COMMENTARY

Anne Peters: The Year in Diabetes

Anne L. Peters, MD; Mark Harmel, MPH

Disclosures

December 10, 2013

In This Article

Diabetes Prevention and Early Treatment

We all work hard at managing patients with diabetes, and with obesity increasing in the United States, we will have an endless stream of new patients. In addition to the 26 million people already diagnosed with diabetes, there are another 79 million Americans with prediabetes. Only 11% of the people with prediabetes know that they have the condition, so there is a need for early identification and treatment to preserve beta cell function and delay the progression of diabetes.

The approach promoted by the Centers for Disease Control and Prevention's (CDC's) National Diabetes Prevention Program is implementation of evidence-based lifestyle changes in diabetes, which demonstrated that a modest weight loss of 5%-7% in their 16-session program can reduce the risk of developing type 2 diabetes by 58%. The CDC is active in disseminating the program with a public/private model using the YMCA, the UnitedHealth Group, Viridian Health Management, and other groups. However, the "if you build it, they will come" idea works better in movies than in diabetes prevention. The focus is now on increasing employer and insurance reimbursement, and recently the AMA moved to promote physician referrals.

A different approach recognizes the challenge in getting people to lose weight and increase activity, relying instead on a medication model developed by Ralph DeFronzo, MD, from the University of Texas Health Science Center at San Antonio. His triple therapy approach simultaneously starts patients on metformin, pioglitazone, and exenatide.[21]

That intervention was compared with the conventional stepwise approach of first using metformin, adding a sulfonylurea, and then adding basal insulin. After 24 months, those on triple therapy had an average A1c value of 6.0%, compared with 6.6% for those on conventional therapy. Both groups started with an A1c of 8.6%, and there were less hypoglycemia and treatment failure in the triple therapy group and a mean weight loss of 1.2 kg vs 4.1 kg in the conventional group.

The demand is great to prevent the development of diabetes either through lifestyle interventions or beta cell preservation, and it will take multiple approaches for different patient types to have an impact on prediabetes and diabetes.

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