Effectiveness of two procedures for deploying a facilitated collaborative modeling implementation strategy-the PVS-PREDIAPS strategy-to optimize type 2 diabetes prevention in primary care: the PREDIAPS cluster randomized hybrid type II implementation trial

Alvaro Sanchez, Susana Pablo, Arturo Garcia-Alvarez, Silvia Dominguez, Gonzalo Grandes, PREDIAPS Group, Amaia Bengoetxea, Olga Galarza, Elsa Martínez, Itziar Zalduegi, Dorothea Chausson, Agurtzane Gorroño, Alicia Pollán, Marisol Bernabéu, Mª Yolanda Calvo, Ander Artiagoitia, Nerea Zaramillo, Lidia Gonzalez, Asier Aurrekoetexea, Jon Azkarate, María Muñoa, Mar Bilbao, Vicki Camineiro, Gonzalo Gómez de Iturriaga, Fernando Gago, Iciar Ochoa de Retana, Ana Zorrilla, Mª Luisa Gutiérrez, Jone Capetillo Serra, Mª Nieves Lopez, Nekane Iguerregui, Dolores López, Maite Gastañaga, Antonia Flores, Marcos Pereda, Amaya González, Ana Castresana, Laura Saiz, Nerea Regulez, Estibaliz Peciña, Jasone De la Plaza, Lucía Irastoza, Jose Contreras, Idoia Etxebarria, Begoña Oleaga, Cristina Herrero, Nora Cabezón, Fátima Calvo, J Manuel Llamazares, Mª Ángeles Gutierrez, Monica Prieto, Concepción Estébanez, María José Cordovilla, Alicia Domínguez, Isabel Lázaro, Elena Resines, Yolanda Villalba, Begoña Ayerdi, Florencia Martín, Magdalena Presmanes, Floreal Crespo, Araceli Benito, Mª Belén Molina, Mª Mar García, Mª Gracia Díaz, Mª Luisa Rodriguez Ortiz de Zarate, Rebeca San Cristóbal, M Zugazaga Prieto, Pedro Martínez, Mercedes Crespo, Estíbaliz Albitre, Adelina García-Roldán, Amaia García, Maite Castro, Iñaki Gorospe, Amelia V Hernández, Maite López, Mirian Sainz, Irene Marín, María Jesús Aragón, Leire Ulayar, Encarnación Santamaría, Carmen Sánchez, Javier Bayo, Begoña Urkullu, Ana Inés Pereda, Mercedes Garcia, Pilar Blanco, Silvia Soler Valverde, Jose I Atela, Hiart Trespalacios, Anabel Llarena, Verónica Ruiz, Begoña Cabieces, Concepción Ugarte, Guadalupe Icaza, Edurne Zubeldia, Idoia González, Ángeles Gayo, Itxaso Arévalo, Gloria Intxausti, Esther García, Teresa Sánchez, Igone Lobato, Noelia Fuente, Naiara Ortolachipi, Edelweiss Sánchez, Victoria Cosgaya, Ángeles Gayo, Arantza Azazeta, Patricia Zaballa, Ana Isabel Ramila, Teresa Rodeño, Inmaculada Rodríguez, Teresa Vázquez, Raquel Ruíz, Rosa Herrero, María Valvanera, Saioa Setién, Begoña Ruíz, Juan José Casas, Joana Clemente, Javier Amiama, Javier Angulo, Belén Aramendia, Soledad Asenjo, Mª Sonia Mayoral, Remedios Oyarzun, Bergoi Calvar, Belinda Zulueta, Edurne Elola, Josu Egaña, Gemma Díaz, Mª Ángeles Sola, Laura Balague, Mª Ángeles Ganzarain, Arantxa Aramburu, Ana Mª Guinea, Edurne Lizarazu, Inma Valverde, Nekane Arenas, Susana Alonso, Rosa Salaberria, Javier Merino, Mercedes Álvarez, Ester Lázaro, Juncal Izcara, Leire González, Ainhoa García Leunda, Idoia Sánchez, Esther Usandiaga, Eluska Yetano, Jaione Larrea, Inés Mendinueta, Asún Uria, Ana Belén Gaztañaga, Eva Mayo, Onintza Aranzadi, Eulalia Medina, Rosa González, Ione Gutiérrez, Arantxa Perez, Mª Ángeles Izquierdo, Alejandro García, Ainhoa Ugarte, Mª Teresa Zubeldia, Bingen Uriondo, Mª Carmen Aranegui, Arantxa Mendiguren, Yolanda Fernández, Maite Zapirain, Mª Jose Garín, Aitziber Ayerbe, Jon Urkia, Alvaro Sánchez, Josep Cortada, Esther Gorostiza, Susana Pablo, Heather Lynn Rogers, Arturo García-Alvarez, Gonzalo Grandes, Alicia Cortazar, Virginia Bellido, Patxi Ezkurra, Rafa Rotaetxe, Alvaro Sanchez, Susana Pablo, Arturo Garcia-Alvarez, Silvia Dominguez, Gonzalo Grandes, PREDIAPS Group, Amaia Bengoetxea, Olga Galarza, Elsa Martínez, Itziar Zalduegi, Dorothea Chausson, Agurtzane Gorroño, Alicia Pollán, Marisol Bernabéu, Mª Yolanda Calvo, Ander Artiagoitia, Nerea Zaramillo, Lidia Gonzalez, Asier Aurrekoetexea, Jon Azkarate, María Muñoa, Mar Bilbao, Vicki Camineiro, Gonzalo Gómez de Iturriaga, Fernando Gago, Iciar Ochoa de Retana, Ana Zorrilla, Mª Luisa Gutiérrez, Jone Capetillo Serra, Mª Nieves Lopez, Nekane Iguerregui, Dolores López, Maite Gastañaga, Antonia Flores, Marcos Pereda, Amaya González, Ana Castresana, Laura Saiz, Nerea Regulez, Estibaliz Peciña, Jasone De la Plaza, Lucía Irastoza, Jose Contreras, Idoia Etxebarria, Begoña Oleaga, Cristina Herrero, Nora Cabezón, Fátima Calvo, J Manuel Llamazares, Mª Ángeles Gutierrez, Monica Prieto, Concepción Estébanez, María José Cordovilla, Alicia Domínguez, Isabel Lázaro, Elena Resines, Yolanda Villalba, Begoña Ayerdi, Florencia Martín, Magdalena Presmanes, Floreal Crespo, Araceli Benito, Mª Belén Molina, Mª Mar García, Mª Gracia Díaz, Mª Luisa Rodriguez Ortiz de Zarate, Rebeca San Cristóbal, M Zugazaga Prieto, Pedro Martínez, Mercedes Crespo, Estíbaliz Albitre, Adelina García-Roldán, Amaia García, Maite Castro, Iñaki Gorospe, Amelia V Hernández, Maite López, Mirian Sainz, Irene Marín, María Jesús Aragón, Leire Ulayar, Encarnación Santamaría, Carmen Sánchez, Javier Bayo, Begoña Urkullu, Ana Inés Pereda, Mercedes Garcia, Pilar Blanco, Silvia Soler Valverde, Jose I Atela, Hiart Trespalacios, Anabel Llarena, Verónica Ruiz, Begoña Cabieces, Concepción Ugarte, Guadalupe Icaza, Edurne Zubeldia, Idoia González, Ángeles Gayo, Itxaso Arévalo, Gloria Intxausti, Esther García, Teresa Sánchez, Igone Lobato, Noelia Fuente, Naiara Ortolachipi, Edelweiss Sánchez, Victoria Cosgaya, Ángeles Gayo, Arantza Azazeta, Patricia Zaballa, Ana Isabel Ramila, Teresa Rodeño, Inmaculada Rodríguez, Teresa Vázquez, Raquel Ruíz, Rosa Herrero, María Valvanera, Saioa Setién, Begoña Ruíz, Juan José Casas, Joana Clemente, Javier Amiama, Javier Angulo, Belén Aramendia, Soledad Asenjo, Mª Sonia Mayoral, Remedios Oyarzun, Bergoi Calvar, Belinda Zulueta, Edurne Elola, Josu Egaña, Gemma Díaz, Mª Ángeles Sola, Laura Balague, Mª Ángeles Ganzarain, Arantxa Aramburu, Ana Mª Guinea, Edurne Lizarazu, Inma Valverde, Nekane Arenas, Susana Alonso, Rosa Salaberria, Javier Merino, Mercedes Álvarez, Ester Lázaro, Juncal Izcara, Leire González, Ainhoa García Leunda, Idoia Sánchez, Esther Usandiaga, Eluska Yetano, Jaione Larrea, Inés Mendinueta, Asún Uria, Ana Belén Gaztañaga, Eva Mayo, Onintza Aranzadi, Eulalia Medina, Rosa González, Ione Gutiérrez, Arantxa Perez, Mª Ángeles Izquierdo, Alejandro García, Ainhoa Ugarte, Mª Teresa Zubeldia, Bingen Uriondo, Mª Carmen Aranegui, Arantxa Mendiguren, Yolanda Fernández, Maite Zapirain, Mª Jose Garín, Aitziber Ayerbe, Jon Urkia, Alvaro Sánchez, Josep Cortada, Esther Gorostiza, Susana Pablo, Heather Lynn Rogers, Arturo García-Alvarez, Gonzalo Grandes, Alicia Cortazar, Virginia Bellido, Patxi Ezkurra, Rafa Rotaetxe

Abstract

Background: The most efficient procedures to engage and guide healthcare professionals in collaborative processes that seek to optimize practice are unknown. The PREDIAPS project aims to assess the effectiveness and feasibility of different procedures to perform a facilitated interprofessional collaborative process to optimize type 2 diabetes prevention in routine primary care.

Methods: A type II hybrid cluster randomized implementation trial was conducted in nine primary care centers of the Basque Health Service. All centers received training on effective healthy lifestyle promotion. Headed by a local leader and an external facilitator, centers conducted a collaborative structured process-the PVS-PREDIAPS implementation strategy-to adapt the intervention and its implementation to their specific context. The centers were randomly allocated to one of two groups: one group applied the implementation strategy globally, promoting the cooperation of all health professionals from the beginning, and the other performed it sequentially, centered first on nurses, who later sought the pragmatic cooperation of physicians. The following patients were eligible for inclusion: all those aged ≥ 30 years old with at least one known cardiovascular risk factor and an impaired fasting glucose level (≥ 110-125 mg/dl) but without diabetes who attended centers during the study period. The main outcome measures concerned changes in type 2 diabetes prevention practice indicators after 12 months.

Results: After 12 months, 3273 eligible patients at risk of type 2 diabetes had attended their family physician at least once, and of these, 490 (15%) have been addressed by assessing their healthy lifestyles in both comparison groups. The proportion of at-risk patients receiving a personalized prescription of lifestyle change was slightly higher (8.6%; range 13.5-5.9% vs 6.8%; range 7.2-5.8%) and 2.3 times more likely (95% CI for adjusted hazard ratio, 1.38-3.94) in the sequential than in the global centers, after 8 months of the intervention program implementation period. The probability of meeting the recommended levels of physical activity and fruit and vegetable intake were four- and threefold higher after the prescription of lifestyle change than only assessment and provision of advice. The procedure of engagement in and execution of the implementation strategy does not modify the effect of prescribing healthy habits (p interaction component of intervention by group, p > 0.05).

Discussion: Our results show that the PVS-PREDIAPS implementation strategy manages to integrate interventions with proven efficacy in the prevention of type 2 diabetes in clinical practice in primary care. Further, they suggest that implementation outcomes were somewhat better with a sequential facilitated collaborative process focused on enhancing the autonomy and responsibility of nurses who subsequently seek a pragmatic cooperation of GPs.

Trial registration: Clinicaltrials.gov identifier: NCT03254979 . Registered 16 August 2017-retrospectively registered.

Keywords: Diabetes prevention; Implementation strategy; Interprofessional collaboration; Primary healthcare.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Compared procedures for engagement of professionals and deployment of the PVS-PREDIAPS implementation strategy
Fig. 2
Fig. 2
Flow of patients through the PREDIAPS study (following the CONSORT extension for cluster trials). Note: FP, family physician; IHO, integrated healthcare organization; NP, nurse practitioner; ≥ 30 years, patient aged ≥ 30 years that attended their family physician at least once; No T2D, patients without registered diagnosis of type 2 diabetes; CVRF, patients with a cardiovascular risk factor (e.g., overweight or obese patients with normal glucose levels); IFG, patients with impaired fasting glucose level at any visit during the program implementation period
Fig. 3
Fig. 3
Reach and implementation of the PVS-PREDIAPS clinical intervention for type 2 diabetes prevention by center and comparison group. Note: Columns represent the percentage of non-diabetic patients aged ≥ 30 years with a known cardiovascular risk factor and an impaired fasting glucose level (≥ 110-125 md/dl) exposed to A1: assessment of healthy lifestyles or A4: prescription of lifestyle change with a personalized plan
Fig. 4
Fig. 4
Cumulative exposure of patients to healthy lifestyle assessment and prescription over the 12-month program implementation period. Note: solid lines describe A1-assessment cumulative incidence; dotted lines describe A4-prescription cumulative incidence; cumulative event is measured in percentage; time is measured in days
Fig. 5
Fig. 5
Effect of the personalized prescription in post-intervention lifestyle change in an incidental sample of patients exposed to the healthy lifestyle promotion program not meeting recommended levels at baseline
Fig. 6
Fig. 6
PREDIAPS clinical intervention delivery models

References

    1. Balk EM, Earley A, Raman G, Avendano EA, Pittas AG, Remington PL. Combined diet and physical activity promotion programs to prevent type 2 diabetes among persons at increased risk: a systematic review for the community preventive services task force. Annals of internal medicine. 2015;163(6):437–451. doi: 10.7326/M15-0452.
    1. Stevens JW, Khunti K, Harvey R, Johnson M, Preston L, Woods HB, Davies M, Goyder E. Preventing the progression to type 2 diabetes mellitus in adults at high risk: a systematic review and network meta-analysis of lifestyle, pharmacological and surgical interventions. Diabetes Res Clin Pract. 2015;107(3):320–331. doi: 10.1016/j.diabres.2015.01.027.
    1. National Institute for Health and Clinical Excellence. Preventing type 2 diabetes: risk identification and interventions for individuals at high risk. NICE public health guidance 38. London, National Institute for Health and Clinical Excellence, 2012. [Retrieved 28 December 2015]. Available from:
    1. Aziz Z, Absetz P, Oldroyd J, Pronk NP, Oldenburg B. A systematic review of real-world diabetes prevention programs: learnings from the last 15 years. Implement Sci. 2015;10(1):172. doi: 10.1186/s13012-015-0354-6.
    1. Cardona-Morrell M, Rychetnik L, Morrell SL, Espinel PT, Bauman A. Reduction of diabetes risk in routine clinical practice: are physical activity and nutrition interventions feasible and are the outcomes from reference trials replicable? A systematic review and meta-analysis. BMC Public Health. 2010;10(1):653. doi: 10.1186/1471-2458-10-653.
    1. Davies MJ, Gray LJ, Troughton J, Gray A, Tuomilehto J, Farooqi A, Khunti K, Yates T. Let’s Prevent Diabetes Team. A community based primary prevention programme for type 2 diabetes integrating identification and lifestyle intervention for prevention: the Let’s Prevent Diabetes cluster randomised controlled trial. Prev Med. 2016;84:48–56. doi: 10.1016/j.ypmed.2015.12.012.
    1. Sanchez A, Silvestre C, Campo N, Grandes G, PredDE Group Effective translation of a type-2 diabetes primary prevention programme into routine primary care: The PreDE cluster randomised clinical trial. Diabetes Res Clin Pract. 2018;139:32–42. doi: 10.1016/j.diabres.2018.01.006.
    1. Sanchez A, Silvestre C, Cortazar A, Bellido V, Ezkurra P, Rotaeche Del Campo R, et al. Prevención de la diabetes mellitus tipo 2 en Atención Primaria de Salud mediante estilos de vida saludables: cuidados e intervención clínica recomendada. Vitoria-Gasteiz: Departamento de Salud-Gobierno Vasco; 2016.
    1. Costa-Pinel B, Mestre-Miravet S, Barrio-Torrell F, Cabré-Vila J-J, Cos-Claramunt X, Aguilar-Sanz S, Solé-Brichs C, Castell-Abat C, Arija-Val V, Lindström J, Catalan Diabetes Prevention Research Group Implementation of the DP-TRANSFERS project in Catalonia: a translational method to improve diabetes screening and prevention in primary care. Plos one. 2018;13(3):e0194005. doi: 10.1371/journal.pone.0194005.
    1. Sanchez A, Grandes G, Pablo S, Espinosa M, Torres A, García-Alvarez A, PREDIAPS Group Engaging primary care professionals in collaborative processes for optimising type 2 diabetes prevention practice: the PREDIAPS cluster randomised type II hybrid implementation trial. Implement Sci. 2018;13(1):94. doi: 10.1186/s13012-018-0783-0.
    1. Lau R, Stevenson F, Ong BN, Dziedzic K, Treweek S, Eldridge S, Everitt H, Kennedy A, Qureshi N, Rogers A, Peacock R, Murray E. Achieving change in primary care--causes of the evidence to practice gap: systematic reviews of reviews. Implement Sci. 2016;11:40. doi: 10.1186/s13012-016-0396-4.
    1. Morgan S, Pullon S, McKinlay E. Observation of interprofessional collaborative practice in primary care teams: an integrative literature review. Int J Nurs Stud. 2015;52(7):1217–1230. doi: 10.1016/j.ijnurstu.2015.03.008.
    1. Reeves S, Pelone F, Harrison R, Goldman J, Zwarenstein M. Interprofessional collaboration to improve professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2017;6(6):CD000072.
    1. White D, Suter E, Parboosingh IJ, Taylor E. Communities of practice: creating opportunities to enhance quality of care and safe practices. Healthcare Quarterly. 2008;11(sp):80–84. doi: 10.12927/hcq.2008.19654.
    1. Bentley C, Browman GP, Poole B. Conceptual and practical challenges for implementing the communities of practice model on a national scale--a Canadian cancer control initiative. BMC Health Services Research. 2010;10(1):3–10. doi: 10.1186/1472-6963-10-3.
    1. Baker L, Egan-Lee E, Martimianakis M, Reeves S. Relationships of power: implications for interprofessional education and practice. J Interprofessional Care. 2011;25(2):98–104. doi: 10.3109/13561820.2010.505350.
    1. Xyrichis A, Lowton K. What fosters or prevents interprofessional teamworking in primary and community care? A literature review Int. J. Nurs. Stud. 2008;45(1):140–153. doi: 10.1016/j.ijnurstu.2007.01.015.
    1. Kislov R, Walshe K, Harvey G. Managing boundaries in primary care service improvement: a developmental approach to communities of practice. Implement Sci. 2012;7(1):97. doi: 10.1186/1748-5908-7-97.
    1. Ferlie E, Fitzgerald L, Wood M, Hawkins C. The nonspread of innovations: the mediating role of professionals. Acad Manage J. 2005;48(1):117–134. doi: 10.5465/amj.2005.15993150.
    1. Sanchez A, Grandes G, Cortada JM, Pombo H, Martinez C, Corrales MH, de la Peña E, Mugica J, Gorostiza E, PVS group Feasibility of an implementation strategy for the integration of health promotion in routine primary care: a quantitative process evaluation. BMC Fam Pract. 2017;18(1):24. doi: 10.1186/s12875-017-0585-5.
    1. Martinez C, Bacigalupe G, Cortada JM, Grandes G, Sanchez A, Pombo H, Bully P, PVS group The implementation of health promotion in primary and community care: a qualitative analysis of the ‘Prescribe Vida Saludable’ strategy. BMC Fam Pract. 2017;18(1):23. doi: 10.1186/s12875-017-0584-6.
    1. Lanham HJ, McDaniel RR, Jr, Crabtree BF, Miller WL, Stange KC, Tallia AF, Nutting P. How improving practice relationships among clinicians and nonclinicians can improve quality in primary care. Jt Comm J Qual Patient Saf. 2009;35(9):457–466. doi: 10.1016/S1553-7250(09)35064-3.
    1. Flottorp SA, Oxman AD, Krause J, Musila NR, Wensing M, Godycki-Cwirko M, Baker R, Eccles MP. A checklist for identifying determinants of practice: a systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice. Implement Sci. 2013;8:35. doi: 10.1186/1748-5908-8-35.
    1. Powell BJ, McMillen JC, Proctor EK, Carpenter CR, Griffey RT, Bunger AC, Glass JE, York JL. A compilation of strategies for implementing clinical innovations in health and mental health. Med Care Res Rev. 2012;69(2):123–157. doi: 10.1177/1077558711430690.
    1. MacNaughton K, Chreim S, Bourgeault IL. Role construction and boundaries in interprofessional primary health care teams: a qualitative study. BMC Health Serv Res. 2013;13(1):486. doi: 10.1186/1472-6963-13-486.
    1. Grandes G, Sanchez A, Cortada JM, Pombo H, Martinez C, Balagué L, Corrales MH, de la Peña E, Mugica J, Gorostiza E, PVS group Collaborative modeling of an implementation strategy: a case study to integrate health promotion in primary and community care. BMC Res Notes. 2017;10(1):699. doi: 10.1186/s13104-017-3040-8.
    1. Glasgow RE, Goldstein MG, Ockene JK, Pronk NP. Translating what we have learned into practice. Principles and hypotheses for interventions addressing multiple behaviors in primary care. Am J Prev Med. 2004;27(2 Suppl):88–101. doi: 10.1016/j.amepre.2004.04.019.
    1. Sanchez A, Rogers HL, Pablo S, García E, Rodríguez I, Flores MA, Galarza O, Gaztañaga AB, Martínez PA, Alberdi E, Resines E, Llarena AI, Grandes G, on behalf of the PREDIAPS Group Fidelity evaluation of the compared procedures for conducting the PVS-PREDIAPS implementation strategy to optimize diabetes prevention in Primary Care. BMC Fam Prac. 2021;22(1):34. doi: 10.1186/s12875-021-01378-z.
    1. Bully P, Sanchez A, Grandes G, Pombo H, Arietalenizbeaskoa MS, Arce V, Martinez C, PVS Group Metric properties of the “prescribe healthy life” screening questionnaire to detect healthy behaviors: a cross-sectional pilot study. BMC Public Health. 2016;16(1):1228. doi: 10.1186/s12889-016-3898-8.
    1. Domínguez-Berjón MF, Borrell C, Cano-Serral G, Esnaola S, Nolasco A, Pasarín MI, Ramis R, Saurina C, Escolar-Pujolar A. Constructing a deprivation index based on census data in large Spanish cities(the MEDEA project) Gac Sanit. 2008;22(3):179–187. doi: 10.1157/13123961.
    1. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89(9):1322–1327. doi: 10.2105/AJPH.89.9.1322.
    1. Brunisholz KD, Conroy MB, Belnap T, Joy EA, Srivastava R. Measuring adherence to U.S. preventive services task force diabetes prevention guidelines within two healthcare systems. J Healthc Qual. 2020. 10.1097/JHQ.0000000000000281 Online ahead of print.
    1. Keck JW, Roper KL, Hieronymus LB, Thomas AR, Huang Z, Westgate PM, Fowlkes JL, Cardarelli R. Primary care cluster RCT to increase diabetes prevention program referrals. Am J Prev Med. 2020;59(1):79–87. doi: 10.1016/j.amepre.2020.02.008.
    1. Rafferty AM, Ball J, Aiken LH. Are teamwork and professional autonomy compatible, and do they result in improved hospital care? Qual Health Care. 2001;10(Supplement 2):ii32–ii37. doi: 10.1136/qhc.0100032.
    1. Sangster-Gormley E, Martin-Misener R, Downe-Wamboldt B, Dicenso A. Factors affecting nurse practitioner role implementation in Canadian practice settings: an integrative review. [Review] J Adv Nurs. 2011;67(6):1178–90.
    1. Schadewaldt V, McInnes E, Hiller JE, Gardner A. Views and experiences of nurse practitioners and medical practitioners with collaborative practice in primary health care - an integrative review. BMC Fam Pract. 2013;14(1):132. doi: 10.1186/1471-2296-14-132.
    1. Salas-Salvadó J, Bulló M, Estruch R, Ros E, Covas MI, Ibarrola-Jurado N, Corella D, Arós F, Gómez-Gracia E, Ruiz-Gutiérrez V, Romaguera D, Lapetra J, Lamuela-Raventós RM, Serra-Majem L, Pintó X, Basora J, Muñoz MA, Sorlí JV, Martínez-González MA. Prevention of diabetes with Mediterranean diets: a subgroup analysis of a randomized trial. Ann Intern Med. 2014;160(1):1–10. doi: 10.7326/M13-1725.
    1. Gilis-Januszewska A, Lindström J, Tuomilehto J, Piwońska-Solska B, Topór-Mądry R, Szybiński Z, Peltonen M, Schwarz PE, Windak A, Hubalewska-Dydejczyk A. Sustained diabetes risk reduction after real life and primary health care setting implementation of the diabetes in Europe prevention using lifestyle, physical activity and nutritional intervention (DE-PLAN) project. BMC Public Health. 2017;17(1):198. doi: 10.1186/s12889-017-4104-3.
    1. Li R, Qu S, Zhang P, Chattopadhyay S, Gregg EW, Albright A, Hopkins D, Pronk NP. Economic evaluation of combined diet and physical activity promotion programs to prevent type 2 diabetes among persons at increased risk: a systematic review for the community preventive services task force. Ann Intern Med. 2015;163(6):452–460. doi: 10.7326/M15-0469.

Source: PubMed

Sponsorit ja yhteistyökumppanit

Sairaudet

Huumeiden interventiot

3
Tilaa