COMMENTARY

The Best Way to Prevent Type 2 Diabetes? Change Our Target

Hertzel C. Gerstein, MD; Mark Harmel, MPH

Disclosures

July 07, 2021

This transcript has been edited for clarity.

Preventing type 2 diabetes is an extremely important goal that we should strive for. We know from some long-term studies that if we can prevent type 2 diabetes, we can prevent the risk for long-term consequences of diabetes. There's at least one trial that shows that 30 years after diabetes prevention, there's a lower risk for cardiovascular events and even death in people in whom diabetes was prevented.

How do we identify preventive strategies? We do it by using randomized controlled trials that identify strategies that work. In fact, these trials have identified that lifestyle therapies such as weight loss, diet, and physical activity are effective preventive strategies, in addition to a number of different drug classes. If one had to think about what sorts of strategies prevent diabetes, there are things that reduce the amount of work that the beta cells in the pancreas need to do.

So, we know how to prevent diabetes, but the question is, how do we actually do it?

One Option: Target Everybody at Risk

One approach is to target everybody at risk. We can do a screening test to see if people are at risk for diabetes, and everybody who's at risk for diabetes can be offered one of the several preventive strategies that work. The problem with that — and we know this from COVID and we know this from experience as doctors — is that patients are reluctant to take preventive therapies if there's no other benefit associated with it.

So if you say, "Alright, take this drug. You won't have any major side effects or anything. You may have a few, but it won't be a big deal and you'll have a lower risk down the line of having diabetes or some other outcome." That's a hard concept for many patients to get their heads around because they say, "Well, I'm feeling fine right now. Why should I take this medication?"

And if you doubt what I'm saying, just think of what we see with vaccinations. People are hesitant even to take the COVID vaccine because they don't have the disease now. It's hard to convince patients to take a statin to prevent heart disease if I can't show them that their cholesterol is high and that they're lowering cholesterol at the same time.

The idea of prevention is a difficult one, and it is more effective when you can show patients that they have a number of things that can be treated at the same time as preventing a future disease from happening.

The Better Option: Target the Environment

The other approach is to target the environment. There have now been several studies that show, for instance, that people who live in a more walkable environment, where it's easier to walk, actually have lower rates of obesity. So, environmental approaches are probably the best way to prevent chronic diseases (such as type 2 diabetes) that are very dependent on our lifestyles.

One hundred years ago, there was very little type 2 diabetes. It's not that patients have changed, it's that the environment in which we live has changed. Trying to change those environments back to diabetes-friendly environments will certainly reduce the risk for diabetes.

And then we can reserve individualized strategies for patients who are at very high risk, in whom it's easier to convince to take things that will prevent them from developing diabetes.

I think the focus on prevention has been a good one, but it needs to be focused on environmental changes more than on individual changes.

Prevention vs Remission

The other thing that's becoming a big issue now is the concept of diabetes remission. As opposed to prevention, when you're trying to prevent something that isn't there now, diabetes remission is when you have the disease — let's see if we can make it go away.

There is now lots of evidence that therapies such as bariatric surgery and some intensive weight loss regimens can promote and achieve diabetes remission in some patients. And there are ongoing research studies happening right now to identify medical therapies that can induce remission.

I think we will have a situation where we will be able to really help solve the diabetes epidemic by changing the environment to prevent it, and to help people who have it by putting them into remission.

The final point that I like to tell people is: When you think about it from a big picture, prevention is for populations; remission is for individual patients.

Hertzel C. Gerstein, MD, is a professor at McMaster University, where he holds the Population Health Research Institute Chair in Diabetes and is the director of the Diabetes Care and Research Program. His research has been published in more than 450 articles over 50 countries.

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