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Metabolism: Effect of Lifestyle Intervention in Patients With Type 2 Diabetes: A Meta-Analysis
Metabolism: Effect of Lifestyle Intervention in Patients With Type 2 Diabetes: A Meta-Analysis
Metabolism
www.metabolismjournal.com
A R T I C LE I N FO
Article history:
AB S T R A C T
Objective. The effect of lifestyle intervention on clinical risk factors in patients with type
2 diabetes is unclear. The aim of this meta-analysis was to evaluate the effects of
comprehensive lifestyle change, such as diet, exercise, and education, on clinical markers
that are risk-factors for cardiovascular disease in patients with type 2 diabetes.
Keywords:
Methods. We searched Medline, Cochrane, EMBASE, and Google Scholar (up to August 31,
Lifestyle
2013) for randomized controlled trials that compared standard of care (control group) with
Intervention
treatment regimens that included changes in lifestyle (intervention group). The primary
Type 2 diabetes
outcome was reduction in risk factors of cardiovascular disease including body mass index
Meta-analysis
(BMI), glycated hemoglobin (HbA1c), systolic blood pressure (SBP), diastolic blood pressure (DBP),
high-density lipoprotein cholesterol (HDL-c), and low-density lipoprotein cholesterol (LDL-c).
Results. A total of 16 studies were included in the meta-analysis. The standardized difference
in means of change from baseline significantly favored the intervention compared with the
control group in BMI (0.29; 95% CI, 0.52 to 0.06, P = 0.014), HbA1c (0.37; 95% CI, 0.59 to 0.14,
P = 0.001), SBP (0.16: 95% CI, 0.29 to 0.03, P = 0.016), DBP (0.27, 95% CI = 0.41 to 0.12,
P < 0.001). There was no difference between the intervention and control groups in HDL-c (0.05;
95% CI, 0.10 to 0.21; P = 0.503) and LDL-c (0.14; 95% CI, 0.29 to 0.02; P = 0.092).
Conclusions. The meta-analysis found that lifestyle intervention showed significant
benefit in risk factors that are known to be associated with development of cardiovascular
disease in patients with type 2 diabetes.
2015 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NCND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
1.
Introduction
Abbreviations: BMI, body mass index; HbA1c, glycated hemoglobin; SBP, systolic blood pressure; DBP, diastolic blood pressure; HDL-c,
high-density lipoprotein cholesterol; LDL-c, low-density lipoprotein cholesterol.
Corresponding author. Tel.: +86 13538785491.
E-mail address: acchenliang@gmail.com (L. Chen).
http://dx.doi.org/10.1016/j.metabol.2014.10.018
0026-0495/ 2015 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.
org/licenses/by-nc-nd/3.0/).
M ET ABOL I SM CL IN I CA L A N D EX PE RI ME N TA L 6 4 ( 2 0 15 ) 33 83 4 7
behaviors on disease progression and development of comorbidities (eg, vascular disease) in patients with type 2
diabetes [513]. However, the benefit of lifestyle changes in
reducing all-cause mortality or cardiovascular disease is less
clear as the findings from these analyses are inconsistent or the
data are inconclusive [513]. To our knowledge, there have been
no meta-analyses that evaluated the effect of interventions that
result in multiple lifestyle changes on risk factors for cardiovascular disease in patients with type 2 diabetes. The aim of this
meta-analysis was to evaluate the effects of changes in lifestyle
that included dietary behavior, exercise, or physical activities on
clinical markers of cardiovascular disease in patients with type
2 diabetes.
2.
2.1.
Search strategy
2.2.
Data extraction
2.3.
Quality assessment
The included studies were assessed for risk bias using the Risk
of Bias assessment tool, Review Manager 5.1, and recommendations for judging risk of bias provided in Chapter 8 of the
Cochrane Handbook for Systematic Reviews Interventions [14].
2.4.
339
3.
Results
3.1.
Statistical analysis
3.2.
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M ET ABOL I SM CL IN I CA L A N D E XP E RI ME N TAL 6 4 ( 2 0 15 ) 33 83 47
3.3.
HbA1c
3.4.
3.6.
4.
3.5.
Discussion
Total enrolled
patient number
Groups
Description of groups
Number of
patients
Age, y
(mean SD)
Sex, males
(n, %)
Length of
program
Ali M (2012)
RCT
48
Intervention
23
66.4 12.7
10, 43.5%
12 months
23
66.8 10.2
13, 56.5%
51
54
70
70
132
63.2 9.5
61.7 11.2
57 6
56 6
NA
30, 58.8%
28, 51.9%
41, 59%
40, 57%
38, 29%
6 months
133
94
NA
62.6 10.3
46, 34.8%
71, 75.5%
18 months
95
300
300
2570
2575
45
48
1017
1016
32
29
303
303
90
88
123
123
35
35
56
56
40
46
60.3 10.7
66.06 8
67.28 19
58.6 6.8
58.9 6.9
56.6 8.8
58.4 8.8
58.5 6.9
58.6 7.0
54.3 1.4
51.3 1.8
NA
NA
55.0 9.0
56.0 10.2
61 10
61 11
57.6 7.9
NA
62.0 (3580)
61.0 (4378)
NA
NA
72, 75.8%
139, 46.2%
152, 50.7%
1044, 40.7%
1038, 40.4%
17,38%
21, 44%
549, 54.0%
538, 53.0%
20,62%
18, 62%
NA
NA
44, 48.9%
34, 38.6%
121, 98%
117, 95%
35, 50%
NA
27, 48.2%
34, 60.7%
NA
NA
Control
Chan CW (2012)
RCT
120
Dobrosielski DA (2012)
RCT
140
Sevick MA (2012)
RCT
265
Intervention
Control
Intervention
Control
Intervention
Crasto W (2011)
RCT
189
Control
Intervention
Salinero-Fort MA (2011)
RCT
608
The LookAHEAD
Research Group (2010)
Coppell KJ (2010)
RCT
5145
RCT
93
Sone H (2010)
RCT
2033
Wisse W (2010)
RCT
74
Balducci S (2010)
RCT
606
Ko GT (2004)
RCT
180
Krein SL (2004)
RCT
246
Kirk A (2004)
RCT
70
Trento M (2002)
RCT
112
Uusitupa M (1993)
RCT
86
Control
Intervention
Control
Intervention
Control
Intervention
Control
Intervention
Control
Intervention
Control
Intervention
Control
Intervention
Control
Intervention
Control
Intervention
Control
Intervention
Control
Intervention
Control
9 months
26 weeks
2 years
4 years
6 months
8 years
2 years
12 months
1 year
18 months
12 months
M ET ABOL I SM CL IN I CA L A N D EX PE RI ME N TA L 6 4 ( 2 0 15 ) 33 83 4 7
Study
4 years
15 months
341
342
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Fig. 2 The quality assessment for each included study was summarized in (A) risk of bias summary or (B) as percentages
across all included studies in risk of bias graph.
M ET ABOL I SM CL IN I CA L A N D EX PE RI ME N TA L 6 4 ( 2 0 15 ) 33 83 4 7
343
Fig. 3 Forest plot comparing intervention and control groups for change from baseline in (top to bottom) BMI, HbA1c, SBP, DBP,
LDL-c and HDL-c. Abbreviations: CI, confidence interval; std diff, standardized difference.
not dependent on any one study and did not result from
publication bias. There are several strengths to our analysis.
For example, we focused on long-term effects of lifestyle
344
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Fig. 4 Sensitivity analysis of the influence of each study on the pooled estimate of (A) BMI or (B) HbA1c. The leave-one-out
approach was used. Abbreviations: CI, confidence interval; std diff, standardized difference.
Our findings are consistent with several previous metaanalyses and systematic reviews which also found that multifaceted lifestyle intervention improved several cardiovascularassociated risk factors, including BMI and HbA1c, in patients
with or at risk for type 2 diabetes [57,12,13]. One prior metaanalysis examined the effect of lifestyle intervention focused on physical activity (regular movement such as
walking) and exercise (structured activities such as cycling,
running etc.) on levels of HbA1c and BMI in patients with type
2 diabetes [5]. The meta-analysis included 17 randomized
controlled trials and found that interventions which increased
physical and exercise activity were associated with improvements in HbA1c (weighted mean difference [WMD], 0.32%, 95%
CI, 0.44% to 0.21%) and BMI (WMD, 1.05 kg/m2, 95% CI, 1.31
to 0.80) [5].
Other meta-analyses and systematic reviews found that
multi-faceted lifestyle intervention improved several cardiovascular-associated risk factors, including BMI and HbA1c, in
M ET ABOL I SM CL IN I CA L A N D EX PE RI ME N TA L 6 4 ( 2 0 15 ) 33 83 4 7
345
5.
Conclusion
In summary, our meta-analysis found that lifestyle intervention which included change in diet, exercise, and education
showed significant benefit in a number of risk factors which
are known to be associated with cardiovascular disease in
patients with type 2 diabetes.
Supplementary data to this article can be found online at
http://dx.doi.org/10.1016/j.metabol.2014.10.018.
Author contributions
Liang Chen: guarantor of integrity of the entire study; Jian-Hao
Pei: study concepts; Jian Kuang: study design, statistical
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Acknowledgments
None.
Conflict of interest
None.
REFERENCES
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