primary prevention of type 2 diabetes

Primary Primary Prevention of Prevention of

Type 2 DiabetesType 2 Diabetes

Lifetime Risk for Lifetime Risk for DiabetesDiabetes

If born in 2000:If born in 2000: 32.8% if male (1 in 3)32.8% if male (1 in 3)

If Hispanic, 45.4%If Hispanic, 45.4% 38.5% if female (2 in 5)38.5% if female (2 in 5)

If Hispanic, 52.5%If Hispanic, 52.5% Life expectancy:Life expectancy:

If diagnosed at age 40:If diagnosed at age 40: Men will lose 11.6 life yearsMen will lose 11.6 life years Women will lose 14.3 life yearsWomen will lose 14.3 life years

JAMA, October 8, 2003 – Vol 290, No. 14, p 1884-1890JAMA, October 8, 2003 – Vol 290, No. 14, p 1884-1890

Copyright restrictions may apply.

Narayan, K. M. V. et al. JAMA 2003;290:1884-1890.

Cumulative Lifetime Risk for Diagnosis of Diabetes

Undiagnosed diabetes

5.9 million

Prevalence of all Glycemic Prevalence of all Glycemic Abnormalities Abnormalities

in the United Statesin the United States

Additional 24.6 million

with IGT

Diagnosed type 2 diabetes

10 million

Diagnosed type 1 diabetes

~1.0 million

Centers for Disease Control. Available at: http://www.cdc.gov/diabetes/pubs/estimates.htm; Harris MI. In: National Diabetes Data Group. Diabetes in America. 2nd ed. Bethesda, Md: NIDDK; 1995:15-36; U.S. Census Bureau Statistical Abstract of the U.S.; 2001

US Population: 275 Million in 2000

10

Source: Mokdad et al., Diabetes Care 2000;23:1278-83.

Diabetes Trends* Among Adults in the Diabetes Trends* Among Adults in the U.S.,U.S.,

(Includes Gestational Diabetes)(Includes Gestational Diabetes) BRFSS 1990BRFSS 1990

<4% 4-6% 6-8%


(Includes Gestational Diabetes)(Includes Gestational Diabetes) BRFSS 1991-92BRFSS 1991-92




Source: Mokdad et al., Diabetes Care 2001;24:412.

8-10%



Source: Mokdad et al., J Am Med Assoc 2001;286:10.



Source: Mokdad et al., J Am Med Assoc 2001;286:10.

> 10%> 10%

19961991

2003

Obesity Trends* Among U.S. AdultsBRFSS, 1991, 1996, 2003

(*BMI 30, or about 30 lbs overweight for 5’4” person)

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Increase in Clinically Severe Obesity (BMI > 40)Sturm,R. Arch Intern Med. 2003;163:2146-2148

Diabetes in ChildrenDiabetes in Children 151,000 people below the age of 20 151,000 people below the age of 20

years have diabetesyears have diabetes Prevalence In the 15-to-19-year age Prevalence In the 15-to-19-year age

groupgroup 50.9 per 1000 for Pima Indians from Arizona 50.9 per 1000 for Pima Indians from Arizona 4.5 per 1000 for all U.S. American Indian 4.5 per 1000 for all U.S. American Indian

populations (reported cases from the U.S. populations (reported cases from the U.S. Indian Health Service outpatient clinics); Indian Health Service outpatient clinics);

2.3 per 1000 for Canadian First Nation 2.3 per 1000 for Canadian First Nation people from Manitoba (reported cases from people from Manitoba (reported cases from outpatient clinics).outpatient clinics).

Diabetes in ChildrenDiabetes in Children

Cincinnati, Ohio, found an incidence Cincinnati, Ohio, found an incidence for type 2 diabetes of 7.2 per for type 2 diabetes of 7.2 per 100,000 for African Americans and 100,000 for African Americans and whites aged 10-19 years in 1994. whites aged 10-19 years in 1994.

In most of the U.S. case reports, In most of the U.S. case reports, type 2 diabetes accounted for 8% to type 2 diabetes accounted for 8% to 46% of all new cases of diabetes 46% of all new cases of diabetes (type 1 and type 2) referred to (type 1 and type 2) referred to pediatric centers. pediatric centers.

Diabetes Prevention in Diabetes Prevention in ChildrenChildren

Obesity preventionObesity prevention

Increased physical activityIncreased physical activity

Decreased sedentary behaviorDecreased sedentary behavior

Diabetes Prevention in Diabetes Prevention in AdultsAdults

People with Impaired Glucose People with Impaired Glucose Tolerance (Pre-Diabetes)Tolerance (Pre-Diabetes) Da Qing (1997)Da Qing (1997) Finnish DPS (2001)Finnish DPS (2001) Reduced fat diet (2001)Reduced fat diet (2001) DPP (2002)DPP (2002) STOP-NIDDM (2002)STOP-NIDDM (2002) Nateglinide study (2002)Nateglinide study (2002) SLIM (2004)SLIM (2004) XENDOS (2004)XENDOS (2004)

Glucose Tolerance Glucose Tolerance CategoriesCategories

American Diabetes Association. Diabetes Care. 2003;26(suppl 1):S5-S20

FPG 2-h PPG (OGTT)

126

110

60

80

100

120

140

160

180

200

Plasma glucose(mg/dL)

Normal

Diabetes Mellitus

240

220

Diabetes Mellitus

Normal

IGT

IFG

8

Finnish DPS study. Mean BMI = 31; all patients had IGT. Intervention included counseling aimed at reducing weight, total intake of fat, and intake of saturated fat and increasing intake of fiber and physical activity. the risk of diabetes was reduced by 58 percent (P<0.001) in the intervention group

(Eriksson et al., Diabetologia 1991;34:891-8.

5 year effects of a reduced-fat diet intervention in patients with IGT. Fasting glucose was significantly improved and maintained over 5 years in most

compliant experimental group. (Swinburn et al., Diabetes Care201;24:619-24)

CD group (– – – –)

least compliant RF group (- - - -)

most compliant RF group (——–)

Diabetes Prevention Program (DPP): Incidence of DM according to group

(p<0.001)

Diabetes Prevention Program (DPP): Changes in body weight and activity level according to group (p<0.001)

STOP-NIDDM trial: Patients assigned to acarbose received a mean daily dose of 194 mg (SD 87). These patients were 25% less likely to develop diabetes than those on placebo. This effect was noted at 1

year and persisted throughout the study. The beneficial effect of acarbose was consistent irrespective of age, sex, and BMI

(Chiasson et al., Lancet 2002;359:2072-7)

Nateglinide reduced postprandial hyperglycemia in subjects with IGT. Longer-term studies needed to determine whether this agent

can delay or prevent the development of type 2 diabetes

(Saloranta et al., Diabetes Care 202;25:2141-6)

The addition of orlistat (120 mg) or placebo t.i.d. with breakfast, lunch, and dinner to lifestyle changes in XENDOS reduced the incidence of type 2

diabetes in subjects with IGT by 52% when compared with the placebo and lifestyle group. In the IGT population, the results suggest that treating 10 patients with orlistat plus lifestyle (rather than lifestyle alone) for 4 years

would prevent the development of one case of diabetes

(Diabetes Care 2004;27:155-61)

Obese-Normal Glucose Obese-Normal Glucose ToleranceTolerance

XENDOS (2004)XENDOS (2004) SOS (1999)SOS (1999) Liposuction (2004)Liposuction (2004) Ohio African American-troglitazone Ohio African American-troglitazone

(2003)(2003)

Swedish Obese Subjects Swedish Obese Subjects (SOS Study(SOS Study

2000 matched patient pairs, one to 2000 matched patient pairs, one to undergo bariatric surgery, the other undergo bariatric surgery, the other provided with conventional obesity provided with conventional obesity treatment, followed for 10 years. treatment, followed for 10 years.

Aims are mortality, morbidity and Aims are mortality, morbidity and QOL related to weight loss and QOL related to weight loss and methodmethod

After 8 years the surgical group had After 8 years the surgical group had lost 16.5% while controls maintained-lost 16.5% while controls maintained-gained weight. Incidence of diabetes gained weight. Incidence of diabetes was 5-fold lower in surgical group.was 5-fold lower in surgical group.

Liposuction Study: Women with Liposuction Study: Women with normal glucose tolerancenormal glucose tolerance

Liposuction Study: Women with Liposuction Study: Women with DiabetesDiabetes

Ohio African American Troglitazone Ohio African American Troglitazone Study:Study:

Placebo

Troglitazone

Women with previous Women with previous GDM GDM TRIPOD studyTRIPOD study

Troglitazone reduced the incidence of diabetes in women who returned for follow-up by at least 50%.

(Buchanan et al., Diabetes 2002;51:2796-803)

Dyslipidemia & Dyslipidemia & HypertensionHypertension

HOPE (2001)HOPE (2001) CAPP (1999)CAPP (1999) LIFE (2002)LIFE (2002) WOSCOPS (2001)WOSCOPS (2001)

HOPE study: The relative risk for developing diabetes among patients taking ramipril vs placebo is 0.66 (95% confidence interval, 0.51-0.85; P<.001). Ramipril is associated with lower rates of new diagnosis of diabetes in high-risk individuals. Because these results have important clinical and public health implications, this hypothesis requires prospective confirmation.

CAPP StudyCAPP Study

Captopril, titrated to keep supine Captopril, titrated to keep supine DBP < 90 mm Hg, was associated DBP < 90 mm Hg, was associated with diabetes incidence of 13.3%, with diabetes incidence of 13.3%, compared with 15.2% over 5 years compared with 15.2% over 5 years in those treated with diuretics and in those treated with diuretics and --blockers for HTN.blockers for HTN.

Post-hoc analysis of sub-group of Post-hoc analysis of sub-group of patients without diabetespatients without diabetes

New-onset diabetes mellitus occurred in 242 patients receiving losartan (13.0 per 1000 person-years) and 320 receiving atenolol (17.5 per 1000

person-years); relative risk 0.75 (95% confidence interval 0.63 to 0.88;P < 0.001). Retrospective analysis. Needs prospective confirmation.

LIFE Study

WOSCOPS: Time to development of diabetes mellitus according to (A) median BMI (<25.65 or >=25.65 kg/m2), (B) median natural log triglyceride (<0.5 or >=0.5

natural log [mmol/L]), (C) median baseline glucose (<4.7 or >=4.7 mmol/L), and (D) treatment assignment (placebo or pravastatin 40 mg/d).

Obesity prevention in Obesity prevention in childrenchildren

Decreased TV watching study (1999)Decreased TV watching study (1999) Pathways study (2003)Pathways study (2003) MCG “Fit Kid” program (2005)MCG “Fit Kid” program (2005)

Parental lifestyle changeParental lifestyle change Dietary interventionsDietary interventions Increased physical activityIncreased physical activity Drug therapyDrug therapy Environmental policyEnvironmental policy

Pathways: Pathways: The three-year intervention The three-year intervention included components related to physical included components related to physical activity, school food service, classroom activity, school food service, classroom

curriculum, and family support. Began with 3rd curriculum, and family support. Began with 3rd

grade children and lasted through 5grade children and lasted through 5th th

-- -- -- -- NL - - - - - - - Intervention --------------- Control

The aims were not met. No significant difference between groups.

MCG “Fit Kid” ProgramMCG “Fit Kid” Program

Bernard Gutin, et al., Medical College of Georgia

Obesity in AdultsObesity in Adults

Easier to prevent than to cureEasier to prevent than to cure Clinically severe obesity (>100 lbs Clinically severe obesity (>100 lbs

overweight) is increasing much overweight) is increasing much faster than obesity. Prevalence of faster than obesity. Prevalence of BMI >50 has increased over 400% BMI >50 has increased over 400% since 1986.since 1986.

Popular diets all have low adherance Popular diets all have low adherance and one offers little lasting benefit and one offers little lasting benefit over another (JAMA, 2005)over another (JAMA, 2005)

Obesity Prevention in Obesity Prevention in AdultsAdults

Decreasing sedentary behaviorsDecreasing sedentary behaviors Increasing physical activityIncreasing physical activity


Hu, F. B. et al. JAMA 2003;289:1785-1791.

Percentage Changes in Risk of Developing Obesity Among Nonobese Women and in Risk of Developing Type 2 Diabetes Among Nondiabetic Women Associated With Television (TV)

Watching, Other Sedentary Behaviors, and Walking

Weight Loss in AdultsWeight Loss in Adults

Diet comparison study (2005)Diet comparison study (2005) National Weight Control RegistryNational Weight Control Registry Portion-controlled servingsPortion-controlled servings Meal replacementMeal replacement

Table 1. Lifestyle modification for obesity, 1974 to 2002

1974

1985 to 1987

1991 to 1995

1996 to 2002*

Number of studies 15 13 5 9

Sample size 53.1 71.6 30.2 28.0

Initial weight (kg) 73.4 87.2 94.9 92.2

Length of treatment (weeks)

8.4 15.6 22.2 31.4

Weight loss (kg) 3.8 8.4 8.5 10.7

Loss per week (kg) 0.5 0.5 0.4 0.4

Attrition 11.4 13.8 18.5 21.2

Length of follow-up (weeks)

15.1 48.3 47.7 41.8

Loss at follow-up (kg) 4.0 5.3 5.9 7.2

Group treatment induced a significantly greater weight loss than individual care after 6 mos of treatment, even in patients

who preferred individual treatment

(Renjilian et al., J Consult Clin Psychol. 2001;69:717-21)

Long-term behavioral treatment appears only to delay rather than to

prevent weight re-gain

(Perri et al. J Consult Clin Psychol. 2001;69:722-6)

Benefits of low vs. high levels of physical activity in a randomized controlled trial. High =

2500 kcal/wk, Low = 1000 kcal/wk. No difference in weight loss after 6 mos; high level maintained

significantly better

(Jeffery et al., Am J Clin Nutr. 2003;78:684-9)

National Weight Control National Weight Control RegistryRegistry 18 years and older, who have successfully maintained 18 years and older, who have successfully maintained

a 30 pound weight loss for a minimum of 1 year. a 30 pound weight loss for a minimum of 1 year. Currently, the registry includes approximately 4,500 Currently, the registry includes approximately 4,500 individuals.individuals.

Successful weight losers report making substantial Successful weight losers report making substantial changes in eating and exercise habits to lose weight changes in eating and exercise habits to lose weight and maintain their losses. and maintain their losses.

The average registrant has lost approximately 60 The average registrant has lost approximately 60 pounds and has maintained that loss for roughly 5 pounds and has maintained that loss for roughly 5 years. years.

Two-thirds of these successful weight losers were Two-thirds of these successful weight losers were overweight as children and 60% report a family overweight as children and 60% report a family history of obesity. history of obesity.

Approximately 50% of participants lost weight on Approximately 50% of participants lost weight on their own without any type of formal program or help. their own without any type of formal program or help.

Walking is the most frequently cited physical activity Walking is the most frequently cited physical activity performed by performed by NWCRNWCR members. members.

Table 3. Eating habits of National Weight Control Registry members

Women (n = 629)

Men (n = 155)

Maximum weight (kg) 94.6 121.0Maximum BMI (kg/m2) 34.6 37.2Current weight (kg) 66.0 85.6Current BMI (kg/m2) 24.1 26.4Energy intake (kcal/d) 1296 1724Energy from fat (%) 24 23Energy from protein (%) 19 18Energy from carbohydrate (%) 55 56Number of meals or snacks per day 5.0 4.5Number of meals at fast food restaurants per week

0.7 0.8

Number of meals at non-fast food restaurants per week

2.4 2.9

During first 3 mos Group A patients ate 1200 – 1500 kcal/d diet of conventional foods. Group B patients had same calorie goal but replaced

two meals and two snacks with shakes and bars. After 3 mos, both groups replaced 1

meal/snack daily.

(Flechtner-Mors et al., Obes Res. 2000;8:399-402)


Dansinger, M. L. et al. JAMA 2005;293:43-53.

One-Year Changes in Body Weight as a Function of Diet Group and Dietary Adherence Level for All Study Participants

Evidence-Based Evidence-Based RecommendationsRecommendations

Primary prevention of Type 2 Diabetes:Primary prevention of Type 2 Diabetes: Level 1: 7% weight loss and 150 minutes of Level 1: 7% weight loss and 150 minutes of

moderate physical activity/weekmoderate physical activity/week Level 2: Bariatric surgeryLevel 2: Bariatric surgery

Primary prevention of obesityPrimary prevention of obesity Children: No evidenceChildren: No evidence Adults: Avoidance of sedentary behaviorsAdults: Avoidance of sedentary behaviors

Obesity TreatmentObesity Treatment No evidence supports one method over anotherNo evidence supports one method over another Group support/meal replacements provide Group support/meal replacements provide

strongest evidencestrongest evidence

primary prevention of type 2 diabetes

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