When you read Diabetes in Control you have to know that we are first and foremost diabetes professionals and secondly journalists. Often I share my heart on my shirtsleeve with you. This week our Publisher, Stephen Freed, BSPharm, has prepared a compelling feature The Expanding Evidence for Diabetes Prevention that will let you know why we are your best partners for diabetes care.
The Ever Expanding Evidence for Diabetes Prevention
Stephen Freed, BSPharm, Publisher
The Time is Now!
By the time type 2 diabetes mellitus is detected, patients may already be suffering from one or more of its many complications. This raises the ante for early diagnosis—and, better still, for prevention.
Not sure what we are waiting for? There are over 50 million people in the U.S. with prediabetes and 90% of them don’t even know it. Every person who is overweight should be tested for prediabetes. If we can diagnosis people with prediabetes, we can do so much more with very little effort to prevent the complications of diabetes. The cost to diagnosis prediabetes is insignificant compared to what we will spend if we wait until they get diabetes. Maybe we could provide an A1c test for those that are overweight, or even a fasting blood glucose test, anything would be better then nothing! What are we waiting for, the evidence is in?
Evidence that diabetes can be prevented with both lifestyle interventions and medications has been available for some time. Regrettably, physicians are not very adept at detecting so-called prediabetes or at providing adequate support for lifestyle changes; in addition, they may be concerned about the balance of benefit versus harm with early drug intervention.
Cumulative evidence and new studies should make physicians think twice about focusing all our attention on patients who already have diabetes. First, prediabetes is easy to detect, especially if we target people with risk factors for diabetes: excess weight, a family history of diabetes, a history of gestational diabetes, or cardiovascular risk factors (especially hypertension or dyslipidemia). Prediabetes is present if fasting plasma glucose levels are at least 110 mg/dl (6.1 mmol/L) but less than 126 mg/dl (7.0 mmol/L) or if the patient has impaired glucose tolerance (i.e., a plasma glucose level of at least 140 mg/dl [7.8 mmol/L] but less than 200 mg/dl [11.1 mmol/L] 2 hours after an oral glucose load).
What’s the latest evidence about interventions that make a difference? A new report from the Finnish trial of lifestyle intervention for overweight, middle-aged men and women showed a 43% relative risk reduction (number needed to treat per patient-year [NNT], 33) in the incidence of diabetes after a median of 4 years of active intervention (weight and diet control and exercise).1 Importantly, this reduction was sustained over 7 years (33% relative risk reduction)—3 years on average after the intervention was discontinued. This extends the observations of previous trials showing benefits from lifestyle intervention, notably, the Diabetes Prevention Project (NNT, seven over 3 years).2
New evidence has also been published concerning the use of medication to prevent diabetes in high-risk individuals. The benefits of acarbose,3 which included a reduction of major cardiovascular events (NNT, 44 over 3.3 years) and metformin2 (NNT, 14 over 3 years for preventing diabetes) were documented some time ago. Even Rosiglitazone has now joined this group for preventing diabetes (NNT, seven over 3 years), with much controversy due to the increased risk of heart failure (NNT, 167 over 3 years). The hope that ramipril would be confirmed as a preventive drug received a partial blow in the Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medication (DREAM) trial4: although a higher proportion of patients on ramipril experienced regression to normoglycemia (NNT, 22 over 3 years), the incidence of diabetes was not reduced. Further, a new meta-analysis of hypertension studies5 found that angiotensin receptor blockers and angiotensin-converting enzyme inhibitors were least likely among antihypertensive drugs to induce incident diabetes, followed by calcium channel blockers. Beta blockers and diuretics slightly increased the risk of incident diabetes in these trials.
The evidence concerning the benefits of interventions to prevent type 2 diabetes is sufficiently compelling to warrant screening for glucose intolerance in all patients at risk. Of those found to have glucose intolerance, most will prefer to take action by making lifestyle changes. Such changes can be achieved much more successfully with adequate support than with simple advice.1,2 The key is to get patients into credible lifestyle modification programs with specific goals for weight control, food choices, and physical activity.
By providing a simple pedometer, which costs less then ten dollars and some education, we can have a major impact.
Finally, patients should be apprised of the medication options that are available. Some patients will prefer this route, especially if lifestyle measures fail.
www.diabetesincontrol.com Newsletter for medical professionals and patients who want to be informed.
1. Lindstrom J, Ilanne-Parikka P, Peltonen M, et al: Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. Lancet 368:1673, 2006 [PMID 17098085]
2. Knowler WC, Barrett-Connor E, Fowler SE, et al: Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. Diabetes Prevention Program Research Group: N Engl J Med 346:393, 2002 [PMID 11832527]
3. Chiasson JL, Josse RG, Gomis R, et al: Acarbose treatment and the risk of cardiovascular disease and hypertension in patients with impaired glucose tolerance: the STOP-NIDDM trial. JAMA 290:486, 2003 [PMID 12876091]
4. Bosch J, Yusuf S, Gerstein HC, et al: Effect of ramipril on the incidence of diabetes. N Engl J Med 355:1, 2006 [PMID 16980380]
5. Elliott WJ, Meyer PM: Incident diabetes in clinical trials of antihypertensive drugs: a network meta-analysis. Lancet 369:201, 2007 [PMID 17240286]