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Diabetes Prevention Programs are a group of programs that are created to prevent the onset of Type 2 Diabetes, often in people who have been identified as at-risk. Most include behavior changes, social support, and include weight loss as a metric and/or the primary outcome.
The assumption is typically that any health changes and/or reductions in the development of T2D are because of any weight loss. In discussing these programs previously I’ve expressed the concern that any differences in health/T2D development were more likely due to behavior changes/support than any weight loss and that, because of their insistence on a weight-loss focus, the programs likely included much more restriction than is necessary to create any health changes, which could create harms including weight cycling (which can actually drive T2D,) weight stigma (which can actually drive T2D,) and disengagement from behaviors that might actually support health and make T2D less likely (with the clear and critical understanding that whether or not someone develops T2D involves myriad factors, many of which are completely outside of their control, including genetics.)
Enter the new systematic review “Potential mechanisms for change in diabetes prevention programs” which sought “to investigate potential mechanisms for change in diabetes prevention programs (DPPs), and assess the strength of associations.” Their hypothesis was that “ Weight loss would be less strongly associated with improved health than other mechanisms.”
Summary
A group of researchers, several of whom work in weight inclusive Type 2 Diabetes preventions and management, sought to fill a gap in research around Diabetes Prevention Programs (DPPs). These program seek to delay/prevent onset of Type 2 Diabetes and typically include multiple interventions but often target an end goal of weight loss. There is a significant lack of research that even attempts to determine which aspects of DPPs might actually be responsible for any benefits and which might be unhelpful or cause harm. These researchers undertook a systematic review to attempt to determine just that.
The Authors
We’ll begin, as we always do, with the authors. Spoiler alert, this is going to be much shorter than these typically are. The study received no funding and the authors disclosed no conflicts of interest. I’ll do my usual deeper dive into their work and, as a reminder, working in the space in which you are researching is not considered a conflict of interest that requires disclosure but is something that always makes me give extra scrutiny to methodology. As usual, if you want to skip this part you can scroll down to where it says “The Study.”
Margit I. Berman is an Associate Professor at the Graduate School of Professional Psychology at the University of St. Thomas. Dr. Berman is the author of a “A Clinician’s Guide to Acceptance-Based Approaches for Weight Concerns: The Accept Yourself! Framework” This is not a DPP program but does have a section on Health at Every Size™ approaches to Diabetes and Cardiovascular Health. [Note: that Health at Every Size is the trademarked brand of the Association for Size Diversity and Health)
Martha Burla - per LinkedIn currently works at the Feinberg School of Medicine in the Department of Medical Social Sciences where she supports research on patient reported outcomes and shared decision making. She is also pursuing a PhD in Health Sciences from Rush University with the hope of continuing to research patient decision making and autonomy.
Hannah Martin - per her Linkedin she is a PhD candidate at the University of Otago, Dunedin New Zealand. Her research focuses on Intuitive Eating
Megrette Fletcher - is the owner of Inclusive Diabetes Care, LLC which offers free and paid resources for weight-inclusive diabetes care. Full disclosure, Megrette and I have worked together including speaking on the same panel and on a writing project.
Elizabeth A. Michaels - per LinkedIn, works at Christopher Rural Health Planning Corporation Primary Care including Coordination of Diabetes Program in accordance with AADE Standards , Individualized Nutrition Consultation and Diet Instruction, Nutrition Therapy for Emotional Eating, Personalized Meal Plans and Recipe Development, Provision and Marketing of Community Health Classes, Development of Educational Resources and Materials, Diabetes Medication and Insulin Management, Continuous Quality Improvement Tracking, Patient Goal Setting and Ongoing Support, Auditor AADE Programs, and Development and initiation of CDCs Diabetes Prevention Program
Lauren Brittany Beach- Per LinkedIn they are an Assistant Professor at Northwestern University’s Department of Medicine Social Sciences and Department of Preventive Medicine in the Feinberg School of Medicine and “a leader with a strong track record of scientific research and business development across a wide variety of therapeutic areas, including infectious disease, oncology, cardiology, endocrinology, nephrology, rare disease, and more. In my roles as Assistant Professor, ADVOCATE Center Director, and Robert H. Lurie Comprehensive Cancer Center Executive Team member at the Northwestern University Feinberg School of Medicine, I am recognized for innovative and high impact contributions in research, mentorship, education, and service. I have 20 years of experience translating results from cutting-edge science into narratives that resonate with funding agencies, regulators, clinicians, and the public. I have experience directing interdisciplinary teams in the United States and globally of up to 60 people to solve complex research and operational challenges on time and on budget. Trained in genetics, law, and epidemiology, I am a skilled data scientist and technical writer with experience in research and regulatory communication in both the discovery and clinical research domains.”
Michelle L. May - per LinkedIn May is an Associate Professor in the Psychology Department at Arizona State University and the creator of the Am I Hungry? Mindful eating program offering “experiential mindful eating workshops, retreats, and corporate wellness programs. We have trained over 800 health and wellness professionals in over 40+ countries to offer mindful eating programs, coaching, and therapy in their communities, practices, and workplaces.“
Pamela J. Bagley - per LinkedIn Bagley is Coordinator of Biomedical Research Support at Dartmouth Biomedical Libraries.
Heather B. Blunt - is a Research and Education Librarian, Public Health Lead in Medical and Health Sciences at the Dartmouth Biomedical Libraries with subspecialties in Medical and Health Sciences
The Study
The authors begin by explaining diabetes prevention programs (DPPs), including that they can vary but often have multiple components including medical and/or psychosocial interventions. They point to the DPP-ILI (Intensive Lifestyle Intervention) as a typical intervention that focuses on creating 7% weight loss using multiple components. They also point out that in one study the DPP-ILI reduced diabetes incidence by 58% compared to a placebo, but that participants don’t necessarily find the program either “helpful or tolerable” and the programs often having drop out rates from 40-80%. They also note that the DPP-ILI contains multiple elements - change in weight, physical activity, food, social support, psychological change, education, and self-monitoring and self-awareness that may impact onset of diabetes. Finally, the authors point out that “despite their efficacy, it is possible that DPPs may include harmful elements such as exposure to weight stigma or healthism.” I’ll also add, based on about 100 years of research, exposure to the harms of weight cycling since the vast majority of people who lose weight will gain it back.
Here the researchers hit on an issue I would suggest is not just with DPPs but with all health interventions that are based on weight loss. As these authors put it, “it is striking how little is known about which components of these interventions cause a delay in diabetes onset, and which components may cause harm.” As is, again, the case with almost all, if not all , research that tries to claim that weight loss create health benefits, more than twenty years in, the research into the DPP-ILI “was not designed to test the relative contributions of dietary changes, increased physical activity, and weight loss to the reduction in the risk of diabetes.” Given our culture’s obsession with weight loss (driven by, and with tremendous profit to, the weight loss industry,) the assumption with the DPP (and in general) is always that weight loss (and, typically, very small amounts of weight loss) causes health benefits, literally ignoring all of the behavior changes and other components that precede both the (small, typically temporary) weight loss and the health changes/benefits. The researchers note that “clinicians have focused on the importance of weight loss…recommending weight loss, however, may be a particularly likely candidate to cause harmful or null effects in DPPs.”
Considering weight loss, the researchers note that long-term weight loss is “not achievable for most people” and, further, that weight loss programs can induce or exacerbate weight stigma and expose participants to discrimination. They point out that despite the “transient” nature of weight loss in DPPS, “the delayed onset of diabetes can be largely retained, suggesting that mechanisms other than weight loss may contribute to the benefits.”
In part 2 we’ll look at the study methodology and what they found.
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*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings’ Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.
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