type 2 diabetes screening detection and prevention dr. ghanei endocrinologist
TRANSCRIPT
Type 2 Diabetes
Screening detection
and prevention
Dr. Ghanei Endocrinologist
• Affects 85 - 90% of all cases of diabetes.• Age – extremely variable but becoming commoner in children.• Triggered by environmental and genetic factors.
Type 2 diabetes is a progressive disease with complex aetiology
• Treated with exercise, diet, oral regimens and injectables –GLP-1 therapy and insulin but condition is best described as insulin requiring rather than insulin dependent.
• Affects 85 - 90% of all cases of diabetes.• Age – extremely variable but becoming commoner in children.• Triggered by environmental and genetic factors.• Two endocrine defects: insulin resistance and failure of the beta
cell. Progressive deterioration
• Not a mild disease – tissue damage affecting microvasculature – eyes, kidneys and nerves.
• Long-term risk of life threatening premature macrovascular complications – heart attacks, stroke, leg amputation, early death.
Emerging Risk Factor Collaboration N Engl J Med 2011; 364: 829-841
Deaths Diabetics vs Non Diabetics
All Causes
Cancer
Non-vascular
Vascular
97 cohort studies, 125 million person-years, 820,900 subjects, 123,205 deaths
Life lost due to Diabetes
Emerging Risk Factor Collaboration N Engl J Med 2011; 364: 829-841
A 50 year–old with diabetes died, on average, 6 years earlier
than a counterpart without diabetes, with about 60% of the
difference in survival attributable to vascular deaths and
40% excess to non-vascular/cancer deaths
Deaths from unknown causes Non cancer non vascularCancer deathsVascular deaths
0
2
4
6
8
10
12
14
16
% o
f A
ll-C
au
se
De
ath
s
Africa Europe Mid-EastN. Africa
SouthCentralAmerica
North America
Caribbean
WesternPacific
Percentage of All-Cause Deaths Attributed to Diabetes
.
Diabetes is a Leading Cause of Death Worldwide
World
IDF Diabetes Atlas, 5th edition, IDF 2011: www.idf.org/diabetesatlas
8.2%
High Rate of Complications at Diagnosis
50% of patients had tissue damage at enrolment
21% Retinopathy ( > 1 microaneurysm )
18% Abnormal ECG
14% Two or more absent foot pulses
7% Impaired reflexes or diminished vibration sense
3% Angina pectoris
3% Intermittent claudication
2% Myocardial infarction
1% Stroke or TIA
UKPDS 8 . Diabetologia 1991; 34: 877-889
UKPDS
Magnitude of the Problem
0
50
100
150
200
250
300
millions
199520002025
The number of people with diabetes will nearly double within the first quarter of this millennium.
World Health Report, 1997; Geneva: WHO.
71.4 120.9 (69%)
131.9 187.9 (42%)
14.7 28.0(90%)
32.8 59.7(83%)
52.6 64.0(22%) 37.7
51.2(36%)
25.1 39.9(59%)
IDF Diabetes Atlas, 5th edition, IDF 2011: www.idf.org/diabetesatlas
IGT2011 = 280 million2030 = 398 million
Increase 42%
Diabetes2011 = 366
million2030 = 552
millionIncrease 51%
Global Projections for the Diabetes Epidemic 2011-2030 (millions) – 51% increase
2
10
7
13
20
5
1112
2
7
0
2
4
6
8
10
12
14
16
18
20
18.5–24.9 25.0–29.9 30.0–34.9 35.0–39.9 ≥40.0
BMI (kg/m2)
Pre
va
len
ce
(%
)
Men (n = 6,987) Women (n = 7,689)
Prevalence of T2DM*
Adapted from NHANES III, Must A, et al. JAMA. 1999;282:1523-1529
Higher Prevalence of Type 2 Diabetes with increasing BMI: NHANES III
Developed Vs Developing
Region 2000 2025
Developed countries
6.2%54.8 million
7.6%72.2 million
Developing countries
3.5%99.6 million
4.9%227.7 million
King et al, Diabetes Care 1998; 21: 1414-31
Prevalence of Diabetes and IGT(MENA countries)
Al-Maatouq M. Int J Clin Pract 2010; 64: 149-159
4 in 10 subjects
Harris MI et al. Consultant 1997;37 Suppl:S9
IGT
Undiagnosedtype 2 diabetes
Diagnosedtype 2 diabetes
50
40
30
20
10
0
20-44 45-54 55-64 65
Age (years)
% o
f p
op
ula
tio
n
IGT is driving the worldwide diabetes pandemic
Diagnostic criteria for IGT and IFG
IFG
60 90 120 150 180300-30
MinutesFasting
Plasma Glucose (mmol/L)
8
11
IGT
DiabetesFPG >7
NormalFPG <6.1
Diabetes
>11.1
Normal<7.8
OGTTAdapted from The Expert Committee on the Diagnosis and Classification of Diabetes MellitusDiabetes Care. 1997;20:1183-97
mmol/L mg/dL
6.1 110
7.0 126
7.8 140
11.1 200
IFG IGT IFG + IGT Type 2 diabetes
Normal glucose tolerance
1.3 3.9 0.5 0.6
IFG - 3.7 6.5 2.4
IGT - - 0.9 2.7
IFG + IGT - - - 9.9
Progression to type 2 diabetes
Annual rates of progression to moresevere forms of glucose intolerance
Koehler et al. Diabetologia 2001;44 Suppl 1:A108
Obesity and prevalence of IGT
Lindahl et al. Diabetes Care 1999;22:1988-92
Body mass index (kg/m2)
0
2
4
6
8
10
12
14
<20
20-2
2.4
22.5
-24.
9
25-2
6.9
27-2
9.9
30-3
4.9
>35
(%)
IGT
0
100
200
300
<20
20-2
2.4
22.5
-24.
9
25-2
6.9
27-2
9.9
30-3
4.9
>35To
tal n
o. w
ith
IGT
PATHWAYS TO IGT
Insulin resistance / hyperinsulinaemia
Intra-uterinemalnutrition
Genes
Sedentarylifestyle
Diet
Obesity
Beta cell defect
IGTMajor causative pathways
Secondary consequences of hyperglycaemia
NATURAL HISTORY OF IGT
After 10 years
33%
33%
33%
Normal
Diabetes
IGT
IGT
What are the Drivers of the Epidemic for type 2 diabetes ?
Obesity & diet
Lack of exercise
Urbanisation
Aging
Prosperity
Ethnicity
Family history (genetics)
Four seats for two customers !!!!
Obesity
Factors associated with Type 2 diabetes
Non Modifiable
1- Genetic factors.
2- Demographic determinants: such as age and ethnicity.
Modifiable
1- Behavioral and lifestyle-related: such as obesity and physical inactivity.
2- Metabolic and intermediate risk categories: such as IGT, IFG and GDM.
Family History (Genetics)
o Positive for type 2 diabetes
- one parent - both parents - siblings - identical twin
* Probability varies according to age at diagnosis
7% - 14% *45% by age 657% - 14% *58% - 75%
American Diabetes Assoc Diabetes 2011 Vital Statistics
A call to action for all UN member states to develop national policies for the prevention, treatment and cure of diabetes. ‘The significance is monumental’.
Professor Martin SilinkIDF President and ChairThe Unite for Diabetes Campaign
UN Resolution21st December 2006
Prevalence of Diabetes and IGT(MENA countries)
Al-Maatouq M. Int J Clin Pract 2010; 64: 149-159
4 in 10 subjects
Harris MI et al. Consultant 1997;37 Suppl:S9
IGT
Undiagnosedtype 2 diabetes
Diagnosedtype 2 diabetes
50
40
30
20
10
0
20-44 45-54 55-64 65
Age (years)
% o
f p
op
ula
tio
n
IGT is driving the worldwide diabetes pandemic
Diagnostic criteria for IGT and IFG
IFG
60 90 120 150 180300-30
MinutesFasting
Plasma Glucose (mmol/L)
8
11
IGT
DiabetesFPG >7
NormalFPG <6.1
Diabetes
>11.1
Normal<7.8
OGTTAdapted from The Expert Committee on the Diagnosis and Classification of Diabetes MellitusDiabetes Care. 1997;20:1183-97
mmol/L mg/dL
6.1 110
7.0 126
7.8 140
11.1 200
IFG IGT IFG + IGT Type 2 diabetes
Normal glucose tolerance
1.3 3.9 0.5 0.6
IFG - 3.7 6.5 2.4
IGT - - 0.9 2.7
IFG + IGT - - - 9.9
Progression to type 2 diabetes
Annual rates of progression to moresevere forms of glucose intolerance
Koehler et al. Diabetologia 2001;44 Suppl 1:A108
PATHWAYS TO IGT
Insulin resistance / hyperinsulinaemia
Intra-uterinemalnutrition
Genes
Sedentarylifestyle
Diet
Obesity
Beta cell defect
IGTMajor causative pathways
Secondary consequences of hyperglycaemia
Obesity and prevalence of IGT
Lindahl et al. Diabetes Care 1999;22:1988-92
Body mass index (kg/m2)
0
2
4
6
8
10
12
14
<20
20-2
2.4
22.5
-24.
9
25-2
6.9
27-2
9.9
30-3
4.9
>35
(%)
IGT
0
100
200
300
<20
20-2
2.4
22.5
-24.
9
25-2
6.9
27-2
9.9
30-3
4.9
>35To
tal n
o. w
ith
IGT
NATURAL HISTORY OF IGT
After 10 years
33%
33%
33%
Normal
Diabetes
IGT
IGT
Why should we prevent diabetes?
To reduce human suffering.
To alleviate the economic burden.
To prevent morbidity and mortality from diabetes-related CVD.
Progression to diabetes leads to the need for intervention measures with limited success. Diabetes is irreversible
Patients with diabetes develop complications of the eye, kidneys and nerves
Patients have excess risk of strokes, heart attacks and premature death
What are the benefits of prevention ?
Prevention is Superior to Treatment
Pratley RE. Br J Diabetes Vasc Dis 2007; 7: 120-129
Levels of prevention in Type 2 diabetes
Primary: Includes activities aimed at preventing diabetes from occurring in susceptible populations or individuals.
Secondary: Early diagnosis and effective control of diabetes in order to avoid or at least delay the progress of the disease.
Tertiary: Includes measures taken to prevent complications and disabilities due to diabetes.
Preventive strategies: approaches in the design
A population-based strategy, involving altering the lifestyle and environmental determinants of Type 2 diabetes.
A high-risk strategy applying preventive measures on individuals identified as high-risk for Type 2 diabetes.
Primary prevention
Most of the results on prevention come from studies on high risk groups rather than populations.
Studies have shown that people with IGT has a 2-7 fold higher risk of progression to Type 2 diabetes than persons with normal glucose tolerance.
Among the factors that predicted progression were obesity, elevated fasting and 2-h blood glucose and fasting insulin concentrations.
Types of interventions
Behavioral interventions: including changing diet and increasing physical activity.
And/or
Pharmacological interventions: utilizing pharmaceutical agents to improve glucose tolerance and insulin sensitivity.
Behavioral interventions
Several studies has shown that diet and physical activity reduced the incidence of Type 2 diabetes.
Example: The Swedish Malmo study showed that diet and exercise for 5 years in men with IGT reduced the incidence of Type 2 diabetes by 50%.
Eriksson et al, Diabetologia 1991; 34: 891-8
Finish Diabetes Prevention Study
Risk of developing diabetes reduced by 58% after 4 years
11% vs 23%
Cumulative risk of developing diabetes
NNT = 8
Diabetes Prevention Programme (DPP)
27 centres
3234 participants
> Or = 25 years
BMI > or = 24 (22 for indo Asian)
IGT
– American Indian, African American, Hispanic American, Asia American, pacific islanders
Study Interventions
Eligible participants
Randomized
Standard lifestyle recommendations
Intensive Metformin PlaceboLifestyle 850mg bd
(n = 1079) (n = 1073) (n = 1082)
MEAN AGE = 51y BMI =34
IFG 5.3-6.9 IGT 7.8-11.0
DPPAverage Age 51 Years
BMI 34
Lifestyle intervention
Weight reduction 7%
Low fat diet
Exercise for 150 mins per week
OR metformin 850mgs BD
DPPTrial stopped 1 year early, after 2.8
yr of follow-up
• 29% Diabetes in controls
• 14% in Diet and exercise
• 22% in Metformin
3 year Data Risk Reduction
• 58% whole group
• 71% those aged >60yrs
• 31% Metformin (less effect in older and less obese)
Cu
mu
lati
ve d
iab
etes
inci
den
ce
(%
)
Years in Study
RR 58%
Placebo
Metformin
Lifestyle
40
30
20
10
00 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0
RR31%
N Engl J Med 2002; 346: 393-403
Diabetes Prevention Programme
MEDIAN FOLLOW-UP = 2.8 YEARS
Treatment Incidence of diabetes
per 100 person years
NNT
Placebo 11.0
Metformin 7.8 13.9
Lifestyle 4.8 6.9
Re
du
ctio
n in
dia
bet
es
ris
kv
ersu
s p
lace
bo
(%
)
Intensive lifestyle intervention Metformin
Age (y)
25–4445–59
>60
FPG (mmol/L)
5.3–<6.1
6.1–7.0BMI (kg/m2)
22–<30
30–<35>35
Subgroup Analyses in theDiabetes Prevention Program
N Engl J Med 2002; 346: 393-403
Effect of Interventions on Weight
0 1 2 3 4 5 6 7 8 9 10
YEARS
DPP+DPPOS
DPP Research Group Lancet 2009; 374: 1654-1663
16% RR of diabetes per kg weight loss
DPP Research Group Lancet 2012; 379: 2243-2251
NEVER REACHED NORMAL GLUCOSE REGULATION IN DPP
REACHED (AT LEAST ONCE) NORMAL GLUCOSE REGULATION IN DPP
YEARS in DPPOS follow-up
Dia
bet
es c
um
ula
tive
inci
den
ce r
ates
56%
Effect of regression to normal glucose regulation on risk of progressing to diabetes
Normalising glucose regulation even transiently in high risk subjects reduces onset of T2DM
DPP Research Group Lancet 2012; 379: 2243-2251
NEVER REACHED NORMALGLUCOSE REGULATION IN DPP
REACHED (AT LEAST ONCE) NORMAL GLUCOSE REGULATION IN DPP
LIFESTYLE
METFORMIN
PLACEBO
Effect of regression to normal glucose regulation on risk of progressing to diabetes
[Stratified by treatment group in DPP]
Subjects on lifestyle intervention with intractible IFG/IGT are at greatest risk of developing T2DM.
Think about additional treatment (metformin?)
DPP Outcomes for Subjects with past history of GDM
0
5
10
15
20
25
30
35
40
45
50
0 0.5 1 1.5 2 2.5 3
PLACEBONo=122
METFORMINNo=110
LIFESTYLENo=117
Years from randomization
Cu
mu
lati
ve i
nci
den
ce (
%)
Ratner RE et al. J Clin Endocrinol Metab 2008; 93: 4774-9
Risk reduction vs placebo51% by metformin (p=0.006)55% by lifestyle (p=0.002)
Risk reduction vs metformin8% by lifestyle (p=0.781) NS
Prevention with Low dose Combination therapy – Metformin plus Rosiglitazone
Entry = IGT+IFG +Risk Factor
Zinman B et al. Lancet 2010 ; 376: 103-111
Outcome Median FU 3.9 y
Met 1000mgRosi 4mg
Placebo
Diabetic 15.9% 41.8%NGT 79.6% 53.1%
IFG/IGT 4.6% 5.1%
66% RRR95% CI 41-80
NAVIGATOR Trial in IGT subjects
Navigator Study Group N Engl J Med 2010; 362: 1463-76
• Can lowering postprandial glycaemia reduce
onset of diabetes and protect from CV
complications ?
• 2x2 factorial design with nateglinide 60mg tid ,
placebo and valsartan from Novartis.
• Intensive lifestyle change = DPP study
• 9306 high risk (IGT) followed for 5 years (incident
diabetes) and 6.5 years (CV outcomes)
NATEGLINIDE -- no benefit in reducing the risk of diabetes
NATEGLINIDE -- no benefit in protecting against CV
complications
STOP-NIDDM: Time To Any CVD Event (First Event Only)
Days after Randomization
1.00
0.99
0.98
0.97
0.96
0.95
0.94
0.93
Survival distribution functionMean treatment duration
0 14001300120011001000900800600500400300200100 700 1500
Acarbose
Placebo
p = 0.0326
Chiasson et al. Diabetologia 2002; 45, Suppl. 2: A104
Effect of Acarbose on Reversion of IGT to NGT
P<0.0001
Placebo Acarbose
Nu
mb
er
of
Pa
tien
ts
200
210
220
230
240
250
n=241(35.3%)
n=212(30.9%)
IGT, impaired glucose tolerance; NGT, normal glucose tolerance.Chiasson JL, et al. Lancet. 2002;359:2072-2077.
The Study to Prevent Non-Insulin Dependent Diabetes Mellitus (STOP-NIDDM)
Xendos Trial:Cumulative Incidence Type 2 Diabetes
Sjostrom et al. 9th ICO, Sao Paulo 2002
Incidence
of T2D (%)
p=0.0032
0 26 52 78 104 130 156 182 2080
2
4
6
8
10
Week
9.0%
6.2%
RR^37%
^Hazard ratio reduction vs placebo plus lifestyle
Placebo + lifestyle Xenical + lifestyle
Diabetes Prevention Trials: Lifestyle and Oral Antidiabetic Agents
Trial Treatment Relative Risk
Finnish Diabetes Intensive lifestyle vs Control 58%
Da Qing Study Intensive lifestyle vs Control 38%
Diabetes Preven- Intensive lifestyle vs Placebo 58%
tion Program (DPP) Metformin vs Placebo 31%
STOP-NIDDM Acarbose vs. Placebo 21%
CANOE Rosiglitazone + Metformin vs Placebo 66%
Dream Rosiglitazone
Navigator Nateglinide vs Placebo 7%39%
Lifestyle , if intensive, produces the best outcomes
Lifestyle unresponsive subjects – add p’cological therapy
Lifestyle , watch out for weight gain with time
Small dose of combined p’cological therapy worth trying
Lifestyle plus p’cological therapy additive – check ethnicity
Lifestyle , also metformin has benefits in MS and GDM
Conclusions from Intervention Trials
P’cological therapy can be most cost effective
Secondary prevention
The purpose of secondary prevention activities such as screening is to identify asymptomatic people with diabetes.
Is there an effective intervention that may retard the progression of disease or the severity of its complications?
Screening approaches
Population screening
Selective screening
Opportunistic screening
Subjects at High Risk of Type 2 Diabetes
Subjects in the transistional state of glucose intolerance
First degree relatives of type 2 diabetics.
Overweight and obese subjects.
Subjects developing gestational diabetes.
Some ethnic groups
a) White people aged over 40 years and people from Black, Asian and minority ethnic groups aged over 25 with one or more of the risk factors below: - a first degree family history of diabetes and/or who are overweight/obese/morbidly obese with a BMI of 25-30 kg/m2
and above(8,9), and who have a sedentary lifestyle - Waist measurement of over > 94cm (> 37 inches) for White and Black men and > 80cm (> 31.5 inches) for White, Black and Asian women, and > 90cm (> 35 inches) for Asian men.b) People who have ischaemic heart disease, CVD, PVD or treated hypertension
c) Women who have had gestational diabetes who have tested normal following delivery (screen within 6 weeks of delivery, then 1 and 3 yearsd) Women with polycystic ovary syndrome who have a BMI > 30e) People who are known to have impaired glucose tolerance or impaired fasting glycaemia. f) People who have severe mental health problems. g) People who have hypertriglyceridemia not due to alcohol excess or renal disease.
Diabetes UK –criteria for screening
Risk Assessment Diabetes UK
ADA CDA
Age YES YES YES
Gender YES YES YES
Ethnicity YES YES YES
Relatives with diabetes YES YES YES
Waist circumference YES NO YES
BMI YES YES YES
High blood pressure YES YES YES
Physical activity NO YES YES
Vegetable /fruit eater YES
History of raised BG YES
Level of Education YES
General Health YES
Smoking YES
Risk Assessment Questionnaires(United States, Canada and UK)
Screening Questionnaire based on risk( Public Health Agency of Canada 2009 )
Screening Questionnaire based on risk( Public Health Agency of Canada 2009 )
SCORING GUIDE CATEGORISES YOU INTO
LOW , INCREASED, MODERATE or HIGH RISK
Tertiary prevention
Includes actions taken to prevent and delay the development of acute or chronic complications.
Acute complications: such as hypoglycemia, severe hyperglycemia and infections.
Chronic complications: such as atherosclerosis, retinopathy, nephropathy, neuropathy and foot problems.
Current Scenario
Focus on treatment and prevention of complications – secondary prevention ( mainly individual based)
Needs a ‘paradigm’ shift- from secondary prevention to primary prevention
Three strategies for primary prevention- – Upstream- whole population
– Midstream- special high risk groups eg children, elderly etc
– Downstream- high risk ‘individuals’
Effective interventions
Strict metabolic control, education and effective treatment.
Screening for complications in their early stages when intervention is more effective.
Who should take the responsibility for prevention policies ?
Nathan. Diabetes Care 2007; 30: 753-759 Alberti. Diabet Med 2007; 24: 451-463
ADA
IDFPreventing diabetes:• How can we?• Lifestyle or drugs?• How can we identify those at greatest risk• Is prevention possible in real life?• Is prevention cost-effective?
Public Health Authorities, Medical AssociationsDiabetes Organisations
Obstacles and barriers for prevention
Economic problems: unavailability of needed resources.
Socio-cultural problems.
Lack of data, knowledge and skills.
Exercise is not an option for everyone:
particularly disabled
elderly subjects
increased risk of “sports” injuries.
Diet is not always on option either
Economic
Availability etc
Prevention Of Type 2 Diabetes:Barriers To Lifestyle Interventions
Examples of socio-cultural barriers:
Obesity is not considered negatively.
No value given to physical exercise.
Changing diet is very difficult.
No time is granted to do physical exercise at work.
Central issues in Type 2 diabetes prevention
Type 2 diabetes prevention must be integrated in a major program addressing the prevention of other lifestyle related disorders like CVD and some cancers.
Primary prevention is of the essence especially in resource-constrained countries.
Diabetes prevention is an inter-sectoral effort requiring cooperation and coordination.
Central issues in Type 2 diabetes prevention- Cont
Diabetes prevention should be addressed within the context of health system reform ensuring the availability of acceptable health care standards.
Culturally appropriate and economically feasible interventions should be adopted. Imposing unacceptable or unaffordable interventions will have a negative impact.
What do we know about Type 2 diabetes prevention?
Type 2 diabetes is a major challenge to human health.
Type 2 diabetes can be prevented.
Primary prevention is a suitable and affordable choice.
There is strong evidence that lifestyle interventions are effective in diabetes prevention.
Barriers for prevention should be addressed.
AACE Prediabetes Consensus Statement: Summary• Untreated individuals with prediabetes are at increased
risk for diabetes as well as for micro- and macrovascular complications
• Treatment goals are to prevent deterioration in glucose levels and modify other risk factors such as obesity, hypertension, and dyslipidemia – The same blood pressure and lipid goals are suggested for
prediabetes and diabetes
• Intensive lifestyle management is the cornerstone of all prevention efforts; pharmacotherapy targeted at glucose may be considered in high-risk patients
Handelsman Y, et al. Endocr Pract. 2011;17(Suppl 2):1-53. Garber AJ, et al. Endocr Pract. 2008;14:933-946.
77
• There is a long period of glucose intolerance that precedes the development of diabetes
• Screening tests can identify persons at high risk • There are safe, potentially effective interventions
that can address modifiable risk factors: – Obesity– Body fat distribution – Physical inactivity– High blood glucose
T2DM, type 2 diabetes mellitus.Garber AJ, et al. Endocr Pract. 2008;14:933-946.
Feasibility of Preventing T2DM
Lifestyle Intervention in Prediabetes
Persons with prediabetes should reduce weight by 5% to 10%, with long-term maintenance at this
level
A diet that includes caloric restriction, increased fiber intake, and (in some cases) carbohydrate
intake limitations is advised.
• A program of regular moderate-intensity physical activity for 30-60 minutes daily, at least 5 days a week, is recommended
Garber AJ, et al. Endocr Pract. 2008;14:933-946.
Interventions Proven to Delay or Prevent T2DM Development
T2DM, type 2 diabetes mellitus.Sherwin RS, et al. Diabetes Care. 2004;27,(Suppl 1): S47-S54.
Eriksson K-F, Lindgärde F. Diabetologia. 1991;34:891-898.Ramachandran A, et al. Diabetologia 2006;49:289-297.
Knowler WC, et al. N Engl J Med. 2002;346:393-403.Defronzo RA, et al. N Engl J Med. 2011;364:1104-15.
InterventionRate of Conversion to Normal
Glucose Tolerance
Lifestyle (3 trials) 52%-58%
Metformin (2 trials) 26%-31%
Acarbose (1 trial) 25%
Pioglitazone (1 trial) 48%
T2DM Prevention in Women With a History of GDM:
Effect of Metformin and Lifestyle Interventions
• Findings from the DPP:– Progression to diabetes is more common in
women with a history of GDM vs those without, despite equivalent degrees of IGT at baseline
• Both intensive lifestyle and metformin are highly effective in delaying or preventing diabetes in women with IGT and a history of GDM
DPP, Diabetes Prevention Program; GDM, gestational diabetes mellitus;IGT, impaired glucose tolerance; T2DM, type 2 diabetes mellitus.
Ratner RE, et al. J Clin Endocrinol Metab. 2008;93:4774-4779.
1389 -1388