LIFESTYLE REDESIGN AND TYPE 2 DIABETES 1

Systematic Review: Evaluating the effects of Lifestyle Redesign on reducing risk factors for type
2 diabetes in adults.

Tara N. Sivulka and Tayler C. Stokes

University of Utah Department of Occupational and Recreational Therapies

Introduction
LIFESTYLE REDESIGN AND TYPE 2 DIABETES 2

In the United States, almost half (48.3%) of adults 65 years old and older have

prediabetes and over half of those over the age of sixty have metabolic syndrome. These two

groups are at a greater risk for developing type 2 diabetes (Kramer, et al., 2018). An estimated

69% of adults in the United States are overweight, which increases an individual’s risk for

developing type 2 diabetes. Increasing physical activity and decreasing weight by a modest

amount of 5-10% can reduce the chance of developing type 2 diabetes by up to 58% (Ma, et al.,

2013).

It is estimated that by the year 2034, more than forty-four million Americans will have

diabetes resulting in healthcare spending of nearly 336 billion dollars. This increasing strain on

health care and the economy warrants the public health system making the prevention of type 2

diabetes a priority (Zhou, et al., 2012).

The Diabetes Prevention Program (DPP) study compared three interventions: a lifestyle

intervention program, medication, and placebo. The lifestyle intervention program included 150

minutes of physical activity weekly and a weight loss goal of 7% of body weight. Results from

the study found decreased rates in developing diabetes of 58% in the lifestyle intervention group

compared to the placebo group, while those in the medication group only had a decrease of 31%

compared to placebo (Delahanty, Trief, Cibula, & Weinstock, 2019).

Obesity is a preventable and reversible health condition that has a huge impact on

developing diabetes. The DPP has shown effectiveness at helping participants increase physical

activity and achieve modest weight loss. Since the DPP program is a resource-intensive lifestyle

intervention, it is difficult to administer in real world settings (Ackerman, et al., 2015).

LIFESTYLE REDESIGN AND TYPE 2 DIABETES 3

One approach to Occupational Therapy (OT) interventions is prevention, which addresses

the needs of an individual who is at risk for developing problems related to occupational

performance (OTPF, 2017).

Using principles from the DPP program, researchers have attempted to create lifestyle

intervention programs that are easier to facilitate and for participants to implement into their

daily lives. This review will look at studies that have implemented lifestyle interventions in a

variety of settings to determine their effectiveness at reducing type 2 diabetes risk factors,

specifically at achieving weight loss.

Methods

Our searches were based on the following PICO question: Is Lifestyle Redesign effective

at reducing risk factors for type 2 diabetes in adults? Two databases were used in order to search

for articles: PsychINFO and CINAHL. They were accessed between January - April 2020. We

began our search using specific key terms, these terms include “lifestyle intervention AND

diabetes prevention AND adults.” Initially, we found 414 articles. After scanning through the

articles within Endnote, we deleted any duplicates and were left with 306 articles. We filtered

through the articles and selected those that fit our inclusion criteria and PICO question and

excluded those that fit our exclusion criteria. Our inclusion criteria consisted of studies between

the years 2010-2020--studies that contained a Lifestyle Redesign type of program, studies on

individuals that do not currently have type 2 diabetes, along with studies about preventing type 2

diabetes. Our exclusion criteria consisted of studies on individuals that currently have type 2

diabetes, studies that were completed before 2010, along with studies that included individuals

with prior injuries or conditions. After title and abstract screening our articles, there were 21
LIFESTYLE REDESIGN AND TYPE 2 DIABETES 4

articles left. We full-text screened these articles and discarded those that were geared towards

specific populations, such as single gender or ethnic populations. Studies not conducted in the

United States were also excluded.

Results

After the screening process, we were left with 6 articles that fit our PICO question along

with all of our other criteria. We assessed the risk of bias in these studies by placing the studies

into a bias table and determining the amount of high risk factors. The Bias Table (See Table 1)

reflects that all of the studies used have a moderate risk of bias. Due to this, the results of the

studies should be interpreted cautiously.

In order to establish the level of evidence of the articles, we had to individually assess

each article and categorize its type of evidence using “The Oxford 2011 Levels of Evidence.”

Three of the articles reflect a 1B level of evidence, which consist of an individual randomized

control trial (RCT). The other three reflect a 2B level of evidence, which consist of individual

prospective cohort studies--low quality RCT.

The strength of evidence of the articles was determined by using the guidelines of the

U.S. Preventive Services Task Force. The studies that we chose reflect a strong level of

evidence, since 3 of the studies are level I studies.

Interventions were based on adapted DPP programs to fit the environment, or the client

being served. The goals of all interventions included weight loss and increased physical activity.

Most intervention goals were to achieve at least a 7% decrease in weight and to engage in at least

150 minutes weekly of physical activity (Weinhold, et al., 2015).

LIFESTYLE REDESIGN AND TYPE 2 DIABETES 5

Figure 1.

YMCA Based Programs

Ackermann, et al. (2011), examined The PLAN4WARD (P4W) program, administered at

the YMCA, which gave all participants in the program information about their risk for

developing diabetes, and then advised them that a moderate weight loss of 5-10% was effective
LIFESTYLE REDESIGN AND TYPE 2 DIABETES 6

at preventing or delaying the development of the condition. For the first four weeks of the

program, 60 minutes sessions were offered. After the four weeks, monthly sessions followed

with topics on healthy eating and exercise to prevent diabetes. After 28 months, the P4W group

showed significant weight loss with a total loss of -1.5%.

Ackermann, et al. (2015), also looked at the effects of another YMCA DPP program

called YMCA Diabetes Prevention Program (YDPP), which was developed to reach a larger

population--primarily low-income adults at risk of developing diabetes. This program was

delivered over 16-24 weeks and consisted of 16 in-person meetings with groups of 8-12

participants. The meetings lasted 60 to 90 minutes. Participants were also given tools such as

food scales, fat and calorie trackers, and recipe guides. Those who participated in the program

versus standard care alone had a 2.3% kg higher weight loss.

DPP – Lifestyle Balance Programs

Weinhold, et al. (2015), studied the effectiveness of an adapted DPP Outcomes Study

Lifestyle Balance program that was offered to employees at a university in the midwestern

United States. Groups of 10 to 15 participants met for 60 minutes weekly, either during their

lunch hour or after work. Participants worked with lifestyle coaches to set weekly goals. The

intervention group had a 5.5% weight decrease compared to .4% for the control group.

Kramer, et al. (2014), evaluated a Group Lifestyle Balance (GLB) program adapted from

a DPP and its effects on weight loss. Participants could attend up to 12 weekly sessions that

lasted 1 hour each. They were given home assignments to monitor their eating habits and also to
LIFESTYLE REDESIGN AND TYPE 2 DIABETES 7

monitor their physical activity level by tracking their physical activity minutes. After the

participants' weekly sessions, they could attend monthly meetings for 9 times. The total number

of sessions attended was positively correlated with weight loss at 12 months. Participants had a

mean weight loss of 5.5%. They also showed significant decreases in waist circumference, BMI,

fasting glucose, diastolic blood pressure, along with a significant increase in HDL C.

Kramer, et al. (2018), evaluated an adapted DPP Group Lifestyle Balance (DPP-GLB)

program in 3 economically diverse senior/community centers. The study design was a

randomized wait list design. Participants could choose from two inventions--either face-to-face

or through a DVD program. The program consisted of 22 sessions delivered over a year, starting

with 12 weekly sessions, and then moving to monthly sessions. The immediate group had a

greater weight loss of 5.6% versus 0.9% for the wait list group after six months.

Ma, et al. (2013), also evaluated the DPP-GLB program. However, participants were

randomized into the intervention groups--either a coach-led group, self-directed DVD, or the

control group of usual care. This intervention also incorporated the use of information

technology as participants in either intervention group received periodic emails from coaches. At

15 months, the BMI mean for the coach-led group was -6.3, self-directed -4.5, and -2.4 for the

control group of usual care..

Conclusion

In each of the above studies, weight loss for the intervention group was higher than in no

intervention or standard care alone. Due to the high number of adults in the United States that are

overweight and at risk for developing type 2 diabetes, the use of Occupational Therapy may be
LIFESTYLE REDESIGN AND TYPE 2 DIABETES 8

beneficial in altering the lifestyle of at-risk individuals. The Occupational Therapy Practice

Framework (OTPF) outlines specific Occupational Therapy outcomes that are related to the

effects of reducing the risk factors of type 2 diabetes. These include prevention, health and

wellness, quality of life, and well-being. Risk factors for type 2 diabetes can decrease health

related quality of life for adults. Lifestyle intervention programs can reduce the risk factors for

developing type 2 diabetes and therefore help improve health-related quality of life for

individuals (Eaglehouse, et al., 2016). Quality of life and health and wellness are possible

outcomes from the occupational therapy process (OTPF). Lifestyle Redesign® is a current

Occupational Therapy program that is used with diabetics to manage the condition. Since

complications from diabetes can cause disability and even death, the program focuses on health

management occupations such as taking medication and monitoring blood glucose levels. The

program teaches people how to incorporate healthy routines and habits (Pyatak, et al., 2019).

This same type of approach could easily be implemented as an intervention to prevent type 2

diabetes.
LIFESTYLE REDESIGN AND TYPE 2 DIABETES 9

References

Ackerman, R. T., Finch, E. A., Caffrey, H. M., Lipscomb, E. R., Hays, L. M., & Saha, C. (2011).

Long-term effects of a community-based lifestyle intervention to prevent type 2 diabetes:

the DEPOLY extension pilot study. Chronic Illness, 279-290.

Ackerman, R. T., Liss, D. T., Finch, E. A., Schmidt, K. K., Hays, L. M., Marrero, D. G., & Saha,

C. (2015). A randomized comparative effectiveness trial for preventing type 2 diabetes.

American Journal of Public Health, 2328-2334.

Delahanty, L. M., Trief, P. M., Cibula, D. A., & Weinstock, R. S. (2019). Barriers to weight loss

and physical activity, and coach approaches to addressing barriers, in a real-world

adaptation of the DPP lifestyle intervention. The Diabetes Educator, 596-606.

Eaglehouse, Y. L., Schafer, G. L., Arena, V. C., Kramer, M. K., Miller, R. G., & Andrea, M. K.

(2016). Impact of a community-based lifestyle intervention program on health-related

quality of life. Quality of Life Research, 1903-1912. doi:10.1007/s11136-016-1240-7

Kramer, M. K., Miller, R. G., & Siminerio, L. M. (2014). Evaluation of a community Diabetes

Prevention Program delivered by diabetes educators in the United States: One-year

follow up. Diabetes Research and Clinical Practice, 106(3). doi:

10.1016/j.diabres.2014.10.012

Kramer, M. K., Vanderwood, K. K., Arena, V. C., Miller, R. G., Meehan, R., Eaglehouse, Y.

L., . . . Kriska, A. M. (2018). Evaluation of a diabetes prevention program lifestyle

intervention in older adults: A randomized controlled study in three senior/community

centers of varying socioeconomic status. The Diabetes Educator, 118-129.

LIFESTYLE REDESIGN AND TYPE 2 DIABETES 10

Ma, J., Yank, V., Xiao, L., Lavori, P. W., Wilson, S. R., Rosa, L. G., & Strafford, R. S. (2013).

Translating the diabetes prevention program lifestyle intervention for weight loss into

primary care. American Medical Association, 113-121.

Occupational therapy practice framework: Domain and process (3rd Edition). (2017). American

Journal of Occupational Therapy, 68. doi:10.5014/ajot.2014.682006

Pyatak, E., King, M., Vigen, C. L. P., Salazar, E., Diaz, J., Schepens Niemiec, S. L., . . . Shukla,

J. (2019). Addressing diabetes in primary care: Hybrid effectiveness–implementation

study of Lifestyle Redesign® occupational therapy. American Journal of Occupational

Therapy, 73, 7305185020. https://doi.org/10.5014/ajot.2019.037317

Weinhold, K. R., Miller, C. K., Marrero, D. G., Nagaraja, H. N., Focht, B. C., & Gascon, G. M.

(2015). A randomized controlled trial translating the diabetes prevention program to a

university worksite, ohio, 2012-2014. Preventing chronic disease public health research,

practice, and policy, 1-15.

Zhou, X., Zhang, P., Gregg, E. W., Barker, L., Hoerger, T. J., Pearson-Clarke, T., & Albright, A.

(2012). A nationwide community-based lifestyle program could delay or prevent type 2

diabetes cases and save $5.7 billion in 25 years. Health Affairs, 50-60.

doi:10.1377/hlthaff.2011.1115

OCEBM Levels of Evidence Working Group*. "The Oxford 2011 Levels of Evidence".

Oxford Centre for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o=5653

 LIFESTYLE REDESIGN AND TYPE 2 DIABETES 11

Table 1. Bias Table

Risk of Bias Table: RCT and 2 or 2+ Non-RCT

Selection Bias (risk of bias Performance Bias Detection Bias Attritio Reporti
arising from randomization (effect of n Bias ng Bias
process) assignment to
intervention)
Blinding
of
Outcome
Assessmen
t: Selectiv
Objective e
Baseline Outcomes Reporti Overall
Allocati differenc Blindin Blindin (assessors ng Risk of
on es g of g of aware of Incomple (results Bias
Conceal between Study Outcom interventio te being Assessm
ment intervent Personn e n Outcome reporte ent
(until ion el Assess received?) Data d (low,
Rando particip groups Blinding During ment: (data for selected moderat
m ants (suggest of the Self- all or on the e, high
Seque enrolled problem Participa Trial reporte nearly basis of risk)
nce and with nts d all the
Gener assigned randomi During outcom participa results?
Citation ation ) zation?) the Trial es nts) )
Ackermann + + - + - - _ + + M
2015
Kramer + + + - - - + ? + M
2018
Weinhold + + + - + - - - + M
2015
Ma 2013 + + + - - - - ? + M
Ackermann - + + - - + - + + M
2011
Kramer, - - - - - + - + + M
Miller &
Siminerio
2014
Note. Categories for risk of bias are as follows: Low risk of bias (+), unclear risk of bias (?), high risk
of bias (-).
Scoring: 0-3 minuses=Low risk of bias (L), 4-6 minuses=Moderate risk of bias (M), 7-9 minuses=
High risk of bias (H)

Higgins JPT, Sterne JAC, Savović J, Page MJ, Hróbjartsson A, Boutron I, Reeves B, Eldridge S. A revised tool for
assessing risk of bias in randomized trials In: Chandler J, McKenzie J, Boutron I, Welch V (editors). Cochrane
Methods. Cochrane Database of Systematic Reviews 2016, Issue 10 (Suppl 1).
dx.doi.org/10.1002/14651858.CD201601.
 LIFESTYLE REDESIGN AND TYPE 2 DIABETES 12

Table 2. Literature Review Chart

Author/Date Sample Design/ Variables Measures/ Findings

Data Collection
Ackerman et al. After 28 months, the
(2011) 92 adults Group-randomized Body weight measured PLAN4WARD (P4W)
intervention trial using a calibrated beam group was the only
BMI ≥24 kg/m^2 balanced scale group that had
IV – lifestyle significant weight loss
Capillary blood glucose maintenance A1c was measured using by within subjects
of 6.1-11.1 mmol/L intervention a DCA 2000 analyzer analysis. Changes in
mg/dL mean body weight
DV – weight loss, A1c Cholesterol and vHDL-c consisted of -1.5%;
levels, cholesterol were measured using an p=0.004.
levels, blood pressure LDX lipid analyzer
levels
Blood pressure was
Level 1B measure using an
aneroid
From United States
sphygmomanometer
Ackerman et al. 509 adults, age 18 or RCT Biometric assessments, Those assigned to the
(2015) older, predominately fingerstick blood tests. YDPP program
women (70.7%) and IV – 12-month effect of achieved a 2.3
African American random treatment Collected at baseline, 6 kilogram greater
(57.0%) BMI of 24 or assignment (YDDP or months, and 12 months. weight loss than
higher, no previous Standard Care) those assigned to
diabetes, at least 1 YDPP – YMCA Diabetes standard care alone.
blood test indicating Prevention Program –
high risk for type 2 16 small group lessons
diabetes. Household over 16 to 24 weeks.
income less than $25k Standard care –
a year. information on diabetes
prevention.

DV – Change in body
weight (primary), blood
pressure, total and high-
density lipoprotein
(HDL) Cholesterol, and
A1C.

Level 1B
Kramer et al.
(2014) 81 participants Non-randomized 12 weekly sessions Total number of
prospective study lasting 1 hour sessions attended was
43 female, 9 male positively correlated
IV – Group Lifestyle Home assignments – with weight loss at 12
 LIFESTYLE REDESIGN AND TYPE 2 DIABETES 13

Overweight/obese Balance (GLB) program monitoring eating and months

adapted from a physical activity levels –
Pre-diabetic (fasting Diabetes Prevention measured by tracking the Mean weight loss of
glucose 100-125 mg/dl) Program (DPP) number of physical the 52 remaining
and/or activity minutes participants was 5.5
DV – weight loss kg (5.5%)
Metabolic syndrome After weekly sessions,
(NCEP ATPIII definition) Level 2B participants attended Participants showed
monthly meetings for 9 significant decreases
Out of 81 participants month in waist
52 completed the circumference -6.8
study and completed a cm, BMI -2.0 kg/m^2,
clinical assessment fasting glucose -4.7
mg/dl, and diastolic
From United States blood pressure -6.7
mm/Hg along with a
significant increase in
HDL C +4.3 mg/dl
Kramer et al. 134 adults with a BMI Randomized Waitlist Weight Immediate group had
( 2018) equal to or greater Design Achievement of weight greater weight loss at
than 24 and evidence loss goal 6 months than
of prediabetes. IV – DPP Lifestyle Change in BMI delayed control group
Balance Group Physical activity (PA) – (5.6% vs 0.9%).
immediately or 6 Month using MAQ (modifiable
Delay activity questionnaire) Immediate group had
A1C greater
DV – change in weight improvements in
at 6 months Measurements taken at physical activity, A1C,
baseline, 6, 12, and 18 fasting insulin, and
Level – 2B months waist circumference
than delayed control
group.
Ma, et al. 241 adults aged 18 or Randomized, controlled BMI (Weight and Height), At 15 months the
(2013) older, BMI ≥ 25, pre- Trial BP and fingerstick for mean BMI ± SE
DM or metabolic fasting glucose an change from baseline
syndrome IV - 2 Group Lifestyle cholesterol. for :
Balance GLB (Coach Led, -6.3 coach-led
face-to-face, or self- Baseline, 3, 6, and 15 intervention
directed DVD months -4.5 self-directed
intervention) and usual intervention
care. -2.4 usual care group

DV – BMI (primary), Coach-led

waist circumference, intervention
fasting glucose, BP, improvements
Cholesterol reached statistical
significance for waist
 LIFESTYLE REDESIGN AND TYPE 2 DIABETES 14

Level – 1B circumference, fasting

plasma glucose levels.

Coach-led and self-

directed
Improved BP and
Cholesterol

Weinhold et al., 69 adults aged 18-65, Randomized pretest- Weight change Postintervention:
(2015) BMI of 25.0 to 50.0 posttest control group Anthropometric Intervention Group >
kg/m2 and design. Measures: weight change than
prediabetes. Height, waist control. 5.5%
IV – 16-week group- circumference (collected compared to .4%.
based lifestyle twice per visit and mean Intervention group >
intervention group. values were used for reduction in waist
Group met weekly for analysis) circumference,
60 minutes with Clinical Meausre: fasting, glucose, and
dieticians as coaches. Glucose, blood lipids, systolic and diastolic
Control Group – blood pressure blood pressure than
received usual care Dietary intake and PA the control group.
from health care levels Intervention group>
providers. reduction in
Evaluated at baseline, percentage energy
DV – Weight Change postintervention, and 3- from fat (P=.008) and
month follow-up an increase in fiber
Level – 2B intake (P=.05) higher
than the control
group.
Base

Baseline to 3-month
follow-up:
7% body weight loss
goal
Intervention = 32.4%
Control = 2.9%
Intervention group:
had smaller waist
circumference, better
BP.
Both groups improved
in dietary intake and
PA.