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Prevention of Type 2 Diabetes Mellitus

Prevention of Type 2 Diabetes Mellitus. Key Questions and A Call to Action. Prevention of Type 2 Diabetes Mellitus: Table of Contents. Section 1. Why is prevention of type 2 diabetes imperative?. Projecting the Future Diabetes Population: The Imperative for Change.

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Prevention of Type 2 Diabetes Mellitus

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  1. Prevention of Type 2 Diabetes Mellitus Key Questions and A Call to Action

  2. Prevention of Type 2 Diabetes Mellitus: Table of Contents

  3. Section 1 Why is prevention of type 2 diabetes imperative?

  4. Projecting the Future Diabetes Population: The Imperative for Change U.S. Population withDiabetes (%) Boyle JP, et al. Popul Health Metr. 2010;8(29):1-12.

  5. Percentage of U.S. Adults Who Were Obese or Had Diagnosed Diabetes 2008 1994 2000 2008 1994 2000 No Data <14.0% 14.0-17.9% 18.0-21.9% 22.0-25.9% 26.0% Obesity (BMI ≥30 kg/m2) Diabetes No Data <4.5% 4.5-5.9% 6.0-7.4% 7.5-8.9% ≥9.0% Centers for Disease Control and Prevention: National Diabetes Surveillance System. Available online at: http://apps.nccd.cdc.gov/DDTSTRS/default.aspx. Accessed 10/3/2011.

  6. Section 2 whaT IS THE EVIDENCE THAT TYPE 2 DIABETESCAN BE PREVENTED OR DELAYED?

  7. Lifestyle InterventionsCan Prevent Type 2 Diabetes Onset • Several randomized trials have shown interventions (lifestyle, medications) can decrease rate of onset of diabetes • Lifestyle: Da Qing, Finnish Diabetes Prevention Study, Diabetes Prevention Program • Medications: Diabetes Prevention Program (metformin), The Stop-NIDDM (acarbose), DREAM (rosiglitazone), ACT-NOW (pioglitazone)

  8. Lifestyle InterventionsDa Qing Study Methods • 110,660 adults from 33 Da Qing, China, health care clinics screened in 1986 for IGT, type 2 diabetes mellitus • 577 adults with IGT (WHO criteria) randomized to control (n=138) or one of three lifestyle interventions (n=438) • Diet only • Exercise only • Diet + exercise • Follow-up at 2-year intervals over 6 years to identify those who developed diabetes Pan XR, et al. Diabetes Care. 1997;20:537-544.

  9. Lifestyle InterventionsDa Qing Study Results • Cumulative incidence of diabetes at6 years was significantly decreased in the active intervention groups (P<0.05) • When analyzed by clinic, each active intervention group differed significantly from the control (P<0.05) Pan XR, et al. Diabetes Care. 1997;20:537-544.

  10. Lifestyle InterventionsDa Qing Study Results • When stratified as lean or overweight(BMI < or ≥25 kg/m2), relative decrease in rate of development of diabetes in lifestyle intervention groups was similar • After adjusting for differences in baseline BMI and fasting glucose, all interventions were associated with diabetes risk reduction Pan XR, et al. Diabetes Care. 1997;20:537-544.

  11. Lifestyle InterventionsDa Qing Study Conclusions • Active intervention with diet and/or exercise led to a significant decrease in incidence of diabetes over a 6-year period (1986-1992) among those with IGT • Diabetes incidence (per 100 person years) per year • Control: 14.1 (95% CI 11.2-17.0) • Lifestyle intervention: 7.9 (95% CI, 6.8-9.1) Pan XR, et al. Diabetes Care. 1997;20:537-544.

  12. Lifestyle InterventionsFinnish Diabetes Prevention Study • 522 subjects, 40-65 years of age • BMI ≥25 kg/m2;IGT: 2-h PPG 140-200 mg/dL • Control group: general oral and written information diet and exercise • Intervention group: individualized • Reduce weight ≥5% • Decrease fat ≤30%, saturated fat ≤10% energy • Increase fiber to at least 15 g/1000 kcal • Moderate exercise ≥30 minutes/day • Primary end point: diagnosis of diabetes Tuomilehto J, et al for the Finnish Diabetes Prevention Study Group.N Engl J Med. 2001;344:1343-1350.

  13. Lifestyle InterventionsFinnish Diabetes Prevention Study • 172 men, 350 women; mean age 55 y • Mean BMI 31 kg/m2 • Mean duration of follow-up 3.2 years *P<0.001 Tuomilehto J, et al for the Finnish Diabetes Prevention Study Group.N Engl J Med. 2001;344:1343-1350.

  14. Lifestyle InterventionsFinnish Diabetes Prevention Study • Reduction in incidence of type 2 diabetes was directly associated with changes in lifestyles of high-risk subjects (ie, those with IGT) • Modifiable risk factors such as obesity, physical inactivity, suggested as main nongenetic determinants of diabetes • These results demonstrate that 22 subjects with IGT must be treated with lifestyle intervention for 1 year (or 5 subjects for 5 years) to prevent 1 case of diabetes Tuomilehto J, et al for the Finnish Diabetes Prevention Study Group.N Engl J Med. 2001;344:1343-1350.

  15. Lifestyle InterventionsDiabetes Prevention Program • 3,234 nondiabetic persons in 27 clinical centers • BMI ≥24 kg/m2 (≥22 kg/m2 in Asians) • IGT: FPG 95-125 mg/dL or 2-h PPG 140-199 mg/dL • From 1996-1999, randomly assigned to • Standard lifestyle + placebo (n=1082) • Standard lifestyle + metformin, initiated at 850 mg orally once daily; at 1 month, increased to 850 mg twice daily (n=1073) • Intensive lifestyle intervention (n=1079) Knowler WC, et al. for the Diabetes Prevention Program Research Group.N Engl J Med. 2002;346:393-403.

  16. Lifestyle InterventionsDiabetes Prevention Program Goals of intensive lifestyle intervention • 7% loss of body weight • Dietary fat goal: 25% of calories from fat • Calorie intake goal: 1200-1800 kcal/day based on initial body weight • >150 minutes of physical activities weekly • Similar in intensity to brisk walking; at least 700 kcal/week • Group received 16-lesson curriculum Knowler WC, et al. for the Diabetes Prevention Program Research Group.N Engl J Med. 2002;346:393-403.

  17. Lifestyle InterventionsDiabetes Prevention Program • Mean age 50.6 years • 67.7% women; 45.3% members of minority groups • Mean BMI 34.0 kg/m2 • 69.4% had a family history of diabetes • Average follow-up: 2.8 years(range, 1.8-4.6) Knowler WC, et al. for the Diabetes Prevention Program Research Group.N Engl J Med. 2002;346:393-403.

  18. Lifestyle InterventionsDiabetes Prevention Program • Those assigned to lifestyle intervention had greater weight loss and increase in physical activity than participants receiving metformin or placebo • Lifestyle intervention more effective in restoring normal post-load glucose values Results: average weight loss (P<0.001) Knowler WC, et al. for the Diabetes Prevention Program Research Group.N Engl J Med. 2002;346:393-403.

  19. Lifestyle InterventionsDiabetes Prevention Program Results: intensive lifestyle intervention Knowler WC, et al. for the Diabetes Prevention Program Research Group.N Engl J Med. 2002;346:393-403.

  20. MedicationsDPP: Metformin Intervention • Metformin, intensive lifestyle modification delayed or prevented type 2 diabetes vs placebo (11%/year incidence) • Placebo: 11%/year incidence • Metformin: 7.8%/year incidence* • Lifestyle intervention: 4.8%/year incidence* • Risk reduction: • 31% by metformin • 58% by lifestyle • 39% lifestyle vs metformin *P<0.001 vs placebo Knowler WC, et al. for the Diabetes Prevention Program Research Group.N Engl J Med. 2002;346:393-403.

  21. MedicationsDPP: Metformin Intervention • Intensive lifestyle intervention more effective than either metformin or placebo • By subgroup, metformin more effective if: • FPG >110 mg/dL • Age <60 years • BMI >35 kg/m2 • Gender, ethnicity, 2-h PGG, NOT predictive of response • Use metformin in high-risk individuals Knowler WC, et al. for the Diabetes Prevention Program Research Group.N Engl J Med. 2002;346:393-403.

  22. MedicationsThe STOP-NIDDM: Acarbose • Acarbose reduced risk of new • Hypertension >140/90; 5.3% absolute risk reduction (P=0.006) • Myocardial infarction (P=0.02) • Any CVD event: CHD, CV death or stroke, CHF, PVD (P=0.03) Acarbose100 mg TIDn=682 Placebon=686 25% Relative Risk Reduction P=0.0022 Reprinted with permission from Chiasson JL, et al. Lancet. 2002;359(9323): 2072-2077;Chiasson JL, et al. JAMA. 2003;290(4):486-494.

  23. MedicationsDREAM: Rosiglitazone 60%Relative Risk Reduction HR 0.40 (0.35–0.46) P<0.0001 Reprinted with permission from DREAM Trial Investigators. Lancet. 2006;368(9541):1096-1105.

  24. MedicationsACT NOW: Pioglitazone • Pioglitazone reduced risk of type 2 diabetes mellitus by 72% vs placebo (HR 0.28; 95% CI 0.16–0.49 P<0.001) • Conversion to normal glucose tolerance: 48% of patients with pioglitazone vs 28% with placebo (P<0.001) • Pioglitazone reduced fasting glucose,2-hour glucose, HbA1c • Weight gain, edema observed in the pioglitazone arm DeFronzo RA, et al, for the ACT NOW Study. N Engl J Med. 2011;364:1104-1115.

  25. Section 3 DO PREVENTION INTERVENTIONS HAVE SUSTAINED EFFECTS?

  26. Lifestyle InterventionsDa Qing Study 20-Year Follow-Up • Combined lifestyle intervention vs control • 51% lower incidence of diabetes during active intervention • 43% lower incidence over 20 years • 3.6 years fewer with diabetes Li G, et al. Lancet. 2008;371:1783-1789.

  27. Lifestyle InterventionsDa Qing Study 20-Year Follow-Up • No significant difference in rate of • First CVD event (HR 0.98; 95% CI, 0-71-1.37) • CVD mortality (HR 0.83; 0.48-1.40) • All-cause mortality (HR 0.96; 0.65-1.41) • Study had limited statistical power to detect differences in these outcomes • Lifestyle interventions over 6 years can prevent, delay diabetes for up to 14 years after active intervention • Unclear whether lifestyle interventions also lead to reduced CVD, mortality Li G, et al. Lancet. 2008;371:1783-1789.

  28. Lifestyle InterventionsFinnish DPS 7-Year Follow-Up 43% Relative Risk Reduction Reprinted with permission from Lindström J, et al. Lancet. 2006;368(9548):1673-1679.

  29. DPP: Metformin Had Sustained EffectAfter Drug Washout • Brief (1-2 week) drug washout study at end of Diabetes Prevention Program trial • After washout, diabetes was more frequently diagnosed in metformin vs. placebo (1.49; 0.93, 2.38; P=0.098) • DPP primary analysis: metformin decreased diabetes risk by 31% • Washout: 26% accounted for by pharmacological effect of metformin • Postwashout: diabetes reduced by 25% Diabetes Prevention Program Research Group. Diabetes Care. 2003;26:977-980.

  30. Rosiglitazone Had No Sustained EffectAfter Drug Washout: DREAM • During rosiglitazone vs placebo washout • Primary outcome, new-onset diabetes or death: 10.5% vs 9.8% (P=0.59) • Secondary outcome, regression to normoglycemia: 21.5% vs 23.8% (P=0.33) • Median follow-up: 71 days (range, 63-86 days) • Rosiglitazone substantially reduced incidence of type 2 diabetes (DREAM); however, when withdrawn, this effect is not sustained The DREAM Trial Investigators. Diabetes Care. 2011;34:1265-1269.

  31. Lifestyle InterventionsSummary • Lifestyle intervention continues to have an effect; most drugs do not Lifestyle Pharmacologic Diabetes Care. 1997;20:537-544; N Engl J Med. 2002;344:1343-1350;N Engl J Med. 2002;346;393-403; Diabetes Care. 2011;34:1265-1269;Lancet. 2002;359(9323): 2072-2077 N Engl J Med. 2011;364:1104-1115.

  32. Section 4 Are we preventing type 2 diabetes or delaying it?

  33. Diabetes Prevention Program10-Year Follow-Up Study • During 10-year follow-up since randomization • Original lifestyle group lost, then partly regained weight • Modest weight loss with metformin maintained • Diabetes incidence per 100 person-years *vs placebo Diabetes Prevention Program. Lancet. 2009;374:1677-1686.

  34. Section 5 Is diabetes prevention cost-effective?

  35. Cost-Effectiveness of Lifestyle Modification or Metformin: DPP • Active interventions (vs placebo) would: QALY = Quality Adjusted Life Years Herman WH, et al for the Diabetes Prevention Program Research Group.Ann Intern Med. 2005:142:323-332.

  36. Diabetes Prevention Program 10-Year Cost-Effectiveness • 10-year within-trial cost-effectiveness of the interventions • Intensive lifestyle • Metformin • Data on resource utilization, cost, and quality of life collected prospectively • Economic analyses performed from health system and societal perspectives Diabetes Prevention Program Research Group. Diabetes Care. 2012;35:723-730.

  37. Diabetes Prevention Program 10-Year Cost-Effectiveness • Lifestyle cost-effective, metformin marginally cost-saving vs placebo • Investment in lifestyle, metformin interventions for diabetes prevention in high-risk adults provides good value Incremental cost-effectiveness ratios from three different perspectives; ∆cost/∆QALY *Includes direct medical costs and direct nonmedical costs including participant time †Both costs and QALYs are discounted at 3% Diabetes Prevention Program Research Group. Diabetes Care. 2012;35:723-730.

  38. Section 6 Can evidence-based interventions be delivered effectively in lower-cost settings?

  39. DEPLOY Pilot Study: Diabetes Prevention in the Community • Adults BMI ≥24 kg/m2, ≥2 diabetes risk factors, blood glucose 110-199 mg/dL • Randomized to group-based DPP lifestyle intervention or brief counseling (control) Ackermann RT, et al. Am J Prevent Med. 2008;35:357-363.

  40. Practice-Based Opportunities for Weight Reduction (POWER) • Obese patients achieve, sustain significant weight loss with behavioral interventions *P<0.001 vs control arm Appel LJ, et al. N Engl J Med. 2011;365:1959-68.

  41. Diabetes TeleHealth Improves Diabetes Self-Management • 1-year remote DSME intervention, Diabetes TeleCare (dietitian, nurse/certified diabetes educator • Improved metabolic control, reduced CV risk *P=0.003 vs. baseline †P=0.004 vs. baseline Davis RM, et al. Diabetes Care. 2010;33:1712–1717.

  42. Section 7 Will diabetes prevention “bend the curve” of the epidemic?

  43. CDC Modeling Study to ReduceFuture Diabetes Prevalence • Five-state model • Potential effect of hypothetical preventive intervention delivered to all with IFG • If 50% participated and incidence reduced by 50%, would equal 25% reduction in annual incidence of diabetes in the population with IFG • Would lower the increase in prevalence by 2050 to 1 in 4 (vs 1 in 3) Boyle JP, et al. Popul Health Metr. 2010;8(29):1-12.

  44. Section 8 How can we most effectively prevent or delay type 2 diabetes?

  45. Most People with Diabetes Are Unaware of Their Condition • Data analyzed from 1,402 adults without diabetes • 2005–2006 NHANES participants • Valid fasting plasma glucose, oral glucose tolerance tests • Almost 30% of the US adult population had prediabetes in 2005–2006; only 7.3% were aware they had it • Adoption of risk reduction behaviors suboptimal Geiss LS, et al. Am J Prevent Med. 2010;38:403-409.

  46. We Need to Test People at Risk *For all three tests, risk is continuous, extending below the lower limit of a range and becoming disproportionately greater at higher ends of the range. ADA. I. Classification and Diagnosis. Diabetes Care 2012;35(suppl 1):S13. Table 3.

  47. Recommendations: Testing for Diabetes in Asymptomatic Patients • Consider testing overweight/obese adults with one or more additional risk factors • In those without risk factors, begin testing at age 45 years (B) • If tests are normal • Repeat testing at least at 3-year intervals (E) • Use A1C, FPG, or 2-h 75-g OGTT (B) • In those with increased risk for future diabetes • Identify and, if appropriate, treat other CVD risk factors (B) ADA. II. Testing in Asymptomatic Patients. Diabetes Care. 2012;35(suppl 1):S13.

  48. Criteria for Testing for Diabetes in Asymptomatic Adult Individuals (1) 1. Testing should be considered in all adults who are overweight (BMI ≥25 kg/m2*) and have additional risk factors: • HDL cholesterol level<35 mg/dl (0.90 mmol/l) and/or a triglyceride level >250 mg/dl (2.82 mmol/l) • Women with polycystic ovarian syndrome (PCOS) • A1C ≥5.7%, IGT, or IFG on previous testing • Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans) • History of CVD *At-risk BMI may be lower in some ethnic groups. ADA. Testing in Asymptomatic Patients. Diabetes Care. 2012;35(suppl 1):S14. Table 4.

  49. Criteria for Testing for Diabetes in Asymptomatic Adult Individuals (2) ADA. Testing in Asymptomatic Patients. Diabetes Care. 2012;35(suppl 1):S14. Table 4.

  50. DPP: Managing Prediabetes • For those found to have prediabetes, provide support or referral to encourage • Weight loss of at least 7% • Moderate exercise of at least 150 minutes per week • Consider metformin for certain patients • Obese (BMI ≥35 kg/m2) • <60 years (most effective, 25-44 years) • Lifestyle interventions feasible, morecost-effective than medications American Diabetes Association, 2012.

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