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Translation of Lifestyle Modification Programs

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Int.J. Behav. Med.
DOI 10.1007/s12529-014-9438-y
Translation of Lifestyle Modification Programs Focused
on Physical Activity and Dietary Habits Delivered in Community
Settings
Mark Stoutenberg & Katie Stanzilis & Ashley Falcon
# International Society of Behavioral Medicine 2014
Abstract
Background Lifestyle modification programs (LMPs) can
provide individuals with behavioral skills to sustain long-
term changes to their physical activity (PA) levels and dietary
habits. Yet, there is much work to be done in the translation of
these programs to community settings.
Purpose This review identified LMPs that focused on
changing both PA and dietary behaviors and examined
common features and barriers faced in their translation to
community settings.
Methods A search of multiple online databases was conduct-
ed to identify LMPs that included participants over the age of
18 who enrolled in LMPs, offered in community settings, and
had the goal of improving both PA and dietary behaviors. Data
were extracted on participant demographics, study design
characteristics, and study outcome variables including chang-
es in PA, dietary habits, body weight, and clinical outcomes.
Results We identified 27 studies that met inclusion criteria.
Despite high levels of retention and adherence to the interven-
tions, varying levels of success were observed in increasing
PA levels, improving dietary habits, reducing body weight,
and improving clinic outcomes.
Conclusion LMPs addressing issues of PA and dietary
habits can be successfully implemented in a community
setting. However, inconsistent reporting of key compo-
nents in the translation of these studies (participant re-
cruitment, utilization of behavioral strategies) may limit
M. Stoutenberg (*) : K. Stanzilis : A. Falcon
Department of Public Health Sciences, University of Miami, 1120
NW 14th Street, Suite 1008, Miami, FL 33136, USA
e-mail: mstoutenberg@med.miami.edu
A. Falcon
Department of Wellness and Recreation, University of Miami, Coral
Gables, FL, USA
their replication and advancement of future programs.
Future efforts should better address issues such as iden-
tifying barriers to participation and program implementa-
tion, utilization of community resources, and evaluating
changes across multiple health behaviors.
Keywords Translation . Physical activity . Dietary habits .
Implementation . Lifestyle modification
Introduction
In recent decades, there has been a shift in the disease burden
from infectious to noncommunicable diseases (NCDs) as
result of various interrelated factors including the following:
an aging population, the introduction of new technologies,
advancements in medicine and public health, and changes in
diets and lifestyles [1, 2]. NCDs are on the rise and are now
documented as the leading cause of mortality globally [3]. In
the USA, seven in ten deaths were attributed to NCDs [4]
accounting for an estimated economic burden as high as $1.1
trillion after assessing for lost productivity and treatment [5].
According to the Centers for Disease Control and Prevention
(CDC), the treatment of NCDs accounts for approximately
75 % of national health care expenditures [5]. Health systems
are not equipped to deal with this growing burden of chronic
illness that requires years of ongoing care [6]. The alarming
growth of NCDs has catalyzed discussions across all levels of
society on solutions and best practices for containing or mit-
igating this epidemic [79].
Prevention strategies have been successfully used to alle-
viate disease burden and improve general well-being [10, 11].
Efforts in cancer prevention, for example, have decreased
overall morbidity and long-term health care costs through
screening and early treatment [12, 13]. However, NCDs
resulting from unhealthy lifestyles, such as poor diet and

Fig 1 Flow diagram of the initial
study search in the PubMed
electronic database
Articles met all
search criteria
1 Randomized
Control Trial
physical inactivity, pose a new and growing challenge to
conventional prevention strategies. Dietary habits and physi-
cal activity (PA) are two key modifiable risk factors that can
have a significant impact on reducing NCDs [1416]. The
promotion of PA and improved dietary choices are highlighted
as two of the best buy strategies in the World Health
Organizations 20082013 Action Plan for the Global Strate-
gy for the Prevention and Control of NCDs [17]. These
modifiable risk factors are highly associated with obesity,
which in turn is associated with diabetes, cardiovascular dis-
ease (CVD), and other leading causes of mortality and mor-
bidity [18]. According to Prevention for a Healthier America,
an investment of $10 per person in proven community-based
programs can yield a $16 billion savings annually [19]. Thus,
prevention strategies aimed at reducing rates of NCDs provide
an important alternative to rising health care costs while
improving quality of life.
There have been numerous approaches utilized in var-
ious settings that target the prevention of NCDs through
weight loss, PA promotion, healthy eating, or a combina-
tion of these components. The Diabetes Prevention Pro-
gram (DPP) serves as a landmark study linking weight
loss, dietary modifications, and increased PA to a reduc-
tion in the incidence of diabetes [20]. Other large clinical
trials, such as the Trial of Nonpharmacologic Interven-
tions in the Elderly (TONE; [21]), the Dietary Approaches
to Stop Hypertension (DASH; [22]), the PREMIER trial
[23], and the Look Ahead trial [24] have provided en-
couraging evidence of similar approaches to primary dis-
ease prevention or treatment. Together, these trials have
Int.J. Behav. Med.
2,171
Articles in initial
PubMed search
181 1,990
Articles after applying Didnt have any of the
MESH terms in PubMed MESH terms
41 140
Articles after Articles didnt meet
group review search criteria
17 24
Articles didnt meet
search criteria
5 Quasi- 11 Single
Experimental Studies Arm Trials
shown that, in a controlled environment, significant pos-
itive health outcomes can be attained through lifestyle
modification. However, many of these studies were con-
ducted in time and resource intensive settings among
highly selective populations with limited generalizability,
rendering the results less conducive to real world envi-
ronments [25, 26]. The challenge then remains translating
the results from these clinical trials to large-scale, popu-
lation health practices.
Several individuals and organizations have suggested
that the community setting can be a prime location for
lifestyle modification programs (LMPs) and the translation
of evidence-based practices into real world settings across a
wide and diverse population of individuals [27, 28]. Anal-
ysis of models utilizing behavior change strategies for the
reduction of NCDs suggests that these LMPs can be imple-
mented in a cost-effective manner in community-based
settings [29, 30]. Furthermore, the use of behavioral strat-
egies provides individuals with the skills and techniques to
sustain changes in their diet and activity levels over an
extended period of time. Nonetheless, there is still much
work left to do in the implementation of these LMPs within
the context of existing community resources, opportunities,
and constraints. Therefore, the objectives of this review are
to: (1) identify studies that have attempted to implement
evidence-based LMPs, (2) examine common components
and strategies used by these LMPs, (3) identify barriers
faced during the implementation of these LMPs, and (4)
provide suggestions for the implementation of future
community-based LMPs.
Int.J. Behav. Med.
Methods
Data Sources
A comprehensive search of the PubMed database was con-
ducted between June and December 2012. The initial search
of published literature included combinations of several key-
words (lifestyle modification, behavior, community, research team, 41 articles were selected for full review by each
community-based, interventions, programs, physical team member, from which a total of 17 were selected for
activity, and nutrition) and medical risk factors and comor- inclusion in the review. A review of the references used in
bidities (obesity, diabetes mellitus, cardiovascular dis- these articles led to the inclusion of four additional studies.
ease, blood pressure, metabolic syndrome). In addition, Finally, the most recent database search using the Ovid
other sources of candidate studies, including reference lists of
relevant articles and reviews, were referenced to identify any
studies that were missed. An additional search of literature
published since our original review was conducted in July
2014 with the previously employed search strategy in the
Ovid MEDLINE and Scopus online databases to ensure com-
prehensive retrieval of eligible studies.
Study Selection
The following criteria were used to determine inclusion in the
study: (i) publications were written in English, (ii) studies
involved participants over the age of 18, (iii) participants were
engaged in group-based LMPs offered in community settings,
(iv) interventions that utilized behavioral counseling as a
primary component of the LMP, and (v) LMPs that focused
on changing both PA and dietary behaviors. Exclusion criteria
included the following: (i) reviews or meta-analyses; (ii) stud-
ies utilizing technology (i.e., cell phones, internet-based pro-
grams) to deliver the intervention; and (iii) studies deemed not
to have taken place in a community setting, such as worksite
wellness programs or those that were performed in a clinical
setting or primary care settings. Studies that were hosted or
utilized space at health care settings or worksites, but were not
a direct part of integrated care or a program offered through
these sites, were included. Since the focus of this review was
to identify programs that promoted self-managed behavioral
and lifestyle changes, studies that included structured or pre-
scribed exercise training and/or diet programs were not in-
cluded. Finally, given the growing and diverse field of tech-
nological innovations being tested in program implementa-
tion, we chose to exclude studies that utilized technology as
the primary delivery tool, but did not exclude studies that used
technology to support the in-person, group-based LMP. We
elected not to apply traditional standards for assessing study
quality, many of which are used in determining research
validity and the existence of causal relations [31, 32], to the
studies selected in this review due to the multiple complexities
involved in implementing community-based LMPs, many of
which are not covered under previously established criteria
[33].
An initial review of the PubMed database identified 2,171
studies for further review (Fig. 1). Of these 1,943 studies, 181
were selected based on relevant key MESH terms. The rele-
vance of these studies was further assessed by each team
member who independently examined the title and abstracts
of these articles to determine which ones appeared to meet the
pre-determined inclusion criteria. Following consensus of the
MEDLINE and Scopus online databases led to the identifica-
tion of an additional five studies. In reviewing the articles
referenced within these five studies, one final study was
identified for inclusion.
Data Extraction
The following study characteristics were extracted from the
original studies including: participant demographic informa-
tion such as age and gender, individuals who delivered the
intervention and the level of training that they received, loca-
tion of the community setting, participant recruitment strate-
gies, the length (number of weeks) and intensity (hours per
week) of the LMP, and post-program follow-up support. Next,
data on behavior change models and strategies and the fol-
lowing study outcomes were extracted by members of the
research team: participant adherence and retention rates, as-
sessment of PA and dietary habits and the changes seen in
these variables postintervention, weight loss, clinical out-
comes including lipid, blood sugar, triglyceride, and hemo-
globin A1c concentrations, as well as barriers to the imple-
mentation of the LMP. All investigators assisted in the data
extraction process and collection of reports. Disagreements
were resolved by consensus of the group.
Results
The review process resulted in 27 articles that were deemed
acceptable for inclusion. Table 1 presents the basic character-
istics of the studies included in this review. Studies were
categorized into one of three categories based on their research
design: (a) single-arm trials with no comparison group, (b)
quasi-experimental trials that utilized a comparison group, and
(c) randomized controlled trials. Data extracted from these
trials included descriptive information on the study setting,
recruitment techniques, personnel and training, program char-
acteristics such as the intensity of the intervention (frequency
and duration of intervention sessions), descriptive character-
istics of the study participants, and study outcomes on changes

Table 1 Key features of cognitive behavioral, lifestyle modification
programs included in review. min minute, hr hours, wk week, mo(s)
month(s), yo years old, yrs years, kcal kilocalorie, lb(s) pound(s), BMI
body mass index, BP blood pressure, CBPR community-based participa-
tory research, CHIP Coronary Health Improvement Project, CVD cardio-
vascular disease, DE-PLAN Diabetes in Europe-Prevention using
in body weight, clinical outcomes (blood pressure, lipid con-
centrations, fasting blood glucose), psychosocial variables, PA
levels, and dietary habits.
Description of the Selected Studies
Of the 27 studies selected for this review, 14 were classified as
single-arm trials that did not use a comparison group. Seven of
these single-arm trials were considered feasibility or pilot
studies [3440], three were classified as translation studies
[4143], and the remaining four were considered implemen-
tation studies across a larger (or multiple) communities or
cities [4447]. Five studies were categorized as quasi-
experimental studies: two pilot studies [48, 49], one transla-
tion study [50], one implementation trial [51], and one com-
parative effectiveness trial in which one arm involved the
translation of an evidence-based LMP in a community setting
[51]. Of these studies that used a quasi-randomized design,
Int.J. Behav. Med.
Lifestyle, Physical Activity and Nutritional Intervention, DPP Diabetes
Prevention Program, GLB Group Lifestyle Balance, HbA1c hemoglobin
A1c, MetS metabolic syndrome, NHOPI Native Hawaiian and other
Pacific Islanders, NIH National Institutes of Health, PA physical activity,
PREDIAS Prevention of Diabetes Self-Management Program, T2D type 2
diabetes
control subjects were recruited from secondary sites or com-
munities that were not selected for the intervention [4850,
52] or through participant self-selection to the control arm
[51]. Finally, of the randomized controlled trials, three were
considered feasibility or pilot studies [5355], while the other
five focused on translation of evidence-based LMPs [5660].
These studies allocated participants to comparison groups that
had delayed or wait-list controls [53, 56], provided informa-
tion via written materials [58], basic general education [54,
60], or used a form of usual care [55, 57, 59]. Five of the
studies included in this review employed community-based
participatory (CBPR) methodologies in tailoring their pro-
grams to the local communities [34, 38, 40, 42, 53].
Collectively, six studies targeted individuals with at least
one CVD risk factor or individuals with an elevated risk of
CVD [37, 44, 45, 49, 56], five targeted overweight/obese
individuals [3840, 42, 52], as well as cancer survivors [55]
and individuals with the metabolic syndrome [43]. Two
Int.J. Behav. Med.
Table 1 (continued)
studies did not specify the disease or risk factor(s) that they
targeted [47, 60]. The remaining 12 studies were targeted to
prediabetic individuals or those who were considered at high
risk for diabetes. Four studies in this review were conducted in
Europe [46, 55, 58, 60], one was conducted in Japan [51], and
the remaining studies took place in the USA.
Characteristics of the Community Setting, Delivery
Personnel, and Staff Training
The majority of the studies in this review were conducted in
local community centers and churches. Other community
locations that were used included meetings in home settings,
community worksites, and senior centers. Eight studies did
not specify where in the community setting their study was
conducted [43, 45, 5153, 55, 56, 58]. There was a great deal
of variability in the personnel who delivered the LMPs. Com-
monly used personnel included registered dietitians [39, 43,
46, 57], diabetes educators [41, 58], research team members
[49, 60], study nurses or nurse educators [35, 39], volunteer
medical staff [36, 51], psychologists [58], and exercise
physiologists [43]. In ten cases, local community resources,
such as community [42, 44, 48, 50, 54] or church [38] staff, as
well as volunteers from the community [34, 47, 52, 59], were
utilized. Commonly used staff training methods included ei-
ther the 2-day intensive Coronary Health Improvement Pro-
ject (CHIP) training protocol [37, 45, 47], a 2-day intensive
group lifestyle balance training program for diabetes preven-
tion [39, 41, 43, 52], or the 2-day Fit Body and Soul training
[38]. One study conducted their staff training over a 2.5-day
time period [48], and three others conducted extensive train-
ing with their community health workers and volunteers [34,
42, 59]. Twelve studies did not report training procedures used
with their intervention staff [35, 36, 40, 44, 46, 4951, 54, 55,
58, 60].
Description of Program Participants
Eighteen studies enrolled participants with a mean, or median,
age between 50 and 65 years, five enrolled participants be-
tween the ages of 4050 years [3840, 53, 60], while two
other studies enrolled participants with a mean age less than

Table 1 (continued)
40 years [42] or greater than 65 years of age [49]. Two studies
did not report the mean age of their participants [35, 50]. Ten
studies had a female enrollment between 60 and 80 %, nine
others had a female enrollment greater than 80 %, and two
studies recruited exclusively females [55, 60]. Only three
studies had a male enrollment rate greater than 40 % [49, 57,
58].
Participants were recruited through a variety of methods with
11 studies reporting the use of more than one recruitment
strategy. The most commonly used strategies included the fol-
lowing: local TV and newspaper ads [40, 41, 43, 44, 52, 59],
newsletters and flyers [34, 40, 41, 46, 49, 52, 54], advertise-
ments in physician offices and physician referrals [41, 46, 47,
54, 57, 59], promotion to church groups [3436, 38, 43, 44, 54],
health fairs and information sessions [39, 42, 49, 57, 60], direct
postal mailings [41, 48, 51, 55, 57], and worksite recruitment
[44, 46, 57]. Nineteen of the studies included in this review
provided comprehensive details of their recruitment efforts,
including the total eligible population, numbers of individuals
prescreened and screened for study eligibility, the number eligi-
ble, and those who agreed to participate in the study.
Int.J. Behav. Med.
Program Characteristics, Adherence, and Retention
The majority of studies included in this review conducted their
program sessions either weekly [3436, 38, 39, 41, 44, 5255,
57] or one to three times per month [40, 42, 43, 48, 51, 58, 59].
Four other studies, those using the CHIP program [37, 45, 47,
56], conducted sessions more frequently than one time per
week, while two studies conducted their intervention sessions
less than once per month [46, 60]. One other study allowed the
community health advisors to tailor the number and frequency
of sessions to their participants needs [50]. Fourteen of the
studies in this review consisted of program interventions
lasting 6090 min, six were greater than 90 min [37, 45, 47,
51, 54, 56], and six did not report the duration of their program
sessions [35, 40, 46, 50, 55, 57, 60]. Seven programs offered
additional 36 monthly booster sessions after the conclusion
of the main intervention program [39, 41, 42, 44, 48, 49, 54],
and two studies conducted bimonthly follow-up sessions for
the subsequent 9 [51] and 18 months [57]. Six other studies
did not conduct booster sessions, but did assess the long-term
impact of the program three or more months after the end of
Int.J. Behav. Med.
Table 1 (continued)
the intervention [35, 36, 43, 53, 55, 59]. The remaining 12
studies did not conduct follow-up sessions or assessments [34,
37, 38, 40, 4547, 50, 52, 56, 58, 60].
A wide range of participant retention was reported across
the studies included in this review. Two studies reported
dropout rates between 0 and 5 % [36, 45], six studies reported
a rate between 6 and 10 % [35, 37, 5659], eight reported rates
of 10 and 20 % [38, 39, 41, 44, 49, 52, 53, 55, 60], three
reported rates between 20 and 30 % [43, 48, 51], and five
reported dropout rates greater than 30 % [34, 42, 46, 50, 54].
Two studies did not report participant retention levels [40, 47].
High levels of program adherence, defined as attendance at
70 % or more of the primary intervention sessions, were
reported in nine studies [35, 37, 39, 41, 44, 49, 52, 56, 57].
Twelve studies did not report participant attendance levels [38,
40, 43, 45, 47, 50, 51, 5355, 58, 60].
Behavior Change Theories and Constructs
Nine of the studies in this review reported one or more
established behavior change theories or models, including
the Health Belief Model, Self-Management Theory, Social
Action Theory, and Social Learning Theory. Twenty-two
of the studies mentioned one or more behavioral con-
structs, many of which were not discussed in the context
of an associated theory. Self-monitoring (of food intake,
PA, or body weight) was the most commonly discussed
construct followed by goal setting and problem-solving.
Additionally, perceived barriers, social support, perceived
benefits, and stimulus control were frequently indicated,
largely through referencing the rationale and key features
of the DPP Intensive Lifestyle Intervention [61]. Six
additional constructs that were not mentioned, but were
alluded to in the studies, included the following: behav-
ioral capacity, consciousness raising, counterconditioning,
decisional balance, emotional coping responses, and self-
liberation. Five of the reviewed studies did not mention or
directly reference any behavior change theories or con-
structs [37, 41, 4547]. Behavioral theories, models, and
constructs were included whether they were discussed
directly within the current article or were referred in a
previously published study or article. A breakdown of

Table 1 (continued)
theoretical models and behavioral constructs used in the
selected studies can be found in Table 2.
Barriers to Implementation of the Lifestyle Modification
Programs
Four studies directly assessed (i.e., through surveys, indi-
vidual interviews, or focus groups at the conclusion of the
program) and reported barriers that affected the implemen-
tation of their LMP [34, 53, 55, 59]. Barriers that were
identified in these studies included the following: high
rates of illiteracy, time requirements and the burden of
the program on the participants, scheduling issues and
competing interests in the lives of the participants, partic-
ipant satisfaction with the LMP, difficulties conducting the
study assessments, and maintaining fidelity to the LMP
curriculum by the group leaders, especially the community
health workers and volunteers. Several other investigators
discussed the barriers, as well as the strengths, of their
respective studies, but did so primarily within the context
of explaining their study outcomes. Two additional studies
Int.J. Behav. Med.
provided information on the cost of implementing their
program [35, 41].
Physical Activity and Dietary Outcomes
Sixteen of the 27 studies included in this review assessed
and reported changes in PA and/or physical fitness.
Among these studies, four [39, 41, 44, 58] used a form
of self-monitoring (i.e., PA logs), 10 utilized a variety of
self-report questionnaires [34, 39, 40, 42, 45, 49, 51, 53,
59], two included the use of daily step counts [51, 56],
one used a PA recall log [50], and another performed
physical fitness testing (6-min walk test; [40]). The dif-
ferent self-report questionnaires included the following:
the Global PA Questionnaire [53], the International PA
Questionnaire Short Version (IPAQ-Short; [42]), the Rap-
id Eating and Activity Assessment for Patients (REAP;
[49]), the Godin Leisure Time Questionnaire [55], a
modified DPP PA questionnaire [39], an exercise fre-
quency questionnaire [45], three unspecified self-
administered questionnaire [34, 40, 51], and information
Int.J. Behav. Med.
Table 1 (continued)
collected as a part of a 24-hr dietary recall [59]. Overall,
the majority of these studies reported significant in-
creases in PA, or physical fitness, with participants
attaining a range of 52.570 % of PA goals. Four studies
reported no changes in the following: (a) leisure or total
daily PA [34, 53, 59] or (b) female participants meeting
PA study goals [51]. Of the five studies that employed a
control group, two reported a significant interaction be-
tween the intervention and control conditions [55, 58].
Fifteen of the 27 studies included in this review assessed
and reported dietary modifications. Of the studies that
assessed dietary changes, ten used self-report questionnaires
[38, 40, 45, 4951, 53, 54, 56, 58], three used self-monitoring
food logs [41, 44, 55], and two others used the 24-hr dietary
recall [39, 59]. The different self-report questionnaires includ-
ed the following: the Three-Factor Eating Questionnaire [58],
the full length Block 98 [56], the REAP [49], the Diet Habits
Questionnaire [38], a Food Frequency Questionnaire [42],
two used self-monitoring food logs [41, 44], an Eating Habit
Questionnaire [40], two used self-monitoring food logs [41,
44], a Lifestyle Nutrition Test [45], and unspecified self-
administered questionnaires [51, 54]. All but one study [51]
found improvements in the dietary outcomes that were
assessed. However, of the nine studies that employed a control
group and assessed dietary habits [4951, 5356, 58, 59], only
one reported significant decreases in fat intake [59] while
another reported an increase in green salads and a decrease
in sugar-sweetened beverages [53] between study groups.
Weight Loss Outcomes
Only one study did not assess changes in body weight or
composition [49]. Four studies reported a mean weight
loss of 02.49 kg [40, 42, 46, 53], seven reported a mean
weight loss of 2.504.99 kg [35, 36, 39, 47, 54, 55, 58],
and five others reported a mean weight loss of 5.07.5 kg
[41, 44, 48, 52, 57]. There was a similar distribution of
changes in BMI. The remaining studies reported individ-
uals achieving study goals [43], changes in body mass
index (BMI) only [56, 60], number of participants that
met different levels of percentages of weight change [38,
59], or reported results by gender only [37, 45, 51]. Only
two interventions did not result in significant changes in
body weight or BMI [34, 50]. Nine studies assessed waist
circumference (WC; [3943, 46, 47, 54, 58]). Seven re-
ported significant improvements [39, 41, 42, 54, 58],
particularly in those with an unhealthy WC [43] or in
those who achieved a healthy WC [47], while two
reported nonsignificant changes over the course of the
intervention [40, 46]. Finally, one study assessed, but
did not observe, significant changes in body fat percent-
age in comparison to their control group [51]. Of the 12
 Int.J. Behav. Med.

Table 2 Use of theoretical models and behavioral constructs in selected studies

# Directly discussed Relevant articles # Indirectly Relevant articles

(frequency) referenceda
Theoretical models

Continuous Care Problem- 0 1 (57)

Solving Model
Health Belief Model
Maxwells 5 M training model
Patient-Centered Counseling
Model
Self-Efficacy Theory
Self-Management Theory
Social Action Theory
Social Cognitive Theory
Social Learning Theory
Behavioral Constructs
Cognitive Restructuring
Empowerment
Goal Setting
Locus of Control
Outcome Expectations
Perceived Barriers
Perceived Benefits
Perceived Severity
Perceived Susceptibility
Problem-Solving
Relapse Prevention
Self-Efficacy
Self-Esteem
Self-Monitoring
Social Support
Stimulus Control
a
Theories and/or constructs that are referenced in previously published work but not directly discussed in the current article. Current articles that directly
discussed and referenced other work were only counted in the directly discussed category
1 (39) 0 .
1 (34) 0
2 (54,59) 0 .
1 (53) 0 .
1 (58) 0 .
0 1 (49)
3 (54,55,59) 1 (57)
0 1 (39)
0 1 (57)
1 (60) 1 (53)
9 (35,39,40,48,49,51,55,57,59) 10 (34,36,38,41-44,50,52, 55)
1 (58) 0 .
0 . 1 (57)
2 (43,52) 12 (35,36,38,39,42,44,48,49,50,53,54,57)
1 (39) 13 (35,36,38,40,42-44,48-50,52,54,57)
0 1 (39)
0 1 (39)
7 (39,40,48,49,54,57,59) 11 (35,36,38,42-44,50, 5255)
1 (55) 14 (35,36,38,39,40,42-44, 4850,52,54,57)
4 (5355,59) 1 (57)
0 . 1 (53)
11 (35,39,40-43,48,49,52, 55,59) 8 (34,36,38,44,50,53,54,57)
3 (35,50,54) 11 (36,39,40,42-44,48,52, 53,57,59)
0 14 (35,36,38,39,40,42-44, 4850,52,54,57)

studies that used control groups and assessed changes in mentioned in six other studies, but the results were not report-
body weight or BMI, seven reported significant between- ed [39, 42, 45, 52, 56, 57].
group interactions [48, 5153, 5759].

Psychosocial Outcomes
Only three studies in this review assessed and reported psy-
chosocial outcomes [50, 58, 59]. The psychosocial variables
that were assessed and reported included anxiety (The State-
Trait Anxiety Inventory; [58]), depression (Center for Epide-
miologic Studies Depression scale; [58, 59]), social support
[50], and general well-being (WHO-5 Well-Being Index;
[58]). In only one case was there a significant decrease in
anxiety compared to the control group [58]. Different psycho-
social outcomes (stress levels, quality of life, physical and
mental functioning, barriers to PA, and healthy eating) were
Clinical Outcomes
Of the 27 studies selected for this review, only six did not
measure or report any clinical outcomes [38, 39, 42, 44, 50,
55]. Seventeen studies assessed changes in fasting blood
glucose (FBG) concentrations. One other study completed a
comprehensive assessment of changes in FBG, hemoglobin
A1c, and oral glucose tolerance [60]. Of the studies that
assessed changes in FBG, 11 showed significant improve-
ments over the course of the intervention [35, 36, 37, 41, 45,
46, 47, 51, 57, 58, 60]. Of the eight studies that employed a
control condition, only three reported significant between-
group differences in FBG [57, 58, 60] with a fourth reporting
Int.J. Behav. Med.
significant between-group changes in only the female partic-
ipants [51]. Of the five studies that examined hemoglobin A1c
levels [48, 51, 53, 5860], two reported significant reductions
in their participants [51, 59].
Fourteen studies did not assess or report changes in cho-
lesterol concentrations [3436, 3840, 42, 44, 49, 50, 54, 55,
57, 59]. Of those that did, a total of nine studies reported
varying levels of improvements in cholesterol levels while
four others reported no significant changes as a result of the
intervention [43, 51, 53, 60]. Four studies reported significant
reductions in LDL concentrations [37, 41, 45, 46] while three
studies reported no significant improvements in LDL concen-
trations [46, 51, 53]. Two studies reported significant changes
in high-density lipoprotein (HDL) concentrations [37, 58]
while six other studies reported no improvements in HDL
concentrations [41, 43, 46, 48, 51, 60] and three others report-
ed significant decreases [47, 52, 56]. Of the nine studies that
examined changes in triglyceride concentrations, six reported
significant decreases [37, 41, 45, 47, 56, 58], while three
others reported no significant changes [46, 51, 60]. Of the
seven studies [28, 5153, 56, 58, 60] that used a control group
and assessed participant lipid profiles or triglyceride concen-
trations, only one noted significant between-group changes in
total cholesterol concentrations [28].
Of the 27 studies included in this review, seven did not
assess or report changes in blood pressure (BP; [38, 39,
42, 44, 50, 54, 55]). Nine studies reported varying levels
of improvements in systolic BP [3537, 40, 41, 45, 46,
49, 58] and ten studies reported varying levels of im-
provements in diastolic BP [3537, 40, 41, 45, 49, 51,
58, 60]. Two studies did not report absolute changes, but
did mention a significant decrease in the proportion of
individuals who were hypertensive [43, 52], while two
others reported decreases across ranges of BP [47, 56].
Only three studies did not report significant improvements
in either systolic or diastolic BP [34, 48, 53]. Of the eight
studies that employed a comparison group, only one re-
ported a significant improvement in systolic BP in men
compared to the control condition [51].
Discussion
Substantial efforts and resources have been dedicated toward
conducting efficacy trials that investigate the health benefits of
LMPs [62, 63]. However, efforts to translate and implement
these evidence-based programs into real-world settings have
lagged far behind [64]. In this review, we identified 27 studies
that implemented LMPs in community settings focusing on
changing both the PA and dietary behaviors of the partici-
pants. In the following, we discuss key methodological
characteristics of these studies and provide recommendations
for future efforts.
Study Design, Characteristics, and Participants
The types of studies in this review varied both in study design
(i.e., single arm, quasi-experimental, randomized control trial)
and the purpose of the study (i.e., serving as a feasibility or
pilot trial). There was a great deal of heterogeneity of the
studies included in this review as several were conducted as
pilot studies examining the feasibility of conducting larger
implementation trials [35, 36, 39, 43, 48], others examined
the translation of evidence-based programs, such as the DPP,
to community settings [41, 51, 52], while others were con-
ducted as implementation programs across several communi-
ties [37, 44, 45, 47]. This heterogeneity leads to varying
implementation procedures and methods of program
evaluation.
Within the studies selected, multiple strategies were
employed for participant recruitment, often varying by the
location of the program (i.e., programs adapted for church
versus community settings). Given the difficulty of participant
recruitment often experienced by most investigators [65], we
found it interesting that only ten studies used multiple recruit-
ment strategies. Furthermore, most of the studies enrolled a
high proportion of female participants, presenting an oppor-
tunity for future studies to concentrate on better engaging
male participants. Greater discussion of recruitment strategies,
as well as lessons learned during this process, may help future
studies employ more effective strategies in engaging commu-
nity members. Similarly, few studies in this review discussed
steps taken to adapt their study to the local community. Stud-
ies that adapted their intervention for the local community
setting typically employed one of two techniques; the inter-
vention was modified by the research team to fit the local
context in which it was delivered [36, 49] or the research team
hosted focus groups with community members and/or worked
with the local community leaders who assisted in its cultural
adaptation [34, 39, 40, 42, 44, 53, 59]. Given that the end goal
of implementation research is to ensure that evidence-based
LMPs are acceptable to the local community, we feel it is
imperative that community members and leaders are involved
in the adaptation process.
Participant Retention and Adherence
One encouraging finding of this review was that most of
studies reported high levels of participant retention and adher-
ence to the interventions. We identified three main formats for
the delivery of the program materials: studies that followed a
more traditional weekly intervention schedule (similar to the
DPP), those that decreased the number and frequency of
intervention sessions (biweekly or less), and those that

delivered their curriculum in an intense format over a short
period of time, usually over several weeks. Retention rates
varied equally among the different implementation formats
(i.e., daily, weekly, or bimonthly sessions) from those that had
high levels (>90 %) to those that had dropout rates as high as
one third of all participants. However, few studies reported
participant barriers that contributed to participant loss to
follow-up and low retention levels, information that could be
of great usefulness in the translation of future LMPs. Similar-
ly, participant attendance rates appeared to vary among the
different studies, independent of the delivery and intensity of
the program. However, few studies directly assessed levels of
participant adherence and the resulting impact on study out-
comes. This information may prove to be critical in a future
pooled analysis for determining the optimal number (or
threshold) of sessions to achieve meaningful results. Given
the challenges of translating evidence-based LMPs in a real-
world setting, this information is crucial, and efforts should be
made to assess the factors influencing participant adherence
and retention to better inform future studies.
This review focused primarily on the implementation of
the LMP and changes seen at the end of the intervention
phase. However, tracking of long-term behaviors and out-
comes is an area that should also receive greater attention.
While many studies performed assessments several months
after the end of the intervention to observe the long-term
impact of their program, less than half of these studies pro-
vided ongoing follow-up sessions for their participants. To
ensure long-term maintenance and determine the sustainabil-
ity of these LMPs, research teams should consider frame-
works that provide program graduates with continuing
support and reassess maintenance of study outcomes on a
long-term basis.
Utilization of Behavior Change Strategies
The use and reporting of behavioral theories employed in the
implementation of LMPs are of critical importance. While a
majority of the studies in this review did refer to using behav-
ior change methodologies, few provided details on how these
theories and/or constructs were formally integrated into their
program or clearly outlined the role of these strategies and
how they matched with program activities. Baker et al. [66], in
a review of DPPs, found that of the 95 studies reviewed, few
directly specified a behavioral theory that underpinned their
approach. Given that the goal of the programs in this review
was to elicit change through behavioral processes, and not just
the prescription of exercise or diet regimens, these studies
should be grounded in a theoretical frameworks customized
for each community setting.
Furthermore, few of the studies in this review examined
changes in behavioral attitudes or mechanisms responsible for
the observed behavior changes. It may be particularly useful
Int.J. Behav. Med.
for future studies to explicitly examine changes in specific
social cognitive processes of the participants (i.e., increases
in self-efficacy). Identifying these meditators will also bet-
ter inform future studies as to which behavioral strategies
may be the best avenue for allocating their time and re-
sources. Employing existing behavior change taxonomy
[67] to systematically quantify and report the behavior
change techniques utilized in an LMP will also allow for
greater replication of successful strategies and comparison
across studies.
Study Outcomes
Given that studies in this review were selected because of their
emphasis on modifying PA levels and dietary habits, it is
surprising that few directly measured changes in these behav-
iors, instead focusing primarily on weight loss and clinical
outcomes. Studies that did assess changes in PA and dietary
habits used a wide variety of assessments, several of which
have not been validated or were not fully described. Although
conducting objective measures of PA levels or more detailed
measures of dietary intake may not be feasible in large imple-
mentation trials, multiple dietary [68, 69] and PA [70, 71]
assessment measures have been validated for use in popula-
tion studies, as well as various measures to assess cardiore-
spiratory fitness adapted for use in community settings
[7274]. The utilization of basic and commonly used self-
report questionnaires is necessary in providing useful infor-
mation as to the direct impact of these programs, as well as
mediators that account for observed changes in body weight,
clinical outcomes, and disease status.
The assessment of changes in BMI and/or body weight was
common across nearly all of the studies in this review. While
changes in BMI and body weight have been traditionally
measured as an indication of health risk, we suggest that future
investigations consider the role of other key mediators, such as
cardiorespiratory fitness [75]. Additionally, we recommend
that all future studies consider assessing WC given its ease
of measurement, low cost, and its growing importance in
determining future health risk [76].
Finally, the majority studies included in this review collect-
ed a standardized set of clinical outcomesmost notably
FBG, BP, and cholesterol concentrations. Standardization in
the collection and evaluation of FBG, BP, and cholesterol
concentrations allows for a greater level of comparison of
study results and pooling of results. However, despite the
relative ease and inexpensiveness of collecting these variables,
it is often difficult to administer them to a large number of
participants (i.e., need for specialized personnel, increased
cost, and time commitments) and may limit the desired reach
and impact of the LMP. While these variables certainly offer
greater detail into the impact of the intervention, future trans-
lation studies may be better served by collecting these
Int.J. Behav. Med.
outcomes, whenever possible, to supplement the changes in
PA levels, dietary habits, and changes in body weight and
WC.
Study Outcomes and Evaluation
The purpose of this review was not to provide a quantitative
analysis of study outcomes. However, it is important to note
that 65, 45, 69, and 92 % of studies included in this review
reported significant improvements in FBG, BP, total choles-
terol concentrations, and reductions in body weight, respec-
tively, providing evidence that translation of LMPs in a com-
munity setting can be effective in improving participant health
profiles. However, these studies lacked a common methodol-
ogy for assessing data collected and reporting it in a consistent
manner. For example, several studies did not report baseline or
post-intervention values, nor the magnitude of change across
the duration of the study. Instead, percentages of individuals
who demonstrated levels of change or those who met certain
guidelines or study goals were reported. We feel that it is
important that future studies follow a standard format that
includes: (a) reporting baseline and post-intervention values
of all participants, (b) presenting absolute levels of change
during the intervention, and finally (c) including additional
subgroup (i.e., gender) analyses.
Similarly, we feel that it is important to establish consis-
tency for determining the inclusion of participants in the final
analyses. Several studies analyzed the results of participants
who completed the program or attended a majority of the
sessionsthereby skewing their results by not including
noncompleters or nonadherent individuals, both key factors
with implementation studies. Other studies included all of the
individuals who enrolled in the program, regardless of their
participation level or completion status, providing a potential-
ly very different series of results. One potential strategy is to
conduct primary analyses of all participants who enroll in the
LMP (similar to intent-to-treat strategies commonly used in
randomized control trials), using secondary analyses to pres-
ent differences in various subgroups, such as program
completers.
Last, we found that there was a wide range of control
conditions employed in the studies included in our review.
In many cases, the use of a comparison group may be neither
feasible nor practical due to logistical reasons. Fifty-two per-
cent of our studies, many of them in the early stages of
intervention development, did not employ comparison
groups. When feasible, the use of comparison groups can
provide several benefits, such as accounting for natural dete-
rioration of health outcomes due to aging or seasonal varia-
tions over a prolonged study period. For example, in the study
conducted by Fernandez et al. [49], participants in the treat-
ment arm did not increase their PA levels. However, during
the same time period, those in the comparison group
significantly reduced their PA, which was attributed to the
aging process. For those studies that do include a comparison
group, it is important that appropriate statistic methodology is
used to examine the interaction effects between intervention
and comparison groups. This was not the case for several
studies that reported results for within-group differences, but
not the interaction effect with their control participants.
Barriers to Program Implementation in Community Settings
One area of concern identified in this review is a lack of a
formal assessment and reporting of barriers in translating the
LMPs to community settings. While several studies conducted
focus groups, worked with community advisory boards, and
collaborated with local coalitions in culturally tailoring the
intervention prior to the study, few performed systematic
evaluations after the actual implementation of the program.
These post-intervention evaluations could include the assess-
ment and reporting of the following: challenges to participant
recruitment, barriers that contribute to low study adherence or
retention levels, difficulties working with the local communi-
ties, fidelity of the intervention using local volunteers as
leaders, and cultural barriers that may have limited the effec-
tiveness of the program. Several studies included in this
review discussed perceived facilitators for their interventions,
factors that included establishing strong partnerships with
local organizations and leaders, adapting the program to the
local community and culture, use of local study personnel
(i.e., community health workers). However, these facilitators
were not identified through a formal process and were, more
often than not, discussed in relation to the significant findings
(or lack of) reported in their study. Based on the findings of
this review, we recommend that future trials include in their
study planning a formal post-intervention assessments of the
program implementation with the participants, team leaders,
and community stakeholders through surveys, individual in-
terviews, and focus group sessions. Given the challenges of
translating evidence-based LMPs in a real-world setting, this
information is crucial and greater efforts should be made to
collect it to better inform future studies.
The present study has a number of limitations that should
be considered. First, as with most review articles, publication
bias remains a possibility. It is possible that other community-
based LMPs that did not experience significant improvements
that were not published, may provide important information
on the lessons learned in the translation of their program to
community settings. Additionally, it is possible that articles
that may have been eligible for this review were not identified
and retrieved during our literature search. Finally, 82 % of the
studies included in this review were conducted in the USA
suggesting either that few community-based LMPs are being
implemented around the world or that our literature review did
not adequately identify studies in other countries or that these

studies were not published in English. However, our intention
was not to provide an exhaustive search of all existing LMPs,
but rather to discuss key concepts related to common features
seen among these programs in their translation to community
settings.
Future Direction
Based on this review of LMPs conducted in a community
setting, we recommend several strategies that should be
employed in the future. First, more rigorous efforts should
be made in the collection and reporting of study-related infor-
mation (i.e.,recruitment strategies, participant adherence, out-
comes). Second, translational studies should have a greater
focus on assessing not only the success of the program, but
also the barriers to implementation and participation, both at
the individual and community levels. Third, we feel that future
studies should make greater efforts to utilize existing commu-
nity resources, such as local community centers and churches
(as site locations), established local communication networks
(for recruitment efforts), community leaders and stakeholders
(for study promotion and community acceptance), and local
personnel that may be more culturally competent in
implementing the program. Additionally, only a small number
of studies in this review discussed sharing their results with
the local community. Given the recommendation to increase
the involvement of local stakeholders and community leaders
at the onset of the study, investigators should, at a minimum,
strive to create a bidirectional flow of information that pro-
vides communities with the results of the studies and assis-
tance in the long-term sustainability of the program.
Fourth, although not discussed in this review, the use of
technology, such as text messaging [77], the Internet [78, 79],
and mobile phone applications [80], may play an important
role in future translation efforts and that evidence-based strat-
egies to incorporate these tools should be considered. Fifth,
we recommend that future investigators include more com-
prehensive evaluation frameworks, such as the Reach Effec-
tiveness Adoption Implementation Maintenance framework
(RE-AIM; [81]), that provides for a more comprehensive
assessment of the sustainable adoption and overall impact of
the implementation of their community-based program. Final-
ly, given page and word limitations of manuscripts, it may be
difficult for investigators to include all relevant information on
their study design and methodology in their main outcome
paper. Increasing the publication of methodoligical and lesson
learned papers may be particularly useful in describing key
intervention components, participant recruitment, staff selec-
tion and training, study setting, and adaptation of the inter-
vention. There needs to be a greater emphasis on making
public work describing the translation and implementation
of interventions, as well as lessons learned, to better inform
future program iterations.
Int.J. Behav. Med.
Conclusions
Translation research is a multifactorial process that engages
individuals and communities on several different levels; there-
fore, the evaluation schemes that are used should assess many,
if not all, of these processes [27]. Overall, our review revealed
that LMPs addressing PA and diet habits can be successfully
implemented in a community setting. Many programs includ-
ed in this review were successful in their efforts, despite
limited financial resources, by using existing community re-
sources and personnel. Even though many of the studies
included in this review were designed as translation or imple-
mentation trials, and not as highly controlled experimental
trials, a high-level scientific rigor should be maintained in
their design, implementation, evaluation, and reporting of
results. It is encouraging that large-scale implementation trials
focusing on LMPs are currently in progress in locations such
as the USA (CDC National DPP; [82]) and in Australia
(Sydney Prevention Program; [83]). However, more effort
and attention need to be dedicated to continuing the expansion
of implementing evidence-based LMPs as a direct form of
primary prevention in our communities.
Conflict of Interest Mark Stoutenberg, Katie Stanzilis, and Ashley
Falcon declare that they have no conflict of interest.
Ethical Standard All procedures followed were in accordance with the
ethical standards of the responsible committee on human experimentation
(institutional and national) and with the Helsinki Declaration of 1975, as
revised in 2000. Informed consent was obtained from all patients for
being included in the study.
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