Secular changes in prediabetes indicators among older-adult Americans, 1999-2010.

BACKGROUND: Sex-specific prediabetes estimates are not available for older-adult Americans. PURPOSE: To estimate prediabetes prevalence, using nationally representative data, in civilian, non-institutionalized, older U.S. adults. METHODS: Data from 7,995 participants aged ≥50 years from the 1999-2010 National Health and Nutrition Examination Surveys were analyzed in 2013. Prediabetes was defined as hemoglobin A1c=5.7%-6.4% (39-47 mmol/mol [HbA1c5.7]), fasting plasma glucose of 100-125 mg/dL (impaired fasting glucose [IFG]), or both. Crude and age-adjusted prevalences for prediabetes, HbA1c5.7, and IFG by sex and three age groups were calculated, with additional adjustment for sex, age, race/ethnicity, poverty status, education, living alone, and BMI. RESULTS: From 1999 to 2005 and 2006 to 2010, prediabetes increased for adults aged 50-64 years (38.5% [95% CI=35.3, 41.8] to 45.9% [42.3, 49.5], p=0.003) and 65-74 years (41.3% [37.2, 45.5] to 47.9% [44.5, 51.3]; p=0.016), but not significantly for adults aged ≥75 years (45.1% [95% CI=41.1, 49.1] to 48.9% [95% CI=45.2, 52.6]; p>0.05). Prediabetes increased significantly for women in the two youngest age groups, and HbA1c5.7 for both sexes (except men aged ≥75 years), but IFG remained stable for both sexes. Men had higher prevalences than women for prediabetes and IFG among adults aged 50-64 years, and for IFG among adults aged ≥75 years. Across demographic subgroups, adjusted prevalence gains for both sexes were similar and most pronounced for HbA1c5.7, virtually absent for IFG, but greater for women than men for prediabetes. CONCLUSIONS: Given the large, growing prediabetes prevalence and its anticipated burden, older adults, especially women, are likely intervention targets.

Odds of Getting Adequate Physical Activity by Dog Walking.

BACKGROUND: We aimed to determine the likelihood that adult dog owners who walk their dogs will achieve a healthy level of moderate-intensity (MI) physical activity (PA), defined as at least 150 mins/wk. METHODS: We conducted a systematic search of 6 databases with data from 1990-2012 on dog owners' PA, to identify those who achieved MIPA. To compare dog-walkers' performance with non-dog walkers, we used a random effects model to estimate the unadjusted odds ratio (OR) and corresponding 95% confidence interval (CI). RESULTS: We retrieved 9 studies that met our inclusion criterion and allowed OR calculations. These yielded data on 6980 dog owners aged 18 to 81 years (41% men). Among them, 4463 (63.9%) walked their dogs. Based on total weekly PA, 2710 (60.7%) dog walkers, and 950 (37.7%) non-dog walkers achieved at least MIPA. The estimated OR was 2.74 (95% CI 2.09-3.60). CONCLUSION: Across 9 published studies, almost 2 in 3 dog owners reported walking their dogs, and the walkers are more than 2.5 times more likely to achieve at least MIPA. These findings suggest that dog walking may be a viable strategy for dog owners to help achieve levels of PA that may enhance their health.

Examining variations of resting metabolic rate of adults: a public health perspective.

PURPOSE: There has not been a recent comprehensive effort to examine existing studies on the resting metabolic rate (RMR) of adults to identify the effect of common population demographic and anthropometric characteristics. Thus, we reviewed the literature on RMR (kcal·kg(-1)·h(-1)) to determine the relationship of age, sex, and obesity status to RMR as compared with the commonly accepted value for the metabolic equivalent (MET; e.g., 1.0 kcal·kg(-1)·h(-1)). METHODS: Using several databases, scientific articles published from 1980 to 2011 were identified that measured RMR, and from those, others dating back to 1920 were identified. One hundred and ninety-seven studies were identified, resulting in 397 publication estimates of RMR that could represent a population subgroup. Inverse variance weighting technique was applied to compute means and 95% confidence intervals (CI). RESULTS: The mean value for RMR was 0.863 kcal·kg(-1)·h(-1) (95% CI = 0.852-0.874), higher for men than women, decreasing with increasing age, and less in overweight than normal weight adults. Regardless of sex, adults with BMI ≥ 30 kg·m(-2) had the lowest RMR (<0.741 kcal·kg(-1)·h(-1)). CONCLUSIONS: No single value for RMR is appropriate for all adults. Adhering to the nearly universally accepted MET convention may lead to the overestimation of the RMR of approximately 10% for men and almost 15% for women and be as high as 20%-30% for some demographic and anthropometric combinations. These large errors raise questions about the longstanding adherence to the conventional MET value for RMR. Failure to recognize this discrepancy may result in important miscalculations of energy expended from interventions using physical activity for diabetes and other chronic disease prevention efforts.

A novel use of structural equation models to examine factors associated with prediabetes among adults aged 50 years and older: National Health and Nutrition Examination Survey 2001-2006.

OBJECTIVE: To use structural modeling to test a hypothesized model of causal pathways related with prediabetes among older adults in the U.S. RESEARCH DESIGN AND METHODS: Cross-sectional study of 2,230 older adults (≥ 50 years) without diabetes included in the morning fasting sample of the 2001-2006 National Health and Nutrition Examination Surveys. Demographic data included age, income, marital status, race/ethnicity, and education. Behavioral data included physical activity (metabolic equivalent hours per week for vigorous or moderate muscle strengthening, walking/biking, and house/yard work), and poor diet (refined grains, red meat, added sugars, solid fats, and high-fat dairy). Structural-equation modeling was performed to examine the interrelationships among these variables with family history of diabetes, high blood pressure, BMI, large waist (waist circumference: women, ≥ 35 inches; men, ≥ 40 inches), triglycerides ≥ 200 mg/dL, and total and HDL (≥ 60 mg/dL) cholesterol. RESULTS: After dropping BMI and total cholesterol, our best-fit model included three single factors: socioeconomic position (SEP), physical activity, and poor diet. Large waist had the strongest direct effect on prediabetes (0.279), followed by male sex (0.270), SEP (-0.157), high blood pressure (0.122), family history of diabetes (0.070), and age (0.033). Physical activity had direct effects on HDL (0.137), triglycerides (-0.136), high blood pressure (-0.132), and large waist (-0.067); poor diet had direct effects on large waist (0.146) and triglycerides (0.148). CONCLUSIONS: Our results confirmed that, while including factors known to be associated with high risk of developing prediabetes, large waist circumference had the strongest direct effect. The direct effect of SEP on prediabetes suggests mediation by some unmeasured factor(s).

Secular changes in U.S. Prediabetes prevalence defined by hemoglobin A1c and fasting plasma glucose: National Health and Nutrition Examination Surveys, 1999-2010.

OBJECTIVE: Using a nationally representative sample of the civilian noninstitutionalized U.S. population, we estimated prediabetes prevalence and its changes during 1999-2010. RESEARCH DESIGN AND METHODS: Data were from 19,182 nonpregnant individuals aged ≥ 12 years who participated in the 1999-2010 National Health and Nutrition Examination Surveys. We defined prediabetes as hemoglobin A1c (A1C) 5.7 to <6.5% (39 to <48 mmol/mol, A1C5.7) or fasting plasma glucose (FPG) 100 to <126 mg/dL (impaired fasting glucose [IFG]). We estimated the prevalence of prediabetes, A1C5.7, and IFG for 1999-2002, 2003-2006, and 2007-2010. We calculated estimates age-standardized to the 2000 U.S. census population and used logistic regression to compute estimates adjusted for age, sex, race/ethnicity, poverty-to-income ratio, and BMI. Participants with self-reported diabetes, A1C ≥ 6.5% (≥ 48 mmol/mol), or FPG ≥126 mg/dL were included. RESULTS: Among those aged ≥ 12 years, age-adjusted prediabetes prevalence increased from 27.4% (95% CI 25.1-29.7) in 1999-2002 to 34.1% (32.5-35.8) in 2007-2010. Among adults aged ≥ 18 years, the prevalence increased from 29.2% (26.8-31.8) to 36.2% (34.5-38.0). As single measures among individuals aged ≥ 12 years, A1C5.7 prevalence increased from 9.5% (8.4-10.8) to 17.8% (16.6-19.0), a relative increase of 87%, whereas IFG remained stable. These prevalence changes were similar among the total population, across subgroups, and after controlling for covariates. CONCLUSIONS: During 1999-2010, U.S. prediabetes prevalence increased because of increases in A1C5.7. Continuous monitoring of prediabetes is needed to identify, quantify, and characterize the population of high-risk individuals targeted for ongoing diabetes primary prevention efforts.

Aging, diabetes, and the public health system in the United States.

Diabetes (diagnosed or undiagnosed) affects 10.9 million US adults aged 65 years and older. Almost 8 in 10 have some form of dysglycemia, according to tests for fasting glucose or hemoglobin A1c. Among this age group, diagnosed diabetes is projected to reach 26.7 million by 2050, or 55% of all diabetes cases. In 2007, older adults accounted for $64.8 billion (56%) of direct diabetes medical costs, $41.1 billion for institutional care alone. Complications, comorbid conditions, and geriatric syndromes affect diabetes care, and medical guidelines for treating older adults with diabetes are limited. Broad public health programs help, but effective, targeted interventions and expanded surveillance and research and better policies are needed to address the rapidly growing diabetes burden among older adults.

Prevalence of diagnosed arthritis and arthritis-attributable activity limitation among adults with and without diagnosed diabetes: United States, 2008-2010.

OBJECTIVE: To estimate the prevalence of diagnosed arthritis among U.S. adults and the proportion of arthritis-attributable activity limitation (AAAL) among those with arthritis by diagnosed diabetes mellitus (DM) status. RESEARCH DESIGN AND METHODS: We estimated prevalences and their ratios using 2008-2010 U.S. National Health Interview Survey of noninstitutionalized U.S. adults aged ≥ 18 years. Respondents' arthritis and DM status were both based on whether they reported a diagnosis of these diseases. Other characteristics used for stratification or adjustment included age, sex, race/ethnicity, education level, BMI, and physical activity level. RESULTS: Among adults with DM, the unadjusted prevalences of arthritis and proportion of AAAL among adults with arthritis (national estimated cases in parentheses) were 48.1% (9.6 million) and 55.0% (5.3 million), respectively. After adjusting for other characteristics, the prevalence ratios of arthritis and of AAAL among arthritic adults with versus without DM (95% CI) were 1.44 (1.35-1.52) and 1.21 (1.15-1.28), respectively. The prevalence of arthritis increased with age and BMI and was higher for women, non-Hispanic whites, and inactive adults compared with their counterparts both among adults with and without DM (all P values < 0.05). Among adults with diagnosed DM and arthritis, the proportion of AAAL was associated with being obese, but was not significantly associated with age, sex, and race/ethnicity. CONCLUSIONS: Among U.S. adults with diagnosed DM, nearly half also have diagnosed arthritis; moreover, more than half of those with both diseases had AAAL. Arthritis can be a barrier to physical activity among adults with diagnosed DM.

Sedentary behaviour and cardiovascular disease: a review of prospective studies.

BACKGROUND: Current estimates from objective accelerometer data suggest that American adults are sedentary for ∼7.7 h/day. Historically, sedentary behaviour was conceptualized as one end of the physical activity spectrum but is increasingly being viewed as a behaviour distinct from physical activity. METHODS: Prospective studies examining the associations between screen time (watching television, watching videos and using a computer) and sitting time and fatal and non-fatal cardiovascular disease (CVD) were identified. These prospective studies relied on self-reported sedentary behaviour. RESULTS: The majority of prospective studies of screen time and sitting time has shown that greater sedentary time is associated with an increased risk of fatal and non-fatal CVD. Compared with the lowest levels of sedentary time, risk estimates ranged up to 1.68 for the highest level of sitting time and 2.25 for the highest level of screen time after adjustment for a series of covariates, including measures of physical activity. For six studies of screen time and CVD, the summary hazard ratio per 2-h increase was 1.17 (95% CI: 1.13-1.20). For two studies of sitting time, the summary hazard ratio per 2-h increase was 1.05 (95% CI: 1.01-1.09). CONCLUSIONS: Future prospective studies using more objective measures of sedentary behaviour might prove helpful in quantifying better the risk between sedentary behaviour and CVD morbidity and mortality. This budding science may better shape future guideline development as well as clinical and public health interventions to reduce the amount of sedentary behaviour in modern societies.

State-specific synthetic estimates of health status groups among inactive older adults with self-reported diabetes, 2000-2009.

INTRODUCTION: Physical activity helps diabetic older adults who have physical impairments or comorbid conditions to control their disease. To enable state planners to select physical activity programs for these adults, we calculated synthetic state-specific estimates of inactive older adults with diabetes, categorized by defined health status groups. METHODS: Using data from the 2000 through 2009 National Health Interview Survey (NHIS) and the Behavioral Risk Factor Surveillance System (BRFSS), we calculated synthetic state-specific estimates of inactive adults with diabetes who were aged 50 years or older for 5 mutually exclusive health status groups: 1) homebound, 2) frail (functional difficulty in walking one-fourth mile, climbing 10 steps, standing for 2 hours, and stooping, bending, and kneeling), 3) functionally impaired (difficulty in 1 to 3 of these functions), 4) having 1 or more comorbid conditions (with no functional impairments), and 5) healthy (no impairments or comorbid conditions). We combined NHIS regional proportions for the health status groups of inactive, older diabetic adults with BRFSS data of older diabetic adults to estimate state-specific proportions and totals. RESULTS: State-specific estimates of health status groups among all older adults ranged from 2.2% to 3.0% for homebound, 5.8% to 8.8% for frail, 20.1% to 26.1% for impaired, 34.9% to 43.7% for having comorbid conditions, and 4.0% to 6.9% for healthy; the remainder were older active diabetic adults. Except for the homebound, the percentages in these health status groups varied significantly by region and state. CONCLUSION: These state-specific estimates correspond to existing physical activity programs to match certain health status characteristics of groups and may be useful to program planners to meet the needs of inactive, older diabetic adults.

Recommendations to improve the accuracy of estimates of physical activity derived from self report.

CONTEXT: Assessment of physical activity using self-report has the potential for measurement error that can lead to incorrect inferences about physical activity behaviors and bias study results. OBJECTIVE: To provide recommendations to improve the accuracy of physical activity derived from self report. PROCESS: We provide an overview of presentations and a compilation of perspectives shared by the authors of this paper and workgroup members. FINDINGS: We identified a conceptual framework for reducing errors using physical activity self-report questionnaires. The framework identifies 6 steps to reduce error: 1) identifying the need to measure physical activity, 2) selecting an instrument, 3) collecting data, 4) analyzing data, 5) developing a summary score, and 6) interpreting data. Underlying the first 4 steps are behavioral parameters of type, intensity, frequency, and duration of physical activities performed, activity domains, and the location where activities are performed. We identified ways to reduce measurement error at each step and made recommendations for practitioners, researchers, and organizational units to reduce error in questionnaire assessment of physical activity. CONCLUSIONS: Self-report measures of physical activity have a prominent role in research and practice settings. Measurement error may be reduced by applying the framework discussed in this paper.

Absolute and relative energy costs of walking in a Brazilian adult probability sample.

BACKGROUND: Walking is commonly recommended for enhancing energy expenditure (EE), a basic principle in weight management, and cardiorespiratory fitness. However, walking EE varies with characteristics of a given population, especially by sex and age. PURPOSE: The study's purpose was to measure EE of walking as influenced by physical and physiological characteristics of a sample of adults (≥ 20 yr) living in Niterói, Rio de Janeiro, Brazil. METHODS: Walking EE and HR were measured during a submaximal multistage treadmill test. The test stages lasted for 3 min each and started at a speed of 1.11 m·s(-1) and a grade of 0%. In the second stage, the grade was maintained at 0%, but the speed was increased to 1.56 m·s(-1) and maintained at this speed but with grade raised by 2.5% at each stage until 10% at stage 6. We measured resting oxygen consumption (MET m) before the test with the participants sitting quietly. RESULTS: MET m (mL O2·kg(-1)·min(-1), mean ± SE) was lower both in women (2.85 ± 0.03) and in men (2.97 ± 0.04) by almost 19% and 15%, respectively, compared with the conventionally estimated MET (METe) of 3.5 mL O2·kg(-1)·min(-1). Walking EE for any given speed and grade had an absolute intensity, expressed as multiples of MET m or MET e, that was practically equal between sexes and age groups, but it incurred higher individual physiological demand or relative intensity for women and older adults. CONCLUSIONS: Resting EE reflected by using METe is overestimated in the adult population of Niterói. Prescription of activities to counteract the existing worldwide obesity epidemic should be ideally based on individual physiological information, especially among women and older individuals.

Physical activity levels and differences in the prevalence of diabetes between the United States and Canada.

OBJECTIVE: To examine the American-Canadian difference in physical activity and its association with diabetes prevalence. METHODS: We used cross-sectional data from nationally representative samples of adults (8688 persons aged > or =18 years) participating in the 2004 Joint Canada/U.S. Survey of Health. Using data on up to 22 activities in the past 3 months, we defined 3 physical activity groups (in metabolic equivalents-hours/day) as low (<1.5), moderate (1.5-2.9), and high (> or =3.0). We employed logistic regression models in our analyses. RESULTS: Self-reported diabetes prevalence was 7.6% in the U.S. and 5.4% in Canada. The prevalence of low physical activity was considerably higher in the U.S. (70.9%) than in Canada (52.3%), while levels of moderate and high physical activity were higher in Canada (24.6% and 23.1%, respectively) than in the U.S. (14.3% and 14.8%, respectively). Using nationality (Canada as reference) to predict diabetes status, the adjusted odds ratio was 1.48 (95%CI, 1.22-1.79), and became 1.38 (95%CI, 1.15-1.66) when additionally adjusting for physical activity level. We estimate that 20.8% of the U.S.-Canada difference in diabetes prevalence is associated with physical activity. CONCLUSIONS: The difference in the prevalence of diabetes between U.S. and Canadian adults may be partially explained by differences in physical activity between the two countries.

Television viewing, computer use, and BMI among U.S. children and adolescents.

BACKGROUND: To examine the prevalence of television (TV) viewing, computer use, and their combination and associations with demographic characteristics and body mass index (BMI) among U.S. youth. METHODS: The 1999 to 2006 National Health and Nutrition Examination Survey (NHANES) was used. Time spent yesterday sitting and watching television or videos (TV viewing) and using the computer or playing computer games (computer use) were assessed by questionnaire. RESULTS: Prevalence (%) of meeting the U.S. objective for TV viewing (< or =2 hours/day) ranged from 65% to 71%. Prevalence of no computer use (0 hours/day) ranged from 23% to 45%. Non-Hispanic Black youth aged 2 to 15 years were less likely than their non-Hispanic White counterparts to meet the objective for TV viewing. Overweight or obese school-age youth were less likely than their normal weight counterparts to meet the objective for TV viewing. CONCLUSIONS: Computer use is prevalent among U.S. youth; more than half of youth used a computer on the previous day. The proportion of youth meeting the U.S. objective for TV viewing is less than the target of 75%. Time spent in sedentary behaviors such as viewing TV may contribute to overweight and obesity among U.S. youth.

Epidemiology of walking and type 2 diabetes.

PURPOSE: Diabetes is prevalent, deadly, serious, and costly. It affects an estimated 20.8 million Americans in 2005, having doubled from 1980, and is expected to reach at least 29 million by 2050. In 2002, diabetes was responsible for an estimated $132 billion in costs. Diabetes concerns leaders in public health and clinicians, and its personal, social, and economic burdens require preventive efforts such as the promotion of walking. As such, we reviewed the limited epidemiologic data of walking and incident diabetes (two studies) and walking and mortality outcomes among diabetic persons (three studies). METHODS: We abstracted information from each paper to identify characteristics of the study population, details of the disease outcomes (diabetes incidence, mortality outcomes, or cardiovascular disease events among persons with diabetes), relative risks, risk reductions, and adjustment for covariates. RESULTS: The reviewed studies were adjusted for important covariates such as age, body mass index, the coexistence of other nonwalking and vigorous activities, and so on and for biases such as differential misclassification of exposure. The strength of the observed reductions in risk were between approximately 20% and 40% for incident diabetes and between 40% and 55% for mortality due to all causes and due to cardiovascular disease (and related nonfatal events). Moderate to faster pace of walking seemed to enhance risk reduction. These reductions fit well with results of earlier reviews of physical activity and diabetes, and basically corresponded to 2-3 h of weekly walking. CONCLUSION: Available dose-response data between walking and the aforementioned outcomes suggest that public health recommendations for physical activity might also apply to walking in particular. Regardless, important areas remain for future research on walking and diabetes.

Age and sex differences in physical activity of Portuguese adolescents.

PURPOSE: This study sought to examine sex- and age-associated variations in physical activity (PA) among Portuguese adolescents aged 10-18 yr. METHODS: A total of 12,577 males and females at the primary or secondary education level were sampled across four regions of Portugal. PA was assessed by a questionnaire, producing four different indexes: work/school (WSI), sport (SI), leisure time (LI), and total physical activity index (PAI). We examined sex and age differences by using two-way analysis of variance. RESULTS: Males had higher mean values of PA than did females. In both sexes, mean values for all four PA indexes increased from ages 10 to 16 yr. After age 16, females decreased their mean values, whereas males continued to increase their values (except for LI). In both sexes, the average annual rate of change for the mean values of all four PA indexes correspond to three sensitive age periods (10-13, 13-16, and 16-18 yr). Until age 16, average mean changes for females ranged from +0.7 to +1.6% per year, except for SI in the youngest group (a modest decrease). For males under 16 yr, the pattern was similar, with increases ranging from 0.4 to 1.9% per year. After age 16, females experienced decreases of 1-2.1% per year for the four PA indexes, whereas males showed an increase for three indexes and an average decrease of 1.3% per year for LI. CONCLUSIONS: These results suggest that it is important to consider sex differences in PA levels among Portuguese adolescents. Unlike their male counterparts, Portuguese females may reduce much of their PA during late adolescence.

Muscle-strengthening activity and its association with insulin sensitivity.

OBJECTIVE: Muscle-strengthening activities (MSAs) may increase insulin sensitivity, thereby reducing the risk of diabetes. The purpose of this study was to assess the relationship between MSAs and insulin sensitivity among American adults. RESEARCH DESIGN AND METHODS: We analyzed data on 4,504 adults without diabetes, aged 20-79 years, who participated in the National Health and Nutrition Examination Survey 1999-2004 and had information on MSAs. Self-reported frequency (times/week) of MSAs was grouped as low (<1), moderate (1-2.9), or high (>or=3). Insulin sensitivity was measured by the fasting quantitative insulin sensitivity check index x 100 (QUICKI). RESULTS: After adjustment for age, race/ethnicity, physical activity other than MSAs, BMI, smoking, alcohol consumption, and daily total caloric intake, the mean values for QUICKI by low, moderate, and high MSA were 33.6, 33.9, and 34.2, respectively (P for linear trend = 0.008) for men and 34.2, 34.6, 34.6, respectively (P for linear trend = 0.009) for women. Mean fasting insulin (picomols per liter) concentrations were 75.0, 68.9, and 65.9, respectively (P for linear trend = 0.017) for men and 66.9, 63.3, 61.2, respectively (P for linear trend = 0.007) for women. There were no significant differences across MSA groups for fasting glucose among men or women. CONCLUSIONS: MSA is independently associated with higher insulin sensitivity among U.S. adults. Efforts to increase MSA may be a realistic, feasible, and effective method of reducing insulin resistance among the U.S. population.

Public health and clinical recommendations for physical activity and physical fitness: special focus on overweight youth.

Numerous physical activity and physical fitness recommendations exist for youth. To date, however, no investigator has systematically reviewed these public health and clinical guidelines to determine whether the recommendations address overweight youth. This review examines youth-oriented physical activity and physical fitness recommendations for both the public health community and the clinical community, and assesses how overweight youth are specifically targeted by each of these two groups. Our review determined the extent to which the recommendations assessed four components of physical activity (i.e. frequency, intensity, duration and type) and four components of physical fitness (i.e. cardiorespiratory capacity, strength, flexibility and body composition). We further reviewed clinical recommendations to determine how they included two facets of the physician-patient encounter: assessment and counselling. After identifying all current physical activity and physical fitness recommendations for youth, we evaluated whether public health (n = 13) and clinical recommendations (n = 12) addressed physical activity and physical fitness for overweight youth. Findings revealed inconsistent, yet explicit, recommendations for the public health community where most organisations (12 of 13, 92%) included > or =3 physical activity components. In addition, organisations encouraged volumes of daily moderate- to vigorous-intensity physical activity for youth ranging from 30-60 or more minutes. Recommendations for the clinical community generally did not provide explicit physical activity and fitness recommendations to advise physicians on the assessment and counselling of patients and their families. Overweight youth were addressed within some recommendations (6 of 12, 50%) for the clinical community, but within few recommendations (2 of 13, 15%) for the public health community. To best inform public health and clinical communities, organisations developing future recommendations should include information fully documenting the decision-making processes used to develop the recommendations. In cases where mutual goals exist, public health and clinical communities should consider collaborating across agencies to develop joint recommendations.

Community-based lifestyle interventions to prevent type 2 diabetes.

OBJECTIVE: To conduct a literature review of community-based interventions intended to prevent or delay type 2 diabetes. RESEARCH DESIGN AND METHODS: Recently published findings about the potential to prevent or delay type 2 diabetes with intensive lifestyle interventions prompted a literature search for community-based diabetes prevention interventions. The literature review design was a search of databases for publications in 1990-2001 that identified reports on community-based interventions designed to prevent or modify risk factors for type 2 diabetes. RESULTS: The search revealed 16 published interventions, 8 of which were conducted in the U.S. and involved populations disproportionately burdened by diabetes (e.g., American Indians, Native Hawaiians, Mexican Americans, and African Americans). Of the studies reporting results among youth, there were posttest improvements in intervention groups in knowledge, preventive behaviors, and self-esteem. Among studies reporting results among adults, most reported improvements in intervention groups in knowledge or adoption of regular physical activity. Several investigators offered important reflections about the process of engaging communities and sharing decision making in participatory research approaches, as well as insights about the expectations and limitations of community-based diabetes prevention research. Many of the studies reported limitations in their design, including the lack of control or comparison groups, low response rates or lack of information on nonresponders, or brief intervention periods. CONCLUSIONS: There is a critical need to conduct and publish reports on well-designed community-based diabetes prevention research and share information on the process, results, and lessons learned. Armed with recent positive findings about diabetes prevention and literature documenting community-based efforts, advocates at local, state, and national levels can collaborate to stem the rising tide of diabetes in communities.