In this episode of One Step Ahead, Brad Dieter, PhD breaks down the landmark Diabetes Prevention Program trial, where intensive lifestyle intervention outperformed metformin (58% vs. 31% risk reduction), the 21-year follow-up showing the effect still holds decades later, and independent replications from Finland and China. Then: why only about half of people in even the most structured version of this intervention hit their goals — and why the whole population still benefited anyway — and why cardiorespiratory fitness might be one of the strongest predictors of how long you live, even for people managing a chronic disease like type 2 diabetes.
Everyone assumes medication beats lifestyle change when it comes to preventing chronic disease. The data says otherwise — and it's not just one study.
In this episode of One Step Ahead, Brad Dieter, PhD breaks down the landmark Diabetes Prevention Program trial, where intensive lifestyle intervention outperformed metformin (58% vs. 31% risk reduction), the 21-year follow-up showing the effect still holds decades later, and independent replications from Finland and China. Then: why only about half of people in even the most structured version of this intervention hit their goals — and why the whole population still benefited anyway — and why cardiorespiratory fitness might be one of the strongest predictors of how long you live, even for people managing a chronic disease like type 2 diabetes.
Timestamps:
00:00 – Cold open
00:47 – The original DPP trial: lifestyle vs. metformin
03:35 – Does it last? The 21-year follow-up
05:26 – Global replication: Finland and China
07:42 – Why only half of people hit their goals — and it still worked
10:44 – Fitness as one of the strongest predictors of mortality
15:26 – What this means for you
References
Brad Dieter (00:00)
In a clinical trial that ran for three years and followed more than three thousand people at risk for type two diabetes, one group cut their risk of developing the disease by fifty eight percent. Another group, taking one of the most widely prescribed diabetes medications in the world, cut their risk by just thirty one percent. And the first group wasn't taking a drug, they were changing how they lived. And they had real structure behind it. And that's what most doctors never bring up, and that
Brad Dieter (00:29)
is we're talking about today.
Brad Dieter (00:47)
That study was the diabetes prevention program, and that study was actually published back in 2002. It had three thousand two hundred and thirty-four participants who were at high risk for diabetes. They had a mean age of about fifty-one and it was really they have a really good mix of kind of race, ethnicities, minorities, et cetera. and they were randomized into three arms the placebo, metformin, and lifestyle intervention.
Brad Dieter (01:13)
And so the headline results from that study, which was published in two thousand two, was that after a mean of about or an average of about two point eight, so almost three years, that the lifestyle arm reduced diabetes incidence, so the actual development of the disease, so this is where we're talking about prevention here, not you know, treatment, was about fifty-eight percent versus placebo, and metformin was about thirty-one percent versus placebo. And so even then, back in two thousand two, lifestyle was
Brad Dieter (01:42)
more effective than using metformin for prevention. Now what was really interesting too is that they actually stopped the trial early because the effect was so clear. And so, you know, when we think about what what we know about diabetes, and we're going to talk about this in more detail. I'm going to have a a guest on for a couple episodes here coming up. We'll dive more into, you know, kind of the the actual root causes of some of these chronic diseases. But
Brad Dieter (02:08)
What the lifestyle intervention really addressed was that it led to body weight reduction. So the lifestyle intervention, they their goal was to lose about seven percent of body weight with at least a hundred and fifty minutes per week of moderate activity, and they also did some nutrition interventions. And so the average weight loss ended up being about five point six kilos for the lifestyle group and about two point one kilos for the metformin group versus basically no change. It was like point one kilograms for placebo.
Brad Dieter (02:39)
And so what we see here is the lifestyle piece actually addresses the body weight way more than the medication does. Now, when we talk about kind of newer medications, that you know, more specifically address body weight, we'll talk about those later. But when we think about you know over the last twenty years, what has been the most effective thing for prevention of one of the biggest chronic diseases, which is type two diabetes, we see that lifestyle can be more effective. And this goes back to two thousand two.
Brad Dieter (03:05)
And so a different way to kind of frame this initial study, this original diabetes prevention program, was that in order to prevent kind of one case of incident diabetes over three years, only about seven people had to go through the lifestyle intervention program. But we needed about fourteen people to take metformin to get a reduction of one case of diabetes over, you know, the three-year period. And so that obviously leads to, you know, another question. You know, one is
Brad Dieter (03:35)
What is the long term outcome, right? Is it easier to just give somebody a medication and reduce risk, or is it as effective to have the lifestyle intervention? And so this was actually published within the last, you know, 18 months. there was a paper that was published in the Lancet Diabetes and Endocronology, and it was a twenty one year follow up of thirty two hundred almost of the original deep diabetes prevention program participants. And so what they found is that
Brad Dieter (04:02)
I mean, sure, over time as risk accumulates, that effect kind of fades, but it doesn't disappear. Right? At twenty-one years, lifestyle intervention still reduced diabetes development by twenty four percent versus placebo. and metformin by seventeen percent. So that's down from, you know, fifty eight and thirty one a year three, but there's still a real effect ten year or two decades later, excuse me. Now, kind of a a useful middle point.
Brad Dieter (04:29)
From the tenure combined kind of follow up that was published in two thousand nine was that it was a thirty-four percent reduction for lifestyle and eighteen percent for metformin. So what we basically see is kind of over time, the the discrepancy gets smaller, but lifestyle interventions still appear to be more beneficial. And a lot of this is because what we're gonna talk about over this first season is the outcome data shows lifestyle is more effective.
Brad Dieter (04:57)
But when we actually start kind of going in under the hood and we actually start looking at okay, what is it about lifestyle that actually helps chronic disease and ask it kind of in reverse what actually drives chronic disease? The lifestyle piece is doing a much more effective job, a much better job at actually addressing the root causes. And so, you know, these follow up studies continue to show us that. Now, that was the diabetes prevention.
Brad Dieter (05:26)
program which was here in the US. but what about globally, right? Kind of at Fitter, we're we're building a global preventive health platform. So what does this mean in in different populations? Well we know that in the Finnish Diabetes Prevention Study, which was published in the New England Journal in two thousand one, they basically found almost the exact same risk reduction as the diabetes prevention program, right? They had a fifty eight percent reduction in diabetes incidence with lifestyle intervention.
Brad Dieter (05:55)
The I'm gonna butcher this name and I apologize. The the Docking Diabetes Prevention Outcome Study in China, which started even earlier, they saw, you know, a pretty big risk reduction as well. over a 30 year follow up, they actually had twenty six percent fewer cardiovascular disease events, reduced microvascular complications, and lower all cause mortality, plus increased life expectan expectancy.
Brad Dieter (06:23)
And so we see that these lifestyle pieces really reduce the risk of developing chronic disease and the reduce the risk of outcomes like all cause mortality. And so I think it's really important that we just continue to kind of reframe these things of what do we actually care about at the end of the day, right? We're gonna spend some time this season talking about mechanisms and how these things work, but the thing we actually care about at the end of the day is how do you live better longer?
Brad Dieter (06:49)
And these studies actually show us that lifestyle intervention, when we compare it to certain medications, is as effective or more effective. And we'll talk about a lot of those reasons why, kind of in these coming episodes. And so kind of, you know, why we're talking about this today, and and what I want to talk about a little bit, you know, as we dive more into this topic, is that this lifestyle piece.
Brad Dieter (07:14)
And a big part of that is just like physical activity, right? So let's not talk about like super structured exercise or you know going to the gym and doing like exact workouts, but just for like physical activity and kind of meeting the guidelines. What's interesting is we know that these things are wildly important, but it appears like only half of the population hits that goal when they're in kind of structured
Brad Dieter (07:42)
settings, right? So in the diabetes prevention program, even inside their kind of structured, fully supported lifestyle arm, they had, you know, regular sessions, they had a case manager, they had defined curriculum. Only about 50% of participants actually hit the 7% weight loss goal by 24 weeks. And in that about 74% kind of hit the 150 minutes per week of activity goal. but that means this is something that's going to require
Brad Dieter (08:09)
a substantial amount of effort, not just from the individual, but also from kind of the the infrastructure, the practitioners, et cetera. And so, you know, really
Brad Dieter (08:22)
There's kind of two ways to look at this, right? One way is, hey, even in these like highly structured environments, only about fifty percent of people actually hit a weight loss goal and only about three quarters of people actually hit a physical activity goal. But think about it from the other side, right? These people in these trials, if only fifty percent hit the weight loss goal and only seventy four percent hit the physical activity goal, but we still saw a fifty to sixty percent reduction in overall risk of developing type two diabetes.
Brad Dieter (08:51)
That means you don't have to be perfect to get most of the benefit. And that the pop the intervention works at a population level, even when adherence isn't perfect. Right. If you have no good adherence but not perfect adherence, you're still gonna get a huge amount of the benefit. And so this is kind of the the strongest argument for why I think structure and support and having like a real platform built around getting people like structured lifestyle intervention matters, is that
Brad Dieter (09:20)
know, people in the these trials, they had real support and they still struggled with full adherence. But look at the difference, right? The placebo group who had, you know, no lifestyle intervention, they're just kind of left to their their own devices, the reduction in risk of the people who didn't have perfect adherence, but they had support and they had a structure and they had a system, they had a fifty to sixty percent reduction in risk, right? So that means these interventions
Brad Dieter (09:47)
Like the things that we're building here at FITR, while they may not be perfect and they may not create perfect adherence, they're gonna have meaningful risk reduction, right? Imagine if we could roll this out to the entire population, we could reduce the risk of developing a chronic disease like type two diabetes by fifty to sixty percent of population. I mean, that's huge, right? That's a massive reduction in risk. And so if we take that and we just kind of extend it into
Brad Dieter (10:17)
one of the kind of concepts we have is this idea of like physical activity is quote unquote medicine, right? I'm all I like I like to say, you know, people say things like food is medicine, exercise is medicine. I mean, yes, it's kind of a good catchphrase. I still think like medicine is medicine and physical activity is physical activity and food is food. But when we just kind of, you know, use that tongue in cheek perspective, there's a lot of validity to it, right?
Brad Dieter (10:44)
I mean if we look at what does physical activity and like actually chasing improved wellness and not just kind of preventing disease actually look like. I mean we know that like from a cardiorespiratory fitness perspective, like VO two max, which is a measure of kind of your total capacity of your cardiovascular system, it may actually be one of the strongest predictors of all cause mortality. Right? I mean you can look at look at a framing ham risk score, look at your LDL, look at your, you know,
Brad Dieter (11:12)
Glucose, your blood pressure, all those things. VO2 Max is actually probably a better predictor of all-cause mortality than many of those other things. there was another paper that was published, it was actually a really big paper. I think it came out of the Cleveland Clinic and it had like 122,000 people. but what they were able to show is that your physical fitness, and let's take your cardiovascular fitness, let's just take VO2 Max as an example. The discrepancy between people who have
Brad Dieter (11:40)
or quote very fit and people who are unfit is substantial. Right? I think in this paper they showed the people in the kind of least fit group, they actually had a five times higher mortality risk than the people in the elite fitness group. And that like the better you got, the lower your risk were the lower your risk for all cause mortality was. And this is not that was not the only paper, right? We've had a bunch of follow ups on this,
Brad Dieter (12:10)
I think the Journal of the American College of Cardiology, they looked at like seven hundred and fifty thousand people. I think they were mostly veterans from the United States military across all sorts of age ranges, racial backgrounds, biological sex. they found an inverse relationship between fitness and mortality. So that means the more physically fit people are, the longer they live. And this, you know
Brad Dieter (12:38)
This idea of being physically active and physically fit having a preventive effect also ties into people who already have established chronic disease. And so there was a a separate paper that came out of the the NHANES, so the National Health and Nutrition Examination Survey or study, I think is what NHANES stands for. But they found that even people who had a chronic disease, specifically type two diabetes, those in the highest fitness kind of third, the top third.
Brad Dieter (13:08)
They had an all-cause mortality risk as low or lower than people who did not have diabetes but were at a lower fitness level. So having high kind of physical fitness, especially when we talk about like cardiovascular fitness, that can offset a meaningful share of kind of chronic disease-related mortality risk, right? And so we have to start thinking about like
Brad Dieter (13:35)
On the preventive health side, physical fitness, like having your body be fully prepared and like at its peak or close to its peak or functioning at a very high level compared to being highly sedentary and like not having a robust cardiovascular system, a a robust musculoskeletal system. I mean, that is a huge piece of prevention and how we can reduce risk over time. And so those are like
Brad Dieter (14:03)
Those concepts I think are wildly important, right? There are things that will happen in your life that you can't always stop from happening that maybe increase your risk of chronic disease, right? Maybe it's just your genetics of how your lipids work, maybe it's, you know, the genetics of your your insulin sensitivity, right? We know that body adiposity is a big predictor of whether you develop type two diabetes. And everybody's kind of threshold is different, right? Some people can carry a much higher BMI or higher adiposity.
Brad Dieter (14:31)
body adiposity and not have insulin resistance. And some people can have a very low amount of body adiposity and have insulin resistance. So there's some of those things that like are kind of out of your control. But even when you layer in, hey, maybe you have, you know, you have hypertension, you have kind of a a lipid profile genetically that increases your risk of cardiovascular disease. You have a genetic profile that increases your risk of type 2 diabetes. Having a layer of physical fitness on top of that
Brad Dieter (14:58)
substantially reduces your risk of kind of all cause mortality, right? This is the part of the live better longer, regardless of everything else that's going on, matters so much. And so I think, you know, when we take these things into perspective and like what does this mean for you as the listener, is, you know, one, lifestyle is one of the most effective tools we have for preventing chronic disease, right? Especially here in kind of modern day life. That means
Brad Dieter (15:26)
some level of physical activity that's consistent, managing your nutrition and just kind of generally taking care of your body by managing stress, managing sleep, etcetera. Like in many cases that is far more effective than a lot of frontline medications. I know that doesn't mean don't go see your doctor and take the medications that are required, but it means that a lifestyle piece can do a l much of the heavy lifting for disease prevention.
Brad Dieter (15:53)
The second thing is you don't need to have perfect adherence to benefit, right? If we go back to the original diabetes prevention program study, those population level results held up with even kind of fifty percent of goal attainment on weight loss. So let's say you join, you know, some program maybe like ours and one of the big focuses is to to lose body weight. Let's say you set a target of twenty five pounds and you only lose twelve and a half, like you're still gonna have a huge amount of benefit on the prevention side.
Brad Dieter (16:23)
So you don't need perfect adherence, you just need structure and support. The next thing is like fitness itself, independent of, you know, body weight, chronic disease status, et cetera, it's one of the most powerful levers you have available. And like unlike any sort of diagnosis, it's directly in trainable and intervenable, interventionable, whatever word I'm trying to put there is.
Brad Dieter (16:49)
at any starting point, right? You can literally decide to go on a walk today. You can literally decide to sign up for a gym membership today. Start working with a trainer, start working with one of our coaches. That can be at any point. And so kind of the the through line here is the idea of you have to have some really wild intervention, like you have to have some really rigorous exercise routine. You have to some have some really rigorous dietary approach.
Brad Dieter (17:17)
That's not true, right? You just have some level of consistent intervention that has support, structure, et cetera. And it's really tied around lifestyle. And so this episode's really just to show you that, you know, one, these effects are real. We've seen them in a wide variety of kind of clinical cases. Two, they have tracked for long periods of time, right? Ten, twenty years of follow up. Three, adherence doesn't have to be perfect.
Brad Dieter (17:46)
and four, that the effect sizes are pretty meaningful, right? A fifty to sixty percent reduction in risk is one of the biggest effect sizes we see in pretty much all of medical literature. So the first episode we kind of talked about what is the difference between prevention and early detection. Today we're kinda talking about, hey, these lifestyle interventions that we're gonna be focused on for this first season. What is the like the magnitude of this effect and how perfect do you have to be in your adherence? And so as we go into the next episodes, we're gonna start talking about
Brad Dieter (18:16)
What are some of the metrics that you can track that kind of say, hey, is my lifestyle intervention working? What are some of the kind of parameters you can measure from like wearables? What are some of the parameters you can measure in your blood? Which ones matter, which ones don't? And then we'll start talking about, hey, why do certain types of diets, exercise routines, et cetera, why do some of them work a little bit better than others? So that kind of tees us up for the the next few episodes of this season. So
Brad Dieter (18:41)
I'm Doctor Brad. Thank you guys so much for tuning in and excited for next week. We're gonna have a much longer episode. We're gonna have a guest here with us. So thank you guys very much and we will see you next time.