Effectiveness of Clinical Prevention of type 2 diabetes Complete Group Presentation Topic: Effectiveness of Clinical Prevention of type 2 diabetes Powerpo

Effectiveness of Clinical Prevention of type 2 diabetes Complete Group Presentation Topic: Effectiveness of Clinical Prevention of type 2 diabetes
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At least 3 References within 5 years (1 must be Healthy People 2020) Diabetes Care Volume 42, Supplement 1, January 2019
3. Prevention or Delay of Type 2
Diabetes: Standards of Medical
Care in Diabetesd2019
American Diabetes Association
Diabetes Care 2019;42(Suppl. 1):S29–S33 | https://doi.org/10.2337/dc19-S003
The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes”
includes ADA’s current clinical practice recommendations and is intended to
provide the components of diabetes care, general treatment goals and guidelines,
and tools to evaluate quality of care. Members of the ADA Professional Practice
Committee, a multidisciplinary expert committee, are responsible for updating
the Standards of Care annually, or more frequently as warranted. For a detailed
description of ADA standards, statements, and reports, as well as the evidencegrading system for ADA’s clinical practice recommendations, please refer to the
Standards of Care Introduction. Readers who wish to comment on the Standards
of Care are invited to do so at professional.diabetes.org/SOC.
For guidelines related to screening for increased risk for type 2 diabetes (prediabetes),
please refer to Section 2 “Classification and Diagnosis of Diabetes.”
3.1 At least annual monitoring for the development of type 2 diabetes in those
with prediabetes is suggested. E
Screening for prediabetes and type 2 diabetes risk through an informal assessment
of risk factors (Table 2.3) or with an assessment tool, such as the American
Diabetes Association risk test (Fig. 2.1), is recommended to guide providers on
whether performing a diagnostic test for prediabetes (Table 2.5) and previously undiagnosed type 2 diabetes (Table 2.2) is appropriate (see Section
2 “Classification and Diagnosis of Diabetes”). Those determined to be at high
risk for type 2 diabetes, including people with A1C 5.726.4% (39247 mmol/mol),
impaired glucose tolerance, or impaired fasting glucose, are ideal candidates
for diabetes prevention efforts. Using A1C to screen for prediabetes may
be problematic in the presence of certain hemoglobinopathies or conditions
that affect red blood cell turnover. See Section 2 “Classification and Diagnosis of
Diabetes” and Section 6 “Glycemic Targets” for additional details on the appropriate
use of the A1C test.
At least annual monitoring for the development of diabetes in those with
prediabetes is suggested.
3.2 Refer patients with prediabetes to an intensive behavioral lifestyle intervention program modeled on the Diabetes Prevention Program (DPP) to achieve
Suggested citation: American Diabetes Association. 3. Prevention or delay of type 2 diabetes:
Standards of Medical Care in Diabetesd2019.
Diabetes Care 2019;42(Suppl. 1):S29–S33
© 2018 by the American Diabetes Association.
Readers may use this article as long as the work
is properly cited, the use is educational and not
for profit, and the work is not altered. More information is available at http://www.diabetesjournals
Prevention or Delay of Type 2 Diabetes
and maintain 7% loss of initial body weight and increase
moderate-intensity physical activity (such as brisk walking) to
at least 150 min/week. A
3.3 Based on patient preference,
technology-assisted diabetes
prevention interventions may
be effective in preventing type
2 diabetes and should be considered. B
3.4 Given the cost-effectiveness of
diabetes prevention, such intervention programs should be covered by third-party payers. B
The Diabetes Prevention Program
Several major randomized controlled trials, including the Diabetes Prevention
Program (DPP) (1), the Finnish Diabetes
Prevention Study (DPS) (2), and the Da
Qing Diabetes Prevention Study (Da Qing
study) (3), demonstrate that lifestyle/
behavioral therapy featuring an individualized reduced calorie meal plan is
highly effective in preventing type 2
diabetes and improving other cardiometabolic markers (such as blood pressure,
lipids, and inflammation). The strongest
evidence for diabetes prevention comes
from the DPP trial (1). The DPP demonstrated that an intensive lifestyle intervention could reduce the incidence of
type 2 diabetes by 58% over 3 years.
Follow-up of three large studies of lifestyle intervention for diabetes prevention has shown sustained reduction in
the rate of conversion to type 2 diabetes:
45% reduction at 23 years in the Da Qing
study (3), 43% reduction at 7 years in the
DPS (2), and 34% reduction at 10 years (4)
and 27% reduction at 15 years (5) in the
U.S. Diabetes Prevention Program Outcomes Study (DPPOS). Notably, in the
23-year follow-up for the Da Qing study,
reductions in all-cause mortality and
cardiovascular disease–related mortality were observed for the lifestyle
intervention groups compared with the
control group (3).
The two major goals of the DPP intensive, behavioral, lifestyle intervention
were to achieve and maintain a minimum
of 7% weight loss and 150 min of physical
activity similar in intensity to brisk walking per week. The DPP lifestyle intervention was a goal-based intervention: all
participants were given the same weight
loss and physical activity goals, but individualization was permitted in the
Diabetes Care Volume 42, Supplement 1, January 2019
specific methods used to achieve the
goals (6).
The 7% weight loss goal was selected
because it was feasible to achieve and
maintain and likely to lessen the risk of
developing diabetes. Participants were
encouraged to achieve the 7% weight
loss during the first 6 months of the
intervention. However, longer-term
(4-year) data reveal maximal prevention
of diabetes observed at about 7–10%
weight loss (7). The recommended pace
of weight loss was 122 lb/week. Calorie
goals were calculated by estimating the
daily calories needed to maintain the
participant’s initial weight and subtracting 50021,000 calories/day (depending
on initial body weight). The initial focus
was on reducing total dietary fat. After
several weeks, the concept of calorie
balance and the need to restrict calories
as well as fat was introduced (6).
The goal for physical activity was selected to approximate at least 700 kcal/
week expenditure from physical activity.
For ease of translation, this goal was
described as at least 150 min of moderateintensity physical activity per week
similar in intensity to brisk walking. Participants were encouraged to distribute
their activity throughout the week with
a minimum frequency of three times per
week with at least 10 min per session. A
maximum of 75 min of strength training
could be applied toward the total
150 min/week physical activity goal (6).
To implement the weight loss and
physical activity goals, the DPP used an individual model of treatment rather than
a group-based approach. This choice was
based on a desire to intervene before
participants had the possibility of developing diabetes or losing interest in the
program. The individual approach also
allowed for tailoring of interventions to
reflect the diversity of the population (6).
The DPP intervention was administered as a structured core curriculum
followed by a more flexible maintenance
program of individual sessions, group
classes, motivational campaigns, and restart opportunities. The 16-session core
curriculum was completed within the
first 24 weeks of the program and included sections on lowering calories, increasing physical activity, self-monitoring,
maintaining healthy lifestyle behaviors,
and psychological, social, and motivational
challenges. For further details on the core
curriculum sessions, refer to ref. 6.
Structured behavioral weight loss therapy, including a reduced calorie meal
plan and physical activity, is of paramount importance for those at high
risk for developing type 2 diabetes who
have overweight or obesity (1,7). Because weight loss through lifestyle
changes alone can be difficult to maintain
long term (4), people being treated with
weight loss therapy should have access
to ongoing support and additional therapeutic options (such as pharmacotherapy) if needed. Based on intervention
trials, the eating patterns that may be
helpful for those with prediabetes
include a Mediterranean eating plan
(8–11) and a low-calorie, low-fat eating
plan (5). Additional research is needed
regarding whether a low-carbohydrate
eating plan is beneficial for persons with
prediabetes (12). In addition, evidence
suggests that the overall quality of food
consumed (as measured by the Alternative Healthy Eating Index), with an emphasis on whole grains, legumes, nuts,
fruits and vegetables, and minimal refined and processed foods, is also important (13–15).
Whereas overall healthy low-calorie
eating patterns should be encouraged,
there is also some evidence that particular dietary components impact diabetes
risk in observational studies. Higher intakes of nuts (16), berries (17), yogurt
(18,19), coffee, and tea (20) are associated with reduced diabetes risk. Conversely, red meats and sugar-sweetened
beverages are associated with an increased risk of type 2 diabetes (13).
As is the case for those with diabetes,
individualized medical nutrition therapy
(see Section 5 “Lifestyle Management”
for more detailed information) is effective in lowering A1C in individuals diagnosed with prediabetes (21).
Physical Activity
Just as 150 min/week of moderateintensity physical activity, such as brisk
walking, showed beneficial effects in
those with prediabetes (1), moderateintensity physical activity has been
shown to improve insulin sensitivity
and reduce abdominal fat in children
and young adults (22,23). On the basis
of these findings, providers are encouraged to promote a DPP-style program,
including its focus on physical activity, to
all individuals who have been identified
Prevention or Delay of Type 2 Diabetes
to be at an increased risk of type 2
diabetes. In addition to aerobic activity,
an exercise regimen designed to prevent
diabetes may include resistance training
(6,24). Breaking up prolonged sedentary
time may also be encouraged, as it is
associated with moderately lower postprandial glucose levels (25,26). The preventive effects of exercise appear to
extend to the prevention of gestational
diabetes mellitus (GDM) (27).
are promising (39). In an effort to expand
preventive services using a cost-effective
model that began in April 2018, the Centers
for Medicare & Medicaid Services has
expanded Medicare reimbursement coverage for the National DPP lifestyle intervention to organizations recognized by the
CDC that become Medicare suppliers for
this service (https://innovation.cms.gov/
Technology-Assisted Interventions to
Deliver Lifestyle Interventions
Tobacco Use
Technology-assisted interventions may
effectively deliver the DPP lifestyle
intervention, reducing weight and,
therefore, diabetes risk (28–31). Such
technology-assisted interventions may
deliver content through smartphone
and web-based applications and telehealth (28). The Centers for Disease
Control and Prevention (CDC) Diabetes
Prevention Recognition Program (DPRP)
lifestyle-program) does certify technologyassisted modalities as effective vehicles
for DPP-based interventions; such programs must use an approved curriculum, include interaction with a coach
(which may be virtual), and attain the
DPRP outcomes of participation, physical activity reporting, and weight loss.
The selection of an in-person or virtual
program should be based on patient
A cost-effectiveness model suggested that
the lifestyle intervention used in the DPP
was cost-effective (32,33). Actual cost data
from the DPP and DPPOS confirmed this
(34). Group delivery of DPP content in
community or primary care settings has
the potential to reduce overall program
costs while still producing weight loss and
diabetes risk reduction (35–37). The use of
community health workers to support DPP
efforts has been shown to be effective with
cost savings (38) (see Section 1 “Improving
Care and Promoting Health in Populations”
for more information). The CDC coordinates the National Diabetes Prevention
Program (National DPP), a resource designed to bring evidence-based lifestyle
change programs for preventing type 2
diabetes to communities (www.cdc.gov/
diabetes/prevention/index.htm). Early
results from the CDC’s National DPP
during the first 4 years of implementation
Smoking may increase the risk of type 2
diabetes (40); therefore, evaluation for
tobacco use and referral for tobacco
cessation, if indicated, should be part
of routine care for those at risk for diabetes. Of note, the years immediately
following smoking cessation may represent a time of increased risk for diabetes (40–42) and patients should be
monitored for diabetes development
and receive evidence-based interventions for diabetes prevention as described in this section. See Section
5 “Lifestyle Management” for more detailed information.
3.5 Metformin therapy for prevention of type 2 diabetes should be
considered in those with prediabetes, especially for those with
BMI $35 kg/m2, those aged
,60 years, and women with
prior gestational diabetes mellitus. A
3.6 Long-term use of metformin may
be associated with biochemical
vitamin B12 deficiency, and periodic measurement of vitamin
B12 levels should be considered
in metformin-treated patients,
especially in those with anemia
or peripheral neuropathy. B
Pharmacologic agents including metformin, a-glucosidase inhibitors, glucagonlike peptide 1 receptor agonists,
thiazolidinediones, and several agents approved for weight loss have been shown in
research studies to decrease the incidence
of diabetes to various degrees in those with
prediabetes (1,43–49), though none are
approved by the U.S. Food and Drug
Administration specifically for diabetes
prevention. One has to balance the risk/
benefit of each medication. Metformin
has the strongest evidence base (50) and
demonstrated long-term safety as pharmacologic therapy for diabetes prevention (48). For other drugs, cost, side
effects, and durable efficacy require
Metformin was overall less effective
than lifestyle modification in the DPP
and DPPOS, though group differences
declined over time (5) and metformin
may be cost-saving over a 10-year period
(34). It was as effective as lifestyle modification in participants with BMI $35
kg/m2 but not significantly better than
placebo in those over 60 years of age (1).
In the DPP, for women with history of
GDM, metformin and intensive lifestyle
modification led to an equivalent 50%
reduction in diabetes risk (51), and both
interventions remained highly effective
during a 10-year follow-up period (52).
In the Indian Diabetes Prevention Programme (IDPP-1), metformin and the
lifestyle intervention reduced diabetes
risk similarly at 30 months; of note, the
lifestyle intervention in IDPP-1 was
less intensive than that in the DPP (53).
Based on findings from the DPP, metformin should be recommended as an
option for high-risk individuals (e.g.,
those with a history of GDM or those
with BMI $35 kg/m2). Consider monitoring vitamin B12 levels in those taking
metformin chronically to check for
possible deficiency (54) (see Section 9
“Pharmacologic Approaches to Glycemic
Treatment” for more details).
3.7 Prediabetes is associated with
heightened cardiovascular risk;
therefore, screening for and treatment of modifiable risk factors
for cardiovascular disease is suggested. B
People with prediabetes often have other
cardiovascular risk factors, including hypertension and dyslipidemia (55), and are
at increased risk for cardiovascular disease (56). Although treatment goals for
people with prediabetes are the same as
for the general population (57), increased vigilance is warranted to identify
Prevention or Delay of Type 2 Diabetes
and treat these and other cardiovascular
risk factors (e.g., smoking).
3.8 Diabetes self-management education and support programs may
be appropriate venues for people
with prediabetes to receive education and support to develop
and maintain behaviors that
can prevent or delay the development of type 2 diabetes. B
As for those with established diabetes,
the standards for diabetes self-management
education and support (see Section 5
“Lifestyle Management”) can also apply
to people with prediabetes. Currently,
there are significant barriers to the provision of education and support to those
with prediabetes. However, the strategies for supporting successful behavior
change and the healthy behaviors recommended for people with prediabetes
are comparable to those for diabetes.
Although reimbursement remains a barrier, studies show that providers of diabetes self-management education and
support are particularly well equipped to
assist people with prediabetes in developing and maintaining behaviors that
can prevent or delay the development
of diabetes (21,58).
1. Knowler WC, Barrett-Connor E, Fowler SE,
et al.; Diabetes Prevention Program Research
Group. Reduction in the incidence of type 2
diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393–403
2. Lindström J, Ilanne-Parikka P, Peltonen M,
et al.; Finnish Diabetes Prevention Study Group.
Sustained reduction in the incidence of type 2
diabetes by lifestyle intervention: follow-up of
the Finnish Diabetes Prevention Study. Lancet
3. Li G, Zhang P, Wang J, et al. Cardiovascular
mortality, all-cause mortality, and diabetes incidence after lifestyle intervention for people
with impaired glucose tolerance in the Da Qing
Diabetes Prevention Study: a 23-year follow-up
study. Lancet Diabetes Endocrinol 2014;2:474–
4. Knowler WC, Fowler SE, Hamman RF, et al.;
Diabetes Prevention Program Research Group.
10-year follow-up of diabetes incidence and
weight loss in the Diabetes Prevention Program
Outcomes Study. Lancet 2009;374:1677–1686
5. Nathan DM, Barrett-Connor E, Crandall JP,
et al. Long-term effects of lifestyle intervention or metformin on diabetes development
Diabetes Care Volume 42, Supplement 1, January 2019
and microvascular complications over 15-year
follow-up: the Diabetes Prevention Program
Outcomes Study. Lancet Diabetes Endocrinol
6. Diabetes Prevention Program (DPP) Research
Group. The Diabetes Prevention Program (DPP):
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7. Hamman RF, Wing RR, Edelstein SL, et al.
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8. Salas-Salvadó J, Bulló M, Babio N, et al.;
PREDIMED Study Investigators. Reduction in
the incidence of type 2 diabetes with the Mediterranean diet: results of the PREDIMED-Reus
nutrition intervention randomized trial. Diabetes Care 2011;34:14–19
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Estruch R, Clish CB, Ros E. Protective effects
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10. Bloomfield HE, Koeller E, Greer N,
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12. Noto H, Goto A, Tsujimoto T, Noda M. Longterm low-carbohydrate diets and type 2 diabetes risk: a systematic review and meta-analysis
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