Diabetes prevention strategies in India nad abroad

 

 

Prevention of T2D  Is it a still a myth ?? :

In Indian study it was revealed that  behavior modification  can slow the progression toT2D but can’t prevent the DM .Not only Lifestyle but  metformin independently reduced progression of IGT toT2DM but can’t prevent its onset.

The diabetes pre­vention trials, in general, involved intensive individualized interventions. Translational of such research has shown that less expensive, group based lifestyle interventions are also effec­tive in achieving weight loss, thereby reducing risk of T2D.

Prevention of T2D is undoubtedly cost effective. Several large clinical trials have demonstrated that T2D can be delayed or prevented by lifestyle intervention or medications. Most of these studies involved subjects with impaired glucose tolerance (1GT). Almost 40-50 % of those with IGT progress to T2D during their lifetime. Firstly, one should change her/ his Lifestyle Intervention

One of the earliest trials, Study 1:-The Da Qing study in China, demon­strated reduction in risk of T2D with diet, exercise or both, risk reduction by 31-46 %.

Study 2:-  The Finnish Diabetes Prevention Study (DPS) showed a risk reduction of 58 % at 4 years in the intervention group compared to controls. It involved 522 subjects and the interven­tion targeted at five goals; (1) modest weight loss of 5 %, (2) decrease fat intake to <30 %, (3) decrease saturated fat to <10 %, (4) increase fiber and (v), moderate physical activity of at least 30 min per day. Furthermore, the DPS demonstrated that the reduced risk  was proportional to the number of lifestyle goals obtained.’

 

 Study 3  :-The  Diabetes Prevention Program (DPP)one of the   largest randomized control trials, studied 3,234 American multiethnic obese subjects with IGT with a median follow-up of 2.8 years. It showed similar risk reduction of 58 % with intensive life style as in DPS. It has to be noted that in all the above trials, (the benefit persisted for several years after cessation of active intervention.

 

 Study 4:- The Indian Diabetes Prevention Program (IDPP) also showed that lifestyle and metformin independently reduced progression of IGT toT2 Dm though the above trials have proven that behavior modification  can slow the progression toT2D. The intensive personal contact methods used by them may not be universally adaptable due to inadequate resources. Reassuringly,

a recent study in India has demonstrated that less expensive methods like mobile phone messaging can be successfully used to reduce the risk ofT2D. The IDPP showed that metformin was also effective in a lower dose of 500 mg/day in reducing the progression toT2D in Asian Indians. ;

 

 

Study 5 :-In this randomized controlled trial, lifestyle advice through regular text messaging was acceptable to the participants and reduced the risk of progression to T2D by 36 % over 2 years. As the study was conducted on working men with impaired glucose tolerance in an urban population, it remains to be seen if it is acceptable and effective in other popu­lations. However it is an exciting prospect considering the rapid increase in mobile phone ownership, particularly in developing countries with poor health care infrastructure where the impact can be substantial.

Medications for overt DM:- No medication is licensed for use in, those people at high risk of diabetes.

Medications used in treatment of T2D and obesity have also been found useful in prevention, although all have significant side effects. Since not all people who are at risk of diabetes will develop diabetes it therefore becomes important to con­sider the risk-benefit ratio. Currently, in the UK and many' countries across the world, no medication is licensed for use in, those people at high risk of diabetes.

Study 6 : Metformin at a dose of 1,700 mg/day was effective in DPP with 31 % risk reduction and the benefit was more pro­nounced in younger, more obese subjects and in women with prior gestational diabetes.) :-The IDPP showed that metformin was also effective in a lower dose of 500 mg/day in reducing the progression toT2D in Asian Indians. ;

Thiazolidinediones (Troglitazone, rosiglitazone and piogli- tazone) have proven very effective with a 50-70 % reduction m IGT conversion to diabetes in various trials, as has acarbose. though adverse effects are common.

 

What about orlistat ??  Orlistat in combi­nation of lifestyle changes reduced the progression to diabetes by 52 % when compared to lifestyle and placebo; however this drug was poorly tolerated by the participants.

What about Incretin based therapies (GLP-1 agonists and DPP-4 inhibitors) as a mode of prevention/ deferring DM??  Their role in prevention of T2D remains largely to be explored). Such drugs are being increasingly used for their beneficial effects on weight and glycemic control in T2D, but their role in prevention of T2D

remains largely to be  explored).

 

 Liraglutide has been shown to achieve significant weight loss and reduction in prevalence of prediabetes in obese subjects. Nonetheless, there are also cur­rent safety concerns with the use of these drugs in people with established disease

Bariatric Surgery

Several studies have shown benefit of bariatric surgery in resolution ofT2D and arresting progression toT2D in obese subjects. The Swedish Obese Subjects (SOS) study demon­strated a reduction in risk of developing T2D of 75 % at 10-year follow up in the surgical group. In practice, bariatric surgery is recommended in selected subjects with obesity and co-morbidities including conditions like T2D but not for pre­vention of T2D by itself.

Vitamin D

Vitamin D is found to be inversely associated with risk of T2D. A recent meta-analysis of 11 prospective studies found that risk of T2D was 41 % lower for those in top quartile com­pared to bottom quartile of circulating 25-hydroxyvitamin D levels.  The DPP group also demonstrated negative association even with multiple measurements of 2OH -hydroxyvitamin D and adjustment for weight loss/lifestyle/The trials on effects of vitamin D supplementation on risk orT2D have, however, yielded inconsistent results. Though it has been found to reduce insulin resistance, improve beta-cell function and attenuate HbA_|c rise, there is a need for large randomized tri­als with adequate doses of vitamin D over longer periods to establish if supplementation can reduce risk of T2D

 

Take home message

The epidemic of T2D along with growing evidence that it is preventable has triggered international efforts to adapt the

General lifestyle recommendations for prevention of

Obese/overweight men / women. The  aim to lose 5-10 % of body weight initially; continue to lose weight until BMI is in the normal range and maintain weight loss. Physical  activity, as we all know is relevant .Moderate physical activity implies such as walking/ activity cycling/swimming for at least 150 min/week

Increase intake of fibre (wholegrain bread, cereals, lentils

and beans)

Reduce intake of fat and saturated fat will pay a great dividend.

 

Choose fish and lean meat instead of fatty meat Reduce portion sizes particularly if overweight/obese Include fruits and vegetables  

. How helpful is  Screening for T2D and ‘at risk’ population, followed by appropriate intervention ? Ans: Screening for T2D and ‘at risk’ population, followed by appropriate intervention is likely to be cost effective. Individuals with prediabetes (1GT, IFG or an HbA_u. of 5.7-6.4 % according to ADA) should be referred to a support programme aiming for weight loss of 7 %. Dietary modification (total fat. saturated fat and fibre) and modest physical activity (e.g. walking) of 150 min/week.

Metformin may be considered particularly if BMI >35 kg/m², age <60 years and in women with prior GDM although it would be re-assuring to have the evidence base that metformin also reduced the risk of associated cardiovascular disease, from the public health point of view, it is important that the health sector, government and relevant stake holders such as the food industry, develop community-based efforts and national action plans to prevent this growing epidemic of T2D especially in high risk communities.

 still a myth ?? : In Indian study it was revealed that  behavior modification  can slow the progression toT2D but can’t prevent the DM .Not only Lifestyle but  metformin independently reduced progression of IGT toT2DM but can’t prevent its onset. The diabetes pre­vention trials, in general, involved intensive individualized interventions. Translational research has shown that less expensive, group based lifestyle interventions are also effec­tive in achieving weight loss, thereby reducing risk of T2D.

Prevention of T2D is undoubtedly cost effective. Several large clinical trials have demonstrated that T2D can be delayed or prevented by lifestyle intervention or medications. Most of these studies involved subjects with impaired glucose tolerance (1GT). Almost 40-50 % of those with IGT progress to T2D during their lifetime. Firstly, one should change her/ his Lifestyle Intervention

One of the earliest trials, Study 1:-The Da Qing study in China, demon­strated reduction in risk of T2D with diet, exercise or both, risk reduction by 31-46 %. Study 2:-  The Finnish Diabetes Prevention Study (DPS) showed a risk reduction of 58 % at 4 years in the intervention group compared to controls. It involved 522 subjects and the interven­tion targeted at five goals; (1) modest weight loss of 5 %, (2) decrease fat intake to <30 %, (3) decrease saturated fat to <10 %, (4) increase fibre and (v), moderate physical activity of at least 30 min per day. Furthermore, the DPS demonstrated that the reduced risk was proportional to the number of lifestyle goals obtained.’ Study 3  :-The  Diabetes Prevention Program (DPP)one of the   largest randomized control trials, studied 3,234 American multiethnic obese subjects with IGT with a median follow-up of 2.8 years. It showed similar risk reduction of 58 % with intensive life style as in DPS. It has to be noted that in all the above trials, (the benefit persisted for several years after cessation of active intervention.

Study 4:- The Indian Diabetes Prevention Program (IDPP) also showed that lifestyle and metformin independently reduced progression of IGT toT2 Dm though  the above trials have proven that behavior modification  can slow the progression toT2D. the intensive personal contact methods used by them may not be universally adaptable due to inadequate resources. Reassuringly,

a recent study in India has demonstrated that less expensive methods like mobile phone messaging can be successfully used to reduce the risk ofT2D.

Study 5 :-In this randomized controlled trial, lifestyle advice through regular text messaging was acceptable to the participants and reduced the risk of progression to T2D by 36 % over 2 years. As the study was conducted on working men with impaired glucose tolerance in an urban population, it remains to be seen if it is acceptable and effective in other popu­lations. However it is an exciting prospect considering the rapid increase in mobile phone ownership, particularly in developing countries with poor health care infrastructure where the impact can be substantial.

Medications for overt DM:- No medication is licensed for use in, those people at high risk of diabetes.

Medications used in treatment of T2D and obesity have also been found useful in prevention, although all have significant side effects. Since not all people who are at risk of diabetes will develop diabetes it therefore becomes important to con­sider the risk-benefit ratio. Currently, in the UK and many' countries across the world, no medication is licensed for use in, those people at high risk of diabetes.

Study 6 : Metformin at a dose of 1,700 mg/day was effective in DPP with 31 % risk reduction and the benefit was more pro­nounced in younger, more obese subjects and in women with prior gestational diabetes. Study 5(contd) :-The IDPP showed that metformin was also effective in a lower dose of 500 mg/day in reducing the progression toT2D in Asian Indians. ;

Thiazolidinediones (troglitazone, rosiglitazone and piogli- tazone) have proven very effective with a 50-70 % reduction m IGT conversion to diabetes in various trials, as has acarabose. though adverse effects are common.

 

What about orlistat ??  Orlistat in combi­nation of lifestyle changes, reduced the progression to diabetes by 52 % when compared to lifestyle and placebo; however this drug was poorly tolerated by the participants.

What about Incretin based therapies (GLP-1 agonists and DPP-4 inhibitors) as a mode of prevention/ deferring DM??  Their role in prevention of T2D

remains largely to be explored) Such drugs are being increasingly used for their beneficial effects on weight and glycemic control in T2D, but their role in prevention of T2D

remains largely to be explored) Liraglutide has been shown to achieve significant weight loss and reduction in prevalence of prediabetes in obese subjects. Nonetheless, there are also cur­rent safety concerns with the use of these drugs in people with established disease (see Chap. 3).

Bariatric Surgery

Several studies have shown benefit of bariatric surgery in resolution ofT2D and arresting progression toT2D in obese subjects. The Swedish Obese Subjects (SOS) study demon­strated a reduction in risk of developing T2D of 75 % at 10-year follow up in the surgical group. In practice, bariatric surgery is recommended in selected subjects with obesity and co-morbidities including conditions like T2D but not for pre­vention of T2D by itself.

Vitamin D

Vitamin D is found to be inversely associated with risk of T2D. A recent meta-analysis of 11 prospective studies found that risk of T2D was 41 % lower for those in top quartile com­pared to bottom quartile of circulating 25-hydroxyvitamin D levels.  The DPP group also demonstrated negative association even with multiple measurements of 2OH -hydroxyvitamin D and adjustment for weight loss/lifestyle/The trials on effects of vitamin D supplementation on risk orT2D have, however, yielded inconsistent results. Though it has been found to reduce insulin resistance, improve beta-cell function and attenuate HbA_|c rise, there is a need for large randomized tri­als with adequate doses of vitamin D over longer periods to establish if supplementation can reduce risk of T2D

 

Take home message

The epidemic of T2D along with growing evidence that it is preventable has triggered international efforts to adapt the

General lifestyle recommendations for prevention of

Obese/overweight men / women. The  aim to lose 5-10 % of body weight initially; continue to lose weight until BMI is in the normal range and maintain weight loss. Physical  activity, as we all know is relevant .Moderate physical activity implies such as walking/ activity cycling/swimming for at least 150 min/week

Increase intake of fibre (wholegrain bread, cereals, lentils

and beans)

Reduce intake of fat and saturated fat will pay a great dividend.

 

Choose fish and lean meat instead of fatty meat Reduce portion sizes particularly if overweight/obese Include fruits and vegetables   

. Some common lifestyle interventions to reduce progression to T£D are summarized in Table 1.4.

Screening for T2D and ‘at risk’ population, followed by appropriate intervention is likely to be cost effective. Individuals with prediabetes (1GT, IFG or an HbA_u. of 5.7-6.4 % according to ADA) should be referred to a support programme aiming to weight loss of 7 %. dietary modification (total fat. saturated fat and fibre) and modest physical activity (e.g. walking) of 150 min/week. Metformin may be considered particularly if BMI >35 kg/m², age <60 years and in women with prior GDM although it would be re-assuring to have the evidence base that metformin also reduced the risk of associated cardiovascular disease, from the public health point of view, it is important that the health sector, government and relevant stake holders such as the food industry, develop community-based efforts and national action plans to prevent this growing epidemic of T2D especially in high risk communities.