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{\u0022basePath\u0022:\u0022\\\/\u0022,\u0022pathPrefix\u0022:\u0022\u0022,\u0022highwire\u0022:{\u0022markup\u0022:[{\u0022requested\u0022:\u0022full-text\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;8\\\/7\\\/9\u0022},{\u0022requested\u0022:\u0022long\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;8\\\/7\\\/9\u0022}],\u0022ac\u0022:{\u0022spmdc;8\\\/7\\\/9\u0022:{\u0022access\u0022:{\u0022reprint\u0022:true,\u0022full\u0022:true},\u0022pisa_id\u0022:\u0022spmdc;8\\\/7\\\/9\u0022,\u0022atom_uri\u0022:\u0022\u0022,\u0022jcode\u0022:\u0022spmdc\u0022}}},\u0022googleanalytics\u0022:{\u0022trackOutbound\u0022:1,\u0022trackMailto\u0022:1,\u0022trackDownload\u0022:1,\u0022trackDownloadExtensions\u0022:\u00227z|aac|arc|arj|asf|asx|avi|bin|csv|doc(x|m)?|dot(x|m)?|exe|flv|gif|gz|gzip|hqx|jar|jpe?g|js|mp(2|3|4|e?g)|mov(ie)?|msi|msp|pdf|phps|png|ppt(x|m)?|pot(x|m)?|pps(x|m)?|ppam|sld(x|m)?|thmx|qtm?|ra(m|r)?|sea|sit|tar|tgz|torrent|txt|wav|wma|wmv|wpd|xls(x|m|b)?|xlt(x|m)|xlam|xml|z|zip\u0022,\u0022trackUrlFragments\u0022:1},\u0022ajaxPageState\u0022:{\u0022js\u0022:{\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/jquery.cluetip.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.hoverIntent.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.bgiframe.min.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_at_symbol.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_article_reference_popup.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/contrib\\\/google_analytics\\\/googleanalytics.js\u0022:1,\u00220\u0022:1}}});\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Clink type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article not only discusses the best treatment option for diagnosed type 2 diabetes mellitus (T2DM), but also the most prudent ways to prevent the onset of diabetes including managing at-risk individuals who (at present) only show evidence of impaired glucose tolerance, insulin resistance, or beta-cell function \u2014 so-called \u201cprediabetics.\u201d\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Eprevention \u0026amp; screening\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eendocrinology\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ediabetes mellitus\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \n         \u003Cp id=\u0022p-2\u0022\u003EAt issue is not necessarily the best treatment option for diagnosed type 2 diabetes mellitus (T2DM) but the most prudent way to prevent the onset of diabetes; managing at-risk individuals who, at present, only show evidence of impaired glucose tolerance, insulin resistance, or beta-cell function \u2013 so-called \u201cprediabetics.\u201d\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ETake a Pill\u003C\/h2\u003E\n         \u003Cp id=\u0022p-3\u0022\u003ELarge-scale initiatives that use lifestyle modification in a prediabetic population have been attempted, and results are encouraging. The Finnish Diabetes Prevention Study recorded a 58% reduction in risk for the intervention at 6 years, relative to the control group (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). \u201cBut at what cost?\u201d asked Paul Zimmet, MD, PhD, Baker IDI Heart and Diabetes Institute, Melbourne, Australia. The Finnish lifestyle cohort required 7 nutritionist sessions in the first year, and one every 3 months thereafter. Patients were offered individualized guidance on physical activity and were engaged in this and other types of counseling for an average of 150 minutes\/week. The Diabetes Prevention Program in the United States employs a similar expenditure of resources (with similar success).\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/7\/9\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Diabetes Development During Lifestyle Intervention: DPS Finland.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-303855305\u0022 data-figure-caption=\u0022Diabetes Development During Lifestyle Intervention: DPS Finland.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/7\/9\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/7\/9\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/7\/9\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11168\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-4\u0022 class=\u0022first-child\u0022\u003EDiabetes Development During Lifestyle Intervention: DPS Finland.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EThe tremendous costs of these intensive lifestyle programs aside, it still is an open question as to whether all lifestyle programs actually work. A recent paper that looked at this issue concluded that \u201ca facilitated theory-based behavioral intervention was no more effective than an advice leaflet for promotion of physical activity\u201d and that true, lasting change in individual lifestyle was unlikely to occur under current societal conditions (Kinmonth et al. \u003Cem\u003ELancet\u003C\/em\u003E 2008).\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003EReflecting this lack of faith in behavioral interventions are the American Diabetes Association\u0027s recently published treatment guidelines for patients with impaired fasting glucose and impaired glucose tolerance, which recommend lifestyle modification or metformin (Nathan et al. \u003Cem\u003EDiabetes Care\u003C\/em\u003E 2007). \u201cThis is a basic rejection of the idea that lifestyle alone works,\u201d said Dr. Zimmet. On the surface, the approach seems sound, but many individuals cannot or will not avail themselves of such a program; patients may be disabled; suffer from other chronic conditions, such as psychiatric disorders; have cultural or economic impediments to proper diet and exercise; or simply not have physical access to care.\u003C\/p\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EIn contrast, pharmacotherapy, easily obtained and simply administered, has been shown in numerous studies to be effective in the prevention of T2DM; these include the US DPP, STOP NIDDM, Xendos, and DREAM trials. In DREAM, treatment with rosiglitazone resulted in a 60% relative risk reduction for the prevention of diabetes as compared with placebo at 4 years (p\u0026lt;0.01); although no real impact on mortality has been shown.\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EResearch has shown that microvascular complications occur well before a patient gains the artificial threshold of metabolic measures called \u201cdiabetes.\u201d Evidence that lifestyle intervention reduces the incidence of cardiovascular disease (CVD) is scarce, but ample evidence does exist for the reduction of CVD with drug therapy in prediabetes. STOP-NIDDM showed a 49% reduction in CVD with acarbose (Chiasson et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2004).\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003E\u201cThe real issue for me is not prevention of type 2 diabetes,\u201d said Dr. Zimmet. \u201cIt\u0027s preventing the cardiovascular disease in people who get type 2 diabetes \u2013 that\u0027s the major cause of morbidity and mortality.\u201d\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ETake a Hike\u003C\/h2\u003E\n         \u003Cp id=\u0022p-10\u0022\u003E\u201cAdverse lifestyle factors are the root cause of the current epidemic of T2DM,\u201d began Nick Wareham, MD, PhD, MRC Epidemiology Unit, Institute of Metabolic Science, Cambridge, UK. Individually focused lifestyle changes are demonstrably effective in reducing progression to diabetes. A meta-analysis by Gillies et al. \u003Cem\u003E(BMJ\u003C\/em\u003E 2007) consistently showed a halving of risk of progression to diabetes with changed behavior among high-risk individuals. \u201cThe point from our own ProActive study (Kinmonth et al. \u003Cem\u003ELancet 2008)\u003C\/em\u003E is not that lifestyle programs don\u0027t work but rather that this detailed behavioral approach was no more successful than simple advice.\u201d\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EWith lifestyle intervention, cost is relative. In terms of quality-adjusted life-years (QALYs), lifestyle change costs $31,512 per QALY versus $99,611 for metformin over the course of a clinical trial and, projected over a lifetime, amounts to $1100 per QALY for lifestyle and $31,300 for metformin (Herman et al. \u003Cem\u003EAnnals of Internal Med\u003C\/em\u003E 2005). If the intervention begins at the early ages of 25 to 44, lifestyle change actually is cost-saving to society. \u201cThere are few interventions in medicine that I can think of that are actually cost saving,\u201d said Dr. Wareham, \u201cso we are dealing with interventions that are cost-beneficial rather than just cost-effective.\u201d\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EThe pharmacological benefits to diabetes prevention only last as long as the duration of the drug treatment, and people revert to the same risk as those in the placebo group when the drug is discontinued. In contrast, the benefits of lifestyle intervention are prolonged. This effect was shown to be very long-term by Li et al., who published 20-year follow-up data from the Da Qing intervention study \u003Cem\u003E(Lancet\u003C\/em\u003E 2008).\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003E\u201cAlthough we would ideally want long-term data from behavioral trials with clinical endpoints such as cardiovascular events, these are difficult to conduct and have so far not been undertaken,\u201d Dr. Wareham said. The Da Qing study did demonstrate a favorable impact on cardiovascular risk, but this was not statistically significant because the study was relatively small. \u201cGiven the importance of these issues for public health, we would hope that funders would acknowledge the need for large randomized controlled trials to address this issue in the future,\u201d commented Dr. Wareham. In contrast to drugs, which only tend to impact a single risk factor, there is a clear argument for additional benefits of lifestyle interventions or \u201chalo effects,\u201d which translate as improvements in physical, mental, and social function that are included in the concept of general well-being. The assessment of general health \u2013how you feel about your health \u2013 is a strong predictor of all-cause mortality and was modified favorably by the physical activity intervention in the ProActive study.\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EDr. Wareham also questioned the level of evidence that is required to start pharmacological therapy for people who are at risk for a disease to prevent a condition from arising in the future. Because these people are not patients, but are offered preventive treatments on the basis of their risk profile, he argued that the level of evidence should be high. \u201cOne would question the wisdom of basing our policy decisions on assumptions,\u201d Dr. Wareham added. Although data from highly publicized trials like DREAM show that pharmacological intervention can reduce risk of progression to diabetes by 60%, this really is a proxy intermediate outcome. The data from these studies on prevention of cardiovascular outcomes are far less impressive, which perhaps is not surprising because glucose is not a particularly strong cardiovascular risk factor. Even if one could achieve the level of CVD risk that is predicted from observational data (Levitan et al. \u003Cem\u003EArch Int Med\u003C\/em\u003E 2004), then glucose-lowering alone would be a poor individual therapeutic strategy, because the predicted absolute risk reduction would not be great and the number that is needed to treat for 3 years to prevent one cardiovascular event would be high at 554.\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EGiven that the behavior issues that drive the current obesity and diabetes epidemics are societal issues, the only appropriate strategy that meaningfully impacts this public health problem is to move away from focusing on high-risk strategies. Instead we need to concentrate on understanding the determinants of the population distribution of behaviors and on public policy approaches to trying to move that distribution in a favorable direction. Dr. Wareham concluded, \u201cPublic health problems require public health solutions,\u201d and these require a considerable scaling-up of investment in public health research to underpin those solutions.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2008 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/8\/7\/9.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzmbuq\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzmbuq\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}