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Preventive Medicine Reports logoLink to Preventive Medicine Reports
. 2024 Feb 15;39:102655. doi: 10.1016/j.pmedr.2024.102655

A systematic review of diabetes prevention programs adapted to include family members

Susan J Andreae a,, Hailey Reeves a, Thomas Casey a, Anna Lindberg a, Kristen A Pickett a,b
PMCID: PMC10882182  PMID: 38390312

Highlights

  • Family-based programs may be a strategy to prevent health conditions with hereditary risk such as diabetes.

  • We conducted a review of studies that adapted the Diabetes Prevention Program's curriculum to include family members.

  • More research is needed to better understand the mechanisms of action and the most effective strategies to engage family members.

Keywords: Diabetes Prevention Program, Systematic review, Family-based lifestyle change program, Adaptation, Health promotion

Abstract

Objectives

Family-based programs may be a strategy to prevent health conditions with hereditary risk such as diabetes. This review examined the state of the science regarding interventions that adapted the Diabetes Prevention Program (DPP) lifestyle change curriculum to include family members.

Methods

CINAHL, Cochrane Central, PsycINFO, PubMed, and Scopus were searched for reports that were peer reviewed, written in English, evaluated interventions that adapted the DPP lifestyle change curriculum to be family-based, reported diabetes risk related outcomes, and published between 2002 and August 2023. Records were reviewed, data extracted, and quality assessed by two researchers working independently. A narrative synthesis was completed. Meta-analysis was not completed due to the small number of studies and the heterogeneity of the study characteristics.

Results

2177 records were identified with four meeting inclusion criteria. Primary participants for three studies were adults and one study focused on youth. Family participants were adult family members, children of the primary participant, or caregivers of the enrolled youth. For primary participants, two studies found significant intervention effects on weight-related outcomes. Of the studies with no intervention effects, one was a pilot feasibility study that was not powered to detect changes in weight outcomes. Three studies assessed outcomes in family participants with one finding significant intervention effects on weight.

Conclusions

While DPP interventions adapted to include family showed promising or similar results as individual-based DPP interventions, additional studies are needed to better understand the mechanisms of action and the most effective methods to engage family members in the programs.

1. Introduction

Type 2 diabetes mellitus (T2DM) continues to be a public health issue that negatively impacts multiple dimensions of health and wellness with significant economic burdens. (American, 2018)Approximately 11 % of the U.S. population live with T2DM (National Diabetes Statistics Report, 2017) with trends predicting that prevalence will increase 54 % by 2030. (Rowley et al., 2017) Moreover, rates of T2DM in youth continue to grow. (National Diabetes Statistics Report, 2017, Imperatore et al., 2012, SEARCH, 2006, Dabelea et al., 2014, Lawrence et al., 2021) Onset of T2DM earlier in life is associated with greater mortality, more severe diabetes-related health complications, and higher risk for cardiovascular disease in adulthood. (Constantino et al., 2013, Maahs et al., 2014).

The Centers for Disease Control and Prevention (CDC) National Diabetes Prevention Program (DPP) is an evidence-based strategy to reduce diabetes risk. DPP includes public–private partnerships that deliver the structured, group-based lifestyle change program focused on reducing weight through healthy eating and physical activity for people with prediabetes. (Program, 1999, Knowler et al., 2002) The program demonstrated that the lifestyle change curriculum supported individuals at risk for T2DM in weight loss and increasing physical activity. Participants achieved 5 to 7 % weight loss, reducing the risk of developing diabetes by 58 %. (Knowler et al., 2002) The 10-year follow-up study, the Diabetes Prevention Program Outcomes Study, showed that program effects were sustained with intervention participants being one-third less likely to develop T2DM or delay disease onset by around 4 years compared to control participants. (Knowler et al., 2009).

Programs using the DPP curriculum have been translated into multiple populations and settings. However, compared to the original DPP and the 10-year follow-up findings, these programs have varied results. (Ali et al., 2012, Aziz et al., 2015, Neamah et al., 2016, Nhim et al., 2019, Whittemore, 2011, Tabak et al., 2015, Jackson, 2009) For example, a meta-analysis of 28 studies using the DPP found that participants lost an average of 4 % of baseline body weight. (Ali et al., 2012) And, a review that examined the implementation of DPP in four distinct settings (hospital outpatient, primary care, community, and work/church) found that there was significant variability in reaching DPP benchmarks between the settings with weight change ranging from −2l.7 % to −6% of baseline. (Whittemore, 2011) Furthermore, the literature shows that more work is needed with regard to sustainability of behaviors and long-term retention of participants in DPP programs. (Cannon et al., 2020, Haw et al., 2017).

Changing the social environment by engaging the participant's family in the intervention, may address long term retention and effectiveness goals. Family-based lifestyle change programs acknowledge that diet, physical activity, and other health behaviors are shaped and influenced by familial and social relationships and environmental contexts. Engaging family has been effective in supporting and sustaining behavior change for other health conditions. For example, the U.S. Preventive Services Task Force Recommendations for addressing overweight and obesity in children noted that the most effective behavioral interventions were family-based and focused on healthy eating and physical activity. (US Preventive Services Task Force et al., 2017) The recommendations are based in reviews of available evidence that the most effective behavioral interventions included change strategies and skill-building activities for both children and parents and changing the social and physical environment. (US Preventive Services Task Force et al., 2017) Moreover, family-based programs addressing childhood obesity have been shown to be economically beneficial since multiple family members are being treated simultaneously, as compared to individual-focused treatments. (Epstein et al., 2014, Quattrin et al., 2017) This is especially true for conditions that run in the family such as obesity and overweight. Because family history and being overweight are significant risk factors for diabetes, family-based diabetes prevention programs may be a potential way to address and reduce the risk in the individual with prediabetes and the entire family. (History, 2022).

Therefore, this review examined the state of the science regarding the inclusion of family in programs using the DPP lifestyle change curriculum on program outcomes. We examined if DPP-based programs adapted to include family members are effective in improving primary outcomes among participants at risk for T2DM and their family members enrolled in the program.

2. Methods

This review protocol was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (Page et al., 2021) and Synthesis Without Meta-analysis (SWiM) reporting guidelines. (Campbell et al., 2020) The protocol was registered in PROSPERO (CRD42022346892) and was developed and conducted in July 2022-August 2023.

2.1. Search strategy and information sources

Working with a research librarian, our team developed the initial search strategy that was validated by using it to identify a set of eligible papers. In July 2022, articles were identified by conducting an electronic search within CINAHL, Cochrane Central, PsycINFO, PubMed, and Scopus. Because DPP results were published in 2002, the search used the dates 2002 to 2022. (Knowler et al., 2002) The review was updated in August 2023. The results from this update were reviewed and subjected to the same screening process that was used for the initial search. Appendix 1 has the complete search terms and search strategy used. Articles identified were imported for review into Covidence systematic review software, a web-based collaboration software platform that streamlines the production of systematic and other literature reviews. (Covidence, 2022) Studies were excluded if they were not published in a peer-reviewed journal and were not available in English.

2.2. Eligibility criteria

Studies were eligible for inclusion if they reported the outcomes of an intervention that adapted the DPP lifestyle change curriculum (Knowler et al., 2002) to include family members. Studies must have enrolled participants at risk for diabetes and their family members. Family members were broadly defined as anyone residing in the same household or had regular contact with the participant at risk for diabetes. Table 1 includes the definition of family used by each included study. Interventions were defined as family-based if the family member(s) enrolled in the program as an active participant of the program. For example, studies were not included if the program simply sent health information to family members or if the program asked participants to reach out to or engage with family outside of the program. Studies with experimental and quasi-experimental designs were considered for inclusion. Non-experimental designs that investigated any relationship between an aspect of the intervention and an outcome of interest were also eligible for inclusion. Qualitative studies were excluded. For outcomes, we included studies reporting measures used to indicate diabetes risk, including self-reported or objectively observed clinical outcomes (e.g. weight, glycosylated hemoglobin (HbA1c), glucose, insulin resistance, insulin sensitivity) and behavioral outcomes (e.g. physical activity, diet).

Table 1.

Characteristics of included studies.

Study Aims Study dates Sample Size Primary Pt Family Pt Primary outcome(s) Inclusion Exclusion Comparison description
Bhopal (Bhopal et al., 2014) Evaluate a family-based program promoting weight loss and increased physical activity in individuals of south Asian descent in the UK 2007–2009 (enrollment) 171 pts and 124 family Adults, Indian or Pakistani origin aged 35 years or older, at risk for diabetes Adult relatives, had weekly interactions with pts Change in weight at 3 years Adults, 35 yrs or older, south Asian descent, impaired glucose tolerance or impaired fasting glucose according to WHO criteria, no diagnosis of diabetes other than gestational diabetes, cooperative family cook Receiving long-term oral corticosteroids, weight loss medication, health disorders making adherence to the program contraindicated or improbable, or pregnant, or unlikely to remain in the UK for 3 years 4 visits with dietitian over 3 years, received standardized diabetes prevention info and info for accessing services
Hannon (Hannon et al., 2018) To comparative effectiveness of two DPP based curriculums adapted to be family centered 2012–2016 128 pts
Mothers with history of gestational diabetes or prediabetes with children aged 8 to 15 years Biological children, aged 8–15 years Change in weight of adult pts at 3 months BMI ≥ 25 kg/m2 and at least one of the following: history of GDM, history of giving birth to an infant who weighed ≥ 9 lb at delivery, or current prediabetes. At least one child (aged 8–15 years) who participated to provide outcomes measures.
Diabetes diagnosis, conditions that could limit ability to become physically active or limit life span to < 5 years, history of anti-diabetic medication use except during past gestational diabetes, any other condition associated with disordered glucose metabolism, conditions or behaviors likely to affect participation Intervention 1 was an adapted family based DPP curriculum for mothers without direct involvement of children
Hingle (Hingle et al., 2021) Evaluate the feasibility and preliminary efficacy of a T2DM prevention intervention for mother–child dyads at Federally Qualified Health Centers (FQHC) 2018–2020 42 dyads (women and their child) Mothers with history of gestational diabetes or prediabetes with children aged 8 to 12 years Biological children, aged 8–12 years Feasibility, weight, BMI in adult pts; BMI-z score in children at 8 months Female FQHC patients with a history of gestational diabetes or prediabetes; had children aged 8 to 12 years Not reported Wait-listed control participants received standard of care from the FQHC
Sauder (Sauder et al., 2018) To test the effect of a multi-component,
culturally appropriate adaptation of the DPP on obesity measures, cardiometabolic
measures, health behaviors and self-efficacy.
2014–2015 62 pts from 52 families; 29I, 33C Youth, aged 7–10 years, American Indian, high risk for diabetes Primary caregiver Feasibility, BMI, BMI-z at 24 months 7–10 years old, tribal members, overweight / obese, at least one caregiver willing to participate Diabetes diagnosis, health concerns that could interfere with participation, plans to move out of the area Three one-hour group classes covering general health and safety topics

2.3. Study selection

Covidence (Covidence, 2022) software was used for eligibility screening and data extraction. Article selection was completed in two phases. First, two research team members independently screened titles and abstracts using the inclusion and exclusion criteria. Disagreements regarding abstracts were discussed and a consensus was reached by the original reviewers in consultation with the third reviewer. Next, full-text reports were reviewed in the same manner, with two team members independently reviewing all included papers. If papers reported different outcomes of the same study, the papers were combined into one record. Separately published study protocols and intervention development papers were reviewed as needed. As with the abstract, disagreements regarding full-text paper inclusions were discussed and a consensus was reached by the original reviewers in consultation with a third reviewer. Finally, reference lists of review papers, conference abstracts, and trial registrations identified during the initial search as well as the reference lists of included papers were reviewed manually by the study team to ensure no eligible reports were missed.

2.4. Data extraction

Data were extracted by two reviewers working independently using a tool developed in Covidence. Study design, methodologies, participant characteristics, intervention characteristics, outcome results, and study results were extracted. Appendix Table 2 includes the variables that were extracted.

2.5. Risk of bias assessment

Risk of bias assessments were completed using version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB 2). (Sterne et al., 2019) Two reviewers working independently scored each study. Differences in assessments were resolved through discussion with a third reviewer.

2.6. Narrative synthesis

To summarize and explain the included studies, a narrative synthesis was structured around the characteristics of the primary participant and family, study outcomes related to diabetes risk factors, how the DPP curriculum was changed to include the family, and intervention characteristics. Meta-analyses were not completed due to the small number of studies and the heterogeneity of the study characteristics.

3. Results

The study flow diagram is presented in Fig. 1. The search identified 2177 records and 374 duplicate citations were removed across the databases. 1803 references were imported into Covidence with 61 additional duplicate records identified by the software before screening. 1742 reports were reviewed for abstract screening. During the abstract review, 1697 records did not meet the inclusion criteria and were removed. Two reports were merged as one study. Thus, 44 studies were included for full-text review. During the full-text review, 40 reports were excluded. Of these, 29 reports were excluded because the intervention did not meet the inclusion criteria, five were conference abstracts, four were protocol or descriptive papers, and two did not report outcomes related to diabetes risk factors. Of the 29 reports excluded because the intervention did not meet the inclusion criteria, 17 interventions were not family-based as defined by this review, 9 interventions were not adapted from the DPP lifestyle curriculum, and 3 intervention focused diabetes self-management versus prevention in the primary participant. Four studies remained after full-text screening and were included in the review.

Fig. 1.

Fig. 1

Flow diagram of the systematic review.

3.1. Study characteristics

Table 1 summarizes the characteristics of the included studies. Studies were randomized controlled trial designs with one being a cluster randomized trial, (Bhopal et al., 2014) one comparative effectiveness design, (Hannon et al., 2018) and two testing feasibility of the intervention. (Hingle et al., 2021, Sauder et al., 2018) One trial was conducted in National Health Service regions of the United Kingdom (Bhopal et al., 2014) and three were conducted in the United States. (Hannon et al., 2018, Hingle et al., 2021, Sauder et al., 2018) Studies were conducted between 2007 and 2020. The comparative effectiveness trial compared two adapted DPP-based interventions, (Hannon et al., 2018) one study used a waitlist control group (Hingle et al., 2021) and two studies used usual care or attention control groups. (Bhopal et al., 2014, Sauder et al., 2018) Weight change at post intervention data collection was the primary outcome for all studies. Data were collected for family members in three studies. (Bhopal et al., 2014, Hannon et al., 2018, Hingle et al., 2021) Time frames for post-intervention data collections varied from 3 months to 3 years. Three studies enrolled adults with prediabetes or were at high risk for diabetes as the primary participant. (Bhopal et al., 2014, Hannon et al., 2018, Hingle et al., 2021) One study focused on youth aged 7 to 10 years who were overweight or obese. (Sauder et al., 2018) Family participants were adult family members, (Bhopal et al., 2014) children of the adult participant, (Hannon et al., 2018, Hingle et al., 2021) or primary caregivers of the enrolled youth. (Sauder et al., 2018) Two studies specifically focused on mothers and their young children. (Hannon et al., 2018, Hingle et al., 2021).

As seen in Table 2, the characteristics of the interventions, format, frequency, dose, and mode of delivery differed across studies. All studies adapted the DPP lifestyle change curriculum by incorporating program content or activities into their curriculum. Only one study (Hannon et al., 2018) retained the original DPP dose and frequency which consisted of 16 weekly sessions delivered over 16–20 weeks. Of the three remaining studies, one intervention had a time frame that was shorter than 12 months. (Hingle et al., 2021) Two studies had fewer than 16 sessions. (Bhopal et al., 2014, Sauder et al., 2018) One study delivered the intervention using home visits (Bhopal et al., 2014) and three studies used a group format (Hannon et al., 2018, Hingle et al., 2021, Sauder et al., 2018) with one supplementing the group sessions with individualized motivational interviewing counseling sessions. (Sauder et al., 2018).

Table 2.

Intervention description and characteristics, method used to adapt the DPP program, and how the family participant was engaged in the intervention.

Study Intervention Description Intervention format Intervention frequency / length DPP incorporated or adapted How family was engaged
Bhopal (Bhopal et al., 2014) Family based program promoting weight loss and increased physical activity based off systematic review of DPP curriculum. A consultation with a dietitian for both participants and family volunteers with the goal to achieve weight loss through diet and physical activity using culturally adapted and translated resources. (Dennison et al., 2019) Home-based, delivered by dietitians 15 visits over 3 years; monthly for the first 3 months, then every 3 months Adapted for delivery by dietitians and used a multilingual panel and professional translators to help translate and/or develop materials. In both groups, family asked to follow program advice and support participants
Hannon (Hannon et al., 2018) Both interventions used adapted DPP curriculum for mothers and their children. Intensive version had home activities to reinforce lessons and additional content which made mothers aware of the content included in the children’s sessions. Group format, delivered by trained YMCA staff 16 sessions that lasted 60 to 90 min, delivered over 16 to 20 weeks Adapted DPP curriculum, modified scripts to apply session content to family members versus the individual. Children’s curriculum introduced themes from the DPP curriculum adjusted to be age appropriate. Both interventions used adapted DPP curriculum for mothers and their children. Children in the intensive intervention attended separate program sessions.
Hingle (Hingle et al., 2021) Intervention included strategies for diabetes risk reduction, behavior change techniques, and behavioral targets. Mothers participated in parenting discussions focusing on strategies to engage the entire family in lifestyle change, while children engaged in age-appropriate physical activities. Group format, delivered by
FQHC staff
1.5-hour long sessions for 13 weekly sessions in English or Spanish delivered by group leaders who were FQHC staff Evidence-based behavior change techniques and behavioral targets were incorporated into each session. Dyads attended sessions together. Last half of sessions were divided into moms and children’s groups.
Sauder (Sauder et al., 2018) DPP content adapted to be culturally and age appropriate for youth. Group class supplemented with individual motivational interviewing counselling, and a resource toolbox delivered by lay health coaches who were members of the tribes or non-Native individuals already integrated with the tribes. Group classes and individual motivational interviewing sessions by lay health coaches 12 group classes (10 2-hr classes over 4 months in the fall with 2 booster sessions in the spring) and 5 dyadic sessions (3 in the fall, 2 in the spring) Work groups of academic and community partners developed a common curriculum with tribe-specific materials, retaining as original DPP content as possible considering the number of sessions, cultural and community relevance, and participant ages. Sessions attended by the youth and a participating caregiver.

The methods in which the family members were engaged in the interventions ranged from family attending sessions with the participants, (Hingle et al., 2021, Sauder et al., 2018) attending separate sessions, (Hannon et al., 2018, Hingle et al., 2021) or being asked to follow the program advice with the participant. (Bhopal et al., 2014) The two studies that focused on behavior change to improve the health of children in addition to preventing diabetes in the mother included tailored program sessions designed for the children. (Hannon et al., 2018, Hingle et al., 2021) The first of these studies compared two interventions that adapted the DPP curriculum for mothers and their children. (Hannon et al., 2018) Their first intervention, noted as the comparison in this review, adapted the DPP curriculum to apply the content to family members versus the individual. (Hannon et al., 2018) Their second and more intensive intervention included separate program sessions for the children as well as healthy activities to complete in the home. (Hannon et al., 2018) The second study with tailored program sessions for the family was structured so that mother and child dyads attended sessions together with the last half of each session divided into separate groups for mom and children. (Hingle et al., 2021) This intervention included program messaging on the family history component of diabetes risk factors and encouraged changes to the home food and physical activity environments. (Hingle et al., 2021).

Finally, in addition to adding the family component to the program, the studies translated the DPP curriculum for a community identified to be higher risk for developing diabetes using a participatory approach to adapt the DPP curriculum to their intended population. Three studies worked with organizations that had established relationships with the community or engaged members of the intended community during the intervention adaptation process. (Hannon et al., 2018, Hingle et al., 2021, Sauder et al., 2018).

3.2. Study outcomes

Results of the studies were mixed (Table 3). Studies primarily used weight, BMI, or BMI z-scores as the main outcome and used a range of additional measures to assess clinical and behavioral outcomes associated with diabetes risk such as waist circumference, glucose levels, blood pressure, cholesterol, and behaviors such as diet, physical activity, and sleep habits. Two studies found significant intervention effects on weight-related outcomes. (Bhopal et al., 2014, Sauder et al., 2018) Bhopal et al., (Bhopal et al., 2014) found significant between-group differences with intervention group participants losing more weight at the one and three year time points. In addition to demonstrating feasibility and acceptability of their intervention, Sauder et al., (Sauder et al., 2018) found significant intervention effects on BMI, BMI z-score, and waist circumference in the intervention participants compared to the control participants. No treatment effects were seen on cardiometabolic or behavioral outcomes. Two studies did not find significant intervention effects. Although Hingle et al., (Hingle et al., 2021) demonstrated program feasibility and acceptability in their intended population of majority low-income and Hispanic women, the study was not powered to detect statistically significant changes in weight and BMI outcomes. Hannon et al., (Hannon et al., 2018) found that there were no between-group differences changes in weight or BMI at follow-up. And, while there were significant decreases in HbA1c at 3 months in both intervention groups, there were no significant differences between the two interventions, both of which used an adapted DPP curriculum.

Table 3.

Summary of study outcomes for participants and family members.

Study Weight-related outcomes summary Primary weight-related outcome Other outcomes Family member outcomes
Bhopal30 Significant between group differences at 3 years in weight loss, the proportion of participants who had lost 2.5 kg, and the proportion of participants who lost 5 % of body weight. Adjusted mean difference (95 %CI) in change in weight at three years was –1.64 (–2.83 to –0.44) for the intervention group compared with the control group (p = 0.0076) No significant group differences found in change in physical activity levels, fasting glucose levels, blood pressure, or progression to diabetes. No significant changes in weight and other measures of adiposity between the groups
Adjusted mean difference (95 %CI) in change in weight at 3 years was –0.44 (–2.20 to 1.33) for the intervention group compared with the control group (p = 0.6258)
Hannon31 There were no between group differences in weight change, percent weight change, or BMI change. Weight change (kg) HbA1c was significantly decreased at 3 months in both groups but no difference in HbA1c change between treatment groups. Children in the mothers + child group had a significant decrease in BMI percentile at all time points. No changes in BMI percentiles in the mothers only group.
3-months BMI percentile reduction
Mothers only: 0.00±0.60 3-months
Mothers + child: 0.47±0.57 Mothers only: 0.07±0.80
P-value (group difference) = 0.58 Mothers + child: −1.77±0.71
6-months P-value (group difference) = 0.12
Mothers only: −0.01±0.76 6-months
Mothers + child: −0.90±0.73 Mothers only: −0.43±1.03
P-value (group difference) = 0.40 Mothers + child: −2.99±0.93
12-months P-value (group difference) = 0.07
Mothers only: −1.15±0.89 12-months
Mothers + child: −0.88±0.88 Mothers only: 0.44±1.08
P-value (group difference) = 0.83 Mothers + child: −2.90±1.00
  P-value (group difference) = 0.02
Hingle32 No significant differences in body weight or BMI change. Weight change (kg), mean (SD) Intervention was feasible to deliver, acceptable to participants. No between group changes seen in waist circumference, HbA1c changes, diet quality, physical activity time, child sleep or healthy home environment scores. There were no significant differences in changes in child weight or BMI z-scores at post intervention (13 weeks).
Post intervention (13 weeks): Weight (kg), Mean (SD)
Control: −0.5 (1.8) Control: 1.4 (1.0)
Intervention: −1.8 (2.3) Intervention: 1.5 (1.9)
Difference: −1.2 (2.1), p = 0.07 Difference: 0.01 (1.5) p = 0.99
BMI (kg/m2), mean (SD) BMI-z score, mean (SD)
Post intervention (13 weeks): Control: −0.033 (0.166)
Control: −0.2 (0.7) Intervention: −0.055 (0.209)
Intervention: −0.7 (0.8) Difference: −0.022 (0.186), p = 0.74
Difference: −0.5 (0.8), p = 0.06  
Sauder33 BMI significantly increased over time among control participants but not intervention participants. Change at post intervention (24 months): Intervention was feasible to deliver, acceptable to participants. Outcomes not assessed in family members.
BMI z-score significantly decreased in the intervention group but did not change in the control group. BMI: Control: +1.0 kg m2, p < 0.001 Waist circumference significantly increased in the control but not the intervention. No differences seen in cardiometabolic or behavioral outcomes.
  Intervention: +0.3 kg m2, p = 0.13  
  Treatment effect: unadjusted p = 0.02; adjusted p = 0.08  
  Body mass index z-score:  
  Control: +0.01, p = 0.82  
  Intervention: −0.17, p = 0.004  
  Treatment effect: unadjusted p = 0.02; adjusted p = 0.04  

Intervention effects on family outcomes were also mixed. One study did not measure outcomes in family members. (Sauder et al., 2018) Of the three studies that assessed outcomes, two studies found no statistically significant intervention effects on family members. (Bhopal et al., 2014, Hingle et al., 2021) Hannon et al., found that children in the intensive version of their intervention had a decreased mean BMI percentile and a decreased proportion of youth with BMI in the 95th percentile at 12 months. (Hannon et al., 2018).

3.3. Risk of bias

Using the ROB 2.0 tool (Sterne et al., 2019) to assess the risk of bias, studies were determined to have low risk of bias for majority of domains. Area of some concern for the studies was the domain “deviations from the intended intervention” because blinding was not possible due to the nature of the interventions. Also, it was not reported by the studies if randomization allocation was concealed until data were collected or if the assessors were blinded except for Bhopal et al., (Bhopal et al., 2014) who reported that their outcomes for their 3-year follow-up were collected by blinded research nurses. Assessment results are included in Appendix Table 3.

4. Discussion

This review identified four studies that evaluated the impact of adapting the DPP lifestyle curriculum to include family members. In general, the studies showed that engaging the family in lifestyle change programs was feasible to implement and acceptable to the participants while having similar results as other DPP lifestyle change interventions translated into community settings. All studies reported that the content was adapted to be culturally relevant to the intended community; however, the adapted interventions differed in format, frequency, length, implementation staff, and setting. In two studies, (Bhopal et al., 2014, Sauder et al., 2018) despite family members attending program sessions it was difficult to determine based on the intervention descriptions included in the papers to what degree family members were engaged in the intervention other than being supportive of the primary participant. Finally, the lack of uniformity across studies regarding which DPP curriculum components were dropped, retained, or were adapted makes it challenging to identify if the modifications described impacted program effectiveness.

Prior works have examined the implementation of DPP interventions in various settings and communities. (Ali et al., 2012, Aziz et al., 2015, Neamah et al., 2016, Nhim et al., 2019, Whittemore, 2011, Tabak et al., 2015) These studies have identified program characteristics that are important to consider during the adaptation process. For example, Ali et al., found in their review and meta-analysis of 28 U.S.-based studies that higher program session attendance resulted in greater weight loss and the use of nonmedical personnel such as lay educators lowered implementation costs but did not reduce the effectiveness of the program. (Ali et al., 2012) Similarly, Aziz et al., examined programs implemented over a period of 15 years and also found that program intensity and dose were associated with effectiveness. (Aziz et al., 2015) However, their analysis found that even low or moderately intense programs reduced diabetes risk. (Aziz et al., 2015) Finally, Neamah et al., found in their review of commonly used program modifications and translational strategies that programs that reported fewer adaptions from the original DPP curriculum were associated with slightly better outcomes in weight and BMI. (Neamah et al., 2016) Similar to the reported adaptations from the studies included in this review, common adaptations found in the literature were aimed to make the curriculum more culturally relevant to the intended community by including adaptations to the program messaging, themes, and images, addition of cultural dietary preferences, or delivering the program in languages other than English. (Neamah et al., 2016) The authors also noted that program sites that used cultural adaptations had higher attendance and retention than sites that did not report culturally adapting the programs, especially for programs reaching non-Hispanic Black participants and Hispanic participants. (Nhim et al., 2019) This is important to note, as a recent analysis of long-term retention of individuals enrolled in CDC-recognized DPP programs revealed that more work is needed. (Cannon et al., 2020) This review found that there was a need for strategies to retain younger participants, participants from racial and ethnic minority communities, and participants who are less physically active or report losing less weight early in the programs. (Cannon et al., 2020) Moreover, another meta-analysis of 43 studies found that lifestyle modification programs for adults were effective in reducing diabetes incidence for several years but program effects declined over time. (Haw et al., 2017) Thus, the need remains for effective strategies to reach and retain individuals at higher risk for developing diabetes.

Using family-based programs similar to the ones included in this review may be a potential strategy to engage such individuals. For example, Richie et al., found that women of childbearing age were less likely to enroll in a DPP intervention compared to older women. (Ritchie et al., 2017) However, those who participated benefited equally from the program. (Ritchie et al., 2017) This analysis also found that younger women were less likely to have confirmed prediabetes compared to older women participants. Rather, they were more likely to have a history of gestational diabetes or a positive risk test which has been noted by prior reviews to negatively impact program retention. (Nhim et al., 2019, Cannon et al., 2020) On the other hand, Dennison et al., found that mothers with a history of gestational diabetes were more likely to consider relationships and the impact of health behaviors on their families when considering lifestyle choices. (Dennison et al., 2019) Moreover, women face additional barriers that may impact engagement and retention in programs like DPP. Women are reported to often share greater responsibility and loads for caregiving and household tasks. (Hankonen et al., 2010, U.S. Bureau of Labor Statistics, 2021, Brenan, 2020) This may contribute to women delaying or participating in less self-care because of limited time or to avoid added feelings of stress or guilt. (Dennison et al., 2019, Mailey et al., 2014) Two studies included in this review focused on mothers and their young children and integrated strategies to make changes to the home environment. One study specifically included program messaging that focused on primary prevention of diabetes in children. (Hingle et al., 2021) Hannon et al., (Hannon et al., 2018) included program adaptations to include activities to support health-enhancing activities for both the parent and child in the home. As noted above, family-based behavioral interventions for other health conditions such as childhood obesity have been found to be both cost and time-effective compared to individually focused intervention. (Epstein et al., 2014, Quattrin et al., 2017) Thus, a family-based program has the potential to reduce some of the barriers to participation and may have benefits such as increasing motivation, social support, and improved health outcomes for both the individual and their family. Adapting the intervention to include family members has the potential to further improve retention and sustainability of behavior change by creating a more supportive social and physical environment by including the family.

However, because of the study designs used, three studies were unable to determine if the family-based interventions were more effective compared to individually focused DPP interventions. Of these, two studies found an intervention effect that was similar to the DPP results. The single study using the comparative effective trial design found that both interventions had no impact on weight for the mothers, but the intensive intervention improved outcomes in the children. Finally, in the three studies that measured family members outcomes, only one found significant intervention effects. These results are similar to other family-based diabetes self-care interventions for adults where there is often variability of family involvement and participation, making it difficult to clearly identify the most effective strategies to engage the family in the program. (Baig et al., 2015).

Additional research is needed to identify specific roles of family members, engagement strategies, and intervention components for family-based lifestyle change programs for diabetes prevention. Specifically, a better understanding of effective program’s mechanisms of action in improving health outcomes and reducing diabetes risks would fill an important gap in the literature. There is also a need for measuring and reporting outcomes that are meaningful for both participants and their family members.

This review’s strengths include following registered PRISMA-based protocol guidelines and working with an academic librarian who provided guidance in the development of the review protocol and the design of a comprehensive literature search process. However, the review has several limitations. This review was limited by the exclusion of non-English language publications which may have excluded relevant publications on this topic. Next, we only included family-based programs that reported that their intervention was adapted using DPP. There are likely other effective family-based diabetes prevention programs that were excluded from the review or programs that included adapted content from DPP that may have been missed because details regarding the adaptation process were not reported. While we reviewed cited reports that provided details on the program development process, it is possible that ancillary reports were missed with more details.

This review examined the state of the literature regarding behavioral intervention studies that reported adapting the DPP lifestyle change curriculum to include family members. We found that additional studies are needed to better understand the mechanisms of actions and the most effective intervention methods and messages to best engage entire family members in changing and then maintaining health-enhancing behaviors as our review only found a few family-based programs adapted from the DPP curriculum. In addition, we found that there is a need for greater details regarding the process used to develop and adapt behavior change programs so that we can better identify the most effective strategies to support family members as they participate in health promotion programs together. However, the included studies had promising or similar effectiveness as individual-based DPP interventions. Moreover, there was promising evidence of positive effects on the health outcomes of family members included in the program.

CRediT authorship contribution statement

Susan J. Andreae: Writing – review & editing, Writing – original draft, Supervision, Resources, Methodology, Conceptualization. Hailey Reeves: Writing – review & editing, Investigation. Thomas Casey: Writing – review & editing, Investigation. Anna Lindberg: Writing – review & editing, Investigation. Kristen A. Pickett: Writing – review & editing, Methodology, Investigation.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

Thank you to Mary Hitchcock, Health Science Librarian at the Ebling Library, University of Wisconsin-Madison, for her expertise and guidance in developing the review protocol, search strategies, and conducting the final searches in the databases.

Funding

S. Andreae is supported in part by the Eunice Kennedy Shriver National Institute of Child Health & Human Development, the Office of Research on Women’s Health, Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) program, the Office of The Director, National Institutes of Health and the National Cancer Institute, under Award Number K12HD101368. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

Appendix A

Supplementary data to this article can be found online at https://doi.org/10.1016/j.pmedr.2024.102655.

Appendix A. Supplementary data

The following are the Supplementary data to this article:

Supplementary data 1
mmc1.pdf (304.7KB, pdf)

Data availability

Data will be made available on request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary data 1
mmc1.pdf (304.7KB, pdf)

Data Availability Statement

Data will be made available on request.


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