The effect of lifestyle interventions using behavior change techniques to improve physical activity, sedentary behavior and/or sleep in adults with type 2 diabetes mellitus: a systematic review and meta-analysis of randomized controlled trials

Introduction/Aim: Type 2 diabetes (T2D) is a growing global health burden, with lifestyle behaviors playing a key role in its management. Physical activity (PA), sedentary behavior (SB), and sleep are increasingly conceptualized as interdependent components of 24-hour movement behaviors. While behavior change techniques (BCTs) are commonly used to target individual behaviors, their effectiveness across multiple behaviors in adults with T2D remains unclear. This systematic review and meta-analysis aimed to evaluate the effectiveness of behavior change interventions incorporating BCTs on PA, SB, and sleep outcomes, and to identify effective BCT clusters. Methods: A systematic search of PubMed, Web of Science, and Embase was conducted from inception to December 18, 2023. Randomized and non-randomized controlled trials including adults with T2D were eligible if they evaluated behavior change or lifestyle interventions targeting PA, SB, and/or sleep and included at least one BCT. Data extraction, BCT coding (using the BCT Taxonomy), and risk of bias assessment (Cochrane RoB 2) were performed independently by multiple reviewers. Meta-analyses using random-effects models were conducted for relevant outcomes. Subgroup analyses examined the effects of three common BCT clusters: goals and planning, feedback and monitoring, and social support. Results: Sixty-six studies (n = 18,725 participants) were included. Interventions significantly improved several PA outcomes, including steps/day (+1991 steps/day; p<0.001), total PA (SMD=0.36; p=0.02), moderate-to-vigorous PA (SMD=0.55; p<0.001), and light-intensity PA (SMD=0.62; p=0.01). Sedentary time decreased significantly (SMD=-0.32; p=0.008). Sleep quality improved (MD=-1.39; p=0.02), whereas sleep duration showed no significant change. Subgroup analyses demonstrated that BCT clusters involving goals and planning, feedback and monitoring, and social support were consistently associated with improvements in PA and SB, with comparable effect sizes to overall analyses. Effects on sleep outcomes were limited due to the small number of studies. Conclusion: Behavior change interventions incorporating BCTs effectively increase PA, reduce SB, and improve sleep quality in adults with T2D. BCTs such as goal setting, self-monitoring, feedback, and social support appear particularly beneficial. However, sleep - especially duration - remains underexplored. Future interventions should adopt a 24-hour movement behavior perspective and more explicitly integrate and report BCTs to optimize long-term diabetes management.