Intended for healthcare professionals

Rapid response to:


Prevention of diabetes

BMJ 2006; 333 doi: (Published 12 October 2006) Cite this as: BMJ 2006;333:764

Rapid Response:

Lifestyle modfication remains the gold standard in primary prevention of diabetes

I read the timely article by Heneghan et al[1] with lots of interest.
They have rightly advocated balance in approach to prevention of
diabetes—especially in light of the DREAM trial[2]. However, their
argument against the use of composite endpoint (new onset of diabetes plus
all cause mortality) in this important trial is debatable. It is well
documented that increase in glucose either on therapy or otherwise is an
important risk factor for all cause and cardiovascular mortality[3].
Therefore, adoption of this composite endpoint-- however contentious--is
understandable[4], especially, when glucose is a risk factor for both
diabetes as well as all cause mortality.

They do not support, and rightly so, the use of pharmacotherapy in
primary prevention of diabetes due to its greater adverse-at times serious
- events, and consequently high attrition rate. However, it needs to be
highlighted that pharmacotherapy as compared to lifestyle modifications
is not cost-effective nor it is comparable- if not better—to lifestyle
modification in sustainability of benefits after discontinuation of
therapy, or in-term of prevention of other important cardiovascular

Lifestyle modifications, on the other hand, often have been stated to
less practical purely on the basis of the complex intervention as in
DPP[5]. However, most of the other studies had interventions, which were
much simpler and perhaps easily transferable to the general practice
setting e.g. in Finish diabetes prevention[6] study there were on average
16 session for median follow-up of 3.2 years in sharp comparison with DPP
which had 16 curriculum session in first 6 months. In Da-Qing[7] and
Indian diabetes prevention study[8], again the lifestyle interventions are
not that complex, and can be translated in general practice-- although
with some costs and efforts, and may be with slightly lower reduction in
diabetes development.

In summary, the lifestyle modification is cheap and effective
intervention, benefits of which, persists beyond the intervention as well
as is on cardiovascular outcomes. Their implementation in the general
clinical practice need not be hampered due to misplaced fear of either its
labour intensive nature or costs.

1. Heneghan, C., M. Thompson, and R. Perera, Prevention of diabetes
10.1136/bmj.38996.709340.BE, in BMJ. 2006. p. 764-765.
2. Gerstein, H.C., et al., Effect of rosiglitazone on the frequency of
diabetes in patients with impaired glucose tolerance or impaired fasting
glucose: a randomised controlled trial, in Lancet. 2006. p. 1096-105.
3. Dunder, K., et al., Increase in blood glucose concentration during
antihypertensive treatment as a predictor of myocardial infarction:
population based cohort study, in Bmj. 2003. p. 681.
4. Schulgen, G., et al., Sample sizes for clinical trials with time-to-
event endpoints and competing risks. Contemp Clin Trials, 2005. 26(3): p.
5. Knowler, W.C., et al., Reduction in the incidence of type 2 diabetes
with lifestyle intervention or metformin, in N Engl J Med. 2002. p. 393-
6. Tuomilehto, J., et al., Prevention of type 2 diabetes mellitus by
changes in lifestyle among subjects with impaired glucose tolerance, in N
Engl J Med. 2001. p. 1343-50.
7. Pan, X.R., et al., Effects of diet and exercise in preventing NIDDM in
people with impaired glucose tolerance. The Da Qing IGT and Diabetes
Study, in Diabetes Care. 1997. p. 537-44.
8. Ramachandran, A., et al., 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), in
Diabetologia. 2006. p. 289-97.

Competing interests:
None declared

Competing interests: No competing interests

14 October 2006
Ajay K Gupta
Clinical Research Fellow
Dr Jaya Ahuja
International Centre for Circulatory Health, NHLI, Imperial College London, W2 1PG