ADA 81st Symposium: Optimizing Prevention Interventions for Type 2 Diabetes

American Diabetes Association mini-symposium on type 2 diabetes prevention presented by Mike Sampson, MD.

How can we prevent diabetes? Many established preventative measures have been proven to prevent or delay type 2 diabetes, such as adopting the Mediterranean diet, avoiding a prolonged sedentary lifestyle, weight loss, smoking cessation, and well-controlled concomitant disease states. However, how applicable are the preventive measures to a specific population? How can we provide primary care-based screening programs to determine individuals at high risk of diabetes development? Can prevention strategies help individuals after a diagnosis of type 2 diabetes? The Norfolk Diabetes Prevention Study (NDPS) randomized controlled trial, published in the JAMA Internal medicine journal in February of 2021, aims to evaluate these questions.

NDPS followed Norfolk, Suffolk, Essex, GTR London, and Cambridgeshire counties in England from 2010 to 2019. The population in the study included 141,793 individuals at high risk of developing type 2 diabetes, 12,778 screened participants with fasting blood glucose or HbA1C, and 104 fully trained diabetes prevention mentors. The trial arms consisted of usual care controls, the standard intervention group with theory-based lifestyle core and maintenance sessions, and the intervention group, the same as the traditional intervention but with diabetes prevention mentors. Overall, there were 1,669 participants evaluated in the NDPS 3 trial arms. Nondiabetic hyperglycemia is an HbA1C greater than 6%, but less than 6.5%, and impaired fasting glucose more significant than 6.1 but less than 7. Thus, the primary endpoint is an HbA1C greater than 5.5% or fasting glucose greater than 7.0%

Mean baseline characteristics include average age of 66, predominantly white at 97%, Male population ranging from 60-65%, the average weight of 90 kg, impaired fasting glucose in 60-64% of participants, nondiabetic hyperglycemia 36-39% of individuals, and HbA1C of 43 mmol/mol. The intervention comprises increasing motivation to change, behavior change, individual goal setting, and support lifestyle change delivered by diabetes prevention facilitators (DPF) or trained lay volunteers with type 2 diabetes (DPM). The mainstay goal was an intake reduction in saturated fats, 150 minutes per week of moderate physical activity, and a 7% weight loss. The 2 hours sessions were initially performed six times in 12 weeks, then up to 15 maintenance sessions in 46 months.

After two years, the primary prevention trial demonstrated a 40-47% reduction in type 2 diabetes in the intervention groups compared to the control group (OR 0.58; 95% CI 0.41,0.84; p=0.003). The lifestyle intervention effects on HbA1C after 12 months established a small but significant reduction in the combined intervention groups compared to the control group. A substantial benefit was observed with diabetes prevention mentors for the screen detection of type 2 diabetes. The group-based method is a low-cost approach to help reduce the risk of complications attributed to undiagnosed type 2 diabetes. The implemented lifestyle interventions improved diabetes prevention outcomes and benefited individuals with type 2 diabetes to support optimal glycemic control. Weight loss in the NDPS was modest and maintained for two years. These results are similar to previously conducted national prevention studies.

The study analysis identified inadequate translation of the design to the program manuals, resulting in 34% of intended behavior change technique delivery. The National Institute of Health Research funded NDPS. Future quality improvement measures should implement a detailed translation of program manuals to avoid an impact on analysis and a more diverse selection of participants for generalizability. The NDPS of East England supports the current practices of diabetes prevention efforts and applies to the modern-day population at high risk of developing type 2 diabetes.

Practice Pearls:

• The diabetes prevention mentors significantly improved the screen detection of type 2 diabetes.
• The NDPS primary prevention trial demonstrated a 40-47% reduction in T2D in the intervention groups compared to the control group.
• The NDPS supports the current practices of diabetes prevention efforts and applies to the modern-day population at high risk of developing type 2 diabetes.

Sampson M. Successful diabetes prevention interventions- lessons learned. American Diabetes Association Mini-Symposium. June 28 2021. (Requires ADA Symposium login.)

Sampson M, Clark A, Bachmann M, et al. Lifestyle intervention with or without lay volunteers to prevent type 2 diabetes in people with impaired fasting glucose and nondiabetic hyperglycemia: a randomized clinical trial. JAMA Intern Med. 2021

Jasmine Dumontier-Hiott, PharmD Candidate 2022, University of South Florida Taneja College of Pharmacy