Prevention Science

, Volume 17, Issue 3, pp 386–397 | Cite as

A Comprehensive Lifestyle Intervention to Prevent Type 2 Diabetes and Cardiovascular Diseases: the German CHIP Trial

  • Katharina WennehorstEmail author
  • Klas Mildenstein
  • Brunhild Saliger
  • Corinna Tigges
  • Hans Diehl
  • Thomas Keil
  • Heike Englert


The prevalence of type 2 diabetes is continuously increasing. This chronic metabolic disorder is difficult to treat and imposes a considerable economic burden on the healthcare system. In view of the fact that type 2 diabetes is primarily caused by behavioral factors, effective preventive strategies are urgently needed. We examined the effects of a holistic lifestyle intervention on clinical and laboratory parameters as well as on the long-term diabetes risk in patients at risk to develop diabetes. We conducted a randomized controlled trial in a primary care setting in Hannover, Germany, with 83 patients diagnosed as (pre)diabetic or at risk for diabetes. CHIP Germany is a 40-hour coaching lifestyle intervention program for the primary and secondary prevention of type 2 diabetes and cardiovascular diseases. The intervention included a comprehensive nutrition and health educational program based on the American CHIP approach. The primary outcome parameter was the body mass index (BMI). Secondary outcome parameters included body weight, blood pressure, fasting glucose, HbA1c, blood lipids, and the FINDRISK score, which assesses long-term diabetes risk. At the final measurement after 12 months, in the intervention group the BMI was reduced by 1.4 versus 0.2 kg/m2 in controls (p = .119). The mean sustained weight loss after 12 months was −4.1 kg in the intervention group versus −0.8 kg in controls. Furthermore, we found a trend toward a stronger reduction in blood pressure, fasting glucose, and HbA1c as well as an improved FINDRISK score in the intervention group, compared to controls. Although failing to reach statistical significance at the final assessment, this comprehensive lifestyle intervention showed a noticeable reduction in several cardiometabolic risk factors which may facilitate the prevention of diabetes.


Type 2 diabetes Cardiovascular risk Lifestyle coaching Health behavior Empowerment 



The authors are indebted to the DAK Deutsche Angestellten-Krankenkasse Hannover, Germany, for recruitment of study participants, making available their training classrooms, and refunding the intervention program’s admission fee. The authors are also grateful to the reviewers for thoughtful comments on the manuscript and to Dr. Wolfgang Reimers for participation in the first statistical analyses. They also wish to thank Bengt Wennehorst for assistance in the final statistical analyses and Karel Vermeulen for helping with the implementation of the permutation based Augmented Mann-Whitney U test.

Compliance with Ethical Standards


This study was funded by a grant to Heike Englert from the German Diabetes Foundation (DDS) (grant number: 185/03/0).

Conflict of interest

Hans Diehl invented the Complete Health Improvement Program (CHIP; formerly Coronary Health Improvement Project); he was the director and is currently the consultant of the Lifestyle Medicine Institute, LLC (Loma Linda, CA, USA), which promotes the Complete Health Improvement Program. Klas Mildenstein developed the “ChipListe” food nutrition table utilized in the German CHIP program. Heike Englert was principle investigator of the German CHIP trial. Katharina Wennehorst, Brunhild Saliger, Corinna Tigges and Thomas Keil declared no conflict of interest.

Ethical approval

Prior to initiating this research, the study protocol was reviewed by, and approval was obtained from, the ethical review committee Campus Charité Mitte (CCM) of the Charité-Universitätsmedizin Berlin, Germany. All procedures performed in this study were in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Participants granted written consent prior to participation in this study.


  1. ADA. (2006). Diagnosis and classification of diabetes mellitus. Diabetes Care, 29, 43–48.Google Scholar
  2. Aldana, S., Greenlaw, R., Diehl, H., Englert, H., & Jackson, R. J. (2002). Impact of the Coronary Health Improvement Project (CHIP) on several employee populations. Journal of Occupational and Environmental Medicine, 44, 831–839.CrossRefPubMedGoogle Scholar
  3. AlJaroudi, W. A., & Petersen, J. L. (2006). Obesity, diabetes and associated risk factors. Current treatment options in cardiovascular medicine, 8, 67–78.CrossRefPubMedGoogle Scholar
  4. Bender, R., & Lange, S. (2001). Adjusting for multiple testing—when and how? Journal of Clinical Epidemiology, 54, 343–349.CrossRefPubMedGoogle Scholar
  5. Bradley, C. (1994). The well-being questionnaire. In C. Bradley (Ed.), Handbook of psychology and diabetes: A guide to psychological measurement in diabetes research and practice (pp. 89–109). Switzerland, Harwood Academic: Chur.Google Scholar
  6. Buuren S. van, & Groothuis-Oudshoorn, K. (2011). mice: Multivariate imputation by chained equations in R. Journal of Statistical Software 45(3), ISSN 1548-7660.Google Scholar
  7. Costa, B., Barrio, F., Cabré, J. J., Piñol, J. L., Cos, X., Solé, C., … & Tuomilehto, J. (2012). Delaying progression to type 2 diabetes among high-risk Spanish individuals is feasible in real-life primary healthcare settings using intensive lifestyle intervention. Diabetologia, 55, 1319–28.Google Scholar
  8. Deutsche Diabetes-Stiftung (DDS). (2013). Die ChipListe—Ernährungswissen einfach, übersichtlich, motivierend - Gewichtsreduktion mit niedrigschwelliger Intervention zur Diabetes-Prävention. Diabetes aktuell, 11, 136–137. doi: 10.1055/s-0033-1348005.CrossRefGoogle Scholar
  9. Diabetes Prevention Program Research Group. (1999). The diabetes prevention program: Design and methods for a clinical trial in the prevention of type 2 diabetes. Diabetes Care, 22, 623.CrossRefGoogle Scholar
  10. Diehl, H. A. (1998). Coronary risk reduction through intensive community-based lifestyle intervention: The Coronary Health Improvement Project (CHIP) experience. American Journal of Cardiology, 82, 83–87.CrossRefGoogle Scholar
  11. Englert, H., Diehl, H., & Greenlaw, R. (2004). Rationale and design of the Rockford CHIP, a community-based coronary risk reduction program: Results of a pilot phase. Preventive Medicine, 38, 432–441.CrossRefPubMedGoogle Scholar
  12. Englert, H. S., Diehl, H. A., Greenlaw, R. L., Willich, S. N., & Aldana, S. (2007). The effect of a community-based coronary risk reduction: The Rockford CHIP. Preventive Medicine, 44, 513–519.CrossRefPubMedGoogle Scholar
  13. Englert, H. S., Diehl, H. A., Greenlaw, R. L., & Aldana, S. (2012). The Effects of Lifestyle Modification on Glycemic Levels and Medication Intake: The Rockford CHIP. Primary Care at a Glance – Hot Topics and New Insights,
  14. Esselstyn, C. B., Jr., Gendy, G., Doyle, J., Golubic, M., & Roizen, M. F. (2014). A way to reverse CAD? J Fam Pract, 63, 356–364b.PubMedGoogle Scholar
  15. Graham, J. W., Olchowski, A. E., & Gilreath, T. D. (2007). How many imputations are really needed? Some practical clarifications of multiple imputation theory. Prevention Science, 8, 206–213.CrossRefPubMedGoogle Scholar
  16. Grumbach, K., & Coffman, J. (1998). Physicians and nonphysician clinicians: complements or competitors? JAMA, 280, 825–826.CrossRefPubMedGoogle Scholar
  17. Hanefeld, M., Koehler, C., Fuecker, K., Henkel, E., Schaper, F., & Temelkova-Kurktschiev, T. (2003). Insulin secretion and insulin sensitivity pattern is different in isolated impaired glucose tolerance and impaired fasting glucose—The risk factor in impaired glucose tolerance for atherosclerosis and diabetes study. Diabetes care, 26, 868–874.CrossRefPubMedGoogle Scholar
  18. Hamman, R. F., Wing, R. R., Edelstein, S. L., Lachin, J. M., Bray, G. A., Delahanty, L., & Wylie-Rosett, J. (2006). Effect of weight loss with lifestyle intervention on risk of diabetes. Diabetes care, 29, 2102–2107.CrossRefPubMedPubMedCentralGoogle Scholar
  19. Harsha, D. W., & Bray, G. A. (2008). Weight loss and blood pressure control (Pro). Hypertension, 51, 1420–1425.CrossRefPubMedGoogle Scholar
  20. Hermanns, N., Kulzer, B., Gorges, D., Schwarz, P., & Haak, T. (2009). Wie viel Gewichtsabnahme ist für die Erzielung eines positiven Effekts in Hinblick auf die Prävention des Typ 2 Diabetes notwendig? Diabetologie und Stoffwechsel, 4, 256.Google Scholar
  21. Klein, S., Sheard, N. F., Pi-Sunyer, X., Daly, A., Wylie-Rosett, J., Kulkarni, K., & Clark, N. G. (2004). Weight management through lifestyle modification for the prevention and management of type 2 diabetes: Rationale and strategies—A statement of the American Diabetes Association, the North American Association for the Study of Obesity, and the American Society for Clinical Nutrition. Diabetes Care, 27, 2067–2073.Google Scholar
  22. Knowler, W. C., Barrett-Connor, E., & Fowler, S. (2002). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. The diabetes prevention program research group. New England Journal of Medicine, 346, 393–403.CrossRefPubMedGoogle Scholar
  23. Kulzer, B., Hermanns, N., Gorges, D., Schwarz, P., & Haak, T. (2009). Prevention of Diabetes Self-Management Program (PREDIAS): Effects on weight, metabolic risk factors, and behavioral outcomes. Diabetes Care, 32, 1143–1146.CrossRefPubMedPubMedCentralGoogle Scholar
  24. Kurth, B. M. (2012). Erste Ergebnisse aus der „Studie zur Gesundheit Erwachsener in Deutschland “(DEGS). Bundesgesundheitsblatt 2012, 55:980–990, Springer-Verlag 2012, doi:  10.1007/s00103-011-1504-5.
  25. Liebl, A., Neiss, A., Spannheimer, A., Reitberger, U., Wieseler, B., Stammer, H., & Goertz, A. (2002). Complications, comorbidity, and blood glucose control in type 2 diabetes mellitus patients in Germany—Results from the CODE-2™ study. Experimental and Clinical Endocrinology and Diabetes, 110, 10–16. doi: 10.1055/s-2002-19988.CrossRefPubMedGoogle Scholar
  26. Lindström, J., Louheranta, A., Mannelin, M., et al. (2003). The Finnish Diabetes Prevention Study (DPS): Lifestyle intervention and 3-year results on diet and physical activity. Diabetes Care, 26, 3230–3236.CrossRefPubMedGoogle Scholar
  27. Lindström, J., & Tuomilehto, J. (2003). The diabetes risk score: a practical tool to predict type 2 diabetes risk. Diabetes Care, 26, 725–731.CrossRefPubMedGoogle Scholar
  28. Look AHEAD Research Group. (2007). Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes: one-year results of the look AHEAD trial. Diabetes Care, 30, 1374–1383.Google Scholar
  29. Ma, J., Yank, V., Xiao, L., Lavori, P. W., Wilson, S. R., Rosas, L. G., & Stafford, R. S. (2012). Translating the Diabetes Prevention Program lifestyle intervention for weight loss into primary care: A randomized trial. Archives of Internal Medicine, 173, 113–121.Google Scholar
  30. Mancia, G., De Backer, G., Dominiczak, A., Cifkova, R., Fagard, R., Germano, G., & O'Brien, E. (2007). 2007 Guidelines for the management of arterial hypertension. The task force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). European Heart Journal, 28, 1462–1536.PubMedGoogle Scholar
  31. Moore, L. L., Visioni, A. J., Wilson, P. W., D’Agostino, R. B., Finkle, W. D., & Ellison, R. C. (2000). Can sustained weight loss in overweight individuals reduce the risk of diabetes mellitus? Epidemiology, 11, 269–273.CrossRefPubMedGoogle Scholar
  32. Morton, D., Rankin, P., Kent, L., & Dysinger, W. (2014). The Complete Health Improvement Program (CHIP): History, Evaluation, and Outcomes. American Journal of Lifestyle Medicine. doi: 10.1177/1559827614531391.
  33. Neter, J. E., Stam, B. E., Kok, F. J., Grobbee, D. E., & Geleijnse, J. M. (2003). Influence of weight reduction on blood pressure. A meta-analysis of randomized controlled trials. Hypertension, 42, 878–884.CrossRefPubMedGoogle Scholar
  34. Ornish, D. (1998). Avoiding revascularization with lifestyle changes: The multicenter lifestyle demonstration project. The American journal of cardiology, 82(10), 72–76.CrossRefGoogle Scholar
  35. Østbye, T., Yarnall, K. S., Krause, K. M., Pollak, K. I., Gradison, M., & Michener, J. L. (2005). Is there time for management of patients with chronic diseases in primary care? The Annals of Family Medicine, 3, 209–214.CrossRefPubMedGoogle Scholar
  36. Rankin, P., Morton, D. P., Diehl, H., Gobble, J., Morey, P., & Chang, E. (2012). Effectiveness of a volunteer-delivered lifestyle modification program for reducing cardiovascular disease risk factors. American Journal of Cardiology, 109, 82–86.CrossRefPubMedGoogle Scholar
  37. Schulz, K. F., Altman, D. G., & Moher, D. for the CONSORT Group (2010). CONSORT 2010 Statement: Updated guidelines for reporting parallel group randomised trials. Annals of Internal Medicine. 152.Google Scholar
  38. Shurney, D., Hyde, S., Hulsey, K., Elam, R., Cooper, A., & Groves, J. (2012). CHIP lifestyle program at Vanderbilt University demonstrates an early ROI for a diabetic cohort in a workplace setting: A case study. Journal of Managed Care Medicine, 15, 5–15.Google Scholar
  39. Tigges, C., Wennehorst, K., Saliger, B., & Englert, H. (2015). CHIP Deutschland: Das sozial-kognitive Prozessmodell gesundheitlichen Handelns (HAPA) und die Verbesserung des Bewegungsverhaltens durch ein Lebensstilcoaching-Programm zur Primär- und Sekundärprävention des Diabetes mellitus Typ 2. Verhaltenstherapie, 25, 23–30.CrossRefGoogle Scholar
  40. Tuomilehto, J., Lindström, J., Eriksson, J. G., Valle, T. T., Hamalainen, H., Ilanne-Parikka, P., et al. (2001). Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. New England Journal of Medicine, 344, 1343–1350.CrossRefPubMedGoogle Scholar
  41. Vermeulen, K., Thas, O., & Vansteelandt, S. (2015). Increasing the power of the Mann-Whitney test in randomized experiments through flexible covariate adjustment. Statist. Medicine, 34, 1012–1030.CrossRefGoogle Scholar
  42. Wadden, T. A., West, D. S., Neiberg, R. H., Wing, R. R., Ryan, D. H., Johnson, K. C., … & Vitolins, M. Z. (2009). One‐year Weight Losses in the Look AHEAD Study: Factors Associated With Success. Obesity, 17(4), 713-722.Google Scholar
  43. Wadden, T. A., Volger, S., Sarwer, D. B., Vetter, M. L., Tsai, A. G., Berkowitz, R. I., … & Moore, R. H. (2011). A two-year randomized trial of obesity treatment in primary care practice. New England Journal of Medicine, 365(21), 1969-1979.Google Scholar
  44. Ware, J. E., Kosinski, M., & Keller, S. D. (1996). A 12-item short-form health survey. Medical Care, 34, 220–3.CrossRefPubMedGoogle Scholar
  45. Ware, J. E., Kosinski, M., & Keller, S. D. (1998). SF-12: How to score the SF-12 physical and mental health summary scales (3rd ed.). Lincoln: QualityMetric Incorporated.Google Scholar
  46. Wilson, P. W., D'Agostino, R. B., Sullivan, L., Parise, H., & Kannel, W. B. (2002). Overweight and obesity as determinants of cardiovascular risk: The Framingham experience. Archives of Internal Medicine, 162, 1867–1872.CrossRefPubMedGoogle Scholar

Copyright information

© Society for Prevention Research 2016

Authors and Affiliations

  • Katharina Wennehorst
    • 1
    • 5
    Email author
  • Klas Mildenstein
    • 2
  • Brunhild Saliger
    • 3
  • Corinna Tigges
    • 3
  • Hans Diehl
    • 4
  • Thomas Keil
    • 5
    • 6
  • Heike Englert
    • 3
  1. 1.Department of Internal MedicineVinzenzkrankenhaus HannoverHannoverGermany
  2. 2.Medical practice Dr. MildensteinLaatzenGermany
  3. 3.Department of Nutritional ScienceUniversity of Applied Sciences MünsterMünsterGermany
  4. 4.Lifestyle Medicine InstituteLoma LindaUSA
  5. 5.Institute for Social Medicine, Epidemiology and Health EconomicsCharité - Universitätsmedizin BerlinBerlinGermany
  6. 6.Institute for Clinical Epidemiology and BiometryUniversity of WürzburgWürzburgGermany

Personalised recommendations