Reducing Environmental Risks to Modify Lifestyle Behaviors

I t has been more than 10 years since the Diabetes Prevention Program (DPP) reported that changes in diet and physical activity resulted in a larger reduction in the incidence of type 2 diabetes than medication alone (1). We have acquired abundant and well-replicated scientific evidence from national and international multisite, multiyear intervention trials showing the benefits of lifestyle change for health, yet prevention programs and healthier behaviors are not being widely adopted and translated to reach the population at large. Consequently, the prevalence of diabetes and associated risk factors has continued to increase. Between 1999 and 2010, the prevalence of hyperglyce-mia increased from 12.9 to 19.9%. The portion of the population having a waist size above the recommended threshhold also increased from 45.4 to 56.1%, indicating a rise in the rate of abdominal obesity (2). Among the U.S. elderly Medicare population, diabetes is estimated to have increased by 1.69% per year between 1999 and 2005 (3). The co-occurrence of two or more lifestyle-related chronic conditions also increased between 2002 and 2009 by 2% (4). Successfully disseminating lifestyle interventions requires overcoming many challenges—screening and recruiting individuals, providing instruction, promoting adherence, and supporting maintenance. When the interventions are long and complex, as was the case with the DPP, which had a core curriculum of 16 weekly education sessions, these challenges and costs can be overwhelming. Group interventions that have been developed to reduce costs and reach a larger population may not be able to replicate the magnitude of impact of the original DPP. For example, a community-based lifestyle intervention program in Pennsylvania yielded a <20% reduction in diabetes and no change in complications rates (5). Even if the efficacy of the DPP can be maintained in programs that can be widely disseminated, an estimated 86 million Americans now have pre-diabetes (6). Reaching that many people not only would require the training of thousands of instructors, but also the personal motivation and interest of individuals with prediabe-tes. The odds of being able to scale a multisession class to reach millions of people are relatively small, especially given that most people with predia-betes are unaware of their condition. However, the nature of the programs themselves may also limit their impact. For example, people with insight and motivation are more likely to attend the numerous classes (7), but not all would be able to absorb all of the information provided (8). As a result, …