The Finnish Diabetes Prevention Study (DPS): Lifestyle Intervention and 3-Year Results on Diet and Physical Activity

Jaana Lindström, MSC; Anne Louheranta, PHD; Marjo Mannelin, MSC; Merja Rastas, MSC; Virpi Salminen, MSC; Johan Eriksson, MD, PHD; Matti Uusitupa, MD, PHD; Jaakko Tuomilehto, MD, PHD

Disclosures

Diabetes Care. 2003;26(12)

Abstract and Introduction

Objective: To describe the 1) lifestyle intervention used in the Finnish Diabetes Prevention Study, 2) short- and long-term changes in diet and exercise behavior, and 3) effect of the intervention on glucose and lipid metabolism.
Research Design and Methods: There were 522 middle-aged, overweight subjects with impaired glucose tolerance who were randomized to either a usual care control group or an intensive lifestyle intervention group. The control group received general dietary and exercise advice at baseline and had an annual physician's examination. The subjects in the intervention group received additional individualized dietary counseling from a nutritionist. They were also offered circuit-type resistance training sessions and advised to increase overall physical activity. The intervention was the most intensive during the first year, followed by a maintenance period. The intervention goals were to reduce body weight, reduce dietary and saturated fat, and increase physical activity and dietary fiber.
Results: The intervention group showed significantly greater improvement in each intervention goal. After 1 and 3 years, weight reductions were 4.5 and 3.5 kg in the intervention group and 1.0 and 0.9 kg in the control group, respectively. Measures of glycemia and lipemia improved more in the intervention group.
Conclusions: The intensive lifestyle intervention produced long-term beneficial changes in diet, physical activity, and clinical and biochemical parameters and reduced diabetes risk. This type of intervention is a feasible option to prevent type 2 diabetes and should be implemented in the primary health care system.

The Finnish Diabetes Prevention Study (DPS) was one of the first controlled, randomized studies to show that type 2 diabetes is preventable with lifestyle intervention.^[1] The risk of diabetes was reduced by 58% in the intensive lifestyle intervention group compared with the control group. These results have been reproduced by the Diabetes Prevention Program (DPP), in which lifestyle intervention, with a similar 58% risk reduction, was superior to the metformin treatment.^[2] The lifestyle intervention used in the DPP was not designed to be used in community settings,^[3] whereas one of the main objectives in the DPS was to test an intervention feasible in primary health care.

In this study, we describe the lifestyle intervention program used in the DPS, the changes in dietary habits and exercise behavior that were achieved during the first year and the maintenance of these changes after 3 years, and assess the efficacy of the intervention on body weight, plasma glucose, and lipids.

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Table 1. Baseline Characteristics
	Intervention group	Control group
n (male/female)	265 (91/174)	257 (81/176)
Age (years)	55 ± 7	55 ± 7
First-degree relatives with diabetes (%)	66	61
Schooling in years (%)
0-9	40	40
10-12	27	27
≥13	33	33
Type of work (%)
Agricultural or industrial	9	10
Office work or student	42	44
Homemaker, retired, or unemployed	49	49
Weight (kg)	86.7 ± 14.0	85.5 ± 14.4
BMI (kg/m²)	31.4 ± 4.5	31.1 ± 4.5
Waist circumference (cm)	102.0 ± 11.0	100.5 ± 10.9
Fasting plasma glucose (mmol/l)	6.1 ± 0.8	6.2 ± 0.7
2-h plasma glucose (mmol/l)	8.9 ± 1.5	8.9 ± 1.5
HbA_1c (%)	5.7 ± 0.6	5.6 ± 0.6
Serum total cholesterol (mmol/l)	5.6 ± 1.0	5.6 ± 0.9
Serum HDL cholesterol (mmol/l)	1.2 ± 0.3	1.2 ± 0.3
Serum total cholesterol-to-HDL cholesterol ratio	4.9 ± 1.3	4.8 ± 1.2
Serum triglycerides (mmol/l)	1.7 ± 0.8	1.7 ± 0.8
Blood pressure-lowering medication (%)	29	31
Lipid-lowering medication (%)	5	7
Total LTPA (min/week)	339 (193-545)	329 (173-586)
Moderate-to-vigorous LTPA (min/week)	156 (62-288)	169 (65-352)
Energy (kcal/day)	1,771 ± 520	1,744 ± 527
Carbohydrates
E%	43.6 ± 7.5	43.2 ± 6.7
g	190 ± 57	185 ± 54
Fat
E%	36.0 ± 6.7	37.1 ± 6.5
g	72 ± 28	73 ± 29
Saturated fat (E%)*	16.2 ± 4.0	17.0 ± 4.3
Monounsaturated fat (E%)	12.9 ± 2.8	13.0 ± 2.9
Polyunsaturated fat (E%)	5.7 ± 1.7	5.8 ± 2.2
Alcohol
E%	2.8 ± 5.1	2.1 ± 4.1
g	8 ± 17	6 ± 12
Cholesterol (mg)	312 ± 137	304 ± 130
Fiber
g	20 ± 7	20 ± 8
g/1,000 kcal	11.7 ± 4.0	11.7 ± 3.9
Water soluble (g)	4.6 ± 1.7	4.6 ± 1.6
Water soluble (g/1,000 kcal)	2.7 ± 1.0	2.7 ± 0.9
Water insoluble (g)	14.4 ± 5.4	14.1 ± 5.9
Water insoluble (g/1,000 kcal)	8.4 ± 2.9	8.4 ± 2.9

Data are mean ± SD or median (interquartile range).
* Difference between the groups (Student's unpaired t test), P = 0.0188.

Table 2. Changes in Physical Activity and Nutrient Intakes From Baseline to Years 1 and 3
	From baseline to year 1			From baseline to year 3
	Intervention group	Control group	P*	Intervention group	Control group	P*
n	256	250		231	203
Total LTPA (min/week)	16 (-126 to 115)	21 (-133 to 138)	0.9045	50 (-126 to 115)	23 (-142 to 171)	0.2415
Moderate-to-vigorous LTPA (min/week)	49 (-41 to 140)	14 (-47 to 90)	0.0073	61 (-33 to 168)	6 (-91 to 104)	0.0057
Energy (kcal/day)	-247 ± 438	-108 ± 464	0.0001	-204 ± 489	-97 ± 458	0.0067
Carbohydrates
E%	3.3 ± 8.1	1.7 ± 7.3	0.0023	3.3 ± 8.0	2.0 ± 7.6	0.0070
g	-13 ± 52	-4 ± 48	0.0590	-11 ± 57	-1 ± 50	0.1042
Fat
E%	-3.4 ± 8.2	-2.1 ± 7.6	0.0002	-4.7 ± 7.7	-3.2 ± 7.5	<0.0001
g	-16 ± 25	-8 ± 28	<0.0001	-16 ± 27	-11 ± 27	0.0003
Saturated fat (E%)	-2.7 ± 4.6	-1.2 ± 5.1	<0.0001	-3.2 ± 4.5	-1.9 ± 4.9	<0.0001
Monounsaturated fat (E%)	-0.8 ± 3.8	-0.4 ± 3.4	0.0257	-1.0 ± 3.6	-0.6 ± 3.5	0.0453
Polyunsaturated fat (E%)	-0.0 ± 2.1	-0.2 ± 2.5	0.5020	0.0 ± 2.4	-0.4 ± 2.3	0.0872
Alcohol
E%	-1.1 ± 4.4	-0.3 ± 4.6	0.1452	-0.2 ± 4.1	-0.2 ± 4.3	0.6836
g	-4 ± 15	-1 ± 13	0.1168	-0 ± 14	-0 ± 14	0.8580
Cholesterol (mg)	-69 ± 138	-28 ± 148	0.0005	-63 ± 167	-31 ± 155	0.0586
Fiber
g	1 ± 7	0 ± 7	0.1146	1 ± 8	1 ± 7	0.4393
g/1,000 kcal	2.5 ± 4.6	0.7 ± 4.1	<0.0001	2.4 ± 4.7	1.1 ± 4.1	0.0013
Water soluble (g)	0.2 ± 1.7	0.5 ± 1.5	0.2218	0.1 ± 1.7	0.1 ± 1.5	0.7275
Water soluble (g/1,000 kcal)	0.5 ± 1.1	0.2 ± 1.0	<0.0001	0.5 ± 1.1	0.2 ± 1.0	0.0050
Water insoluble (g)	0.6 ± 5.5	0.0 ± 5.5	0.1136	0.7 ± 5.9	0.4 ± 5.7	0.5608
Water insoluble (g/1,000 kcal)	1.7 ± 3.3	0.5 ± 3.0	<0.0001	1.7 ± 3.4	0.9 ± 3.1	0.0034

Data are means ± SD or median (interquartile range).
* ANCOVA adjusting for baseline value or Mann-Whitney test for two unpaired groups. Values in bold are statistically significant.

Table 2. Changes in Physical Activity and Nutrient Intakes From Baseline to Years 1 and 3
	From baseline to year 1			From baseline to year 3
	Intervention group	Control group	P*	Intervention group	Control group	P*
n	256	250		231	203
Total LTPA (min/week)	16 (-126 to 115)	21 (-133 to 138)	0.9045	50 (-126 to 115)	23 (-142 to 171)	0.2415
Moderate-to-vigorous LTPA (min/week)	49 (-41 to 140)	14 (-47 to 90)	0.0073	61 (-33 to 168)	6 (-91 to 104)	0.0057
Energy (kcal/day)	-247 ± 438	-108 ± 464	0.0001	-204 ± 489	-97 ± 458	0.0067
Carbohydrates
E%	3.3 ± 8.1	1.7 ± 7.3	0.0023	3.3 ± 8.0	2.0 ± 7.6	0.0070
g	-13 ± 52	-4 ± 48	0.0590	-11 ± 57	-1 ± 50	0.1042
Fat
E%	-3.4 ± 8.2	-2.1 ± 7.6	0.0002	-4.7 ± 7.7	-3.2 ± 7.5	<0.0001
g	-16 ± 25	-8 ± 28	<0.0001	-16 ± 27	-11 ± 27	0.0003
Saturated fat (E%)	-2.7 ± 4.6	-1.2 ± 5.1	<0.0001	-3.2 ± 4.5	-1.9 ± 4.9	<0.0001
Monounsaturated fat (E%)	-0.8 ± 3.8	-0.4 ± 3.4	0.0257	-1.0 ± 3.6	-0.6 ± 3.5	0.0453
Polyunsaturated fat (E%)	-0.0 ± 2.1	-0.2 ± 2.5	0.5020	0.0 ± 2.4	-0.4 ± 2.3	0.0872
Alcohol
E%	-1.1 ± 4.4	-0.3 ± 4.6	0.1452	-0.2 ± 4.1	-0.2 ± 4.3	0.6836
g	-4 ± 15	-1 ± 13	0.1168	-0 ± 14	-0 ± 14	0.8580
Cholesterol (mg)	-69 ± 138	-28 ± 148	0.0005	-63 ± 167	-31 ± 155	0.0586
Fiber
g	1 ± 7	0 ± 7	0.1146	1 ± 8	1 ± 7	0.4393
g/1,000 kcal	2.5 ± 4.6	0.7 ± 4.1	<0.0001	2.4 ± 4.7	1.1 ± 4.1	0.0013
Water soluble (g)	0.2 ± 1.7	0.5 ± 1.5	0.2218	0.1 ± 1.7	0.1 ± 1.5	0.7275
Water soluble (g/1,000 kcal)	0.5 ± 1.1	0.2 ± 1.0	<0.0001	0.5 ± 1.1	0.2 ± 1.0	0.0050
Water insoluble (g)	0.6 ± 5.5	0.0 ± 5.5	0.1136	0.7 ± 5.9	0.4 ± 5.7	0.5608
Water insoluble (g/1,000 kcal)	1.7 ± 3.3	0.5 ± 3.0	<0.0001	1.7 ± 3.4	0.9 ± 3.1	0.0034

Data are means ± SD or median (interquartile range).
* ANCOVA adjusting for baseline value or Mann-Whitney test for two unpaired groups. Values in bold are statistically significant.

Table 3. Changes in Clinical and Metabolic Characteristics From Baseline to Years 1 and 3
	From baseline to year 1			From baseline to year 3
	Intervention group	Control group	P*	Intervention group	Control group	P*
n	256	250		231	203
Weight
kg	-4.5 ± 5.0	-1.0 ± 3.7	<0.0001	-3.5 ± 5.1	-0.9 ± 5.4	<0.0001
%	-5.1 ± 5.3	-1.1 ± 4.2	<0.0001	-4.0 ± 5.8	-1.1 ± 6.2	<0.0001
BMI (kg/m²)	-1.6 ± 1.8	-0.4 ± 1.3	<0.0001	-1.3 ± 1.9	-0.3 ± 2.0	<0.0001
Waist circumference (cm)	-4.4 ± 5.2	-1.3 ± 4.8	<0.0001	-3.3 ± 5.7	-1.2 ± 5.9	0.0005
Fasting plasma glucose (mmol/l)	-0.2 ± 0.7	0.0 ± 0.7	<0.0001	-0.0 ± 0.7	0.1 ± 0.7	0.0664
2-h plasma glucose (mmol/l)	-0.9 ± 1.9	-0.3 ± 2.2	0.001	-0.5 ± 2.4	-0.1 ± 2.2	0.0664
HbA_1c (%)	-0.1 ± 0.7	0.1 ± 0.6	0.0003	-0.2 ± 0.6	0.0 ± 0.6	0.002
Serum total cholesterol (mmol/l)	-0.1 ± 0.7	-0.1 ± 0.7	0.5097	-0.1 ± 0.9	0.1 ± 0.8	0.0712
Serum HDL cholesterol (mmol/l)	0.05 ± 0.19	0.02 ± 0.17	0.0681	0.14 ± 0.20	0.11 ± 0.19	0.1354
Serum total cholesterol-to-HDL cholesterol ratio	-0.4 ± 0.8	-0.1 ± 0.8	0.0011	-0.6 ± 0.9	-0.3 ± 0.8	0.0009
Serum triglycerides (mmol/l)	-0.2 ± 0.6	-0.0 ± 0.7	<0.0001	-0.1 ± 0.6	-0.0 ± 0.8	0.024

Data are means ± SD.
* ANCOVA adjusting for baseline value. Values in bold are statistically significant.

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