Diabetes Prevention: what work in diabetes

1. Diabetes Prevention: What Works?
Guillermo E. Umpierrez, MD, CDCES, FACE, MACP
Professor of Medicine
Emory University School of Medicine
American Diabetes Association
President 2022

2. Conficts
Guillermo E. Umpierrez, MD, CDCES, FACE, MACP
Research support to Emory University: Dexcom, Bayer, Abbott, Sanofi, Lilly
Speaker’s Bureau:
Advisory Panel/Consultant: Dexcom, Glycare
Stock/Shareholder:

3. • 541 million adults (20-79 years) have carbohydrate intolerance (1 in 9)
• 319 million adults (20-79 years) have impaired fasting glucose (1 in 18)
The Diabetes & Prediabetes Epidemic
Global Diabetes Statistics, IDF
The number of
diabetes is expected
to rise to 643
million by 2030 and
783 million by 2045.
IDF Diabetes Atlas 2021 – 10th edition www.diabetesatlas.org
US:
DM:37.3 M
India: DM 101 M
(40% underdiagnosed)

4. Global estimates and projections of the number of people
with diabetes
Herman. Nutrition Reviews Vol. 75(S1):13–18, 2017
The number of adults with diabetes will increase by:
- 20% in Europe
- 42% in North America
- 47% in the Western Pacific
- 84% in Southeast Asia*
*International Diabetes Federation Diabetes Atlas, 8th edition, 2017
One in six people with
diabetes in the world
is from India.

5. The Diabetes Epidemic
Global Diabetes Statistics, IDF and CDC
Trends in Age-Adjusted Prevalence and Awareness of Prediabetes
Among US Adults Aged 18 Years or Older, 2005–2016
CDC’s National Health and Nutrition Examination Survey, 2005–2016.
Trends in Age-Adjusted Prevalence and Awareness of Prediabetes
Among US Adults, Aged 18 Years or Older, 2005-2016

6. Diagnostic Criteria for Prediabetes
(1) JAMA. 2023;329(14):1206-1216
(2) Menke et al. Epidemiol. 2018 Oct;28(10):681-685
An estimated 96 million adults aged 18 years or older had prediabetes in 2019. In a nationally
representative cross-sectional US study, fasting plasma glucose identified 28.3%of individuals as
having prediabetes compared with 21.7% using HbA1c and 13.3%using 2hPG.(2)
The same study reported a concordance rate for prediabetes diagnosis among all 3 tests (fasting
plasma glucose, HbA1c, and 2hPG) of 4.1%.(2)

7. Early screening for diabetes and prediabetes
El-Sayed, Gabbay, Umpierrez. Thelancet.com/diabetes-endocrinology April 2022
Diabetes Care 2023;46(Suppl. 1); | https://doi.org/10.2337/dc23-S016
Recommendation change:
• Diabetes screening in adults with overweight or
obesity (BMI ≥25 kg/m2) and one or more risk
factors starting at 18 years, and screening in all
asymptomatic adults from 35 years instead of
45 years.

8. Incidence of Diabetes (WHO Criteria) for Combinations of
IFG and IGT (WHO Criteria) for Combinations of IFG and IGT
FPG/2hPG Incidence OR
(mg/dl) (%) (95% CI)
Normal <110/140 4.5 1.0
IFG and NGT 110-126/<140 33 10.0
NFG and IGT <110/140-200 33.8 10.9
IFG and IGT 110-126/140-200 64.5 39.5
Hoorn Study, Follow-up 5-6 year
De Vegt et al, JAMA 285:2109-13, 2001
US: Randomized clinical trials reported annual rates of progression from prediabetes to
diabetes that ranged from 5.8% to 18.3%

9. Association between prediabetes and risk of all-cause
mortality and cardiovascular disease: meta-analysis
Cai et al. BMJ 2020;370:m2297
100-109
vs.
110-125
mg/dl

10. Prediabetes & microvascular complications
Prediabetes & mental and Cognitive diseases
Schlesinger et al. Diabetologia (2022) 65:275–285

11. Association between prediabetes and risk of all-cause
mortality and heart failure
Mai et al. Diabetes Obes Metab. 2021;23:2476–2483.

12. Prediabetes
& All-Cause
and CV
Mortality
Schlesinger et al. Diabetologia (2022) 65:275–285

13. Macrovascular complications associated with prediabetes
Endocrinol Metab Clin N Am 47 (2018) 33–50

14. Early detection of diabetes and prediabetes
1El-Sayed, Gabbay, Umpierrez. The Lancet.com/diabetes-endocrinology April 2022
Recommendation change:
• Screen for diabetes in overweight or obese adults (BMI ≥25
kg/m2) with more than one risk factor after the age of 18, and in
asymptomatic adults from the age of 35 instead of the age of 45.
• Screening should be repeated every 3 years if
results are normal, or sooner if prediabetes or a
change in risk factors is found.

15. Diabetes Prevention: What Works?
• Type 1 Diabetes
• Type 2 Diabetes

16. 0
10
20
30
40
50
60
70
1950 1960 1970 1980 1990 2000
Finland
Sweden
Colorado
Germany
The incidence of T1D increases between 3% and 5% per year
Incidence /100.000/ year
in children 0 a 14 years

17. T1D disease progression
• Starting point
• Genetic risk
• The road to T1D starts here
• All people with type 1 diabetes have
the genes associated with type 1
diabetes.
• The risk in the general population is 1
in 300
• Family members have a 15 times
higher risk of developing T1D
• The relative risk is 1 in 20
1
20

18. T1D disease progression
Normal blood glucose
≥ 2 autoantibodies
Abnormal blood glucose
≥ 2 autoanticuerpos
Clinical diagnosis
≥ 2 autoanticuerpos
Immune response
development of a
single
autoantibody
Genetic
risk
Immune
activation
Immune
response
STAGE 1 STAGE 2 STAGE 3
Longstanding
T1D
Immune activation
beta cells are attacked
Stages of T1D
STAGE 4
Beginning of T1D

19. Genetics: HLA and other immunity genes
19

20. T1D disease progression
Normal blood glucose
≥ 2 autoantibodies
Abnormal blood glucose
≥ 2 autoanticuerpos
Clinical diagnosis
≥ 2 autoanticuerpos
Immune response
development of a
single
autoantibody
Genetic
risk
Immune
activation
Immune
response
STAGE 1 STAGE 2 STAGE 3
Longstanding
T1D
Immune activation
beta cells are attacked
Stages of T1D
STAGE 4
Beginning of T1D

21. Development of T1D from Stage 2 (multiple Ab+,
abnormal glucose tolerance)
21
40% within 1 year
(95% CI 35% to 45%)
60% by 2 years
Age 8 and above
21
Progression from Stage 1 (multiple antibodies,
normal glucose tolerance) to Stage 3 (clinical T1D)
85% by 15 years
T1D disease progression

22. Dendritic cell/
Macrophage
naive
T-cell
TCR
CD3
Teff
IFN-g
TNF-a
IL-12
IL-23
IL-1b
IL-6
IL-
-15
Treg
Ag
MHC/pep
APC
Signal 1 - TCR
Signal 2 –
Co-stimulation
B-cell
T-cell – B-cell help
β-cell β-cell
apoptosis
β-cell
Regeneration?
Activated
Macrophage
IL-10 TGF-b
CD2
ISLET
CD80/CD86 CD28
IL-2
Teplizumab
(hOKT3g1 (ala-ala)
Rituximab
(anti-CD20)
Abatacept
(CTLA4-Ig)
Tm
CD2
LFA3
Alefacept
(Anti-CD2)
Low dose ATG
22

23. Type 1 Diabetes Prevention
FDA Approves Teplizumab En Familiares De Personas A Riezgo Con Diabetes Tipo1
Time to diagnosis to T1D of 48.4 vs. 24.4 months on PBO
Annualized rates: 14.9% vs. 35.9% in PBO
Anti-CD3 monoclonal antibodies, such as
teplizumab; multiple patient studies reduce
loss of beta cell function, even up to 7 years
after diagnosis.
Teplizumab (Tzield)
Requires 14-day infusion
Type 1 diabetes prevention
price is ~$194,000

24. Pathway to Prevention
24
Genetic
Risk
Immune
Activation
Immune Response
Development of single
autoantibody
Immune
Response
Immune Activation
Beta cells are attacked STAGE 2
STAGE 1 STAGE 3
Normal Glucose Tolerance
≥ 2 Autoantibodies
START OF T1D
Abnormal Glucose Tolerance
≥ 2 Autoantibodies
Clinical Diagnosis
≥ 2 Autoantibodies
Immune Effects of Oral
Insulin
Abatacept
Teplizumab
NIP
Mechanistic Studies
LIFT
Oral Insulin
* With ITN
** With DirectNet
Hydroxychloroquine
Abatacept
MMF/DZB
Ritixumab
IL-2/Rapamycin*
Thymoglobulin*
GAD-alum
Metabolic control**
Canakinumab
Tocilizumab*
Teplizumab*
Alefacept*
ATG/GCSF
Starting Point
If you have a relative:
15x greater risk of
developing T1D
Methyldopa
Rituximab/ Abatacept

25. Lifestyle
Intervention
Pharmacological
Intervention
Diabetes Prevention
American Diabetes Association. Diabetes Care. 2023, Standards of Care
Metabolic
Surgery
Type 2 Diabetes

26. Prediabetes: Screening, Diagnosis, Early Intervention
• Screen for diabetes in overweight or
obese adults (BMI >25 kg/m2) with
one or more risk factors at any age.
• Screen asymptomatic adults from
the age of 35 (instead of 45 years)
• Diagnostic tests:
• fasting glucose
• glucose tolerance curve
• HbA1c
ADA Standards of Care.
Diabetes Care Suppl 1, 2013
Consider intensive preventive
approaches in people at high risk
of progression to diabetes:
•BMI >35 kg/m2
•Fasting plasma glucose levels of
110 to 125 mg/dL
•2-h glucose tolerance curve:
173 to 199 mg/dL
•A1C > 6.0%
•History of gestational diabetes
mellitus

27. Important trials using intensive lifestyle interventions for
the prevention of diabetes
Endotext. Prediabetes. www.endotext.org
Lifestyle intervention is effective in
preventing or delaying the
progression to type 2 diabetes.
After 1 and 3 years of
intervention, there is a 36% - 54%
lower risk of progressing to type 2
diabetes compared with usual
treatment.

28. Study Country N
Baseline
BMI
(kg/m2)
Intervention
period
(years)
RRR
(%) NNT
Diabetes
Prevention
Program
USA 3234 34.0 2.8 58 21
Diabetes
Prevention
Study
Finland 523 31 4 39 22
Da Qing China 577 25.8 6 51 30
NNT, number needed to treat; RRR, relative risk reduction; T2D, type 2 diabetes.
DPP Research Group. N Engl J Med. 2002;346:393-403. Eriksson J, et al. Diabetologia. 1999;42:793-801.
Li G, et al. Lancet. 2008;371:1783-1789. Lindstrom J, et al. Lancet. 2006;368:1673-1679.
T2D Prevention: Lifestyle Modification Trials

29. Effects of lifestyle changes on adults with prediabetes: A
systematic review and meta-analysis

30. National Diabetes Prevention Program
Eli et al. Diabetes Care 2017

31. National Diabetes Prevention Program
Ely et al. Diabetes Care, 40(10):1331-1341, 2017
35.5% achieved a 5%
weight loss (average
weight loss 4.2%) and
median weight loss
3.1%)
Data from 14,747 adults enrolled 2/2012-2016:
35.5% achieved the 5% weight loss (average weight loss 4.2%; median weight loss 3.1%)
152 min of physical activity with 41.8% meeting the physical activity goal of 150 min
per week.

32. 2
-2
-4
-6
-8
0
DPP Research Group. Lancet. 2009;374:1677-1686.
Long-Term Weight Loss Is Difficult to Maintain
1
0 3
2 5
4 7
6 8 10
9
Years
DPP Outcomes Study (N = 2766)
Change
in
Weight
(kg)
Metformin
Lifestyle Placebo
DPP Research Group. Lancet. 2009;374:1677-

33. Prediabetes: Ensayos randomizados
Lifestyle Intervention Trials Glucose lowering Medications
Lifestyle interventions have used a low-fat, hypocaloric diet (<30% calories from fat; <10% saturated fat) and moderate-
intensity exercise ~150 minutes per week with the aim of reducing 5-7 % of weight.
Endotext. Prediabetes. www.endotext.org

34. Medical interventions that prevent T2D
Intervention Follow-up Period
Reduction in Risk of T2D
(P value vs placebo)
Antihyperglycemic agents
Metformin1 2.8 years 31% (P<0.001)
Acarbose2 3.3 years 25% (P=0.0015)
Pioglitazone3 2.4 years 72% (P<0.001)
Rosiglitazone4 3.0 years 60% (P<0.0001)
Weight loss interventions
Orlistat5 4 years 37% (P=0.0032)
Phentermine/topiramate6 2 years 79% (P<0.05)
Bariatric surgery7 10 years 75% (P<0.001)
1. DPP Research Group. N Engl J Med. 2002;346:393-403. 2. STOP-NIDDM Trial Research Group. Lancet. 2002;359:2072-2077.
3. Defronzo RA, et al. N Engl J Med. 2011;364:1104-15. 4. DREAM Trial Investigators. Lancet. 2006;368:1096-1105.
5. Torgerson JS, et al. Diabetes Care. 2004;27:155-161. 6. Garvey WT, et al. Diabetes Care. 2014;37:912-921.
7. Sjostrom L, et al. N Engl J Med. 2004;351:2683-2693.

35. 0 1 2 3 4
0
10
20
30
40
Placebo (n=1082)
Metformin (n=1073, p<0.001 vs.
Plac)
Percent developing diabetes
All participants
All participants
Years from randomization
Cumulative
incidence
(%)
Placebo (n=1082)
Metformin (n=1073, p<0.001 vs. Placebo)
Lifestyle (n=1079, p<0.001 vs.
Metformin,
p<0.001 vs. Placebo)
Risk reduction
31% by
metformin
58% by lifestyle
Diabetes Prevention Program: Progression to Type 2 Diabetes
DPP Research Group. NEJM. 2002;346:393-403.

36. 4,8
7,8
11
0
2
4
6
8
10
12
Intensive Lifestyle Intervention Effectively Prevents
Progression From IGT to T2D
Intensive lifestyle
intervention*
(n=1079)
Diabetes
Incidence
per
100
Person-Years
Placebo
(n=1082)
Metformin
850mg BID
(n=1073)
Diabetes Prevention Program
(N=3234)
58%
31%
*Goal: 7% reduction in baseline body weight through low-calorie, low-fat diet and ≥150 min/week moderate intensity exercise .
IGT, impaired glucose tolerance; T2D, type 2 diabetes.
DPP Research Group. N Engl J Med. 2002;346:393-403.

37. 11,6
10,8 10,8
6,7
7,6
9,6
6,2
4,7
3,1
0
2
4
6
8
10
12
14
25-44 45-59 ≥60
Placebo
Metformin
Lifestyle
Lifestyle Intervention More Effectively Prevents Diabetes as
Populations Age
7
Diabetes
Incidence
per
100
Person-Years
Diabetes Prevention Program
(N=3234)
Age (years)
*Goal: 7% reduction in baseline body weight through low-calorie, low-fat diet and ≥150 min/week moderate intensity exercise .
DPP Research Group. N Engl J Med. 2002;346:393-403.
48%
59%
71%

38. 78
32
0
20
40
60
80
Control (n=250) Diet intervention (n=256)
Cumulative Incidence of Diabetes Over 4 Years
Incidence
of
diabetes
(cases/1000
person-years)
DBP, diastolic blood pressure; SBP, systolic blood pressure.
Tuomilehto J, et al. N Engl J Med. 2001;344:1343-1350.
58%
The Finnish Diabetes Prevention Study

39. The Effect of Metformin on the Progression of IGT to T2DM
Incidence
of
Diabetes
(%/yr)
Control Metformin
The Chinese Prevention Study
(N=321)
IGT, impaired glucose tolerance; RRR, relative risk reduction.
Yang W, et al. Chin J Endocrinol Metab. 2001;17:131-136.
11,6
4,1
0
2
4
6
8
10
12
14
65%

40. 23-Year Incidence of T2D in Asian Patients with IGT
Li G, et al. Lancet Diabetes Endocrinol. 2014;2:474-478.
Da Qing Diabetes Prevention Study

41. Cumulative incidence of diabetes
Ramachandran et al. Diabetologia 49: 289-297, 2006
Indian Diabetes Prevention
Programme (IDPP)
Native Asian Indians with IGT
Primary outcome: development of
diabetes by OGTT
Median follow-up: 30 months
- Control group (n= 136)
- Lifestyle modification (LSM) (n=
133)
- Metformin (n= 133)
- LSM + Metformin (n=129)

42. Effect of Lifestyle Modification and Metformin on
Cumulative Diabetes Incidence
42
3-y
Cumulative
Incidence
(%)
Control
(n=136)
DPP, Diabetes Prevention Program; LSM, lifestyle modification; MET, metformin; RRR, relative risk reduction.
Ramachandran A, et al. Diabetologia. 2006;49:289-297.
The Indian DPP (N=531)
55.0
39,3 40,5 39,5
0
10
20
30
40
50
60
Lifestyle
Modification
(n=133)
Metformin
(n=133)
Lifestyle
Modification
+ Metformin
(n=129)
29%
P=0.02
26%
P=0.03
28%
P=0.02

43. Effect of Acarbose on
Reversion of IGT to NGT
30,9
35,3
0
5
10
15
20
25
30
35
40
43
P<0.0001
Placebo
(n=715)
Acarbose
(n=714)
Patients
(%)
IGT, impaired glucose tolerance; NGT, normal glucose tolerance; STOP-NIDDM, Study to Prevent Non-Insulin Dependent Diabetes Mellitus.
Chiasson JL, et al. Lancet. 2002;359:2072-2077.
STOP-NIDDM

44. Effect of Rosiglitazone on New-Onset Diabetes or
Death in Patients with Prediabetes
44
DREAM, Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medication.
DREAM Trial Investigators. Lancet. 2006;368:1096-1105.
No. at risk
Placebo
Rosiglitazone
2634
2635
2470
2538
2150
2414
1148
1310
177
217
0.6
0.5
0 1 2 3 4
Follow-up (years)
0.4
0.3
0.2
0.1
0.0
Placebo
Cumulative
hazard
rate
Rosiglitazone
60%
DREAM
(Rosiglitazone)

45. Effects of Phentermine/Topiramate ER in Patients at
High Risk of Developing T2D
45
*All groups had lifestyle intervention.
NS, not significant; Phen/TPM ER, phentermine/topiramate extended release; T2D, type 2 diabetes.
Garvey WT, et al. Diabetes Care. 2014;37:912-921.
SEQUEL Prediabetes/Metabolic Syndrome Cohort
(N=475)
3,5
6,4
1,8
1,5
0,4
1,3
0
1
2
3
4
5
6
7
89%
49%
Annualized
incidence
rate
of
T2D
Prediabetes
(n=316)
Metabolic syndrome
(n=451)
80%
77%
P=0.013
P=NS
P<0.001
P=0.009
Placebo* Phen/TPM ER 7.5/46 mg* Phen/TPM ER 15/92 mg*

46. Effects of Liraglutide in Obese Patients with Prediabetes
46
*P<0.001 vs placebo.
Pi-Sunyer X, et al. N Engl J Med. 2015;373:11-22.
Liraglutide 3 mg Placebo
SCALE Obesity and Prediabetes
(N=3731)
7,2
30,8
20,7
67,3
0
10
20
30
40
50
60
70
80

Weight
(kg)
Normoglycemia at
screening
Patients with Prediabetes After 56
Weeks
Patients
(%)
Prediabetes at screening
-8,4
-2,8
-9
-8
-7
-6
-5
-4
-3
-2
-1
0
Weight Change After 56 Weeks
*
*
*

47. Effect of Bariatric Surgery on Incidence of Type 2 Diabetes
Carlsson LM, et al. N Engl J Med. 2012;367:695-704.
Swedish Obesity Study

48. ACT Now: Pioglitazone& Diabetes Prevention (IGT)
ACT NOW, Actos Now for the Prevention of Diabetes; IGT, impaired glucose tolerance; T2D, type 2 diabetes.
Defronzo RA, et al. N Engl J Med. 2011;364:1104-1115.
ACT NOW (Pioglitazone)
Kaplan-Meier plot of Hazard Ratios for Time to Development of T2D

49. The Twin Pandemics
World Health Organization has termed the increased prevalence
of obesity and diabetes as a ‘21st Century epidemic
PREDIABETES

50. A relatively small weight loss (approximately 3-7% of initial
weight) improves glycemia and other intermediate
cardiovascular risk factors. TO
Larger, sustained weight losses (>10%) generally confer
greater benefit and possible remission of prediabetes and
type 2 diabetes, and may improve cardiovascular outcomes
and long-term mortality.
Weight Control: Realistic Goal
Diabetes Care 2023;46(Suppl. 1); | https://doi.org/10.2337/dc23-S016

51. Redrawn from: Hamman, et al Diabetes Care 29:2102-2107, 2006
Change in weight from baseline (kg)
0
-10 -5 +5
Incidence
rate
per
100
person-years
10
20
15
5
0
How much weight loss is needed to prevent type 2 diabetes? the DPP experience

53. Conclusions
Reduced-calorie diets result in clinically meaningful weight loss regardless of
which macronutrients they emphasize.
n engl j med 360;9 nejm, Feb 26, 2009

54. Significant weight loss.
It makes no difference which diet is used
Vetter et al Ann of Int Med, 2010; 152:334

55. - 10 kg at 2 year follow-up = 64%
diabetes remission
Lean et al. The Lancet Diabetes & Endocrinology 2019;7:344-355.
Intensive Structured Weight Management: the DiRect RCT

56. Todos los datos sustraídos de placebo, dosis máxima, ITT-LOCF, 1 año, a menos que se
indique lo contrario
Eficacia comparativa de los medicamentos para bajar de peso
Garvey WT. Endocr Pract. 2013;19(5):864-874. Sep 6:1–31.
Wadden TA et al. Int J Obes (Lond). 2013;37(11):1443-1451.
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Phentermine/
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Liraglutide
3 mg
Naltrexone/
Bupropion
Lorcaserin Orlistat Phentermine
Comparative effectiveness of weight loss medications
All data subtracted from placebo, maximum dose, ITT-LOCF, 1 year of therapy

57. Semaglutide 2·4 mg once a week in adults with overweight or
obesity, and type 2 diabetes (STEP 2)
Comparison of bodyweight parameters for semaglutide 2·4 mg versus semaglutide 1·0 mg versus placebo, given once a week
Davies et al. STEP 2 Study Group Lancet 2021; 397: 971–84

58. Tirzepatide Once Weekly for the treatment of Obesity
Jastreboff and SURMOUNT-1 Investigators. N Engl J Med. 2022 Jun 4.
Mean reduction in total body fat mass was 33.9% with tirzepatide, as compared with 8.2% with placebo.
40.6% had prediabetes at baseline; of them, 95% reversed to normal glucose profile,

60. • Obesity Management for the Treatment of Type 2 Diabetes
Obesity Management for the Treatment of Type 2 Diabetes:
Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S128-S139
Metabolic surgery should be an option to treat T2D in individuals with BMI ≥40 kg/m2
and in adults with BMI 30.0–34.9 kg/m2 (27.5–32.4 kg/m2 in Asian Americans) who
do not achieve durable weight loss and improvement in comorbidities (including
hyperglycemia) with nonsurgical methods

62. 2022

63. Study Country N
Baseline
BMI
(kg/m2)
Intervention
period
(years)
RRR
(%) NNT
Diabetes
Prevention
Program
USA 3234 34.0 2.8 58 21
Diabetes
Prevention
Study
Finland 523 31 4 39 22
Da Qing China 577 25.8 6 51 30
NNT, number needed to treat; RRR, relative risk reduction; T2D, type 2 diabetes.
DPP Research Group. N Engl J Med. 2002;346:393-403. Eriksson J, et al. Diabetologia. 1999;42:793-801.
Li G, et al. Lancet. 2008;371:1783-1789. Lindstrom J, et al. Lancet. 2006;368:1673-1679.
Prevention of T2D:
Selected Lifestyle Modification Trials

64. Prevention or Delay of T2DM: Metformin
• Metformin therapy for prevention of
type 2 diabetes should be considered
in those with prediabetes, especially
for those with:
• BMI >35 kg/m2,
• Age < 60 years,
• Women with prior gestational diabetes (GDM),
• Rising A1C despite lifestyle intervention. A
American Diabetes Association Standards of Medical Care in Diabetes.
Prevention or delay of type 2 diabetes. Diabetes Care 2023

65. The Twin Pandemics
World Health Organization has termed the increased prevalence
of obesity and diabetes as a ‘21st Century epidemic
PREDIABETES

66. Lifestyle
Intervention
Pharmacologic
Intervention
Thank You