Clinically Practical and Affordable Lifestyle Modification to Prevent Diabetes Mellitus in Real Practice

Inji Lee; Minji Kang; Ji Hye Choi; Hyunjung Lim; Suk Chon

doi:10.4093/dmj.2025.0675

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Lee, Kang, Choi, Lim, and Chon: Clinically Practical and Affordable Lifestyle Modification to Prevent Diabetes Mellitus in Real Practice

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Lifestyle and Behavioral Interventions

Diabetes Metab J (Seoul) 2025;49(5):951-963.

Published online: 1 September 2025

DOI: https://doi.org/10.4093/dmj.2025.0675

Clinically Practical and Affordable Lifestyle Modification to Prevent Diabetes Mellitus in Real Practice

Inji Lee^1,²

, Minji Kang^1,², Ji Hye Choi^3,⁴, Hyunjung Lim^1,²

, Suk Chon⁵

¹Department of Medical Nutrition, Graduate School of East-West Medical Science, Kyung Hee University, Yongin, Korea

²Research Institute of Medical Nutrition, Kyung Hee University, Seoul, Korea

³Department of Endocrinology and Metabolism, Kyung Hee University Hospital, Seoul, Korea

⁴Department of Regulatory Science, Graduate School, Kyung Hee University, Seoul, Korea

⁵Department of Endocrinology and Metabolism, Kyung Hee University Hospital, College of Medicine, Kyung Hee University, Seoul, Korea

Corresponding authors: Suk Chon https://orcid.org/0000-0001-5921-2989 Department of Endocrinology and Metabolism, Kyung Hee University Hospital, College of Medicine, Kyung Hee University, 23 Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Korea E-mail: imdrjs@khu.ac.kr

Hyunjung Lim https://orcid.org/0000-0001-7632-7315 Department of Medical Nutrition, Graduate School of East-West Medical Science, Kyung Hee University, 1732 Deogyeong-daero, Giheung-gu, Yongin 17104, Korea E-mail: hjlim@khu.ac.kr

Received 27 July 2025 Accepted 28 August 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

As the prevalence of type 2 diabetes mellitus continues to rise, the development of effective and sustainable prevention strategies has become a critical public health priority. Evidence from large-scale randomized controlled trials has established that lifestyle modification (LSM) programs can substantially reduce the risk of diabetes in high-risk individuals. However, routine implementation is limited by high intensity, costs, and resource requirements. We summarize major prevention trials and their effectiveness, feasibility, and limitations. Building on these insights, we introduce the Korean Diabetes Prevention Study (KDPS) as a contextually tailored model for the Korean healthcare system. The KDPS-LSM program was designed to integrate cultural and clinical relevance with practical applicability, consisting of a 6-month intensive phase of structured nutrition and lifestyle education followed by a maintenance phase to support long-term adherence. To promote sustainable change, the program incorporates the ‘10 habit’ lifestyle messages, grounded in the transtheoretical model of behavior change, which are designed for easy implementation in daily life. This review underscores the importance of developing culturally appropriate LSM programs that balance effectiveness with feasibility, and suggests that the KDPS-LSM model could serve as a useful foundation for establishing practical diabetes prevention strategies within national healthcare systems.

Keywords: Diabetes mellitus, type 2, Lifestyle, Nutrition therapy, Korea

KEY FIGURE

Highlights

• Lifestyle modification is central to diabetes prevention and self-management.

• Practical, affordable, and culturally adapted programs are essential.

• KDPS-LSM is tailored for the Korean healthcare and sociocultural context.

• KDPS-LSM integrates intensive nutrition therapy and “10 habits” using the TTM model.

• Feasible educator-supported delivery ensures affordability and sustainability.

INTRODUCTION

Diabetes is one of the most pressing global public health concerns, contributing substantially to healthcare expenditures and socioeconomic burden worldwide [1]. According to the International Diabetes Federation, 589 million adults aged 20 to 79 are currently living with diabetes, and this number is projected to rise to 853 million by 2050 [2]. As diabetes is largely preventable, increasing attention has been directed toward identifying effective prevention strategies that are both clinically impactful and economically sustainable [3].

Among these, lifestyle modification (LSM) has emerged as one of the most effective and practical approaches. By promoting healthier eating habits, increasing physical activity, and supporting behavioral change, LSM targets modifiable risk factors that are central to the development of type 2 diabetes mellitus (T2DM) [4]. Numerous clinical trials have demonstrated that structured LSM programs can significantly reduce diabetes incidence, especially in high-risk individuals such as those with prediabetes [4-6]. Moreover, growing evidence supports the cost-effectiveness of LSM, making it a valuable strategy not only for improving health outcomes but also for reducing long-term healthcare expenditures [7,8].

This paper explores the role of LSM in the prevention of T2DM. It reviews major risk factors and highlights the importance of early intervention. In addition, it examines the effectiveness, economic value, and real-world applicability of LSM programs across various populations. Through this review, the paper aims to provide insights for designing sustainable and culturally appropriate diabetes prevention strategies, with particular attention to the Korean context.

BACKGROUND ON DIABETES PREVENTION

Risk factors of type 2 diabetes mellitus

T2DM is a complex metabolic disorder associated with metabolic dysfunction syndrome, and its development is primarily driven by insulin resistance and β-cell dysfunction [9]. These pathophysiological mechanisms are influenced by a range of factors, including genetic predispositions, environmental exposures, and lifestyle behaviors [10].

Genetic predisposition plays a substantial role in diabetes risk. Genome-wide association studies have revealed that most genetic variants increase susceptibility by impairing insulin secretion, while fewer influence insulin sensitivity [11]. Individuals with one parent affected by T2DM have an estimated 40% lifetime risk, rising to 70% when both parents are affected [12,13]. However, a large part of this familial aggregation reflects the heritability of obesity, which is a primary driver of T2DM, rather than diabetes itself [12]. Ethnicity also contributes to risk variation. Native Americans, Hispanics, Asians, and African Americans have consistently shown higher prevalence rates compared to White populations [14,15]. Although these differences were once attributed mainly to genetic differences, recent evidence indicates that social and environmental conditions, such as disparities in access to healthcare, healthy food, or opportunities for healthy lifestyle behaviors, may play a more critical role [14,16].

While non-modifiable risk factors help identify individuals at elevated risk, modifiable lifestyle factors play a crucial role in the actual development and prevention of T2DM. Behaviors such as poor diet and physical inactivity are central contributors to disease onset and progression [17]. A systematic review has identified food environment, walkability, and access to physical activity resources as environmental elements associated with increased or decreased diabetes risk [18,19]. Evidence from large-scale observational cohort studies has shown that individuals who adopt healthier behaviors such as engaging in regular physical activity, maintaining a balanced diet, and avoiding smoking have a significantly lower risk of developing diabetes [20,21].

Although non-modifiable factors establish baseline risk, modifiable lifestyle behaviors offer a critical and actionable window for prevention. Since most cases of T2DM are preventable through healthier lifestyle choices, early identification and targeted intervention focused on these modifiable risk factors are essential. This underscores the importance of timely preventive efforts before irreversible metabolic changes occur.

Importance of early intervention in diabetes prevention

Early intervention and treatment for diabetes prevention can significantly reduce not only the incidence of diabetes but also broader health risks. In this context, a meta-analysis found that effective preventive interventions for diabetes were associated with a 17% reduction in all-cause mortality [5].

Currently, there are no approved pharmacological treatments for prediabetes. However, some studies have demonstrated that early intervention—through LSM or pharmacotherapy—can delay the progression to T2DM [22]. Accordingly, the American Diabetes Association recommends LSM as the primary therapeutic approach for individuals with prediabetes [23].

In Korea, recent data indicate some positive trends in health behaviors among adults with diabetes, such as increased physical activity, decreased smoking rates, and reduced alcohol consumption [24]. However, these behavioral improvements have not been accompanied by meaningful reductions in obesity or abdominal obesity, which remain prevalent in this population [24]. This indicates that while progress has been made, further enhancement of health behaviors and additional interventions are still needed to achieve optimal clinical outcomes. In particular, Korea’s traditionally high carbohydrate intake may contribute to ongoing challenges in diabetes management, underscoring the importance of comprehensive dietary strategies in conjunction with behavioral support.

LIFESTYLE MODIFICATION PROGRAMS

A number of intervention trials have demonstrated the effectiveness of structured LSM programs in preventing T2DM across diverse populations and settings. Based on the findings from the seven selected studies, LSM programs have adopted various approaches in terms of structure, intensity, and delivery methods (Table 1). Most programs provided a combination of dietary and physical activity counseling, but they differed in duration, frequency, behavioral strategies, and the level of professional involvement.

Some programs offered individualized or semi-structured counseling delivered by trained professionals. For example, Oldroyd et al. [25] applied the ‘stages of change’ model through one-on-one sessions with dietitians and physiotherapists over 2 years. Others, like Bo et al. [26] and Roumen et al. [27], adopted more structured protocols with periodic sessions focused on diet and exercise, including both aerobic and resistance training. These longer-term and professionally supported interventions demonstrated positive effects on weight, insulin sensitivity, and diabetes incidence. However, their effectiveness may have been limited by factors such as infrequent contact or lack of follow-up to support long-term behavior maintenance.

Several studies also examined interventions delivered in community or workplace settings, which may offer better feasibility in real-world contexts. Oh et al. [28] implemented a nurse-led, multi-component lifestyle program in a Korean community setting, while Nanri et al. [29] conducted a behavior- focused intervention for office workers that included goal setting and self-monitoring tools like pedometers. Maruyama et al. [30] introduced a hybrid model combining in-person sessions with web-based monitoring. The lower-intensity interventions described above, generally characterized by shorter program duration, less frequent participant contact, reduced involvement of multidisciplinary teams, and fewer structured components than high-intensity intervention, as well as context-specific approaches tailored to settings such as community or workplace environments with simplified delivery strategies or self-monitoring tools, have demonstrated beneficial effects in diabetes prevention. However, their effectiveness has often been constrained by methodological limitations, including brief study durations, small sample sizes, and insufficient assessment of long-term adherence.

Some studies, like Lu et al. [31], integrated lifestyle education with pharmacologic treatments. While this approach achieved excellent metabolic outcomes and diabetes prevention, the added effect of medication complicates the interpretation of the efficacy of the lifestyle intervention itself.

Collectively, these findings suggest that while diverse in format, lifestyle interventions can be beneficial when structured and supported appropriately. Nevertheless, most studies were limited by short follow-up periods and a lack of data on long-term behavioral sustainability. Few programs incorporated strategies to maintain adherence after the intervention ended, and standardized tools for monitoring lifestyle change were seldom used.

These implementation challenges highlight the need to identify scalable and sustainable lifestyle strategies that can maintain health gains over time. In light of these considerations, recent studies have turned attention to the cost-effectiveness of such programs.

Recent studies have demonstrated that LSM is a highly cost-effective strategy for preventing T2DM [32]. Ma et al. [32] conducted an economic evaluation using a diabetes simulation model and found that structured lifestyle interventions for individuals with prediabetes significantly reduced diabetes incidence while also lowering healthcare costs—making the intervention both effective and economically favorable. Similarly, Jacobs-van der Bruggen et al. [8] used modeling based on multiple clinical trials and concluded that lifestyle programs for people with T2DM were generally cost-effective, with some programs providing strong health benefits at relatively low cost. Together, these findings highlight LSM as a valuable and economically sound approach for both preventing and managing T2DM. However, the evidence for the long-term sustainability of health improvements remains limited, and future research is needed to compare the cost-effectiveness of different intervention strategies and to assess their long-term maintenance effects [8].

COMPARISON OF INTERNATIONAL DIABETES PREVENTION PROGRAMS

Various large-scale randomized controlled trials conducted both globally and locally have consistently demonstrated that structured LSM interventions are effective in preventing T2DM in high-risk populations [33-37].

Table 2 provides an overview of each study’s key characteristics, including the study population, study groups, and main outcomes related to diabetes risk reduction. These studies have confirmed that intensive LSM can lower the incidence of diabetes by approximately 30% to 60%, but there were differences in aspects such as target age range, body mass index (BMI) profiles, risk classification, and how intervention and control groups were organized based on each country’s specific context.

Table 3 presents additional details about the specific components of the lifestyle interventions implemented in each study and compares their respective strengths and limitations. For example, the China Da Qing Diabetes Prevention Study was the first randomized trial to demonstrate that LSM involving changes in diet and physical activity could prevent diabetes. However, its generalizability was limited due to its cluster randomized setting, and the behavioral intervention was less standardized, with no structured manuals, inconsistent delivery across educators, limited individual tailoring, and no clearly defined quantitative goals for weight loss or physical activity [33]. The Finnish Diabetes Prevention Study (DPS) offered practical strategies such as regular dietary counseling sessions, personalized exercise guidance, and self-monitoring, which showed high adherence but required significant time and cost investment [34]. In contrast, the U.S. Diabetes Prevention Program (DPP) delivered a highly structured, goal-oriented lifestyle intervention with clear targets for weight loss and physical activity, multiple individual and group counseling sessions, and direct comparison with metformin (MET) treatment [35]. This provided strong long-term evidence but also highlighted the challenge of real-world adoption due to its intensive and resource-heavy design. Meanwhile, the Japan Diabetes Prevention Program and the Indian Diabetes Prevention Programme demonstrated the potential of lower-intensity, culturally tailored approaches using simpler individual or group counseling, behavior modification education, and regular phone follow-ups suitable for Asian populations with generally lower BMI profiles [36,37]. However, these studies also underscored practical difficulties in sustaining consistent behavior change and providing standardized, repeated education and support over time [37]. Taken together, the content outlined in Tables 2 and 3 illustrates both the proven effectiveness and the practical operational challenges of these global programs, providing important implications for the development of sustainable diabetes prevention strategies.

Therefore, although not included in the comparison table, some recent studies implemented programs aimed at practically applying lifestyle interventions within public health systems to address these challenges. In Australia, both the Greater Green Triangle Diabetes Prevention Program and the Melbourne Diabetes Prevention Study modified the DPS model to create pragmatic formats suitable for primary care [38,39]. These programs delivered short-term interventions targeting individuals at high risk of developing T2DM through local general practice clinics. While diabetes incidence was not a primary outcome, both studies demonstrated significant improvements in key metabolic indicators, including reductions in body weight, blood pressure, and lipid levels, thereby confirming the feasibility of implementing structured interventions in routine clinical practice [40].

In the United Kingdom, the National Health Service Diabetes Prevention Programme (NHS DPP), implemented from 2016 to 2018, represents a prominent example of a nationally scaled lifestyle intervention. To improve accessibility, the program integrated digital platforms alongside in-person group sessions, allowing individuals to participate remotely when needed. The educational content was standardized and grounded in behavior change theory, incorporating strategies such as goal setting, self-monitoring, and food logging to ensure consistency and effectiveness. Furthermore, the intervention was delivered by third-party providers rather than clinical staff, enabling scalable and cost-efficient delivery. Supported by comprehensive government policy, the NHS DPP has been institutionalized as a nationally standardized service model for diabetes prevention [41,42].

These findings support the importance of developing sustainable diabetes prevention strategies and further emphasize the critical need to design and implement culturally appropriate, cost-effective, and practically feasible programs tailored to each country’s unique cultural and healthcare context.

KOREAN DIABETES PREVENTION STUDY

Program overview

The Korean Diabetes Prevention Study (KDPS; NCT02981121) is a nationwide clinical trial designed to develop and evaluate diabetes prevention strategies tailored to the Korean healthcare setting. Initiated in 2016, the study compares the preventive effects of MET, LSM, and standard management (STM). Between November 2016 and April 2022, 1,611 individuals were screened across 15 university hospitals, and 810 overweight or obese adults aged 30 to 70 years with prediabetes were randomized to three groups (STM, n=270; LSM, n=272; MET, n=268). KDPS is the second largest diabetes prevention trial worldwide and the largest in Asia, with interventions and follow-up still ongoing as of 2025. The LSM intervention was based on the hypothesis that achieving and maintaining a reduction of more than 5% in body weight through structured LSM could effectively prevent diabetes in high-risk individuals.

Background of the lifestyle modification program

Previous landmark trials such as the DPP and DPS have demonstrated that structured LSM can effectively prevent the development of T2DM. However, these studies also revealed several limitations, including the complexity of implementation, the delivery of excessive amounts of information during individual sessions, and participants’ tendency to forget the material within a short period [37,43,44]. In addition, participants often struggled to apply the acquired knowledge to daily life and to sustain behavioral changes over time. Because a wide range of topics was covered each week, the interventions frequently lacked sufficient repetition, and components such as exercise, dietary behavior, and LSM were difficult to maintain voluntarily once the study ended [34,35,44]. Accordingly, it has been emphasized that lifestyle education should extend beyond short-term weight loss and instead promote long-term weight maintenance and the establishment of sustainable healthy habits [33-37,45].

To address these challenges, the Lifestyle Modification Task Force Team of the Korean Diabetes Association—comprising nutritionists, behavioral psychologists, exercise physiologists, and physicians—developed a structured LSM program tailored to the Korean population. The KDPS lifestyle intervention was designed as a multidisciplinary program integrating medical nutrition therapy, exercise therapy, and behavioral counseling, while incorporating cultural and social factors to improve feasibility and adherence. To ensure both practicality and effectiveness in real-world clinical settings, the program adjusted the number and intensity of in-person visits to realistic levels and provided personalized, stage-matched education and counseling. In addition, standardized educational materials and protocols were developed in accordance with national clinical guidelines, thereby ensuring consistent delivery and applicability across diverse healthcare environments.

Clinical applicability

Considering that a high-intensity and high-cost structure, as applied in overseas programs, would pose limitations not only for study implementation but also for practical application and sustainability in real clinical practice, the KDPS was designed as a pragmatic, moderate-intensity intervention that maintains effectiveness while reducing the cost burden. By adopting a structure that balances feasibility with efficacy, the program enhances accessibility and adherence among participants and allows for practical implementation across diverse healthcare institutions and community settings.

Rather than relying solely on conventional information delivery, the program utilizes simple, campaign style messages that aim to change habits and attitudes by raising participants’ awareness of healthy eating and lifestyle practices and enhancing their motivation for behavioral change. To operationalize this, the ‘10 habits’ program was developed as a set of 10 simple, action-oriented messages focused on daily practice (Fig. 1). Designed to be easy to remember and apply in everyday life, these messages cover one item related to exercise therapy, five related to dietary therapy, and four related to behavioral therapy, providing a comprehensive approach to improving dietary and lifestyle habits. Importantly, the messages are delivered in a stepwise manner according to each participant’s stage of behavior change following the transtheoretical model (TTM) of behavior change, which includes the pre-contemplation and contemplation stage, preparation stage, and action and maintenance stage. For each of these stages, educational materials were developed and counseling is provided accordingly to help participants gradually form and maintain healthy habits over the long term. In previous studies, this repetitive and practice-oriented ‘10 habits’ approach has been shown to have a significant effect on improving participants’ dietary behaviors and lifestyle practices when delivered as stage-matched nutrition education [46,47].

In addition, to ensure the program’s effectiveness and sustainability in various clinical settings, a comprehensive training curriculum was established for educators, including nurses and dietitians. Since, for the LSM group, variations in outcomes such as weight change are inevitably influenced by the competency of intervention educators, including clinical dietitians and health coordinators, it is essential to provide standardized training to maintain a consistently high level of educator proficiency. This training program offers both in-person and remote workshops, enabling facilitators to consistently deliver the KDPS-LSM intervention and adapt its components to the needs of different populations and healthcare environments. In addition, a practical manual was developed for educators so that the program can be easily used in hospitals, community health centers, and other local settings. By adjusting the LSM program to fit the specific conditions of each institution, it is expected that an adaptable version can be widely distributed and utilized in primary and secondary medical institutions, workplaces, and regional public health centers.

International differentiation

In the case of the DPP, the intervention included 16 in-person education sessions over the initial 24 weeks (approximately two to three times per month), followed by at least 1 monthly visit for the next 6 months, and continued with monthly visits for up to 3 years. This resulted in a total of 26 in-person visits during the first year. However, considering the social and healthcare environment in South Korea, it was determined that directly applying the same number of visits used in other countries would pose challenges not only for research implementation but also for practical application and sustainability in real clinical practice. Therefore, the program was designed by fully taking into account Korea’s healthcare system and its practical feasibility, with an initial plan of seven in-person education sessions over the first 24 weeks, followed by visits every 3 months during the subsequent 6 months, resulting in a total of nine visits in the first year. This approach was designed to ensure that the program could be realistically implemented in domestic institutions, and its higher cost-effectiveness increases its acceptability within national health insurance schemes and public health policies.

In addition, the LSM program was developed to ensure cultural relevance and appropriateness for the Korean context. In particular, the in-person education materials for intensive lifestyle intervention were designed with careful consideration of Koreans’ unique food culture, general eating habits, drinking practices, and sleep patterns. This culturally tailored design, which reflects the dietary and lifestyle characteristics of Korean adults, helps increase participant acceptance and contributes to achieving more effective intervention outcomes.

Furthermore, to accommodate various situations such as the coronavirus disease 2019 (COVID-19) pandemic, a non-face-to-face education platform model was developed and piloted, and practical exercise intervention videos were also produced and used to help participants consistently maintain healthy lifestyle behaviors. Through these efforts, the program has been designed so that a flexible and customized prevention and management system can be established and effectively adapted and implemented in diverse real-world settings. Building on this foundation, the KDPS-LSM program could be further utilized to develop evidence-based non-face-to-face education programs, ensuring that effective remote prevention interventions can be delivered as they will inevitably be needed in the future.

Key elements of the lifestyle modification program

Table 4 shows the intervention schedule for the KDPS-LSM group, which aims for participants to achieve at least 5% weight loss within the initial 6 months. They visit the hospital to receive four intensive nutrition education sessions from clinical dietitians and also participate in seven healthy lifestyle education sessions and eight telephone counseling sessions with health coordinators [48]. After the first 6 months, participants visit the hospital every 3 months to review the 10 healthy lifestyle habits with health coordinators and receive monthly health messages to support diabetes prevention and management [49]. Additionally, participants complete a dietary record once a year to regularly monitor their eating habits [49].

After the first year, participants continued to receive follow-up visits every 3 months, with the LSM period lasting for a minimum of 36 months and up to 72 months, resulting in a total of 30 visits.

Efficacy of the KDPS lifestyle modification program: interim results (unpublished)

As the KDPS trial is still in progress, definitive conclusions regarding its long-term efficacy in diabetes prevention cannot yet be drawn. Nevertheless, interim analyses provide meaningful preliminary evidence. In the 6-month analysis (manuscript under review), participants in the LSM group achieved significantly greater weight reduction, a higher proportion reached the ≥5% weight loss goal, and improvements in metabolic parameters were observed compared with the STM (control) group. Moreover, unpublished analyses conducted after more than 2 years of intervention suggest that the LSM group experienced an approximately 30% lower incidence of diabetes relative to the STM group. These interim findings indicate the potential of the KDPS-LSM program to contribute to diabetes prevention in real-world clinical settings, pending confirmation by final outcome analyses.

CONCLUSIONS

This study comprehensively reviewed the effectiveness, clinical applicability, and cost-effectiveness of domestic and international LSM programs for T2DM prevention. Numerous large-scale studies have shown that structured and intensive LSM can reduce T2DM incidence by approximately 30% to 60% among high-risk groups; however, programs designed with high-intensity and high-cost structures, as seen in many international cases, require significant time and resources, making them difficult to sustain in real practice. In response, this study proposes a practical, moderate-intensity, and cost-effective structure that maintains effectiveness while considering the realities of the Korean healthcare system and sociocultural context. Rather than relying on conventional information delivery alone, the program was designed to help participants form and maintain healthy habits through repetitive, practice-oriented campaign style messages delivered according to the TTM. To ensure stable implementation in various clinical and community settings, a standardized training curriculum for educators and a detailed manual were also developed. Additionally, to enhance accessibility and adaptability during situations such as the COVID-19 pandemic, remote delivery platforms and online materials were prepared.

In summary, the LSM program that fully reflects the characteristics and needs of the target population and includes a feasible delivery system and educator support can achieve both practical feasibility and cost-effectiveness. This approach can improve participant satisfaction and encourage sustained behavior change, leading to meaningful T2DM prevention outcomes. Furthermore, for such evidence-based standardized programs to be stably disseminated across healthcare institutions and communities, systematic educator training and financial support must be provided. By doing so, practical and affordable LSM can become part of daily life, making a substantial contribution to T2DM prevention and the reduction of the national healthcare burden.

Notes

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

FUNDING

This research was supported by the National Institute of Health (NIH) research project (project No. 2020-ER6402-00, -01, -02, 2023-ER1103-00, -01, -02).

ACKNOWLEDGMENTS

None

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Fig. 1.

10 keys to a healthier lifestyle (Sib-si-il-gang).

Table 1.

Summary of lifestyle modification studies for patients at risk for diabetes

Study	Study population	Duration	Intervention	Results
Oldroyd et al. (2006) [25]	Adults aged 24–75 with IGT (n=78)	2 yr	Intervention group received individualized counseling by dietitians and physiotherapists based on the ‘stages of change’ model.	Compared to control:
				Greater reductions in total fat intake and body weight
			Dietary: Guidance on regular meals, increased fruits/vegetables, reduced fat/sugar, target BMI <25 kg/m², <30% fat energy	Improved insulin sensitivity at 12 months
			Physical activity: Plan tailored to lifestyle; goal of ≥20– 30 minutes aerobic activity once per week	No significant changes in glucose tolerance or serum lipids
Bo et al. (2007) [26]	Dysmetabolic patients aged 45–64 (n=335)	1 yr	Received five structured lifestyle counseling sessions (diet, physical activity, behavior change) by trained professionals. Diet plans were normo- or hypocaloric; guidance included reduced saturated fat and sugar, increased fiber, and ≥150 min/week of physical activity.	Body weight, waist circumference, hs-CRP, and most components of the metabolic syndrome decreased in the intervention group but increased in the control group over 12 months. The intervention group showed significantly lower odds of abdominal obesity, hypertriglyceridemia, and incident diabetes.
Roumen et al. (2008) [27]	Adults with IGT (n=147)	3 yr	Intervention group received personalized dietary and physical activity counseling every 3 months. Dietary advice was based on national guidelines; physical activity goal was ≥30 min/day, ≥5 days/week. Aerobic and resistance exercise at ≥70% VO₂ max was encouraged.	Lifestyle intervention improved body weight, HOMA-IR, and 2-hour free fatty acid. 2-hour glucose concentrations improved in the intervention group, but worsened in the control group. Diabetes incidence was reduced by 58% in the intervention group.
Oh et al. (2010) [28]	Women aged ≥40 with metabolic syndrome (n=52)	6 mo (+6-mo follow-up)	Intervention consisted of five components: (1) health monitoring, (2) counseling, (3) health education, (4) exercise, and (5) diet. Participants attended exercise sessions and were instructed to follow a low-calorie, low-carbohydrate diet. The initial session included health monitoring and brief counseling. Interventions were delivered by community nurses.	Compared to control:
Oh et al. (2010) [28]	Women aged ≥40 with metabolic syndrome (n=52)	6 mo (+6-mo follow-up)		Significant reductions in body weight, BMI, and waist circumference (maintained at 6-month follow-up)
Nanri et al. (2012) [29]	Men with metabolic syndrome (n=107)	6 mo	Lifestyle modification program based on behavioral theory delivered at baseline, 1, and 3 months by occupational health nurses. Participants set body weight goals and 3–5 lifestyle behavior targets. Tools such as pedometers, weight scales, and diaries were provided. Intervention included increased physical activity, reduced cereal and sugar intake, and moderate alcohol consumption.	Significant reductions in body weight (–2.0 kg), waist circumference (–2.5 cm), and glycosylated hemoglobin (–0.17%) were observed in the intervention group compared to the control group. Physical activity time increased significantly in the intervention group.
Maruyama et al. (2010) [30]	Middle-aged male white-collar workers with metabolic syndrome risk factors (n=101)	4 mo	Individualized dietary and physical activity counseling delivered by a registered dietitian and physical trainer. Participants attended three in-person sessions (base-line, 1st and 2nd month) and one web-based session (3rd month). Participants self-monitored dietary intake and physical activity (steps) using a dedicated website and pedometer. Diet guidance focused on increasing intake of group A foods (e.g., vegetables, seaweed) and reducing group B foods (e.g., sweets, alcohol).	Significant improvements in body weight, BMI, fasting glucose, insulin, and HOMA-IR compared to control.
Lu et al. (2011) [31]	Adults with IGR, aged 40–80 (n=210)	2 yr	Intensive integrated intervention including:	A significantly higher percentage of patients in the intervention group achieved target levels for plasma glucose, blood pressure, BMI, and triglycerides. No participants in the intervention group progressed to type 2 diabetes mellitus, whereas 9.3% (n=8) of the control group developed type 2 diabetes mellitus.
			Lifestyle education (diet & exercise lectures quarterly, monthly phone follow-up)
			Glucose-lowering medication (metformin or acarbose depending on IGR type)
			Antihypertensives, lipid-lowering agents, aspirin when indicated

IGT, impaired glucose tolerance; BMI, body mass index; hs-CRP, high-sensitivity C-reactive protein; VO₂ max, maximal oxygen consumption; HOMAIR, homeostasis model assessment of insulin resistance; IGR, impaired glucose regulation (encompasses both impaired fasting glucose and IGT).

Table 2.

Comparison of key characteristics and outcomes in major international diabetes prevention programs

Study	Country	Study population	Results (risk reduction)
China Da Qing Diabetes Prevention Study (CDQDPS) [33]	China (1986–1992)	Adults with IGT (n=577)	31% (diet), 46% (exercise), 42% (diet+exercise) vs. control; mean follow-up 6 years
Finnish Diabetes Prevention Study (DPS) [34]	Finland (1993–2001)	Adults aged 40–64 years with IGT (n=523)	58% (Intervention) vs. control; mean follow-up 3.2 years
Diabetes Prevention Program (DPP) [35]	USA (1996–2002)	Adults aged ≥25 years at high risk of developing diabetes (n=3,234)	58% (lifestyle), 31% (metformin) vs. control; mean follow-up 2.8 years
Japan Diabetes Prevention Program (JDPP) [36]	Japan (1999–2006)	Adults aged 30–60 years with IGT (n=304)	55% (intervention) vs. control; follow-up 3 years
Indian Diabetes Prevention Programme (IDPP) [37]	India (2001–2005)	Adults with IGT (n=531)	28.5% (lifestyle), 26.4% (metformin), 28.2% (combined) vs. control; mean follow-up 3 years

IGT, impaired glucose tolerance.

Table 3.

Comparison of intervention designs and strengths & limitations in major international diabetes prevention programs

Study	Study groups	Lifestyle intervention details	Strengths & Limitations
China Da Qing Diabetes Prevention Study (CDQDPS) [33]	1) Diet group	Diet:	First RCT to demonstrate the long-term effect of lifestyle-only diabetes prevention; however, the behavioral intervention was non-standardized, with no structured manual, limited individual tailoring, and inconsistent delivery across educators. Generalizability is limited due to its single-region setting.
	2) Exercise group	Individualized diet plan based on BMI; those with BMI ≥25 kg/m² aimed for gradual weight loss to BMI 23 kg/m²; advice to increase vegetables, reduce alcohol and sugar; individual and group counseling weekly for the first month, monthly for the next 3 months, and every 3 months thereafter.
	3) Diet+exercise group	Exercise:
	4) Control group	Participants were instructed to increase leisure-time physical activity by at least one exercise unit per day, or two units for those under 50 years old without cardiovascular disease or arthritis. Activity plans were adjusted based on age, health status, and season, with indoor activities recommended in winter counseling aligned with diet group.
Finnish Diabetes Prevention Study (DPS) [34]	1) Intervention group	An initial weight loss of at least 5% was targeted, alongside engaging in moderate-intensity physical activity for at least 30 minutes daily, maintaining dietary fat intake below 30% of total energy, saturated fat below 10%, and consuming at least 15 g of dietary fiber per 1,000 kcal. This was supported by individualized dietary counseling (seven sessions in the first year, then every 3 months), tailored aerobic and strength exercise guidance, and personalized goals based on regular 3-day food records.	High adherence and effective tailored coaching; higher program costs require careful cost-effectiveness considerations for large-scale adoption.
Finnish Diabetes Prevention Study (DPS) [34]	2) Control group
Diabetes Prevention Program (DPP) [35]	1) Lifestyle intervention group	Lifestyle intervention:	Large, multi-ethnic RCT with robust long-term outcomes and direct comparison with metformin; very intensive design limits real-world feasibility and increases costs.
	2) Metformin group	The intervention encouraged participants to achieve an initial weight loss of at least 7% and engage in moderate-intensity activities such as walking or cycling for at least 150 minutes per week, while maintaining dietary fat intake below 25% of total energy. If weight loss was insufficient, calorie restriction was added. This was supported by individualized and group-based education on diet, physical activity, and behavior modification techniques, including at least 16 individual sessions during the first 24 weeks with monthly contacts thereafter, culturally tailored to local communities, with a strong emphasis on psychological motivation, social support, self-monitoring, goal setting, stimulus control, problem-solving, and relapse prevention.
	3) Control group
Japan Diabetes Prevention Program (JDPP) [36]	1) Intervention group	For overweight individuals, the program aimed for at least 5% weight loss, an increase in leisure-time physical activity by approximately 700 kcal per week, appropriate calorie intake with less than 25% of energy from fat, and daily alcohol intake limited to under 160 kcal. Participants were encouraged to follow regular three meals while avoiding late-night snacks. Support included four initial group sessions over 6 months on diabetes prevention, healthy eating, exercise injury prevention, and enjoyable activity methods, plus individualized counseling every 6 months for 3 years (20–40 minutes each), with exercise goal setting (e.g., ≥20 minutes moderate-to-vigorous walking daily) and behavioral strategies based on self-efficacy and self-monitoring. Phone counseling was offered as an option after the first year.	Feasible East Asian model reflecting local culture with community–hospital link; limited by small sample size and regional focus, needs larger-scale expansion.
Japan Diabetes Prevention Program (JDPP) [36]	2) Control group
Indian Diabetes Prevention Programme (IDPP) [37]	1) Lifestyle modification group	Lifestyle modification:	Low-cost, low-intensity program applicable to resource-limited settings; modest weight loss effect and less standardized sessions may limit reproducibility.
	2) Metformin group	Lifestyle advice focused on reducing total calorie intake, decreasing consumption of refined carbohydrates, fats, and sugars, and adopting a fiber-rich diet while aiming for at least 30 minutes of walking daily. This was reinforced by an initial individual session at randomization, a follow-up call or letter 2 weeks later, and monthly phone contacts to encourage sustained lifestyle changes.
	3) Combined group
	4) Control group

BMI, body mass index; RCT, randomized controlled trial.

Table 4.

Intervention schedule including education and evaluation: KDPS lifestyle modification group

Visit date	Intervention
	Baseline	Intensive intervention program						Maintenance intervention program
	0 day	2 wk	4 wk	8 wk	12 wk	18 wk	6 mo	9 mo	12 mo	15 mo	18 mo	21 mo	24 mo	27 mo	30 mo	33 mo	36 mo	…	72 mo
Standard education for all participants all participants	√
Lifestyle management offline training
Intensive nutrition education	√		√		√		√	Additional nutritional counseling for participants failing to maintain weight goals after 6 months										Visit every 3 months continued for 36–72 months
3-Day food record	√		√		√		√		√				√				√ (annually)		√
‘10 key healthy habits’ education and assessment	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√	√ (every visit)		√
Exercise diary	√	√	√	√	√	√	√
Global Physical Activity Questionnaire (GPAQ)	√						√		√		√		√		√		√ (every 6 months)		√
Lifestyle management phone counseling	1, 3, 6, 10, 14, 16, 20, 22 weeks Telephone intervention							Telephone call 1 week prior to visit Digital activity tracker (optional)

KDPS, Korean Diabetes Prevention Study.

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