Special communication| Volume 97, ISSUE 9, SUPPLEMENT , S238-S246, September 2016

Download started.


Model Programs to Address Obesity and Cardiometabolic Disease: Interventions for Suboptimal Nutrition and Sedentary Lifestyles

  • Mark S. Nash
    Corresponding author Mark S. Nash, PhD, FACSM, University of Miami Miller School of Medicine, 1095 NW 14th Terrace, R-48, Miami, FL 33136.
    Departments of Neurological Surgery, Physical Medicine and Rehabilitation, Physical Therapy, and Kinesiology and Sports Sciences, Leonard M. Miller School of Medicine, University of Miami, Miami, FL

    Miami Project to Cure Paralysis, Miami, FL
    Search for articles by this author
  • Jochen Kressler
    School of Exercise and Nutritional Sciences, College of Health and Human Services, San Diego State University, San Diego, CA
    Search for articles by this author


      Problems posed by obesity-related endocrine diseases embody a national health crisis. Caloric excess and sedentary lifestyle from which they develop also pose significant challenges for rehabilitation providers. Almost two thirds of the U.S. population are currently overweight or obese, a number that has increased by >10% within the last decade and is expected to grow. An overweight body habitus is strongly associated with clinical hazards, including cardiometabolic syndrome, diabetes hypertension, and coronary artery disease. The component health risks of the cardiometabolic syndrome include coalescing of risk factors that predict a health calamity unless effective interventions can be developed and widely adopted. Obesity by itself is now considered an American Diabetes Association–qualified disability, but it is also disturbingly prevalent in other physical disability groupings of adults and children. This monograph describes successes of the Diabetes Prevention Program (DPP), a National Institutes of Health multisite randomized controlled trial that reported significant weight reduction and a 58% decreased incidence of type-2 diabetes accompanying 1 year of structured lifestyle intervention. This treatment benefit (1) exceeded that of metformin pharmacotherapy, (2) was so powerful that the trial was closed before reaching endpoints, and (3) was judged cost-effective for the patient and society. The DPP roadmap incorporating physical activity, diet, and behavioral approaches has been widely adapted to specific community, faith, racial, ethnic, school, and national populations with excellent outcomes success. The lockstep physical activity approach, activity prescription, and long-term success of the program are described and compared with other programs to illustrate effective countermeasures for the pandemics of obesity and obesity-related cardioendocrine disease. We will illustrate adaptation of the DPP for a cohort of persons with disability from spinal cord injury and the benefits observed.


      List of abbreviations:

      DPP (Diabetes Prevention Program), HRQOL (health-related quality of life), T2DM (type 2 diabetes mellitus)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Brown W.V.
        • Fujioka K.
        • Wilson P.W.
        • Woodworth K.A.
        Obesity: why be concerned?.
        Am J Med. 2009; 122: S4-S11
        • Mozlin R.
        Childhood obesity–a public health crisis.
        Optometry. 2005; 76: 685-691
        • Reilly J.J.
        Descriptive epidemiology and health consequences of childhood obesity.
        Best Pract Res Clin Endocrinol Metab. 2005; 19: 327-341
        • Hensrud D.D.
        • Klein S.
        Extreme obesity: a new medical crisis in the United States.
        Mayo Clin Proc. 2006; 81: S5-S10
      1. Obesity: preventing and managing the global epidemic. Report of a WHO consultation.
        World Health Organ Tech Rep Ser. 2000; 894: 1-253
        • Mokdad A.H.
        • Ford E.S.
        • Bowman B.A.
        • et al.
        Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001.
        JAMA. 2003; 289: 76-79
        • Ogden C.L.
        • Carroll M.D.
        • Curtin L.R.
        • McDowell M.A.
        • Tabak C.J.
        • Flegal K.M.
        Prevalence of overweight and obesity in the United States, 1999-2004.
        JAMA. 2006; 295: 1549-1555
        • Baron A.D.
        Impaired glucose tolerance as a disease.
        Am J Cardiol. 2001; 88: 16H-19H
        • Mensah G.A.
        • Mokdad A.H.
        • Ford E.
        • et al.
        Obesity, metabolic syndrome, and type 2 diabetes: emerging epidemics and their cardiovascular implications.
        Cardiol Clin. 2004; 22: 485-504
        • Wang A.
        • Kinsinger L.S.
        • Kahwati L.C.
        • et al.
        Obesity and weight control practices in 2000 among veterans using VA facilities.
        Obes Res. 2005; 13: 1405-1411
        • Das S.R.
        • Kinsinger L.S.
        • Yancy Jr., W.S.
        • et al.
        Obesity prevalence among veterans at Veterans Affairs medical facilities.
        Am J Prev Med. 2005; 28: 291-294
        • Weaver F.M.
        • Collins E.G.
        • Kurichi J.
        • et al.
        Prevalence of obesity and high blood pressure in veterans with spinal cord injuries and disorders: a retrospective review.
        Am J Phys Med Rehabil. 2007; 86: 22-29
        • Christensen R.
        • Bartels E.M.
        • Astrup A.
        • Bliddal H.
        Effect of weight reduction in obese patients diagnosed with knee osteoarthritis: a systematic review and meta-analysis.
        Ann Rheum Dis. 2007; 66: 433-439
        • Rimmer J.H.
        • Rauworth A.
        • Wang E.
        • Heckerling P.S.
        • Gerber B.S.
        A randomized controlled trial to increase physical activity and reduce obesity in a predominantly African American group of women with mobility disabilities and severe obesity.
        Prev Med. 2009; 48: 473-479
        • Rimmer J.H.
        • Wang E.
        Obesity prevalence among a group of Chicago residents with disabilities.
        Arch Phys Med Rehabil. 2005; 86: 1461-1464
        • Rimmer J.H.
        • Yamaki K.
        • Lowry B.M.
        • Wang E.
        • Vogel L.C.
        Obesity and obesity-related secondary conditions in adolescents with intellectual/developmental disabilities.
        J Intellect Disabil Res. 2010; 54: 787-794
        • Castro J.P.
        • El-Atat F.A.
        • McFarlane S.I.
        • Aneja A.
        • Sowers J.R.
        Cardiometabolic syndrome: pathophysiology and treatment.
        Curr Hypertens Rep. 2003; 5: 393-401
        • Alberti K.G.
        • Zimmet P.
        • Shaw J.
        Metabolic syndrome–a new world-wide definition. A Consensus Statement from the International Diabetes Federation.
        Diabet Med. 2006; 23: 469-480
        • Unwin N.
        • Shaw J.
        • Zimmet P.
        • Alberti K.G.
        Impaired glucose tolerance and impaired fasting glycaemia: the current status on definition and intervention.
        Diabet Med. 2002; 19: 708-723
        • National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)
        Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report.
        Circulation. 2002; 106: 3143-3421
        • Grundy S.M.
        • Brewer Jr., H.B.
        • Cleeman J.I.
        • et al.
        Definition of metabolic syndrome: report of the National Heart, Lung, and Blood Institute/American Heart Association conference on scientific issues related to definition.
        Circulation. 2004; 109: 433-438
        • Grundy S.M.
        • Cleeman J.I.
        • Merz C.N.
        • et al.
        Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines.
        J Am Coll Cardiol. 2004; 44: 720-732
        • Alberti K.G.
        • Zimmet P.Z.
        Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus provisional report of a WHO consultation.
        Diabet Med. 1998; 15: 539-553
        • Ford E.S.
        Prevalence of the metabolic syndrome defined by the International Diabetes Federation among adults in the U.S.
        Diabetes Care. 2005; 28: 2745-2749
        • Bremer A.A.
        • Mietus-Snyder M.
        • Lustig R.H.
        Toward a unifying hypothesis of metabolic syndrome.
        Pediatrics. 2012; 129: 557-570
        • Alam I.
        • Lewis K.
        • Stephens J.W.
        • Baxter J.N.
        Obesity, metabolic syndrome and sleep apnoea: all pro-inflammatory states.
        Obes Rev. 2007; 8: 119-127
        • DeMarco V.G.
        • Johnson M.S.
        • Whaley-Connell A.T.
        • Sowers J.R.
        Cytokine abnormalities in the etiology of the cardiometabolic syndrome.
        Curr Hypertens Rep. 2010; 12: 93-98
        • Dandona P.
        • Chaudhuri A.
        • Ghanim H.
        • Mohanty P.
        Proinflammatory effects of glucose and anti-inflammatory effect of insulin: relevance to cardiovascular disease.
        Am J Cardiol. 2007; 99: 15B-26B
        • Diabetes Prevention Program Outcomes Study Research Group
        • Orchard T.J.
        • Temprosa M.
        • et al.
        Long-term effects of the Diabetes Prevention Program interventions on cardiovascular risk factors: a report from the DPP Outcomes Study.
        Diabet Med. 2013; 30: 46-55
        • Diabetes Prevention Program (DPP) Research Group
        The Diabetes Prevention Program (DPP): description of lifestyle intervention.
        Diabetes Care. 2002; 25: 2165-2171
        • Ford E.S.
        Body mass index, diabetes, and C-reactive protein among U.S. adults.
        Diabetes Care. 1999; 22: 1971-1977
        • Seidell J.C.
        Obesity, insulin resistance and diabetes–a worldwide epidemic.
        Br J Nutr. 2000; 83: 5-8
        • Moore T.J.
        • Alsabeeh N.
        • Apovian C.M.
        • et al.
        Weight, blood pressure, and dietary benefits after 12 months of a Web-based Nutrition Education Program (DASH for health): longitudinal observational study.
        J Med Internet Res. 2008; 10: e52
        • Bantle J.P.
        • Wylie-Rosett J.
        • Albright A.L.
        • et al.
        Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association.
        Diabetes Care. 2008; 31: S61-S78
        • Due A.
        • Larsen T.M.
        • Hermansen K.
        • et al.
        Comparison of the effects on insulin resistance and glucose tolerance of 6-mo high-monounsaturated-fat, low-fat, and control diets.
        Am J Clin Nutr. 2008; 87: 855-862
        • Esposito K.
        • Maiorino M.I.
        • Ciotola M.
        • et al.
        Effects of a Mediterranean-style diet on the need for antihyperglycemic drug therapy in patients with newly diagnosed type 2 diabetes: a randomized trial.
        Ann Intern Med. 2009; 151: 306-314
        • Esposito K.
        • Marfella R.
        • Ciotola M.
        • et al.
        Effect of a mediterranean-style diet on endothelial dysfunction and markers of vascular inflammation in the metabolic syndrome: a randomized trial.
        JAMA. 2004; 292: 1440-1446
        • Estruch R.
        • Martinez-Gonzalez M.A.
        • Corella D.
        • et al.
        Effects of a Mediterranean-style diet on cardiovascular risk factors: a randomized trial.
        Ann Intern Med. 2006; 145: 1-11
        • Shai I.
        • Schwarzfuchs D.
        • Henkin Y.
        • et al.
        Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet.
        N Engl J Med. 2008; 359: 229-241
        • Esposito K.
        • Ciotola M.
        • Giugliano D.
        Low-carbohydrate diet and coronary heart disease in women.
        N Engl J Med. 2007; 356 (author reply 750-2): 750
        • Esposito K.
        • Ciotola M.
        • Giugliano D.
        Mediterranean diet and the metabolic syndrome.
        Mol Nutr Food Res. 2007; 51: 1268-1274
        • Ceriello A.
        • Quagliaro L.
        • Piconi L.
        • et al.
        Effect of postprandial hypertriglyceridemia and hyperglycemia on circulating adhesion molecules and oxidative stress generation and the possible role of simvastatin treatment.
        Diabetes. 2004; 53: 701-710
        • Sofi F.
        • Cesari F.
        • Abbate R.
        • Gensini G.F.
        • Casini A.
        Adherence to Mediterranean diet and health status: meta-analysis.
        BMJ. 2008; 337: a1344
        • Helmrich S.P.
        • Ragland D.R.
        • Leung R.W.
        • Paffenbarger Jr., R.S.
        Physical activity and reduced occurrence of non-insulin-dependent diabetes mellitus.
        N Engl J Med. 1991; 325: 147-152
        • Haskell W.L.
        • Lee I.M.
        • Pate R.R.
        • et al.
        Physical Activity and Public Health: Updated Recommendation for Adults from the American College of Sports Medicine and the American Heart Association.
        Med Sci Sports Exerc. 2007; 39: 1423-1434
      2. U.S. Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion; 1996.

        • Knowler W.C.
        • Barrett-Connor E.
        • Fowler S.E.
        • et al.
        Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.
        N Engl J Med. 2002; 346: 393-403
        • Ratner R.
        • Goldberg R.
        • Haffner S.
        • et al.
        Impact of intensive lifestyle and metformin therapy on cardiovascular disease risk factors in the diabetes prevention program.
        Diabetes Care. 2005; 28: 888-894
        • Knowler W.C.
        • Fowler S.E.
        • Hamman R.F.
        • et al.
        10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study.
        Lancet. 2009; 374: 1677-1686
        • Ackermann R.T.
        • Marrero D.G.
        Adapting the Diabetes Prevention Program lifestyle intervention for delivery in the community: the YMCA model.
        Diabetes Educ. 2007; 33 (74-5, 77-8): 69
        • Boltri J.M.
        • Davis-Smith Y.M.
        • Zayas L.E.
        • et al.
        Developing a church-based diabetes prevention program with African Americans: focus group findings.
        Diabetes Educ. 2006; 32: 901-909
        • Jackson L.
        Translating the Diabetes Prevention Program into practice: a review of community interventions.
        Diabetes Educ. 2009; 35: 309-320
        • Delahanty L.M.
        • Meigs J.B.
        • Hayden D.
        • Williamson D.A.
        • Nathan D.M.
        Psychological and behavioral correlates of baseline BMI in the diabetes prevention program (DPP).
        Diabetes Care. 2002; 25: 1992-1998
        • Andersson C.M.
        • Bjaras G.E.
        • Ostenson C.G.
        A stage model for assessing a community-based diabetes prevention program in Sweden.
        Health Promot Int. 2002; 17: 317-327
        • Ackermann R.T.
        • Finch E.A.
        • Brizendine E.
        • Zhou H.
        • Marrero D.G.
        Translating the Diabetes Prevention Program into the community. The DEPLOY Pilot Study.
        Am J Prev Med. 2008; 35: 357-363
        • Weil E.
        • Wachterman M.
        • McCarthy E.P.
        • et al.
        Obesity among adults with disabling conditions.
        JAMA. 2002; 288: 1265-1268
        • Nash M.S.
        • Gater D.
        Exercise to reduce obesity in SCI.
        Top Spinal Cord Inj Rehabil. 2007; 12: 76-93
        • Buchholz A.C.
        • Bugaresti J.M.
        A review of body mass index and waist circumference as markers of obesity and coronary heart disease risk in persons with chronic spinal cord injury.
        Spinal Cord. 2005; 43: 513-518
        • Chen Y.
        • Henson S.
        • Jackson A.B.
        • Richards J.S.
        Obesity intervention in persons with spinal cord injury.
        Spinal Cord. 2006; 44: 82-91
        • de Groot S.
        • Post M.W.
        • Postma K.
        • Sluis T.A.
        • van der Woude L.H.
        Prospective analysis of body mass index during and up to 5 years after discharge from inpatient spinal cord injury rehabilitation.
        J Rehabil Med. 2010; 42: 922-928
        • Emmons R.R.
        • Garber C.E.
        • Cirnigliaro C.M.
        • et al.
        The influence of visceral fat on the postprandial lipemic response in men with paraplegia.
        J Am Coll Nutr. 2010; 29: 476-481
        • Gorgey A.S.
        • Gater D.R.
        Regional and relative adiposity patterns in relation to carbohydrate and lipid metabolism in men with spinal cord injury.
        Appl Physiol Nutr Metab. 2011; 36: 107-114
        • Groah S.L.
        • Nash M.S.
        • Ljungberg I.H.
        • et al.
        Nutrient intake and body habitus after spinal cord injury: an analysis by sex and level of injury.
        J Spinal Cord Med. 2009; 32: 25-33
        • Bauman W.A.
        • Spungen A.M.
        Metabolic changes in persons after spinal cord injury.
        Phys Med Rehabil Clin N Am. 2000; 11: 109-140
        • Sturgeon J.D.
        • Folsom A.R.
        • Longstreth Jr., W.T.
        • Shahar E.
        • Rosamond W.D.
        • Cushman M.
        Hemostatic and inflammatory risk factors for intracerebral hemorrhage in a pooled cohort.
        Stroke. 2008; 39: 2268-2273
        • Manns P.J.
        • McCubbin J.A.
        • Williams D.P.
        Fitness, inflammation, and the metabolic syndrome in men with paraplegia.
        Arch Phys Med Rehabil. 2005; 86: 1176-1181
        • Nash M.S.
        • Gintel S.L.
        • Mendez A.J.
        • Hamm L.F.
        • Lewis J.E.
        • Groah S.L.
        Elevated CRP and vascular disease after SCI: inflammatory epiphenomenon or pathologic agent?.
        J Spinal Cord Med. 2006; 29: 252
        • Liang H.
        • Mojtahedi M.C.
        • Chen D.
        • Braunschweig C.L.
        Elevated C-reactive protein associated with decreased high-density lipoprotein cholesterol in men with spinal cord injury.
        Arch Phys Med Rehabil. 2008; 89: 36-41
        • Boninger M.L.
        • Cooper R.A.
        • Baldwin M.A.
        • Shimada S.D.
        • Koontz A.
        Wheelchair pushrim kinetics: body weight and median nerve function.
        Arch Phys Med Rehabil. 1999; 80: 910-915
        • Rajan S.
        • McNeely M.J.
        • Warms C.
        • Goldstein B.
        Clinical assessment and management of obesity in individuals with spinal cord injury: a review.
        J Spinal Cord Med. 2008; 31: 361-372
        • Manns P.J.
        • Chad K.E.
        Components of quality of life for persons with a quadriplegic and paraplegic spinal cord injury.
        Qual Health Res. 2001; 11: 795-811
        • Crane D.A.
        • Little J.W.
        • Burns S.P.
        Weight gain following spinal cord injury: a pilot study.
        J Spinal Cord Med. 2011; 34: 227-232
        • Gerhart K.A.
        • Bergstrom E.
        • Charlifue S.W.
        • Menter R.R.
        • Whiteneck G.G.
        Long-term spinal cord injury: functional changes over time.
        Arch Phys Med Rehabil. 1993; 74: 1030-1034
        • Frankenfield D.C.
        • Muth E.R.
        • Rowe W.A.
        The Harris-Benedict studies of human basal metabolism: history and limitations.
        J Am Diet Assoc. 1998; 98: 439-445
        • Cox S.A.
        • Weiss S.M.
        • Posuniak E.A.
        • Worthington P.
        • Prioleau M.
        • Heffley G.
        Energy expenditure after spinal cord injury: an evaluation of stable rehabilitating patients.
        J Trauma. 1985; 25: 419-423
        • Jacobs P.L.
        • Nash M.S.
        • Rusinowski J.W.
        Circuit training provides cardiorespiratory and strength benefits in persons with paraplegia.
        Med Sci Sports Exerc. 2001; 33: 711-717
        • Nash M.S.
        • Jacobs P.L.
        • Mendez A.J.
        • Goldberg R.B.
        Circuit resistance training improves the atherogenic lipid profiles of persons with chronic paraplegia.
        J Spinal Cord Med. 2001; 24: 2-9
        • Nash M.S.
        • van de Ven I.
        • van Elk N.
        • Johnson B.M.
        Effects of circuit resistance training on fitness attributes and upper-extremity pain in middle-aged men with paraplegia.
        Arch Phys Med Rehabil. 2007; 88: 70-75
        • Jankowski L.
        • Sullivan S.
        Aerobic and neuromuscular training: effect on the capacity, efficiency, and fatigability of patients with traumatic brain injuries.
        Arch Phys Med Rehabil. 1990; 71: 500-504
        • Bhambhani Y.
        • Rowland G.
        • Farag M.
        Effects of circuit training on body composition and peak cardiorespiratory responses in patients with moderate to severe traumatic brain injury.
        Arch Phys Med Rehabil. 2005; 86: 268-276
        • Nash M.S.
        • Cowan R.E.
        • Kressler J.
        Evidence-based and heuristic approaches for customization of care in cardiometabolic syndrome after spinal cord injury.
        J Spinal Cord Med. 2012; 35: 278-292
        • Kressler J.
        • Cowan R.E.
        • Bigford G.E.
        • Nash M.S.
        Reducing cardiometabolic disease in spinal cord injury.
        Phys Med Rehabil Clin N Am. 2014; 25 (viii): 573-604
        • Centers for Disease Control (CDC)
        Healthy people 2000: national health promotion and disease prevention objectives for the year 2000.
        MMWR Morb Mortal Wkly Rep. 1990; 39: 689-690
      3. U.S. Department of Health and Human Services: Office of Disease Prevention and Health Promotion. Healthy People 2010.
        Nasnewsletter. 2000; 15: 3
        • Fine J.T.
        • Colditz G.A.
        • Coakley E.H.
        • et al.
        A prospective study of weight change and health-related quality of life in women.
        JAMA. 1999; 282: 2136-2142
        • Fontaine K.R.
        Health-related quality of life among obese subgroups.
        Obes Res. 2002; 10: 854-855
        • Rubin R.R.
        • Wadden T.A.
        • Bahnson J.L.
        • et al.
        Impact of intensive lifestyle intervention on depression and health-related quality of life in type 2 diabetes: the Look AHEAD Trial.
        Diabetes Care. 2014; 37: 1544-1553