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Review • Arch. Endocrinol. Metab. 66 (2) • Mar-Apr 2022 • https://doi.org/10.20945/2359-3997000000441 copy

Effects of lifestyle interventions on glucose regulation and diabetes risk in adults with impaired glucose tolerance or prediabetes: a meta-analysis

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

The prevalence of diabetes mellitus is increasing and is related to sedentary lifestyles and obesity. Many studies were published on the effect of lifestyle interventions on glucose regulation and delay the onset of diabetes in adults with impaired glucose tolerance (IGT) or prediabetes. This study aimed to investigate the role of lifestyle interventions in individuals with IGT or prediabetes using a meta-analytic approach. PubMed, Embase, and the Cochrane Central Register of Controlled Trials databases were searched from their inception up to January 2020 to select eligible randomized controlled trials (RCTs). The weighted mean difference (WMD; for fasting plasma glucose (FPG) and 2-hour plasma glucose (2hPPG)) or relative risk (RR; for the risk of diabetes) with 95% confidence interval (CI) were calculated for pooled effect estimates using the random-effects model. Thirteen RCTs involving 3376 individuals with IGT or prediabetes were selected for this meta-analysis. The results showed that lifestyle interventions were associated with lower FPG (WMD: -0.14; 95% CI: -0.24 to -0.05 mmol/L; p=0.004) and 2hPPG (WMD: -0.66; 95% CI: -1.12 to -0.20 mmol/L; p=0.005) in adults with IGT or prediabetes. Moreover, the risk of diabetes was significantly reduced in individuals who received lifestyle interventions (RR: 0.75; 95% CI: 0.60-0.95; p=0.015). Lifestyle interventions could help improve glucose dysregulation and prevent the progression of diabetes in adults with IGT or prediabetes. Further large-scale RCTs should be conducted to assess the effects of long-term lifestyle interventions on diabetic complications in adults with IGT or prediabetes.

Keywords
Diabetes; adults; glucose tolerance; lifestyle interventions; risk

Study	Country	Sample size	Age (years)	Male (%)	BMI (kg/m²)	Status of participants	Intervention	Control	Follow-up duration	Study quality
Pan 1997 ( ²⁵25 Pan XR, Li GW, Hu YH, Wang JX, Yang WY, An ZX, et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study. Diabetes Care. 1997;20(4):537-44. )	China	530	45.0	283 (53.4%)	25.8	IGT	Dietary and/or exercise individual advice	Information about diabetes and IGT	72.0 months	3
Lindahl 1999 ( ²⁶26 Lindahl B, Nilsson TK, Jansson JH, Asplund K, Hallmans G. Improved fibrinolysis by intense lifestyle intervention. A randomized trial in subjects with impaired glucose tolerance. Journal of internal medicine. 1999;246(1):105-12. )	Sweden	186	55.5	69 (37.1%)	30.6	IGT and obesity	Dietary and physical activity intervention	Usual advice	12.0 months	4
Lindstrom 2003 ( ²⁷27 Lindström J, Eriksson JG, Valle TT, Aunola S, Cepaitis Z, Hakumäki M, et al. Prevention of diabetes mellitus in subjects with impaired glucose tolerance in the Finnish Diabetes Prevention Study: results from a randomized clinical trial. J Am Soc Nephrol. 2003;14(7 Suppl 2):S108-113. )	Finland	522	55.0	172 (33.0%)	31.2	IGT and overweight	Dietary and exercise individual advice	Information about diet and exercise	38.0 months	5
Oldroyd 2006 ( ²⁸28 Oldroyd JC, Unwin NC, White M, Mathers JC, Alberti KG. Randomised controlled trial evaluating lifestyle interventions in people with impaired glucose tolerance. Diabetes Res Clin Pract. 2006;72(2):117-27. )	UK	69	57.9	39 (56.5%)	NA	IGT	Dietary and physical activity advice	No dietary or physical activity advice	24.0 months	3
Kawahara 2008 ( ²⁹29 Kawahara T, Takahashi K, Inazu T, Arao T, Kawahara C, Tabata T, et al. Reduced progression to type 2 diabetes from impaired glucose tolerance after a 2-day in-hospital diabetes educational program: the Joetsu Diabetes Prevention Trial. Diabetes Care. 2008;31(10):1949-54. )	Japan	426	51.4	199 (46.7%)	24.6	IGT	Diabetes education and support	Information about diabetes and IGT	37.0 months	2
Roumen 2008 ( ³⁰30 Roumen C, Corpeleijn E, Feskens EJ, Mensink M, Saris WH, Blaak EE. Impact of 3-year lifestyle intervention on postprandial glucose metabolism: the SLIM study. Diabet Med. 2008;25(5):597-605. )	Netherlands	106	56.3	58 (54.7%)	29.4	IGT	Dietary and physical activity advice	Information about diet and exercise	36.0 months	4
Yates 2009 ( ³¹31 Yates T, Davies M, Gorely T, Bull F, Khunti K. Effectiveness of a pragmatic education program designed to promote walking activity in individuals with impaired glucose tolerance: a randomized controlled trial. Diabetes Care. 2009;32(8):1404-10. )	UK	87	65.0	57 (65.5%)	29.2	IGT	Structured education program	Advice leaflet	12.0 months	4
Bhopal 2014 ( ³²32 Bhopal RS, Douglas A, Wallia S, Forbes JF, Lean ME, Gill JM, et al. Effect of a lifestyle intervention on weight change in south Asian individuals in the UK at high risk of type 2 diabetes: a family-cluster randomised controlled trial. Lancet Diabetes Endocrinol. 2014;2(3):218-27. )	UK	171	52.5	78 (45.5%)	30.5	IGT	Dietary and physical activity advice	Standardized written and verbal advice	36.0 months	4
O’Dea 2015 ( ³³33 O’Dea A, Tierney M, McGuire BE, Newell J, Glynn LG, Gibson I, et al. Can the Onset of Type 2 Diabetes Be Delayed by a Group-Based Lifestyle Intervention in Women with Prediabetes following Gestational Diabetes Mellitus (GDM)? Findings from a Randomized Control Mixed Methods Trial. J Diabetes Res. 2015;2015:798460. )	Ireland	50	NA	0 (0.0%)	35.5	IGT	Multidisciplinary team of nurses, dieticians, and physical activity specialists	Standard healthcare advice	12.0 months	2
Van Name 2016 ( ³⁴34 Van Name MA, Camp AW, Magenheimer EA, Li F, Dziura JD, Montosa A, et al. Effective Translation of an Intensive Lifestyle Intervention for Hispanic Women With Prediabetes in a Community Health Center Setting. Diabetes Care. 2016;39(4):525-31. )	USA	122	43.4	0 (0.0%)	35.3	Prediabetes	Dietary, behavior, physical activity, and weight loss advice	Usual care	12.0 months	3
Nanditha 2016 ( ³⁵35 Nanditha A, Snehalatha C, Ram J, Selvam S, Vijaya L, Shetty SA, et al. Impact of lifestyle intervention in primary prevention of Type 2 diabetes did not differ by baseline age and BMI among Asian-Indian people with impaired glucose tolerance. Diabet Med. 2016;33(12):1700-4. )	India	709	46.0	NA	25.9	IGT	Dietary and physical activity advice	Standard lifestyle modification advice	24.0 months	4
Gokulakrishnan 2017 ( ³⁶36 Gokulakrishnan K, Ranjani H, Weber MB, Pandey GK, Anjana RM, Balasubramanyam M, et al. Effect of lifestyle improvement program on the biomarkers of adiposity, inflammation and gut hormones in overweight/obese Asian Indians with prediabetes. Acta diabetologica. 2017;54(9):843-52. )	India	150	44.5	91 (60.6%)	28.0	Prediabetes and overweight/obese	Dietary and physical activity advice	Standard lifestyle advice	12.0 months	2
Salas-Salvado 2019 ( ³⁷37 Salas-Salvadó J, Díaz-López A, Ruiz-Canela M, Basora J, Fitó M, Corella D, et al. Effect of a Lifestyle Intervention Program With Energy-Restricted Mediterranean Diet and Exercise on Weight Loss and Cardiovascular Risk Factors: One-Year Results of the PREDIMED-Plus Trial. Diabetes Care. 2019;42(5):777-88. )	Spain	248	65.0	NA	32.5	Prediabetes and overweight/obese	Dietary, behavior, physical activity advice	Educational sessions on an ad libitum med-diet	12.0 months	4

Outcomes	Factors	Subgroup	WMD and 95%CI	p-value	Heterogeneity (%)	p-value for heterogeneity	p-value between subgroups
Fasting blood glucose	Country	Eastern	-0.21 (-0.38 to -0.05)	0.009	0.0	0.482	0.512
	Country	Western	-0.12 (-0.23 to 0.00)	0.054	39.9	0.102	0.512
	Mean age (years)	≥ 55.0	-0.21 (-0.30 to -0.12)	< 0.001	0.0	0.597	0.079
	Mean age (years)	< 55.0	-0.12 (-0.35 to 0.11)	0.317	56.2	0.102	0.079
	Percentage male (%)	≥ 50.0	-0.20 (-0.33 to -0.07)	0.003	0.0	0.896	0.484
	Percentage male (%)	< 50.0	-0.10 (-0.29 to 0.10)	0.327	65.8	0.020	0.484
	Mean BMI (kg/²)	≥ 30.0	-0.09 (-0.25 to 0.07)	0.255	60.9	0.025	0.627
	Mean BMI (kg/²)	< 30.0	-0.22 (-0.35 to -0.08)	0.002	0.0	0.917	0.627
	Intervention	Combined	-0.14 (-0.24 to -0.03)	0.009	36.7	0.115	0.229
		Diet	-0.65 (-1.54 to 0.24)	0.152	−	−
		Exercise	-0.45 (-1.00 to 0.09)	0.104	54.5	0.138
	Study quality	High	-0.22 (-0.31 to -0.13)	< 0.001	0.0	0.555	0.062
	Study quality	Low	-0.06 (-0.23 to 0.11)	0.501	41.1	0.147	0.062
2-hour blood glucose	Country	Eastern	-2.23 (-3.27 to -1.19)	< 0.001	−	−	0.002
	Country	Western	-0.51 (-0.91 to -0.11)	0.013	54.5	0.031	0.002
	Mean age (years)	≥ 55.0	-0.66 (-0.93 to -0.40)	< 0.001	0.0	0.957	< 0.001
	Mean age (years)	< 55.0	-1.45 (-2.90 to 0.01)	0.052	79.8	0.026	< 0.001
	Percentage male (%)	≥ 50.0	-1.18 (-1.81 to -0.56)	< 0.001	41.7	0.161	0.010
	Percentage male (%)	< 50.0	-0.32 (-0.89 to 0.25)	0.270	69.6	0.011	0.010
	Mean BMI (kg/²)	≥ 30.0	-0.32 (-0.89 to 0.25)	0.270	69.6	0.011	0.026
	Mean BMI (kg/²)	< 30.0	-1.32 (-2.20 to -0.45)	0.003	55.6	0.105	0.026
	Intervention	Combined	-0.65 (-1.15 to -0.16)	0.010	71.9	0.001	< 0.001
		Diet	-2.48 (-3.58 to -1.38)	< 0.001	−	−
		Exercise	-1.70 (-3.34 to -0.06)	0.043	75.9	0.042
	Study quality	High	-0.64 (-0.92 to -0.37)	< 0.001	0.0	0.928	0.772
	Study quality	Low	-0.67 (-1.93 to 0.60)	0.301	87.5	< 0.001	0.772

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