Margarita Cozzan, M.S., a Registered Dietitian since 2009, has a Master of Science degree in Nutrition and has been an ACE Certified Personal Trainer since 2006. With more than 15 years of experience in coaching and supporting lifestyle change, Margarita has supported clients in variety of settings including an outpatient bariatric surgery clinic, skilled nursing and rehabilitation facilities, doctors’ offices, spas, and gyms.
The Case for Behavior-change Coaching in Diabetes Prevention
Evidence citing the success of and need for personalized lifestyle coaching in preventing and managing type 2 diabetes continues to solidify. In 2002, the results of the Diabetes Prevention Program (DPP), a major research study supported by the Centers for Disease Control and Prevention (CDC) and National Institutes of Health (NIH), showcased the significant benefits of intensive lifestyle modification coaching. The success and quality of this study kicked off a string of research and resulting policy changes that continue to change care for persons affected by prediabetes and diabetes worldwide. This is a call to action for professionals trained in behavior-change coaching to join in the multidisciplinary efforts to decrease the incidence of diabetes and diabetes-related health problems. Health coaches and exercise professionals can build on their behavior-change expertise by incorporating the elements of the DPP and subsequent research findings into their coaching sessions with clients who are at risk of developing diabetes.
The Original DPP Study
The original five-year long study involved more than 3,000 participants and found that the DPP’s lifestyle-change program resulted in a 58% reduction in the development of diabetes compared to an oral medication placebo in individuals with prediabetes. Here are some key elements of the program:
- It focused on weight loss and physical activity via goal-based behavioral interventions. All participants were given the same goals: weight loss of 7% of current body weight within the first six months of the 12-month long program and performance of moderate physical activity of at least 150 minutes per week.
- Participants were given nutrition education that focused on reducing fat intake, dining out healthily and following the USDA’s Food Guide Pyramid (the predecessor to MyPlate).
- Individuals were taught self-monitoring skills for tracking fat intake, physical activity and weight.
- It utilized behavior-change strategies such as stimulus control, problem solving, relapse prevention, coping strategies, stress management, behavioral contracts and positive self-talk via one-on-one coaching sessions.
- The standardized program was delivered by “lifestyle coaches.” Experienced health and exercise professionals received two-day mandatory training and continued, easily accessible support with a focus on role-playing, reflective listening, motivational interviewing and empowerment strategies.
- Study participants received frequent and ongoing contact and a maintenance program.
- It featured individualized utilization of resources that addressed individuals’ identified barriers to success such as cookbooks, sessions with a personal trainer, aerobic exercise videos or portion-controlled meals.
At the start of the DPP study in 1996, there were only a few other published papers that researched lifestyle modifications, and they were observational in design. The DPP was the first randomized controlled trial to analyze the effects of intensive lifestyle intervention on preventing diabetes.
DPP Outcome Studies
There were two DPP follow-up studies, completed at 10 and 15 years, to review outcomes of the lifestyle-change program’s effects on adverse health variables. Both studies found long-term success and continued significance of the program. At 10 years, participants of the program were found to have been diagnosed with diabetes at a 34% lower rate than those who did not receive the lifestyle intervention. At 15 years, the participants had developed diabetes at a 27% lower rate.
Modified DPP in Group and Community Settings
After the documented success of the DPP, modified programs based on the DPP lifestyle-change program were analyzed to determine whether they would be effective outside of a clinical trial, such as community settings like the YMCA or in group coaching. Researchers concluded there was “potential for less intensive interventions to be both feasible and to have an impact on future progression to diabetes in at-risk individuals.” The success of these modified programs paved the way to making the DPP more easily available and cost-effective to the 86 million Americans with prediabetes.
Effective Healthcare Spending
In 2017, the Centers for Medicare and Medicaid Services (CMS) funded a three-year study of the DPP delivered at the YMCA to participants receiving Medicare benefits. The resulting healthcare cost savings were significant. Healthcare spending for medicare beneficiaries who were enrolled in the DPP at the YMCA decreased by an average of $278 per quarter. The study also reported significantly fewer trips to the emergency room for participants of the program.
Several study reviews confirm that delivery of a DPP-like program in a group or even in virtual settings with a live health coach are more cost-effective than in-person, one-on-one coaching. Regardless of the delivery method, the DPP and similar programs have been found to be a smarter way of spending healthcare dollars, resulting in improved quality of life of individuals and an improved healthcare system overall.
Additional Health Benefits
Additional benefits of diabetes prevention programs in the United States have been documented. Several studies have found that the physical goals set by the DPP’s lifestyle-change program had positive effects on cardiovascular health. In 2016, a review of 44 studies utilizing lifestyle modifications reported positive cardiometabolic improvements in health. An earlier study with the same DPP goals found a decreased incidence of high waist circumference, high blood pressure, hyperglycemia and elevated blood lipids in its participants. Improvements in obstructive sleep apnea, quality of life, and overall mental health and well-being have also been reported as results of diabetes prevention programs utilizing lifestyle change intervention.
Other Coaching Platforms
A study from the Montana Department of Public Health and Human Services between 2008 and 2015 used virtual coaching platforms and analyzed for differences in success rates between the classic face-to-face diabetes prevention programs and virtual DPPs. The virtual DPPs had a designated coach delivering telehealth sessions from afar. Researchers found no difference in results between the two methods. Participants from both groups lost 5 to 7% of their body weight, suggesting it is feasible to effectively deliver the DPP lifestyle change program virtually.
National Diabetes Month
November is National Diabetes Month, which is a great opportunity to educate your clients about diabetes and its link to cardiovascular disease. The National Institute of Diabetes and Digestive and Kidney Diseases offers these basic, but important reminders worth sharing:
Adults with diabetes are nearly twice as likely to die from heart disease or stroke as people without diabetes. This is because over time, high blood glucose from diabetes can damage the blood vessels and the nerves that control the heart. The good news is that the steps an individual takes to manage diabetes can also help lower his or her chances of having heart disease or a stroke:
- Stop smoking or using other tobacco products.
- Manage A1C, blood pressure and cholesterol levels.
- Develop or maintain healthy lifestyle habits—be more physically active and learn ways to manage stress.
- Take medicines as prescribed by your doctor.
Diabetes Prevention Coaching Today
Today, the CDC’s National DPP Lifestyle Change Program is comprised of a list of CDC-recognized lifestyle-change programs. Since 2018, participant enrollment in a CDC-recognized program is covered by Medicare. The eligibility requirements to become a CDC-recognized program are set by the Diabetes Prevention Recognition Program (DPRP). Meeting the DPRP Standards is the best way for a modified diabetes prevention program to gain visibility, but it can be challenging. Health and exercise professionals are still encouraged to offer evidence-based diabetes-prevention coaching sessions to their clients even if they implement programs that are not recognized by the CDC.
Given the significant amount of published research regarding frequency, goals, curriculum, cost and other details of successful modified DPPs, diabetes-prevention coaches can utilize this research to create structured programs to deliver to clients at risk of developing diabetes.
Offering effective diabetes-prevention coaching is feasible for health and exercise professionals educated in behavior-change coaching, pathophysiology of prediabetes and diabetes-prevention strategies. Coaches should consider the following aspects when designing programs for their clients:
- Identify participants via completion of the CDC Prediabetes Risk Test, and create a structured schedule based on published DPP evidence. This includes offering a program that lasts at least one year, with at least 16 or more sessions occurring the first 24 weeks of the program. Additionally, the program should include a structured maintenance schedule of at least six sessions during the last six months. Sessions can be offered individually, in groups, live, virtually or in any combination. Additional support etween appointments via text messaging and emails are suggested to increase efficacy and program adherence.
- Build the program around the key DPP program participant goals:
- Achieve weight loss of 5–7% within the first six months of the program
- Participate in at least 150 minutes of moderate physical activity per week
- Aim for balanced nutrition via evidence-based eating patterns such as the USDA’s MyPlate, the Mediterranean eating plan and the Dietary Approaches to Stop Hypertension (DASH) diet
- Create lesson plans covering the topics of self-monitoring, behavior-change strategies, stress management, relapse prevention, physical activity and nutrition education.
- Make time for sessions to be person-centered and remember that according to the principles of adult learning, education must:
- Be relevant and timely (a client needs to know why and how it applies to his or her life right now)
- Build on previous knowledge (follow the elicit-provide-elicit method of motivational interviewing)
- Provide a lesson the client is ready to adopt at that time according to his or her stage of readiness
- Encourage autonomy and self-directedness of learning
- Be offered in a way that is personal and interesting to the client
- Be implemented in a way that matches the client’s learning style (visual, auditory or kinesthetic)
- Be presented in a way that is consistent with the client’s beliefs, attitudes and coping skills
- Encourage weekly weigh-ins for live sessions or request weekly reporting of weight if virtual.
- Perform an assessment of the program upon completion, utilizing participant surveys, physical data and attrition rates to continually make improvements.
More than one in three adults has prediabetes and 90% of those individuals do not know they have it. Screening clients who possess risk factors for diabetes, such as having excess weight, a family history of diabetes, a prior diagnosis of gestational diabetes, hypertension or smoking, is key. If clients lose 5 to 7% of their body weight, meet physical-activity guidelines and improve their nutrition, they can cut in half their risk of developing diabetes.
Tens of millions of Americans could benefit from diabetes-prevention coaching to help them make lasting lifestyle modifications. Combining the health and exercise professional’s expertise in behavior-change coaching with evidence-based practice in diabetes prevention can make a significant impact on the health of the nation.
These videos produced by the Centers for Disease Control and Prevention were created for lifestyle coaches of recognized programs and can be an additional resource for health and exercise professionals looking to create evidence-based, diabetes-prevention coaching programs:
Expand Your Knowledge
Diabetes Prevention Coaching [online course]
Expand your impact and increase your income by coaching lifestyle-change strategies to fight the diabetes epidemic.
ACE Behavior Change Specialist Program [ACE Specialist Program]
As an ACE Behavior Change Specialist, you’ll learn to build supportive client-coach relationships to help people make healthy, productive and permanent life changes.