Prevention of Type 2 Diabetes- Life style modification

with diet and physical activity Vs physical activity alone.

- A comparative literature review
ANIMESH BISWAS


THESIS FOR DEGREE IN HEALTH PROMOTION

YEAR 2006

SUPERVISOR
KOUSTUV DALAL


REVISED VERSION
KAROLINSKA INSTITUTET
Master of Public Health Education
Department of Public Health Sciences

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Report series of Master theses in Public Health

These reports come from the Board of Education in Public Health
Sciences at Karolinska Institutet.
The master education of Public Health at KI is a collaborative work
of mainly three departments: Department of Public Health Sciences,
The Department of Biosciences at Novum , Division of Preventive
Nutrition, and The Institute of Environmental Medicine.
These reports are presented as pdf files on the webbpages of Master
of Public Health Education at Karolinska Institutet



Leif Svanstrm
Professor and Programme Director

3
Abstract
Background: Diabetes is part of the growing epidemic of non communicable
diseases, with a high burden for the society on developing countries in future.
Primary prevention is the realistic way to curb the rise in the diabetes pandemic.
Life style changes aimed to prevention of type-2 diabetes by means of diet and
weight control by physical activities and exercises and dietary modification.
Aim: The aim of this review study is to make a comparative analysis between
lifestyle modifications included diet and physical activity and increased physical
activities alone in prevention of type-2 diabetes.
Method: We have searched PUBMED as source of literature with certain search
criteria towards objective.
Results: Different randomised control trails and prospective studies and literatures
have suggested a strong relationship between lifestyle modification and diabetes
prevention. Lifestyle changes by dietary modification and increased physical
activity reduced relative risk for development of type 2 diabetes rather than
physical activity alone. Leisure time physical activity has shown to be inversely
associated with type 2 diabetes.
Conclusions: Magnitude of lifestyle modification with diet and physical activity
showed most promising event to prevent disease than physical activity alone.
Key Words: Diabetes prevention, diet and exercise, lifestyle, non-insulin
dependent diabetes (Type 2 diabetes).





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Abbreviations

BMI- Body mass index
DM Diabetes mellitus
DPP- Diabetes prevention programme
FDPS- Finnish Diabetes prevention study
LTPA- Leisure time physical activity
IDPP- Indian diabetes prevention programme
IGT- Impaired glucose tolerance
NIDDM- Non insulin dependent diabetes mellitus.
OGTT- Oral glucose tolerance test
SDPP- Stockholm diabetes prevention programme
WHO- World health organization











5
Content

ABSTRACT..................................................................................................................................... 3
DEFINITION AND CONCEPTS.................................................................................................. 6
DIABETES MELLITUS ..................................................................................................................... 6
TYPE-2 DIABETES ......................................................................................................................... 6
COMPLICATION OF DIABETES ....................................................................................................... 7
IMPAIRED GLUCOSE TOLERANCE (IGT)......................................................................................... 7
ORAL GLUCOSE TOLERANCE TEST (OGTT) ................................................................................... 7
BMI (BODY MASS INDEX) ............................................................................................................. 8
PHYSICAL ACTIVITY...................................................................................................................... 8
EXERCISE...................................................................................................................................... 8
INTRODUCTION .......................................................................................................................... 8
BACKGROUND........................................................................................................................... 10
GLOBAL PREVALENCE OF DIABETES............................................................................................ 10
RISK FACTORS............................................................................................................................. 12
BODY WEIGHT AND DIABETES..................................................................................................... 12
PHYSICAL ACTIVITY AND DIABETES ............................................................................................ 12
DIET AND DIABETES.................................................................................................................... 13
PRIMARY PREVENTION................................................................................................................ 14
HEALTH PROMOTION CONCEPTS IN DIABETES PREVENTION......................................................... 14
AIM................................................................................................................................................ 16
METHODS.................................................................................................................................... 17
DATA COLLECTION..................................................................................................................... 17
DATA ANALYSIS ......................................................................................................................... 18
RESULTS...................................................................................................................................... 19
DISCUSSION................................................................................................................................ 25
LIMITATION OF STUDY................................................................................................................ 28
RECOMMENDATION..................................................................................................................... 28
CONCLUSION............................................................................................................................. 29
REFERENCE................................................................................................................................ 30

6
Definition and concepts
DIABETES MELLITUS
Diabetes is a clinical syndrome characterized by hyperglycemia due to absolute or
relative deficiency of insulin, (Haslett et al. 2002).Diabetes is usually irreversible
and patients can lead a reasonably normal life style. Lack of the key hormone,
insulin in the body secreted from beta cell of pancreas of human body affects the
metabolism of carbohydrate, protein and fat and causes significant disturbances of
water and electrolyte homeostasis. There are 3 types of diabetes: Type 1, Type 2
and Gestational diabetes (Haslett et al. 2002).
Blood glucose levels are closely regulated by insulin, major regulator of
intermediary metabolism. The principal organ of glucose transport is liver which
store glucose as glycogen and release in the peripheral tissue when need.
TYPE-2 DIABETES
It is the most common type of diabetes which is also called non-insulin dependent
diabetes that usually happens in the adult age. It is a metabolic disorder has two
metabolic defects, impaired insulin action and insufficient insulin secretion to
compensate for the degree of insulin resistance. Disease may undiagnosed for
many years caused increased risk of complications (Wass and Shalet 2002). Type-
2 diabetes is relatively common in all population enjoying affluent lifestyle. The
four major determinants for development of typt-2 diabetes mellitus are increase
in age, obesity, ethnicity and family history (Kumar and Clark 2005).
Diet and physical exercise have a marked effect in deferring the onset of type2
diabetes (Kumar and Clark 2005).Epidemiological studies have shown that
lifestyle changes with diet and physical activity can prevent development of type-
2 diabetes. (Pan et al. 1997, Tuomilehto et al. 2001, Knowler et al. 2002, Kosaka ,
Noda & Kuzuya ,2005 and Ramachandran et al 2006).

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COMPLICATION OF DIABETES
Diabetes complication leads to death due to cardiovascular problem in 70% cases
and 10% in renal failure and 6% due to infections. Duration and degree of
hyperglycemia play a major role in production of complications (Kumar and
Clark 2005).
1) Micro vascular complications: Arthrosclerosis
2) Macro vascular complication: In retina- Diabetes retinopathy, in renal
glomerulus- Diabetes nephropathy and in nerve sheath- Diabetes neuropathy.

IMPAIRED GLUCOSE TOLERANCE (IGT)
IGT is not a clinical entity but a risk factor for future diabetes. Obesity and lack of
regular physical exercise make progression to frank diabetes more likely.
Fasting plasma glucose between 6.1 and 6.9 mmol/L is not a clinical entity but
does predict future risk of diabetes. Diet and increased physical daily exercise as a
part of life style modification reduce weight; trunkal fat and glucose sensitivity to
the tissue make marked effect in onset of diabetes mellitus (Haslett et al. 2002).
ORAL GLUCOSE TOLERANCE TEST (OGTT)
OGTT is the accepted standard for the diagnosis for diabetes. It involves the
administration of 75 gm glucose to a person who has been an a diet contains at
least 250gm carbohydrate payday over the previous three days and who has fasted
overnight prior to the test. Plasma glucose is measured before and tow hour after
consumption of the glucose done. (Wass and Shalet, 2002)

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BMI (BODY MASS INDEX)
Body mass index (BMI) is a marker to measure of body fat. Obesity detected by
measuring BMI and obesity is a high risk factor associated with increased insulin
resistance and that causes development of type 2 diabetes. It is measured by body
weight (in kilograms) divided by the square of the height (in meters). BMI is
normal from 18.5 to 24.9kg/m
2
, more than 25kg/m
2
is called overweight and
above 30kg/m
2
is called obese (Ganong 2005).
PHYSICAL ACTIVITY
It maybe defined as bodily movement produced by the contraction of skeletal
muscle that requires energy expenditure in excess of resting energy expenditure
(Ronald et al. 2004).
EXERCISE
Definition is based on physical activity and health the 1996 report of the
surgeon general, Exercise is a subset of physical activity: Planned, structures and
repetitive bodily movement preformed to improve or maintain one or more
component of physical fitness. In the present view the terms physical activity
and exercise will be used interchangeably (Ronald et al. 2004)

Introduction
Health promotion is the process of enabling people to increase control over their
health and its determinants, and thereby improve their health (WHO, 2005). Is not
just the responsibility of the health sector, but goes beyond healthy lifestyles to
wellbeing three basic strategy of health promotion is Advocate, enable and
mediate (WHO,1986). Health promotion is used as the prevention of disease often

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through targeting high risk groups who have an increased chance of developing a
specific disease and as an umbrella in aspects of health education. Health
promotion concepts used in behavioral changes in individuals in order to get
health lifestyle and create supportive environment for primary prevention of
diseases like diabetes (Naidoo and Wills 2000).
Diabetes is one of the most costly and burdensome chronic disease increasing
tends to be an epidemic problem throughout the world, (King, Aubert & Herman,
1998). The global pandemic principally involves type 2 diabetes (Haslett et al,
2002). The dramatic worldwide increase in the prevalence of type2 diabetes is
posing a massive health problem in both developed and developing countries.
Interestingly .in developed countries, lower socioeconomic group are most
affected while in developing countries it is reverse (Shaw &Chisholm, 2003).The
complications resulting from the disease are significant causes of morbidity and
mortality and are associated with danger or failure of various organs like eyes,
kidneys and nerves(American diabetes association 2002).
Type 2 diabetes has long been connected with behavioral and environmental
factors such as overweight, physical inactivity and dietary habits (Narayan
Bowman & Engelgau, 2001). Major lifestyle changes resulting from
industrialization are contributing a rapid rise in diabetes worldwide. Life style
intervention has shown effective significant changes over control in body weight
and improving insulin sensitivity and that causes prevention of diabetes
(American diabetes association 2005).Physical activity alone plays a pivotal role
in health promotion and diabetes (American diabetes association 2003).
This study reviews the recent concepts on association between lifestyle
modification with increased physical activity plus change in diet and physical
activity alone in primary prevention of diabetes. Health promotional concepts on
primary prevention of diabetes could be helpful in empowerment, education,
strategy, policy making and create supportive environment in prevention of
disease.

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Background
The number of people with diabetes is due to increasing population growth, aging,
urbanization and increasing prevalence of obesity and physical activity (Wild et
al. 2004)
In developing countries, the majority of people with diabetes age groups are 35-64
years, while in developed countries people suffers more above 64 years of ages. It
is estimated that by year 2030, the number of people with diabetes ages64+ will
be more than 82 million in developing countries and 48 million in developed
countries (Wild et al. 2004).
GLOBAL PREVALENCE OF DIABETES
According to the World Health Organization (WHO, 2006), diabetes mellitus
affects at least 171 million people and causes 3.2 million deaths, six deaths every
minute and 8700 deaths everyday. WHO estimates that in 2030 there will be an
increase of 70% in the number of cases of diabetes in developed countries, and
42% in developing countries. Currently the overall direct health care costs of
diabetes mellitus ranges from 2.5% to 15% of annual health care budgets of
developed and developing countries. This is likely to affect 366 million people by
2030 (WHO, 2006). In this report, WHO has also anticipated that number of
people with diabetes will be more than double in 2030 as a consequence of
population aging and urbanization.
There are two types of diabetes consisting of type-1 and type-2. The growing
incidence of type2 diabetes accounts for more than 90% of all diabetes cases and
the increased risk of premature illness and death and cardio vascular diseases with
diabetes. In developing countries those most frequently affected are in the middle,
productive years of their lives, aged between 35 and 64( WHO, 2006).
Wild et al ranked the countries with the largest numbers of diabetes (Table.1)

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Table 1 Countries with the highest numbers of estimated cases of diabetes for 2000 and 2030
Year 2000 Year 2030
Ranking Country People with
diabetes
(Millions)
Country People with
diabetes
(Millions)
1 India 31.7 India 79.4
2 China 20.8 China 42.3
3 U.S. 17.7 U.S. 30.3
4 Indonesia 8.4 Indonesia21.3
5 Japan 6.8 Pakistan 13.9
6 Pakistan 5.2 Brazil 11.3
7 Russian Federation 4.6 Bangladesh 11.1
8 Brazil 4.6 Japan 8.9
9 Italy 4.3 Philippines 7.8
10 Bangladesh 3.2 Egypt 6.7

Wild et al reports showed that women suffer more than men; there is a clear
association with age, as diabetes more often occurs 35-64 years of ages (Wild et
al. 2004)

Figure 1Global diabetes prevalence by age and sex for 2000

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RISK FACTORS
Different risks factors are associated with type 2 diabetes. Increased body weight
and insulin insensitivity causes increase blood glucose level is responsible for
diabetes. Gadsby R (2002) has noted different risk factors involve type 2 diabetes.
Those are increased of age, gender, country and place of residence, ethnicity,
socioeconomic status, lifestyle (physical inactivity & diet) and obesity.
BODY WEIGHT AND DIABETES
1. Relation with increased weight, obesity and diabetes:
Obesity is the most common nutritional problem is measured with the indicator of
body mass index (BMI). As body weight increases, insulin resistance also
increases, which decreases the ability of insulin to move glucose into fat and
muscle and to shut off glucose release from the liver and weight reduction
decreases insulin resistance (Ganong 2005).
2. How obesity influences on insulin?
The fat produces a chemical signal or signals that act on muscle and the liver to
increase insulin resistance. This includes glucose transporters selectively knocked
out in adipose tissue and there is an associated decrease in glucose transport in
muscle in vivo. (Ganong 2005)
PHYSICAL ACTIVITY AND DIABETES
1. Relation with physical activity/exercise and diabetes:
Physical activity has been shown to be inversely related with obesity and fat
distribution, particularly visceral obesity. Studies have shown that physical
activity may reduce risk of type-2 diabetes both directly by improving insulin
sensitivity and indirectly by producing beneficial changes in body mass and body
composition (Kriska, 2003).

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2. How physical activity influences on Insulin?
The entry of glucose into skeletal muscle is increased during exercise in the
absence of insulin by causing an insulin independent increase in the number of
GLUT-4 transporters in muscle cell membrane, increase in glucose entry persists
for several hours after exercise and regular exercise training can produce
prolonged increase in insulin sensitivity. (Ganong 2005)
During physical activity whole body oxygen consumption may increase as much
as 20 fold and even more in the working muscles. To meet the energy needs under
these circumstances, skeletal muscle and its storage of glycogen and triglyceride,
free fatty acid (FFA) from the breakdown of adipose tissue, triglycerides and
glucose that release from the liver (American diabetes association, 2003).
DIET AND DIABETES
1. Relation with diet and diabetes
Daily diet intake has a role on increased weight, central obesity and insulin
resistance and causing future developing of diabetes. There are growing evidences
that an increased level of free fatty acid and more importantly the relative amounts
of saturated and unsaturated fatty acids play an important role in development of
insulin resistance. Cross sectional epidemiological studies demonstrate positive
associations between intake of saturated fat and heyperinsulinemia (Dippenaar &
Haag 2005).
2. How diet play role on Insulin?
Diet with high saturated fat causes decreased the insulin sensitivity and insulin
resistance that progress to dysfunction of pancreatic beta cells and causes
diabetes. Several large prospective cohort studies showed negative association
between dietary fiber intake and risk of developing type 2 diabetes. (Bazzano,
Serdula & Liu 2005).

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PRIMARY PREVENTION
Prevention is essential to delay and protects from the disease. Primary prevention
identifies high risk individuals and from developing diabetes. Different studies
suggested that primary prevention of type-2 diabetes can be possible. Health
education has shown promising results in the primary prevention of type 2
diabetes (Haslett et al. 2002).Life style changes with diet and physical activity
have proven scientifically in clinical trials that diabetes can be preventable among
high risk groups by dietary habit changes and regular physical activity. (Pan et al.
1997, Tuomilehto et al. 2001, Knowler et al. 2002, Kosaka , Noda & Kuzuya
,2005 and Ramachandran et al 2006).

Some condition that should meet to justify initiating a programme to prevent the
diseases are as follows:
1) Risk factors associated with diabetes: It should be noted that when risk factors
combined with increased glucose levels are more predictive of future diabetes.
2) There should be a test to detect the pre disease state that is safe, acceptable and
predictive. Test like fasting plasma glucose (FPG) and oral glucose tolerance test
(OGTT) .Positive value either is predictive of development of diabetes.
HEALTH PROMOTION CONCEPTS IN DIABETES
PREVENTION
In Ottawa Charter 1986, Health promotion concepts was used to advocate people
to creation of conditions favorable to health, enabling by create a supportive
environment and mediation between different groups to ensure the pursuit of
health (WHO 1986).
Health promotion concept has been used in primary prevention of diabetes by
Canadian diabetes association and Diabetes-Austria and they used useful steps in
order to prevent diabetes. Canadian diabetes association in 2001 finds out each

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direction to establish a broad goal and identify the critical issues and actions and
intensive lifestyle interventions to prevention diabetes. Those steps are Provision
of professional education, Creation of awareness and increased public education,
Building capacity, Creation of healthy public policy and legislation, increased
research and Creation of supportive environments for health (Canadian Diabetes
Association & Newfoundland and Labrador Division, 2001).
According to Diabetes Australia-Victoria (2004), Health professionals can play a
key role in prevention of type 2 diabetes and pre-diabetes in their local
communities by-
Raising awareness of the risk factors, symptoms and complications of diabetes
Educating people about how they can reduce their risk of developing type 2
diabetes
Promoting early diagnosis and treatment of pre-diabetes and diabetes
Participating in activities that aim to provide supportive environments for physical
activity and
Healthy eating, such as advocacy and community action. (Diabetes Australia,
Victoria 2005).
Diabetes prevention unit in Karolinska Hospital, Stockholm have developed a
programme The Stockholm diabetes prevention programme (SDPP), and
addressed community development, policy advocacy, education, life style changes
and supportive environment. The programme has focused on preventable
behavioral risk factors known to cause type 2 diabetes such as physical activity,
obesity, tobacco use and a high fat/low diet. SDPP developed an effective health
promotional model for healthy outcome and prevention of type 2 diabetes by life
style changes (Andersson et al. 2002). This model is a useful tool to prevent
diabetes by lifestyle changes in the community level and reduced incidence of
diabetes.
Figure 2: An effect model of the health promotion process of SDPP, Source: (Andersson
et al. 2002).

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Aim
The aim of this review study is to make a comparative analysis between lifestyle
modification with diet and physical activity and increased physical activities alone
in prevention of type 2 diabetes.
Research questions:
1. What is the role of life style modification with diet and physical activity in
prevention of type 2 diabetes?
2. Which intervention (Among the above two) is effective in health
promotion perspective?

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Methods
DATA COLLECTION
We have searched Journal database PUBMED for all resource articles by using
search words-Diabetes prevention, diet and exercise, lifestyle, non insulin
dependent diabetes and found 11 articles. Among them five articles related with
lifestyle modification and six articles with physical activity alone. We were using
certain criteria in order search those articles.
Inclusion criteria:
Randomized control trails for lifestyle intervention studies and perspective studies
for physical activity. Duration of all studies have chosen from 1 January 1991 to 1
may 2006, in english and in human.
All studies samples were in risk group of developing diabetes.
Exclusion criteria:
No studies have chosen among diabetes subjects for prevention.
No studies have chosen associated with others diseases like cardiovascular
diseases.
Few articles have published on lifestyle modification .Among those randomized
controlled trails have shown significant results. Articles related with Lifestyle
modification in diabetes prevention, the following search words were initially
used: diabetes prevention and life style and diet and exercise. When using in
combination-Diabetes prevention and lifestyle and limit those articles from
1January, 1991 to 1May 2006, In Human, English, clinical and randomize control
trails we found 72 articles. Only four articles found relevant. In another search
using combination- Diabetes prevention and diet and exercise and limit those

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articles from 1January, 1991 to 1May 2006, In Human, English, clinical and
randomize control trails we again found 72 articles and selected one article to
review. Finally we have got in total five full articles which have categorized for
randomized control trial. We have read those articles and approved for review.
Articles related with Physical activity alone and diabetes prevention, there were
no randomized controlled trials published, most of them perspective studies with
long duration of follow up and showed results. We have used the following search
words: physical activity and non-insulin dependent diabetes and limit those
articles from 1 January1991 to 1 May 2006, in Human, English, we have found
745 articles. But initial screening showed that six full articles have fulfilled our
objective to see single association with physical activities in prevention of type 2
diabetes. We have read the articles and accepted for our studies.

Search word used: Diabetes prevention, diet and exercise, lifestyle, non insulin
dependent diabetes.
DATA ANALYSIS
We have used database, PUBMED for articles selection and found 11 articles in
total with full text. Among them five articles with lifestyle interventions used
randomized controlled trails and six articles with physical activity alone were
perspective studies. Then read all papers and formulated our results in two
different tables, one for lifestyle modification and another for physical activity. In
order to analysis those results, we discuss in brief and make a comparative
discussion with two different results and concludes with which interventions
showed more effectiveness.



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ResuIts
Lifestyle intervention studies have shown reduced relative risk of diabetes
significantly with diet and physical activity. In Those studies, intervention group
compared with controlled group where intervention group were instructed by diet and
regular physical activity counseling. The Da Qing study (1997) shown 42%, The
Finish Diabetes Prevention Study, FDPS (2001) and the diabetes prevention
programme in US, DPP (2002) shown 58%, A Japanese trail (2005) shown 67.4%
and Indian Diabetes Prevention programme, IDPP (2006) shown 28.5% relative
risk reduction during different follow up time. It was demonstrated that life style
intervention by proper diet and increased moderate level of physical activity was
an effective method to reduce progression to diabetes and that causes significant
relative risk reduction in long term follow up (Table-3).

Studies related with physical activity alone in diabetes prevention in this reviewed
six articles agreed on several points and shown as an important modifiable factor
in the prevention of diabetes.
Manson J.E. et al study has examined the association between regular vigorous
exercise and the subsequent incidence of NIDDM in a prospective cohort 87,253
US nurses in 1991 and found 1303 cases of diabetes in 8 years follow up. In 1992,
Manson J.E. et al done another study on 21,271US male physicians to find out the
association between regular exercise and the subsequent development of NIDDM
in a prospective cohort and found 285 cases of diabetes in five years follow up.



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Kriska et al (2003) study has examined the longitudinal association among
physical activity, body mass index and development of type 2 diabetes in Pima
individuals and has found 346 cases of diabetes among 1728 subjects during six
years follow up. Hu et al (2004) in their study have examined the single and joint
association of physical activity, body mass index and blood glucose levels with
the risk of type 2 diabetes prospectively in Finnish individuals and found 120
cases of diabetes during 9.4years follow up. Meisinger et al study has examined
sex specific association between leisure time physical activity and incident type 2
diabetes in Germany and found 227cases of diabetes. Finnish diabetes study group
have found association between leisure time physical activity and diabetes
prevention and 107 new cases were found during 4.1 years follow up (Table 4).

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Table 3. Results from large randomized, controlled clinical trail in primary prevention of type 2 Diabetes by lifestyle intervention.
Title and journal Background Study design Results Conclusions/ Interpretation.
Effects of diet and exercise in
preventing NIDDM in people with
impaired glucose tolerance.
The Da Qing IGT and diabetes study.
Author: Pan XR et al
Journal: Diabetes care
Date: April 1997
The purpose of the study
was to determine whether
diet and exercise
interventions in those with
IGT may delay the
development of NIDDM,
that causes reduce
incidence of NIDDM.
Study: Randomized control trial
Sample size-557individuals with impaired glucose
tolerance.
Study group- control and intervention group with
diet alone, exercise alone, diet and exercise
combined arm.
Follow up period: 6 years


Relative risk
reduction with Diet
alone 31%,
Exercise alone
46%,
Combined Diet and
exercise 42%
Diet and / or exercise interventions
lead to a significant decrease in the
incidence of diabetes.
Prevention of type 2 diabetes
mellitus by change in lifestyle among
subjects with impaired glucose
tolerance.
Author: Tuomilehto et al
Journal: The New England journal of
medicine
Date: 3 May,2001
Primary prevention of
T2diabetes is the most
powerful way to prevent
diabetes and its
complication. It need to
investigate whether type 2
diabetes prevented by
interventions that affect
lifestyle.
Study-Randomized control trial
Sample size: 522 (172men, 350women) with
impaired glucose tolerance test and Overweight,
BMI- >25kg/m
2
Study group: Control and lifestyle intervention
group with diet and physical activity.
Follow up period: 3.2 years

Relative risk of
diabetes was
reduced by 58% in
the intervention
group.
The reduction of incidence of
diabetes was directly associated
with number and magnitude of
lifestyle change. The average
weight reduction by diet and
physical activity reduced the
incidence of disease.
Reduction in the incidence of type 2
diabetes with lifestyle intervention.
Author: Knowler WC et al
Journal: The New England journal of
medicine.
Date: 7
th
February 2002
Modified of diet and
physical activity with a
life style intervention
programme would prevent
or delay the development
of disease.
Study-Randomized control trial
Sample size: 3234 non diabetic
Study group- Control: Placebo pills plus diet instruction,
exercise and behavior modification, Intervention group-
1. Lifestyle: Intensives individual diet instruction, exercise and
behavior modification.
2. Metformin plus some information on diet and exercise and
annual individual session
3. Troglitazone- discontinued after discover of nephrotoxycity.
Follow up period: 2.8years
Relative risk
reduction Life style
58%, Metformin is
31%
Study shown that life style
modification was particularly
effective than Metformin and
reduce incidence of diabetes in
person at high risk.

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Title and journal Background Study design Results Conclusions/Interpretation.
Prevention of type 2 diabetes by
lifestyle intervention. A Japanese
trial in IGT males
Author:
Kosaka K, Noda M, Kuzuya T.
Journal:
Diabetes Research and Clinical
Practice
Date:
February 2005
Prevention of type 2
diabetes by intensive
lifestyle intervention
designed to achieve and
maintain body weight was
assessed in subjects with
impaired glucose
tolerance
Study: Randomized control trail
Sample size: 458 male with IGT.
Study group: Control: advise to maintain BMI by
diet and exercise. Intervention group: Detailed
instruction of lifestyle (Diet and physical activity)
was repeated every 3-4 months hospital visits.
Follow up period: 4 years.
.
Relative risk
reduction was
67.4%in
intervention group
with diet and
regular physical
activity.
Lifestyle intervention aimed at
achieving ideal body weight in
men with IGT is effective means
of reducing incidence of type 2
diabetes.
Title:
Lifestyle modification and
metformin prevent type 2 diabetes in
Asian Indian subjects with impaired
glucose tolerance(IDPP-1)
Author:
Ramachandran A et al
Journal:
Diabetologia
Date:
February 2006

The benefit of lifestyle
modification in subjects
with IGT is unknown.
This study has design to
investigate whether
lifestyle modification
could be effective in
prevention of disease.
Study: Randomized control trail
Sample size:531 subjects with IGT
Study group: Control and intervention group-
1.life style modification (LSM) by diet and
physical activity.
2. Treated with Metformin(MET),
3. Given LSM plus MET.
Follow up period : 30months
.

Relative risk
reduction was
maximum in LSM
28.5%, 26.4% with
MET and 28.2%
with LSM+ MET
as compared with
the control group.
Study showed that lifestyle
modification involving moderate
but consistent physical activity and
diet modification help to prevent
diabetes. Addition of Metformin to
LSM didnt enhance the
effectiveness.





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Table 4. Results from trail on physical activity alone in primary prevention of type 2 diabetes.
Title and Journal Background Study design Results Interpretations
Physical activity and incidence of non
insulin dependent diabetes mellitus in
women
Author: Manson J.E. et al
Journal: The lancet
Date: 1991
The potential role of physical
activity in the primary prevention
of NIDDM has not been widely
investigated. It examined the
association between physical
activity and subsequent incidence
of clinical NIDDM.
Sample size: 87253 US women
with free of DM.
Age- 34-59 years.
Follow up period- 8 years.
Methods: Questionnaire on
physical activity.
1303 cases of
NIDDM were
identified
compared with
sedentary
women.

Physical activity appears to have an
important role in the prevention of
NIDDM through its association with
reduced body weight and through
independent effects on insulin
resistance and glucose tolerance.
A prospective study of exercise and
incidence of diabetes among US male
physicians.
Author: Manson J.E. et al
Journal: The Journal of the American
medical association.
Date: 1
st
July, 1992
It was need to investigate the
association between regular
exercise and the subsequent
development of non insulin
dependent diabetes mellitus.
Sample size: 21,271 US male
physicians with free of DM.
Age- 40-84 years
Follow up Period- 5 years
Methods:

285 new cases of
NIDDM were
detected.

Exercise appears to reduce the
development of NIDDM even after
adjusting for body mass index.
Increased physical activity may be a
promising approach to the primary
prevention of NIDDM.
Physical activity, obesity and incidence of
type 2 diabetes in a high risk population
Author: Kriska AM et al
Journal: American journal of epidemiology
Date: 7 April, 2003.
Previous study has shown physical
activity in conjunction with diet
and weight loss can prevent
diabetes. It is likely that Physical
activity can play an independent
role in the prevention of type2
diabetes from its effect on weight
loss and body composition.
Sample size- 1,728 individuals
with free of DM.
Age- 15- 59 years
Follow up period: 6 years
Methods: Physical activity
questionnaire.
346 cases of
NIDDM were
detected.
The results suggest that the adoption
and maintenance of a physical active
lifestyle can play a significant role in
preventing type 2 diabetes.
Physical activity, body mass index and risk of
type 2 diabetes in patients with normal or
impaired glucose regulation
Author:Hu G et al
Journal: Archives of internal medicine Date: 26
April, 2004
Sedentary lifestyle, obesity and
impaired glucose regulation are
associated with the risk of type 2
diabetes. However the joint
associations of those risk factors
are not known.
Sample size - 2017 men and
2352women with free of DM..
Age- 45- 64 years
Follow up period: 9.4 years
Methods: Self administrated
questionnaire
120 incident
cases of NIDDM
were detected.
The protective effect of physical activity
was observed in subjects with an excessive
BMI and elevated glucose levels. Physical
activity and weight control are critical
factors in diabetes prevention in subjects
with both normal and impaired blood
glucose regulation.

24


Title and Journal

Background

Study design

Results

Interpretations
Leisure time physical activity and the risk
of type 2 diabetes in men and women from
the general population. The
MONICA/KORA Augsburg study
Author: Meisinger C et al
Journal: Diabetologia
Date: January 2005
A number of prospective studies
reported that higher level of
physical activity reduced risk of
type 2 diabetes. Data on the
association of physical activity and
risk of type 2 diabetes in men and
women from the gnarl population
are rather scarce.
Sample size: 4,069 men and
4034 women with free of DM.
Age: 25- 74years
Follow up period-7.4 years.
Methods: Follow up
questionnaire.
Men was 145
and 82 among
women of
NIDDM were
detected.
Leisure time physical activity is
effective in preventing type 2 diabetes,
especially in non obese women in the
general population.
Physical activity in the prevention of type 2
diabetes. The Finnish diabetes prevention
study.
Author: Laaksonen D.E. et al
Journal: Diabetes
Date: January 2005.
Clinical trials have identified
lifestyle changes can prevent type
2 DM. But importance of leisure
time physical activity (LTPA) is
still unclear.
Sample size: 487 men and
women with free of DM.
Age: 40-65 years.
Follow up period: 4.1 years.
Methods: LTPA questionnaires.
107 new cases of
DM were
diagnosed.
Increased moderate to vigorous and
strenuous , structured LTPA strongly
decreased the risk of type 2 diabetes,
LTPA decrease the risk of diabetes
through mechanisms beyond weight
loss alone.

25

Discussion
Association with lifestyle changes including diet and physical activity
Lifestyle modification with diet and physical activity has shown strong evidence
in primary prevention of diabetes in last decade studies. The Da Qing study
(1997) study had investigated exercise alone, diet alone, diet and exercise. It
compared with control group and shown lifestyle interventions were more
effective in those participants with a lower index of insulin resistance and higher
index of insulin secretion. Low caloric diet and physical activity one unit per day
reduced incidence of diabetes. There were no significant differences in
effectiveness between a change in diet and a change in exercise habit alone.
Tuomilehto et al (2001) study provide evidence that type 2 diabetes can be
prevented by changes in the lifestyles of both men and women at high risk . Over
all incidence of diabetes was reduced by 58 percent. The lifestyle intervention
with diet and physical activity were given advice about how to achieve goals by a
reduction in weight of 5% or more, in total intake of fat to less than 30 percent of
energy consumed, and in intake of saturated fat to less than 10 percent of energy
consumed, an increase in fiber intake to at least 15g per 100kcal and moderate
exercise for at least 30 minute per day. Similar study by Knowler WC (2002) has
shown the incidence of diabetes was reduced by 58% with the lifestyle
intervention. They investigate lifestyle compare with oral hypoglycemic drugs.
Lifestyle intervention were to achieve and maintain a weight reduction of at least
7 percent of initial body weight through a healthy low caloric, low fat diet and to
engage in physical activity of moderate intensity, such as brisk walking for at least
150 minute per week. Kosaka et al (2005) study have presented prevention of type
2 diabetes by intensive lifestyle intervention achieved by maintaining ideal body
weight was an effective means to reduced incidence and risk reduction. After
effective diet control and moderate exercise, such as walking 30-40 min a day
reduced weight 2.18kg in the intervention group during 4 years follow up. Most

26
recent study in India has shown the similar outcome compared with Diabetes
prevention program (DPP) in the USA. This study has shown lifestyle
modification involving diet and enhances physical activity helps to delay or
prevent the progression of IGT to diabetes. Compare with pharmaceutical agent,
lifestyle intervention had 28.5% risk reduction of diabetes during 30 months
follow up. Physical activity was demonstrated by motivated to walk briskly for at
lat 30 min each day and dietary advised included reduction of total calories,
refined carbohydrate and fat, avoidance of sugar and inclusion of fiber rich foods.
Association with physical activity alone and type 2 diabetes
Physical activity has shown alone as an important factor to prevent diabetes. It is
found studies in 1991 and 1992 by Manson et al among US nurses and men
physician have shown vigorous exercise in prevention of diabetes. Kriska et al.
(2003) study estimated total physical activity by the combination of occupational
and leisure activity and leisure physical activity was the largest contributor to total
physical activity levels. Increased Leisure time physical activity and subsequent
development of type 2 diabetes was first found in Helmrich et al. (1991) and then
Kriska et al. (1993) found the same findings in Pima men and women. Recent
study by Meisinger C et al. (2004) shown leisure time activity reduce the risk of
diabetes. Most recently the Finnish diabetes prevention study has shown increased
moderate to vigorous leisure time physical activity (LTPA) or strenuous,
structured LTPA was responsible to develop diabetes (Laaksonen et al 2005).
Effectiveness of lifestyle intervention with diet and physical activity in
compare with physical activity alone
In last decade life style modification in combined with diet and physical activity
have shown the most powerful evidence to prevent type 2 diabetes. DPP study,
FDPS study, IDPP-1 study and a Japanese trail in IGT males have shown
significant reduction of risk of diabetes with dietary restriction and moderate daily
physical activity. In DPP study, lifestyle modification compared with oral
diabetic drug Metformin and 16 lesson curriculum include a low caloric, low fat
diet and engaged in physical activity of moderate intensity were given. While,

27
FDPS and Japanese study compared lifestyle group with control group. In FDPS
Study, intervention group had sessions with nutritionist and received guidance on
increasing level of physical activity and dietary advice. In Japanese study,
intervention group were instructed of lifestyle in every three to four months
monitoring. Only The Da Qing study in china has shown results in exercise alone
and emphasis was given on increase rate of leisure physical activity, primarily
walking. Follow up evaluation was done every two year intervals. Even though
results was significant with combination with diet and exercise that reduced
relative risk rather than exercise alone. All studies were compared with control
group for duration period of time. IN 1991, The 6 year Malmo feasibility studies
supported those lifestyle intervention studies and conclude that long term
intervention in the form of diet and physical exercise and enduring weight loss is
feasible to metabolic improvement, weight reduction and may contribute to
prevent or postpone manifest diabetes. (Eriksson & Lindgarde 1991).
Studies related with physical activity were mostly prospective studies; physical
activity was assessed on given specific physical activity questionnaires and follow
up for a long duration. There were none of physical activity groups were tested
with controlled groups. So it is difficult to identify that only physical activity is
much better option than lifestyle intervention for diabetes prevention. Recently
one randomized control trial evaluated the effectiveness lifestyle intervention in
people with IGT by nutrient intake, physical activity, glucose tolerance and
insulin sensitivity and found that pragmatic lifestyle intervention in improvements
in obesity and whole body insulin sensitivity in individuals with IGT. These
findings complement the findings of the DPP and FDPS study, (Oldroyd et al.
2005).
Most successful outcome of diabetes prevention can be performed on health
promotional ground by awareness, diabetic education, creating Supportive
environment, empowerment and advocacy. Logic model of Stockholm diabetes
prevention programme is a useful tool to reach the goal in the community level
prevention.

28

LIMITATION OF STUDY
Till now only five randomized control trails have published on lifestyle
modification that have shown significant results in reduced incidence of diabetes.
Most of the lifestyle modification studies designed with the intervention group
while diabetic drugs used with control group. Only one study compares with
different arms: with diet alone, exercise alone, and diet plus exercise. So without
large number of studies it is difficult to generalize the hypothesis that life style
modification has better effects than only physical activities. In physical activity
alone in prevention studies, there were no randomized control clinical trial
compare with the control group for a period of time.

RECOMMENDATION
Studies have shown significant results on lifestyle intervention in primary
prevention of type 2 diabetes. Lifestyle changes included increased in daily
physical activity and diet modification were reduced the risk of diabetes. It needs
to put due emphasis on lifestyle changes in individuals with high risk with
impaired glucose tolerance (IGT), obese and overweight people in order to
primary prevention.

29

ConcIusion
The reviewed five large randomized clinical trials have shown that lifestyle
intervention with dietary changes and moderate physical activity significantly
reduced the rate of conversion to diabetes among high risk groups than physical
activity alone and it reduced the risk of future complication and reduces morbidity
and mortality. It needs to be tested those clinical trails in health care system in the
community and development of health promotional initiatives to prevent such
conditions. The promise of achieving primary prevention of diabetes by lifestyle
intervention should be consider as health policy issue. Further studies needed in
randomize clinical trails to find out the association with physical activity alone
(Leisure time activity) and lifestyle modification.
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