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Prediabetes

Neil Skolnik, MD, Heidi James, MD, and Brandon Grove, MD
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There is plenty of rock solid evidence showing the role of exercise and weight loss in preventing DM 2.  In fact, in the Diabetes Prevention Program Outcomes Study, participants who were asked to lose 7% of their body weight and exercise 150 minutes/week decreased their risk of developing DM2 by 58% compared to placebo. And because we know some of you are wondering, yes, this was as superior prevential strategy than Metformin 850mg BID as it was only associated with a 38% decreased risk compared to placebo. Move it!!

Pearls:

  • Prediabetes is a risk factor for progression to diabetes defined by a blood sugar between 100 and 125, an A1c between 5.7 and 6.4 or an oral glucose tolerance test of 140 to 200.

  • The Diabetes Prevention Program (DPP) Trial demonstrated that intensive lifestyle modification (weight loss of 7% body weight, 150 minutes per week of exercise and 500 calorie per day deficit for 6 months) decreased progression to diabetes by 58%, superior to metformin 850mg BID (30% reduction) and to regular doctor visits.

  • The results of the DPP have been replicated in real world settings so get your patients up and moving!

 

  • Prediabetes: defined by people who have blood sugars between 100 and 125, an A1c between 5.7 and 6.4, or an oral glucose tolerance test of 140 to 200.

    • It is not a disease but is a risk factor for disease.

    • One-third of people in the United States fall into this category and over half of people over the age of 65 also fall in this range.

  • The Diabetes Prevention Program (DPP) Trial:

    • Over 3000 patients with prediabetes in the Diabetes Prevention Program (DPP) Trial published in 2002 in the New England Journal of Medicine were randomized to:

      • 1. Usual care of visits to the doctor

      • 2. Metformin 850mg BID

      • 3. Intensive lifestyle modification of 500 calorie deficit a day, goal weight loss of 7% of body weight over the course of 6 months to a year and 30 minutes of moderate to vigorous exercise five times a week.

    • Those in group 2 saw a 30% decrease in progression to diabetes while those in group 3 saw a 58% reduction!

    • Average age was 51 with a BMI of 34.

    • Adults over 60 were the ones that benefited the most.

    • Knowler WC et. al. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002. PMID: 11832527.

  • The Diabetes Prevention Program Outcome Study (DPPOS)

    • Took the cohorts from the DPP trial and followed them over time.

    • There continued to be a decrease in the incidence of diabetes in lifestyle group but that difference diminished over time.

    • The diminishing difference between the groups was likely in part due to the fact that the other groups were given the option of the lifestyle intervention because the original trial was halted for ethical reasons as the intervention was doing so much better. Furthermore, the original lifestyle intervention group did not receive additional lifestyle training.

    • Diabetes Prevention Program Research Group. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet. 2009 Nov 14;374(9702):1677-86. PMID: 19878986.

    • Diabetes Prevention Program Research Group. Long-term effects of lifestyle intervention or metformin on diabetes development and microvascular complications over 15-year follow-up: the Diabetes Prevention Program Outcomes Study. Lancet Diabetes Endocrinol. 2015 Nov;3(11):866-75. PMID: 26377054.

  • Are there trials comparing lifestyle + metformin to just one or the other?

    • No - there haven’t been any trials but the closer your A1c to 6.5, the more at risk you are of developing diabetes so would probably benefit from both things combined.

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What’s Your (Code) Status? Full episode audio for MD edition 170:42 min - 80 MB - M4AHippo Primary Care RAP - March 2018 Written Summary 508 KB - PDF

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