# Presentation: 678102

## PREVENTION OFTYPE 2 DIABETES 

**Francine Ratner Kaufman, M.D.**
**Professor of Pediatrics**
**The Keck School of Medicine of USC **
**Head, Center of Diabetes, Endocrinology and Metabolism**
**Childrens Hospital Los Angeles**
**President, American Diabetes Association**

## Burden of Diabetes in USA

**17 Million Americans Have Diabetes **
**16 Million Americans Have Prediabetes**
**210,000 Diabetes-Related Deaths/year**
**Leading Cause of Blindness, Kidney Failure, Amputation**
**65% Cardiovascular Disease-Related Death**
**Cost $132 Billion/2002**

- Mokdad, et al, JAMA 2001 286,1195

## Diabetes Prevalence Among Minority Populations in the U.S.

**Non-Hispanic Whites**

**Latinos**

**African Americans**

**Native Americans & Alaska Natives**

**Diabetes Prevalence Among Minority Populations in the U.S.**

**Centers for Disease Control  and Prevention (CDC) 1999  www.cdc.gov/diabetes**

**Percentage of each population with diabetes**

**     **

**7.8%   ****(11.4 million)**

**10.2%   ****(2 million)**

**13%    ****(2.8 million)**

**15.1%   ****(105,000)**

***Asian Americans and Pacific Islanders are  2-5 times more likely to have diabetes than Non-Hispanic Whites.***

- 

## Natural History of Type 2 Diabetes

**Natural History of Type 2 Diabetes**

**Genetic****susceptibility**
**Environmental****factors****	****Nutrition****	****Obesity****	****Physical inactivity**

**Hyperinsulinemia******** HDL-C******** Triglycerides****Atherosclerosis****Hypertension**

**Atherosclerosis****Hyperglycemia****Hypertension**

**Retinopathy****Nephropathy****Neuropathy**

**Blindness****Renal failure****CHD****Amputation**

**Onset of****diabetes**

**Complications**

**Disability**

**Death**

**Ongoing hyperglycemia**

**IGT**

**Insulin resistance**

## The Diabetes Prevention Program  A Randomized Clinical Trial to Prevent Type 2 Diabetes in Persons at High Risk The DPP Research Group

## Study Interventions

**Eligible participants**
**Randomized**
**Standard lifestyle recommendations**

**Intensive               DRUG            Placebo**
**Lifestyle****	****        Metformin**
**(n = 1079)           (n = 1073)        (n = 1082)**

## Weight Change

**Placebo**

**Metformin**

**Lifestyle**

**Weight Change**

**The DPP Research Group, *****NEJM 346*****:393-403, 2002**

## Type 2 Diabetes Prevention

- 0

- 1

- 2

- 3

- 4

- 0

- 10

- 20

- 30

- 40

- Placebo (n=1082)

- Metformin (n=1073, p<0.001 vs. Plac)

- Lifestyle (n=1079, p<0.001 vs. Met , p<0.001 vs. Plac )

- Percent developing diabetes

-  All participants

-  All participants

- Years from randomization

- Cumulative incidence (%)

**Placebo **

**Metformin**

**Lifestyle**

**Type 2 Diabetes Prevention**

_**Risk reduction**_
**31% by metformin**
**58% by lifestyle**

**The DPP Research Group, *****NEJM 346*****:393-403, 2002**

## Prevention of Type 2 with Lifestyle Intervention        Tuomilehto, et al ,  Turku ADA 2000

**Intervention – 523  IGT, mean age 55, BMI 31**
**Diet, exercise, frequent visits vs advice yearly**

| Weight 
Loss | 1st Year | 2nd Year | 4th Year |
| --- | --- | --- | --- |
| Intervention | -4.2 | -3.5 | 26 cases
10% |
| Control | -0.8 | -0.8 | 57 Cases
22% |

**Incidence of diabetes reduced – 58% (p=.0003)**

## DIABETES INCIDENCE IN  PREVENTION STUDIES

| Group
(Study) | No | Population | Age | Dura | Interv’n | Ctrl | Active |
| --- | --- | --- | --- | --- | --- | --- | --- |
| Finnish
(DPS) | 522 | IGT + BMI > 25 Age 40-65 | 55 | 3.2 | Lifestyle | 6 | 3 |
| US DPP | 3234 | IGT + BMI > 24 & FPG >5.3 (95) | 51 | 3 | Diet & Exercise | 10 | 4.3 |
| US DPP | 3234 | IGT + BMI > 24 & FPG >5.3 (95) | 51 | 3 | Metformin | 10 | 7.3 |
| Chinese (DaQing) | 530 | IGT 
(by Clinic) | 45 | 6 | Diet & Exercise | 15.7 | 9.6 |
| European
(STOP) | 1419 | IGT & 
FPG > 5.6 (101) | 40-70 | 4 | Acarbose | 41.8       32.8 |  |

**Translation of the**
** ****DPP Results**

## ADA/NIDDK Screening Recommendations For Prediabetes in AdultsDiabetes Care, 25:2002

**Case Finding**
**Test: **
_**>**_**45 years, BMI > 25 kg/m2 **
**<45 years with + FH, GDM, baby > 9 lbs, dyslipidemia, hypertension, non-Caucasian **
**At 3 yr intervals, if negative**

## ADA/NIDDK Recommendations In AdultsDiabetes Care, 25:2002

**How to Test: **
**In context of health care visit **
**FPG, 2-h OGTT**
**Intervention: **
**Prediabetes counsel for weight loss and PA, Follow-up counseling **
**Monitor for DM q 1-2 years, CVD risk factors**
**Avoid drug therapy**

## What Children Should be Tested ADA/AAP RecommendationsDiabetes Care 23:2000

**Age **_**>**_** 10 years or onset of puberty**
**BMI > 85th%**
**First or Second Degree Relative**
**Race/Ethnic Group**
**Signs of Insulin Resistance – **
**Acanthosis nigricans**
**Hypertension**
**PCOS**
**Dyslipidemia**
***	******	***

## Small Steps – Big Rewards

**Diabetes Prevention Program**
**For People at High Risk**

**Weight Loss**
**Diet**
**Exercise**
**Lower Risk for Diabetes**

**Small Steps – Big Rewards**

**Notes:**
And now we have great news about preventing diabetes. In August 2001, the National Institutes of Health announced the results of a major clinical trial-- the Diabetes Prevention Program.  The study results indicate that adults who are at high risk for diabetes can sharply reduce their risk through diet, moderate exercise, and weight loss.

## Studies to Treat Or Prevent Pediatric Type 2 Diabetes(STOPP-T2D)

- TODAY

- Funded by
- National Institute of Diabetes and Digestive and Kidney Diseases
- National Institutes of Health

## Weight Loss Reduces Medical Costs

**Costs of diabetes:  $132 billion (2002)**
**Direct Costs: 5.7% National Health Expenditure**
**7% ****–**** 10% Weight Loss**
**58% Reduction in Diabetes **
**Treatment Cost Reduction**
**$123 for the insulin-treated patient/month**
**$61 for the hyperlipidemic patient/month**

- (Wolf AM, Colditz GA. *Obes Res*. 1998)  (Greenway FL, et al. *Obes Res*. 1999)

## GLOBAL  PROJECTIONS FOR THE DIABETES EPIDEMIC: 2000-2010

**GLOBAL  PROJECTIONS FOR THE DIABETES EPIDEMIC: 2000-2010**

**14.2**
**17.5**
***23%***

**15.6**
**22.5**
***44%***

**26.5**
**32.9**
***24%***

**1.0**
**1.3 **
***33%***

** ****9.4**
**14.1**
***50%***

**World**
**2000 = 151 million**
**2010 = 221 million**
***Increase 46%***

**84.5**
**132.3**
***57%***