Lifestyle INtervention for Diabetes prevention After pregnancy (LINDA-Brasil): study protocol for a multicenter randomized controlled trial

Maria Inês Schmidt, Bruce B Duncan, Cristina Castilhos, Eliana Márcia Wendland, Pedro C Hallal, Beatriz D'Agord Schaan, Michele Drehmer, Adriana Costa E Forti, Cristina Façanha, Maria Angélica Nunes, Maria Inês Schmidt, Bruce B Duncan, Cristina Castilhos, Eliana Márcia Wendland, Pedro C Hallal, Beatriz D'Agord Schaan, Michele Drehmer, Adriana Costa E Forti, Cristina Façanha, Maria Angélica Nunes

Abstract

Background: Gestational diabetes mellitus (GDM), a hyperglycemic state detected during pregnancy, is an established risk factor for diabetes. However, treatment during pregnancy in and of itself is not able to eliminate this risk, and a considerable fraction of women with GDM will develop frank diabetes in the decade following pregnancy. Our aim is to conduct a multicenter randomized controlled trial to investigate the effectiveness of a lifestyle intervention program implemented after a pregnancy complicated by GDM in delaying or preventing the development of type 2 diabetes.

Methods: Women aged 18 or older identified as having recent GDM are recruited and followed by telephone to assess eligibility for the trial. To be eligible, women must have used insulin during pregnancy or present intermediate hyperglycemia postpartum. Women are encouraged to enter the trial as early as 10 weeks, and are permitted to do so up to 2 years after a pregnancy with GDM. An estimated 740 women will be randomized to either conventional care or to coach-based interventions focused on breastfeeding, weight loss, healthy eating, and increased physical activity, and predominantly delivered by telephone. Women are followed annually to detect new onset diabetes, the primary outcome, and additional secondary outcomes which include reversion to normoglycemia, weight loss, physical activity and fitness, and insulin resistance.

Discussion: Though previous studies have demonstrated that type 2 diabetes can be delayed or prevented, no study has yet demonstrated the feasibility and effectiveness of similar interventions implemented in the postpartum period for women with recent GDM. If shown to be successful, this approach could become an important means of preventing diabetes in primary care settings.

Trial registration: ClinicalTrials.gov Identifier: NCT02327286; Registered 23 December 2014.

Keywords: Gestational diabetes; Randomized controlled trial; Telemedicine; Type 2 diabetes mellitus; Weight loss.

Figures

Fig. 1
Fig. 1
Description of the study protocol, including major actions taken during each of its phases

References

    1. World Health Organization . Preventing chronic diseases: a vital investment. 2005.
    1. Tuomilehto J, Lindstrom J, Eriksson JG, Valle TT, Hamalainen H, Ilanne-Parikka P, Keinanen-Kiukaanniemi S, Laakso M, Louheranta A, Rastas M, Salminen V, Uusitupa M. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med. 2001;344(0028–4793 (Print)):1343–50. doi: 10.1056/NEJM200105033441801.
    1. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, Nathan DM. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393–403. doi: 10.1056/NEJMoa012512.
    1. Ratner RE, Christophi CA, Metzger BE, Dabelea D, Bennett PH, Pi-Sunyer X, Fowler S, Kahn SE, The Diabetes Prevention Program Research Group Prevention of diabetes in women with a history of gestational diabetes: effects of metformin and lifestyle interventions. J Clin Endocrinol Metab. 2008;93:4774–9. doi: 10.1210/jc.2008-0772.
    1. Aroda VR, Christophi CA, Edelstein SL, Zhang P, Herman WH, Barrett-Connor E, Delahanty LM, Montez MG, Ackermann RT, Zhuo X, Knowler WC, Ratner RE, for the Diabetes Prevention Program Research Group The Effect of Lifestyle Intervention and Metformin on Preventing or Delaying Diabetes Among Women With and Without Gestational Diabetes: The Diabetes Prevention Program Outcomes Study 10-Year Follow-Up. J Clin Endocrinol Metab. 2015;100:1646. doi: 10.1210/jc.2014-3761.
    1. O’Sullivan JB. Diabetes mellitus after GDM. Diabetes. 1991;40:131–5. doi: 10.2337/diab.40.2.S131.
    1. Linne Y, Barkeling B, Rossner S. Natural course of gestational diabetes mellitus: long term follow up of women in the SPAWN study. BJOG. 2002;109:1227–31. doi: 10.1016/S1470-0328(02)01973-0.
    1. Buchanan TA, Xiang AH, Peters RK, Kjos SL, Marroquin A, Goico J, Ochoa C, Tan S, Berkowitz K, Hodis HN, Azen SP. Preservation of pancreatic {beta}-cell function and prevention of type 2 diabetes by pharmacological treatment of insulin resistance in high-risk hispanic women. Diabetes. 2002;51:2796–803. doi: 10.2337/diabetes.51.9.2796.
    1. Shek NWM, Ngai CSW, Lee CP, Chan JYC, Lao TTH. Lifestyle modifications in the development of diabetes mellitus and metabolic syndrome in Chinese women who had gestational diabetes mellitus: a randomized interventional trial. Arch Gynecol Obstet. 2014;289:319–27. doi: 10.1007/s00404-013-2971-0.
    1. Hu G, Tian H, Zhang F, Liu H, Zhang C, Zhang S, Wang L, Liu G, Yu Z, Yang X, Qi L, Zhang C, Wang H, Li M, Leng J, Li Y, Dong L, Tuomilehto J. Tianjin gestational diabetes mellitus prevention program: study design, methods, and 1-year interim report on the feasibility of lifestyle intervention program. Diabetes Res Clin Pract. 2012;98:508–17. doi: 10.1016/j.diabres.2012.09.015.
    1. Shih STF, Davis-Lameloise N, Janus ED, Wildey C, Versace VL, Hagger V, Asproloupos D, O’Reilly S, Phillips PA, Ackland M, Skinner T, Oats J, Carter R, Best JD, Dunbar JA, MAGDA Research Group Mothers After Gestational Diabetes in Australia Diabetes Prevention Program (MAGDA-DPP) post-natal intervention: study protocol for a randomized controlled trial. Trials. 2013;14:339. doi: 10.1186/1745-6215-14-339.
    1. Ferrara A, Hedderson MM, Albright CL, Brown SD, Ehrlich SF, Caan BJ, Sternfeld B, Gordon NP, Schmittdiel JA, Gunderson EP, Mevi AA, Tsai A-L, Ching J, Crites Y, Quesenberry CP. A pragmatic cluster randomized clinical trial of diabetes prevention strategies for women with gestational diabetes: design and rationale of the Gestational Diabetes’ Effects on Moms (GEM) study. BMC Pregnancy Childbirth. 2014;14:21. doi: 10.1186/1471-2393-14-21.
    1. Chasan-Taber L, Marcus BH, Rosal MC, Tucker KL, Hartman SJ, Pekow P, Braun B, Moore Simas TA, Solomon CG, Manson JE, Markenson G. Estudio Parto: postpartum diabetes prevention program for hispanic women with abnormal glucose tolerance in pregnancy: a randomised controlled trial - study protocol. BMC Pregnancy Childbirth. 2014;14:100. doi: 10.1186/1471-2393-14-100.
    1. Miller WR, Rollnick S. Motivational interviewing, third edition: helping people change. 3. New York, NY: The Guilford Press; 2012.
    1. Bricker J, Tollison S. Comparison of motivational interviewing with acceptance and commitment therapy: a conceptual and clinical review. Behav Cogn Psychother. 2011;39:541–59. doi: 10.1017/S1352465810000901.
    1. Simmons LA, Wolever RQ. Integrative health coaching and motivational interviewing: synergistic approaches to behavior change in healthcare. Glob Adv Health Med. 2013;2:28–35. doi: 10.7453/gahmj.2013.037.
    1. Gunderson EP, Kim C, Quesenberry CP, Marcovina S, Walton D, Azevedo RA, Fox G, Elmasian C, Young S, Salvador N, Lum M, Crites Y, Lo JC, Ning X, Dewey KG. Lactation intensity and fasting plasma lipids, lipoproteins, non-esterified free fatty acids, leptin and adiponectin in postpartum women with recent gestational diabetes mellitus: The SWIFT cohort. Metab Clin Exp. 2014;63:941–50. doi: 10.1016/j.metabol.2014.04.006.
    1. Gunderson EP, Hedderson MM, Chiang V, Crites Y, Walton D, Azevedo RA, Fox G, Elmasian C, Young S, Salvador N, Lum M, Quesenberry CP, Lo JC, Sternfeld B, Ferrara A, Selby JV. Lactation intensity and postpartum maternal glucose tolerance and insulin resistance in women with recent GDM: the SWIFT cohort. Diabetes Care. 2012;35(1935–5548 (Electronic)):50–6. doi: 10.2337/dc11-1409.
    1. Dewey KG, Heinig MJ, Nommsen LA. Maternal weight-loss patterns during prolonged lactation. Am J Clin Nutr. 1993;58:162–6.
    1. Ram KT, Bobby P, Hailpern SM, Lo JC, Schocken M, Skurnick J, Santoro N. Duration of lactation is associated with lower prevalence of the metabolic syndrome in midlife--SWAN, the study of women’s health across the nation. Am J Obstet Gynecol. 2008;198:268.
    1. Wiklund P, Xu L, Lyytikainen A, Saltevo J, Wang Q, Volgyi E, Munukka E, Cheng S, Alen M, Keinanen-Kiukaanniemi S, Cheng S. Prolonged breast-feeding protects mothers from later-life obesity and related cardio-metabolic disorders. Public Health Nutr. 2012;15(1475–2727 (Electronic)):67–74. doi: 10.1017/S1368980011002102.
    1. Ip S, Chung M, Raman G, Chew P, Magula N, DeVine D, Trikalinos T, Lau J. Breastfeeding and maternal and infant health outcomes in developed countries Lau J. Evid Rep Technol Assess. 2007;153:1–183.
    1. Baker JL, Gamborg M, Heitmann BL, Lissner L, Sorensen TI, Rasmussen KM. Breastfeeding reduces postpartum weight retention. Am J Clin Nutr. 2008;88(1938–3207 (Electronic)):1543–51. doi: 10.3945/ajcn.2008.26379.
    1. Kjos SL, Henry O, Lee RM, Buchanan TA, Mishell DR. The effect of lactation on glucose and lipid metabolism in women with recent gestational diabetes. Obstet Gynecol. 1993;82:451–5.
    1. Villegas R, Gao YT, Yang G, Li HL, Elasy T, Zheng W, Shu XO. Duration of breast-feeding and the incidence of type 2 diabetes mellitus in the Shanghai Women’s Health Study. Diabetologia. 2008;51(0012-186X (Print)):258–66. doi: 10.1007/s00125-007-0885-8.
    1. Ziegler AG, Wallner M, Kaiser I, Rossbauer M, Harsunen MH, Lachmann L, Maier J, Winkler C, Hummel S. Long-term protective effect of lactation on the development of type 2 diabetes in women with recent gestational diabetes mellitus. Diabetes. 2012;61(1939-327X (Electronic)):3167–71. doi: 10.2337/db12-0393.
    1. Schwarz EB, Brown JS, Creasman JM, Stuebe A, McClure CK, Van Den Eeden SK, Thom D. Lactation and maternal risk of type 2 diabetes: a population-based study. Am J Med. 2010;123(1555–7162 (Electronic)):863–6.
    1. Institute of Medicine . Nutrition during lactation. Washington, D.C: National Academies Press; 1991.
    1. Baker JL, Michaelsen KF, Sorensen TI, Rasmussen KM. High prepregnant body mass index is associated with early termination of full and any breastfeeding in Danish women. Am J Clin Nutr. 2007;86(0002–9165 (Print)):404–11.
    1. Finkelstein SA, Keely E, Feig DS, Tu X, Yasseen AS, Walker M. Breastfeeding in women with diabetes: lower rates despite greater rewards. A population-based study. Diabet Med. 2013;30:1094–101. doi: 10.1111/dme.12238.
    1. Metzger BE, Cho NH, Roston SM, Radvany R. Prepregnancy weight and antepartum insulin secretion predict glucose tolerance five years after gestational diabetes mellitus. Diabetes Care. 1993;16:1598–605. doi: 10.2337/diacare.16.12.1598.
    1. Drehmer M, Camey S, Schmidt MI, Olinto MT, Giacomello A, Buss C, Melere C, Hoffmann J, Manzolli P, Soares RM, Ozcariz S, Nunes MA. Socioeconomic, demographic and nutritional factors associated with maternal weight gain in general practices in Southern Brazil. Cad Saude Publica. 2010;26(1678–4464 (Electronic)):1024–34. doi: 10.1590/S0102-311X2010000500024.
    1. Lovelady C. Balancing exercise and food intake with lactation to promote post-partum weight loss. Proc Nutr Soc. 2011;70(1475–2719 (Electronic)):181–4. doi: 10.1017/S002966511100005X.
    1. Amorim AR, Linne YM, Lourenco PM. Diet or exercise, or both, for weight reduction in women after childbirth. Cochrane Database Syst Rev. 2007;3(1469-493X (Electronic)):CD005627.
    1. Nascimento SL, Pudwell J, Surita FG, Adamo KB, Smith GN. The effect of physical exercise strategies on weight loss in postpartum women: a systematic review and meta-analysis. Int J Obes (Lond) 2014;38:626–35. doi: 10.1038/ijo.2013.183.
    1. Bertz F, Brekke HK, Ellegard L, Rasmussen KM, Wennergren M, Winkvist A. Diet and exercise weight-loss trial in lactating overweight and obese women. Am J Clin Nutr. 2012;96(1938–3207 (Electronic)):698–705. doi: 10.3945/ajcn.112.040196.
    1. Brekke HK, Bertz F, Rasmussen KM, Bosaeus I, Ellegård L, Winkvist A. Diet and exercise interventions among overweight and obese lactating women: randomized trial of effects on cardiovascular risk factors. PLoS One. 2014;9:e88250. doi: 10.1371/journal.pone.0088250.
    1. Ferrara A, Hedderson MM, Albright CL, Ehrlich SF, Quesenberry CP, Jr, Peng T, Feng J, Ching J, Crites Y. A pregnancy and postpartum lifestyle intervention in women with gestational diabetes mellitus reduces diabetes risk factors: a feasibility randomized control trial. Diabetes Care. 2011;34:1519–25. doi: 10.2337/dc10-2221.
    1. Salas-Salvado J, Bullo M, Babio N, Martinez-Gonzalez MA, Ibarrola-Jurado N, Basora J, Estruch R, Covas MI, Corella D, Aros F, Ruiz-Gutierrez V, Ros E, for the PREDIMED Study Investigators Reduction in the Incidence of Type 2 Diabetes With the Mediterranean Diet: Results of the PREDIMED-Reus nutrition intervention randomized trial. Diabetes Care. 2011;34:14–9. doi: 10.2337/dc10-1288.
    1. Micha R, Michas G, Mozaffarian D. Unprocessed red and processed meats and risk of coronary artery disease and type 2 diabetes--an updated review of the evidence. Curr Atheroscler Rep. 2012;14:515–24. doi: 10.1007/s11883-012-0282-8.
    1. Gao D, Ning N, Wang C, Wang Y, Li Q, Meng Z, Liu Y, Li Q. Dairy products consumption and risk of type 2 diabetes: systematic review and dose–response meta-analysis. PLoS One. 2013;8:e73965. doi: 10.1371/journal.pone.0073965.
    1. Aune D, Norat T, Romundstad P, Vatten LJ. Dairy products and the risk of type 2 diabetes: a systematic review and dose–response meta-analysis of cohort studies. Am J Clin Nutr. 2013;98:1066–83. doi: 10.3945/ajcn.113.059030.
    1. Yao B, Fang H, Xu W, Yan Y, Xu H, Liu Y, Mo M, Zhang H, Zhao Y. Dietary fiber intake and risk of type 2 diabetes: a dose–response analysis of prospective studies. Eur J Epidemiol. 2014;29:79–88. doi: 10.1007/s10654-013-9876-x.
    1. Martins APB, Levy RB, Claro RM, Moubarac JC, Monteiro CA. Increased contribution of ultra-processed food products in the Brazilian diet (1987–2009) Rev Saude Publica. 2013;47:656–65. doi: 10.1590/S0034-8910.2013047004968.
    1. Canella DS, Levy RB, Martins APB, Claro RM, Moubarac J-C, Baraldi LG, Cannon G, Monteiro CA. Ultra-processed food products and obesity in Brazilian households (2008–2009) PLoS One. 2014;9:e92752. doi: 10.1371/journal.pone.0092752.
    1. Suez J, Korem T, Zeevi D, Zilberman-Schapira G, Thaiss CA, Maza O, Israeli D, Zmora N, Gilad S, Weinberger A, Kuperman Y, Harmelin A, Kolodkin-Gal I, Shapiro H, Halpern Z, Segal E, Elinav E. Artificial sweeteners induce glucose intolerance by altering the gut microbiota. Nature. 2014;514:181–6.
    1. Pereira MA. Diet beverages and the risk of obesity, diabetes, and cardiovascular disease: a review of the evidence. Nutr Rev. 2013;71:433–40. doi: 10.1111/nure.12038.
    1. Huxley R, Lee CM, Barzi F, Timmermeister L, Czernichow S, Perkovic V, Grobbee DE, Batty D, Woodward M. Coffee, decaffeinated coffee, and tea consumption in relation to incident type 2 diabetes mellitus: a systematic review with meta-analysis. Arch Intern Med. 2009;169(1538–3679 (Electronic)):2053–63. doi: 10.1001/archinternmed.2009.439.
    1. Natella F, Scaccini C. Role of coffee in modulation of diabetes risk. Nutr Rev. 2012;70(1753–4887 (Electronic)):207–17. doi: 10.1111/j.1753-4887.2012.00470.x.
    1. Ohnaka K, Ikeda M, Maki T, Okada T, Shimazoe T, Adachi M, Nomura M, Takayanagi R, Kono S. Effects of 16-week consumption of caffeinated and decaffeinated instant coffee on glucose metabolism in a randomized controlled trial. J Nutr Metab. 2012;2012(2090–0732 (Electronic)):207426.
    1. Wedick NM, Brennan AM, Sun Q, Hu FB, Mantzoros CS, van Dam RM. Effects of caffeinated and decaffeinated coffee on biological risk factors for type 2 diabetes: a randomized controlled trial. Nutr J. 2011;10(1475–2891 (Electronic)):93. doi: 10.1186/1475-2891-10-93.
    1. Wedick NM, Mantzoros CS, Ding EL, Brennan AM, Rosner B, Rimm EB, Hu FB, van Dam RM. The effects of caffeinated and decaffeinated coffee on sex hormone-binding globulin and endogenous sex hormone levels: a randomized controlled trial. Nutr J. 2012;11(1475–2891 (Electronic)):86. doi: 10.1186/1475-2891-11-86.
    1. Kempf K, Herder C, Erlund I, Kolb H, Martin S, Carstensen M, Koenig W, Sundvall J, Bidel S, Kuha S, Tuomilehto J. Effects of coffee consumption on subclinical inflammation and other risk factors for type 2 diabetes: a clinical trial. Am J Clin Nutr. 2010;91(1938–3207 (Electronic)):950–7. doi: 10.3945/ajcn.2009.28548.
    1. Nehlig A, Debry G. Consequences on the newborn of chronic maternal consumption of coffee during gestation and lactation: a review. J Am Coll Nutr. 1994;13(0731–5724 (Print)):6–21. doi: 10.1080/07315724.1994.10718366.
    1. Appel LJ, Clark JM, Yeh HC, Wang NY, Coughlin JW, Daumit G, Miller ER, III, Dalcin A, Jerome GJ, Geller S, Noronha G, Pozefsky T, Charleston J, Reynolds JB, Durkin N, Rubin RR, Louis TA, Brancati FL. Comparative effectiveness of weight-loss interventions in clinical practice. N Engl J Med. 2011;365(1533–4406 (Electronic)):1959–68. doi: 10.1056/NEJMoa1108660.
    1. Levine DM, Savarimuthu S, Squires A, Nicholson J, Jay M. Technology-assisted weight loss interventions in primary care: a systematic review. J Gen Intern Med 2014. doi: 10.1007/s11606-014-2987-6
    1. American Diabetes Association Standards of medical care in diabetes: 2014. Diabetes Care. 2014;37(Suppl 1):S14–80. doi: 10.2337/dc14-S014.
    1. Hallal PC, Gomez LF, Parra DC, Lobelo F, Mosquera J, Florindo AA, Reis RS, Pratt M, Sarmiento OL. Lessons learned after 10 years of IPAQ use in Brazil and Colombia. J Phys Act Health. 2010;7(Suppl 2):S259–64.
    1. 45 and Up Study Collaborators. Banks E, Redman S, Jorm L, Armstrong B, Bauman A, Beard J, Beral V, Byles J, Corbett S, Cumming R, Harris M, Sitas F, Smith W, Taylor L, Wutzke S, Lujic S. Cohort profile: the 45 and up study. Int J Epidemiol. 2008;37:941–7. doi: 10.1093/ije/dym184.
    1. Jakes RW, Day NE, Khaw K-T, Luben R, Oakes S, Welch A, Bingham S, Wareham NJ. Television viewing and low participation in vigorous recreation are independently associated with obesity and markers of cardiovascular disease risk: EPIC-Norfolk population-based study. Eur J Clin Nutr. 2003;57:1089–96. doi: 10.1038/sj.ejcn.1601648.
    1. The Scottish Health Survey - 2003 Results. []. Accessed 16 Jan 2016.
    1. Ware JE, Gandek B. Overview of the SF-36 health survey and the International Quality of Life Assessment (IQOLA) project. J Clin Epidemiol. 1998;51:903–12. doi: 10.1016/S0895-4356(98)00081-X.
    1. Santos IS, Matijasevich A, Tavares BF, Barros AJD, Botelho IP, Lapolli C, Magalhães PV da S, Barbosa APPN, Barros FC. Validation of the Edinburgh Postnatal Depression Scale (EPDS) in a sample of mothers from the 2004 Pelotas Birth Cohort Study. Cad Saude Publica. 2007;23:2577–88.
    1. Stunkard AJ, Sørensen T, Schulsinger F. Use of the Danish adoption register for the study of obesity and thinness. Res Publ Assoc Res Nerv Ment Dis. 1983;60:115–20.
    1. Bertolazi AN, Fagondes SC, Hoff LS, Dartora EG, Miozzo IC, de Barba ME, Barreto SSM. Validation of the Brazilian Portuguese version of the Pittsburgh sleep quality index. Sleep Med. 2011;12:70–5. doi: 10.1016/j.sleep.2010.04.020.
    1. Kim C, McEwen LN, Piette JD, Goewey J, Ferrara A, Walker EA. Risk perception for diabetes among women with histories of gestational diabetes mellitus. Diabetes Care. 2007;30:2281–6. doi: 10.2337/dc07-0618.
    1. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002;166:111–7. doi: 10.1164/ajrccm.166.1.at1102.
    1. Zamboni M, Turcato E, Armellini F, Kahn HS, Zivelonghi A, Santana H, Bergamo-Andreis IA, Bosello O. Sagittal abdominal diameter as a practical predictor of visceral fat. Int J Obes Relat Metab Disord. 1998;22:655–60. doi: 10.1038/sj.ijo.0800643.
    1. Hayashi T, Boyko EJ, Sato KK, McNeely MJ, Leonetti DL, Kahn SE, Fujimoto WY. Patterns of insulin concentration during the OGTT predict the risk of type 2 diabetes in Japanese Americans. Diabetes Care. 2013;36:1229–35. doi: 10.2337/dc12-0246.
    1. Bandura A. Social foundations of thought and action: a social cognitive theory. 1. Englewood Cliffs: Prentice Hall; 1985.
    1. Rogers CR. Client-centered therapy: its current practice, implications, and theory. Reprint. London: Constable; 1995.
    1. Laine C, Davidoff F. Patient-centered medicine. A professional evolution. JAMA. 1996;275:152–6. doi: 10.1001/jama.1996.03530260066035.
    1. Beach MC, Inui T, Relationship-Centered Care Research Network Relationship-centered care. A constructive reframing. J Gen Intern Med. 2006;21(Suppl 1):S3–8. doi: 10.1111/j.1525-1497.2006.00302.x.
    1. Neuner-Jehle S, Schmid M, Grüninger U. The “Health Coaching” programme: a new patient-centred and visually supported approach for health behaviour change in primary care. BMC Fam Pract. 2013;14:100. doi: 10.1186/1471-2296-14-100.
    1. Tudor-Locke C, Schuna JM. Steps to preventing type 2 diabetes: exercise, walk more, or sit less? Front Endocrinol (Lausanne) 2012;3:142.
    1. Tudor-Locke C, Craig CL, Thyfault JP, Spence JC. A step-defined sedentary lifestyle index: <5000 steps/day. Appl Physiol Nutr Metab. 2013;38:100–14. doi: 10.1139/apnm-2012-0235.
    1. Tudor-Locke C, Craig CL, Brown WJ, Clemes SA, De Cocker K, Giles-Corti B, Hatano Y, Inoue S, Matsudo SM, Mutrie N, Oppert J-M, Rowe DA, Schmidt MD, Schofield GM, Spence JC, Teixeira PJ, Tully MA, Blair SN. How many steps/day are enough? For adults. Int J Behav Nutr Phys Act. 2011;8:79. doi: 10.1186/1479-5868-8-79.
    1. Alberti KGMM, Eckel RH, Grundy SM, Zimmet PZ, Cleeman JI, Donato KA, Fruchart J-C, James WPT, Loria CM, Smith SC, International Diabetes Federation Task Force on Epidemiology and Prevention, Hational Heart, Lung, and Blood Institute, American Heart Association, World Heart Federation, International Atherosclerosis Society, International Association for the Study of Obesity Harmonizing the metabolic syndrome: a joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation. 2009;120:1640–5. doi: 10.1161/CIRCULATIONAHA.109.192644.
    1. Cox JL, Holden JM, Sagovsky R. Development of the 10-item Edinburgh postnatal depression scale. Br J Psychiatry. 1987;150:782–6. doi: 10.1192/bjp.150.6.782.
    1. Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh sleep quality index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28:193–213. doi: 10.1016/0165-1781(89)90047-4.

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