ADA Prevention Slide Set
ADA Prevention Slide Set
ADA Prevention Slide Set
Topic
Slide No.
3-5
6-23
24-30
31-32
33-36
37-40
41-42
43-51
52-53
Section 1
WHY IS PREVENTION OF
TYPE 2 DIABETES
IMPERATIVE?
No Data
2000
<14.0%
14.0-17.9%
18.0-21.9%
2008
22.0-25.9%
26.0%
Diabetes
1994
No Data
9.0%
2000
<4.5%
4.5-5.9%
6.0-7.4%
2008
7.5-8.9%
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.
Section 2
Lifestyle Interventions
Can 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)
Lifestyle Interventions
Da 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
Lifestyle Interventions
Da Qing Study Results
Cumulative incidence of diabetes at
6 years was significantly decreased in the
active intervention groups (P<0.05)
Control
Diet
Exercise
Diet + exercise
Lifestyle Interventions
Da 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
Diet
31% (P<0.03)
Exercise
46% (P<0.0005)
Diet + exercise
42% (P<0.005)
Pan XR, et al. Diabetes Care. 1997;20:537-544.
Lifestyle Interventions
Da 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)
Lifestyle Interventions
Finnish Diabetes Prevention Study
522 subjects, 40-65 years of age
BMI 25 kg/m2; IGT: 2-h PPG 140-200 mg/dL
Reduce weight 5%
Decrease fat 30%, saturated fat 10% energy
Increase fiber to at least 15 g/1000 kcal
Moderate exercise 30 minutes/day
Lifestyle Interventions
Finnish Diabetes Prevention Study
172 men, 350 women; mean age 55 y
Mean BMI 31 kg/m2
Mean duration of follow-up 3.2 years
Weight Loss, Kg
Mean SD
Cumulative
Incidence of
Diabetes
After 4 Years
Year 1
Year 2
Control
0.83.7
0.84.4
23%
(95% CI, 17-29)
Intervention
*
4.25.1*
3.55.5*
11%
(95% CI, 6-15)
P<0.001
Risk Reduction
58%
*
Tuomilehto J, et al for the Finnish Diabetes Prevention Study Group.
N Engl J Med. 2001;344:1343-1350.
Lifestyle Interventions
Finnish 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
Lifestyle Interventions
Diabetes 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
Lifestyle Interventions
Diabetes 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
Lifestyle Interventions
Diabetes 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.
Lifestyle Interventions
Diabetes 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)
Lifestyle
Metformin
Placebo
5.6 kg
2.1 kg
0.1 kg
Knowler WC, et al. for the Diabetes Prevention Program Research Group.
N Engl J Med. 2002;346:393-403.
Lifestyle Interventions
Diabetes Prevention Program
Results: intensive lifestyle intervention
Weight loss 7%
50%
At Final
Study Visit
38%
Exercise >150
minutes/week
38%
58%
At 24 Weeks
Knowler WC, et al. for the Diabetes Prevention Program Research Group.
N Engl J Med. 2002;346:393-403.
Medications
DPP: 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.
Medications
DPP: 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
Medications
The STOP-NIDDM: Acarbose
Acarbose
100 mg TID
n=682
Placebo
n=686
25% Relative
Risk Reduction
P=0.0022
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)
Reprinted with permission from Chiasson JL, et al. Lancet. 2002;359(9323): 2072-2077;
Chiasson JL, et al. JAMA. 2003;290(4):486-494.
Medications
DREAM: Rosiglitazone
60%
Relative Risk
Reduction
HR 0.40
(0.350.46)
P<0.0001
Medications
ACT NOW: Pioglitazone
Pioglitazone reduced risk of type 2 diabetes
mellitus by 72% vs placebo (HR 0.28; 95%
CI 0.160.49 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.
Section 3
DO PREVENTION
INTERVENTIONS HAVE
SUSTAINED EFFECTS?
Lifestyle Interventions
Da 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
Controls
Combined lifestyle
intervention
Average
Annual
Incidence
11%
20-Year
Cumulative
Incidence
93%
7%
80%
Li G, et al. Lancet. 2008;371:1783-1789.
Lifestyle Interventions
Da 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)
Lifestyle Interventions
Finnish DPS 7-Year Follow-Up
43%
Relative
Risk
Reduction
Lifestyle Interventions
Summary
Lifestyle intervention continues to have an
effect; most drugs do not
Pharmacologic
Lifestyle
Study
Intervention
Treatment
Risk
Reduction
34% - 69%
Da Qing
IGT
577
Lifestyle
6 years
20 years
Finnish DPS
IGT
523
Lifestyle
3+ years
7 years
58%
DPP
IGT
3324
Lifestyle
3 years
58%
Intervention
Treatment
Risk
Reduction
Study
DPP
IGT
3324
Metformin
3 years
31%
DREAM
IGT
5269
Rosiglitazone
3 years
60%
STOP-NIDDM
IGT
1429
Acarbose
3 years
21%
ACT NOW
IFG
~600
Pioglitazone
3 years
81%
Section 4
Metformin
Placebo
vs placebo
Section 5
IS DIABETES PREVENTION
COST-EFFECTIVE?
Cost-Effectiveness of Lifestyle
Modification or Metformin: DPP
Active interventions (vs placebo) would:
Intensive
Lifestyle
Metformin
11.1 years
3.4 years
20%
8%
Increase life
expectancy by
0.5 years
0.2 years
$1,124
$31,286
Delay onset of
type 2 diabetes by
Reduce incidence of
type 2 diabetes by
DPP Group
Lifestyle vs
Lifestyle vs
Metformin
Placebo
Lifestyle vs
Placebo
Metformin
vs Placebo
Undiscounted
11,274
Costsaving
44,562
Costsaving
Discounted
14,365
Costsaving
42,753
1,681
Section 6
CAN EVIDENCE-BASED
INTERVENTIONS BE
DELIVERED EFFECTIVELY IN
LOWER-COST SETTINGS?
Control
(n=38)
Intervention
(n=39)
P value
(vs control)
% change
in weight
2
(3.3, 0.6)
6
(7.3, 4.7)
< 0.001
% change
BMI
2.3
(3.7, 0.8)
5.8
(7.3, 4.4)
0.001
Change total
cholesterol
+6 mg/dL
(2.8, 14.8)
21.6 mg/dL
29.9, 13.3)
<0.001
Control
Remote
Support Only
In-Person
Support
0.8 kg
4.6 kg*
5.1 kg*
18.8%
38.2%
41.4%
Baseline
6 Months
12 Months
Diabetes
TeleCare
group
9.40.3
8.30.3*
8.20.4
Usual care
group
8.80.3
8.60.3
8.60.3
Section 7
WILL DIABETES
PREVENTION BEND THE
CURVE OF THE EPIDEMIC?
Section 8
A1C 5.7-6.4%
*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.
Generate goals
Record
Section 9
CONCLUSIONS:
CALL TO ACTION