Prevention of type 2 diabetes mellitus
This presentation is the property of its rightful owner.
Sponsored Links
1 / 54

Prevention of Type 2 Diabetes Mellitus PowerPoint PPT Presentation


  • 155 Views
  • Uploaded on
  • Presentation posted in: General

Prevention of Type 2 Diabetes Mellitus. Key Questions and A Call to Action. Prevention of Type 2 Diabetes Mellitus: Table of Contents. Section 1. Why is prevention of type 2 diabetes imperative?. Projecting the Future Diabetes Population: The Imperative for Change.

Download Presentation

Prevention of Type 2 Diabetes Mellitus

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Prevention of type 2 diabetes mellitus

Prevention of Type 2 Diabetes Mellitus

Key Questions

and

A Call to Action


Prevention of type 2 diabetes mellitus table of contents

Prevention of Type 2 Diabetes Mellitus: Table of Contents


Why is prevention of type 2 diabetes imperative

Section 1

Why is prevention of type 2 diabetes imperative?


Prevention of type 2 diabetes mellitus

Projecting the Future Diabetes Population: The Imperative for Change

U.S. Population withDiabetes (%)

Boyle JP, et al. Popul Health Metr. 2010;8(29):1-12.


Prevention of type 2 diabetes mellitus

Percentage of U.S. Adults Who Were Obese or Had Diagnosed Diabetes

2008

1994

2000

2008

1994

2000

No Data <14.0% 14.0-17.9% 18.0-21.9% 22.0-25.9% 26.0%

Obesity (BMI ≥30 kg/m2)

Diabetes

No Data <4.5% 4.5-5.9% 6.0-7.4% 7.5-8.9% ≥9.0%

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.


What is the evidence that type 2 diabetes can be prevented or delayed

Section 2

whaT IS THE EVIDENCE THAT TYPE 2 DIABETESCAN BE PREVENTED OR DELAYED?


Prevention of type 2 diabetes mellitus

Lifestyle InterventionsCan 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)


Prevention of type 2 diabetes mellitus

Lifestyle InterventionsDa 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

    • Follow-up at 2-year intervals over 6 years to identify those who developed diabetes

Pan XR, et al. Diabetes Care. 1997;20:537-544.


Prevention of type 2 diabetes mellitus

Lifestyle InterventionsDa Qing Study Results

  • Cumulative incidence of diabetes at6 years was significantly decreased in the active intervention groups (P<0.05)

  • When analyzed by clinic, each active intervention group differed significantly from the control (P<0.05)

Pan XR, et al. Diabetes Care. 1997;20:537-544.


Prevention of type 2 diabetes mellitus

Lifestyle InterventionsDa 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

Pan XR, et al. Diabetes Care. 1997;20:537-544.


Prevention of type 2 diabetes mellitus

Lifestyle InterventionsDa 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)

Pan XR, et al. Diabetes Care. 1997;20:537-544.


Lifestyle interventions finnish diabetes prevention study

Lifestyle InterventionsFinnish Diabetes Prevention Study

  • 522 subjects, 40-65 years of age

    • BMI ≥25 kg/m2;IGT: 2-h PPG 140-200 mg/dL

    • Control group: general oral and written information diet and exercise

    • Intervention group: individualized

      • Reduce weight ≥5%

      • Decrease fat ≤30%, saturated fat ≤10% energy

      • Increase fiber to at least 15 g/1000 kcal

      • Moderate exercise ≥30 minutes/day

  • Primary end point: diagnosis of diabetes

Tuomilehto J, et al for the Finnish Diabetes Prevention Study Group.N Engl J Med. 2001;344:1343-1350.


Prevention of type 2 diabetes mellitus

Lifestyle InterventionsFinnish Diabetes Prevention Study

  • 172 men, 350 women; mean age 55 y

  • Mean BMI 31 kg/m2

  • Mean duration of follow-up 3.2 years

  • *P<0.001

    Tuomilehto J, et al for the Finnish Diabetes Prevention Study Group.N Engl J Med. 2001;344:1343-1350.


    Prevention of type 2 diabetes mellitus

    Lifestyle InterventionsFinnish 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

    • These results demonstrate that 22 subjects with IGT must be treated with lifestyle intervention for 1 year (or 5 subjects for 5 years) to prevent 1 case of diabetes

    Tuomilehto J, et al for the Finnish Diabetes Prevention Study Group.N Engl J Med. 2001;344:1343-1350.


    Prevention of type 2 diabetes mellitus

    Lifestyle InterventionsDiabetes 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

    • From 1996-1999, randomly assigned to

      • Standard lifestyle + placebo (n=1082)

      • Standard lifestyle + metformin, initiated at 850 mg orally once daily; at 1 month, increased to 850 mg twice daily (n=1073)

      • Intensive lifestyle intervention (n=1079)

    Knowler WC, et al. for the Diabetes Prevention Program Research Group.N Engl J Med. 2002;346:393-403.


    Prevention of type 2 diabetes mellitus

    Lifestyle InterventionsDiabetes 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

    • >150 minutes of physical activities weekly

      • Similar in intensity to brisk walking; at least 700 kcal/week

    • Group received 16-lesson curriculum

    Knowler WC, et al. for the Diabetes Prevention Program Research Group.N Engl J Med. 2002;346:393-403.


    Prevention of type 2 diabetes mellitus

    Lifestyle InterventionsDiabetes 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.


    Prevention of type 2 diabetes mellitus

    Lifestyle InterventionsDiabetes 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)

    Knowler WC, et al. for the Diabetes Prevention Program Research Group.N Engl J Med. 2002;346:393-403.


    Prevention of type 2 diabetes mellitus

    Lifestyle InterventionsDiabetes Prevention Program

    Results: intensive lifestyle intervention

    Knowler WC, et al. for the Diabetes Prevention Program Research Group.N Engl J Med. 2002;346:393-403.


    Prevention of type 2 diabetes mellitus

    MedicationsDPP: 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.


    Prevention of type 2 diabetes mellitus

    MedicationsDPP: 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

    • Gender, ethnicity, 2-h PGG, NOT predictive of response

    • Use metformin in high-risk individuals

    Knowler WC, et al. for the Diabetes Prevention Program Research Group.N Engl J Med. 2002;346:393-403.


    Prevention of type 2 diabetes mellitus

    MedicationsThe STOP-NIDDM: Acarbose

    • 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)

    Acarbose100 mg TIDn=682

    Placebon=686

    25% Relative Risk Reduction P=0.0022

    Reprinted with permission from Chiasson JL, et al. Lancet. 2002;359(9323): 2072-2077;Chiasson JL, et al. JAMA. 2003;290(4):486-494.


    Prevention of type 2 diabetes mellitus

    MedicationsDREAM: Rosiglitazone

    60%Relative Risk Reduction

    HR 0.40 (0.35–0.46) P<0.0001

    Reprinted with permission from DREAM Trial Investigators. Lancet. 2006;368(9541):1096-1105.


    Prevention of type 2 diabetes mellitus

    MedicationsACT NOW: Pioglitazone

    • Pioglitazone reduced risk of type 2 diabetes mellitus by 72% vs placebo (HR 0.28; 95% CI 0.16–0.49 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.


    Do prevention interventions have sustained effects

    Section 3

    DO PREVENTION INTERVENTIONS HAVE SUSTAINED EFFECTS?


    Prevention of type 2 diabetes mellitus

    Lifestyle InterventionsDa 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

    Li G, et al. Lancet. 2008;371:1783-1789.


    Prevention of type 2 diabetes mellitus

    Lifestyle InterventionsDa 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)

    • Study had limited statistical power to detect differences in these outcomes

    • Lifestyle interventions over 6 years can prevent, delay diabetes for up to 14 years after active intervention

    • Unclear whether lifestyle interventions also lead to reduced CVD, mortality

    Li G, et al. Lancet. 2008;371:1783-1789.


    Prevention of type 2 diabetes mellitus

    Lifestyle InterventionsFinnish DPS 7-Year Follow-Up

    43% Relative Risk Reduction

    Reprinted with permission from Lindström J, et al. Lancet. 2006;368(9548):1673-1679.


    Prevention of type 2 diabetes mellitus

    DPP: Metformin Had Sustained EffectAfter Drug Washout

    • Brief (1-2 week) drug washout study at end of Diabetes Prevention Program trial

    • After washout, diabetes was more frequently diagnosed in metformin vs. placebo (1.49; 0.93, 2.38; P=0.098)

    • DPP primary analysis: metformin decreased diabetes risk by 31%

    • Washout: 26% accounted for by pharmacological effect of metformin

    • Postwashout: diabetes reduced by 25%

    Diabetes Prevention Program Research Group. Diabetes Care. 2003;26:977-980.


    Prevention of type 2 diabetes mellitus

    Rosiglitazone Had No Sustained EffectAfter Drug Washout: DREAM

    • During rosiglitazone vs placebo washout

      • Primary outcome, new-onset diabetes or death: 10.5% vs 9.8% (P=0.59)

      • Secondary outcome, regression to normoglycemia: 21.5% vs 23.8% (P=0.33)

      • Median follow-up: 71 days (range, 63-86 days)

    • Rosiglitazone substantially reduced incidence of type 2 diabetes (DREAM); however, when withdrawn, this effect is not sustained

    The DREAM Trial Investigators. Diabetes Care. 2011;34:1265-1269.


    Prevention of type 2 diabetes mellitus

    Lifestyle InterventionsSummary

    • Lifestyle intervention continues to have an effect; most drugs do not

    Lifestyle

    Pharmacologic

    Diabetes Care. 1997;20:537-544; N Engl J Med. 2002;344:1343-1350;N Engl J Med. 2002;346;393-403; Diabetes Care. 2011;34:1265-1269;Lancet. 2002;359(9323): 2072-2077 N Engl J Med. 2011;364:1104-1115.


    Are we preventing type 2 diabetes or delaying it

    Section 4

    Are we preventing type 2 diabetes or delaying it?


    Prevention of type 2 diabetes mellitus

    Diabetes Prevention Program10-Year Follow-Up Study

    • During 10-year follow-up since randomization

      • Original lifestyle group lost, then partly regained weight

      • Modest weight loss with metformin maintained

    • Diabetes incidence per 100 person-years

    *vs placebo

    Diabetes Prevention Program. Lancet. 2009;374:1677-1686.


    Is diabetes prevention cost effective

    Section 5

    Is diabetes prevention cost-effective?


    Prevention of type 2 diabetes mellitus

    Cost-Effectiveness of Lifestyle Modification or Metformin: DPP

    • Active interventions (vs placebo) would:

    QALY = Quality Adjusted Life Years

    Herman WH, et al for the Diabetes Prevention Program Research Group.Ann Intern Med. 2005:142:323-332.


    Prevention of type 2 diabetes mellitus

    Diabetes Prevention Program

    10-Year Cost-Effectiveness

    • 10-year within-trial cost-effectiveness of the interventions

      • Intensive lifestyle

      • Metformin

    • Data on resource utilization, cost, and quality of life collected prospectively

    • Economic analyses performed from health system and societal perspectives

    Diabetes Prevention Program Research Group. Diabetes Care. 2012;35:723-730.


    Prevention of type 2 diabetes mellitus

    Diabetes Prevention Program

    10-Year Cost-Effectiveness

    • Lifestyle cost-effective, metformin marginally cost-saving vs placebo

    • Investment in lifestyle, metformin interventions for diabetes prevention in high-risk adults provides good value

    Incremental cost-effectiveness ratios from three different perspectives; ∆cost/∆QALY

    *Includes direct medical costs and direct nonmedical costs including participant time

    †Both costs and QALYs are discounted at 3%

    Diabetes Prevention Program Research Group. Diabetes Care. 2012;35:723-730.


    Can evidence based interventions be delivered effectively in lower cost settings

    Section 6

    Can evidence-based interventions be delivered effectively in lower-cost settings?


    Prevention of type 2 diabetes mellitus

    DEPLOY Pilot Study: Diabetes Prevention in the Community

    • Adults BMI ≥24 kg/m2, ≥2 diabetes risk factors, blood glucose 110-199 mg/dL

    • Randomized to group-based DPP lifestyle intervention or brief counseling (control)

    Ackermann RT, et al. Am J Prevent Med. 2008;35:357-363.


    Prevention of type 2 diabetes mellitus

    Practice-Based Opportunities for Weight Reduction (POWER)

    • Obese patients achieve, sustain significant weight loss with behavioral interventions

    *P<0.001 vs control arm

    Appel LJ, et al. N Engl J Med. 2011;365:1959-68.


    Prevention of type 2 diabetes mellitus

    Diabetes TeleHealth Improves Diabetes Self-Management

    • 1-year remote DSME intervention, Diabetes TeleCare (dietitian, nurse/certified diabetes educator

    • Improved metabolic control, reduced CV risk

    *P=0.003 vs. baseline

    †P=0.004 vs. baseline

    Davis RM, et al. Diabetes Care. 2010;33:1712–1717.


    Will diabetes prevention bend the curve of the epidemic

    Section 7

    Will diabetes prevention “bend the curve” of the epidemic?


    Prevention of type 2 diabetes mellitus

    CDC Modeling Study to ReduceFuture Diabetes Prevalence

    • Five-state model

    • Potential effect of hypothetical preventive intervention delivered to all with IFG

    • If 50% participated and incidence reduced by 50%, would equal 25% reduction in annual incidence of diabetes in the population with IFG

    • Would lower the increase in prevalence by 2050 to 1 in 4 (vs 1 in 3)

    Boyle JP, et al. Popul Health Metr. 2010;8(29):1-12.


    How can we most effectively prevent or delay type 2 diabetes

    Section 8

    How can we most effectively prevent or delay type 2 diabetes?


    Prevention of type 2 diabetes mellitus

    Most People with Diabetes Are Unaware of Their Condition

    • Data analyzed from 1,402 adults without diabetes

      • 2005–2006 NHANES participants

      • Valid fasting plasma glucose, oral glucose tolerance tests

    • Almost 30% of the US adult population had prediabetes in 2005–2006; only 7.3% were aware they had it

    • Adoption of risk reduction behaviors suboptimal

    Geiss LS, et al. Am J Prevent Med. 2010;38:403-409.


    We need to test people at risk

    We Need to Test People at Risk

    *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.


    Recommendations testing for diabetes in asymptomatic patients

    Recommendations: Testing for Diabetes in Asymptomatic Patients

    • Consider testing overweight/obese adults with one or more additional risk factors

      • In those without risk factors, begin testing at age 45 years (B)

    • If tests are normal

      • Repeat testing at least at 3-year intervals (E)

    • Use A1C, FPG, or 2-h 75-g OGTT (B)

    • In those with increased risk for future diabetes

      • Identify and, if appropriate, treat other CVD risk factors (B)

    ADA. II. Testing in Asymptomatic Patients. Diabetes Care. 2012;35(suppl 1):S13.


    Prevention of type 2 diabetes mellitus

    Criteria for Testing for Diabetes in Asymptomatic Adult Individuals (1)

    1. Testing should be considered in all adults who are overweight (BMI ≥25 kg/m2*) and have additional risk factors:

    • HDL cholesterol level<35 mg/dl (0.90 mmol/l) and/or a triglyceride level >250 mg/dl (2.82 mmol/l)

    • Women with polycystic ovarian syndrome (PCOS)

    • A1C ≥5.7%, IGT, or IFG on previous testing

    • Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)

    • History of CVD

    *At-risk BMI may be lower in some ethnic groups.

    ADA. Testing in Asymptomatic Patients. Diabetes Care. 2012;35(suppl 1):S14. Table 4.


    Prevention of type 2 diabetes mellitus

    Criteria for Testing for Diabetes in Asymptomatic Adult Individuals (2)

    ADA. Testing in Asymptomatic Patients. Diabetes Care. 2012;35(suppl 1):S14. Table 4.


    Dpp managing prediabetes

    DPP: Managing Prediabetes

    • For those found to have prediabetes, provide support or referral to encourage

      • Weight loss of at least 7%

      • Moderate exercise of at least 150 minutes per week

    • Consider metformin for certain patients

      • Obese (BMI ≥35 kg/m2)

      • <60 years (most effective, 25-44 years)

    • Lifestyle interventions feasible, morecost-effective than medications

    American Diabetes Association, 2012.


    Clinical tools effective in promoting lifestyle modification agree

    Clinical Tools Effective in Promoting Lifestyle Modification: AGREE

    Steps in the lifestyle change process: AGREE

    • Assess

    • Generate goals

    • Record

    • Evaluate and Empower

    Re-assess

    American Diabetes Association. 2008.


    Prevention of type 2 diabetes mellitus

    Clinical Tools Effective in Promoting Lifestyle Modification: FIRM

    Steps to setting behavioral goals, objectives

    1. Focus on developing specific objectives

    2. Let the patient take the lead

    3. Keep the objectives “FIRM”

    • Few in number

    • Individualized

    • Realistic

    • Measurable (frequency and duration)

    Saunders JT, Pastors JG. Curr Diabetes Rep. 2008;8;353-360.


    Conclusions call to action

    Section 9

    cONCLUSIONS:Call to Action


    Conclusions call to action1

    Conclusions: Call to Action

    • We must identify patients at highest risk (prediabetes)

    • Modest lifestyle changes are most effective

    • Sustain interventions

    • Increase opportunities for community programs to support prevention

    • Delaying or preventing type 2 diabetes is cost-effective and will help turn the tide on the diabetes epidemic


  • Login