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• Published: 28 May 2024

Prediabetes remission for type 2 diabetes mellitus prevention

• Andreas L. Birkenfeld   ORCID: orcid.org/0000-0003-1407-9023 1 , 2 , 3 , 4 &
• Viswanathan Mohan   ORCID: orcid.org/0000-0001-5038-6210 5 , 6  

Nature Reviews Endocrinology volume  20 ,  pages 441–442 ( 2024 ) Cite this article

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• Pre-diabetes

Current guidelines for the delay and prevention of type 2 diabetes mellitus recommend for people with prediabetes to lose at least 7% of their body weight. Here, we advocate to use glycaemic remission as a goal of prevention in people with prediabetes and those who are at high risk for type 2 diabetes mellitus.

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Nathan, D. M. et al. Does diabetes prevention translate into reduced long-term vascular complications of diabetes? Diabetologia 62 , 1319–1328 (2019).

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Acknowledgements

The authors acknowledge the members of ‘The Prediabetes Group’, who are listed in the Supplementary Information document, for their assistance with reviewing this article. A.L.B. acknowledges the support of funding from the German Federal Ministry for Education and Research (01GI0925) via the German Center for Diabetes Research (DZD e.V.).

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German Center for Diabetes Research (DZD), Neuherberg, Germany

Andreas L. Birkenfeld

Department of Internal Medicine IV, Diabetology, Endocrinology and Nephrology, Eberhard-Karls University Tübingen, Tübingen, Germany

Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany

Department of Diabetes, Life Sciences & Medicine Cardiovascular Medicine & Sciences, King’s College London, London, UK

Madras Diabetes Research Foundation, Chennai, India

Viswanathan Mohan

Dr. Mohan’s Diabetes Specialities Centre, Chennai, India

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Correspondence to Andreas L. Birkenfeld .

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Diabetes mellitus: https://www.who.int/news-room/fact-sheets/detail/diabetes

World Health Organization’s global targets for noncommunicable diseases: https://www.who.int/publications/i/item/9789241506236

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Birkenfeld, A.L., Mohan, V. Prediabetes remission for type 2 diabetes mellitus prevention. Nat Rev Endocrinol 20 , 441–442 (2024). https://doi.org/10.1038/s41574-024-00996-8

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Public Health Approaches to Type 2 Diabetes Prevention: the US National Diabetes Prevention Program and Beyond

• Diabetes Epidemiology (E Selvin and K Foti, Section Editors)
• Open access
• Published: 05 August 2019
• Volume 19 , article number  78 , ( 2019 )

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A Correction to this article was published on 27 June 2020

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Purpose of Review

This article highlights foundational evidence, translation studies, and current research behind type 2 diabetes prevention efforts worldwide, with focus on high-risk populations, and whole-population approaches as catalysts to global prevention.

Recent Findings

Continued focus on the goals of foundational lifestyle change program trials and their global translations, and the targeting of those at highest risk through both in-person and virtual modes of program delivery, is critical. Whole-population approaches (e.g., socioeconomic policies, healthy food promotion, environmental/systems changes) and awareness raising are essential complements to efforts aimed at high-risk populations.

Successful type 2 diabetes prevention strategies are being realized in the USA through the National Diabetes Prevention Program and elsewhere in the world. A multi-tiered approach involving appropriate risk targeting and whole-population efforts is essential to curb the global diabetes epidemic.

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Evidence and Challenges for Translation and Population Impact of the Diabetes Prevention Program

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Lifestyle interventions for diabetes prevention in south asians: current evidence and opportunities.

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Introduction

Worldwide, it is estimated that 425 million adults (20–79 years) have diabetes, projected to reach 629 million by 2045 [ 1 •]. In the USA, about 30 million adults (18 years and older) have diabetes, or 12.2% of the adult population [ 2 ]. Diabetes was estimated to cost $727 billion in 2017 in health expenditures worldwide [ 1 ] and $327 billion in 2017 in total economic costs in the USA [ 3 •]. Increases in diabetes prevalence have led to increases in related complications, such as cardiovascular disease, visual impairment and vision loss, lower extremity amputations, end-stage renal disease, disability, and premature mortality [ 2 ].

The majority of diabetes is type 2, which generally follows a period of prediabetes, a condition where blood glucose levels are higher than normal, but not high enough for a type 2 diabetes diagnosis [ 2 ]. In the USA, risk factors for prediabetes and type 2 diabetes include being overweight or having obesity; having a racial/ethnic background that is African-American, Hispanic/Latino, American Indian, Asian American, or Pacific Islander; having a parent or sibling with diabetes; having hypertension; having a history of gestational diabetes; and living a sedentary lifestyle. An estimated 353 million adults worldwide [ 1 ]—84.1 million in the USA (33.9% of all adults) [ 2 ]—have prediabetes diabetes. Given the magnitude of these numbers, identifying those at risk and preventing or delaying onset of type 2 diabetes are critical to ending the pandemic.

Type 2 diabetes can be prevented or delayed through mitigation of modifiable risk factors, such as healthier eating, weight loss, and increased physical activity. Studies show lifestyle intervention as a sole modality, lifestyle intervention in combination with therapeutics, and whole-population approaches are all promising for type 2 diabetes prevention. Public health interventions using glycemic risk stratification to target individuals at “very high” risk (having obesity and impaired glucose tolerance (IGT)) and “high” risk (being overweight with IGT) have proven to significantly reduce conversion to type 2 diabetes [ 4 ]. Individuals in these categories have a fasting plasma glucose (FPG) > 100 mg/dL, HbA1c levels > 5.7%, and a 10-year diabetes incidence of 20–30% or more [ 5 ]. Individuals in lower risk tiers may be more appropriately targeted via risk counseling and whole-population strategies [ 5 , 6 , 7 ]. Population-level policies, systems, and environmental approaches, along with lifestyle intervention for those at high risk, are likely optimal to achieve the greatest level of impact [ 8 ].

The purpose of this review is to highlight the foundational and current research and translation studies which underlie high-risk population and whole-population strategies for type 2 diabetes prevention worldwide, with particular focus on the U.S. National Diabetes Prevention Program, as catalysts for global prevention efforts.

Worldwide Evidence for Type 2 Diabetes Prevention Through Lifestyle Change

Foundational research.

The scientific evidence for prevention through lifestyle changes is compelling based on a series of randomized control trials (RCTs), which found through intensive, structured, yearlong educational programs focused on moderate weight loss (5–7%), increasing self-efficacy around engagement in one’s health, and moderate increases in physical activity over time, it is possible to prevent or delay type 2 diabetes among those at very high and high risk. RCTs have been conducted in various settings among diverse racial and ethnic populations. Common elements include utilizing a group-based intervention and evaluating effectiveness in terms of increased physical activity and healthy eating, and improved clinical metrics, such as weight, body mass index (BMI), waist circumference, HbA1c, and blood glucose.

The Chinese Da Qing group-based RCT was the first and longest running of such studies. It began in 1986 [ 9 ] with a follow-up study conducted in 1997–2006. The study demonstrated a 43% incidence reduction in the intervention group after 14 years when compared to the control group. Type 2 diabetes was delayed by an average of 3.6 years [ 10 ], and the incidence of severe retinopathy and cardiovascular-related disease and events were reduced [ 10 , 11 ]. After 30 years, 577 adults with IGT were followed from the original trial; the intervention group had a median delay in type 2 diabetes incidence of 3.96 years, an average increase in life expectancy of 1.44 years, and fewer cardiovascular disease and all-cause deaths, reduced incidence of cardiovascular events, and lower incidence of microvascular complications compared to the control group [ 12 ].

The U.S. Diabetes Prevention Program (DPP) was a three-arm RCT, which began in 1996 [ 13 ••]. The study found that a lifestyle change intervention focused on a 5–7% weight loss and a moderate increase in physical activity over one year achieved a 58% relative risk reduction in type 2 diabetes, and that use of metformin achieved a 31% reduction, when compared to a placebo [ 13 ••]. The DPP used intensive one-on-one counseling with a minimum of 50% racially and ethnically diverse individuals across both male and female genders at high risk for type 2 diabetes (elevated plasma glucose of 95 to 125 mmol/L or fasting glucose of 7.8 to 11.0 mmol/L) [ 13 ••]. A follow-up study, the U.S. Diabetes Prevention Program Outcomes Study (DPPOS), reported a 34% reduction in type 2 diabetes incidence 10 years after the completion of the DPP trial for the lifestyle change intervention arm [ 14 ], and a 27% reduction after 15 years (18% for the metformin arm), compared to the placebo group [ 15 ]. Furthermore, the study found that lifestyle change was cost-effective compared to a placebo, and that cumulative quality-adjusted life years (QALYs) gained over a 3-year timeframe were greater for lifestyle (6.81) than either metformin (6.69) or a placebo (6.67) [ 16 ].

The Finnish Diabetes Prevention Study (Finnish DPS), which began in 2001 [ 17 ], tested lifestyle intervention in a community-based primary health care setting, and designed and implemented a high-risk screening assessment for type 2 diabetes that is used worldwide called the Finnish Type 2 Diabetes Risk Score [ 18 ]. The study demonstrated a risk reduction of 58%, as well as a legacy effect of 43% reduction in type 2 diabetes incidence three years after completion of the study. The study has also been successfully translated in Greece with similar results [ 19 ].

The Japanese DPP, conducted in 2005 in male participants with IGT > 140 mg/dL, found a cumulative 4-year incidence of diabetes of 9.3% in the control group, versus 3.0% in the intervention group [ 20 ]. The Indian DPP-1 trial, conducted in 2006, was a community-based RCT involving 531 subjects with IGT across three intervention arms (one was given advice on lifestyle modification (LSM), one was treated with metformin (MET), and another was given LSM plus MET) and one control arm. A relative risk reduction of 26–29% after 30 months was similar in all three intervention arms [ 21 ]. Additional 3-year results suggest that both metformin and lifestyle change were cost-effective in preventing type 2 diabetes [ 22 ].

Translational Research

Translational research, which examines how to best tailor key research findings into policy, program, or practice [ 23 ], further demonstrates that lifestyle interventions are feasible and effective in real-world settings [ 24 ]. A systematic review and meta-analysis of 28 US-based DPP translation studies found a mean weight loss of over 4% across 3797 high-risk participants and demonstrated cost-effectiveness in terms of program, materials, and staff costs [ 24 ].

The European DE-PLAN study (“Diabetes in Europe – Prevention using Lifestyle, Physical Activity, and Nutritional Intervention”), implemented in 17 countries, was a community-based 10-month translation of the Finnish DPS targeting those at high risk for type 2 diabetes [ 19 ]. DE-PLAN began in 2008 and used the Finnish Diabetes Risk Score to determine eligibility [ 19 ]. In 2018, study participants in Poland ( n  = 175) with increased risk for type 2 diabetes received 10 months of lifestyle counseling sessions, physical activity, and self-efficacy sessions [ 25 ••]. Participants with a higher starting BMI and a history of increased glucose were more likely to achieve the goal weight loss of ≥ 5% of initial body weight compared to those with lower risk [ 25 ]. A UK study had similar findings, also determining adults with obesity and higher HbA1c levels (6–6.4%) not only met the weight loss outcomes of the US DPP trial but also gained more QALYs than those with lower risk; the intervention was also determined to be cost-saving [ 26 ].

The Australian Good Ageing in Lahti Region Lifestyle (GOAL) Implementation program, based on the Finnish DPS, found positive associations between changes in self-efficacy and dietary behaviors and improvement in waist circumference, cholesterol levels, triglycerides, diastolic blood pressure, and FPG in the lifestyle intervention arm compared to the control group [ 27 ]. GOAL was further scaled up with over 10,000 participants via the Melbourne DPS with significant improvements in cardiovascular risk factors, waist circumference, BMI, and weight loss [ 28 ].

Alternative modalities of lifestyle change program delivery, such as virtual program delivery and telehealth, have the potential to reach millions of people, even in remote areas. Shortly after publication of the 2002 DPP research study, Tate et al. (2003) conducted the first RCT of a yearlong Internet-based diabetes prevention lifestyle change weight loss program alone vs. one with the addition of e-behavioral counseling [ 29 ]. The group receiving e-behavioral counseling submitted calorie and exercise information and received weekly e-mail behavioral counseling and feedback from a counselor for 12 months and lost 4.8% of original body weight compared to 2.2% among those receiving the Internet program only [ 29 ]. A 2013 text messaging study in India showed that mobile technology can have an impact on clinical outcomes, with cumulative incidence of type 2 diabetes at 2 years of 18% in the text messaging counseling group vs. 27% in the control group [ 30 ], and a sustained reduction in incidence after 5 years [ 31 ]. Similar studies have been conducted (Supplemental Table 1 ) to determine the effectiveness of various forms of virtual delivery, including delivery via television, social networking sites, and online. These published studies on virtual delivery found ~ 4% to 10% weight loss after virtual implementation of a yearlong diabetes prevention lifestyle change program. A summary of results is included in Supplemental Table 1 .

The evidence is clear: lifestyle interventions can prevent or delay type 2 diabetes among various races, ethnicities, genders, and regions. Additionally, type 2 diabetes prevention program interventions continue to demonstrate cost-effectiveness/cost savings in real-world settings over time [ 32 , 33 ].

The US National DPP—a Case Study

Large-scale implementation of the US DPP trial’s lifestyle change program began in 2010, when Congress authorized the US Centers for Disease Control and Prevention (CDC) to establish and lead the National DPP in an effort to make the intervention broadly available to individuals at high risk [ 34 ]. The National DPP is a partnership of public and private organizations working to build a delivery system for the lifestyle intervention. It consists of four core elements: a trained workforce of lifestyle coaches; national quality standards supported by the CDC Diabetes Prevention Recognition Program (DPRP); a network of program delivery organizations sustained through coverage; and participant referral and engagement [ 35 ]. The National DPP lifestyle change program is based on evidence and key features of the US DPP trial that were shown to be successful: realistic weight loss goal after 12 months (minimum 5% of initial body weight), documentation of physical activity minutes (≥ 150 min per week), and attendance throughout the 12-month program, with an emphasis on self-efficacy that focuses on improving problem-solving skills, social supports, the use of built environments, and strategies to adapt to change [ 35 ]. The National DPP is the world’s largest translation of the US DPP study, having reached over 324,000 participants across > 3,000 organizations as of April 12, 2019 [ 36 ]. The DPRP is the quality assurance arm of the National DPP, developing evidence-based standards (DPRP Standards) and monitoring and evaluating participating organizations for fidelity and effectiveness of intervention delivery [ 37 ]. The DPRP Standards are updated every three years based on new dietary, physical activity, self-efficacy, delivery modality, and other type 2 diabetes prevention evidence. Through the DPRP, CDC awards either preliminary (based on participant attendance rather than outcomes) or full (meeting all DPRP Standards) recognition to successful organizations [ 37 ]. CDC recognition is widely accepted in the USA as an assurance of a quality type 2 diabetes prevention program and can result in insurance coverage for participants and reimbursement for program delivery organizations.

Public and private insurance coverage for type 2 diabetes prevention interventions is crucial to widespread adoption and participation in National DPP lifestyle change programs. Insurance coverage expands payment options, thereby reducing the burden of cost for participants. Currently, over 3.8 million public employees and dependents in 20 states have the National DPP lifestyle change program as a covered benefit and over 100 private employers and commercial plans include it as a covered benefit for their employees [ 38 ]. In 2018, the US Centers for Medicare & Medicaid Services (CMS) began coverage for eligible Medicare beneficiaries who participate in CDC-recognized programs and meet performance goals of the National DPP [ 40 ]. CMS provides reimbursement for participants meeting program goals such as 5% weight loss in organizations that have achieved either preliminary or full CDC recognition [ 39 ]. Eight states in the USA also provide Medicaid coverage for eligible beneficiaries [ 38 ].

Based on published translational research, feedback from stakeholder organizations, and gray literature scans (stakeholder materials and policies not found in peer-reviewed journals), CDC concluded that there was sufficient evidence to allow organizations delivering the National DPP lifestyle change program virtually to apply for CDC recognition. Thus, in order to expand availability and increase program participation (especially for those in rural or remote locations), the DPRP Standards were amended in January 2015 to allow online modes of delivery in addition to in-person. The Standards were amended again in February 2018 to also include telehealth and combination (in-person/virtual) delivery and new participant-level variables that include education level, enrollment source, and payer source. All virtual providers are held accountable to the same quality standards as in-person delivery organizations, including the provision of coaching services [ 37 ]. As of April 2019, CDC had 121 recognized virtual providers delivering the yearlong lifestyle change program to over 193,000 people [ 36 ].

Key Findings from In-Person National DPP Delivery in the USA

DPRP data from the first 4 years (February 2012–January 2016) of the National DPP, describing the experience of 14,747 participants who attended 4 or more sessions of the lifestyle change program in 220 organizations, showed an average weight loss of 4.2%, with 35.5% of participants achieving ≥ 5% weight loss [ 40 ]. Participants reported an average 152 min per week of physical activity, with 41.8% meeting the physical activity goal of 150 min per week. Participants with longer retention and greater participation in the program and who were more physically active were more likely to have higher weight loss [ 40 ].

Implementation of the National DPP: New Insights

Analysis sample.

To further assess National DPP implementation success, we examined recent DPRP data and analyzed new variables (education level, enrollment source, and payer source) to assess their relationship with participant outcomes. More than 297,000 participants attended one or more lifestyle change program sessions between February 2012 and January 2019. For the purpose of this new analysis, 143,489 eligible participants across all program modalities (in-person, online, distance learning, and combination) who completed the yearlong lifestyle change program and attended ≥ 3 sessions in the first 6 months (analyzed participants) were included in descriptive analyses. Of those, 29,069 eligible participants who started the program in 2018 and reported new variables (education level, enrollment source, and payer source) were included in the multivariable analysis (Fig.  1 ).

Flow chart for analysis sample. CDC = Centers for Disease Control and Prevention; DPRP = Diabetes Prevention Recognition Program; LCP = CDC-recognized lifestyle change program; National DPP = National Diabetes Prevention Program. 1 Participant eligibility was based on BMI (≥ 25 kg/m 2 , or ≥ 23 kg/m 2 if Asian American), a blood test indicating prediabetes, a CDC Prediabetes Screening Test or American Diabetes Association Type 2 Diabetes Risk Test, or a previous diagnosis of gestational diabetes mellitus. 2 Education level, enrollment sources, and payer sources were not collected before February 2018

Measures and Methods

Percent body weight change was the primary outcome of this analysis, calculated among participants with at least 2 documented body weights using the first (baseline) and last recorded weights. Average weight loss and physical activity minutes per week were calculated among participants who attended ≥ 3 sessions in the first 6 months and whose time from first session attended to last session attended was ≥ 9 months. CDC considers this threshold to be the minimum dose to begin seeing lifestyle and weight change that can impact type 2 diabetes [ 40 ].

Mantel-Haenszel chi-square tests of difference were used to assess bivariate associations between participants’ characteristics and duration of participation. Results were stratified by duration of participation (≥ 9 vs. < 9 months). Multiple logistic regression models were used to estimate the association between participants’ attendance and duration of participation and the likelihood of meeting the minimum 5% weight loss goal conditional on other factors. Adjusted odds ratios (AORs) in relation to a reference category were reported with their respective 95% confidence intervals (CIs). Results with p  < 0.05 were considered statistically significant. All analyses were conducted using SAS, version 9.4.

Overall, about 60% of analyzed participants attended the lifestyle change via an online-only modality, 40% via an in-person only modality, and <  1% via distance learning only or combination modality (Table 1 ). About 40% of analyzed participants attended at least 17 lifestyle change sessions; 31% met the minimum 5% weight loss goal, and 45% met the average 150+ min per week of physical activity goal. Three quarters were females; over half were aged 45–64 years; over 60% were non-Hispanic whites; about half reported having 4 years of college or more; and over 70% had obesity (body mass index (BMI) ≥ 30 kg/m 2 ).

Weight loss success was significantly higher among those who attended ≥ 17 sessions (AOR 3.2), those who stayed in the program for ≥ 9 months (AOR 1.3), and those with ≥ 150 min of physical activity per week (AOR 1.7) (Table 2 ). Participants aged 45–64 and ≥ 65 years had 3.2 and 1.6 times, respectively, the odds of meeting the 5% weight loss goal than those aged 18–44. Females, non-Hispanic blacks, and those with obesity were slightly less likely to meet the 5% weight loss goal than males, non-Hispanic whites, and those overweight (BMI between 25 and 29.9 kg/m 2 ).

This analysis is subjected to some limitations. First, biometric data (weight and physical activity minutes) was self-reported either by CDC-recognized organizations or participants themselves. However, lifestyle coaches were provided guidance to use the same scale at each session for recording participants’ body weight to ensure consistency. Second, calculation of percent weight loss was based on first and last recorded weight. Participants who lost more weight might be more likely to stay in the program longer and continue to lose more weight by the end of the program than those who dropped out early. Third, CDC’s DPRP began requiring organizations to submit information on participants’ education level, enrollment source, and payer source in February 2018; thus, our analyses were limited to a small sample of participants who started the program in 2018 (~ 10% of the total National DPP participants), as the remaining participants had not yet had the opportunity to participate in the program for a year prior to our study. Lastly, the analysis only included eligible participants based on CDC’s DPRP Standards, so it may not be generalizable to ineligible participants who may also benefit from this program.

Participation in Lifestyle Change Intervention

Successful expansion of lifestyle change interventions relies on sufficient enrollment and retention. A recent analysis of 2016–2017 U.S. National Health Interview Survey data showed that 73.5% of adults with overweight or obesity with diagnosed prediabetes and 50.6% of adults with overweight or obesity and elevated American Diabetes Association (ADA) risk scores reported receiving risk reduction advice or referrals to risk reduction activities from their health care providers [ 41 •]. Of those referred, only one third reported engagement in risk-reducing activities in the past year, and less than 3% reported participating in a type 2 diabetes prevention program. The key drivers for engagement in risk-reducing activities and programs included receiving advice from a health professional, having higher education, having insurance, being non-white race/ethnicity, and being middle aged. This study underscores the need for research from fields such as behavioral economics, human-centered design, and habit formation, to understand how to best engage people at high risk in type 2 diabetes prevention programs. Other approaches for systems change include the establishment of referral processes from clinical health care providers to community-based implementation programs, and media and marketing strategies to drive traffic to such programs. A recent study found that primary care providers in the USA who were aware of the National DPP lifestyle change program and the Prevent Diabetes STAT: Screen, Test, and Act Today™ Toolkit developed by CDC and the American Medical Association (AMA) were more likely to screen patients for prediabetes and make referrals to CDC-recognized organizations offering the National DPP. Those who used electronic health records were also more likely to screen, test, and refer [ 42 ].

Offering diabetes prevention programs via businesses and worksites could help lower employee health care costs and increase QALYs, and is an important systems approach still in need of broader consideration among employers [ 43 ]. Evidence-based programs within worksite wellness programs and health-based interventions within worksites are increasing in scope in the USA, and seem to be slowly gaining traction elsewhere in the world as well. To assist employers and insurers in determining the feasibility of providing the National DPP lifestyle change program or including it as part of their employees’ insurance benefits, CDC developed the Diabetes Prevention Impact Toolkit [ 43 ]. The toolkit helps estimate the cost per employee and the associated cost savings related to offering the National DPP lifestyle change program, including estimating the employee’s QALYs gained. A summary of recent peer-reviewed literature on employer-based diabetes prevention programs in the USA found that greater weight loss and maintenance of weight loss were achieved among worksites that implemented the National DPP lifestyle change program compared to worksites that implemented other interventions [ 44 ].

Another key approach to increasing participation focuses on raising awareness of both prediabetes as a serious condition and of type 2 diabetes prevention activities. This is a challenge, as many providers are not screening or testing patients for prediabetes when considering its risk factors (obesity, overweight, glycemic range, and cardiovascular risks) In the USA, CDC, ADA, and AMA partnered with the Ad Council to launch the nation’s first national public service campaign about prediabetes [ 45 ] which encourages people to take a short online test at DoIHavePrediabetes.org to learn their prediabetes risk. From the campaign’s launch on January 21, 2016, through March 31, 2019, 2.5 million people have completed the online risk test [ 46 ].

Whole-Population Approaches

Because of the widespread prevalence of type 2 diabetes and its risk factors, lifestyle change programs for the highest-risk people alone cannot sufficiently impact the diabetes pandemic without approaches that support prevention efforts across whole systems and communities. Larger-scale, population-wide prevention strategies, such as environmental, policy, cost reimbursement, and health marketing/awareness efforts, are therefore needed. Several whole-population approaches have been implemented in the USA. Many focus on socioeconomic policy involving nutrition regulation such as menu labeling; subsidies to increase the affordability of fruits and vegetables, particularly in rural or hard-to-reach areas [ 47 , 48 ]; sugar-sweetened beverage tax and decreased added sugars; and increased whole grains, fibers, nuts, and legumes and elimination of trans fats (or trans fatty acids) as recommended by the American Heart Association [ 49 ]. Globally, supported by WHO, clear nutrition “front-of-pack labeling” has been found to improve dietary habits and reduce cardiovascular complications [ 50 ].

A systematic review found strong evidence in Europe for implementing multiple policies simultaneously, including taxes on unhealthy food, subsidies for healthy food, trans fat elimination, and trade agreements with supportive countries who implement similar taxation and food policies [ 51 ••]. A 2014 systematic review of the evidence behind food taxation and food subsidies (government/local investments in healthy food) found that both should be implemented in tandem at a minimum rate of 10 to 15% to ensure the unhealthy foods are less accessible and healthy foods/beverages are more accessible to purchasers [ 52 ]. Similarly, Colchero et al. studied the effect of taxing sugar-sweetened beverages in stores in Mexico and found reductions in purchases of the taxed beverages associated with increases in purchases of untaxed beverages [ 53 ].

Environmental changes such as targeting the built environment and community planning efforts also show promise in reaching large populations. These approaches include the expansion or building of walking, biking, and hiking trials, and other “safe” routes [ 54 ]. A systematic review evaluating the effect of built environment policies on obesity-related outcomes across the USA, Canada, Chile, the UK, and New Zealand found that physical activity-related policies had a stronger impact when they involved improvements to transportation infrastructure. These improvements included creating more structural access such as building cycling lanes and park trails [ 55 ].

A possible limitation of whole-population approaches is that researchers have to rely largely on modeling studies or intermediate outcomes to determine impact. Short-term and longitudinal impact testing involving actual health and economic trends is more difficult, but critical to assessing intervention success. Also critical is understanding the contexts in which whole-population approaches are most effective.

To achieve large-scale type 2 diabetes prevention, interventions directed to both high-risk populations and the general population are necessary. There is strong evidence for the prevention of type 2 diabetes from RCTs and subsequent translation studies in which people at high risk engage in a structured lifestyle intervention that addresses nutrition, physical activity, and behavior change strategies resulting in a weight loss of ≥ 5%. Whole-population strategies also show promise in reaching large numbers of people and include multi-sector and multi-policy approaches, most successfully in combination. These approaches include taxation of unhealthy foods, enhancing the built environment, addressing food accessibility, offering worksite wellness, and raising awareness of prediabetes among health care providers and the general public.

Large-scale implementation of what has been proven to work, including alternate delivery approaches for type 2 diabetes prevention programs to reach disparate and geographically isolated populations, is needed. Continued examination of outcomes and program effectiveness is needed to refine global prevention efforts. Fortunately, there is much evidence worldwide that type 2 diabetes prevention or delay is attainable, and that prevention strategies can be adapted across cultures and environments. Success will require a combination of policy, systems, environmental, and health marketing/awareness approaches with effective interventions for high-risk populations and partnerships across sectors. Based on the data showing the impact of diabetes it warrants being prioritized to protect the public’s health around the world and curb the increasing burden of diabetes.

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Epidemiology of Type 2 Diabetes – Global Burden of Disease and Forecasted Trends

Moien abdul basith khan.

1 Department of Family Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates

Muhammad Jawad Hashim

Jeffrey kwan king, romona devi govender, halla mustafa, juma al kaabi.

2 Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates

The rising burden of type 2 diabetes is a major concern in healthcare worldwide. This research aimed to analyze the global epidemiology of type 2 diabetes. We analyzed the incidence, prevalence, and burden of suffering of diabetes mellitus based on epidemiological data from the Global Burden of Disease (GBD) current dataset from the Institute of Health Metrics, Seattle. Global and regional trends from 1990 to 2017 of type 2 diabetes for all ages were compiled. Forecast estimates were obtained using the SPSS Time Series Modeler. In 2017, approximately 462 million individuals were affected by type 2 diabetes corresponding to 6.28% of the world’s population (4.4% of those aged 15–49 years, 15% of those aged 50–69, and 22% of those aged 70+), or a prevalence rate of 6059 cases per 100,000. Over 1 million deaths per year can be attributed to diabetes alone, making it the ninth leading cause of mortality. The burden of diabetes mellitus is rising globally, and at a much faster rate in developed regions, such as Western Europe. The gender distribution is equal, and the incidence peaks at around 55 years of age. Global prevalence of type 2 diabetes is projected to increase to 7079 individuals per 100,000 by 2030, reflecting a continued rise across all regions of the world. There are concerning trends of rising prevalence in lower-income countries. Urgent public health and clinical preventive measures are warranted.

1. INTRODUCTION

Type 2 diabetes is recognized as a serious public health concern with a considerable impact on human life and health expenditures. Rapid economic development and urbanization have led to a rising burden of diabetes in many parts of the world [ 1 ]. Diabetes affects individuals’ functional capacities and quality of life, leading to significant morbidity and premature mortality [ 2 ]. Recently, concerns have been raised that more than one-third of the diabetes-related deaths occur in people under the age of 60 [ 3 ]. Increased consumption of unhealthy diets and sedentary lifestyles, resulting in elevated Body Mass Index (BMI) and fasting plasma glucose, have been blamed for these trends [ 4 ]. In particular, persons with higher BMI are more likely to have type 2 diabetes [ 5 ]. The aging of the human population is another contributor, as diabetes tends to affect older individuals [ 6 ]. The cost of diabetes care is at least 3.2 times greater than the average per capita healthcare expenditure, rising to 9.4 times in presence of complications [ 7 ]. Control of blood glucose, blood pressure, and other targets remains suboptimal for many patients [ 8 ]. This has been partly attributed to the lack of awareness and health promotion needed for diabetes control [ 9 ].

Unfortunately, the global epidemiology of diabetes has not been re-evaluated since the availability of recent high-quality data [ 10 ]. We found no studies providing global forecasts for the intermediate future, which would be a critical piece of information for health policymakers.

This research project examines the latest dataset of the Global Burden of Disease (GBD) to assess the burden of type 2 diabetes worldwide. The aim is to study the current global epidemiology of diabetes and highlight the current distribution of disease and emerging epidemiologic trends.

2. MATERIALS AND METHODS

We analyzed descriptive epidemiological data from the GBD dataset managed by the Institute of Health Metrics and Evaluation at the University of Washington, Seattle [ 11 ]. The GBD dataset is actively maintained and updated based on research data, epidemiology studies, and governmental publications from more than 100,000 sources. As a systematic public health project, it carefully builds models and statistical estimates for health loss due to illness, injury, and risk factors based on empirical data. GBD produces annual estimates of disease measures, such as prevalence, incidence, deaths, and Disability-Adjusted Life Years (DALYs). DALYs combine years of life lost due to premature death and years lived with disability, and are a more accurate reflection of human suffering resulting from a disease than prevalence or mortality alone.

We used the latest data refresh from GBD (the 2017 update). This dataset includes annual figures from 1990 to 2017 for type 2 diabetes in all countries and regions. We selected four world regions (Asia, Europe, America, and Africa) instead of other classification schemes based on economic development. All data were directly retrieved from GBD without any adjustments. Estimates were not age adjusted for differences in underlying population age distributions. Thus, the rates for different countries represent the actual burden on their respective health systems.

2.1. Statistical Data Analysis

Forecasting was conducted using IBM SPSS version 25 (IBM Corp., Armonk, NY, USA). The Time Series Modeler was used to develop a forecast model using the Expert Modeler option without any events. None of the observed values were marked as outliers.

Globally, an estimated 462 million individuals are affected by type 2 diabetes, corresponding to 6.28% of the world’s population ( Table 1 ). More than 1 million deaths were attributed to this condition in 2017 alone, ranking it as the ninth leading cause of mortality. This is an alarming rise when compared with 1990, when type 2 diabetes was ranked as the eighteenth leading cause of deaths. In terms of human suffering (DALYs), diabetes ranks as the seventh leading disease.

Disease burden of type 2 diabetes, 2017

The prevalence of type 2 diabetes shows a distribution pattern that matches socio-economic development ( Figure 1 ). Developed regions, such as Western Europe, show considerably higher prevalence rates that continue to rise despite public health measures ( Figure 2 ). The rate of increase does not appear to be slowing down.

Global distribution of diabetes mellitus type 2 prevalence. Note: Colors indicate prevalence rates per 100,000 population in 2017.

Trends in the prevalence of type 2 diabetes. Note: Forecast estimates using SPSS Time Series Modeler (Ljung Box Q, p = 0.16). Dotted lines indicate upper and lower confidence limits.

Remarkably, certain regions, such as Pacific Ocean island nations, are sustaining the highest prevalence of disease. These countries include Fiji (20,277 per 100,000), Mauritius (18,545), American Samoa (18,312), and Kiribati (17,432). Southeast Asian countries, such as Indonesia, Malaysia, Thailand, and Vietnam, have moved up the ranks in the last two decades. Owing to their large population sizes, China (88.5 million individuals with type 2 diabetes), India (65.9 million), and the US (28.9 million) retain the top spots as the countries with the greatest total number of individuals with this condition.

Males show a slightly higher prevalence than females (6219 compared with 5898 cases per 100,000), although this difference is within the margin of uncertainty. The age of onset of new diagnosis is also somewhat earlier among males and shows expected patterns of rising prevalence with increasing age, whereas the incidence peaks at 55–59 years ( Figure 3 ). There appears to be no major shift in the age distribution from 1990 to 2017.

Age distribution of diabetes mellitus type 2, worldwide. (A) Incidence vs. prevalence (both 2017). (B) Incidence in 1990 vs. 2017. p < 0.0001, chi-square test.

Even though it afflicts individuals later in life, type 2 diabetes ranks seventh among the leading causes of disability and years of life lost (DALYs). It has jumped ranks from nineteenth position in 1990, indicating a global transition in disease patterns toward noncommunicable diseases.

Statistical forecasting using a model based on the 1990–2017 data showed that global diabetes prevalence could increase to 7079 per 100,000 by 2030 and 7862 by 2040. This estimate for 2040 is flanked by an upper confidence limit of 9904 and a lower limit of 5821 per 100,000.

4. DISCUSSION

This study reports on the current trends in the global burden of diabetes with emphasis on the burden of human suffering. The high prevalence of type 2 diabetes worldwide continues to rise, and there are no signs of it stabilizing. A concerning finding is the rapidly rising burden in lower-income countries. These findings have implications for health policy planners, physicians, healthcare professionals, and the public.

The burden of suffering due to diabetes, as measured by DALYs, is increasing despite significant investment in clinical care and pharmaceutical research. This increase is in excess of population growth and aging. Notably, Western Europe has a rate of increase greater than that of global and Asian averages. Even with the high levels of clinical and public health expenditure, this region is losing the battle against diabetes. One explanation might be non-modifiable risk factors, such as age and family history [ 12 ]. However, factors like a highly processed, calorie-dense western diet and a sedentary lifestyle may also be contributing. Developed countries like Italy and the US endure the highest burdens of human suffering (DALYs) due to diabetes. Advanced economies in Asia, such as South Korea and Taiwan, are joining the ranks of these countries, based on GBD data. Thus, our findings support the correlation between diabetes and economic development [ 13 ]. We speculate that our current approach to diabetes management, which focuses on expensive oral medications and insulin, is not working. Lowering blood glucose levels is perhaps not sufficient by itself nor effective in reducing all-cause mortality among these patients.

Prevention of new cases of diabetes appears to be not working as well based on our findings from global data. Although research is ongoing to reduce the progression from metabolic syndrome and prediabetes to diabetes, most interventions being tried seem to be unsuccessful in affecting the incidence. According to our data, there is no evidence of a decrease in incidence. Alarmingly high incidence rates recorded in island nations in the Pacific region are an indication of the interaction between genetic predisposition and the effect of rapid nutritional change on these indigenous populations. Meanwhile, the sheer number of individuals with diabetes is testing health systems in China, India, and the US to the limit. Rapid urbanization and its effects on diet and lifestyle has been implicated [ 14 ]. These findings have direct implications for health systems planning and resource allocation. Clearly, hospital-based management and subspecialist care are not sustainable strategies. Resource allocation in healthcare budgets for prevention of diabetes needs to be comparable to expenditures on treatment. Strengthening of primary care and community restructuring for active lifestyles and healthy nutrition are perhaps more likely to be cost effective [ 15 ]. Sadly, the rising tide of type 2 diabetes is out pacing preventive efforts by a wide margin [ 16 ].

The rising incidence of type 2 diabetes at earlier ages warrants closer attention. Previous clinic-based studies have reported a high number of young adults being diagnosed with type 2 diabetes, most of whom are obese [ 17 ]. There appears to be an age gradient with early-onset type 2 diabetes patients (those younger than 45) showing more obesity, dyslipidemia, smoking, sedentary lifestyles, and low-grade inflammation [ 18 ]. In our study, although the incidence of diabetes in young adults has increased over the past decades, the rise is across all ages. Thus, there appears to be no clear indication that the age of onset of type 2 diabetes has shifted to younger age groups. In any case, rising life expectancy in many countries will lead to a substantially greater burden of diabetes in the elderly.

The main limitations of our study include reliance on secondary data, which in turn is affected by the accuracy of measurement, changes in case definition, and heterogeneity in study designs. Yet as GBD evolves and matures, its estimation techniques have become more accurate and reliable. These statistical estimates provide a more complete and continuous picture of disease epidemiology than relying on raw data from isolated studies [ 11 ]. Ultimately, the goal is to guide decision making in clinical care and public health policy.

5. CONCLUSION

Type 2 diabetes continues to increase in prevalence, incidence, and as a leading cause of human suffering and deaths. Despite significant investments in clinical care, research, and public health interventions, there appears to be no sign of reduction in the rate of increase. Certain regions of the world, such as Western Europe and island states in the Pacific, are experiencing a disproportionately high burden. This epidemic will require an urgent and unwavering commitment to aggressive solutions at national levels with public policies, public health funding, and economic incentives for local communities to start diabetes prevention programs. Healthy eating options need to be subsidized, and unhealthy foods need to be taxed or otherwise disincentivized. Healthcare organizations and individual healthcare providers from multiple disciplines (doctors, nurses, pharmacists, dieticians, and diabetes educators) must be given time and resources to collaborate as they educate and care for individual and groups of patients. Unless urgent measures are instituted to reduce unhealthy eating, sedentary lifestyles, rapid urbanization, and other factors related to economic development, the burden of diabetes is expected to continue rising.

ACKNOWLEDGMENT

We would like to thank the Institute of Health Metrics, Seattle for compiling global epidemiological statistics and allowing access to data.

Data availability statement: The data that support the findings of this study are openly available in Global Health Data Exchange by the Institute of Health Metrics at http://ghdx.healthdata.org/gbd-results-tool .

CONFLICTS OF INTEREST

The authors declare they have no conflicts of interest.

AUTHORS’ CONTRIBUTION

MK contributed to writing the manuscript including the literature review. MJH designed the study/basic concept, wrote sections of the manuscript, analyzed the data, and provided overall supervision of the study. JK wrote parts of the manuscripts, proofread, and provided insights into the interpretation. RDG revised the manuscript and provided additional interpretation of results. HM compiled data and wrote the table. JAK revised and proofread the manuscript and provided additional interpretation of results.

This study did not receive any external grants from government, private or commercial sources.

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Diabetes Mellitus Review

• PMID: 27093761

Diabetes mellitus is a group of physiological dysfunctions characterized by hyperglycemia resulting directly from insulin resistance, inadequate insulin secretion, or excessive glucagon secretion. Type 1 diabetes (T1D) is an autoimmune disorder leading to the destruction of pancreatic beta-cells. Type 2 diabetes (T2D), which is much more common, is primarily a problem of progressively impaired glucose regulation due to a combination of dysfunctional pancreatic beta cells and insulin resistance. The purpose of this article is to review the basic science of type 2 diabetes and its complications, and to discuss the most recent treatment guidelines.

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