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It's been proven repeatedly: The progression from pre-diabetes to diabetes can be slowed with appropriate intervention, as can the progression to hypertension, dyslipidemia, and other risk factors.
What it takes is going back to the patient again and again, or "continuity of interaction," according to Ronald B. Goldberg, MD, director of the diabetes and metabolism section at the University of Miami School of Medicine and associate director of the Diabetes Research Institute, also in Miami. Goldberg made his remarks during a keynote presentation at the American Diabetes Association's 21st Annual Southern Regional Conference on Diabetes, Obesity, and Cardiovascular Disease, held May 25–28 in Marco Island, Fla.
Goldberg methodically walked through the challenges of type 2 diabetes, from the increased risk of atherosclerosis that appears in pre-diabetes to the lethal complications of long-standing, uncontrolled diabetes. Then he detailed the feasibility of prevention based on three main points: 1) an extended period of glucose intolerance precedes the development of diabetes, 2) screening tests can identify persons at high risk, and 3) fairly safe, potentially effective interventions are available.
He also detailed prevention strategies and prevention studies, including the Da Qing study,1 the Finnish Diabetes Prevention Study,2 and the Diabetes Prevention Program (DPP) in the U.S.3 "However you lower glucose—with drugs or lifestyle changes—there is a secondary effect of reverse glucotoxicity with improvements in both beta-cell function (insulin secretion) and insulin action," Goldberg says.
In the DPP, weight was the most important parameter predicting diabetes, he notes, although insulin levels and insulin sensitivity also were powerful predictors. "So weight reduction is the key," Goldberg says. "DPP showed us if we can keep interventions going over time—over the entire lifespan—we can have a 20% reduction in the number of people who develop diabetes, which is substantial."
He says lifestyle and drug interventions have proven to be cost-effective,4 but also notes the challenge of matching the conditions of the DPP in real practice, namely the "critical" constant contact with a lifestyle modification facilitator. "A facilitator is to lifestyle management what a blood pressure tablet is to hypertension," Goldberg says. "The treatment has to be durable."
In a separate session on translating diabetes management research into practice, Samuel Dagogo-Jack, MD, director of the endocrinology training program at the University of Tennessee in Memphis, noted that <2% of diabetes-related death is due to hyperglycemia, and >80% is due to cardiovascular disease. "The central premise for treating diabetes has shifted from `doing right by the patient' to preventing toxic complications that cause death to organs."
Even though a greater diabetes disease burden exists among certain ethnic and racial groups, he adds, "there is no evidence of ethnic disparity in response to insulin-sensitizing therapy" (i.e., lifestyle and metformin, as demonstrated in the DPP).
"This fact needs to be translated," Dagogo-Jack says. "We
don't really need another prevention study. We need to get the data into the
nooks and crannies. The Rosetta stone needs to be translated into real
practice." 
References
2. Tuomilehto J, Lindstrom J, Eriksson JG, et al., for the Finnish
Diabetes Prevention Study Group: Prevention of type 2 diabetes mellitus by
changes in lifestyle among subjects with impaired glucose tolerance.
N Engl J Med 344:1343–1350, 2001.
3. Knowler WC, Barrett-Connor E, Fowler SE, et al., for the Diabetes
Prevention Program Research Group: Reduction in the incidence of type 2
diabetes with lifestyle intervention or metformin. N Engl J
Med 346:393–403, 2002.
4. Herman WH, Hoerger TJ, Brandle M, et al., for the Diabetes
Prevention Program Research Group: The cost-effectiveness of lifestyle
modification or metformin in preventing type 2 diabetes in adults with
impaired glucose tolerance. Ann Intern Med 142: 323–332, 2005.
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