Horm Metab Res 2010; 42: S37-S55
DOI: 10.1055/s-0029-1240975

© Georg Thieme Verlag KG Stuttgart · New York

Take Action to Prevent Diabetes – The IMAGE Toolkit for the Prevention of Type 2 Diabetes in Europe

J. Lindström1 , A. Neumann2 , 3 , K. E. Sheppard4 , A. Gilis-Januszewska5 , C. J. Greaves4 , U. Handke6 , P. Pajunen1 , S. Puhl7 , A. Pölönen8 , A. Rissanen9 , M. Roden10 , T. Stemper14 , V. Telle-Hjellset11 , J. Tuomilehto12 , D. Velickiene13 , P. E. Schwarz2 IMAGE Study Group: T. Acosta, M. Adler, A. AlKerwi, N. Barengo, R. Barengo, J. M. Boavida, K. Charlesworth, V. Christov, B. Claussen, X. Cos, E. Cosson, S. Deceukelier, V. Dimitrijevic-Sreckovic, P. Djordjevic, P. Evans, A.-M. Felton, M. Fischer, R. Gabriel-Sanchez, A. Gilis-Januszewska, M. Goldfracht, J. L. Gomez, C. J. Greaves, M. Hall, U. Handke, H. Hauner, J. Herbst, N. Hermanns, L. Herrebrugh, C. Huber, U. Hühmer, J. Huttunen, A. Jotic, Z. Kamenov, S. Karadeniz, N. Katsilambros, M. Khalangot, K. Kissimova-Skarbek, D. Köhler, V. Kopp, P. Kronsbein, B. Kulzer, D. Kyne-Grzebalski, K. Lalic, N. Lalic, R. Landgraf, Y. H. Lee-Barkey, S. Liatis, J. Lindström, K. Makrilakis, C. McIntosh, M. McKee, A. C. Mesquita, D. Misina, F. Muylle, A. Neumann, A. C. Paiva, P. Pajunen, B. Paulweber, M. Peltonen, L. Perrenoud, A. Pfeiffer, A. Pölönen, S. Puhl, F. Raposo, T. Reinehr, A. Rissanen, C. Robinson, M. Roden, U. Rothe, T. Saaristo, J. Scholl, P. E. Schwarz, K. E. Sheppard, S. Spiers, T. Stemper, B. Stratmann, J. Szendroedi, Z. Szybinski, T. Tankova, V. Telle-Hjellset, G. Terry, D. Tolks, F. Toti, J. Tuomilehto, A. Undeutsch, C. Valadas, P. Valensi, D. Velickiene, P. Vermunt, R. Weiss, J. Wens, T. Yilmaz
  • 1Department of Chronic Disease Prevention, Diabetes Prevention Unit, National Institute for Health and Welfare (THL), Helsinki, Finland
  • 2Carl Gustav Carus Medical Faculty, Technical University of Dresden, Dresden, Germany
  • 3Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
  • 4Peninsula Medical School, University of Exeter, Exeter, United Kingdom
  • 5Jagiellonian University Medical College, Department of Endocrinology, Krakow, Poland
  • 6IMAGE Study Group Project Manager (2007–2009), Munich, Germany
  • 7Niederrhein University of Applied Sciences, Mönchengladbach, Germany
  • 8Prevention Project of Diabetes and Cardiovascular Diseases, Pirkanmaa Hospital District, Tampere, Finland
  • 9Vice-President, European Association for the Study of Obesity (EASO) and Obesity Research Unit, Helsinki University Central Hospital, Helsinki, Finland
  • 10Karl-Landsteiner Institute for Endocrinology and Metabolism, Vienna, Austria, and Institute for Clinical Diabetology, German Diabetes Center, and Department of Metabolic Diseases, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
  • 11Institute of General Practice and Community Medicine, University of Oslo, Oslo, Norway
  • 12Hjelt Institute, Department of Public Health, University of Helsinki, Helsinki, Finland, and South Ostrobothnia Central Hospital, Seinäjoki, Finland, and Spanish Diabetes Foundation, Madrid, Spain
  • 13Kaunas University of Medicine, Institute of Endocrinology, Kaunas, Lithuania
  • 14Bergische Universität Wuppertal, Germany
Further Information

Publication History

Publication Date:
13 April 2010 (online)

Executive Summary

When we ask people what they value most, health is usually top of the list. While effective care is available for many chronic diseases, the fact remains that for the patient, the tax payer and the whole of society: Prevention is Better Than Cure.

Diabetes and its complications are a serious threat to the survival and well-being of an increasing number of people. It is predicted that one in ten Europeans aged 20–79 will have developed diabetes by 2030. Once a disease of old age, diabetes is now common among adults of all ages and is beginning to affect adolescents and even children. Diabetes accounts for up to 18 % of total healthcare expenditure in Europe.

The Good News is That Diabetes is Preventable. Compelling evidence shows that the onset of diabetes can be prevented or delayed greatly in individuals at high risk (people with impaired glucose regulation). Clinical research has shown a reduction in risk of developing diabetes of over 50 % following relatively modest changes in lifestyle that include adopting a healthy diet, increasing physical activity, and maintaining a healthy body weight. These results have since been reproduced in real-world prevention programmes. Even a delay of a few years in the progression to diabetes is expected to reduce diabetes-related complications, such as heart, kidney and eye disease and, consequently, to reduce the cost to society.

A comprehensive approach to diabetes prevention should combine population based primary prevention with programmes targeted at those who are at high risk. This approach should take account of the local circumstances and diversity within modern society (e.g. social inequalities). The challenge goes beyond the healthcare system. We need to encourage collaboration across many different sectors: education providers, non-governmental organisations, the food industry, the media, urban planners and politicians all have a very important role to play.

Small Changes in Lifestyle Will Bring Big Changes in Health.
Through Joint Efforts, More People Will be Reached.
The Time to Act is Now.


  • 1 Alberti K, Eckel R H, Grundy S M, Zimmet P Z, Cleeman J I, Donato K A, Fruchart J-C, James P T, Loria C M, Smith S C. Harmonizing the metabolic syndrome – a joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and the International Association for the Study of Obesity.  Circulation. 2009;  120 1640-1645
  • 2 Michie N R S, Fussell A, Hardeman W, Johnston M, Newman S, Yardley L. British Psychological Society Health Psychology Team .Improving health: Changing behaviour. NHS Health Trainer Handbook. London; Department of Health 2008
  • 3 Finnish Diabetes Association .Programme for the prevention of type 2 diabetes in Finland. 2003. Available at:. http://www.diabetes.fi/english/prevention/programme/index.html
  • 4 Gillies C L, Abrams K R, Lambert P C, Cooper N J, Sutton A J, Hsu R T, Khunti K. Pharmacological and lifestyle interventions to prevent or delay type 2 diabetes in people with impaired glucose tolerance: systematic review and meta-analysis.  BMJ. 2007;  334 299-302
  • 5 Hjellset V, Bjorge B, Eriksen H, Hostmark A. Risk factors for type 2 diabetes among female Pakistani immigrants: The InvaDiab-DEPLAN study on Pakistani immigrant women living in Oslo, Norway.  J Immigr Minor Health. 2009;  DOI: 10.1007/s10903-009-9290-3 , Epub ahead of print Sep. 25, 2009
  • 6 Hussain A, Bjorge B, Telle-Hjellset V, Holmboe-Ottesen G, Raberg M, Wandel M. Body size perceptions among Pakistani women in Norway participating in a controlled trial to prevention deterioration of glucose tolerance.  Ethnicity and Health. 2010;  , [in press]
  • 7 International Association for the Study of Obesity .Adult overweight and obesity in the European Union (EU27). London; 2009. Available at:. http://www.iaso.org
  • 8 International Diabetes Federation .IDF Diabetes Atlas, fourth edition. Available at: IDF ed; 9 July 2009:. http://www.eatlas.idf.org
  • 9 Knowler W, Barrett-Connor E, Fowler S E, Hamman R F, Lachin J M, Walker E A, Nathan D M. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.  New Engl J Med. 2002;  346 393-403
  • 10 Laatikainen T, Dunbar J A, Chapman A, Kilkkien A, Vartiainen E, Heistaro S, Philpot B, Absetz P, Bunker S, O'Neil A, Reddy P, Best J D, Janus E D. Prevention of type 2 diabetes by lifestyle intervention in an Australian primary health care setting: Greater Green Triangle (GGT) Diabetes Prevention Project.  BMC Public Health. 2007;  7 249
  • 11 Lindström J, Ilanne-Parikka P, Peltonen M, Aunola S, Eriksson J G, Hemiö K, Hämäläinen H, Härkönen P, Keinänen-Kiukaanniemi S, Laakso M, Louheranta A, Mannelin M, Paturi M, Sundvall J, Valle T T, Uusitupa M, Tuomilehto J. on behalf of the Finnish Diabetes Prevention Study Group . Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: The follow-up results of the Finnish Diabetes Prevention Study.  Lancet. 2006;  368 1673-1679
  • 12 Mann J I, De Leeuw I, Hermansen K, Karamanos B, Karlström B, Katsilambros N, Riccardi G, Rivellese A A, Rizkalla S, Slama G, Toeller M, Uusitupa M, Vessby B. Diabetes and Nutrition Study Group (DNSG) of the European Association . Evidence-based nutritional approaches to the treatment and prevention of diabetes mellitus.  Nutr Metab Cardiovasc Dis. 2004;  14 373-394
  • 13 Miller W R, Rollnick S. Motivational interviewing: Preparing people for change (2nd ed). New York; Guildford Press 2002
  • 14 Pajunen P, Landgraf R, Muylle F, Neumann A, Lindström J, Schwarz P E, Peltonen M. for the IMAGE Study Group . Quality indicators for the prevention of type 2 diabetes in Europe – IMAGE.  Horm Metab Res. 2010;  42 (Suppl. 1) S56-S63
  • 15 Paulweber B, Valensi P, Lindström J, Lalic N M, Greaves C J, McKee M, Kissimova-Skarbek K, Liatis S, Cosson E, Szendroedi J, Sheppard K E, Charlesworth K, Felton A M, Hall M, Rissanen A, Tuomilehto J, Schwarz P E, Roden M. for the Writing Group . A European evidence-based guideline for the prevention of type 2 diabetes.  Horm Metab Res. 2010;  42 (Suppl. 1) S3-S36
  • 16 Perk J. Risk factor management: a practice guide.  Eur J Cardiovasc Prev Rehabil. 2009;  16 (Suppl. 2) S24-S28
  • 17 Sigal R, Kenny G, Boule N, Wells G, Prud'home D, Fortier M, Reid R, Tulloch H, Coyle D, Phillips P, Jennings A, Jaffrey J. Effects of aerobic training, resistance training, or both on glycemic control in type 2 diabetes. A randomized trial.  Ann Intern Med. 2007;  147 357-369
  • 18 Steyn N, Lambert E, Tabana H. Conference on “Multidisciplinary approaches to nutritional problems”. Symposium on “Diabetes and health”. Nutrition interventions for the prevention of type 2 diabetes.  Proc Nutr Soc. 2009;  68 55-70
  • 19 The Diabetes Prevention Program Research Group . Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.  N Eng J Med. 2001;  346 393-403
  • 20 Tuomilehto J, Lindström J, Eriksson J G, Valle T T, Hämäläinen H, Ilanne-Parikka P, Keinänen-Kiukaanniemi S, Laakso M, Louheranta A, Rastas M, Salminen V, Uusitupa M. Finnish Diabetes Prevention Study Group . Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance.  N Eng J Med. 2001;  344 1343-1350
  • 21 Warburton D, Nicol C, Bredin S. Health benefits of physical activity: the evidence.  CMAJ. 2006;  174 801-809
  • 22 Warburton D E, Nicol C W, Bredin S S D. Prescribing exercise as preventive therapy.  CMAJ. 2006;  174 961-974
  • 23 World Health Organization .Diet, nutrition and the prevention of chronic diseases. Report of a joint FAO/WHO consultation. WHO Technical Report Series No. 916. Geneva; World Health Organization 2003
  • 24 World Health Organization .Intervention on diet and physical activity: What works: summary report 2009. Available at:. http://www.who.int/dietphysicalactivity/summary-report-09.pdf
  • 25 World Health Organization .Definition and diagnosis of diabetes mellitus and intermediate hyperglycemia. Report of WHO/IDF consultation. Geneva, Switzerland; WHO Document Production Services 2006
  • 26 Yamaoka K, Tango T. Efficacy of lifestyle education to prevent type 2 diabetes: a meta-analysis of randomized controlled trials.  Diabetes Care. 2005;  28 2780-2786


List of Appendices

Checklist “How to start”

Spreadsheet/budget calculation for program costs

Risk screening tools

Finnish diabetes risk score FINDRISC

Challenges of working with special consideration groups

Example behaviour change session plans

Physical activity diary

Food diary

IMAGE evaluation and quality assurance data collection

The development of the IMAGE toolkit for diabetes prevention

Checklist “How to start”

Preparatory phase

  1. When you plan a diabetes prevention programme, think big and holistically, beyond your initial target group, think about ages, ethnic groups, and family groups. Which members of your community have the highest risk and/or are most in need of preventive activities?

  2. Find out about the target groups in advance

    • Their network and relations

    • Where they live/work etc

    • What do you know about the group

    • What has been done in this group before

    • What worked and what did not, what were the successful factors?

  3. Agree on strategic alliances. This is an aspect of great significance if you plan to carry out a prevention project.

  4. The director/top management must approve the project and future involvement. Create a positive cooperative atmosphere with all employees, show respect, listen, include and involve.

  5. Select suitable premises for the intervention programme, near to where participants live or work. Cooperate with local organisations, insurance companies, healthcare centres, hospitals, sports teams, schools and other.

  6. The premises must have rooms both for big gatherings/meetings/lectures and rooms for individual consultations and testing.

  7. Sufficient rooms/space for taking care of children, with activities that can keep them occupied if necessary.

  8. What is your main objective – what do you plan to achieve? The overall objective must be clear and concrete, and the results should be checked against the programme aims.

  9. Finances: Consider your funding needs and your funding sources. Create a funding plan.

  10. Ethics: Apply for necessary permissions and approvals for data collection (local ethics committee, data protection authorities). Be sure that you have the necessary insurances.

Project description and planning

  1. Make a detailed plan including;

    • Timeframe – realistic estimates regarding the time schedule of different phases ([Fig. 5])

    • Who – who is the target population? What is the target group familiar with, what are they lacking?

    • Estimated number of participants to include

    • How – where will the participants be recruited from, and how?

    • Intervention structure – group/individual sessions, content, and frequency of sessions

    • Intervention content – Practical activities such as; physical activities, exercises indoor or outdoor, cooking sessions, cognitive therapy, phone interviews, Internet platforms, use of mass media etc.

    • Special needs – e.g. translation, limited mobility/access issues

    • Follow-up

Zoom Image

Fig. 5 Example timeframe.

Recruiting project team members

  1. Selecting the optimal multi-disciplinary team is essential. It is absolutely crucial to pick team members that make the project an optimal experience for participants; this will help you with attendance rates and reduce the chance of drop-outs.

  2. Decide the target group (gender, age, ethnicity – or families) before you invite collaborators.

  3. Assess your capabilities and ensure that the skills of your team members are complementary and cover the wide range of skills and knowledge required (including expertise in dietary and physical activity advice and behaviour change). Team members need the following qualities:

    • Talent for team work

    • Fighting spirit

    • Enjoy challenges

    • Respect for the participants independent of ethnicity, sex, religion, occupation, socio-economic status and attitude

  4. When involving cooperating partners make sure everybody is aware of time constraints and that they understand and accept what it means to be involved in the programme.

  5. The team must have and the experience and ability to work within an interdisciplinary team.

  6. Everyone must talk to participants as an equal, and ensure that all participants are acknowledged, even if they are in a group.

Recruiting participants

Recruitment is a crucial part of a project.

  1. Make a realistic time schedule

  2. Use various identification and recruitment strategies, sources may include:

    • Physicians

    • The local health centre/occupational health services/pharmacists

    • Schools, workplaces

    • The participants' own contacts/network

    • Internet

    • Mass media

    • Mailing

Practical project work

A well prepared and planned project will help to simplify the running of an intervention programme, including handling unforeseen events. Include in the project budget items that need to be ordered in advance.

  1. Recruitment

    • Inclusion criteria, how and where to meet the participants

    • Weight scale and height measurements – where is the equipment placed?

    • Plastic measuring tape band for waist circumference – follow international guidelines

    • Questionnaires as necessary/desired

    • Structured documentation sheet

  2. Testing

    • Blood sample supplies and equipment, blood testing, processing, storing and analyses.

    • Treadmill for testing of physical fitness, pedometer, activity measurements

    • Nutrition and physical activity diaries

    • Glucometers

  3. Group sessions/teaching

    • Computer and LCD projector

    • Board/clip board

    • Audiovisual equipment

    • Whiteboard

    • Clear and descriptive illustrations

  4. Diaries for participants to make a note of physical activity and dietary behaviours

  5. Physical and practical activities

    • Group/individuals

    • Indoor/outdoor

    • Weather conditions, vacations, religious feasts etc.

    • New activities

    • Cooking courses

    • Time of day, and the time of year

  6. Support materials

    • Toys & drawing equipment for children

    • CD-player if music is wanted

    • Up-to-date information on teams/organisations in the area that the participants can join

Spreadsheet/Budget Calculation for Programme Costs

Administrative costs

  • Rental fee for use of office, meeting rooms etc.

  • Project management (clerical, accountant)

  • Recruitment of participants

  • Information, advertising, written presentations and Internet access

  • Overhead costs

Salary costs

  • Project coordinator

  • Personnel at test stations

  • Prevention managers – multi-disciplinary team (full/part-time)

  • Interpreters

  • Overhead costs

Travel and subsistence

  • Meetings (programme management, networking, education)

  • Travel and transport for project workers

Costs for risk assessment

  • Premises and equipment for testing (i.e. blood test, analyses, questionnaires)

Costs for the intervention programme

  • Premises and equipment for testing (i.e. blood tests, analyses)

  • Premises and equipment for the different interventions

  • Office equipment (from computers to pencils)

  • Telephones and communication

  • Quality management

Possible sources of incomes

  • Alternative public funding

  • Health insurances

  • Contributions from collaborating partners

  • Private funding, legacies

  • Contributions from participants in seminars

  • Other incomes

Risk Screening Tools

See [Tables 4] and [5].

Table 4 Risk screening tools for prevalent and incident diabetes

Score and source

Predictive variables

Screening scores for prevalent T2D

The Dutch score. Diabetes Care 1999; 22: 213

Age, sex, BMI, presence of obesity, use of antihypertensive medication + family history of diabetes, physical activity

The Cambridge risk score. Diabetic medicine 2006; 23: 996

Age, sex, BMI, family history of diabetes, use of antihypertensive or steroid medication, smoking

The Danish risk score. Diabetes Care 2004; 27: 727–733

Age, sex, BMI, family history of diabetes, known hypertension, physical activity

The Finnish diabetes risk score FINDRISC. www.diabetes.fi/english/risktest

Age, BMI, waist circumference, use of antihypertensive therapy, history of high blood glucose, physical activity, consumption of fruit, vegetables and berries, family history of diabetes

FindRISK Germany Horm Metab Res 2009; 41: 98

Age, BMI, waist circumference, use of blood pressure medication, history of high blood glucose

Australian risk score AUSDRISK . www.ausdrisk.com

Age, sex, ethnicity, family history of diabetes, history of high blood glucose, use of anti-hypertensive medication, current smoking status, consumption of vegetables or fruit, physical activity and waist circumference

The German diabetes risk score. www.dife.de

Age, waist circumference, height, history of hypertension, physical activity, smoking, consumption of red meat, whole-grain bread, coffee, and alcohol

The ADA risk score. Diabetes Care 1995; 18: 382

Age, sex, delivery of macrosomic infant, race, education, obesity, sedentary lifestyle, family history of diabetes

Screening scores for incident T2D

The San Antonio Heart Study. Annals of Internal Medicine 2002; 136: 575

Age, sex, BMI, ethnicity, fasting glucose, systolic blood pressure, HDL cholesterol, family history of diabetes + 2-hour glucose, diastolic blood pressure, total and LDL cholesterol, triglyceride

The Rancho Bernardo Study. Diabetes Care 2005; 28: 404

Age, sex, triglyceride, fasting glucose

The ARIC Study. Diabetes Care 2005; 28: 2013

Age, ethnicity, waist circumference, height, fasting glucose, systolic blood pressure, family history of diabetes + HDL cholesterol and triglyceride

The Finnish diabetes risk score FINDRISC . www.diabetes.fi/english/risktest

Age, BMI, waist circumference, use of antihypertensive therapy, history of high blood glucose, physical activity, consumption of fruit, vegetables and berries, family history of diabetes

DESIR. Diabetes Care 2008; 31: 2056

Waist circumference, hypertension and smoking (M) or familial history of diabetes (W) + fasting blood glucose

The Framingham Offspring Study. Archives of Internal Medicine 2007; 167: 1068

Fasting glucose, body mass index, HDL-cholesterol, triglyceride level, blood pressure, parental history of T2D

Diabetes risk score for urban Asian Indians. Diabetes Research and Clinical Practice 2005; 70: 63

Age, BMI, waist circumference, family history of diabetes, physical activity

University of Nottingham. QDScore® http://www.qdscore.org/

Age, sex, ethnicity, body mass index, smoking status, family history of diabetes, social deprivation, treated high blood pressure, heart disease and use of corticosteroids.

For further details, please see “IMAGE-Guideline for diabetes prevention” [15].

Table 5 Finnish diabetes risk score FINDRISC


Age (years)

  • < 45


  • 45–54


  • 55–64


  • > 64


Body mass index

  • ≤ 25


  • > 25–30


  • > 30


Waist circumference (cm)

  • men < 94, women < 80


  • men 94 – < 102, women 80 – < 88


  • men ≥ 102, women ≥ 88


Do you usually have at least 30 minutes of physical activity at work and/or during leisure time (including normal daily activity)?

  • yes


  • no


How often do you eat vegetables, fruit or berries?

  • every day


  • not every day


Have you ever taken medication for high blood pressure on regular basis?

  • no


  • yes


Have you ever been found to have high blood glucose (e.g. in a health examination, during an illness, during pregnancy)

  • no


  • yes


Have any of the members of your immediate family or other relatives been diagnosed with diabetes (type 1 or type 2)?

  • no


  • yes: grandparent, aunt, uncle or first cousin


  • yes: parent, brother, sister, or own child


Total score:

Challenges of Working with Special Consideration Groups

Ethnic minorities/immigrants

  • Avoid stigmatisation of any kind. Consider and talk to all individuals as equals.

  • The challenges will be different for 1st, 2nd and 3rd generation because of language, education level, and the problems related to living in two different cultures.

  • Non-western immigrants are often classified as a “low socioeconomic status group”, due to low income and education. Some may have no formal education. However, this is often because they never had the opportunity to go to school, so it does not necessarily mean that they are socially deprived.

  • Experiences from immigration projects indicate that the use of interpreters is essential, especially in the introduction phase. Experience from the project InnvaDiab in Norway further indicates that using local lay people as interpreters works better than using professional interpreters. In Germany the initiative MiMi (migrants for migrants) is a successful prevention initiative. The local interpreters aim to talk to the immigrants in a way that gives comfort, “especially at their own religious and cultural level”. Be aware that even if immigrant participants can cope with everyday language, they may not understand medical questions or abstract questions, and it is usually not sufficient to take the right medical actions and only briefly discuss lifestyle changes.

  • As healthcare workers we must be open to and able to accept the various differences between cultures. It is also important to be willing to learn about the client's culture, values and daily life. We must convey this to immigrants so that they feel that we understand and accept their distinctive characteristics. This means that we must have a clear understanding of their situation and their cultural background, both from their native country and in their new country. The need for mutual respect cannot be emphasised enough. Avoidance of misunderstandings is essential for mutual respect.

  • Create a climate that allows for the clients' culture.

  • Consultation at the planning stages with representatives of specific ethnic groups who are to be offered diabetes prevention programmes is essential to inform appropriate planning and adaptation.

People on low incomes

  • Avoid stigmatisation of any kind. Consider and talk to all individuals as equals.

  • It is vital to talk with them – not to them!

  • This group is often difficult to reach, even though they have a high need to undertake lifestyle intervention programmes. They often avoid health information if, for example, they have experienced behaviour changes as overwhelming and restrictive before. The experience with those of low social status is very similar to immigrants, and we can use the same advice and follow similar procedures.

Example Behaviour Change Session Plans

Please find below 3 example session plans, which contain ideas on how to implement a behaviour change session. The session content specified below should be integrated with education on physical activity and healthy diet. It is strongly recommended that specialised training is undertaken to gain the necessary skills and knowledge to undertake such complex work ([Fig. 6]).

Zoom Image

Fig. 6 Intervention process for supporting behaviour change in adults at risk of developing type 2 diabetes. Session plan.

Structure of initiating motivation session (approx. 90 min)

Introduction to behaviour change programme session (15 min)

Welcome everyone & introduce yourself. Explain overall aim of the intervention sessions, format of this session, lead an “ice breaker” activity & agree rules for working in a group. Highlight the client-centred approach of the work: Remind participants that they are the experts in their own behaviour change; the trainer's role is to support change, not to prescribe it.

Knowledge & understanding the process of change (15 min)

  1. Introduce individuals to the process of behaviour change (use diagrams & models). Explain the importance of understanding that behaviour change is a process to work through and explain the rationale for the session.

  2. Explore with the clients their prior knowledge/past experiences of behaviour change. “Has anyone tried to change a behaviour before?” “What happened?” “What helped/hindered your efforts?

Establish motivation for behaviour change (45 min)

  1. Explore clients' perceptions of risk for developing type 2 diabetes. Ask people to suggest what the consequences of having type 2 diabetes would be. Provide information sheet on consequences and complications of type 2 diabetes. Ask clients to work out their risk scores using the risk charts/tools. Ask clients to discuss in groups what might be some of their unhealthy behaviours.

  2. Explore expectations of behaviour change – what do the clients think that making changes in behaviour will lead to? Ask clients to work in groups and identify the benefits of physical activity and a healthy diet and how they prevent the development of type 2 diabetes. Emphasise strongly that it is possible to prevent the development of diabetes by changing unhealthy behaviours – so it is worth them making the effort!

  3. Discuss perceived importance for change. Ask clients to think about the reasons why they are involved in the programme and why they might want to make the effort to change behaviours. Ask clients to assess how important they think it is to change their diet and getting more physically active (importance review). Ask clients to identify expected benefits and costs of changing a behaviour, write it down on a decisional balance sheet.

  4. Explore confidence for change – assess clients' perceived confidence about changing their diet and/or physical activity (confidence review). How do clients feel about their ability to successfully make a change? Explore issues of confidence for physical activity/dietary change – discuss what people perceive to be barriers to change. Ask the group to think of ways round them. Ask the group to make a list of positive attributes that can help people make changes (e.g. organised, committed) and get participants to identify for themselves some that relate to them.

Social support (12 min)

Small group/pair work. Ask participants to identify positive and negative sources of social support. Ask groups/pairs to come up with ideas of how to seek more positive support and avoid negative support. Ask clients to identify their own need to develop social skills. Ask clients to identify social barriers to change. Feedback ideas to the main group (write up on flip chart). Provide information on “the best ways to provide social support” and the important role of good social support in behaviour change. Encourage participants to invite someone to the sessions who will support their attempts to change.

Homework (3 min)

Explain homework: Ask participants to use their decisional balance sheet and think about their review of their confidence and importance. Are they ready to make a change (even a small one)? Ask them to try as an experiment to change (at least for the next week) one simple habit (e.g. eating a piece of fruit once a day; going for a 10-minute walk once in the week etc.

Structure of action planning session (approx. 90 min)

Introduction to action planning session

Welcome everyone. Explain format of the session (2 min)

Review homework set in the previous session (5 min)

Discuss with participants how easy/hard it was to complete the goal they had set themselves. What difficulties (if any) did they face? Did anything/anyone facilitate/prevent them achieving the goal? Praise all successes

Make decisions (10 min)

Revisit perceived importance to change and confidence to change (use decisional balance sheets). Emphasise that it is very important for participants to clarify their motivations for change. Ask participants to make decisions about if they are ready to make changes and if so, what changes they want to make. Remember: it must be their decision.

Key messages on physical activity and healthy diets (20 min)

Discuss basic information on physical activity: What types? Where do you fit it in with your day-to-day life? How much to do?

Discuss basic information on healthy diets: What to eat? When to eat? How much to eat?

Self-monitoring behaviour (5 min)

Explain the importance of self-monitoring as key motivation strategy. Discuss different types of self-monitoring (diaries, pedometers etc).

Create an action plan (20 min)

  1. Introduce the principles of SMART goals and practice setting SMART short- and long-term goals.

  2. Action plan – Ask clients to write out as clearly as possible their action plan for behaviour change. Focus on setting SMART goals and creating a goal ladder to focus on developing a progressive series of goals that will lead to the final outcome goal. Make sure that in addition to SMART goals the action plan contains details on 1) what kind of social support they will need & who will provide it and 2) what coping strategies (see below) they will use if needed ([Table 6]).

Table 6 Action plan worksheet

The most important reasons why I want to make this change are:

  • I want to lose weight so that I will have more energy and feel good about myself.

  • I don't want to get diabetes.

My SMART goals are:

  • Go for a 20-minute walk

Specify: What, how, where, when

  • 20-minute walk, around the nearby local park, every Wednesday after work at 6 pm

Social Support: Other people who could help me to achieve my goal:


Possible ways to help

  • My friend Sarah

  • Come with me on the walk and keep me company

Coping Plan:

Possible obstacle/barrier to change

How will I respond?

If …

Then …

  • … it is raining

  • … I will take an umbrella and/or wear waterproof clothing

Relapse prevention (25 min)

  1. Knowledge of behaviour change: Refresh clients on the process of behaviour change and emphasise the normality of setbacks. Explain that setbacks should be seen as an opportunity for learning.

  2. Problem solving: Give clients tools to deal with setbacks. Explain about “high-risk” situations and “if-then” plans. Work through examples

  3. Problem solving (mood/emotion): how to identify and deal with negative thoughts, moods, and stress.

  4. Identify barriers to change: Address barriers and facilitators to becoming more physically active and improving diet. Look at cost, environment, emotional/cognitive and social support. Identify places & things, people, thoughts and feelings that are or are not helpful.

Homework (3 min)

Put action plan into practice and self-monitor progress. Practice identifying negative thoughts, writing them down and countering then with positive thoughts.

Structure of maintenance session (approx. 90 min)

Introduction to maintenance session (5 min)

Welcome everyone. Explain format of the session Refresh individuals on the process of behaviour change. Place emphasise on the importance of sustainable/lifelong of behaviour change and explain the rationale for, and format of, the session.

Review last session & homework (10 min)

Ask the group to reflect on how easy/hard it has been to achieve their action plans. Did they successfully use their coping strategies? Did participants notice any negative thoughts? Were they able to stop these thoughts and reframe with positive thoughts?

Discuss motivation for behaviour change (5 min)

Discuss motivation for change; ask the clients “why are you making the effort to make changes?”

Review progress: (20 min)

Ask group to reflect on how easy/hard it has been to achieve their action plans. Review achievements in behaviour change in relation to 1) risk outcomes (e.g. weight, pedometer counts) 2) behavioural goals. Review goals sheet and action plan and identify achievements, surpassed goals, or goals not yet achieved. Focus on achievements. Highlight the importance of self-monitoring – ask clients to evaluate their progress using their diaries, goals sheets, action plans. Review successes and setbacks. Do goals need to be re-set?

Relapse management (25 min)

Celebrate success and “re-frame” failure or setbacks as learning opportunities. Reflect on the use of coping strategies – have any been used? If so, what has worked and what has not? Identify barriers which participants have experienced. Separate into groups to discuss the barrier most relevant to them: cost, environmental, emotional, knowledge. In the group, discuss strategies to overcome the barrier and solve the problem. Feedback problem-solving ideas to the main group. Reinforce need for self-monitoring of behaviour change (using pedometers, diaries etc). Explore satisfaction/dissatisfaction with behaviour change. Ask clients to talk reflect on what has worked well & reinforce areas of satisfaction. Reframe dissatisfaction where possible or encourage goals to be re-set where unattainable. Ensure focus is on graded levels of goals so as to build success and confidence. Ask clients to think about their levels of expectation for behaviour change – are they realistic?

Role of rewards (5 min)

Highlight the importance of regularly reviewing goals and progress and rewarding achievements. What achievements are clients most proud of? Have there been any unexpected benefits to change? Ask clients to identify ways in which they can reward themselves for successes.

Social support (10 min)

Ask clients to identify positive & negative sources of social support that they have experienced. Did the social support they put in their action plan work? If not, why not? Ask group to come up with ideas of how to seek more positive support and avoid negative support (e.g. peer pressure at mealtimes).

Rewrite action plans (10 min)

Re-write action plans (where necessary). Focus on adjusting/re-setting goals (consider extending goals if desired), identifying relevant sources of social support, identifying rewards and adapting coping strategies. Conclude with a re-cap of the process of behaviour change, the normality of relapses and encourage clients to self-manage new challenges and ongoing diet and PA changes.

Suggested programme timeline

The group-based intervention programme consists of 7 sessions (with an optional 8th) for 8 to 15 people. The first 3 sessions can be completed weekly, with a 2 week break before the 4th session to allow individuals to go away and attempt their behaviour change. The repeated maintenance sessions are completed at 2 (+ 1 week), 4, 7 and (optional) 12 months. NB: Education on the specifics of diet/cooking/shopping for health and physical activity should be interspersed with or integrated with the content on behaviour change ([Fig. 7]).

Zoom Image

Fig. 7 Suggested timeline for implementing a lifestyle intervention programme.

SMART goals (Source: NHS health trainer handbook)

Once the participant has decided upon a health behaviour they want to change, they need to set a goal to change their behaviour. Your role is to help the participant to set a goal that is detailed and likely to be achieved. Goals should be SMART, that is:

Specific – Measurable – Achievable – Relevant – Timely

Specific – some goals can be vague and difficult to measure. It is important to set goals that are clear and precise. For example, a vague goal would be ‘being fit and healthy’ whereas a clear, specific goal would be “I will work out at the local gym for at least 30 minutes three times a week at 7 pm on Monday and Thursday and 10 am on Saturday.” To help the participant make their goal more specific, ask them questions such as:

  • What are you going to do?

  • How are you going to do it?

  • Where are you going to do it?

  • When are you going to do it?

  • With whom are you going to do it?

Measurable – making the goal specific means that it should be easy to measure whether or not the participant has achieved their goal. The example above, “I will work out at the local gym for at least 30 minutes three times a week at 7 pm on Monday and Thursday and 10am on Saturday,” is measurable. The participant can record the number of times they went to the gym in one week, and also how long they worked out for each time. It would be hard to measure a vague goal like “being fit and healthy”.

Achievable – set goals that are within the participant's reach. Failing to achieve a goal can have a negative effect on their motivation to work towards their goal. For example, an unrealistic goal could be 'eat no chocolate or sweets for the next seven days'. A more realistic goal could be “eat no more than three portions of chocolate or sweets in the next seven days”. It is important to make the first goal quite easy to achieve to boost the participant's self-confidence and encourage them to carry on. Participants should remember that the best way of changing behaviour and maintaining change is to build on small successes.

Relevant – does the participant think that the goal is relevant to them? You need to check with the participant that they see a clear link between their goal and their health or how they feel, and that it is a behaviour that they want to change.

Timely – is this goal the right thing for them to try to achieve right now? If so, set a time frame in which the goal can be achieved. If you don't set a target date for the completion of the goal, it could go on and on without the participant ever achieving it. For example, if your next session with the participant is a week away, aim for the goal to have been completed by that time. If the goal requires a longer time frame, decide together whether there are any mini-goals that the participant could achieve in time for the next session ([Table 6]).

Physical Activity Diary

See [Table 7].

Table 7Physical activity diary (Source: NHS Health Trainer Handbook). Over the next 7 day period, record your daily activities in the table below by marking lines so that each line represents 10 minutes of activity (there is an example of how to do this in the first row). Do not include time spent standing while doing activities – such as gardening and lawn bowls.



Gardening or heavier household work

Weight training, dancing, aerobics, other forms of strength training

Tennis, basketball, golf, other ball sports

Jogging, cycling, swimming, rowing or other vigorous activities

Total time (minutes)














Total time for the week spent on each type of activity

Food Diary

See [Table 8].

Table 8 Food diary



What you ate and drank


→ 9 am

mug of coffee with cream & sugar, croissant, glass of orange juice

ate in a hurry

9 am – 12

12 – 3 pm

large pepperoni pizza, can of soft drink

busy at work, so ate at my desk, was really hungry!

3 pm – 6 pm

2 mugs of coffee with milk and sugar

felt full & tired

6 pm – 9 pm

steak with french fries, small salad (lettuce & tomato, no dressing), pint of beer

in a restaurant with friends

9 pm →

a bag of sweets (100 g)

at home by TV

Why use a food diary?

Keeping a food diary can help your client to become more aware of his/her eating pattern: the health promoting habits and the possible problem areas. It can be an excellent tool for facilitating discussions.

Use the food diary as a basis for goal setting and planning. Later on, repeating the food diary shows what has changed over time and helps to maintain the new habits. Making a note of social surroundings and feelings during meals can also be helpful, especially if your client has particular problems, such as excessive or uncontrolled eating.

A simple template food diary is printed above, but a small notebook can be used as well. Keeping a food diary for a week would be optimal, but even a couple of days can give useful information. Explain to your client that the purpose of the food diary is to help him/her in his/her journey to better diet and well being. Ask him/her to write down everything he/she eats and drinks, and to maintain their usual eating and drinking habits. Short notes are enough, such as “a cup of coffee with sugar and a doughnut” or “a large bowl of vegetable salad with olive oil vinaigrette and two slices of whole grain wheat bread with butter”. Only if you are using the food diary to collect detailed data on nutrient intakes (e.g. for research purposes), would you need to use a more detailed and structured format.

Compare the food diary with your client's personal goals. This can be done either individually or in a small-group session. Pay attention to the number of meals and snacks during a typical day, the amount of certain types of food, such as vegetables, whole grains, deserts, alcoholic beverages, and sources of soft and hard fat. Let the client express his/her own opinions, experiences and ideas; use open-ended questions. Encourage the client to make his/her own suggestions for new solutions and further progression. Remember to give positive feedback!

Image Evaluation and Quality Assurance Data Collection

See [Table 9].

Table 9 Image evaluation and quality assurance data collection

Core items

Additional items

Personal data

Personal identification

Marital status


Employment status


Method used in screening

Risk screening result and interpretation

Health and health behaviour

Chronic diseases and regular medications

Family history of diabetes and CVD


  • never/previously/irregularly/daily

  • products used, amount, frequency

Physical activity:

  • method used in measuring (for example: interview, diary, recall, pedometers, accelerometers)

  • type, frequency, intensity

  • work-related, commuting, leisure


  • method used in measuring (for example: interview, diary, recall, pedometers, accelerometers)

  • Dietary pattern: Number of meals and snacks including beverages, consumption of vegetables, fruits, bread and cereal (whole/refined grain), fats and oil, sweets, beverages, alcohol e.g.

  • Energy proportion (E%) of fat, saturated and trans fat, dietary fibre (g/day, g/1000 kcal), total energy, alcohol (g, E%), added sugar (g, E%)

Clinical data – baseline and follow-up

Body weight

Fasting insulin

Body height

2 hour OGTT glucose + insulin

Waist circumference


Systolic and diastolic blood pressure

Lipids (total, LDL, HDL Cholesterol and triglycerides)

Plasma glucose (fasting, random or postprandial)

Additional measures, e.g. liver function tests

Health related quality of life

Content of the intervention

Intervention facilitator(s)

Type of intervention (group, individual etc.)

Frequency, duration and other details

Focus of the intervention (weight, diet, smoking, physical activity, e.g.)

Reinforcement plan

Success of the intervention

Adherence (proportion of planned intervention visits completed)

Changes in lifestyle (line 3) and clinical (line 4) indicators


Plans how to sustain possible lifestyle changes after intervention

The Development of the IMAGE Toolkit for Diabetes Prevention


The Grant Agreement between the Public Health Executive Agency (PHEA; now European Agency for Health and Consumers, EAHC) and the IMAGE Group 2006309-IMAGE stated that the primary objective was “The development of practice-oriented European guidelines for the prevention of type 2 diabetes (T2DM)”. To implement this specific objective, a working group 4(a) was established. The group collected the latest evidence and summarised their findings in “A European Evidence-Based Guideline for the Prevention of Type 2 Diabetes – IMAGE-Guideline for diabetes prevention”. A second working group, 4(b), was also set up with the aim to create a credible, simplistic, concise, clear, pragmatic, accessible document with a positive message about health promotion (“a toolkit”) with step-by-step tips on how to initiate and manage a lifestyle intervention to prevent type 2 diabetes.

Members of the working group

The members of the working group were selected based on their practical and/or scientific experience in the field of diabetes prevention and were suggested and invited by IMAGE steering group members. Further, the members represent different professional backgrounds which are relevant to diabetes prevention, including health psychology, physical activity, nutrition, health promotion, diabetology, health services provision, health policy development and service user representation.

Group meetings

The IMAGE Toolkit group had two meetings: the first in Frankfurt, Germany 25–26 May 2009, and the second in Helsinki, Finland 24–25 August 2009. Work was assigned to group members during the meetings and the majority of work was completed between and after meetings. Communications were via e-mails and telephone calls.

Target group

The target group for the Toolkit was anyone with an interest in establishing a programme to prevent type 2 diabetes. This includes service providers in the field of health care and health promotion but also politicians and policy-makers. The Toolkit aimed to provide a good balance between clear, accurate information and practical guidance. It is not intended to be a comprehensive source of information, but preferably to be used alongside the “IMAGE Guideline for diabetes prevention” and the associated training curriculum (please see www.image-project.eu). Intervention delivery staff is assumed to have basic knowledge about e.g. diet and physical activity as well as their health effects and supporting behaviour change. Finally, the Toolkit is not designed to be used as intervention materials to be delivered directly to those participating in prevention interventions, although it does contain some examples of information sheets and materials which might be used with participants (for further information, please see www.image-project.eu).

Content of the toolkit

The Toolkit starts with an executive summary including the rationale for diabetes prevention. It is followed by chapters representing the background (type 2 diabetes prevalence, risk factors, consequences, evidence of successful prevention), and giving instructions about the planning and development of prevention programmes and the identification, and recruitment of participants at high risk for T2DM.

One of the core items of the toolkit is the description of what to do and how to do it. Behaviour change is a process which requires individual attention, and effective communication to achieve motivation, self-monitoring, sustained support and other intervention to prevent and manage relapses. This section includes a model of intervention including empowerment and patient-centred messages. It is followed by key messages on behaviour (including physical activity and diet) that are important in prevention of diabetes, and practical advice for patient-centred counselling. The focus is on long-term, sustainable lifestyle changes. Of note, detailed instructions about how to achieve weight reduction were left out because local and national guidelines as well as other information are available elsewhere.

Finally, a brief guide for evaluation and quality assurance in reference to the “IMAGE quality indicators” is included. This section is followed by a consideration of possible risks and adverse effects. The IMAGE toolkit main text ends with a positive mission statement, emphasizing what can be achieved if we work together.

The appendix of the toolkit gives the reader a set of easy-to-use tools including a checklist for prevention programme development, templates for goal-setting and for food and physical activity diaries, an example of a risk screening questionnaire (the FINDRISC questionnaire) and a template for evaluation and quality assurance data collection.

Creation of the toolkit

The first draft of the toolkit was collated in July 2009. The draft was sent to all members of the toolkit working group for comments and suggestions. During the Helsinki meeting in August 2009, the content and structure of the document was addressed page-by-page.

A revised version was prepared in September 2009 and sent to all IMAGE work package leaders for comments and suggestions. In mid-October, the toolkit was sent to the entire IMAGE study group for comments. The IMAGE final convention took place in Lisbon, 29–31 October 2009. During this meeting, the toolkit was presented to the whole IMAGE study group followed by a general discussion regarding, e.g. focus, content and wording. All participants were invited to further comment in writing on the version provided at the final convention. Based on the comments and suggestions from the IMAGE group, a pre-final version was prepared by JL, AN and PS in Dresden in December 2009.

The final revision phase was conducted via the global “Who is active in diabetes prevention” network (www.activeindiabetesprevention.com) between December 2009 and January 2010, by inviting all 2900 members of the Network (who represent a wide range of stakeholders in diabetes prevention from academics to service providers in over 130 countries) to comment on the toolkit.

By the end of January 2010, 13 members of the Network and several members of the IMAGE study group had submitted further comments about the toolkit. These were collated and sent to the chapter authors to give their response. Final revisions to the toolkit were made by JL, AN, PS and JT in February 2010.

Anne Neumann

Carl Gustav Carus Medical Faculty, MK III
Technical University of Dresden

Fetscherstr. 74

01307 Dresden


Phone: + 49 35 14 58 27 82

Fax: + 49 35 14 58 73 19

Email: Anne.Neumann@uniklinikum-dresden.de