Interventions for the prevention of risk factors and incidence of type 2 diabetes in the work environment: a systematic review

Jorge Inolopú Nélida Hilario-Huapaya Martín Alonso Tantaleán-Del-Águila Yamilee Hurtado-Roca Cesar Ugarte-Gil About the authors

ABSTRACT

OBJECTIVE

To evaluate the effectiveness of interventions aimed at the prevention of risk factors and incidence of type 2 diabetes in the workers population.

METHODS

Systematic review of interventions aimed at adult workers at risk of type 2 diabetes published in Medline, Embase, Web of Science, Central Cochrane Registry of Controlled Trials, and Lilacs. Randomized trials, quasi-experimental research and cohort studies were selected; in English, Spanish and Portuguese; published from 2000 to 2017. Intervention effectiveness was evaluated concerning the incidence of type 2 diabetes and a significant reduction in body weight, or another anthropometric or metabolic parameter.

RESULTS

3,024 articles were generated, of which 2,825 that did not answer the research question were eliminated, as well as 130 that did not evaluate original interventions, 57 carried out outside the workplace and two reviews; so that 10 selected items remained. Interventions based on structured programs previously evaluated and integrated into the workplace had a favorable impact on the reduction of body weight and other risk factors.

CONCLUSIONS

The effectiveness of lifestyle interventions for the prevention of type 2 diabetes should be based on structured programs with proven effectiveness and adapted to the workplace, with employer participation in the provision of schedules and work environments.

Type 2 Diabetes Mellitus, prevention & control; Assessment, Outcome (Health Care); Working Environment; Review

INTRODUCTION

Type 2 diabetes (DT2) is estimated to affect 425 million people, which represent 8.8% of the world’s adult population11. International Diabetes Federation. IDF Diabetes Atlas. 8. ed. Brussels (BEL): IDF; 2017 [citado 17 ene 2019]. Disponible en: http://www.diabetesatlas.org/
http://www.diabetesatlas.org/...
. The numbers are expected to increase to 693 million by 204522. Cho NH, Shaw JE, Karuranga S, Huang Y, Fernandes JDR, Ohlrogge AW, et al. IDF Diabetes Atlas: global estimates of diabetes prevalence for 2017 and projections for 2045. Diabetes Res Clin Pract. 2018;138:271-81. https://doi.org/10.1016/j.diabres.2018.02.023
https://doi.org/10.1016/j.diabres.2018.0...
. The prevention of DM2 through structured programs to promote physical activity and healthy diet, also known as lifestyle interventions (LSI), have proved to be effective in reducing the risk of DM233. Tuomilehto J, Lindström J, Eriksson JG, Valle TT, Hämäläinen H, Ilanne-Parikka P, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med. 2001;344(18):1343-50. https://doi.org/10.1056/NEJM200105033441801
https://doi.org/10.1056/NEJM200105033441...
, 44. Diabetes Prevention Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403. https://doi.org/10.1056/NEJMoa012512
https://doi.org/10.1056/NEJMoa012512...
. The Finnish Diabetes Prevention Study (FDPS)55. Eriksson J, Lindström J, Valle T, Aunola S, Hämäläinen H, Ilanne-Parikka P, et al. Prevention of Type II diabetes in subjects with impaired glucose tolerance: the Diabetes Prevention Study (DPS) in Finland. Study design and 1-year interim report on the feasibility of the lifestyle intervention programme. Diabetologia. 1999;42(7):793-801. https://doi.org/10.1007/s001250051229
https://doi.org/10.1007/s001250051229...
and the Diabetes Prevention Program (DPP)66. Diabetes Prevention Program (DPP) Research Group. The Diabetes Prevention Program (DPP): description of lifestyle intervention. Diabetes Care. 2002;25(12):2165-71. https://doi.org/10.2337/diacare.25.12.2165
https://doi.org/10.2337/diacare.25.12.21...
propose as a success indicator the reduction of 5.0 and 7.0% of the initial body weight, respectively. However, the success and sustainability of these interventions also depends on the context in which they are developed77. Dunkley AJ, Bodicoat DH, Greaves CJ, Russell C, Yates T, Davies MJ, et al. Diabetes prevention in the real world: effectiveness of pragmatic lifestyle interventions for the prevention of type 2 diabetes and of the impact of adherence to guideline recommendations: a systematic review and meta-analysis. Diabetes Care. 2014;37(4):922-33. https://doi.org/10.2337/dc13-2195
https://doi.org/10.2337/dc13-2195...
. Work environment represents a challenge for LSIs, considering its known risk factors, such as inadequate diet88. Bonnell EK, Huggins CE, Huggins CT, McCaffrey TA, Palermo C, Bonham MP. Influences on dietary choices during day versus night shift in shift workers: a mixed methods study. Nutrients. 2017;9(3):193. https://doi.org/10.3390/nu9030193
https://doi.org/10.3390/nu9030193...
, 99. Nobrega S, Champagne N, Abreu M, Goldstein-Gelb M, Montano M, Lopez I, et al. Obesity/overweight and the role of working conditions: a qualitative, participatory investigation. Health Promot Pract. 2016;17(1):127-36. https://doi.org/10.1177/1524839915602439
https://doi.org/10.1177/1524839915602439...
and sedentary lifestyle1010. Lin TC, Courtney TK, Lombardi DA, Verma SK. Association between sedentary work and BMI in a U.S. National Longitudinal Survey. Am J Prev Med. 2015;49(6):e117-23. https://doi.org/10.1016/j.amepre.2015.07.024
https://doi.org/10.1016/j.amepre.2015.07...
, 1111. Choi BK, Schnall PL, Yang H, Dobson M, Landsbergis P, Israel L, et al. Sedentary work, low physical job demand, and obesity in US workers. Am J Ind Med. 2010;53(11):1088-101. https://doi.org/10.1002/ajim.20886
https://doi.org/10.1002/ajim.20886...
, added to other yet uunevaluated factors, such as work stress1212. Lian Y, Sun Q, Guan S, Ge H, Tao N, Jiang Y, et al. Effect of changing work stressors and coping resources on the risk of type 2 diabetes: The OHSPIW Cohort Sudy. Diabetes Care. 2018;41(3):453-60. https://doi.org/10.2337/dc17-0749
https://doi.org/10.2337/dc17-0749...
. The prevention of DM2 and its complications in labor contexts aims to maintain workers’ health and well-being, in addition to avoiding absenteeism1313. Ramsey S, Summers KH, Leong SA, Birnbaum HG, Kemner JE, Greenberg P. Productivity and medical costs of diabetes in a large employer population. Diabetes Care. 2002;25(1):23-9. https://doi.org/10.2337/diacare.25.1.23
https://doi.org/10.2337/diacare.25.1.23...
, low productivity1414. Von Korff M, Katon W, Lin EHB, Simon G, Ciechanowski P, Ludman E, et al. Work disability among individuals with diabetes. Diabetes Care. 2005;28(6):1326-32. https://doi.org/10.2337/diacare.28.6.1326
https://doi.org/10.2337/diacare.28.6.132...
and significant expenses that affect the health system1515. Seuring T, Archangelidi O, Suhrcke M. The economic costs of Type 2 Diabetes: a global systematic review. Pharmacoeconomics. 2015;33(8):811-31. https://doi.org/10.1007/s40273-015-0268-9
https://doi.org/10.1007/s40273-015-0268-...
, 1616. Arredondo A. Type 2 diabetes and health care costs in Latin America: exploring the need for greater preventive medicine. BMC Med. 2014;12(1):136. https://doi.org/10.1186/s12916-014-0136-z
https://doi.org/10.1186/s12916-014-0136-...
. This study aimed to evaluate the effectiveness of interventions for the prevention of DM2 risk factors in the worker population.

METHODS

A systematic review of interventions aimed at an adult worker population at risk of DM2 was performed. Original articles in English, Spanish and Portuguese, designed as randomized trial, quasi-experimental or cohort studies, and published between 2000 and 2017 were considered eligible. Such studies included interventions for the prevention of DM2 risk factors, based or not on a previously evaluated program. The study population included adult workers with risk factors for DM2, such as overweight, obesity, pre-diabetes and/or metabolic syndrome. Those with some type of diabetes at the beginning of intervention were excluded.

A highly sensitive search algorithm was used for the PubMed, Embase, Web of Science, and Lilacs databases and in the Central Cochrane Register of Controlled Trials (CENTRAL) ( Chart ).

Chart
Search terms.

A list of titles and abstracts was created, based on results of the database search with a bibliographic reference manager (EndNote TM x8, USA). The selection strategy included a first screening of titles and/or abstracts and a second screening based on full-text reading by two of the authors (JI and NH), resolving the discrepancies of both steps with a third reviewer (CU-G).

Intervention effectiveness considered the incidence of DM2 or a significant reduction of initial body weight, as this parameter is recognized as the main DM2 risk predictor1717. Hamman RF, Wing RR, Edelstein SL, Lachin JM, Bray GA, Delahanty L, et al. Effect of weight loss with lifestyle intervention on risk of diabetes. Diabetes Care. 2006;29(9):2102–7. https://doi.org/10.2337/dc06-0560
https://doi.org/10.2337/dc06-0560...
, 1818. Miller CK, Nagaraja HN, Weinhold KR. Early weight-loss success identifies nonresponders after a lifestyle intervention in a worksite diabetes prevention trial. J Acad Nutr Diet. 2015;115(9):1464-71. https://doi.org/10.1016/j.jand.2015.04.022
https://doi.org/10.1016/j.jand.2015.04.0...
, as well as of any other anthropometric or metabolic parameter recognized as a DM2 risk predictor ( Figure 1 ).

Figure 1
Framework of the systematic review.

RESULTS

The search generated 3,083 articles, of which 59 duplicate articles were eliminated, leaving 3,024. In the first screening, 2,825 articles that did not answer the research question were excluded. In the second screening, 189 articles were excluded because they had another study design (n = 67), did not consider the work environment (n = 57) and did not exclude participants with DM2 (n = 39). Therefore, 10 articles were selected, of which six were randomized trials and four were quasi-experimental studies testing the before and after of a single group ( Figure 2 ). Results show heterogeneity in the number, duration, and content of intervention sessions evaluated, as well as diverse age groups, educational levels and work environments of the participants ( Table 1 ).

Figure 2
Selection process of studies included in the analysis.

Table 1
Characteristics of studies on the prevention of DM2 risk factors in the work environment.

Interventions were classified as: conventional LSI (seven), virtual counseling LSI (two), and exclusively nutritional (one). Of these, six were based on structured programs for the prevention of DM2, such as the DPP1919. Kramer MK, Molenaar DM, Arena VC, Venditti EM, Meehan RJ, Miller RG, et al. Improving employee health: evaluation of a worksite lifestyle change program to decrease risk factors for diabetes and cardiovascular disease. J Occup Environ Med. 2015;57(3):284-91. https://doi.org/10.1097/JOM.0000000000000350
https://doi.org/10.1097/JOM.000000000000...
, FDPS2222. Zyriax BC, Letsch B, Stock S, Windler E. DELIGHT (delay of impaired glucose tolerance by a healthy lifestyle trial) - a feasibility study on implementing a program of sustainable diabetes prevention in German companies. Exp Clin Endocrinol Diabetes. 2014;122(1):20-6. https://doi.org/10.1055/s-0033-1355423
https://doi.org/10.1055/s-0033-1355423...
, 2323. Viitasalo K, Hemiö K, Puttonen S, Hyvärinen HK, Leiviska J, Harma M, et al. Prevention of diabetes and cardiovascular diseases in occupational health care: feasibility and effectiveness. Prim Care Diabetes. 2015;9(2):96-104. https://doi.org/10.1016/j.pcd.2014.07.008
https://doi.org/10.1016/j.pcd.2014.07.00...
and the Life Style Modification Program for Physical Activity and Nutrition program (LiSM10!)2424. Maruyama C, Kimura M, Okumura H, Hayashi K, Arao T. Effect of a worksite-based intervention program on metabolic parameters in middle-aged male white-collar workers: a randomized controlled trial. Prev Med. 2010;51(1):11-7. https://doi.org/10.1016/j.ypmed.2010.04.008
https://doi.org/10.1016/j.ypmed.2010.04....
. Two interventions were ground on DM2 prevention recommendations based on guidelines from The National Institute for Health and Care Excellence (NICE)2525. Limaye T, Kumaran K, Joglekar C, Bhat D, Kulkarni R, Nanivadekar A, et al. Efficacy of a virtual assistance-based lifestyle intervention in reducing risk factors for Type 2 diabetes in young employees in the information technology industry in India: LIMIT, a randomized controlled trial. Diabet Med. 2017;34(4):563-8. https://doi.org/10.1111/dme.13258
https://doi.org/10.1111/dme.13258...
and the Japan Diabetes Society and the American Diabetes Association (JDS/ADA)2626. Watanabe M, Yamaoka K, Yokotsuka M, Tango T. Randomized controlled trial of a new dietary education program to prevent type 2 diabetes in a high-risk group of Japanese male workers. Diabetes Care. 2003;26(12):3209-14. https://doi.org/10.2337/diacare.26.12.3209
https://doi.org/10.2337/diacare.26.12.32...
. In addition, one intervention was based on a DM2 management program called Healthy Living with Diabetes Program2727. Burton WN, Chen C-Y, Li X, Erickson D, McCluskey M, Schultz A. A Worksite Occupational Health Clinic-Based Diabetes Mellitus Management Program. Popul Health Manag. 2015;18(6):429-36. https://doi.org/10.1089/pop.2014.0141
https://doi.org/10.1089/pop.2014.0141...
and one did not report any background2828. Bevis CC, Nogle JM, Forges B, Chen PC, Sievers D, Lucas KR, et al. Diabetes wellness care: a successful employer-endorsed program for employees. J Occup Environ Med. 2014;56(10):1052-61. https://doi.org/10.1097/JOM.0000000000000231
https://doi.org/10.1097/JOM.000000000000...
( Table 2 ). Bias risk assessment was described and assessed as recommended by the Cochrane Collaboration for randomized studies2929. Cochrane Training. Cochrane handbook for systematic reviews of interventions. West Sussex, UK; 2011. (Cochrane Book Series). ( Figure 3 ).

Table 2
Results of studies on the prevention of DM2 risk factors in the work environment.

Figure 3
Summary of the bias risk assessment of randomized studies according to the Cochrane Collaboration.

According to the effectiveness assessment, six studies showed statistically significant reduction in bodyweight2020. Weinhold KR, Miller CK, Marrero DG, Nagaraja HN, Focht BC, Gascon GM. A randomized controlled trial translating the Diabetes Prevention Program to a university worksite, Ohio, 2012-2014. Prev Chronic Dis. 2015;12:150301. https://doi.org/10.5888/pcd12.150301
https://doi.org/10.5888/pcd12.150301...
, all of which were based on structured programs for the prevention of DM2, such as DPP1919. Kramer MK, Molenaar DM, Arena VC, Venditti EM, Meehan RJ, Miller RG, et al. Improving employee health: evaluation of a worksite lifestyle change program to decrease risk factors for diabetes and cardiovascular disease. J Occup Environ Med. 2015;57(3):284-91. https://doi.org/10.1097/JOM.0000000000000350
https://doi.org/10.1097/JOM.000000000000...

20. Weinhold KR, Miller CK, Marrero DG, Nagaraja HN, Focht BC, Gascon GM. A randomized controlled trial translating the Diabetes Prevention Program to a university worksite, Ohio, 2012-2014. Prev Chronic Dis. 2015;12:150301. https://doi.org/10.5888/pcd12.150301
https://doi.org/10.5888/pcd12.150301...
- 2121. Faghri PD, Li R. Effectiveness of financial incentives in a Worksite Diabetes Prevention Program. Open Obes J. 2014;6:1-12. https://doi.org/10.2174/1876823720140107001
https://doi.org/10.2174/1876823720140107...
, FDPS2222. Zyriax BC, Letsch B, Stock S, Windler E. DELIGHT (delay of impaired glucose tolerance by a healthy lifestyle trial) - a feasibility study on implementing a program of sustainable diabetes prevention in German companies. Exp Clin Endocrinol Diabetes. 2014;122(1):20-6. https://doi.org/10.1055/s-0033-1355423
https://doi.org/10.1055/s-0033-1355423...
and LiSM10!2424. Maruyama C, Kimura M, Okumura H, Hayashi K, Arao T. Effect of a worksite-based intervention program on metabolic parameters in middle-aged male white-collar workers: a randomized controlled trial. Prev Med. 2010;51(1):11-7. https://doi.org/10.1016/j.ypmed.2010.04.008
https://doi.org/10.1016/j.ypmed.2010.04....
, as well as on the recommendations given by NICE2525. Limaye T, Kumaran K, Joglekar C, Bhat D, Kulkarni R, Nanivadekar A, et al. Efficacy of a virtual assistance-based lifestyle intervention in reducing risk factors for Type 2 diabetes in young employees in the information technology industry in India: LIMIT, a randomized controlled trial. Diabet Med. 2017;34(4):563-8. https://doi.org/10.1111/dme.13258
https://doi.org/10.1111/dme.13258...
. On the other hand, a nutritional intervention showed a reduction in caloric intake with subsequent reduction of two-hour postprandial glucose levels, based on the JDS/ADA recommendations2626. Watanabe M, Yamaoka K, Yokotsuka M, Tango T. Randomized controlled trial of a new dietary education program to prevent type 2 diabetes in a high-risk group of Japanese male workers. Diabetes Care. 2003;26(12):3209-14. https://doi.org/10.2337/diacare.26.12.3209
https://doi.org/10.2337/diacare.26.12.32...
. In contrast, two non-effective interventions focused on the management of DM22727. Burton WN, Chen C-Y, Li X, Erickson D, McCluskey M, Schultz A. A Worksite Occupational Health Clinic-Based Diabetes Mellitus Management Program. Popul Health Manag. 2015;18(6):429-36. https://doi.org/10.1089/pop.2014.0141
https://doi.org/10.1089/pop.2014.0141...
, 2828. Bevis CC, Nogle JM, Forges B, Chen PC, Sievers D, Lucas KR, et al. Diabetes wellness care: a successful employer-endorsed program for employees. J Occup Environ Med. 2014;56(10):1052-61. https://doi.org/10.1097/JOM.0000000000000231
https://doi.org/10.1097/JOM.000000000000...
, and one had limited sessions and prolonged follow-up2323. Viitasalo K, Hemiö K, Puttonen S, Hyvärinen HK, Leiviska J, Harma M, et al. Prevention of diabetes and cardiovascular diseases in occupational health care: feasibility and effectiveness. Prim Care Diabetes. 2015;9(2):96-104. https://doi.org/10.1016/j.pcd.2014.07.008
https://doi.org/10.1016/j.pcd.2014.07.00...
. No studies showed adverse effects in the study population.

None of the seven effective studies showed results in terms of reducing the risk of DM2 incidence, since their design did not allow it. However, two of them showed results regarding the percentage of initial body weight reduction1919. Kramer MK, Molenaar DM, Arena VC, Venditti EM, Meehan RJ, Miller RG, et al. Improving employee health: evaluation of a worksite lifestyle change program to decrease risk factors for diabetes and cardiovascular disease. J Occup Environ Med. 2015;57(3):284-91. https://doi.org/10.1097/JOM.0000000000000350
https://doi.org/10.1097/JOM.000000000000...
, 2020. Weinhold KR, Miller CK, Marrero DG, Nagaraja HN, Focht BC, Gascon GM. A randomized controlled trial translating the Diabetes Prevention Program to a university worksite, Ohio, 2012-2014. Prev Chronic Dis. 2015;12:150301. https://doi.org/10.5888/pcd12.150301
https://doi.org/10.5888/pcd12.150301...
. Kramer et al.1919. Kramer MK, Molenaar DM, Arena VC, Venditti EM, Meehan RJ, Miller RG, et al. Improving employee health: evaluation of a worksite lifestyle change program to decrease risk factors for diabetes and cardiovascular disease. J Occup Environ Med. 2015;57(3):284-91. https://doi.org/10.1097/JOM.0000000000000350
https://doi.org/10.1097/JOM.000000000000...
determined that 5.0% reduction of average body weight was achieved by 45.0% and 7.0% of the participants involved in the intervention and the control group, respectively1919. Kramer MK, Molenaar DM, Arena VC, Venditti EM, Meehan RJ, Miller RG, et al. Improving employee health: evaluation of a worksite lifestyle change program to decrease risk factors for diabetes and cardiovascular disease. J Occup Environ Med. 2015;57(3):284-91. https://doi.org/10.1097/JOM.0000000000000350
https://doi.org/10.1097/JOM.000000000000...
. In contrast, Weinhold et al.2020. Weinhold KR, Miller CK, Marrero DG, Nagaraja HN, Focht BC, Gascon GM. A randomized controlled trial translating the Diabetes Prevention Program to a university worksite, Ohio, 2012-2014. Prev Chronic Dis. 2015;12:150301. https://doi.org/10.5888/pcd12.150301
https://doi.org/10.5888/pcd12.150301...
determined that 32.4% of the intervention group managed to lose at least 7.0% of the initial body weight, a percentage which was significantly greater than for the control group (2.9%; p <0.01).

On the other hand, they also evaluated economic and non-economic incentives, as well as the role played by the employer’s participation in the intervention results. Faghri et al.2121. Faghri PD, Li R. Effectiveness of financial incentives in a Worksite Diabetes Prevention Program. Open Obes J. 2014;6:1-12. https://doi.org/10.2174/1876823720140107001
https://doi.org/10.2174/1876823720140107...
was the only study to offer a cumulative economic incentive for lost weight. Despite being a low intensity intervention, it was successful in reducing weight, decreasing the risk of DM2 and leading to a healthy diet. Employer participation generally did not go further than supporting the enrollment of participants. The facilities in enrollment, arrangement of environments, and work schedules in the studies of Kramer et al.1919. Kramer MK, Molenaar DM, Arena VC, Venditti EM, Meehan RJ, Miller RG, et al. Improving employee health: evaluation of a worksite lifestyle change program to decrease risk factors for diabetes and cardiovascular disease. J Occup Environ Med. 2015;57(3):284-91. https://doi.org/10.1097/JOM.0000000000000350
https://doi.org/10.1097/JOM.000000000000...
and Weinhold et al.2020. Weinhold KR, Miller CK, Marrero DG, Nagaraja HN, Focht BC, Gascon GM. A randomized controlled trial translating the Diabetes Prevention Program to a university worksite, Ohio, 2012-2014. Prev Chronic Dis. 2015;12:150301. https://doi.org/10.5888/pcd12.150301
https://doi.org/10.5888/pcd12.150301...
were linked to the success of the intervention.

DISCUSSION

Interventions based on structured programs for the prevention of DM2 showed wide effectiveness, which was linked to the degree of similarity with the base program. On the other hand, interventions based on recommendations from the NICE guidelines were statistically effective, but present aspects to be considered. The study by Limaye et al.2525. Limaye T, Kumaran K, Joglekar C, Bhat D, Kulkarni R, Nanivadekar A, et al. Efficacy of a virtual assistance-based lifestyle intervention in reducing risk factors for Type 2 diabetes in young employees in the information technology industry in India: LIMIT, a randomized controlled trial. Diabet Med. 2017;34(4):563-8. https://doi.org/10.1111/dme.13258
https://doi.org/10.1111/dme.13258...
was based on the NICE guideline and shows significant weight reduction, but this is achieved due to an increase in weight in the control group. In this study, the average bodyweight reduction in the intervention group does not reach less than 5.0% post-intervention.

Uneffective interventions2323. Viitasalo K, Hemiö K, Puttonen S, Hyvärinen HK, Leiviska J, Harma M, et al. Prevention of diabetes and cardiovascular diseases in occupational health care: feasibility and effectiveness. Prim Care Diabetes. 2015;9(2):96-104. https://doi.org/10.1016/j.pcd.2014.07.008
https://doi.org/10.1016/j.pcd.2014.07.00...
, 2727. Burton WN, Chen C-Y, Li X, Erickson D, McCluskey M, Schultz A. A Worksite Occupational Health Clinic-Based Diabetes Mellitus Management Program. Popul Health Manag. 2015;18(6):429-36. https://doi.org/10.1089/pop.2014.0141
https://doi.org/10.1089/pop.2014.0141...
, 2828. Bevis CC, Nogle JM, Forges B, Chen PC, Sievers D, Lucas KR, et al. Diabetes wellness care: a successful employer-endorsed program for employees. J Occup Environ Med. 2014;56(10):1052-61. https://doi.org/10.1097/JOM.0000000000000231
https://doi.org/10.1097/JOM.000000000000...
did not have a structured session plan2323. Viitasalo K, Hemiö K, Puttonen S, Hyvärinen HK, Leiviska J, Harma M, et al. Prevention of diabetes and cardiovascular diseases in occupational health care: feasibility and effectiveness. Prim Care Diabetes. 2015;9(2):96-104. https://doi.org/10.1016/j.pcd.2014.07.008
https://doi.org/10.1016/j.pcd.2014.07.00...
, and two of them were focused on the management of DM22727. Burton WN, Chen C-Y, Li X, Erickson D, McCluskey M, Schultz A. A Worksite Occupational Health Clinic-Based Diabetes Mellitus Management Program. Popul Health Manag. 2015;18(6):429-36. https://doi.org/10.1089/pop.2014.0141
https://doi.org/10.1089/pop.2014.0141...
, 2828. Bevis CC, Nogle JM, Forges B, Chen PC, Sievers D, Lucas KR, et al. Diabetes wellness care: a successful employer-endorsed program for employees. J Occup Environ Med. 2014;56(10):1052-61. https://doi.org/10.1097/JOM.0000000000000231
https://doi.org/10.1097/JOM.000000000000...
. Viitasalo et al.2323. Viitasalo K, Hemiö K, Puttonen S, Hyvärinen HK, Leiviska J, Harma M, et al. Prevention of diabetes and cardiovascular diseases in occupational health care: feasibility and effectiveness. Prim Care Diabetes. 2015;9(2):96-104. https://doi.org/10.1016/j.pcd.2014.07.008
https://doi.org/10.1016/j.pcd.2014.07.00...
, in a pre- and post-test study carried out on employees of an airline company, showed a slight increase in anthropometric parameters after the intervention. Such intervention had an average of 1.6 sessions, which is less than in any other existing program; although based on the FDPS, the program differed from the original. Regarding the two interventions aimed at DM2 management, they included a pre-diabetes population in a context of workers with DM2. These types of interventions were based on work welfare programs and, despite having resources, the intervention approach is important.

Overall, the selected articles make a brief description of the labor factors that would favor the development of DM2. Limaye et al.2525. Limaye T, Kumaran K, Joglekar C, Bhat D, Kulkarni R, Nanivadekar A, et al. Efficacy of a virtual assistance-based lifestyle intervention in reducing risk factors for Type 2 diabetes in young employees in the information technology industry in India: LIMIT, a randomized controlled trial. Diabet Med. 2017;34(4):563-8. https://doi.org/10.1111/dme.13258
https://doi.org/10.1111/dme.13258...
evaluated an intervention in IT employees in India who reported a sedentary lifestyle, inadequate eating habits, and work stress. Maruyama et al.2424. Maruyama C, Kimura M, Okumura H, Hayashi K, Arao T. Effect of a worksite-based intervention program on metabolic parameters in middle-aged male white-collar workers: a randomized controlled trial. Prev Med. 2010;51(1):11-7. https://doi.org/10.1016/j.ypmed.2010.04.008
https://doi.org/10.1016/j.ypmed.2010.04....
evaluated Japanese office employees with prolonged periods of work, which would favor a high caloric intake. In contrast, Watanabe et al.2626. Watanabe M, Yamaoka K, Yokotsuka M, Tango T. Randomized controlled trial of a new dietary education program to prevent type 2 diabetes in a high-risk group of Japanese male workers. Diabetes Care. 2003;26(12):3209-14. https://doi.org/10.2337/diacare.26.12.3209
https://doi.org/10.2337/diacare.26.12.32...
, evaluated employees with working conditions related to high caloric intake at night and short periods of sleep.

Employees who carried out these activities are within the framework of “white-collar workers”. This population has a higher risk of being overweight and obese due to the sedentary lifestyle they experience at work, favoring the increase in body mass index1010. Lin TC, Courtney TK, Lombardi DA, Verma SK. Association between sedentary work and BMI in a U.S. National Longitudinal Survey. Am J Prev Med. 2015;49(6):e117-23. https://doi.org/10.1016/j.amepre.2015.07.024
https://doi.org/10.1016/j.amepre.2015.07...
. On the other hand, work with night, rotating shifts, or non-regular, called “shift work,” are associated with the development of DM2 due to insufficient hours of sleep and poor eating habits3131. Gan Y, Yang C, Tong X, Sun H, Cong Y, Yin X, et al. Shift work and diabetes mellitus: a meta-analysis of observational studies. Occup Environ Med. 2014;72(1):72-8. https://doi.org/10.1136/oemed-2014-102150
https://doi.org/10.1136/oemed-2014-10215...
. Nonetheless, these factors were not evaluated in the intervention, but they had to be considered in the evaluation of its impact.

The employer’s participation in the enrollment was given by telephone calls and emails2121. Faghri PD, Li R. Effectiveness of financial incentives in a Worksite Diabetes Prevention Program. Open Obes J. 2014;6:1-12. https://doi.org/10.2174/1876823720140107001
https://doi.org/10.2174/1876823720140107...
, 2323. Viitasalo K, Hemiö K, Puttonen S, Hyvärinen HK, Leiviska J, Harma M, et al. Prevention of diabetes and cardiovascular diseases in occupational health care: feasibility and effectiveness. Prim Care Diabetes. 2015;9(2):96-104. https://doi.org/10.1016/j.pcd.2014.07.008
https://doi.org/10.1016/j.pcd.2014.07.00...

24. Maruyama C, Kimura M, Okumura H, Hayashi K, Arao T. Effect of a worksite-based intervention program on metabolic parameters in middle-aged male white-collar workers: a randomized controlled trial. Prev Med. 2010;51(1):11-7. https://doi.org/10.1016/j.ypmed.2010.04.008
https://doi.org/10.1016/j.ypmed.2010.04....
- 2525. Limaye T, Kumaran K, Joglekar C, Bhat D, Kulkarni R, Nanivadekar A, et al. Efficacy of a virtual assistance-based lifestyle intervention in reducing risk factors for Type 2 diabetes in young employees in the information technology industry in India: LIMIT, a randomized controlled trial. Diabet Med. 2017;34(4):563-8. https://doi.org/10.1111/dme.13258
https://doi.org/10.1111/dme.13258...
. Other studies also developed communication plans to encourage changes in lifestyle1919. Kramer MK, Molenaar DM, Arena VC, Venditti EM, Meehan RJ, Miller RG, et al. Improving employee health: evaluation of a worksite lifestyle change program to decrease risk factors for diabetes and cardiovascular disease. J Occup Environ Med. 2015;57(3):284-91. https://doi.org/10.1097/JOM.0000000000000350
https://doi.org/10.1097/JOM.000000000000...
, 2020. Weinhold KR, Miller CK, Marrero DG, Nagaraja HN, Focht BC, Gascon GM. A randomized controlled trial translating the Diabetes Prevention Program to a university worksite, Ohio, 2012-2014. Prev Chronic Dis. 2015;12:150301. https://doi.org/10.5888/pcd12.150301
https://doi.org/10.5888/pcd12.150301...
, 2222. Zyriax BC, Letsch B, Stock S, Windler E. DELIGHT (delay of impaired glucose tolerance by a healthy lifestyle trial) - a feasibility study on implementing a program of sustainable diabetes prevention in German companies. Exp Clin Endocrinol Diabetes. 2014;122(1):20-6. https://doi.org/10.1055/s-0033-1355423
https://doi.org/10.1055/s-0033-1355423...
, 2727. Burton WN, Chen C-Y, Li X, Erickson D, McCluskey M, Schultz A. A Worksite Occupational Health Clinic-Based Diabetes Mellitus Management Program. Popul Health Manag. 2015;18(6):429-36. https://doi.org/10.1089/pop.2014.0141
https://doi.org/10.1089/pop.2014.0141...
, 2828. Bevis CC, Nogle JM, Forges B, Chen PC, Sievers D, Lucas KR, et al. Diabetes wellness care: a successful employer-endorsed program for employees. J Occup Environ Med. 2014;56(10):1052-61. https://doi.org/10.1097/JOM.0000000000000231
https://doi.org/10.1097/JOM.000000000000...
and even provided environments and schedules for the development of work sessions1919. Kramer MK, Molenaar DM, Arena VC, Venditti EM, Meehan RJ, Miller RG, et al. Improving employee health: evaluation of a worksite lifestyle change program to decrease risk factors for diabetes and cardiovascular disease. J Occup Environ Med. 2015;57(3):284-91. https://doi.org/10.1097/JOM.0000000000000350
https://doi.org/10.1097/JOM.000000000000...
, 2020. Weinhold KR, Miller CK, Marrero DG, Nagaraja HN, Focht BC, Gascon GM. A randomized controlled trial translating the Diabetes Prevention Program to a university worksite, Ohio, 2012-2014. Prev Chronic Dis. 2015;12:150301. https://doi.org/10.5888/pcd12.150301
https://doi.org/10.5888/pcd12.150301...
, 2727. Burton WN, Chen C-Y, Li X, Erickson D, McCluskey M, Schultz A. A Worksite Occupational Health Clinic-Based Diabetes Mellitus Management Program. Popul Health Manag. 2015;18(6):429-36. https://doi.org/10.1089/pop.2014.0141
https://doi.org/10.1089/pop.2014.0141...
. Some interventions provide basic incentives such as glucometers2727. Burton WN, Chen C-Y, Li X, Erickson D, McCluskey M, Schultz A. A Worksite Occupational Health Clinic-Based Diabetes Mellitus Management Program. Popul Health Manag. 2015;18(6):429-36. https://doi.org/10.1089/pop.2014.0141
https://doi.org/10.1089/pop.2014.0141...
, 2828. Bevis CC, Nogle JM, Forges B, Chen PC, Sievers D, Lucas KR, et al. Diabetes wellness care: a successful employer-endorsed program for employees. J Occup Environ Med. 2014;56(10):1052-61. https://doi.org/10.1097/JOM.0000000000000231
https://doi.org/10.1097/JOM.000000000000...
, discount cards when initiating and completing the intervention 1919. Kramer MK, Molenaar DM, Arena VC, Venditti EM, Meehan RJ, Miller RG, et al. Improving employee health: evaluation of a worksite lifestyle change program to decrease risk factors for diabetes and cardiovascular disease. J Occup Environ Med. 2015;57(3):284-91. https://doi.org/10.1097/JOM.0000000000000350
https://doi.org/10.1097/JOM.000000000000...
, 2727. Burton WN, Chen C-Y, Li X, Erickson D, McCluskey M, Schultz A. A Worksite Occupational Health Clinic-Based Diabetes Mellitus Management Program. Popul Health Manag. 2015;18(6):429-36. https://doi.org/10.1089/pop.2014.0141
https://doi.org/10.1089/pop.2014.0141...
, and economic incentives for lost weight2121. Faghri PD, Li R. Effectiveness of financial incentives in a Worksite Diabetes Prevention Program. Open Obes J. 2014;6:1-12. https://doi.org/10.2174/1876823720140107001
https://doi.org/10.2174/1876823720140107...
. However, the long-term results regarding the maintenance of the weight lost by this type of interventions seem to be inconsistent3232. Patel MS, Asch DA, Troxel AB, Fletcher M, Osman-Koss R, Brady J, et al. Premium-based financial incentives did not promote workplace weight loss in a 2013-15 study. Health Aff (Millwood). 2016;35(1):71-9. https://doi.org/10.1377/hlthaff.2015.0945
https://doi.org/10.1377/hlthaff.2015.094...
.

Those employers who offered greater support in the intervention, such as facilities in enrollment, provision of environments (topical, rest environments, coffee shops, etc.) and schedules at work favored the implementation and success of the intervention1919. Kramer MK, Molenaar DM, Arena VC, Venditti EM, Meehan RJ, Miller RG, et al. Improving employee health: evaluation of a worksite lifestyle change program to decrease risk factors for diabetes and cardiovascular disease. J Occup Environ Med. 2015;57(3):284-91. https://doi.org/10.1097/JOM.0000000000000350
https://doi.org/10.1097/JOM.000000000000...
, 2020. Weinhold KR, Miller CK, Marrero DG, Nagaraja HN, Focht BC, Gascon GM. A randomized controlled trial translating the Diabetes Prevention Program to a university worksite, Ohio, 2012-2014. Prev Chronic Dis. 2015;12:150301. https://doi.org/10.5888/pcd12.150301
https://doi.org/10.5888/pcd12.150301...
. Such benefits can be integrated to the intervention, to achieve and maintain the proposed objectives. Companies with food service can implement healthy menu options for people at risk of DM2, and even for diabetics3333. Ni Mhurchu C, Aston LM, Jebb SA. Effects of worksite health promotion interventions on employee diets: a systematic review. BMC Public Health. 2010;10:62. https://doi.org/10.1186/1471-2458-10-62
https://doi.org/10.1186/1471-2458-10-62...
. In our review, interventions that do not report the presence of a program with such benefits are those aimed primarily at “white-collar workers”2424. Maruyama C, Kimura M, Okumura H, Hayashi K, Arao T. Effect of a worksite-based intervention program on metabolic parameters in middle-aged male white-collar workers: a randomized controlled trial. Prev Med. 2010;51(1):11-7. https://doi.org/10.1016/j.ypmed.2010.04.008
https://doi.org/10.1016/j.ypmed.2010.04....

25. Limaye T, Kumaran K, Joglekar C, Bhat D, Kulkarni R, Nanivadekar A, et al. Efficacy of a virtual assistance-based lifestyle intervention in reducing risk factors for Type 2 diabetes in young employees in the information technology industry in India: LIMIT, a randomized controlled trial. Diabet Med. 2017;34(4):563-8. https://doi.org/10.1111/dme.13258
https://doi.org/10.1111/dme.13258...
- 2626. Watanabe M, Yamaoka K, Yokotsuka M, Tango T. Randomized controlled trial of a new dietary education program to prevent type 2 diabetes in a high-risk group of Japanese male workers. Diabetes Care. 2003;26(12):3209-14. https://doi.org/10.2337/diacare.26.12.3209
https://doi.org/10.2337/diacare.26.12.32...
.

The limitations of our review are linked to the heterogeneity of the interventions, which makes meta-analysis impossible. On the other hand, there are no results in terms of DM2 incidence risk due to the short intervention periods of most studies evaluated. Thus, the evaluation of intervention effectiveness is flexible, as they are based on the statistically significant reduction of body weight (p <0.05), but not on the reduction of body weight percentage or on clinically-significant weight reduction (reduction of at least 5.0% post-intervention). In addition, the risk of bias in randomized trials is high. The studies of Weinhold et al.2020. Weinhold KR, Miller CK, Marrero DG, Nagaraja HN, Focht BC, Gascon GM. A randomized controlled trial translating the Diabetes Prevention Program to a university worksite, Ohio, 2012-2014. Prev Chronic Dis. 2015;12:150301. https://doi.org/10.5888/pcd12.150301
https://doi.org/10.5888/pcd12.150301...
and Watanabe et al.2626. Watanabe M, Yamaoka K, Yokotsuka M, Tango T. Randomized controlled trial of a new dietary education program to prevent type 2 diabetes in a high-risk group of Japanese male workers. Diabetes Care. 2003;26(12):3209-14. https://doi.org/10.2337/diacare.26.12.3209
https://doi.org/10.2337/diacare.26.12.32...
show a higher proportion of unclear risk, but with a better rating, while the article by Kramer et al.1919. Kramer MK, Molenaar DM, Arena VC, Venditti EM, Meehan RJ, Miller RG, et al. Improving employee health: evaluation of a worksite lifestyle change program to decrease risk factors for diabetes and cardiovascular disease. J Occup Environ Med. 2015;57(3):284-91. https://doi.org/10.1097/JOM.0000000000000350
https://doi.org/10.1097/JOM.000000000000...
has the lowest rating.

Interventions with a favorable impact on the reduction of body weight and other risk factors of DM2 in the workplace are mainly those based on a program previously evaluated and carried out in the workplace with employer participation. Longitudinal studies are required to evaluate these interventions as potential programs to reduce the incidence of DM2 in the workplace.

Acknowledgments

To Dr. Joshi Acosta and Dr. Manuel Catacora for their comments on the manuscript.

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  • Funding
    Instituto de Evaluación de Tecnologías en Salud e Investigación (IETSI), EsSalud. NH-H receives the FONDECYT/CIENCIACTIVA EF033-235-2015 grant and is supported by the D43 TW007393 training grant provided by the Fogarty International Center of the US National Institutes of Health.

Publication Dates

  • Publication in this collection
    02 Dec 2019
  • Date of issue
    2019

History

  • Received
    26 Aug 2018
  • Accepted
    17 Mar 2019
Faculdade de Saúde Pública da Universidade de São Paulo São Paulo - SP - Brazil
E-mail: revsp@org.usp.br