Clinical Review

Prevention of Type 2 Diabetes: Evidence and Strategies

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

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A combined report from the World Health Organization (WHO) and the IDF published in 2006 defined intermediate hyperglycemia as IFG, but with a higher cutoff for FBG (110–125 mg/dL) than the ADA’s definition, and/or IGT (2-hour OGTT glucose level of 140–199 mg/dL) [11]. The rationale for a higher cut-point for IFG is the concern about the increased prevalence of IFG and its impact on individuals and health systems and the more favorable cardiovascular risk profile and decreased risk of progression to diabetes in the group of patients with FBG of 100 to 110 mg/dL when compared to the group with FBG of 110 to 125 mg/dL. The report does not recommend the use of A1C in the diagnosis of diabetes or intermediate hyperglycemia because of a lack of global consistency and the potential for other factors that can be prevalent in some developing countries, such as hemoglobinopathies and anemia, to interfere with the assay.

Prevalence and Progression to Diabetes

According to CDC data from 2014, up to 86 million American adults, more than 1 in 3, have prediabetes, and 9 out of 10 of these individuals are undiagnosed [2]. It is estimated that approximately 25% of people diagnosed with either IFG or IGT progress to diabetes mellitus over a 3- to 5-year period [12]. If observed for longer periods, most prediabetic persons will probably develop diabetes. The highest rate of progression to diabetes is observed in patients with both IFG and IGT, older age, overweight, or other diabetic risk factors.

Complications

In addition to increasing the risk for progression to diabetes, prediabetes is independently associated with microvascular and macrovascular complications and increased risk of death, prior to the actual onset of diabetes. The DECODE study demonstrated significantly increased mortality in 2766 individuals with IGT after 7 years of follow-up, when compared to normoglycemic patients; this effect was more prominent in participants with IGT than in participants with IFG [13]. In the Australian Diabetes, Obesity and Lifestyle Study, IFG was found to be an independent predictor for cardiovascular mortality after adjustment for age, sex, and other traditional cardiovascular risk factors [14].

Similarly, a recent meta-analysis demonstrated that the presence of IFG was significantly associated with future risk for coronary heart disease (CHD), with the risk increase starting when fasting plasma glucose was as low as 100 mg/dL; however, this finding may have been confounded by the presence of undetected IGT or other cardiovascular risk factors [15]. Another recent systematic review of 53 prospective cohort studies with 1,611,339 participants showed that prediabetes (IFG or IGT) was associated with an increased risk of composite cardiovascular disease, CHD, stroke, and all-cause mortality [16].

The association between retinopathy and prediabetes has been described in multiple reports and this association has helped guide authors on selected thresholds for diagnosis of prediabetes. For example, in 1 study, the incidence of retinopathy in individuals with IGT was 12% among Pima Indians [17]. Similarly, in a follow-up study of the Diabetes Prevention Program, 8% of prediabetic participants who remained nondiabetics had evidence of retinopathy [18].