Sheida Zeraattalab-Motlagh, MSc, and Tracey Ledoux, PhD
Department of Health and Human Performance, University of Houston
Diabetes has become one of the most pressing health challenges in the United States. Over the past 20 years, the number of adults living with diabetes has doubled, affecting 38.1 million people, with about 36 million cases attributed to type 2 diabetes (T2D). T2D is a metabolic disorder characterized by unusually elevated blood glucose levels and remains a leading cause of morbidity and mortality, imposing significant economic and societal costs. But here’s the encouraging news: Prediabetes, a disease state that precedes T2D, is a reversible condition that provides a key opportunity for primary prevention of T2D. Lifestyle modification through behavioral interventions, programs that target improvements in diet and activity behaviors, including physical activity and sedentary behavior, has proven effective in delaying or preventing T2D onset.
The landmark US Diabetes Prevention Program (DPP) showed that lifestyle change reduced T2D incidence by 58%, compared to 31% reduction with the medication metformin. However, translating this evidence into community and real-world contexts remains inconsistent. Programs differ in how they are delivered, which populations they reach, and the strategies they use to promote behavior change.
To better understand diabetes prevention interventions and the key components that make them effective, researchers at the University of Houston, with support from the Episcopal Health Foundation (EHF), conducted a scoping review of US programs that successfully improved eating and activity behaviors among adults without T2D.
Below is an overview of the research findings summarizing the populations reached in these successful diabetes prevention interventions, the context in which these successful interventions were delivered, and the behavior change techniques included in them.
How the Review Was Conducted
The research team analyzed 23 randomized controlled trials conducted across 16 states between 2001 and 2024, involving 2,583 adults. Each study demonstrated statistically significant improvements in eating or activity behaviors aligned with American Diabetes Association guidelines, including:
- Dietary targets: More fiber-rich foods (vegetables, legumes, fruit, and whole grains), fewer added sugars, refined grains, and saturated fats, and improved overall diet quality (such as, Healthy Eating Index (HEI), Alternative HEI, or Dietary Approaches to Stop Hypertension).
- Activity targets: At least 150 minutes of moderate-to-vigorous activity per week and reduced sedentary time.
The Four Common Components of Effective Programs
Each intervention used specific strategies, called Behavior Change Techniques (BCTs), to help people adopt and maintain healthier habits. Across all successful interventions, four core strategies emerged as foundational:
- Goal Setting (96% of interventions): Participants set measurable, specific goals like daily step counts or limits on sugary beverages.
- Clear Instruction (83% of interventions): Programs provided practical, actionable guidance on how to prepare balanced meals, ways to break up sitting time, or techniques for portion control.
- Social Support (79% of interventions): Whether through group meetings, peer mentoring, or online communities, successful programs created connection and accountability.
- Personalized Feedback (67% of interventions): Regular progress reports, app notifications, or coaching sessions helped participants track their journey and stay motivated.
These four elements formed the backbone of effective diabetes prevention efforts, regardless of how the program was delivered.
Intervention Delivery and What Worked Best
The research revealed four main delivery approaches:
- Combined Interventions (54%): These hybrid models merged digital tools with face-to-face counseling or environmental changes. They used the most behavior change techniques and showed the strongest results, proving that multi-component programs are most effective.
- Digital Interventions (29%): Smartphone apps, online platforms, text reminders, and wearable devices like Fitbits offered flexible, scalable solutions.
- Face-to-Face Interventions (8%): In-person counseling, workshops, or supervised exercise provided personalized attention but used fewer behavior change techniques overall.
- Environmental Interventions (8%): These programs changed participants’ surroundings like installing sit-stand desks at work or offering financial incentives for purchasing fruits and vegetables.
- Multi-component programs are most effective.
Over half (54%) combined technology with coaching or peer support, achieving greater adherence and sustained behavior change than single-mode programs.
- Short-term, individual programs can be effective.
Many of these successful programs lasted less than three months. However, individualized models may not work as well in rural, remote, or disadvantaged areas where technology and staffing are limited. Scalable, group-based approaches might improve reach and equity.
Opportunities and Implication For Texas
Although the findings are encouraging, they also highlight areas where further attention and resources are required. Most participants in these studies were ages 31-50, predominantly white and non-Hispanic, with at least some college education. This lack of diversity highlights an important research gap: there remains no consensus on the most successful interventions for younger and older adults from non-white racial groups, the Hispanic ethnic group, and lower educational attainment groups. This gap represents an urgent opportunity, especially in Texas.
With 40% of Texas’s population identifying as Hispanic/Latino, the state’s largest ethnic minority, and about 12.7% of Texas adults diagnosed with diabetes, with most cases being T2D, we need diabetes prevention programs specifically designed for and tested with diverse communities. This means developing interventions that work for younger and older adults, people from non-white racial groups, Hispanic communities, and those with lower educational attainment.
The good news is that the strategies highlighted in this research provide a strong foundation for informing future intervention planning. This review followed American Diabetes Association standards for defining diet and activity outcomes and provides a description of what actually works in diabetes prevention efforts nationwide. By adapting programs that have achieved meaningful change, Texas can lead the way in creating diabetes prevention interventions that truly work for everyone.
- Include proven behavioral strategies, including goal setting, instruction, feedback, and social support.
- Combining digital tools with face-to-face or environmental interventions, making behavior change more engaging and accountable.
- Adapt approaches to community context, ensuring programs are feasible in rural, remote, and disadvantaged settings.
- Prioritize diverse recruitment to close equity gaps in prevention.
By identifying what works and the gaps that remain, EHF is better positioned to invest in prevention strategies that meet Texans where they are. Stay tuned for the full research report, which will detail the methodology, findings, and what works to prevent diabetes in our communities.
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