Strategies for Prevention of Type 2 Diabetes

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Strategies for Prevention of Type 2 Diabetes

• By
• Abdullatif Husseini

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Main topics

• Definitions.
• Magnitude of Type 2 diabetes.
• Factors associated with Type 2 diabetes.
• Levels of prevention.
• Types of interventions.
• Barriers and obstacles.
• Components of prevention programs.
• Central issues in Type 2 diabetes prevention.

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Type 2 Diabetes definition

• It is the most common form of diabetes,
  characterized by disorders of insulin resistance
  and insulin secretion, either of which may be the
  predominant feature. Both are usually present at
  the time that the diabetes is clinically
  manifest.
• 2hr post glucose load venous plasma glucose
  concentration (gt 11.1 mmol/l).

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Impaired glucose tolerance (IGT) definition

• An intermediate category between normal glucose
  tolerance and unequivocal diabetes. It describes
  an abnormality of glucose regulation.
• 2hr post glucose load venous plasma glucose
  concentration (7.8 - lt 11.1 mmol/l).

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Prevention Strategies

• Strategy A set of essential preventive measures
  believed sufficient to control a health problem.
• The word prevention embodies the goals of
  medicine to promote health, to preserve health,
  to restore health when it is impaired, and to
  minimize suffering and distress.
• source Last M, 1995 Dictionary of
  epidemiology.

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Preventive strategies approaches in the design

• A population-based strategy, involving altering
  the lifestyle and environmental determinants of
  Type 2 diabetes.
• A high-risk strategy applying preventive measures
  on individuals identified as high-risk for Type 2
  diabetes.

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Magnitude of the Problem

• The number of people with diabetes will nearly
  double within the first quarter of this
  millennium.
• World Health Report, 1997 Geneva WHO.

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Developed Vs Developing
Region 2000 2025
Developed countries 6.2 54.8 million 7.6 72.2 million
Developing countries 3.5 99.6 million 4.9 227.7 million
King et al, Diabetes Care 1998 21 1414-31
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Why is the prevalence of Type 2 diabetes
increasing?

• Aging of the population.
• Increased incidence due to urbanization
  especially in the developing countries.
• More sedentary lifestyle.
• Food consumption patterns, more foods with high
  fat content and more refined carbohydrates.

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Factors associated with Type 2 diabetes

• Modifiable
• 1- Behavioral and lifestyle-related such as
  obesity and physical inactivity.
• 2- Metabolic and intermediate risk categories
  such as IGT, IFG and GDM.

• Non Modifiable
• 1- Genetic factors.
• 2- Demographic determinants such as age and
  ethnicity.

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Why should we prevent diabetes?

• To reduce human suffering.
• To alleviate the economic burden.
• To prevent morbidity and mortality from
  diabetes-related CVD.

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Levels of prevention in Type 2 diabetes

• Primary Includes activities aimed at preventing
  diabetes from occurring in susceptible
  populations or individuals.
• Secondary Early diagnosis and effective control
  of diabetes in order to avoid or at least delay
  the progress of the disease.
• Tertiary Includes measures taken to prevent
  complications and disabilities due to diabetes.

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Why the primary prevention?

• There is an urgent need to take the prevention
  of cardiovascular disease more seriously. The
  only sensible strategy is the population approach
  to primary prevention.
• Beaglehole, the Lancet 2001 358 661-3

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Metabolic syndrome prevention

• The main components of the metabolic syndrome
  are glucose intolerance (diabetes or IGT),
  obesity, hypertension and dyslipidemia.
• All of those components are risk factors for CVD
  and can be targeted in life style interventions
  to prevent Type 2 diabetes.

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Primary prevention

• Most of the results on prevention come from
  studies on high risk groups rather than
  populations.
• Studies have shown that people with IGT has a 2-7
  fold higher risk of progression to Type 2
  diabetes than persons with normal glucose
  tolerance.
• Among the factors that predicted progression were
  obesity, elevated fasting and 2-h blood glucose
  and fasting insulin concentrations.

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Types of interventions

• Behavioral interventions including changing diet
  and increasing physical activity.
• And/or
• Pharmacological interventions utilizing
  pharmaceutical agents to improve glucose
  tolerance and insulin sensitivity.

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Behavioral interventions

• Several studies has shown that diet and physical
  activity reduced the incidence of Type 2
  diabetes.
• Example The Swedish Malmo study showed that diet
  and exercise for 5 years in men with IGT reduced
  the incidence of Type 2 diabetes by 50.
• Eriksson et al, Diabetologia 1991 34
  891-8

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Examples

• The DaQing Chinese study showed that over 6 years
  there were significant and similar reductions in
  the incidence of diabetes in subjects with IGT
  who were randomized to diet, exercise, or
  combined diet-exercise treatment groups.
• Pan et al, Diabetes Care, 1997 20 537-44

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Cumulative incidence of diabetes at 6 years
Data from Pan et al, Diabetes Care, 1997 20
537-44
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Examples- Cont

• The Finnish Diabetes Prevention Study showed that
  Type 2 diabetes can be prevented by changes in
  the lifestyles of high-risk subjects
  (middle-aged, overweight subjects with IGT). The
  risk of diabetes was reduced by 58 in the
  intervention group. The cumulative incidence was
  11 in the intervention group compared to 23 in
  the control group.
• Tuomilehto et al. NEJM, 2001 344 1343-50

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Pharmacological interventions

• Several studies examined the effects of various
  therapeutics in the prevention of diabetes.
• The evidence for the ability of pharmacological
  interventions to prevent Type 2 diabetes awaits
  confirmation.

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Examples

• The Diabetes Prevention Program (DPP) funded by
  the NIH-USA to perform a major IGT intervention
  to examine the potential for prevention of Type 2
  diabetes. It includes both lifestyle and
  pharmacological interventions.
• Diabetes Prevention Program, Diabetes Care
  1999 22 623-4

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Population-based prevention

• Solid data on the ability of community wide
  programs encouraging healthy diet and exercise to
  reduce the incidence of Type 2 diabetes are not
  yet available.
• However, some studies has shown the ability of
  such programs in reducing the risk factors for
  diabetes among other non-communicable diseases.

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Secondary prevention

• The purpose of secondary prevention activities
  such as screening is to identify asymptomatic
  people with diabetes.
• Is there an effective intervention that may
  retard the progression of disease or the severity
  of its complications?

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Screening approaches

• Population screening
• Selective screening
• Opportunistic screening

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Tertiary prevention

• Includes actions taken to prevent and delay the
  development of acute or chronic complications.
• Acute complications such as hypoglycemia, severe
  hyperglycemia and infections.
• Chronic complications such as atherosclerosis,
  retinopathy, nephropathy, neuropathy and foot
  problems.

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Effective interventions

• Strict metabolic control, education and effective
  treatment.
• Screening for complications in their early stages
  when intervention is more effective.

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Obstacles and barriers for prevention

• Economic problems unavailability of needed
  resources.
• Socio-cultural problems.
• Lack of data, knowledge and skills.

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Examples of socio-cultural barriers

• Obesity is not considered negatively.
• No value given to physical exercise.
• Changing diet is very difficult.
• No time is granted to do physical exercise at
  work.
• Fatalism.

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Major components of effective prevention programs

• Standardized data collection on disease
  magnitude, risk factors and mortality statistics.
• Clear action plan with specific targets, and well
  defined evaluation.
• Initiating community-based interventions for
  primary prevention.
• Advocacy for influencing policies.

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Major components of effective prevention
programs- Cont

• Advocacy for the rights of people with diabetes
  for quality care at all levels.
• Establishing acceptable standards for health care
  for people with diabetes.
• Establishing an effective referral system and
  defining the role of each level of health care.

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Major components of effective prevention
programs- Cont

• Educating the population about this important
  global epidemic.
• Provision of appropriate training for health care
  providers.
• Coordination of prevention efforts.

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Central issues in Type 2 diabetes prevention

• Type 2 diabetes prevention must be integrated in
  a major program addressing the prevention of
  other lifestyle related disorders like CVD and
  some cancers.
• Primary prevention is of the essence especially
  in resource-constrained countries.
• Diabetes prevention is an inter-sectoral effort
  requiring cooperation and coordination.

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Central issues in Type 2 diabetes prevention- Cont

• Diabetes prevention should be addressed within
  the context of health system reform ensuring the
  availability of acceptable health care standards.
• Culturally appropriate and economically feasible
  interventions should be adopted. Imposing
  unacceptable or unaffordable interventions will
  have a negative impact.

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What do we know about Type 2 diabetes prevention?

• Type 2 diabetes is a major challenge to human
  health.
• Type 2 diabetes can be prevented.
• Primary prevention is a suitable and affordable
  choice.
• There is strong evidence that lifestyle
  interventions are effective in diabetes
  prevention.
• Barriers for prevention should be addressed.