Clinical Review

Prevention of Type 2 Diabetes: Evidence and Strategies

Journal of Clinical Outcomes Management. 2017 April;24(4)

References

1. International Diabetes Federation. Diabetes facts and figures. www.idf.org/about-diabetes/facts-figures. Accessed on January 29, 2017.

2. Centers for Disease Control and Prevention. National diabetes statistics report, 2014. www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf. Accessed on January 29, 2017.

3. Centers for Disease Control and Prevention. Number of Americans with diabetes projected to double or triple by 2050. www.cdc.gov/media/pressrel/2010/r101022.html. Accessed on January 29, 2017.

4. World Health Organization (WHO). Diabetes fact sheet. No. 312. November 2016. www.who.int/mediacentre/factsheets/fs312/en/. Accessed on January 29, 2017.

5. Karam JG, McFarlane SI. Update on the prevention of type 2 diabetes. Curr Diab Rep 2011;11:56–63.

6. Menke A, Rust KF, Fradkin J, et al. Associations between trends in race/ethnicity, aging, and body mass index with diabetes prevalence in the United States: a series of cross-sectional studies. Ann Intern Med 2014;161:328–85.

7. Ford ES, Li C, Sattar N . Metabolic syndrome and incident diabetes: current state of the evidence. Diabetes Care 2008;31:1898–904.

8. American Diabetes Association. Standards of medical care in diabetes—2017. Diabetes Care 2017;40(Suppl. 1).

9. Kruszynska YT, Olefsky JM. Cellular and molecular mechanisms of non-insulin dependent diabetes mellitus. J Investig Med 1996;44:413–28..

10. Butler AE, Janson J, Bonner-Weir S, et al. Beta-cell deficit and increased beta-cell apoptosis in humans with type 2 diabetes. Diabetes 2003;52:102–10.

11. Definition and diagnosis of diabetes mellitus and intermediate hyperglycemia. Report of a WHO and IDF Consultation. 2006. http://apps.who.int/iris/bitstream/10665/
43588/1/9241594934_eng.pdf. Accessed on February 1, 2017.

12. Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors. 2001 JAMA 2003;289:76–9.

13. Glucose tolerance and mortality: comparison of WHO and American Diabetes Association diagnostic criteria. The DECODE study group. European Diabetes Epidemiology Group. Diabetes Epidemiology: Collaborative analysis Of Diagnostic criteria in Europe. Lancet 1999;354:617–21.

14. Barr EL, Zimmet PZ, Welborn TA, et al. Risk of cardiovascular and all-cause mortality in individuals with diabetes mellitus, impaired fasting glucose, and impaired glucose tolerance: the Australian Diabetes, Obesity, and Lifestyle Study (AusDiab). Circulation 2007;116:151–7.

15. Xu T, Liu W, Cai X, et al. Risk of coronary heart disease in different criterion of impaired fasting glucose: a meta-analysis. Medicine 2015;94:e1740.

16. Huang Y, Cai X, Mai W, et al. Association between prediabetes and risk of cardiovascular disease and all cause mortality: systematic review and meta-analysis. BMJ 2016;355:i5953.

17. Nagi DK, Pettitt DJ, Bennett PH, et al. Diabetic retinopathy assessed by fundus photography in Pima Indians with impaired glucose tolerance and NIDDM. Diabet Med 1997;14:449 –56.

18. Diabetes Prevention Program Research Group. The prevalence of retinopathy in impaired glucose tolerance and recent-onset diabetes in the Diabetes Prevention Program. Diabet Med 2007;24:137–44

19. Putz Z, Tabák AG, Tóth N, et al. Noninvasive evaluation of neural impairment in subjects with impaired glucose tolerance. Diabetes Care 2009;32:181–3.

20. Hoffman-Snyder C, Smith BE, Ross MA, et al. Value of the oral glucose tolerance test in the evaluation of chronic idiopathic axonal polyneuropathy. Arch Neurol 2006;63:1075–9.

21. Plantinga LC, Crews DC, Coresh J, et al; CDC CKD Surveillance Team. Prevalence of chronic kidney disease in US adults with undiagnosed diabetes or prediabetes. Clin J Am Soc Nephrol 2010;5:673–82.

22. Pan XR, Li GW, Hu YH, et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study. Diabetes Care 1997;20:537–44.

23. Tuomilehto J, Lindstrom J, Eriksson JG, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001;344:1343–50.

24. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393–403.

25. Kosaka K, Noda M, Kuzuya T. Prevention of type 2 diabetes by lifestyle intervention: a Japanese trial in IGT males. Diabetes Res Clin Pract 2005;67:152–62.

26. Ramachandran A, Snehalatha C, Mary S, et al; Indian Diabetes Prevention Programme (IDPP).The Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1). Diabetologia 2006;49:289–97.

27. Saito T, Watanabe M, Nishida J, et al; Zensharen Study for Prevention of Lifestyle Diseases Group. Lifestyle modification and prevention of type 2 diabetes in overweight Japanese with impaired fasting glucose levels: a randomized controlled trial. Arch Intern Med 2011;171:1352–60.

28. Li G, Zhang P, Wang J, et al. The long-term effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a 20-year follow-up study. Lancet 2008;371:1783–9.

29. Li G, Zhang P, Wang J, et al. Cardiovascular mortality, all-cause mortality, and diabetes incidence after lifestyle intervention for people with impaired glucose tolerance in the Da Qing Diabetes Prevention Study: a 23-year follow-up study. Lancet Diabetes Endocrinol 2014;2:474–80.

30. Li G, Zhang P, Wang J, et al. Cardiovascular mortality, all-cause mortality, and diabetes incidence after lifestyle intervention for people with impaired glucose tolerance in the Da Qing Diabetes Prevention Study: a 23-year follow-up study. Lancet Diabetes Endocrinol 2014;2:474–80.

31. 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 2006;368:673–9.

32. Diabetes Prevention Research Group, Knowler WC, Fowler SE, et al. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet 2009;374:1677–86.

33. Salas-Salvadó J, Bulló M, Babio N, et al. Reduction in the incidence of type 2 diabetes with the Mediterranean diet: results of the PREDIMED-Reus nutrition intervention randomized trial. Diabetes Care 2011;34:14–19.

34. Wang P, Fang J, Gao Z, et al. Higher intake of fruits, vegetables or their fiber reduces the risk of type 2 diabetes: A meta‐analysis. J Diabetes Investig 2016;7:56–69.

35. Devlin JT. Effects of exercise on insulin sensitivity in humans. Diabetes Care 1992;15:1690–3.

36. Jeon CY, Lokken RP, Hu FB, van Dam RM. Physical activity of moderate intensity and risk of type 2 diabetes: a systematic review. Diabetes Care 2007;30:744–52.

37. Slentz C, Bateman L, Willis L, et al. Effects of exercise training alone vs a combined exercise and nutritional lifestyle intervention on glucose homeostasis in prediabetic individuals: a randomised controlled trial. Diabetologia 2016;59:2088–98.

38. Hamman RF, Wing RR, Edelstein SL, et al. Effect of weight loss with lifestyle intervention on risk of diabetes. Diabetes Care. 2006;29:2102–7.

39. Kirpichnikov D, McFarlane SI, Sowers JR. Metformin: an update. Ann Intern Med 2002;137:25–33.

40. Ratner RE, Christophi CA, Metzger BE, et al. Prevention of diabetes in women with a history of gestational diabetes: effects of metformin and lifestyle interventions. J Clin Endocrinol Metab 2008;93:4774–9.

41. Diabetes Prevention Program Research Group. Effects of withdrawal from metformin on the development of diabetes in the diabetes prevention program. Diabetes Care 2003;26:977–80.

42. Salpeter SR, Buckley NS, Kahn JA, Salpeter EE. Meta-analysis: metformin treatment in persons at risk for diabetes mellitus. Am J Med 2008;121:149–57.

43. El-Atat F, Nicasio J, Clarke L, et al. Beneficial cardiovascular effects of thiazolidinediones. Therapy 2005;2:113–19.

44. Buchanan TA, Xiang AH, Peters RK, et al. Preservation of pancreatic beta-cell function and prevention of type 2 diabetes by pharmacological treatment of insulin resistance in high-risk hispanic women. Diabetes 2002;51:2796–2803.

45. Azen SP, Peters RK, Berkowitz K. TRIPOD (Troglitazone In the Prevention Of Diabtes): a randomized placebo-controlled study of troglitazone in women with prior gestational diabetes mellitus. Control Clin Trials 1998;19:217–31.

46. Gerstein HC, Yusuf S, Bosch J, et al. Effect of rosiglitazone on the frequency of diabetes in patients with impaired glucose tolerance or impaired fasting glucose: a randomised controlled trial. Lancet 2006;368:1096–1105.

47. DREAM Investigators, Gerstein HC, Mohan V, Avezum A, et al. Long-term effect of rosiglitazone and/or ramipril on the incidence of diabetes. Diabetologia 2011;54:487–95.

48. DeFronzo RA, Tripathy D, Schwenke DC, et al. Pioglitazone for diabetes prevention in impaired glucose tolerance. N Engl J Med 2011;364:1104–15.

49. Ramachandran A, Snehalatha C, Mary S, et al. Pioglitazone does not enhance the effectiveness of lifestyle modification in preventing conversion of impaired glucose tolerance to diabetes in Asian Indians: results of the Indian Diabetes Prevention Programme-2 (IDPP-2). Diabetologia 2009;52:1019–26.

50 Zinman B, Harris SB, Neuman J, et al. Low-dose combination therapy with rosiglitazone and metformin to prevent type 2 diabetes mellitus (CANOE trial): a double-blind randomised controlled study. Lancet 2010;376:103–11.

51. Chiasson JL, Josse RG, Leiter LA, et al. The effect of acarbose on insulin sensitivity in subjects with impaired glucose tolerance. Diabetes Care 1996;19:1190–3.

52. Van de Laar FA, Lucassen PL, Akkermans RP, et al. Alpha-glucosidase inhibitors for people with impaired glucose tolerance or impaired fasting blood glucose. Cochrane Database Syst Rev 2006(4):CD005061.

53. Chiasson JL, Josse RG, Gomis R, et al. Acarbose for prevention of type 2 diabetes mellitus: the STOP-NIDDM randomised trial. Lancet 2002;359:2072–7.

54. Kawamori R, Tajima N, Iwamoto Y, et al. Voglibose for prevention of type 2 diabetes mellitus: a randomised, double-blind trial in Japanese individuals with impaired glucose tolerance. Lancet 2009;373:1607–14.

55. Holman RR, North BV, Tunbridge FK. Possible prevention of type 2 diabetes with acarbose or metformin. Diabetes 2000;49:Suppl 1:A111.

56. Holman RR, Blackwell L, Stratton IM et al. Six-year results from the Early Diabetes Intervention Trial. Diabet Med 2003;20(Suppl 2):15.

57. Holman RR, Haffner SM, McMurray JJ, et al. Effect of nateglinide on the incidence of diabetes and cardiovascular events. N Engl J Med 2010;362:1463–76.

58. Pi-Sunyer X, Astrup A, Fujioka K et al. A randomized, controlled trial of 3.0 mg of liraglutide in weight management. N Engl J Med 2015;373:11–22.

59. ORIGIN Trial Investigators, Gerstein HC, Bosch J, et al. Basal insulin and cardiovascular and other outcomes in dysglycemia. N Engl J Med 2012;367:319–28.

60. Yusuf S, Gerstein H, Hoogwerf B, et al. Ramipril and the development of diabetes. JAMA 2001;286:1882–5.

61. Hansson L, Lindholm LH, Niskanen L, et al. Effect of angiotensin-converting-enzyme inhibition compared with conventional therapy on cardiovascular morbidity and mortality in hypertension: the Captopril Prevention Project (CAPPP) randomised trial. Lancet 1999;353:611–6.

62. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002;288:2981–97.

63. Lindholm LH, Ibsen H, Dahlof B, et al. Cardiovascular morbidity and mortality in patients with diabetes in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet 2002;359:1004–10.

64. Gillespie EL, White CM, Kardas M, et al. The impact of ACE inhibitors or angiotensin II type 1 receptor blockers on the development of new-onset type 2 diabetes. Diabetes Care 2005;28:2261–6.

65. Bosch J, Yusuf S, Gerstein HC, et al. Effect of ramipril on the incidence of diabetes. N Engl J Med 2006;355:1551–62.

66. McMurray JJ, Holman RR, Haffner SM, et al. Effect of valsartan on the incidence of diabetes and cardiovascular events. N Engl J Med 2010;362:1477–90.

67. McFarlane SI, Kumar A, Sowers JR. Mechanisms by which angiotensin-converting enzyme inhibitors prevent diabetes and cardiovascular disease. Am J Cardiol 2003;91(12A):30H–37H.

68. Heymsfield SB, Segal KR, Hauptman J, et al. Effects of weight loss with orlistat on glucose tolerance and progression to type 2 diabetes in obese adults. Arch Intern Med 2000;160:1321–6.

69. Torgerson JS, Hauptman J, Boldrin MN, Sjostrom L. XENical in the prevention of diabetes in obese subjects (XENDOS) study: a randomized study of orlistat as an adjunct to lifestyle changes for the prevention of type 2 diabetes in obese patients. Diabetes Care 2004;27:155–61.

70. Rovellini A, Sommariva D, Branchi A, et al. Effects of slow release bezafibrate on the lipid pattern and on blood glucose of type 2 diabetic patients with hyperlipidaemia. Pharmacol Res 1992;25:237–45.

71. Tenenbaum A, Motro M, Fisman EZ. Dual and pan-peroxisome proliferator-activated receptors (PPAR) co-agonism: the bezafibrate lessons. Cardiovasc Diabetol 2005;4:14.

72. Tenenbaum A, Motro M, Fisman EZ, et al. Effect of bezafibrate on incidence of type 2 diabetes mellitus in obese patients. Eur Heart J 2005;26:2032–8.

73. Tenenbaum A, Motro M, Fisman EZ, et al. Peroxisome proliferator-activated receptor ligand bezafibrate for prevention of type 2 diabetes mellitus in patients with coronary artery disease. Circulation 2004;109:2197–202.

74. Sjostrom L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004;351:2683–93.

75. Sjostrom CD. Surgery as an intervention for obesity. Results from the Swedish obese subjects study. Growth Horm IGF Res 2003;13 Suppl A:S22–26.

76. Carlsson LM, Peltonen M, Ahlin S, et al. Bariatric surgery and prevention of type 2 diabetes in Swedish obese subjects. N Engl J Med 2012;367:695–704.

77. Pories WJ, Swanson MS, MacDonald KG, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995;222:339–50.

78. Long SD, O’Brien K, MacDonald KG Jr, et al. Weight loss in severely obese subjects prevents the progression of impaired glucose tolerance to type II diabetes. A longitudinal interventional study. Diabetes Care 1994;17:372–5.

79. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292:1724–37.

80. Tejirian T, Jensen C, Dutson E. Bariatric surgery and type 2 diabetes mellitus: surgically induced remission. J Diabetes Sci Technol 2008;2:685–91.

Surgery

Over the past decade, bariatric surgery has become one of the most effective interventions for inducing and sustaining weight reduction in severely obese patients, leading to a significant benefit in diabetes prevention or remission. The Swedish Obese Subject Study is a large ongoing prospective nonrandomized cohort study that between 1987 and 2001 enrolled 4047 nondiabetic obese participants who underwent gastric surgery or were matched obese control, with diabetes incidence measured at 2, 10 and 15 years [74–76]. At 15 years, analysis of the available cohort of the initial group showed that T2DM developed in 392 of 1658 control participants and in 110 of 1771 bariatric-surgery participants, corresponding to incidence rates of 28.4 and 6.8 cases per 1000 person-years, respectively ( P < 0.001). The treatment effects on the incidence of T2DM were at least as strong after 2 years and 10 years of follow-up as after 15 years. This effect was most prominent among the 591 patients who had IFG at baseline, with a number needed to treat as low as 1.3. The surgery group maintained an average 20-kg weight loss at 15 years.

In another study of the effects of bariatric surgery, 150 of 152 obese participants with IGT who underwent gastric bypass achieved and maintained a normal glycemic profile at 14 years of follow-up [77]. Similarly, in a follow-up of 136 obese participants with IGT, 109 of whom underwent bariatric surgery, 1 participant in the surgical group developed diabetes, as compared with 6 out of 27 in the control group [78]. In a meta-analysis including studies involving 22,094 patients who underwent bariatric surgery, 76.8% had complete resolution of their diabetes [79]. The rapid improvement of glycemic profile after bariatric surgery is thought to be due to oral intake restriction as well as acute hormonal changes related to the exclusion of the upper gastrointestinal tract (eg, incretin and ghrelin levels variations) [80].

Conclusions and Recommendations

The natural history of T2DM allows identification of patients at risk for diabetes and implementation of prevention strategies, which seems to be a public health need given the alarming increase in diabetes incidence. Indeed, the onset of T2DM is typically preceded by many years of beta cell dysfunction translating into carbohydrate metabolism abnormalities such as IFG and IGT, providing an excellent window of opportunity to identify persons at risk and prevent progression to diabetes. Numerous randomized controlled trials established lifestyle modifications, including dietary changes, moderate weight loss, and moderate intensity physical activity, as safe and effective interventions to prevent diabetes. This protective effect has been consistently shown to be sustained for more than 10 years after the initial intervention. Pharmacologic agents such as metformin, thiazolidinediones, alpha-glucosidase inhibitors, xenical, liraglutide, and insulin have also been associated with diabetes prevention in patients at risk. However, except for metformin, safety concerns or lack of durable efficacy or tolerability seem to outweigh their potential diabetes prevention benefit.

Given their favorable glycemic effect, RAS blockade and fibrates should be considered, when indicated, as reasonable treatment options for hypertension and hyperlipidemia in prediabetic patients. Bariatric surgery has been associated with a dramatic reduction in diabetes incidence in obese prediabetic patients and can be considered an alternative prevention measure in patients with severe obesity and prediabetes.