Prevention of type 2 diabetes (T2D) is a great challenge worldwide. The aim of this evidence synthesis was to summarize the available evidence in order to update the European Association for the Study of Diabetes (EASD) clinical practice guidelines for nutrition therapy. We conducted a systematic review and, where appropriate, meta-analyses of randomized controlled trials (RCTs) carried out in people with impaired glucose tolerance (IGT) (six studies) or dysmetabolism (one study) to answer the following questions: What is the evidence that T2D is preventable by lifestyle changes? What is the optimal diet (with a particular focus on diet quality) for prevention, and does the prevention of T2D result in a lower risk of late complications of T2D? The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was applied to assess the certainty of the trial evidence. Altogether seven RCTs (N = 4090) fulfilled the eligibility criteria and were included in the meta-analysis. The diagnosis of incident diabetes was based on an oral glucose tolerance test (OGTT). The overall risk reduction of T2D by the lifestyle interventions was 0.53 (95% CI 0.41; 0.67). Most of the trials aimed to reduce weight, increase physical activity, and apply a diet relatively low in saturated fat and high in fiber. The PREDIMED trial that did not meet eligibility criteria for inclusion in the meta-analysis was used in the final assessment of diet quality. We conclude that T2D is preventable by changing lifestyle and the risk reduction is sustained for many years after the active intervention (high certainty of evidence). Healthy dietary changes based on the current recommendations and the Mediterranean dietary pattern can be recommended for the long-term prevention of diabetes. There is limited or insufficient data to show that prevention of T2D by lifestyle changes results in a lower risk of cardiovascular and microvascular complications.

Centro de Investigación Biomédica en Red Fisiopatología de la Obesidad y la Nutrición Institute of Health Carlos 3 28029 Madrid Spain

Department of Clinical Medicine and Surgery Federico 2 University 80138 Naples Italy

Department of Endocrinology and Internal Medicine Aarhus University Hospital 8200 Aarhus N Denmark

Department of Endocrinology Charité University Medicine Diabetes and Nutrition Campus Benjamin Franklin Hindenburgdamm 30 D 12203 Berlin Germany

Department of Medicine Endocrinology and Clinical Nutrition Kuopio University Hospital 70210 Kuopio Finland

Department of Nutritional Sciences Faculty of Medicine University of Toronto Toronto ON M5S 1A1 Canada

Diabetes Center 2nd Department of Internal Medicine Medical School National and Kapodistrian University of Athens Hippokration General Hospital of Athens 157 72 Athens Greece

Division of Endocrinology and Metabolism Department of Medicine St Michael's Hospital Toronto M5B 1W8 ON Canada

German Center for Diabetes Research 85764 München Neuherberg Germany

German Institute of Human Nutrition Potsdam Rehbrücke Clinical Nutrition DZD Arthur Scheunert Allee 114 116 D 14558 Nuthetal Germany

Human Nutrition Unit University Hospital of Sant Joan de Reus Department of Biochemistry and Biotechnology Faculty of Medicine and Health Sciences Institut d'Investigació Sanitària Pere Virgili Rovira i Virgili University 43201 Reus Spain

Institute for Clinical and Experimental Medicine 140 21 Prague Czech Republic

Institute of Public Health and Clinical Nutrition School of Medicine University of Eastern Finland P O Box 1627 70211 Kuopio Finland

Li Ka Shing Knowledge Institute St Michael's Hospital Toronto M5B 1T8 ON Canada

Physicians Committee for Responsible Medicine Washington DC 20016 USA

Toronto 3D Knowledge Synthesis and Clinical Trials Unit Clinical Nutrition and Risk Factor Modification Centre St Michael's hospital Toronto ON M5B 1W8 Canada

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Lifestyle Medicine in Diabetes Care: The Lifedoc Health Model

Combination of Multiple Low-Risk Lifestyle Behaviors and Incident Type 2 Diabetes: A Systematic Review and Dose-Response Meta-analysis of Prospective Cohort Studies