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  • 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.

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  • 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
  • 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 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 The DPP Research Group, NEJM 346 :393-403, 2002
  • 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
    Incidence of diabetes reduced – 58% (p=.0003) 57 Cases 22% -0.8 -0.8 Control 26 cases 10% -3.5 -4.2 Intervention 4 th Year 2 nd Year 1 st Year Weight Loss
  • DIABETES INCIDENCE IN PREVENTION STUDIES 7.3 10 Metformin 3 51 IGT + BMI > 24 & FPG > 5.3 (95) 3234 US DPP 4.3 10 Diet & Exercise 3 51 IGT + BMI > 24 & FPG > 5.3 (95) 3234 US DPP 9.6 15.7 Diet & Exercise 6 45 IGT (by Clinic) 530 Chinese (DaQing) 41.8 32.8 Acarbose 4 40-70 IGT & FPG > 5.6 (101) 1419 European (STOP) 6 Ctrl 3.2 Dura Active Interv’n Age Population No Group (Study) Lifestyle 3 55 IGT + BMI > 25 Age 40-65 522 Finnish (DPS)
    • 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
  • Diabetes Prevention Program For People at High Risk
    • Weight Loss
    • Diet
    • Exercise
    • Lower Risk for Diabetes
    Small Steps – Big Rewards
  • S tudies to T reat O r P revent P ediatric T ype 2 D iabetes ( 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 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%