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Individuals who are unaccustomed to regular exercise or have a high-risk profile for CVD should avoid sudden and high-intensity bursts of physical activity. International Journal of Epidemiology , , Uusitupa M et al. Health in Everyday Living. Lancet , , Practising an endurance activity at moderate or greater level of intensity e. Pediatric Clinics of North America , ,

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About the World Bank Group The World Bank Group plays a key role in the global effort to end extreme poverty and boost shared prosperity. The difference between the two recommendations results from the difference in their focus. Because prevention of obesity is a central health goal, the recommendation of 60 minutes a day of moderate-intensity activity is considered appropriate. Activity of moderate intensity is found to be sufficient to have a preventive effect on most, if not all, cardiovascular and metabolic diseases considered in this report.

Higher intensity activity has a greater effect on some, although not all, health outcomes, but is beyond the capacity and motivation of a large majority of the population.

Both recommendations include the idea that the daily activity can be accomplished in several short bouts. It is important to point out that both recommendations apply to people who are otherwise sedentary. Some occupational activities and household chores constitute sufficient daily physical exercise.

In recommending physical activity, potential individual risks as well as benefits need to be assessed. In many regions of the world, especially but not exclusively in rural areas of developing countries, an appreciable proportion of the population is still engaged in physically demanding activities relating to agricultural practices and domestic tasks performed without mechanization or with rudimentary tools.

Even children may be required to undertake physically demanding tasks at very young ages, such as collecting water and firewood and caring for livestock. Similarly, the inhabitants of poor urban areas may still be required to walk long distances to their jobs, which are usually of a manual nature and often require a high expenditure of energy.

Clearly, the recommendation for extra physical activity is not relevant for these sectors of the population. World Cancer Research Fund. Food, nutrition and the prevention of cancer: Protein and amino acid requirements inhuman nutrition.

Geneva, World Health Organization, in press. Fats and oils in human nutrition. Carbohydrates in human nutrition. Preparation and use of food-based dietary guidelines. Recommended iodine levels in salt and guidelines for monitoring their adequacy and effectiveness.

Diet, lifestyle, and the etiology of coronary artery disease: American Journal of Cardiology , , Campbell TC, Junshi C. Diet and chronic degenerative diseases: American Journal of Clinical Nutrition , 59 Suppl. Energy density of foods: Critical Reviews in Food Science and Nutrition , , Dietary approaches to the treatment of obesity. Medical Clinics of North America , , Fat and sugar substitutes and the control of food intake. Annals of the New York Academy of Sciences , , Mann JI et al.

Effects on serum-lipids in normal men of reducing dietary sucrose or starch for five months. Lancet , , 1: The effect of reduced extrinsic sucrose intake on plasma triglyceride levels. European Journal of Clinical Nutrition , , Journal of American Medical Association , , Treating obesity in youth: Advances in Pediatrics , , Relation between consumption of sugar-sweetened drinks and childhood obesity: Lancet , , Raben A et al.

Sucrose compared with artificial sweeteners: American Journal of Clinical Nutrition , , Saris WH et al. Poppitt SD et al. Long-term effects of ad libitum low-fat, high-carbohydrate diets on body weight and serum lipids in overweight subjects with metabolic syndrome.

Report of a WHO Consultation. Weight control and physical activity. Physical activity and health: Almost all countries high-income and low-income alike are experiencing an obesity epidemic, although with great variation between and within countries. In low-income countries, obesity is more common in middle-aged women, people of higher socioeconomic status and those living in urban communities.

In more affluent countries, obesity is not only common in the middle-aged, but is becoming increasingly prevalent among younger adults and children. Furthermore, it tends to be associated with lower socioeconomic status, especially in women, and the urban-rural differences are diminished or even reversed. It has been estimated that the direct costs of obesity accounted for 6. Although direct costs in other industrialized countries are slightly lower, they still consume a sizeable proportion of national health budgets 1.

Indirect costs, which are far greater than direct costs, include workdays lost, physician visits, disability pensions and premature mortality. Intangible costs such as impaired quality of life are also enormous. Because the risks of diabetes, cardiovascular disease and hypertension rise continuously with increasing weight, there is much overlap between the prevention of obesity and the prevention of a variety of chronic diseases, especially type 2 diabetes.

Population education strategies will need a solid base of policy and environment-based changes to be effective in eventually reversing these trends.

The increasing industrialization, urbanization and mechanization occurring in most countries around the world is associated with changes in diet and behaviour, in particular, diets are becoming richer in high-fat, high energy foods and lifestyles more sedentary. In many developing countries undergoing economic transition, rising levels of obesity often coexist in the same population or even the same household with chronic undernutrition. Increases in obesity over the past 30 years have been paralleled by a dramatic rise in the prevalence of diabetes 2.

Mortality rates increase with increasing degrees of overweight, as measured by BMI. As BMI increases, so too does the proportion of people with one or more comorbid conditions. Nutrient factors under investigation include fat, carbohydrate type including refined carbohydrates such as sugar , the glycaemic index of foods, and fibre.

Physical activity is an important determinant of body weight. In addition, physical activity and physical fitness which relates to the ability to perform physical activity are important modifiers of mortality and morbidity related to overweight and obesity. There is firm evidence that moderate to high fitness levels provide a substantially reduced risk of cardiovascular disease and all-cause mortality and that these benefits apply to all BMI levels.

Furthermore, high fitness protects against mortality at all BMI levels in men with diabetes. Low cardiovascular fitness is a serious and common comorbidity of obesity, and a sizeable proportion of deaths in overweight and obese populations are probably a result of low levels of cardio-respiratory fitness rather than obesity per se. Fitness is, in turn, influenced strongly by physical activity in addition to genetic factors. These relationships emphasize the role of physical activity in the prevention of overweight and obesity, independently of the effects of physical activity on body weight.

Regular physical activity protective and sedentary lifestyles causative. There is convincing evidence that regular physical activity is protective against unhealthy weight gain whereas sedentary lifestyles, particularly sedentary occupations and inactive recreation such as watching television, promote it.

Most epidemiological studies show smaller risk of weight gain, overweight and obesity among persons who currently engage regularly in moderate to large amounts of physical activity 4. Studies measuring physical activity at baseline and randomized trials of exercise programmes show more mixed results, probably because of the low adherence to long-term changes.

Therefore, it is ongoing physical activity itself rather than previous physical activity or enrolment in an exercise programme that is protective against unhealthy weight gain. The recommendation for individuals to accumulate at least 30 minutes of moderate-intensity physical activity on most days is largely aimed at reducing cardiovascular diseases and overall mortality. The amount needed to prevent unhealthy weight gain is uncertain but is probably significantly greater than this.

Preventing weight gain after substantial weight loss probably requires about minutes per day. Two meetings recommended by consensus that about minutes of moderate-intensity physical activity is needed on most days or every day to prevent unhealthy weight gain 5, 6.

Studies aimed at reducing sedentary behaviours have focused primarily on reducing television viewing in children. Reducing viewing times by about 30 minutes a day in children in the United States appears feasible and is associated with reductions in BMI. Summary of strength of evidence on factors that might promote or protect against weight gain and obesity a.

Sedentary lifestyles High intake of energy-dense micronutrient-poor foods c. Home and school environments that support healthy food choices for children d Breastfeeding.

Heavy marketing of energy-dense foods d and fast-food outlets d High intake of sugars-sweetened soft drinks and fruit juices Adverse socioeconomic conditions d in developed countries, especially for women.

The World Cancer Research Fund schema was taken as the starting point but was modified in the following manner: Low energy-dense or energy-dilute foods, such as fruit, legumes, vegetables and whole grain cereals, are high in dietary fibre and water. The nomenclature and definitions of NSP dietary fibre have changed with time, and many of the available studies used previous definitions, such as soluble and insoluble fibre. Nevertheless, two recent reviews of randomized trials have concluded that the majority of studies show that a high intake of NSP dietary fibre promotes weight loss.

There were no differences between fibre type or between fibre consumed in food or as supplements. There is convincing evidence that a high intake of energy-dense foods promotes weight gain. In high-income countries and increasingly in low income countries these energy-dense foods are not only highly processed low NSP but also micronutrient-poor, further diminishing their nutritional value. Energy-dense foods tend to be high in fat e.

However, it is difficult to blind such studies and other non-physiological effects may influence these findings While energy from fat is no more fattening than the same amount of energy from carbohydrate or protein, diets that are high in fat tend to be energy-dense. An important exception to this is diets based predominantly on energy-dilute foods e. The effectiveness over the long term of most dietary strategies for weight loss, including low-fat diets, remains uncertain unless accompanied by changes in behaviour affecting physical activity and food habits.

These latter changes at a public health level require an environment supportive of healthy food choices and an active life. High quality trials to address these issues are urgently needed.

A variety of popular weight-loss diets that restrict food choices may result in reduced energy intake and short term weight loss in individuals but most do not have trial evidence of long-term effectiveness and nutritional adequacy and therefore cannot be recommended for populations. Home and school environments that promote healthy food and activity choices for children protective. It appears that access and exposure to a range of fruits and vegetables in the home is important for the development of preferences for these foods and that parental knowledge, attitudes and behaviours related to healthy diet and physical activity are important in creating role models More data are available on the impact of the school environment on nutrition knowledge, on eating patterns and physical activity at school, and on sedentary behaviours at home.

Some studies 12 , but not all, have shown an effect of school-based interventions on obesity prevention. While more research is clearly needed to increase the evidence base in both these areas, supportive home and school environments were rated as a probable etiological influence on obesity.

Heavy marketing of fast-food outlets and energy-dense, micronutrient-poor foods and beverages causative. Part of the consistent, strong relationships between television viewing and obesity in children may relate to the food advertising to which they are exposed Young children are often the target group for the advertising of these products because they have a significant influence on the foods bought by parents Young children are unable to distinguish programme content from the persuasive intent of advertisements.

The evidence that the heavy marketing of these foods and beverages to young children causes obesity is not unequivocal. A high intake of sugars-sweetened beverages causative. Diets that are proportionally low in fat will be proportionally higher in carbohydrate including a variable amount of sugars and are associated with protection against unhealthy weight gain, although a high intake of free sugars in beverages probably promotes weight gain.

The physiological effects of energy intake on satiation and satiety appear to be quite different for energy in solid foods as opposed to energy in fluids. This is supported by data from cross-sectional, longitudinal, and cross-over studies The high and increasing consumption of sugars-sweetened drinks by children in many countries is of serious concern.

Most of the evidence relates to soda drinks but many fruit drinks and cordials are equally energy-dense and may promote weight gain if drunk in large quantities. Overall, the evidence implicating a high intake of sugars-sweetened drinks in promoting weight gain was considered moderately strong. Adverse socioeconomic conditions, especially for women in high-income countries causative. Classically the pattern of the progression of obesity through a population starts with middle-aged women in high-income groups but as the epidemic progresses, obesity becomes more common in people especially women in lower socioeconomic status groups.

The relationship may even be bi-directional, setting up a vicious cycle i. The mechanisms by which socioeconomic status influences food and activity patterns are probably multiple and need elucidation. Breastfeeding as a protective factor against weight gain has been examined in at least 20 studies involving nearly 40 subjects. Five studies including the two largest found a protective effect, two found that breastfeeding predicted obesity, and the remainder found no relationships.

Promoting breastfeeding has many benefits, the prevention of childhood obesity probably being one of them. Low-glycaemic foods have been proposed as a potential protective factor against weight gain and there are some early studies that support this hypothesis. More clinical trials are, however, needed to establish the association with greater certainty. Large portion sizes are a possible causative factor for unhealthy weight gain There is some evidence that people poorly estimate portion sizes and that subsequent energy compensation for a large meal is incomplete and therefore is likely to lead to overconsumption.

In many countries, there has been a steady increase in the proportion of food eaten that is prepared outside the home. In the United States, the energy, total fat, saturated fat, cholesterol and sodium content of foods prepared outside the home is significantly higher than that of home-prepared food. People in the United States who tend to eat in restaurants have a higher BMI than those who tend to eat at home Certain psychological parameters of eating patterns may influence the risk of obesity.

Several other factors were also considered but the evidence was not thought to be strong enough to warrant defining them as protective or causative. There are probably many confounding factors that influence the association. While a high eating frequency has been shown in some studies to have a negative relationship with energy intake and weight gain, the types of foods readily available as snack foods are often high in fat and a high consumption of foods of this type might predispose people to weight gain.

The evidence regarding the impact of early nutrition on subsequent obesity is also mixed, with some studies showing relationships for high and low birth weights. The prevention of obesity in infants and young children should be considered of high priority. For infants and young children, the main preventive strategies are:. Additional measures include modifying the environment to enhance physical activity in schools and communities, creating more opportunities for family interaction e.

In developing countries, special attention should be given to avoidance of overfeeding stunted population groups. Nutrition programmes designed to control or prevent undernutrition need to assess stature in combination with weight to prevent providing excess energy to children of low weight-for-age but normal weight-for-height. In countries in economic transition, as populations become more sedentary and able to access energy-dense foods, there is a need to maintain the healthy components of traditional diets e.

Education provided to mothers and low socioeconomic status communities that are food insecure should stress that overweight and obesity do not represent good health. Low-income groups globally and populations in countries in economic transition often replace traditional micronutrient-rich foods by heavily marketed, sugars-sweetened beverages i.

These trends, coupled with reduced physical activity, are associated with the rising prevalence of obesity. Strategies are needed to improve the quality of diets by increasing consumption of fruits and vegetables, in addition to increasing physical activity, in order to stem the epidemic of obesity and associated diseases.

BMI can be used to estimate, albeit crudely, the prevalence of overweight and obesity within a population and the risks associated with it. It does not, however, account for the wide variations in obesity between different individuals and populations. The classification of overweight and obesity, according to BMI, is shown in Table 8. However, BMI may not correspond to the same degree of fatness in different populations due, in part, to differences in body proportions.

The table shows a simplistic relationship between BMI and the risk of comorbidity, which can be affected by a range of factors, including the nature and the risk of comorbidity, which can be affected by a range of factors, including the nature of the diet, ethnic group and activity level. The interpretation of BMI gradings in relation to risk may differ for different populations.

Both BMI and a measure of fat distribution waist circumference or waist: In recent years, different ranges of BMI cut-off points for overweight and obesity have been proposed, in particular for the Asia-Pacific region At present available data on which to base definitive recommendations are sparse. Waist circumference is a convenient and simple measure which is unrelated to height, correlates closely with BMI and the ratio of waist-to-hip circumference, and is an approximate index of intra-abdominal fat mass and total body fat.

Furthermore, changes in waist circumference reflect changes in risk factors for cardiovascular disease and other forms of chronic diseases, even though the risks seem to vary in different populations. A total of one hour per day of moderate-intensity activity, such as walking on most days of the week, is probably needed to maintain a healthy body weight, particularly for people with sedentary occupations. The fat and water content of foods are the main determinants of the energy density of the diet.

A lower consumption of energy-dense i. Conversely, a higher intake of energy-dilute foods i. Economic costs of obesity and inactivity. Medicine and Science in Sport and Exercise , , 31 Suppl. The world health report Geneva, World Health Organization, Manson JE et al.

Body weight and mortality among women. New England Journal of Medicine , , Fogelholm M, Kukkonen-Harjula K. Does physical activity prevent weight gain - a systematic review. Obesity Reviews , , 1: Dose-response of physical activity in the treatment of obesity-How much is enough to prevent unhealthy weight gain.

Outcome of the First Mike Stock Conference. International Journal of Obesity , , 26 Suppl. Dietary fiber and body-weight regulation. Pediatric Clinics of North America , , Dietary fiber and weight regulation. Nutrition Reviews , , Astrup A et al. The role of low-fat diets in body weight control: International Journal of Obesity , , Dietary fat plays a major role in obesity: Obesity Reviews , , 3: Campbell K, Crawford D. Australian Journal of Nutrition and Dietetics , , Gortmaker S et al.

Reducing obesity via a school-based interdisciplinary intervention among youth: Archives of Pediatrics and Adolescent Medicine , , Does television cause childhood obesity? Journal of the American Dietetic Association , , Taras HL, Gage M. Dietary compensation by humans for supplemental energy provided as ethanol or carbohydrate in fluids. Physiology and Behaviour , , Effect of drinking soda sweetened with aspartame or high-fructose corn syrup on food intake and body weight.

Soft drink consumption among US children and adolescents: Peña M, Bacallao J. Patterns and trends in food portion sizes, Journal of the American Medical Association , , Epidemic obesity in the United States: American Journal of Public Health , , Sydney, Health Communications Australia, Type 2 diabetes, formerly known as non-insulin-dependent diabetes NIDDM , accounts for most cases of diabetes worldwide.

Type 2 diabetes develops when the production of insulin is insufficient to overcome the underlying abnormality of increased resistance to its action.

The early stages of type 2 diabetes are characterized by overproduction of insulin. As the disease progresses, process insulin levels may fall as a result of partial failure of the insulin producing b cells of the pancreas. Complications of type 2 diabetes include blindness, kidney failure, foot ulceration which may lead to gangrene and subsequent amputation, and appreciably increased risk of infections, coronary heart disease and stroke.

The enormous and escalating economic and social costs of type 2 diabetes make a compelling case for attempts to reduce the risk of developing the condition as well as for energetic management of the established disease 1, 2. Lifestyle modification is the cornerstone of both treatment and attempts to prevent type 2 diabetes 3. The changes required to reduce the risk of developing type 2 diabetes at the population level are, however, unlikely to be achieved without major environmental changes to facilitate appropriate choices by individuals.

Criteria for the diagnosis of type 2 diabetes and for the earlier stages in the disease process - impaired glucose tolerance and impaired fasting glucose - have recently been revised 4, 5. Type 1 diabetes, previously known as insulin-dependent diabetes, occurs much less frequently and is associated with an absolute deficiency of insulin, usually resulting from autoimmune destruction of the b cells of the pancreas.

Environmental as well as genetic factors appear to be involved but there is no convincing evidence of a role for lifestyle factors which can be modified to reduce the risk. Although increases in both the prevalence and incidence of type 2 diabetes have occurred globally, they have been especially dramatic in societies in economic transition in much of the newly industrialized world and in developing countries 1, Worldwide, the number of cases of diabetes is currently estimated to be around million.

This number is predicted to double by , with the greatest number of cases being expected in China and India. These numbers may represent an underestimate and there are likely to be many undiagnosed cases. Previously a disease of the middle-aged and elderly, type 2 diabetes has recently escalated in all age groups and is now being identified in younger and younger age groups, including adolescents and children, especially in high-risk populations.

Age-adjusted mortality rates among people with diabetes are 1. In Caucasian populations, much of the excess mortality is attributable to cardiovascular disease, especially coronary heart disease 11, 12 ; amongst Asian and American Indian populations, renal disease is a major contributor 13, 14 , whereas in some developing nations, infections are an important cause of death It is conceivable that the decline in mortality due to coronary heart disease which has occurred in many affluent societies may be halted or even reversed if rates of type 2 diabetes continue to increase.

This may occur if the coronary risk factors associated with diabetes increase to the extent that the risk they mediate outweighs the benefit accrued from improvements in conventional cardiovascular risk factors and the improved care of patients with established cardiovascular disease 3.

Type 2 diabetes results from an interaction between genetic and environmental factors. The rapidly changing incidence rates, however, suggest a particularly important role for the latter as well as a potential for stemming the tide of the global epidemic of the disease. The most dramatic increases in type 2 diabetes are occurring in societies in which there have been major changes in the type of diet consumed, reductions in physical activity, and increases in overweight and obesity.

The diets concerned are typically energy-dense, high in saturated fatty acids and depleted in NSP. In all societies, overweight and obesity are associated with an increased risk of type 2 diabetes, especially when the excess adiposity is centrally distributed.

Conventional BMI categories may not be an appropriate means of determining the risk of developing type 2 diabetes in individuals of all population groups because of ethnic differences in body composition and because of the importance of the distribution of excess adiposity. While all lifestyle-related and environmental factors which contribute to excess weight gain may be regarded as contributing to type 2 diabetes, the evidence that individual dietary factors have an effect which is independent of their obesity promoting effect, is inconclusive.

Evidence that saturated fatty acids increase risk of type 2 diabetes and that NSP are protective is more convincing than the evidence for several other nutrients which have been implicated. The presence of maternal diabetes, including gestational diabetes and intrauterine growth retardation, especially when associated with later rapid catch-up growth, appears to increase the risk of subsequently developing diabetes.

The association between excessive weight gain, central adiposity and the development of type 2 diabetes is convincing.

The association has been repeatedly demonstrated in longitudinal studies in different populations, with a striking gradient of risk apparent with increasing levels of BMI, adult weight gain, waist circumference or waist-to-hip ratio. Indeed waist circumference or waist-to-hip ratio reflecting abdominal or visceral adiposity are more powerful determinants of subsequent risk of type 2 diabetes than BMI Central adiposity is also an important determinant of insulin resistance, the underlying abnormality in most cases of type 2 diabetes Voluntary weight loss improves insulin sensitivity 21 and in several randomized controlled trials has been shown to reduce the risk of progression from impaired glucose tolerance to type 2 diabetes 22, Longitudinal studies have clearly indicated that increased physical activity reduces the risk of developing type 2 diabetes regardless of the degree of adiposity The minimum intensity and duration of physical activity required to improve insulin sensitivity has not been established.

Offspring of diabetic pregnancies including gestational diabetes are often large and heavy at birth, tend to develop obesity in childhood and are at high risk of developing type 2 diabetes at an early age Those born to mothers after they have developed diabetes have a three-fold higher risk of developing diabetes than those born before In observational epidemiological studies, a high saturated fat intake has been associated with a higher risk of impaired glucose tolerance, and higher fasting glucose and insulin levels Higher proportions of saturated fatty acids in serum lipid or muscle phospholipid have been associated with higher fasting insulin, lower insulin sensitivity and a higher risk of type 2 diabetes Higher unsaturated fatty acids from vegetable sources and polyunsaturated fatty acids have been associated with a reduced risk of type 2 diabetes 36, 37 and lower fasting and 2-hour glucose concentrations 32, Furthermore, higher proportions of long-chain polyunsaturated fatty acids in skeletal muscle phospholipids have been associated with increased insulin sensitivity In human intervention studies, replacement of saturated by unsaturated fatty acids leads to improved glucose tolerance 40, 41 and enhanced insulin sensitivity Long-chain polyunsaturated fatty acids do not, however, appear to confer additional benefit over monounsaturated fatty acids in intervention studies A high total fat intake has also been associated with higher fasting insulin concentrations and a lower insulin sensitivity index 44, Considered in aggregate these findings are deemed to indicate a probable causal link between saturated fatty acids and type 2 diabetes, and a possible causal association between total fat intake and type 2 diabetes.

The two randomized controlled trials which showed a potential for lifestyle modification to reduce the risk of progression from impaired glucose tolerance to type 2 diabetes included advice to reduce total and saturated fat 22, 23 , but in both trials it is impossible to disentangle the effects of individual dietary manipulation.

Research relating to the association between NSP intake and type 2 diabetes is complicated by ambiguity with regard to the definitions used the term dietary fibre and NSP are often incorrectly used interchangeably , different methods of analysis and, consequently, inconsistencies in food composition tables.

Observations by Trowell in Uganda more than 30 years ago suggested that the infrequency of diabetes in rural Africa may be the result of a protective effect of substantial amounts of NSP in the diet referred to as dietary fibre associated with a high consumption of minimally-processed or unprocessed carbohydrate.

The author also hypothesized that throughout the world, increasing intakes of highly-processed carbohydrate, depleted in NSP, had promoted the development of diabetes In many controlled experimental studies, high intakes of NSP dietary fibre have repeatedly been shown to result in reduced blood glucose and insulin levels in people with type 2 diabetes and impaired glucose tolerance Moreover an increased intake of wholegrain cereals, vegetables and fruits all rich in NSP was a feature of the diets associated with a reduced risk of progression of impaired glucose tolerance to type 2 diabetes in the two randomized controlled trials previously described 22, Thus the evidence for a potential protective effect of NSP dietary fibre appears strong.

Many foods which are rich in NSP especially soluble forms , such as pulses, have a low glycaemic index. Low glycaemic index foods, regardless of their NSP content, are not only associated with a reduced glycaemic response after ingestion when compared with foods of higher glycaemic index, but are also associated with an overall improvement in glycaemic control as measured by haemoglobin A1c in people with diabetes A low glycaemic index does not, however, per se, confer overall health benefits, since a high fat or fructose content of a food may also result in a reduced glycaemic index and such foods may also be energy-dense.

Thus while this property of carbohydrate-containing foods may well influence the risk of developing type 2 diabetes, the evidence is accorded a lower level of strength than the evidence relating to the NSP content. There is insufficient evidence to confirm or refute the suggestions that chromium, magnesium, vitamin E and moderate intakes of alcohol might protect against the development of type 2 diabetes.

A number of studies, mostly in developing countries, have suggested that intrauterine growth retardation and low birth weight are associated with subsequent development of insulin resistance In those countries where there has been chronic undernutrition, insulin resistance may have been selectively advantageous in terms of surviving famine.

In populations where energy intake has increased and lifestyles have become more sedentary, however, insulin resistance and the consequent risk of type 2 diabetes have been enhanced. In particular, rapid postnatal catch-up growth appears to further increase the risk of type 2 diabetes in later life. Appropriate strategies which may help to reduce type 2 diabetes risk in this situation include improving the nutrition of young children, promoting linear growth and preventing energy excess by limiting intake of energy-dense foods, controlling the quality of fat supply, and facilitating physical activity.

At a population level, fetal growth may remain restricted until maternal height improves. This may take several generations to correct. The prevention of type 2 diabetes in infants and young children may be facilitated by the promotion of exclusive breastfeeding, avoiding overweight and obesity, and promoting optimum linear growth.

The strength of evidence on lifestyle factors is summarized in Table 9. Summary of strength of evidence on lifestyle factors and risk of developing type 2 diabetes.

Overweight and obesity Abdominal obesity Physical inactivity Maternal diabetes a. Measures aimed at reducing overweight and obesity, and cardiovascular disease are likely to also reduce the risk of developing type 2 diabetes and its complications. Some measures are particularly relevant to reducing the risk for diabetes; these are listed below:. Maintaining an optimum BMI, i.

Voluntary weight reduction in overweight or obese individuals with impaired glucose tolerance although screening for such individuals may not be cost-effective in many countries. Practising an endurance activity at moderate or greater level of intensity e.

Achieving adequate intakes of NSP through regular consumption of wholegrain cereals, legumes, fruits and vegetables. A minimum daily intake of 20 g is recommended. Global burden of diabetes, Diabetes Care , , The rising global burden of diabetes and its complications: Diabetic Medicine , , 14 Suppl.

Stemming the tide of diabetes mellitus. Definition, diagnosis and classification of diabetes mellitus and its complications.

Diagnosis and classification of diabetes mellitus. Harris MI et al. Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in U. Flegal KM et al. Mokdad AH et al. Diabetes trends among American Indians and Alaska natives: The continuing epidemics of obesity and diabetes in the United States.

Kleinman JC et al. Mortality among diabetics in a national sample. American Journal of Epidemiology , , Mortality in adults with and without diabetes in a national cohort of the US population, Roper NA et al. Excess mortality in a population with diabetes and the impact of material deprivation: British Medical Journal , , Diabetologia , , 44 Suppl.

Sievers ML et al. Diabetes in tropical Africa: Colditz GA et al. Weight as a risk factor for clinical diabetes in women. Després JP et al. Chan JM et al. Obesity, fat distribution, and weight gain as risk factors for clinical diabetes in men.

Boyko EJ et al. Visceral adiposity and risk of type 2 diabetes: Health consequences of visceral obesity. Annals of Medicine , , McAuley KA et al. Intensive lifestyle changes are necessary to improve insulin sensitivity.

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