Strategies for Prevention
of Type 2 Diabetes
By
Abdullatif Husseini
Main topics:
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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.
Type 2 Diabetes definition
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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 (> 11.1 mmol/l).
Impaired glucose
tolerance (IGT) definition
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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 - < 11.1
mmol/l).
Prevention Strategies
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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.
Preventive strategies:
approaches in the design
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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.
Magnitude of the Problem
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millions
The number of
people with
diabetes will
nearly double
within the first
quarter of this
millennium.
World Health Report, 1997;
Geneva: WHO.
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
Why is the prevalence of
Type 2 diabetes increasing?
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Aging of the population.
Increased incidence due to
urbanization especially in the
developing countries.
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More sedentary lifestyle.
Food consumption patterns, more
foods with high fat content and more
refined carbohydrates.
Factors associated with
Type 2 diabetes
Non Modifiable
1- Genetic
factors.
2- Demographic
determinants:
such as age and
ethnicity.
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Modifiable
1- Behavioral and
lifestyle-related:
such as obesity and
physical inactivity.
2- Metabolic and
intermediate risk
categories: such as
IGT, IFG and GDM.
Why should we prevent
diabetes?
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To reduce human suffering.
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To alleviate the economic burden.
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To prevent morbidity and mortality
from diabetes-related CVD.
Levels of prevention in
Type 2 diabetes
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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.
Why the primary prevention?
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“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
Metabolic syndrome
prevention
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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.
Primary prevention
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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.
Types of interventions
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Behavioral interventions: including
changing diet and increasing
physical activity.
And/or
Pharmacological interventions:
utilizing pharmaceutical agents to
improve glucose tolerance and
insulin sensitivity.
Behavioral interventions
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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
Examples
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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
Cumulative incidence of diabetes
at 6 years
Control
Diet
Exercise
D&E
Data from: Pan et al, Diabetes Care, 1997; 20: 537-44
Examples- Cont
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The Finnish Diabetes Prevention Study
showed that Type 2 diabetes can be
prevented by changes in the lifestyles of highrisk 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
Pharmacological interventions
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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.
Examples
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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
Population-based prevention
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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.
Secondary prevention
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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?
Screening approaches
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Population screening
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Selective screening
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Opportunistic screening
Tertiary prevention
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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.
Effective interventions
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Strict metabolic control, education
and effective treatment.
Screening for complications in
their early stages when
intervention is more effective.
Obstacles and barriers for
prevention
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Economic problems: unavailability
of needed resources.
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Socio-cultural problems.
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Lack of data, knowledge and skills.
Examples of socio-cultural
barriers:
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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.
Major components of effective
prevention programs
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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.
Major components of effective
prevention programs- Cont
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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.
Major components of effective
prevention programs- Cont
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Educating the population about
this important global epidemic.
Provision of appropriate training
for health care providers.
Coordination of prevention efforts.
Central issues in Type 2
diabetes prevention
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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.
Central issues in Type 2
diabetes prevention- Cont
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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.
What do we know about Type
2 diabetes prevention?
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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.