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The Prevention or Delay of Type 2 Diabetes
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Chris Malcolm
Mar 31, 2012, 5:29:36 AM3/31/12
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The current issue of the ADA's journal "Diabetic Care" features an editorial
"Steps Toward the Meaningful Translation of Prevention Strategies for
Type 2 Diabetes"
http://care.diabetesjournals.org/content/35/4/663.full
"As a scientific and medical community, we are clearly in a position
to take the next logical steps toward the ultimate goal to reduce
progression to type 2 diabetes for our populations at risk."
[...]
"... evidence to date suggests that we are able to identify
individuals in prediabetic states. and that we can delay the
progression to overt diabetes, at least as documented with
intervention strategies tested in well-designed clinical trials. Thus,
it appears that we are at a stage where we can begin discussions on
implementing effective prevention strategies at a population-based
level."
[...]
"The ADA's Strategic Plan, in many ways, relies on and specifically
promotes the effective translation of the clinical research findings
from the prevention studies to the community and primary care
levels. As specifically outlined (5), the ADA's plan proposes to
monitor progress in the prevention of diabetes by specific metrics,
and it is proposed that by the end of 2015, the percentage of
Americans with prediabetes who are aware of their condition will
double from 7.3 to 15%. In addition, the plan calls for at least a 10%
increase in the percentage of people with prediabetes who report
engaging in specific preventive behaviors including evidenced-based
strategies such as weight control and weight loss, physical activity,
and healthy eating (5)."
So their aim is that by 2015 15% of American prediabetics will know
they have prediabetes, and 10% more of them will be doing something
effective about it. 10% more than what? So far I haven't been able to
find that number. I suspect it won't be a big number :-)
But why has this taken so long? For example ten years ago in 2002 the
ADA's "Diabetic Care" journal published a report
"The Prevention or Delay of Type 2 Diabetes"
http://care.diabetesjournals.org/content/25/4/742.full
in which they said
"Diabetes is one of the most costly and burdensome chronic diseases of
our time and is a condition that is increasing in epidemic proportions
in the U.S. and throughout the world (1). The complications resulting
from the disease are a significant cause of morbidity and mortality
and are associated with the damage or failure of various organs such
as the eyes, kidneys, and nerves. Individuals with type 2 diabetes are
also at a significantly higher risk for coronary heart disease,
peripheral vascular disease, and stroke, and they have a greater
likelihood of having hypertension, dyslipidemia, and obesity (2.6).
"There is also growing evidence that at glucose levels above normal
but below the threshold diagnostic for diabetes, there is a
substantially increased risk of cardiovascular disease (CVD) and death
(5,7.10). In these individuals, CVD risk factors are also more
prevalent (5.7,9,11.14), which further increases the risk but is not
sufficient to totally explain it."
They structured this report around five questions.
Q1: Should we attempt to prevent diabetes?
The answer was yes, we should.
Q2: Who are potential candidates for screening and
intervention?
The answer was those with prediabetes.
Q3: How should diabetes prevention be performed?
They decided lifestyle modification (diet and exercise) was more
effective than any drug therapy. (However later research
concluded that the most effective intervention is d&e plus
metformin, which is what is now recommended.)
They did make an interesting comment about the use of metformin,
rather relevent to those of us who are old or not obese.
"In the DPP, metformin was about half as effective as diet and
exercise in delaying the onset of diabetes overall, but it was nearly
ineffective in older individuals (>60 years of age) or in those who
were less overweight (BMI <30 kg/m2). Conversely, metformin was as
effective as lifestyle modification in individuals age 24-44 years or
in those with a BMI >35 kg/m2. Thus, the population of people in whom
treatment with metformin has equal benefit to that of a lifestyle
intervention is only a small subset of those who are likely to have
IFG or IGT."
Q4: How do strategies to prevent diabetes differ from those
to treat diabetes?
Basically it's the same treatment, except that diabetics often have
diabetic complications which also need to be monitored and treated.
Q5: What additional research is needed?
"There is now substantial evidence that type 2 diabetes can be
prevented or delayed. Individuals at high risk of developing diabetes
can be identified easily. It is not yet known whether the successful
interventions will cost-effectively reduce the morbidity and mortality
associated with diabetes. Diabetes prevention policies that focus on
lifestyle modification, specifically modest weight loss and increased
physical activity, are also very likely to have additional health
benefits. Public health messages, health care professionals, and
health care systems should all encourage behavior changes to achieve a
healthy lifestyle. Further research is necessary to understand better
how to facilitate effective and efficient programs for the primary
prevention of type 2 diabetes."
In other words, it was known that treatment of prediabetes to prevent
or delay the onset of type 2 diabetes works, the only problem is
whether in a cost-benefit analysis it would be worth while putting
expensive national medical effort into doing something about it.
It appears that it's taken ten more years of research to establish
that it is indeed worth while doing something about it, the result
being announced in the editorial to this month's "Diabetic Care"
journal, "Steps Toward the Meaningful Translation of Prevention
Strategies for Type 2 Diabetes".
Which of course will take some years to put into effect. So someone
with prediabetes in 2002 could have read the ADA's recommendations and
have started doing something about preventing (or delaying) the
development of diabetes. In 2002. Or they could simply have waited for
their doctor to tell them they were prediabetic and what to do about
it. If you're one of the lucky ones and the ADA's Strategic Plan
achieves its goals that might happen in a few years. In 2015...
I think that's rather a good argument for keeping an eye on the
research!
--
Chris Malcolm
"Steps Toward the Meaningful Translation of Prevention Strategies for
Type 2 Diabetes"
http://care.diabetesjournals.org/content/35/4/663.full
"As a scientific and medical community, we are clearly in a position
to take the next logical steps toward the ultimate goal to reduce
progression to type 2 diabetes for our populations at risk."
[...]
"... evidence to date suggests that we are able to identify
individuals in prediabetic states. and that we can delay the
progression to overt diabetes, at least as documented with
intervention strategies tested in well-designed clinical trials. Thus,
it appears that we are at a stage where we can begin discussions on
implementing effective prevention strategies at a population-based
level."
[...]
"The ADA's Strategic Plan, in many ways, relies on and specifically
promotes the effective translation of the clinical research findings
from the prevention studies to the community and primary care
levels. As specifically outlined (5), the ADA's plan proposes to
monitor progress in the prevention of diabetes by specific metrics,
and it is proposed that by the end of 2015, the percentage of
Americans with prediabetes who are aware of their condition will
double from 7.3 to 15%. In addition, the plan calls for at least a 10%
increase in the percentage of people with prediabetes who report
engaging in specific preventive behaviors including evidenced-based
strategies such as weight control and weight loss, physical activity,
and healthy eating (5)."
So their aim is that by 2015 15% of American prediabetics will know
they have prediabetes, and 10% more of them will be doing something
effective about it. 10% more than what? So far I haven't been able to
find that number. I suspect it won't be a big number :-)
But why has this taken so long? For example ten years ago in 2002 the
ADA's "Diabetic Care" journal published a report
"The Prevention or Delay of Type 2 Diabetes"
http://care.diabetesjournals.org/content/25/4/742.full
in which they said
"Diabetes is one of the most costly and burdensome chronic diseases of
our time and is a condition that is increasing in epidemic proportions
in the U.S. and throughout the world (1). The complications resulting
from the disease are a significant cause of morbidity and mortality
and are associated with the damage or failure of various organs such
as the eyes, kidneys, and nerves. Individuals with type 2 diabetes are
also at a significantly higher risk for coronary heart disease,
peripheral vascular disease, and stroke, and they have a greater
likelihood of having hypertension, dyslipidemia, and obesity (2.6).
"There is also growing evidence that at glucose levels above normal
but below the threshold diagnostic for diabetes, there is a
substantially increased risk of cardiovascular disease (CVD) and death
(5,7.10). In these individuals, CVD risk factors are also more
prevalent (5.7,9,11.14), which further increases the risk but is not
sufficient to totally explain it."
They structured this report around five questions.
Q1: Should we attempt to prevent diabetes?
The answer was yes, we should.
Q2: Who are potential candidates for screening and
intervention?
The answer was those with prediabetes.
Q3: How should diabetes prevention be performed?
They decided lifestyle modification (diet and exercise) was more
effective than any drug therapy. (However later research
concluded that the most effective intervention is d&e plus
metformin, which is what is now recommended.)
They did make an interesting comment about the use of metformin,
rather relevent to those of us who are old or not obese.
"In the DPP, metformin was about half as effective as diet and
exercise in delaying the onset of diabetes overall, but it was nearly
ineffective in older individuals (>60 years of age) or in those who
were less overweight (BMI <30 kg/m2). Conversely, metformin was as
effective as lifestyle modification in individuals age 24-44 years or
in those with a BMI >35 kg/m2. Thus, the population of people in whom
treatment with metformin has equal benefit to that of a lifestyle
intervention is only a small subset of those who are likely to have
IFG or IGT."
Q4: How do strategies to prevent diabetes differ from those
to treat diabetes?
Basically it's the same treatment, except that diabetics often have
diabetic complications which also need to be monitored and treated.
Q5: What additional research is needed?
"There is now substantial evidence that type 2 diabetes can be
prevented or delayed. Individuals at high risk of developing diabetes
can be identified easily. It is not yet known whether the successful
interventions will cost-effectively reduce the morbidity and mortality
associated with diabetes. Diabetes prevention policies that focus on
lifestyle modification, specifically modest weight loss and increased
physical activity, are also very likely to have additional health
benefits. Public health messages, health care professionals, and
health care systems should all encourage behavior changes to achieve a
healthy lifestyle. Further research is necessary to understand better
how to facilitate effective and efficient programs for the primary
prevention of type 2 diabetes."
In other words, it was known that treatment of prediabetes to prevent
or delay the onset of type 2 diabetes works, the only problem is
whether in a cost-benefit analysis it would be worth while putting
expensive national medical effort into doing something about it.
It appears that it's taken ten more years of research to establish
that it is indeed worth while doing something about it, the result
being announced in the editorial to this month's "Diabetic Care"
journal, "Steps Toward the Meaningful Translation of Prevention
Strategies for Type 2 Diabetes".
Which of course will take some years to put into effect. So someone
with prediabetes in 2002 could have read the ADA's recommendations and
have started doing something about preventing (or delaying) the
development of diabetes. In 2002. Or they could simply have waited for
their doctor to tell them they were prediabetic and what to do about
it. If you're one of the lucky ones and the ADA's Strategic Plan
achieves its goals that might happen in a few years. In 2015...
I think that's rather a good argument for keeping an eye on the
research!
--
Chris Malcolm
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