control group and by 2.18 kg in the intervention group ( P < 0.001 ) . The control group was subclassified according to increase and decrease in body weight . The incidence of diabetes was positively correlated with the changes in body weight , and the improvement in glucose tolerance was negatively correlated . Subjects with higher FPG at baseline developed diabetes at a higher rate than those with lower FPG . Higher 2h plasma glucose values and higher BMI values at baseline were also associated with a higher incidence of diabetes , but the differences were not significant . Subjects with a low insulinogenic index ( DeltaIRI/DeltaPG 30 min after an oral glucose load ) developed diabetes at a significantly higher rate than those with a normal insulinogenic index . Comparison of the BMI data and incidence of diabetes in five diabetes prevention studies by lifestyle intervention revealed a linear correlation between the incidence of diabetes and the BMI values , with the exception of the DaQing Study . However , the slope of the reduction in incidence of diabetes in the intensive intervention groups was steeper than expected simply on the basis of the reduction of BMI , suggesting that the effect of lifestyle intervention can not be solely ascribed to the body weight reduction . We conclude that lifestyle intervention aim ed at achieving ideal body weight in men with IGT  is effective and can be conducted in an outpatient clinic setting OBJECTIVE To compare the effectiveness of diabetes prevention strategies addressing postpartum weight retention for women with gestational diabetes mellitus ( GDM ) delivered at the health system level : mailed recommendations ( usual care ) versus usual care plus a Diabetes Prevention Program (DPP)–derived lifestyle intervention . RESEARCH DESIGN AND METHODS This study was a cluster r and omized controlled trial of 44 medical facilities ( including 2,280 women with GDM ) r and omized to intervention or usual care . The intervention included mailed gestational weight gain recommendations plus 13 telephone sessions between 6 weeks and 6 months postpartum . Primary outcomes included the following : proportion meeting the postpartum goals of 1 ) reaching pregravid weight if pregravid BMI < 25.0 kg/m2 or 2 ) losing 5 % of pregravid weight if BMI ≥25.0 kg/m2 ; and pregravid to postpartum weight change . RESULTS On average , over the 12-month postpartum period , women in the intervention had significantly higher odds of meeting weight goals than women in usual care ( odds ratio [ OR ] 1.28 [ 95 % CI 1.10 , 1.47 ] ) . The proportion meeting weight goals was significantly higher in the intervention than usual care at 6 weeks ( 25.5 vs. 22.4 % ; OR 1.17 [ 1.01 , 1.36 ] ) and 6 months ( 30.6 vs. 23.9 % ; OR 1.45 [ 1.14 , 1.83 ] ) . Condition differences were reduced at 12 months ( 33.0 vs. 28.0 % ; OR 1.25 [ 0.96 , 1.62 ] ) . At 6 months , women in the intervention retained significantly less weight than women in usual care ( mean 0.39 kg [ SD 5.5 ] vs. 0.95 kg [ 5.5 ] ; mean condition difference −0.64 kg [ 95 % CI −1.13 , −0.14 ] ) and had greater increases in vigorous-intensity physical activity ( mean condition difference 15.4 min/week [ 4.9 , 25.8 ] ) . CONCLUSIONS A DPP-derived lifestyle intervention modestly reduced postpartum weight retention and increased vigorous-intensity physical activity AIMS Women with remote histories of gestational diabetes mellitus can reduce their diabetes risk through lifestyle changes , but the effectiveness of interventions in women with more recent histories of gestational diabetes has not been reported . Therefore , we conducted a pilot study of a low-intensity web-based pedometer programme targeting glucose intolerance among women with recent gestational diabetes . METHODS Women with a gestational diabetes delivery within the past 3 years were r and omized to a 13-week intervention consisting of a structured web-based pedometer programme which gave personalized steps-per-week goals , pedometers and education regarding lifestyle modification , or to a letter about diabetes risk reduction and screening after delivery for gestational diabetes ( control condition ) . The main outcome measures were change in fasting plasma glucose and 2-h glucose levels on a 75-g oral glucose tolerance test between baseline and 13-week follow-up . Weight was a secondary outcome and behavioural constructs ( self-efficacy , social support , risk perception ) were also assessed . RESULTS Forty-nine women were enrolled . At 13-week follow-up , women r and omized to the intervention did not have significant changes in behavioural constructs , physical activity or anthropometrics compared with women in the control group . Changes in fasting plasma glucose ( -0.046 mmol/l vs. 0.038 mmol/l , P = 0.65 ) , 2-h glucose values ( -0.48 mmol/l vs. -0.42 mmol/l , P = 0.91 ) and weight ( -0.14 kg vs. -1.5 kg , P = 0.13 ) were similar between the control and intervention groups , respectively . CONCLUSIONS Structured web-based education utilizing pedometers is feasible although uptake may be low . Such programmes may need to be supplemented with additional measures in order to be effective for reduction of diabetes risk Background Offering the overweight or obese patient the option of choosing from a selection of weight loss diets has not been investigated in type 2 diabetes . The aim of the study was to investigate if the option to choose from , and interchange between a selection of diets ( “ Choice ” ) , as opposed to being prescribed one set diet ( “ No Choice ” ) , improves drop out rates and leads to improved weight loss and cardio-metabolic outcomes . Methods The study was a 12 month , r and omized parallel intervention . A total of 144 volunteers with type 2 diabetes or pre-diabetes and a BMI > 27 were r and omized to “ No Choice ” or “ Choice ” . Those in the No Choice group were placed on a set weight loss diet ( CSIRO ) with no change permitted . Those in the Choice group could choose from , and interchange between , the CSIRO , South Beach or Mediterranean diets . Results There were no differences in attrition rates or weight loss between the “ Choice ” and “ No Choice ” . In a secondary analysis of the intention-to-treat weight loss data with last measured weight carried forward gave a highly significant diet group by time by gender interaction ( p = 0.002 ) with men doing better in the No Choice group overall ( maximum difference “ No Choice “ -2.9 ± 4.6 kg vs. “ Choice”-6.2 kg ± 5.3 kg at 6 months ) and women doing better in the Choice group overall ( maximum difference Choice -3.1 ± 3.7 kg vs. “ No Choice ” -2.0 kg ± 2.6 kg at 6 months ) . Conclusions Men prefer direction in their weight loss advice and do less well with choice . A gender-specific approach is recommended when prescribing weight loss diets . Trial registration anzctr.org.au ACTRN12612000310864 Objective To assess effectiveness and implementability of the public health programme Life ! Taking action on diabetes in Australian people at risk of developing type 2 diabetes . Research design and methods Melbourne Diabetes Prevention Study ( MDPS ) was a unique study assessing effectiveness of Life ! that used a r and omized controlled trial design . Intervention participants with AUSDRISK score ≥15 received 1 individual and 5 structured 90 min group sessions . Controls received usual care . Outcome measures were obtained for all participants at baseline and 12 months and , additionally , for intervention participants at 3 months . Per protocol set ( PPS ) and intention to treat ( ITT ) analyses were performed . Results PPS analyses were considered more informative from our study . In PPS analyses , intervention participants significantly improved in weight ( −1.13 kg , p=0.016 ) , waist circumference ( −1.35 cm , p=0.044 ) , systolic ( −5.2 mm Hg , p=0.028 ) and diastolic blood pressure ( −3.2 mm Hg , p=0.030 ) compared with controls . Based on observed weight change , estimated risk of developing diabetes reduced by 9.6 % in the intervention and increased by 3.3 % in control participants . Absolute 5-year cardiovascular disease ( CVD ) risk reduced significantly for intervention participants by 0.97 percentage points from 9.35 % ( 10.4 % relative risk reduction ) . In control participants , the risk increased by 0.11 percentage points ( 1.3 % relative risk increase ) . The net effect for the change in CVD risk was −1.08 percentage points of absolute risk ( p=0.013 ) . Conclusions MDPS effectively reduced the risk of diabetes and CVD , but the intervention effect on weight and waist reduction was modest due to the challenges in recruiting high-risk individuals and the abbreviated intervention OBJECTIVE —The effectiveness of intentional weight loss in reducing cardiovascular disease ( CVD ) events in type 2 diabetes is unknown . This report describes 1-year changes in CVD risk factors in a trial design ed to examine the long-term effects of an intensive lifestyle intervention on the incidence of major CVD events . RESEARCH DESIGN AND METHODS —This study consisted of a multicentered , r and omized , controlled trial of 5,145 individuals with type 2 diabetes , aged 45–74 years , with BMI > 25 kg/m2 ( > 27 kg/m2 if taking insulin ) . An intensive lifestyle intervention ( ILI ) involving group and individual meetings to achieve and maintain weight loss through decreased caloric intake and increased physical activity was compared with a diabetes support and education ( DSE ) condition . RESULTS — Participants assigned to ILI lost an average 8.6 % of their initial weight vs. 0.7 % in DSE group ( P < 0.001 ) . Mean fitness increased in ILI by 20.9 vs. 5.8 % in DSE ( P < 0.001 ) . A greater proportion of ILI participants had reductions in diabetes , hypertension , and lipid-lowering medicines . Mean A1C dropped from 7.3 to 6.6 % in ILI ( P < 0.001 ) vs. from 7.3 to 7.2 % in DSE . Systolic and diastolic pressure , triglycerides , HDL cholesterol , and urine albumin-to-creatinine ratio improved significantly more in ILI than DSE participants ( all P < 0.01 ) . CONCLUSIONS —At 1 year , ILI result ed in clinical ly significant weight loss in people with type 2 diabetes . This was associated with improved diabetes control and CVD risk factors and reduced medicine use in ILI versus DSE . Continued intervention and follow-up will determine whether these changes are maintained and will reduce CVD risk Introduction This study investigated the outcomes and identified influencing factors of intensive integrated intervention over 2 years in Chinese patients with impaired glucose regulation ( IGR ) . Methods Adults in Beijing , China , were screened for IGR using the 75 g oral glucose tolerance test . Participants with IGR received lifestyle and health education ; those who still had IGR after 1 year were r and omly assigned to either a routine care group or to an intensive integrated intervention group . Results Of 2344 adults screened , 463 had IGR . Of these , 210 adults had IGR after 1 year and were therefore recruited and r and omized to an intensive integrated intervention group ( n=106 ) or a control group ( n=104 ) . The percentage of patients who reached the set targets of plasma glucose , blood pressure , body mass index , or triglycerides was significantly higher in the intensive integrated intervention group . None of the patients within the intensive integrated intervention group progressed to diabetes , whereas eight ( 9.3 % ) cases of the control group developed type 2 diabetes mellitus ( T2DM ) . Logistic regression analysis showed that both an increase in waist circumference and systolic blood pressure ( SBP ) were positively correlated with the development of T2DM , whereas improvement in islet beta cell function was negatively correlated with the development of T2DM . Conclusions Intensive integrated intervention may significantly decrease the conversion rate of IGR to T2DM , and increase the conversion ratio to normal glucose tolerance . The increase of waist circumference or SBP and the deterioration of islet beta cell function may be important risk factors for progression from prediabetes to diabetes Introduction Although lifestyle interventions are effective in delaying the onset of diabetes , translating these lessons to routine health care setting s remains a challenge . We investigated the effectiveness of a theory-based , brief , small-group weight loss intervention for diabetes prevention . A secondary purpose was to determine the potential reach of the intervention . Methods A total of 14,379 members of an integrated health care organization newly diagnosed with prediabetes were potentially eligible to participate in this matched cohort longitudinal study . Of this group , 1,030 attended a 90-minute , small-group session that targeted personal action planning for healthful eating , physical activity , and weight management . We accessed electronic medical records to select 1 to 2 controls ( matched on impaired fasting glucose measurement , sex , age , and body mass index ) for each member who attended the small-group session ( n = 760 ) . Weight change , as recorded in the medical record , was the primary outcome . Mixed models analyses were used to adjust for matching variables and covariates and to account for individual r and om effects over time . Results Small-group participants  lost significantly more weight than did their matched controls . A significantly higher proportion of small-group participants  lost at least 5 % of their body weight compared with controls . Conclusion A brief , small-group weight loss intervention was effective . However , it did not reach broadly into the population that was at risk for diabetes OBJECTIVES To study the effectiveness of yoga intervention on oxidative stress , glycemic status , blood pressure and anthropometry in prediabetes . DESIGN R and omized-controlled trial . PARTICIPANTS Twenty nine prediabetes subjects aged 30 - 75 years . SETTING Yoga was conducted at 4 different community diabetes clinics in Mangalore , India . INTERVENTIONS Participants were r and omized to either 3-month yoga or wait-list control groups . MAIN OUTCOME MEASURES Malondialdehyde , glutathione , vitamin C , vitamin E , superoxide dismutase , plasma glucose , glycated haemoglobin , BMI , waist circumference , waist-to-hip ratio and blood pressure . RESULTS Yoga intervention result ed in a significant decline in malondialdehyde ( p<0.001 ) , relative to the control group . In comparison with the control , there was a significant improvement in BMI , waist circumference , systolic blood pressure and fasting glucose levels at follow-up . No significant improvement in glycated haemoglobin , waist-to-hip ratio or any of the antioxidants was observed . CONCLUSIONS Yoga intervention may be helpful in control of oxidative stress in prediabetes subjects . Yoga can also be beneficial in reduction in BMI , waist circumference , systolic blood pressure and fasting glucose . Effect of yoga on antioxidant parameters was not evident in this study . The findings of this study need to be confirmed in larger trials involving active control groups OBJECTIVE To determine A1C cut points for glucose intolerance in Asian Indians . RESEARCH DESIGN AND METHODS A total of 2,188 participants without known diabetes were r and omly selected from the Chennai Urban Rural Epidemiology Study . All had fasting plasma glucose ( FPG ) and 2-h postload plasma glucose measurements after a 75-g load and were classified as having impaired fasting glucose ( IFG ) ( American Diabetes Association [ ADA ] criteria , FPG ≥5.5 and < 7 mmol/l , and World Health Organization [ WHO ] criteria , FPG ≥6.1 and < 7 mmol/l ) , impaired glucose tolerance ( IGT ) ( 2-h postload plasma glucose ≥7.8 and < 11.1 mmol/l ) , or diabetes ( FPG ≥7 mmol/l and /or 2-h postload plasma glucose ≥11.1 mmol/l ) . A1C was measured using the Bio-Rad Variant machine . Based on receiver operating characteristic curves , optimum sensitivity and specificity were derived for defining A1C cut points for diabetes , IGT , and IFG . RESULTS Mean ± SD values of A1C among subjects with normal glucose tolerance , IGT , and diabetes were 5.5 ± 0.4 , 5.9 ± 0.6 , and 8.3 ± 2.0 % , respectively ( Ptrend < 0.001 ) with considerable overlap . To identify diabetes based on 2-h postload plasma glucose , the A1C cut point of 6.1 % had an area under the curve ( AUC ) of 0.941 with 88.0 % sensitivity and 87.9 % specificity . When diabetes was defined as FPG ≥7.0 mmol/l , the A1C cut point was 6.4 % ( AUC = 0.966 , sensitivity 93.3 % , and specificity 92.3 % ) . For IGT , AUC = 0.708 ; for IFG , AUC = 0.632 ( WHO criteria ) and 0.708 ( ADA criteria ) , and the A1C cut point was 5.6 % . CONCLUSIONS In Asian Indians , A1C cut points of 6.1 and 6.4 % defined diabetes by 2-h postload plasma glucose or FPG criteria , respectively . A value of 5.6 % optimally identified IGT or IFG but was < 70 % accurate Objectives To examine the effects of telephone-delivered lifestyle coaching on preventing the development of type 2 diabetes mellitus ( T2DM ) in participants with impaired fasting glucose ( IFG ) . Design Cluster r and omised trial . Setting 40 groups from 17 healthcare divisions in Japan : companies ( 31 ) , communities ( 6 ) and mixed setting s ( 3 ) . Participants Participants aged 20–65 years with fasting plasma glucose ( FPG ) of 5.6–6.9 mmol/L were invited from the 17 healthcare divisions . R and omisation The groups were then r and omly assigned to an intervention or a control arm by independent statisticians according to a computer-generated list . Intervention The intervention arm received a 1-year telephone-delivered intervention provided by three private lifestyle support centres ( at different frequencies : low-frequency ( 3 times ) , middle-frequency ( 6 times ) and high-frequency ( 10 times ) support calls ) . The intervention and control arms both received self-help devices such as a weight scale and pedometer . Outcomes Participants were followed up using data from annual health check-ups and a question naire regarding lifestyle . The primary outcome was the development of T2DM defined as FPG ≥7.0 mmol/L , the diagnosis of diabetes , or use of an antidiabetic drug , confirmed by referring to medical cards . Results Of 14 473 screened individuals , participants were enrolled in either the intervention ( n=1240 ) arm or control ( n=1367 ) arm . Overall , the HR for the development of T2DM in the intervention arm during 5.5 years was 1.00 ( 95 % CI 0.74 to 1.34 ) . In the sub analysis , the HR was 0.59 ( 95 % CI 0.42 to 0.83 ) in the subgroup that received phone calls the most frequently , compared with the control arm . A limitation of the study includes a lack of blinding . Conclusions High-frequency telephone-delivered lifestyle support could effectively prevent T2DM in participants with IFG in a primary healthcare setting , although low-frequency and middle-frequency phone calls did not . Trial registration number This trial has been registered with the University Hospital Medical Information Network ( UMIN000000662 ) Background A r and omized control trial was performed to test whether a lifestyle intervention program , carried out in a primary healthcare setting using existing re sources , can reduce the incidence of type 2 diabetes in Japanese with impaired glucose tolerance ( IGT ) . The results of 3 years ' intervention are summarized . Methods Through health checkups in communities and workplaces , 304 middle-aged IGT subjects with a mean body mass index ( BMI ) of 24.5 kg/m2 were recruited and r and omized to the intervention group or control group . The lifestyle intervention was carried out for 3 years by public health nurses using the curriculum and educational material s provided by the study group . Results After 1 year , the intervention had significantly improved body weight ( -1.5 ± 0.7 vs. -0.7 ± 2.5 kg in the control ; p = 0.023 ) and daily non-exercise leisure time energy expenditure ( 25 ± 113 vs. -3 ± 98 kcal ; p = 0.045 ) . Insulin sensitivity assessed by the Matsuda index was improved by the intervention during the 3 years . The 3-year cumulative incidence tended to be lower in the intervention group ( 14.8 % vs.8.2 % , log-rank test : p = 0.097 ) . In a sub- analysis for the subjects with a BMI > 22.5 kg/m2 , a significant reduction in the cumulative incidence was found ( p = 0.027 ) . Conclusions The present lifestyle intervention program using existing healthcare re sources is beneficial in preventing diabetes in Japanese with IGT . This has important implication s for primary healthcare-based diabetes prevention . Trial registration OBJECTIVE To investigate whether a pragmatic structured education program with and without pedometer use is effective for promoting physical activity and improving glucose tolerance in those with impaired glucose tolerance ( IGT ) . RESEARCH DESIGN AND METHODS Overweight and obese individuals with IGT were recruited from ongoing screening studies at the University Hospitals of Leicester , U.K. Participants were r and omly assigned to one of three groups . Group 1 received a 3-h group-based structured education program design ed to promote walking activity using personalized steps-per-day goals and pedometers . Group 2 received a 3-h group-based structured education program design ed to promote walking activity using generic time-based goals . Group 3 received a brief information leaflet ( control condition ) . Outcomes included an oral glucose tolerance test , st and ard anthropometric measures , ambulatory activity , and psychological variables . Follow-up was conducted at 3 , 6 , and 12 months . RESULTS A total of 87 individuals ( 66 % male , mean age 65 years ) were included in this study . At 12 months , significant decreases in 2-h postchallenge glucose and fasting glucose of −1.31 mmol/l ( 95 % CI −2.20 to −0.43 ) and −0.32 mmol/l ( −0.59 to −0.03 ) , respectively , were seen in the pedometer group compared with the control group . No significant improvements in glucose control were seen in those given the st and ard education program . CONCLUSIONS This study suggests that a pragmatic structured education program that incorporates pedometer use is effective for improving glucose tolerance in those with IGT . This result is likely to have important implication s for future primary care – based diabetes prevention initiatives We compared the effects of two diets on glycated hemoglobin ( HbA1c ) and other health-related outcomes in overweight or obese adults with type 2 diabetes or prediabetes ( HbA1c>6 % ) . We r and omized participants to either a medium carbohydrate , low fat , calorie-restricted , carbohydrate counting diet ( MCCR ) consistent with guidelines from the American Diabetes Association ( n = 18 ) or a very low carbohydrate , high fat , non calorie-restricted diet whose goal was to induce nutritional ketosis ( LCK , n = 16 ) . We excluded participants receiving insulin ; 74 % were taking oral diabetes medications . Groups met for 13 sessions over 3 months and were taught diet information and psychological skills to promote behavior change and maintenance . At 3 months , mean HbA1c level was unchanged from baseline in the MCCR diet group , while it decreased 0.6 % in the LCK group ; there was a significant between group difference in HbA1c change favoring the LCK group ( −0.6 % , 95 % CI , −1.1 % to −0.03 % , p = 0.04 ) . Forty-four percent of the LCK group discontinued one or more diabetes medications , compared to 11 % of the MCCR group ( p = 0.03 ) ; 31 % discontinued sulfonylureas in the LCK group , compared to 5 % in the MCCR group ( p = 0.05 ) . The LCK group lost 5.5 kg vs. 2.6 kg lost in MCCR group ( p = 0.09 ) . Our results suggest that a very low carbohydrate diet coupled with skills to promote behavior change may improve glycemic control in type 2 diabetes while allowing decreases in diabetes medications . This clinical trial was registered with Clinical Trials.gov , number NCT01713764 Background The Finnish Diabetes Prevention Study ( DPS ) was a r and omized controlled trial , which showed that it is possible to prevent type 2 diabetes by lifestyle changes . The aim of the present study was to examine whether the lifestyle intervention had an effect on the ten-year mortality and cardiovascular morbidity in the DPS participants originally r and omized either into an intervention or control group . Furthermore , we compared these results with a population -based cohort comprising individuals of varying glucose tolerance states . Methods and Findings Middle-aged , overweight people with IGT ( n = 522 ) were r and omized into intensive intervention ( including physical activity , weight reduction and dietary counseling ) , or control “ mini-intervention ” group . Median length of the intervention period was 4 years and the mean follow-up was 10.6 years . The population -based reference study cohort included 1881 individuals ( 1570 with normal glucose tolerance , 183 with IGT , 59 with screen-detected type 2 diabetes , 69 with previously known type 2 diabetes ) with the mean follow-up of 13.8 years .  Mortality and cardiovascular morbidity data were collected from the national Hospital Discharge Register and Causes of Death Register . Among the DPS participants who consented for register linkage ( n = 505 ) , total mortality ( 2.2 vs. 3.8 per 1000 person years , hazard ratio HR = 0.57 , 95 % CI 0.21–1.58 ) and cardiovascular morbidity ( 22.9 vs. 22.0 per 1000 person years , HR = 1.04 , 95 % CI 0.72–1.51 ) did not differ significantly between the intervention and control groups . Compared with the population -based cohort with impaired glucose tolerance , adjusted HRs were 0.21 ( 95 % CI 0.09–0.52 ) and 0.39 ( 95 % CI 0.20–0.79 ) for total mortality , and 0.89 ( 95 % CI 0.62–1.27 ) and 0.87 ( 0.60–1.27 ) for cardiovascular morbidity in the intervention and control groups of the DPS , respectively . The risk of death in DPS combined cohort was markedly lower than in FINRISK IGT cohort ( adjusted HR 0.30 , 95 % CI 0.17–0.54 ) , but there was no significant difference in the risk of CVD ( adjusted HR 0.88 , 95 % CI 0.64–1.21 ) . Conclusions Lifestyle intervention among persons with IGT did not decrease cardiovascular morbidity  during the first 10 years of follow-up . However , the statistical power may not be sufficient to detect small differences between the intervention and control groups . Low total mortality among participants of the DPS compared with individuals with IGT in the general population could be ascribed to a lower cardiovascular risk profile at baseline and regular follow-up . Trial Registration Clinical Trials.gov BACKGROUND Type 2 diabetes can often be prevented by lifestyle modification ; however , successful lifestyle intervention programmes are labour intensive . Mobile phone messaging is an inexpensive alternative way to deliver educational and motivational advice about lifestyle modification . We aim ed to assess whether mobile phone messaging that encouraged lifestyle change could reduce incident type 2 diabetes  in Indian Asian men with impaired glucose tolerance . METHODS We did a prospect i ve , parallel-group , r and omised controlled trial between Aug 10 , 2009 , and Nov 30 , 2012 , at ten sites in southeast India . Working Indian men ( aged 35 - 55 years ) with impaired glucose tolerance were r and omly assigned ( 1:1 ) with a computer-generated r and omisation sequence to a mobile phone messaging intervention or st and ard care ( control group ) . Participants in the intervention group received frequent mobile phone messages compared with controls who received st and ard lifestyle modification advice at baseline only . Field staff and participants were , by necessity , not masked to study group assignment , but allocation was concealed from laboratory personnel as well as principal and co-investigators . The primary outcome was incidence of type 2 diabetes , analysed by intention to treat . This trial is registered with Clinical Trials.gov , number NCT00819455 . RESULTS We assessed 8741 participants for eligibility . 537 patients were r and omly assigned to either the mobile phone messaging intervention ( n=271 ) or st and ard care ( n=266 ) . The cumulative incidence of type 2 diabetes was lower in those who received mobile phone messages than in controls : 50 ( 18 % ) participants in the intervention group developed type 2 diabetes compared with 73 ( 27 % ) in the control group ( hazard ratio 0·64 , 95 % CI 0·45 - 0·92 ; p=0·015 ) . The number needed to treat to prevent one case of type 2 diabetes was 11 ( 95 % CI 6 - 55 ) . One patient in the control group died suddenly at the end of the first year . We recorded no other serious adverse events . INTERPRETATION Mobile phone messaging is an effective and acceptable method to deliver advice and support towards lifestyle modification to prevent type 2 diabetes in men at high risk . FUNDING The UK India Education and Research Initiative , the World Diabetes Foundation Objective : To compare the effects of counseling alone with that of additional participation in supervised training courses on exercise capacity in patients with impaired fasting glucose . Design : R and omized , controlled intervention trial using a nested cohort approach . Setting : Primary care centers in western Austria . Patients : Thirty-six patients with impaired fasting glucose ( 16 males , 20 females ; mean age , 57.5 ± 6.9 years ) . Interventions : Participants of both groups were instructed about the preventive effectiveness of changing their lifestyle , especially losing weight and increasing physical activity . One group had additionally been offered supervised , progressive , individually tailored aerobic exercise programs for 1 hour twice a week . Main Outcome Measures : Changes in the levels of exercise capacity , body mass , and fasting blood glucose . Results : The subjects with supervised exercise participated in this program for 1.8 hours ( ± 0.3 ) per week over 12 months . Supervised exercise was sufficient to maintain exercise capacity , whereas counseling alone was not ( + 4.4 % versus -6.9 % ; P = 0.01 ) . After the 12-month intervention period , body mass was reduced in the supervised exercise group ( -3.0 % ) compared with the counseling alone group ( + 1.0 % ) ( P = 0.03 ) and fasting plasma glucose levels had similarly improved by counseling for adequate lifestyle changes alone ( -8.2 % ) and in combination with supervised exercise ( -6.0 % ) . Conclusion : In contrast to counseling alone , 2 sessions of supervised training per week , besides the self-chosen physical activity and nutritional measures , are sufficient to maintain exercise capacity in patients with impaired fasting glucose I was asked recently to name the single most important intervention to reduce  childhood obesity .  My weary reply was that the single most important intervention is to underst and that there is no single most important intervention . This was greeted with predictable dismay , and groans of derision from my colleagues , who chided me for imperious ivory-towered idealism . But I st and by my response . Obesity is the outcome of a complex web of social , cultural , environmental , biological and psychological influences . As has recently been described in this journal ( Raine 2012 ) people ’s diets and physical activity exist within an ecological system of human behaviour that requires upstream actions to shift it . The system map produced for the UK Government ’s Foresight report clearly shows how this complex system acts at all levels of society , with numerous linkages and interactions ( Butl and et al. 2007 ; Finegood et al. 2010 ) . But what do we need to do fully to underst and a complex system such as this , and more importantly how do we decide how best to respond to it ? The scientific underpinnings of public health have made huge advances in recent years , building to a large extent on the principles of evidence -based medicine ( EBM ) . But many complex questions about the most effective ways to influence behaviour and improve health are simply not amenable to this kind of assessment . There is a fundamental epistemological difference between the rigorous EBM methods that can differentiate between two treatments , and the kinds of research that are able to identify effective , sustainable approaches within complex adaptive systems . We need to move from evidence to knowledge ( Rayner and Lang 2012 ) , but public health remains largely in thrall to the EBM approach . In obesity , despite the rhetoric of complexity becoming commonplace , there is still a strong intellectual dependence upon systematic review s and other forms of putatively robust and defensible evidence . The concept of complexity in health care , and in public health , has been around for some years now ( Plsek and Greenhalgh 2001 ) , but remains on the margins of the majority of health and policy activity . This may be at least partly because of the inherent challenge of the perspective to a discipline grounded in biomedicine . R and omised controlled trials and meta analyses are the kinds of tools that have successfully dragged us away from the unhelpful biases of expert opinion and led us to disinterested objectivity . But non-linear systems with feedback , interactions , emergence , compensatory behaviours and small effect sizes are not suited to dichotomous hypothesis testing , result ing in few robust studies and often very little to review . The job of public health is not the same as the one we started on a few years ago , and now is the time for some new tools , and new skills to use them . These tools are commonly used in other fields , such as climate change modelling , defence , and business . They involve a significant shift in thinking , from linear cause and effect to non-linear system-wide dynamics , and much greater tolerance of uncertainty and unpredictability . These ways of thinking allow us to conceptualise and respond to systems problems such as obesity in far more effective H. Rutter ( & ) London School of Hygiene and Tropical Medicine , Keppel Street , London WC1E 7HT , UK e-mail : harry.rutter@lshtm.ac.uk Int J Public Health DOI 10.1007/s00038 - 012 - 0385 - AIM To compare American Diabetes Association and International Expert Committee recommended cut-off values of HbA(1c ) for detecting the presence of pre-diabetes against plasma glucose values obtained from oral glucose tolerance tests in Asian Indians . METHODS A cross-sectional r and omly sample d population survey involving 2368 adults , aged ≥ 20 years .  HbA(1c ) was measured on a Bio-Rad 10 system in 1972 subjects . RESULTS Of the 1972 subjects studied , 329 were detected to have pre-diabetes based on  isolated impaired fasting glucose  in 125 subjects ( 6.3 % ) , isolated impaired glucose tolerance in 141 subjects ( 7.1 % ) and the presence of both in 63 subjects ( 3.2 % ) . The HbA(1c ) cut-off of 34 mmol/mol ( 5.7 % ) , as recommended by the American Diabetes Association for detecting the presence of pre-diabetes , showed sensitivity of 62 % , specificity 77 % , with a positive predictive value of 34.7 % , a negative predictive value of 89.5 % and accuracy of 67.8 % ; whereas the HbA(1c ) cut-off recommended by the International Expert Committee of 42 mmol/mol ( 6 % ) had a sensitivity of 36 % , specificity of 90 % , positive predictive value of 42.7 % , negative predictive of 85.4 % and an accuracy of 77 % . However , both these HbA(1c ) cut-offs underdiagnosed the presence of pre-diabetes in 38 and 64 % of these subjects , respectively . CONCLUSIONS The American Diabetes Association and the International Expert Committee recommended HbA(1c ) cut-off values and oral glucose tolerance tests identify different pre-diabetes cohorts . Long-term prospect i ve studies are required to define the usefulness of one over the other AIMS To evaluate the effect of metformin on glucose metabolism , insulin sensitivity and rate of conversion diabetes in people with impaired glucose tolerance ( IGT ) . METHODS Seventy subjects with IGT were r and omized under double-blind conditions to receive either placebo ( n = 37 ) or metformin ( n = 33 ) at a dosage of 250 mg three times daily for a duration of 12 months . Glycaemic control , plasma insulin and other biochemical indexes were assessed before and after 3 , 6 and 12 months . RESULT At 12 months the conversion rate to diabetes was 16.2 % in the placebo group compared to 3.0 % for the metformin group ( P = 0.011 ) . Of subjects treated with metformin for 12 months , 84.9 % became normoglycaemic compared to 51.4 % of those receiving the placebo . Significant improvements in fasting glucose , glucose tolerance and insulin sensitivity were found at 12 months and at intermediate clinic assessment s. CONCLUSIONS Metformin can improve glucose metabolism in IGT patients and may be a treatment option in their management of IGT subjects BACKGROUND Type 2 diabetes mellitus is increasingly common , primarily because of increases in the prevalence of a sedentary lifestyle and obesity . Whether type 2 diabetes can be prevented by interventions that affect the lifestyles of subjects at high risk for the disease is not known . METHODS We r and omly assigned 522 middle-aged , overweight subjects ( 172 men and 350 women ; mean age , 55 years ; mean body-mass index [ weight in kilograms divided by the square of the height in meters ] , 31 ) with impaired glucose tolerance to either the intervention group or the control group . Each subject in the intervention group received individualized counseling aim ed at reducing weight , total intake of fat , and intake of saturated fat and increasing intake of fiber and physical activity . An oral glucose-tolerance test was performed annually ; the diagnosis of diabetes was confirmed by a second test . The mean duration of follow-up was 3.2 years . RESULTS The mean ( + /-SD ) amount of weight lost between base line and the end of year 1 was 4.2+/-5.1 kg in the intervention group and 0.8+/-3.7 kg in the control group ; the net loss by the end of year 2 was 3.5+/-5.5 kg in the intervention group and 0.8+/-4.4 kg in the control group ( P<0.001 for both comparisons between the groups ) . The cumulative incidence of diabetes after four years was 11 percent ( 95 percent confidence interval , 6 to 15 percent ) in the intervention group and 23 percent ( 95 percent confidence interval , 17 to 29 percent ) in the control group . During the trial , the risk of diabetes was reduced by 58 percent ( P<0.001 ) in the intervention group . The reduction in the incidence of diabetes was directly associated with changes in lifestyle . CONCLUSIONS Type 2 diabetes can be prevented by changes in the lifestyles of high-risk subjects Gestational diabetes mellitus ( GDM ) is associated with adverse foetal and maternal outcomes , and identifies women at risk of future Type 2 Diabetes Mellitus ( T2DM ) . Breast-feeding may improve postpartum maternal glucose tolerance . We prospect ively examined the prevalence of postpartum dysglycaemia after GDM and examined the effect of lactation on postpartum glucose tolerance . We compared postpartum 75 g oral glucose tolerance test ( OGTT ) results from 300 women with GDM and 220 controls with normal gestational glucose tolerance ( NGT ) .  Breast-feeding data was collected at time of OGTT . Postpartum OGTT results were classified as normal [ fasting plasma glucose ( FPG ) < 5.6mmol/l , 2-h < 7.8 mmol/l ] and abnormal [ impaired fasting glucose ( IFG ) , FPG 5.6 - 6.9 mmol/l ; impaired glucose tolerance ( IGT ) , 2-h glucose 7.8 - 11 mmol/l ; IFG+IGT ; T2DM , FPG > or = 7 mmol/l + /- 2h glucose > or = 11.1 mmol/l ] . 6 ( 2.7 % ) with NGT in pregnancy had postpartum dysglycaemia compared to 57 ( 19 % ) with GDM in index pregnancy ( p < 0.001 ) . Non-European ethnicity ( OR 3.40 , 95 % CI 1.45 - 8.02 , p = 0.005 ) , family history of T2DM ( OR 2.14 , 95 % CI 1.06 - 4.32 , p = 0.034 ) and gestational insulin use ( OR 2.62 , 95 % CI 1.17 - 5.87 p = 0.019 ) were associated with persistent dysglycaemia . The prevalence of persistent hyperglycaemia was significantly lower in women who breast-fed versus bottle-fed postpartum ( 8.2 % v 18.4 % , p < 0.001 ) . Breast-feeding may confer beneficial metabolic effects after GDM and should be encouraged Aims /hypothesisLifestyle modification helps in the primary prevention of diabetes in multiethnic American , Finnish and Chinese population s. In a prospect i ve community-based study , we tested whether the progression to diabetes could be influenced by interventions in native Asian Indians with IGT who were younger , leaner and more insulin resistant than the above population s. Methods We r and omised 531 ( 421 men 110 women ) subjects with IGT ( mean age 45.9±5.7 years , BMI 25.8±3.5 kg/m2 ) into four groups . Group 1 was the control , Group 2 was given advice on lifestyle modification ( LSM ) , Group 3 was treated with metformin ( MET ) and Group 4 was given LSM plus MET . The primary outcome measure was type 2 diabetes as diagnosed using World Health Organization criteria . Results The median follow-up period was 30 months , and the 3-year cumulative incidences of diabetes were 55.0 % , 39.3 % , 40.5 % and 39.5 % in Groups 1–4 , respectively . The relative risk reduction was 28.5 % with LSM ( 95 % CI 20.5–37.3 , p=0.018 ) , 26.4 % with MET ( 95 % CI 19.1–35.1 , p=0.029 ) and 28.2 % with LSM + MET ( 95 % CI 20.3–37.0 , p=0.022 ) , as compared with the control group . The number needed to treat to prevent one incident case of diabetes was 6.4 for LSM , 6.9 for MET and 6.5 for LSM + MET . Conclusions /interpretationProgression of IGT to diabetes is high in native Asian Indians .  Both LSM and MET significantly reduced the incidence of diabetes  in Asian Indians with IGT ; there was no added benefit from combining them CONTEXT Glycated hemoglobin ( A1C ) has been recommended by the American Diabetes Association for the diagnosis of diabetes and prediabetes . The diagnostic utility of A1C has not been evaluated in Arabs , a population at increased risk for developing diabetes . OBJECTIVE Our objective was to examine the sensitivity and specificity of A1C for the diagnosis of diabetes and prediabetes in Arabs . DESIGN & SETTING In this cross-sectional study , glucose tolerance was classified by the American Diabetes Association diagnostic criteria specified for A1C , fasting plasma glucose , and 75-g oral glucose tolerance test . PARTICIPANTS A population -based representative sample of 482 r and omly selected adult Arabs without known diabetes was studied . MAIN OUTCOME MEASURES Sensitivity , specificity , and area under the receiver operating characteristic curve of A1C diagnostic cutpoints for diabetes and prediabetes were calculated . κ Coefficients were used to test for agreement between A1C categorization and glucose-based diagnoses . RESULTS A1C testing correctly identified 5 % of individuals diagnosed with diabetes by oral glucose tolerance test , 13 % by fasting plasma glucose , and 41 % by both criteria . A1C alone identified 14 % of individuals diagnosed with impaired glucose tolerance , 9 % with impaired fasting glucose , and 33 % with both abnormalities . Sensitivity , specificity , and area under the receiver operating characteristic curve were 19 % ( 16 - 23 % ) , 100 % ( 99 - 100 % ) , and 77 % ( 69 - 85 % ) for diabetes A1C cutpoint and 14 % ( 11 - 17 % ) , 91 % ( 89 - 94 % ) , and 57 % ( 52 - 62 % ) for prediabetes A1C range . A1C cutpoint of 6.2 % for diabetes and 5.1 % for prediabetes yielded the highest accuracy but still missed 73 % of those with diabetes and 31 % with prediabetes . Agreement between A1C and diabetes ( κ = 0.2835 ) or prediabetes ( κ = 0.0530 ) was low . CONCLUSIONS A1C-based criteria yield a high proportion of false-negative tests for diabetes and prediabetes in Arabs . SUMMARY Racial/ethnic differences in A1C performance for diagnosis and prediction of diabetes exist . This paper examines its utility against glucose measurements in an at-risk Arab population The aim of this study is to evaluate the short-term effectiveness of our individual-based counseling program and tools among individuals in ordinary Japanese communities with impaired fasting glucose ( IFG ) and mild type 2 diabetes . A total of 233 eligible participants ( age 30 - 69 years ) in 14 local study centers were r and omly assigned to an intervention group ( INT , N=119 ) and a control group ( CONT , N=114 ) . During the 4-month intervention , the INT received 4 individual counseling sessions and one reminder on life style modification . The CONT received only an explanation of blood test results and general information on diabetes . Baseline characteristics did not differ significantly between groups . Percentages of participants with desirable changes in glycemic level and weight were significantly higher in INT than CONT : fasting plasma glucose reduction of more than 10 mg/dL ( 39 % in INT vs. 26 % in CONT , p=0.045 ) , hemoglobinA1c reduction greater than 0.3 % ( 14 % vs. 4 % , p=0.01 ) , and weight reduction of more than 4 kg ( 13 % vs. 4 % , p=0.025 ) . Decreases in total energy intake and percentage of heavy alcohol drinkers ( more than 46 g/day ) were significantly greater in INT than CONT . The increase in percentages of participants who engaged in leisure time physical activity more than 12 times per month was significantly greater in INT than CONT . Our program result ed in life style modification and glycemic level improvement in the short-term among individuals with IFG and mild type 2 diabetes . Results indicated that the program was sufficiently effective and feasible for implementation in ordinary communities Aims : To compare data on cardiovascular risk factor changes in lipids , insulin , proinsulin , fibrinolysis , leptin and C-reactive protein , and on diabetes incidence , in relation to changes in lifestyle . Methods : The study was a r and omized lifestyle intervention trial conducted in northern Sweden between 1995 and 2000 , in 168 individuals with impaired glucose tolerance ( IGT ) and body mass index above 27 at start . The intensive intervention group ( n = 83 ) was subjected to a 1-month residential lifestyle programme . The usual care group ( n = 85 ) participated in a health examination ending with a single counselling session . Follow-up was conducted at 1 , 3 and 5 years . Results : At 1-year follow-up , an extensive cardio-metabolic risk factor reduction was demonstrated in the intensive intervention group , along with a 70 % decrease of progress to type 2 diabetes . At 5-year follow-up , most of these beneficial effects had disappeared . Reported physical activity and fibre intake as well as high-density lipoprotein cholesterol were still increased , and fasting insulin and proinsulin were lower . Conclusions : The intervention affected several important cardio-metabolic risk variables beneficially , and reduced the risk for type 2 diabetes , but the effects persisted only as long as the new lifestyle was maintained . Increased physical activity seemed to be the behaviour that was most easy to preserve BACKGROUND Lifestyle interventions can prevent the deterioration of impaired glucose tolerance to manifest type 2 diabetes , at least as long as the intervention continues . In the extended follow-up of the Finnish Diabetes Prevention Study , we assessed the extent to which the originally-achieved lifestyle changes and risk reduction remain after discontinuation of active counselling . METHODS Overweight , middle-aged men ( n=172 ) and women ( n=350 ) with impaired glucose tolerance were r and omly assigned to intensive lifestyle intervention or control group . After a median of 4 years of active intervention period , participants who were still free of diabetes were further followed up for a median of 3 years , with median total follow-up of 7 years . Diabetes incidence , bodyweight , physical activity , and dietary intakes of fat , saturated fat , and fibre were measured . FINDINGS During the total follow-up , the incidence of type 2 diabetes was 4.3 and 7.4 per 100 person-years in the intervention and control group , respectively ( log-rank test p=0.0001 ) , indicating 43 % reduction in relative risk . The risk reduction was related to the success in achieving the intervention goals of weight loss , reduced intake of total and saturated fat and increased intake of dietary fibre , and increased physical activity . Beneficial lifestyle changes achieved by participants in the intervention group were maintained after the discontinuation of the intervention , and the corresponding incidence rates during the post-intervention follow-up were 4.6 and 7.2 ( p=0.0401 ) , indicating 36 % reduction in relative risk . INTERPRETATION Lifestyle intervention in people at high risk for type 2 diabetes result ed in sustained lifestyle changes and a reduction in diabetes incidence , which remained after the individual lifestyle counselling was stopped OBJECTIVES To determine whether a home-based multicomponent physical activity counseling ( PAC ) intervention is effective in reducing glycemic measures in older out patients with prediabetes mellitus . DESIGN Controlled clinical trial . SETTING Primary care clinics of the Durham Veterans Affairs ( VA ) Medical Center between September 29 , 2008 , and March 25 , 2010 . PARTICIPANTS Three hundred two overweight ( body mass index 25 - 45 kg/m(2 ) ) , older ( 60 - 89 ) out patients with impaired glucose tolerance ( fasting blood glucose 100 - 125 mg/dL , glycosylated hemoglobin ( HbA1c ) < 7 % ) r and omly assigned to a  PAC intervention group  ( n = 180 ) or a usual care control group ( n = 122 ) . INTERVENTION A 12-month , home-based multicomponent PAC program including one in-person baseline counseling session , regular telephone counseling , physician endorsement in clinic with monthly automated encouragement , and customized mailed material s. All study participants , including controls , received a consultation in a VA weight management program . MEASUREMENTS The primary outcome was a homeostasis model assessment of insulin resistance ( HOMA-IR ) , calculated from fasting insulin and glucose levels at baseline and 3 and 12 months . HbA1c was the secondary indicator of glycemic control . Other secondary outcomes were anthropometric measures and self-reported physical activity , health-related quality of life , and physical function . RESULTS There were no significant differences between the PAC and control groups over time for any of the glycemic indicators . Both groups had small declines over time of approximately 6 % in fasting blood glucose ( P < .001 ) , and other glycemic indicators remained stable . The declines in glucose were not sufficient to affect the change in HOMA-IR scores due to fluctuations in insulin over time . Endurance physical activity increased significantly in the PAC group ( P < .001 ) and not in the usual care group . CONCLUSION Home-based telephone counseling increased physical activity levels but was insufficient to improve glycemic indicators in older out patients with prediabetes mellitus This study was a r and omised control trial with a waiting control group . It was design ed to evaluate the effectiveness of a 6-month , group-based diabetes prevention programme , The Healthy Living Course and assess whether participation in the programme led to changes in modifiable risk factors for type 2 diabetes among an already at-risk pre-diabetic population . Individuals design ated at risk for diabetes by their general practitioners ( GPs ) were screened using an Oral Glucose Tolerance Test . Volunteers ( N = 307 ) with pre-diabetes were assigned to an intervention or wait-control group in the ratio of approximately 2 : 1 . The sample was pre-tested on biochemical , anthropometric and self-report behavioural , cognitive and mood variables and post-tested either at the end of the educational/support-based lifestyle programme or the end of the wait period . The intervention group significantly improved their diabetes knowledge , motivation to change , positive affect , healthy eating and activity levels and showed significantly greater reductions in weight , body mass index , waist circumference , diastolic blood pressure and fasting plasma glucose in comparison with controls . The intervention group also changed their diagnostic status from pre-diabetes to non-diabetes at a greater rate than the wait group ( 43 % vs. 26 % ) who received st and ard care from their GPs Commonly used tests for the diagnosis of diabetes include measurements of fasting plasma glucose levels and the oral glucose tolerance test ( OGTT ) . Recently , a hemoglobin A1C ( A1C ) level of 6.5 % has been included as a criterion for diabetes diagnosis by the American Diabetes Association . We aim ed to determine appropriate A1C cutoff values for identifying patients with diabetes or prediabetes , including impaired glucose tolerance and impaired fasting glucose among Korean adults and to determine whether these cutoffs vary according to age . We recruited 4616 adults without a history of diabetes from 10 university hospitals . A 75-g OGTT and A1C sampling were performed in all examinees . Pointwise area under the receiver operating characteristic curve was used to evaluate the diagnostic accuracy of the A1C cutoff . An A1C threshold of 6.1 % proved to be the optimal limit for diagnosing diabetes , with 63.8 % sensitivity and 88.1 % specificity . The cutoff value increased with age ( 5.9 % in 18 - 39 years , 6.2 % in 40 - 64 years , and 6.4 % in older than 65 years ) and were similar for men and women . An A1C cutoff of 5.7 % had reasonable sensitivity ( 48.6 % ) and specificity ( 65.7 % ) for the identification of prediabetes . Further prospect i ve studies should be carried out to determine whether the application of age-specific diagnostic criteria is appropriate Thirty-one subjects with impaired glucose tolerance were r and omly allocated to a group receiving advice to improve their diet and physical activity levels over 6 months ( n = 23 ) or to a control group ( n = 8) . At 6 months , 18 of the 23 subjects receiving ' healthy living ' advice  were re-examined ( five subjects had withdrawn ) . Fourteen of the 18 subjects showed an alteration in diet or an increase in exercise . The 18 subjects re-evaluated showed a reduction in systolic blood pressure ( 118 + /- 15 vs 124 + /- 15 mmHg , p less than 0.05 ) and decrease in total plasma cholesterol ( 4.5 + /- 1 vs 5.2 + /- 1 mmol l-1 , p less than 0.01 ) and LDL-cholesterol levels ( 2.8 + /- 0.9 vs 3.2 + /- 0.9 mmol l-1 , p less than 0.05 ) . Plasma glucose levels were unchanged . One subject withdrew from the control group . At 6 months , the seven control subjects examined showed no significant change in metabolic parameters , with little measurable change in diet or exercise . At 2 years , 17 of the 23 ' healthy living ' subjects were reassessed . Nine of the subjects had continued to exercise or maintained a decreased weight compared to baseline . Fasting plasma glucose levels had increased ( 6.0 + /- 1.2 vs 5.5 + /- 0.6 mmol l-1 , p less than 0.05 ) , with the only continued improvement being a reduced LDL level ( 2.8 + /- 0.7 vs 3.1 + /- 0.9 mmol l-1 , p less than 0.05 ) . At 2 years , a similar proportion of the control group were taking regular exercise compared with the ' healthy living ' group . ( ABSTRACT TRUNCATED AT 250 WORDS OBJECTIVE Individuals with impaired glucose tolerance ( IGT ) have a high risk of developing NIDDM . The purpose of this study was to determine whether diet and exercise interventions in those with IGT may delay the development of NIDDM , i.e. , reduce the incidence of NIDDM , and thereby reduce the overall incidence of diabetic complications , such as cardiovascular , renal , and retinal disease , and the excess mortality attributable to these complications . RESEARCH DESIGN AND METHODS In 1986 , 110,660 men and women from 33 health care clinics in the city of Da Qing , China , were screened for IGT and NIDDM . Of these individuals , 577 were classified ( using World Health Organization criteria ) as having IGT . Subjects were r and omized by clinic into a clinical trial , either to a control group or to one of three active treatment groups : diet only , exercise only , or diet plus exercise . Follow-up evaluation examinations were conducted at 2-year intervals over a 6-year period to identify subjects who developed NIDDM . Cox 's proportional hazard analysis was used to determine if the incidence of NIDDM varied by treatment assignment . RESULTS The cumulative incidence of diabetes at 6 years was 67.7 % ( 95 % CI , 59.8–75.2 ) in the control group compared with 43.8 % ( 95 % CI , 35.5–52.3 ) in the diet group , 41.1 % ( 95 % CI , 33.4–49.4 ) in the exercise group , and 46.0 % ( 95 % CI , 37.3–54.7 ) in the diet-plus-exercise group ( P < 0.05 ) . When analyzed by clinic , each of the active intervention groups differed significantly from the control clinics ( P < 0.05 ) . The relative decrease in rate of development of diabetes in the active treatment groups was similar when subjects were stratified as lean or overweight ( BMI < or ≥ 25 kg/m2 ) . In a proportional hazards analysis adjusted for differences in baseline BMI and fasting glucose , the diet , exercise , and diet-plus-exercise interventions were associated with 31 % ( P < 0.03 ) , 46 % ( P < 0.0005 ) , and 42 % ( P < 0.005 ) reductions in risk of developing diabetes , respectively . CONCLUSIONS Diet and /or exercise interventions led to a significant decrease in the incidence of diabetes over a 6-year period among those with IGT BACKGROUND Intensive lifestyle interventions can reduce the incidence of  type 2 diabetes in people with impaired glucose tolerance , but how long these benefits extend beyond the period of active intervention , and whether such interventions reduce the risk of cardiovascular disease ( CVD ) and mortality , is unclear . We aim ed to assess whether intensive lifestyle interventions have a long-term effect on the risk of diabetes , diabetes-related macrovascular and microvascular complications , and mortality . METHODS In 1986 , 577 adults with impaired glucose tolerance from 33 clinics in China were r and omly assigned to either the  control group or to one of three lifestyle intervention groups ( diet , exercise , or diet plus exercise ) . Active intervention took place over 6 years until 1992 . In 2006 , study participants were followed-up to assess the long-term effect of the interventions . The primary outcomes were diabetes incidence , CVD incidence and mortality , and all-cause mortality . FINDINGS Compared with control participants , those in the combined lifestyle intervention groups had a 51 % lower incidence of diabetes ( hazard rate ratio [ HRR ] 0.49 ; 95 % CI 0.33 - 0.73 ) during the active intervention period and a 43 % lower incidence ( 0.57 ; 0.41 - 0.81 ) over the 20 year period , controlled for age and clustering by clinic . The average annual incidence of diabetes was 7 % for intervention participants versus 11 % in control participants , with 20-year cumulative incidence of 80 % in the intervention groups and 93 % in the control group . Participants in the intervention group spent an average of 3.6 fewer years with diabetes than those in the control group . There was no significant difference between the intervention and control groups in the rate of first CVD events ( HRR 0.98 ; 95 % CI 0.71 - 1.37 ) , CVD mortality ( 0.83 ; 0.48 - 1.40 ) , and all-cause mortality ( 0.96 ; 0.65 - 1.41 ) , but our study had limited statistical power to detect differences for these outcomes . INTERPRETATION Group-based lifestyle interventions over 6 years can prevent or delay diabetes for up to 14 years after the active intervention . However , whether lifestyle intervention also leads to reduced CVD and mortality remains unclear BACKGROUND Type 2 diabetes affects approximately 8 percent of adults in the United States . Some risk factors -- elevated plasma glucose concentrations in the fasting state and after an oral glucose load , overweight , and a sedentary lifestyle -- are potentially reversible . We hypothesized that modifying these factors with a lifestyle-intervention program or the administration of metformin would prevent or delay the development of diabetes . METHODS We r and omly assigned 3234 nondiabetic persons with elevated fasting and post-load plasma glucose concentrations to placebo , metformin ( 850 mg twice daily ) , or a lifestyle-modification program  with the goals of at least a 7 percent weight loss and at least 150 minutes of physical activity per week . The mean age of the participants was 51 years , and the mean body-mass index ( the weight in kilograms divided by the square of the height in meters ) was 34.0 ; 68 percent were women , and 45 percent were members of minority groups . RESULTS The average follow-up was 2.8 years . The incidence of diabetes was 11.0 , 7.8 , and 4.8 cases per 100 person-years in the placebo , metformin , and lifestyle groups , respectively . The lifestyle intervention reduced the incidence by 58 percent ( 95 percent confidence interval , 48 to 66 percent ) and metformin by 31 percent ( 95 percent confidence interval , 17 to 43 percent ) , as compared with placebo ; the lifestyle intervention was significantly more effective than metformin . To prevent one case of diabetes during a period of three years , 6.9 persons would have to participate in the lifestyle-intervention program , and 13.9 would have to receive metformin . CONCLUSIONS Lifestyle changes and treatment with metformin both reduced the incidence of diabetes in persons at high risk . The lifestyle intervention was more effective than metformin ISSUE ADDRESSED Substantial numbers of women with past gestational diabetes mellitus ( GDM ) develop type 2 diabetes mellitus ( T2DM ) . In northern New South Wales 23 % of women attending diabetes services between 2007 and 2010 with T2DM previously had GDM . This study investigated whether phone-based lifestyle education using motivational interviewing result ed in positive lifestyle change post GDM for women in a large rural area . METHOD Thirty-eight women were recruited to this pilot study following GDM diagnosis and r and omly allocated to either the control or intervention group . Following baseline assessment , the intervention group received a 6-month phone-based motivational interviewing program , and access to usual care . The control group received usual care only . Measures were collected at baseline ( 6 weeks postnatal ) , and at 6 months follow-up . Outcome measures included body mass index , diet , and physical activity . RESULTS At follow-up , the intervention group compared to the control group significantly reduced total fat intake by -19 g/d ( 95%CI : -37 to -1 ) , total carbohydrate intake by -42 g/d ( 95%CI : -82 to -1 ) , and glycaemic load by -26 units ( 95%CI : -48 to -4 ) . These women also increased leisure physical activity compared to the control group by 11 min/d ( 95%CI : 1 to 22 ) ; no significant change in total physical activity levels occurred . At follow-up , body mass index in the intervention group improved by -1.5 kg/m2 ( 95%CI : -2.8 to -0.1 ) compared to the control group . CONCLUSION The intervention group showed positive trends across lifestyle variables compared to the control group . Further large-scale research on the effectiveness of phone-based lifestyle counselling following GDM is warranted BACKGROUND The susceptibility to type 2 diabetes of people of south Asian descent is established , but there is little trial-based evidence for interventions to tackle this problem . We assessed a weight control and physical activity intervention in south Asian individuals in the UK . METHODS We did this non-blinded trial in two National Health Service ( NHS ) regions in Scotl and ( UK ) . Between July 1 , 2007 , and Oct 31 , 2009 , we recruited men and women of Indian and Pakistani origin , aged 35 years or older , with waist circumference 90 cm or greater in men or 80 cm or greater in women , and with impaired glucose tolerance or impaired fasting glucose determined by oral glucose tolerance test . Families were r and omised ( using a r and om number generator program , with permuted blocks of r and om size , stratified by location [ Edinburgh or Glasgow ] , ethnic group [ Indian or Pakistani ] , and number of participants in the family [ one vs more than one ] ) to intervention or control . Participants in the same family were not r and omised separately . The intervention group received 15 visits from a dietitian over 3 years and the control group received four visits in the same period . The primary outcome was weight change at 3 years . Analysis was by modified intention to treat , excluding participants who died or were lost to follow-up . We used linear regression models to provide mean differences in baseline-adjusted weight at 3 years . This trial is registered , number IS RCT N25729565 . FINDINGS Of 1319 people who were screened with an oral glucose tolerance test , 196 ( 15 % ) had impaired glucose tolerance or impaired fasting glucose and 171 entered the trial . Participants were in 156 family clusters that were r and omised ( 78 families with 85 participants were allocated to intervention ; 78 families with 86 participants were allocated to control ) . 167 ( 98 % ) participants in 152 families completed the trial .  Mean weight loss in the intervention group was 1.13 kg ( SD 4.12 ) , compared with a mean weight gain of 0.51 kg ( 3.65 ) in the control group , an adjusted mean difference of -1.64 kg ( 95 % CI -2.83 to -0.44 ) . INTERPRETATION Modest , medium-term changes in weight are achievable as a component of lifestyle-change strategies , which might control or prevent adiposity-related diseases . FUNDING National Prevention Research Initiative , NHS Research and Development ; NHS National Services Scotl and ; NHS Health Scotl and AIM To determine the independent effects of total and each health professional 's frequency of contacts , on changes in anthropometric measures and physical capacity following a lifestyle intervention offered by a multi-disciplinary team in adults at high risk for type 2 diabetes . MATERIAL S AND METHODS A 12-month lifestyle intervention was performed in 48 adults with prediabetes . Participants were r and omly assigned to either an individual counselling group ( every six weeks)+an optional series of 25 group seminars ( every week ) or to the group seminars only . Physical activity level , energy intake , anthropometric measures , and physical capacity were assessed . RESULTS Total frequency of contacts with any professional was associated with change in body weight , BMI and , waist circumference ( all P ≤.05 ) . However , no frequency of contacts with a specific professional was associated with the studied outcomes , except for changes in physical capacity . The latest was significantly improved in participants who attended at least two group sessions with the kinesiologist ( P=.02 ) . DISCUSSION To improve anthropometric measures , total contact frequency seems to be more important than contact frequency with any specific professionals . However , to improve physical capacity , meeting with a kinesiologist for two or more occasions , in group sessions , seems to be an effective strategy OBJECTIVE To assess whether lifestyle intervention can reduce type 2  diabetes risk in women with prior GDM in the Tianjin Gestational Diabetes Mellitus ( GDM ) Prevention Program . METHODS 1180 women who were diagnosed with GDM from 2005 to 2009 were r and omly assigned to either a lifestyle intervention ( n=586 ) or a control group ( n=594 ) . Major elements of the intervention include six face-to-face meetings with study dietitians in the first year , and two additional sessions and two telephone calls in second year . RESULTS During the first year , average body weight loss in the first 404 subjects was 1.40 kg ( 2.1 % ) in the intervention group vs 0.21 kg ( 0.3 % ) in the control group ( P=0.001 ) , and the decrease was more significant among baseline overweight women ( body bass index [ BMI ] ≥24 kg/m² ) in the intervention ( 2.91 kg/4.2 % ) compared with that in the control group ( 0.51 kg/0.7 % ) ( P<0.001 ) . In addition , women in the intervention group , compared with those in the control group , have decreased BMI , body fat , waist circumference , and plasma insulin levels , and have improved behaviors including increased leisure time activity and dietary fiber intake and decreased sedentary time and fat consumptions . CONCLUSION The interim results support the efficacy and feasibility of the lifestyle intervention program 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 AIM To evaluate the effectiveness of lifestyle interventions in people with impaired glucose tolerance ( IGT ) . METHODS Participants with IGT ( n=78 ) , diagnosed on two consecutive oral glucose tolerance tests ( OGTTs ) , were r and omly assigned to a 2-year lifestyle intervention or to a control group . Main outcome measures were changes from baseline in : nutrient intake ; physical activity ; anthropometry , glucose tolerance and insulin sensitivity . Measurements were repeated at 6 , 12 and 24 months follow-up . RESULTS After 24 months follow-up , there was a significant fall in total fat consumption ( difference in change between groups ( Delta intervention-Delta control)= -17.9 , 95 % confidence interval ( CI ) -33.6 to -2.1g/day ) as a result of the intervention . Body mass was significantly lower in the intervention group compared with controls after 6 months ( -1.6 , 95 % CI -2.9 to -0.4 kg ) and 24 months ( -3.3 , 95 % CI -5.7 to -0.89 kg ) . Whole body insulin sensitivity , assessed by the short insulin tolerance test ( ITT ) , improved after 12 months in the intervention group ( 0.52 , 95 % CI 0.15 - 0.89%/min ) . CONCLUSIONS These findings complement the findings of the Finnish Diabetes Prevention Study and the American Diabetes Prevention Study , both of which tested intensive interventions , by showing that pragmatic lifestyle interventions result in improvements in obesity and whole body insulin sensitivity in individuals with IGT , without change in other cardiovascular risk factors BACKGROUND Previous studies demonstrated that intensive lifestyle modification can prevent type 2 diabetes mellitus among those with impaired glucose tolerance , but similar beneficial results have not been proved among those with impaired fasting glucose levels . We investigated the efficacy of lifestyle modification on  type 2 diabetes  incidence among those with impaired fasting glucose levels . METHODS The present study was an unmasked , multicenter , r and omized , controlled trial . A total of 641 overweight Japanese ( aged 30 - 60 years ) with impaired fasting glucose levels were recruited nationwide in Japan and r and omly assigned to a frequent intervention group ( n = 311 ) or a control group ( n = 330 ) . For 36 months after r and omization , the frequent intervention group received individual instructions and follow-up support for lifestyle modification from the medical staff 9 times . The control group received similar individual instructions 4 times at 12-month intervals during the same period . The primary outcome was type 2 diabetes incidence in annual 75-g oral glucose tolerance tests , diagnosed according to World Health Organization criteria . RESULTS There were no significant differences between the allocation groups in baseline characteristics and dropout rates . Estimated cumulative incidences of type 2 diabetes were 12.2 % in the frequent intervention group and 16.6 % in the control group . Overall , the adjusted hazard ratio in the frequent intervention group was 0.56 ( 95 % confidence interval , 0.36 - 0.87 ) . In the post hoc subgroup analyses , the hazard ratio reduced to 0.41 ( 95 % confidence interval , 0.24 - 0.69 ) among participants with impaired glucose tolerance at baseline , and to 0.24 ( 0.12 - 0.48 ) among those with baseline hemoglobin A(1c ) levels of 5.6 % or more ( the Japan Diabetes Society method ) . Such risk reduction was not observed among those with isolated impaired fasting glucose findings or baseline hemoglobin A(1c ) levels of less than 5.6 % . CONCLUSIONS Lifestyle modifications can prevent type 2 diabetes  among overweight Japanese with impaired fasting glucose levels . In addition , identifying individuals with more deteriorated glycemic status by using 75-g oral glucose tolerance test findings or , especially , measurement of hemoglobin A(1c ) levels , could enhance the efficacy of lifestyle modifications . TRIAL REGISTRATION umin.ac.jp/ctr Identifier : UMIN000001959 BACKGROUND & AIMS Women with prior gestational diabetes mellitus ( GDM ) have a high risk of developing type 2 diabetes mellitus ( DM2 ) in later life . The study aim was to evaluate the efficacy of a lifestyle intervention for the prevention of glucose disorders ( impaired fasting glucose , impaired glucose tolerance or DM2 ) in women with prior GDM . METHODS A total of 260 women with prior GDM who presented with normal fasting plasma glucose at six to twelve weeks postpartum were r and omized into two groups : a Mediterranean lifestyle intervention group ( n = 130 ) who underwent an educational program on nutrition and a monitored physical activity program and a control group ( n = 130 ) with a conventional follow-up . A total of 237 women completed the three-year follow-up ( 126 in the intervention group and 111 in the control group ) . Their glucose disorders rates , clinical and metabolic changes and rates of adherence to the Mediterranean lifestyle were analyzed . RESULTS Less women in the intervention group ( 42.8 % ) developed glucose disorders at the end of the three-year follow-up period compared with the control group ( 56.75 % ) , p < 0.05 . The multivariate analysis indicated a reduction in the rate of glucose disorders with a BMI of less than 27 kg/m(2 ) ( OR 0.28 ; 0.12 - 0.65 ; p < 0.003 ) , low fat intake pattern ( OR 0.30 ; 0.13 - 0.70 ; p < 0.005 ) , low saturated fat pattern ( OR 0.30 ; 0.13 - 0.69 ; p < 0.005 ) and healthy fat pattern ( OR 0.34 ; 0.12 - 0.94 ; p < 0.04 ) . CONCLUSIONS Lifestyle intervention was effective for the prevention of glucose disorders in women with prior GDM . Body weight gain and an unhealthy fat intake pattern were found to be the most predictive factors for the development of glucose disorders . Current Controlled trials : IS RCT N24165302 . http://www.controlled-trials.com/is rct n/pf/24165302 AIMS This study was conducted to compare the effects of two years of lifestyle intervention to no intervention or one year of intervention on diabetes risk factors in male workers with impaired fasting glucose ( IFG ) or diabetes . METHODS We conducted a r and omized lifestyle intervention trial design ed to alter personal lifestyles among 123 industrial male workers ( CG ; control group , n=75 ; OIG ; one-year intervention group , n=23 ; TIG ; two-year intervention group , n=25 ) . The intervention consisted of two parts , the main program ( face-to-face counseling five times/12 weeks ) and a follow-up program ( e-mail counseling ten times/30 weeks ) . Assessment s included biochemical characteristics , anthropometry and nutrient intake at baseline and after two years . RESULTS After two years , systolic blood pressure , HOMA-IR , HDL cholesterol and total energy intake ( p<0.05 ) were reduced in the OIG group , while weight , body mass index , waist circumference , blood pressure , fasting plasma glucose ( FPG ) , HbA1c and nutrient intake ( total energy , carbohydrate , protein and sodium ) were significantly decreased ( p<0.05 , respectively ) in the TIG group . When compared to the CG , subjects in OIG and TIG showed significant improvements in the level of FPG and HbA1c ( p<0.05 ) . CONCLUSIONS Continuous lifestyle intervention for two years is more effective at improving diabetes risk factors than OIG
target: Conclusions HbA1c is neither sensitive nor specific for detecting pre‐diabetes ; fasting glucose is specific but not sensitive .
  Interventions in people classified through screening as having pre‐diabetes have some efficacy in preventing or delaying onset of type 2 diabetes in trial population s. As screening is inaccurate , many people will receives an incorrect diagnosis and be referred on for interventions while others will be falsely reassured and not offered the intervention .
  These findings suggest that “ screen and treat ” policies alone are unlikely to have substantial impact on the worsening epidemic of type 2 diabetes .
background: & NA ; Objectives To assess diagnostic accuracy of screening tests for  pre‐diabetes  and efficacy of interventions ( lifestyle or metformin ) in preventing onset of type 2 diabetes in people with pre‐diabetes .