Learn how to overcome common barriers to diabetes prevention with this downloadable slideset. Richard E. Pratley, MD Format: Microsoft PowerPoint (.ppt) File Size: 3.16 MB Released: October 23, 2018

1. Diabetes in the South: Focus on Prevention
This program is supported by an educational grant from Lilly USA, LLC.

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3. Faculty
Richard E. Pratley, MD
Medical Director of Education and Research
Florida Hospital Diabetes Institute
Senior Scientist
Translational Research Institute for Metabolism and Diabetes
Adjunct Professor
Sanford Burnham Prebys Medical Discovery Institute at Lake Nona
Orlando, Florida
Richard E. Pratley, MD, has disclosed that he has received consulting fees
and/or funds for research support paid to his institution from AstraZeneca,
Boehringer Ingelheim, Eisai, GlaxoSmithKline, Janssen, Lexicon, Ligand, Lilly,
Merck, Novo Nordisk, Pfizer, Sanofi, and Takeda and has served on speakers
bureau for Novo Nordisk and Takeda.

4. Agenda
 Scope of the problem
 Definitions
 Lifestyle interventions
 Pharmacologic therapy, bariatric surgery
 Barriers to prevention

5. Age-Adjusted Prevalence of Obesity and Diagnosed
Diabetes Among US Adults
Obesity (BMI ≥ 30)
Diabetes
No Data < 14.0% 14.0-17.9% 18.0-21.9% 22.0-25.9% ≥ 26.0%
No Data < < 4.5% 4.5-5.9% 6.0-7.4% 7.5-8.9% ≥ 9.0%
1994 2000 2015
201520001994
CDC. Division of Diabetes Translation. United States Diabetes Surveillance System.
Available at: http://www.cdc.gov/diabetes/data. Slide credit: clinicaloptions.com

6. Microvascular Complications of T2DM
 Of adults ≥ 40 yrs of age with diabetes,
4.2 million (28.5%) had diabetic retinopathy*
‒ 655,000 (4.4%) had advanced diabetic retinopathy
 In adults ≥ 20 yrs of age with diabetes,
~ 73,000 nontraumatic lower-limb amputations†
‒ Overall, ~ 60% of nontraumatic lower-limb amputations
among adults are in those with diabetes
 Diabetes listed as the primary cause of kidney failure
in 44% of all new cases‡
*2005-2008. †2010. ‡2011.
CDC. National Diabetes Statistics Report, 2014. Slide credit: clinicaloptions.com

7. Diabetes Doubles the Risk of Vascular Outcomes
Coronary heart disease
Coronary death
Nonfatal MI
Ischemic stroke
Hemorrhagic stroke
Unclassified stroke
Other vascular deaths
HR (95% CI)*
2.00 (1.83-2.19)
2.31 (2.05-2.60)
1.82 (1.64-2.03)
2.27 (1.95-2.65)
1.56 (1.19-2.05)
1.84 (1.59-2.13)
1.73 (1.51-1.98)
1 2 4
Emerging Risk Factors Collaboration. Lancet. 2010;375:2215-2222. Slide credit: clinicaloptions.com
I2 (95% CI)
64 (54-71)
41 (24-54)
37 (19-51)
1 (0-20)
0 (0-26)
33 (12-48)
0 (0-26)
Cases, n
26,505
11,556
14,741
3799
1183
4973
3826
*For vascular outcomes in persons with vs without diabetes. Adjusted for age, smoking status, BMI, and systolic blood pressure;
where appropriate, stratified by sex and trial arm.

8. Prevalence of Diabetes Higher in Certain Racial/Ethnic
Groups
DiabetesPrevalence(%)
Estimated Age-Adjusted Prevalence of Diagnosed Diabetes by
Race/Ethnicity in US Adults ≥ 18 Yrs, 2013-2015
CDC. National Diabetes Statistics Report, 2017. Slide credit: clinicaloptions.com
American Indian/
Alaska Native
Black White
Race/Ethnicity
Asian Hispanic
14.9 15.3
9.0
7.3
12.2
13.2 12.6
11.7
8.1
6.8
Men
Women
0
5
10
15

9. The Diabetes Belt: 2013 Diabetes Prevalence in Adults
Slide credit: clinicaloptions.comCDC. National Diabetes Statistics Report, 2017.
Percentage in Quintiles
0-7.83
7.84-8.80
8.81-9.96
9.97-11.65
≥ 11.66

10. 84.1 million
CDC. National Diabetes Statistics Report, 2017. Slide credit: clinicaloptions.com
Type 2 Diabetes Progresses Over Decades
Normal Prediabetes
Type 2
Diabetes
Complications
Disability
or Death
30.3 million
Primary
Prevention
Secondary
Prevention
Tertiary
Prevention

11. Agenda
 Scope of the problem
 Definitions
 Lifestyle interventions
 Pharmacologic therapy, bariatric surgery
 Barriers to prevention

12. 126
100
FPG, mg/dL
140
200
2-hr PG (OGTT), mg/dL A1C, %
5.7
6.5
American Diabetes Association. Diabetes Care. 2018;41:S13-S27. Slide credit: clinicaloptions.com
Thresholds for Diagnosis of Diabetes
Diabetes
Prediabetes
Normal
Impaired Glucose
Tolerance
Impaired Fasting
Glucose

13. IFG and IGT: Clinical Manifestations
Impaired Fasting Glucose
 Prevalence plateaus in middle age
 More common in men
Impaired Glucose Tolerance
 Prevalence rises into old age
 Slightly more common in women
 Stronger association with CVD
outcomes
Unwin N, et al. Diabet Med. 2002;19:708-723. Slide credit: clinicaloptions.com
 IFG, IGT, and high A1C define different but overlapping groups at risk for
T2DM
 IGT more prevalent than IFG in most populations

14. Framingham Offspring Study Population
RiskofDevelopingDiabetes(%)
Neither IGT Only IFG Only Both
0
10
30
50
70
90
100
1.3
4.3
9.2
25.5
Glucose Abnormalities and Risk for T2DM
Wilson PW, et al. Arch Intern Med. 2007;167:1068-1074. Bloomgarden ZT. Diabetes Care. 2008;31:2404-2409. Slide credit: clinicaloptions.com
20
40
60
80

15.  Prospective study of individuals 45-79 yrs of age in Norfolk, UK
Graded Risk of CHD With Worsening Glucose Tolerance:
A1C
< 5.0 5.0-5.4 5.5-5.9 6.0-6.4 6.5-6.9 ≥ 7.0 Known
Diabetes
3.8 1.7
6.4
2.1
8.7
3.0
10.2
7.3
16.7
9.6
28.4
16.2
21.9
15.7
CHDEvents/100Persons
A1C, %
Khaw KT, et al. Ann Intern Med. 2004;141:413-420. Slide credit: clinicaloptions.com
0
20
Men (n = 4662)
Women (n = 5570)
40
60
80
100

16. Rationale for Preventing T2DM
 Impact on natural history of T2DM
 Prevent progression to complicated, expensive treatment regimens
 Decrease microvascular complications
 Decrease CVD
Slide credit: clinicaloptions.com

17. Feasibility of Preventing T2DM
 A long period of impaired glucose regulation precedes the
development of diabetes
 Screening tests can identify persons at high risk
 Safe, effective interventions can address modifiable risk factors
Slide credit: clinicaloptions.com

18. Most People With Prediabetes Unaware of Their
Condition
 US adults ≥ 20 yrs of age with 2005-2006 NHANES data, no diabetes,
FPG and OGTT results (N = 1402)
‒ Prediabetes: 29.6%
‒ Aware of prediabetes diagnosis: 7.3%
‒ Suboptimal adoption of risk reduction behaviors (eg, increased physical
activity, reduced fat or caloric intake)
Geiss LS, et al. Am J Prev Med. 2010;38:403-409. Slide credit: clinicaloptions.com

19. Adults Who Should Be Screened for Diabetes or
Prediabetes
 If results are
normal, repeat
testing at least
every 3 yrs
 Consider
increased testing
frequency based
on initial results,
risk status
American Diabetes Association. Diabetes Care. 2018;41:S13-S27. Slide credit: clinicaloptions.com
Criteria for Prediabetes/Diabetes Testing in Asymptomatic Adults
Overweight or obese adults (BMI ≥ 25) with ≥ 1 of the following
risk factors:
 First-degree relative with diabetes
 High-risk race/ethnicity
 History of CVD
 Hypertension (≥ 140/90 mmHg or on therapy for hypertension)
 HDL cholesterol < 35 mg/dL and/or triglycerides > 250 mg/dL
 Women with polycystic ovary syndrome
 Physical inactivity
 Other clinical conditions associated with insulin resistance
Patients with prediabetes (A1C ≥ 5.7%, IGT, or IFG)
Women with gestational diabetes mellitus
Anyone reaching 45 yrs of age

20. Agenda
 Scope of the problem
 Definitions
 Lifestyle interventions
 Pharmacologic therapy, bariatric surgery
 Barriers to prevention

21. Finnish Diabetes Prevention Study: Design
 Randomized controlled trial of overweight individuals with IGT
‒ Mean age: 55 yrs; 67% female
 Intensive diet arm aimed at:
‒ Reducing weight ≥ 5%, fat intake to < 30%, saturated fat intake to < 10%
‒ Increasing intake of fiber, fruits, vegetables; physical activity ≥ 30 min/day
Tuomilehto J, et al. N Engl J Med. 2001;344:1343-1350. Slide credit: clinicaloptions.com
Individuals 40-65 yrs of age
with BMI ≥ 25 and 2-hr plasma
glucose 140-200 mg/dL
(N = 522)
Intensive Diet and Lifestyle Advice
(n = 265)
Basic Diet and Exercise Information
(n = 257)

22. Primary Endpoint
Finnish Diabetes Prevention Study Group: Diabetes Risk
Tuomilehto J, et al. N Engl J Med. 2001;344:1343-1349. Slide credit: clinicaloptions.com
HR: 0.4 (95% CI: 0.3-0.7; P < .001)
CumulativeProbabilityof
RemainingFreeofDiabetes
Study Yr
0.4
0.5
0.6
0.7
0.8
0.9
1.0
0 1 2 3 4 5 6
Control group
Intervention group

23.  Randomized controlled trial of individuals with prediabetes in 27 US centers
‒ Mean age: 51 yrs; 68% female
 Primary endpoint: development of diabetes
 Secondary endpoints: insulin sensitivity and secretion; development and/or
progression of vascular disease, obesity, CV risk factors
US Diabetes Prevention Program: Study Design
1. The DPP Research Group. Diabetes Care. 2000;23:1619-1629. 2. Knowler WC, et al.
N Engl J Med. 2002;346:393-403. 3. DPP Research Group. Lancet. 2009;374:1677-1686. Slide credit: clinicaloptions.com
Individuals ≥ 25 yrs of age with
BMI ≥ 24, 2-hr plasma glucose
140-199 mg/dL, fasting plasma
glucose 95-125 mg/dL, and
BP ≤ 180/105 mmHg
(N = 3234)[1]
Intensive Lifestyle Intervention
(n = 1079)
Metformin*
(n = 1073)
Placebo
(n = 1082)
Lifestyle + Group Classes
(n = 910)
Lifestyle + Metformin*
(n = 924)
Lifestyle
(n = 932)
*850 mg BID.
10-Yr Results[3]4-Yr Results[2]

24. US Diabetes Prevention Program: Race/Ethnicity
The DPP Research Group. Diabetes Care. 2000;23:1619-1629. Slide credit: clinicaloptions.com
Caucasian,
1768 (55%)
African
American,
645 (20%)
Hispanic,
508 (16%)
Asian/Pacific Islander, 142 (4%)
American Indian, 171 (5%)

25. US Diabetes Prevention Program:
Intensive Lifestyle Intervention
Goals
 ≥ 7% loss of body weight with
maintenance of weight loss
‒ Dietary fat: ≤ 25% of calories
from fat
‒ Caloric intake: 1200-2000
kcal/day
 ≥ 150 min/wk physical activity
Structure
 16 curriculum sessions in 24 wks
 Long-term maintenance
program
 Supervised by a case manager
 Access to lifestyle support staff
‒ Dietitian, behavior counselor,
exercise specialist
DPP Research Group. Diabetes Care. 2002;25:2165-2171. Slide credit: clinicaloptions.com

26.  In addition, 74% assigned to intensive lifestyle intervention achieved study goal of
≥ 150 min/wk physical activity at 24 wks
US Diabetes Prevention Program: Mean Weight Change
1. Knowler WC, et al. N Engl J Med. 2002;346:393-403. Slide credit: clinicaloptions.com
Yrs Since Randomization
MeanWeight
Change(kg)
420 31
-8
-6
-4
-2
0
2
DPP[1]
Placebo
Metformin
Lifestyle
P < .001 for each
comparison

27. US Diabetes Prevention Program: Mean Weight Change
1. Knowler WC, et al. N Engl J Med. 2002;346:393-403. 2. DPP Research Group. Lancet. 2009;374:1677-1686. Slide credit: clinicaloptions.com
1086 975
DPPOS[2]
 In addition, 74% assigned to intensive lifestyle intervention achieved study goal of
≥ 150 min/wk physical activity at 24 wks
Yrs Since Randomization
MeanWeight
Change(kg)
DPP[1]
-8
-6
-4
-2
0
2
420 31
Placebo
Metformin
Lifestyle

28. US Diabetes Prevention Program: Diabetes Incidence
1. Knowler WC, et al. N Engl J Med. 2002;346:393-403. 2. DPP Research Group. Lancet. 2009;374:1677-1686. Slide credit: clinicaloptions.com
Reduction in
Diabetes Incidence
vs Placebo, %
(95% CI)
Follow-up
2.8 Yrs[1] 10 Yrs[2]
Lifestyle
58*
(48-66)
34†
(24-42)
Metformin
31*
(17-43)
18†
(7-28)
CumulativeDiabetesIncidence(%)
Yrs Since Randomization
1086420
0
30
40
50
60
10
20
Placebo
Metformin
Lifestyle
DPP[1]
DPPOS[2]
*P < .001 vs placebo.
†P = NS vs placebo.

29. US Diabetes Prevention Program:
Diabetes Incidence by Age After 2.8 Yrs
Knowler WC, et al. N Engl J Med. 2002;346:393-403. Slide credit: clinicaloptions.com
Cases/100Person-Yr
Age (Yrs)
25-44
(n = 1000)
45-59
(n = 1586)
≥ 60
(n = 648)
0
4
8
12
16 MetforminLifestyle Placebo

30. US Diabetes Prevention Program:
Diabetes Incidence by Ethnicity After 2.8 Yrs
Knowler WC, et al. N Engl J Med. 2002;346:393-403. Slide credit: clinicaloptions.com
Caucasian
(n = 1768)
Hispanic
(n = 508)
American Indian
(n = 171)
African American
(n = 645)
Asian
(n = 142)
MetforminLifestyle Placebo
Cases/100Person-Yr
0
4
8
12
16

31. US Diabetes Prevention Program:
Diabetes Incidence by BMI After 2.8 Yrs
Knowler WC, et al. N Engl J Med. 2002;346:393-403. Slide credit: clinicaloptions.com
22 to < 30
(n = 1045)
30 to < 35
(n = 995)
≥ 35
(n = 1194)
Body Mass Index
MetforminLifestyle Placebo
0
4
8
12
16
Cases/100Person-Yr

32. US Diabetes Prevention Program:
Consistency of Treatment Effects After 2.8 Yrs
Lifestyle
 More efficacious than placebo
regardless of sex, age, ethnicity,
or BMI
‒ Better than metformin in older
patients or those with lower
BMI
Metformin
 More efficacious than placebo
in those with higher fasting
plasma glucose
‒ Comparable to lifestyle in
younger patients and those
with higher BMI
Slide credit: clinicaloptions.comKnowler WC, et al. N Engl J Med. 2002;346:393-403.

33. US Diabetes Prevention Program:
Summary on Impact of Lifestyle Intervention
 Treating 100 high-risk adults (~ 50 yrs of age) for 3 yrs:
‒ Prevents 15 new cases of T2DM[1]
‒ Prevents 162 missed work days[2]
‒ Avoids the need for BP/cholesterol medications in 11 people[3]
‒ Avoids $91,400 in healthcare costs (estimates scaled to 2008 USD)[4]
‒ Adds the equivalent of 20 perfect yrs of health[5]
1. Knowler WC, et al. N Engl J Med. 2002;346:393-403. 2. DPP Research Group. Diabetes Care.
2003;26:2518-2523. 3. Ratner R, et al. Diabetes Care. 2005;28:888-894. 4. Ackermann RT, et al.
Am J Prev Med. 2008;35:357-363. 5. Herman WH, et al. Ann Intern Med. 2005;142:323-332. Slide credit: clinicaloptions.com

34. Agenda
 Scope of the problem
 Definitions
 Lifestyle interventions
 Pharmacologic therapy, bariatric surgery
 Barriers to prevention

35. Diabetes Prevention: Treatment Options
References in slidenotes. Slide credit: clinicaloptions.com
Treatment Population N
F/u,
Yrs
Reduction in Diabetes Risk*
HR (95% CI)
Effect
Size, %
P Value
Metformin[1] BMI ≥ 24, prediabetes 3234 2.8† -- 31 < .001
Liraglutide[2] BMI ≥ 30, prediabetes 2210 3.0‡ 0.21 (0.13-0.34) 79 < .0001
Pioglitazone[3] BMI ≥ 25, IGT 602 2.4§ 0.28 (0.16-0.49) 72 < .001
Acarbose[4] BMI 25-40, IGT 1368 3.3† -- 25 .0022
Nateglinide[5] IGT, CVD/CV risk 9306 5.0§ 1.07 (1.00-1.15) -- .05
Lorcaserin[6] BMI ≥ 27, prediabetes, CVD/CV risk 3991 3.3§ 0.81 (0.66-0.99) 19 NR
Orlistat[7] BMI ≥ 30 3304 4.0‡ -- 37 .0032
Bariatric surgery[8] Severely obese, IGT 136 5.8† -- 97 < .0001
*Compared with placebo (or no bariatric surgery).
†Mean follow-up. ‡Length of treatment. §Median follow-up.

36. ADA Recommendations for Persons With Prediabetes
 Refer to intensive behavioral lifestyle intervention program for ≥ 7%
weight loss, increased physical activity
‒ Follow-up education and support important for success
‒ Should be covered by third-party payers
 Consider metformin therapy
‒ Especially important for those with BMI ≥ 35, persons < 60 yrs of age, and
women with previous gestational diabetes mellitus
 Screen for and treat modifiable risk factors for CVD
 Monitor for diabetes annually
American Diabetes Association. Diabetes Care. 2018;41:S51-S54. Slide credit: clinicaloptions.com

37. Agenda
 Scope of the problem
 Definitions
 Lifestyle interventions
 Pharmacologic therapy, bariatric surgery
 Barriers to prevention

38. Potential Barriers to Adequate Diabetes Care in
Diverse Populations
 Inadequate education
 Language/literacy barriers
‒ Includes using vocabulary the
patient will understand
 Lack of/inadequate insurance
 Potential for suboptimal
patient–physician relationship
 Reduced self-efficacy
 Limited culturally relevant
educational programs
 Cultural beliefs
 Lack of transportation or time
off of work
 Lack of child care arrangements
Glazier RH, et al. Diabetes Care. 2006;29:1675-1688. Saha S, et al. Am J Public Health.
2003;93:1713-1719. Sarkar U, et al. Diabetes Care. 2006;29:823-829. Slide credit: clinicaloptions.com

39. Dietary Challenges to Weight Reduction:
African Americans
 “Soul food”
‒ High in starch (eg, biscuits,
sweet potatoes, beans) and sodium
‒ High in fat (eg, fried chicken,
cuts of pork prepared with lard
or another saturated fat product)
 Fat intake may comprise close to 50% of calories[1]
 Mean daily intake of fruits and vegetables may be very low (0.88 and
1.64 servings/day, respectively)[2]
1. Kim KH, et al. Health Educ Behav. 2008;35:634-650. 2. Satia JA, et al. Public Health Nutr. 2004;7:1089-1096. Slide credit: clinicaloptions.com

40. Dietary Challenges to Weight Reduction: Hispanics
 Overall shift toward less healthy diets
 With US acculturation, Mexican Americans eat more saturated fat,
sugar, salt, dessert, pizza, and French fries vs counterparts in Mexico[1]
 In Hispanic population, acculturation associated with poorer diet,
higher alcohol consumption, and higher rates of obesity[2,3]
 Interventions that take acculturation factors into account
(eg, DIALBEST) can improve diabetes self-management among Latinos[3]
1. Batis C, et al. J Nutr. 2011;10:1898-1906. 2. Pérez-Escamilla R, et al. J Nutr.
2007;137:860-870. 3. Pérez-Escamilla R, et al. Am J Clin Nutr. 2011;93:1163S-1167S. Slide credit: clinicaloptions.com

41. Improving Outcomes in an Uninsured Hispanic
Population With Diabetes
 Partnership between the Osceola Council on Aging and the Florida
Hospital Diabetes Institute
 Uninsured, predominantly Latino patients with diabetes (N = 180)
‒ Culturally appropriate diabetes education (ie, 6 core modules)
‒ Nutrition and exercise education
‒ Group medical visits
‒ Medication assistance
 Decrease in A1C: 1.7%
Data courtesy of Richard Pratley, MD. Slide credit: clinicaloptions.com

42. Healthy Eatonville Place
Among adults in Eatonville,
 Incidence of diabetes: 24.2%
 Overweight/obese: 68.4%
 Diagnosed with HTN: 45.7%
 Smoke cigarettes: 34.7%
 Have skipped meals
due to lack of money: 17.2%
 Average intake of fruits/vegetables: < 2 servings/day
Data and image courtesy of Richard Pratley, MD. Slide credit: clinicaloptions.com

43. Health Literacy
Weiss BD, e al. Ann Fam Med. 2005;3:514–522. Slide credit: clinicaloptions.com

44. Strategies to Improve Prevention and Diabetes
Outcomes
 Social networks
‒ Family members, peer support groups,
churches, 1-on-1 interactive education,
community health workers
 Culturally tailored interventions and
education
‒ Language, diet, social emphasis, family
participation, cultural beliefs
 Cognitive–behavioral education, self-care
management, adaptations of the
Diabetes Prevention Program
 Improve patient resilience to stressors
 Case management, community health
workers, nonphysician professionals
‒ RNs as patient adjunct to the primary
care team
‒ Assist with case management
‒ Help to overcome social, cultural,
linguistic barriers
‒ Act as powerful change agents
‒ Pharmacist-led medication management
 Medical (or medication) assistance
programs
Baig AA, et al. Med Care Res Rev. 2010;67:163S-197S. Brown SA, et al. Diabetes Care. 2002;25:259-268. Slide credit: clinicaloptions.com
Use vocabulary the patient will understand

45. Why Prevention?
 Diabetes and its complications affect a large and rapidly increasing
number of people worldwide, drain healthcare resources[1]
‒ Prevention strategies are essential to stem this rise, expected to be
cost-effective
 Studies such as the UKPDS suggest that improved blood glucose control
helps to prevent complications[2]
‒ Difficult to prevent deterioration in control once diabetes has developed
Slide credit: clinicaloptions.com
1. van Dieren S, et al. Eur J Cardiovasc Prev Rehabil. 2010;17:S3-S8.
2. King P, et al. Br J Clin Pharmacol. 1999;48:643-648.

46. Summary: Preventing Type 2 Diabetes
 Pharmacologic and lifestyle interventions effective in high-risk
individuals
 Effective treatments, at best, lower incidence rates but not to zero
 Best choices of drugs and time to start are unknown
 Long-term benefits on CVD or other complications?
 Community-based interventions may reduce the need for high-risk
individual approaches (including drugs)
Slide credit: clinicaloptions.com

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