Diabetes Atlas
International Diabetes Federation: An update of the evidence concerning the prevention of type 2 diabetes

https://doi.org/10.1016/j.diabres.2009.10.003Get rights and content

Abstract

This article aims to provide an updated summary of diabetes prevention efforts by reviewing relevant literature published between 2007 and 2009. These include results from the long-term follow-up of diabetes prevention trials and the roll-out of community-based interventions in “real world” settings. Some countries have begun to implement population-based strategies for chronic disease prevention, but investment in developing and evaluating population-level interventions remains inadequate. By focussing on the “small change” approach and involving a number of different agencies, it may be possible to shift the population distribution of risk factors for diabetes and cardiovascular disease in a favourable direction. The cost-effectiveness of primary prevention strategies for type 2 diabetes has not been universally demonstrated. Some of the uncertainties relating to screening for diabetes have now been resolved but longer-term data on hard cardiovascular outcomes are still needed. In summary, individual countries should aim to develop and evaluate cost-effective, setting-specific diabetes risk identification and prevention strategies based on available resources. These should be linked to initiatives aimed at reducing the burden of cardiovascular disease, and complemented with population-based strategies focusing on the control and reduction of behavioural and cardiovascular risk factors by targeting their key determinants.

Introduction

The International Diabetes Federation (IDF) consensus on type 2 diabetes prevention [1] and an accompanying editorial [2], underlined the need for preventive strategies to help combat the rising prevalence of this serious and costly disease. Since the publication of these articles, there has been a number of significant additions to the diabetes prevention literature. These include results from the long-term follow-up of diabetes prevention trials and the roll-out of community-based interventions in “real world” settings. Some of the uncertainties relating to screening for diabetes have now been resolved. Recent findings from cardiovascular (CVD) prevention trials among patients with longstanding diabetes cast doubt on the benefits of very intensive treatment of glycaemia but do highlight the benefits of treatment early in the course of the disease. In this article we aim to review the relevant literature published between 2007 and 2009 in order to provide an updated summary of diabetes prevention efforts. While it is acknowledged that tackling the burden of type 2 diabetes will involve a number of multi-level strategies, this paper focuses on primary and secondary prevention initiatives i.e. prevention and early detection.

Section snippets

Long-term follow-up of diabetes prevention trials

Intensive lifestyle and pharmacological interventions reduce the rate of progression to type 2 diabetes in people with impaired glucose tolerance (IGT). In a meta-analysis of published diabetes prevention trials, Gillies et al. [3] reported pooled hazard ratios of 0.51 (95%CI, 0.44–0.60) for lifestyle interventions vs. standard advice, and 0.70 (0.62–0.79) for oral diabetes drugs vs. control. These corresponded to estimated NNTs (number needed to treat) of 6.4 for lifestyle and 10.8 for oral

Translating findings from diabetes prevention trials into the community

We have proof of concept of the potential to prevent diabetes from trials in people with IGT and long-term results from these studies are encouraging. However, the challenge is now one of translation. Researchers have begun to turn to the design and evaluation of more pragmatic diabetes prevention initiatives that can be implemented in the “real world”. These initiatives are less intensive and costly than those evaluated in the diabetes prevention trials, and hence more readily rolled out into

National efforts to prevent diabetes

Finland is one of the first countries to implement a large-scale, multi-level diabetes prevention strategy. The DEHKO project [17] includes a population strategy aimed at improving nutrition and increasing physical activity in the entire nation, an individualised strategy for those at high risk, and a programme of early detection and management for people with type 2 diabetes. In 2010, the population-level effects of the programme will be studied in terms of coverage, effectiveness, rate of

Cost-effectiveness of diabetes prevention

Three-year results from the Indian-DPP [23] suggest that both metformin and lifestyle are cost-effective for preventing diabetes among those with IGT in India. We have also seen the publication of new modelling studies for diabetes prevention which encompass a screening stage in their calculations of cost-effectiveness. Gillies et al. [24] modelled four different strategies for the screening and prevention of type 2 diabetes in the UK context: screening for diabetes; screening for diabetes and

Screening for diabetes

Since the publication of the IDF consensus, some of the uncertainties relating to screening for diabetes have been resolved. The Anglo-Danish-Dutch Study of intensive treatment of people with newly diagnosed diabetes in primary care (ADDITION) consists of a screening phase followed by a pragmatic open-label cluster randomised controlled trial comparing the effect on cardiovascular risk of intensive multi-factorial therapy with standard care in patients with screen-detected diabetes [29]. Data

Glucose continuum and cardiovascular risk

Observational studies show a consistent and continuous association between glycaemia and CVD risk that extends below the diabetic threshold [38], [39]. However, results from long-term follow-up of diabetes prevention trials show relatively small reductions in glycaemia and have not yet demonstrated reduced CVD morbidity or mortality in intervention groups. Furthermore, recent findings from CVD prevention trials among patients with longstanding diabetes cast doubt on the benefits of very

Discussion

We previously argued for investment in “real world” diabetes prevention initiatives [2]. Encouraging results from community-based prevention efforts have contributed to an emerging evidence base in this field [6], [9], [11], [49], [50]. The translation of evidence from DPS- and DPP-like programmes into larger-scale prevention endeavours has highlighted a number of challenges for the future, including how to identify people at high risk and encourage them to participate; maximizing response and

Conflict of interest

There are no conflicts of interest.

Acknowledgements

We thank Jonathan Shaw, Paul Zimmet and George Alberti for their helpful comments on this paper.

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