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The Diabetes Prevention Program (DPP) study showed that weight loss in high-risk adults lowered diabetes incidence and cardiovascular disease risk. No prior analyses have aggregated weight and cardiometabolic risk factor changes observed in studies implementing DPP interventions in nonresearch settings in the United States. In this systematic review and meta-analysis, we pooled data from studies in the United States implementing DPP lifestyle modification programs (focused on modest [5%-7%] weight loss through ≥150 min of moderate physical activity per week and restriction of fat intake) in clinical, community, and online settings. We reported aggregated pre- and post-intervention weight and cardiometabolic risk factor changes (fasting blood glucose [FBG], glycosylated hemoglobin [HbA1c], systolic or diastolic blood pressure [SBP/DBP], total [TC] or HDL-cholesterol). We searched the MEDLINE, EMBASE, Cochrane Library, and Clinicaltrials.gov databases from January 1, 2003, to May 1, 2016. Two reviewers independently evaluated article eligibility and extracted data on study designs, populations enrolled, intervention program characteristics (duration, number of core and maintenance sessions), and outcomes. We used a random effects model to calculate summary estimates for each outcome and associated 95% confidence intervals (CI). To examine sources of heterogeneity, results were stratified according to the presence of maintenance sessions, risk level of participants (prediabetes or other), and intervention delivery personnel (lay or professional). Forty-four studies that enrolled 8,995 participants met eligibility criteria. Participants had an average age of 50.8 years and body mass index (BMI) of 34.8 kg/m2, and 25.2% were male. On average, study follow-up was 9.3 mo (median 12.0) with a range of 1.5 to 36 months; programs offered a mean of 12.6 sessions, with mean participant attendance of 11.0 core sessions. Sixty percent of programs offered some form of post-core maintenance (either email or in person). Mean absolute changes observed were: weight -3.77 kg (95% CI: -4.55; -2.99), HbA1c -0.21% (-0.29; -0.13), FBG -2.40 mg/dL (-3.59; -1.21), SBP -4.29 mmHg (-5.73, -2.84), DBP -2.56 mmHg (-3.40, 1.71), HDL +0.85 mg/dL (-0.10, 1.60), and TC -5.34 mg/dL (-9.72, -0.97). Programs with a maintenance component achieved greater reductions in weight (additional -1.66kg) and FBG (additional -3.14 mg/dl). Findings are subject to incomplete reporting and heterogeneity of studies included, and confounding because most included studies used pre-post study designs. DPP lifestyle modification programs achieved clinically meaningful weight and cardiometabolic health improvements. Together, these data suggest that additional value is gained from these programs, reinforcing that they are likely very cost-effective.

ObjectiveTo determine whether diabetes prevalence and incidence has remained flat or changed direction during the past 5 years.Research design and methodsWe calculated annual prevalence and incidence of diagnosed diabetes (type 1 and type 2 combined) for civilian, non-institutionalized adults aged 18–79 years using annual, nationally representative cross-sectional survey data from the National Health Interview Survey from 1980 to 2017. Trends in rates by age group, sex, race/ethnicity, and education were calculated using annual percentage change (APC).ResultsOverall, the prevalence of age-adjusted, diagnosed diabetes did not change significantly from 1980 to 1990, but increased significantly (APC 4.4%) from 1990 to 2009 to a peak of 8.2 per 100 adults (95% CI 7.8 to 8.6), and then plateaued through 2017. The incidence of age-adjusted, diagnosed diabetes did not change significantly from 1980 to 1990, but increased significantly (APC 4.8%) from 1990 to 2007 to 7.8 per 1000 adults (95% CI 6.7 to 9.0), and then decreased significantly (APC −3.1%) to 6.0 (95% CI 4.9 to 7.3) in 2017. The decrease in incidence appears to be driven by non-Hispanic whites with an APC of −5.1% (p=0.002) after 2008.ConclusionsAfter an almost 20-year increase in the national prevalence and incidence of diagnosed diabetes, an 8-year period of stable prevalence and a decrease in incidence has occurred. Causes of the plateauing and decrease are unclear but the overall burden of diabetes remains high and deserves continued monitoring and intervention.

Large reductions in diabetes complications have altered diabetes-related morbidity in the USA. It is unclear whether similar trends have occurred in causes of death. Using data from the National Health Interview Survey Linked Mortality files from 1985 to 2015, we estimated age-specific death rates and proportional mortality from all causes, vascular causes, cancers, and non-vascular, non-cancer causes among US adults by diabetes status. From 1988–94, to 2010–15, all-cause death rates declined by 20% every 10 years among US adults with diabetes (from 23·1 [95% CI 20·1–26·0] to 15·2 [14·6–15·8] per 1000 person-years), while death from vascular causes decreased 32% every 10 years (from 11·0 [9·2–12·2] to 5·2 [4·8–5·6] per 1000 person-years), deaths from cancers decreased 16% every 10 years (from 4·4 [3·2–5·5] to 3·0 [2·8–3·3] per 1000 person-years), and the rate of non-vascular, non-cancer deaths declined by 8% every 10 years (from 7·7 [6·3–9·2] to 7·1 [6·6–7·5]). Death rates also declined significantly among people without diagnosed diabetes for all four major mortality categories. However, the declines in death rates were significantly greater among people with diabetes for all-causes (pinteraction<0·0001), vascular causes (pinteraction=0·0214), and non-vascular, non-cancer causes (pinteration<0·0001), as differences in all-cause and vascular disease death between people with and without diabetes were reduced by about a half. Among people with diabetes, all-cause mortality rates declined most in men and adults aged 65–74 years of age, and there was no decline in death rates among adults aged 20–44 years. The different magnitude of changes in cause-specific mortality led to large changes in the proportional mortality. The proportion of total deaths among adults with diabetes from vascular causes declined from 47·8% (95% CI 38·9–58·8) in 1988–94 to 34·1% (31·4–37·1) in 2010–15; this decline was offset by large increases in the proportion of deaths from non-vascular, non-cancer causes, from 33·5% (26·7–42·1) to 46·5% (43·3–50·0). The proportion of deaths caused by cancer was relatively stable over time, ranging from 16% to 20%. Declining rates of vascular disease mortality are leading to a diversification of forms of diabetes-related mortality with implications for clinical management, prevention, and disease monitoring. None.

IntroductionLittle is known about the role diabetes (type 1 (T1D) and type 2 (T2D)) plays in modifying prognosis among kidney transplant recipients. Here, we compare mortality among transplant recipients with T1D, T2D and non-diabetes-related end-stage kidney disease (ESKD).Research design and methodsWe included 254 188 first-time single kidney transplant recipients aged ≥18 years from the US Renal Data System (2000–2018). Diabetes status, as primary cause of ESKD, was defined using International Classification of Disease 9th and 10th Clinical Modification codes. Multivariable-adjusted Cox regression models (right-censored) computed risk of death associated with T1D and T2D relative to non-diabetes. Trends in standardized mortality ratios (SMRs) (2000–2017), relative to the general US population, were assessed using Joinpoint regression.ResultsA total of 72 175 (28.4%) deaths occurred over a median survival time of 14.6 years. 5-year survival probabilities were 88%, 85% and 77% for non-diabetes, T1D and T2D, respectively. In adjusted models, mortality was highest for T1D (HR=1.95, (95% CI: 1.88 to 2.03)) and then T2D (1.65 (1.62 to 1.69)), as compared with non-diabetes. SMRs declined for non-diabetes, T1D, and T2D. However, in 2017, SMRs were 2.38 (2.31 to 2.45), 6.55 (6.07 to 7.06), and 3.82 (3.68 to 3.98), for non-diabetes, T1D and T2D, respectively.ConclusionsIn the USA, diabetes type is an important modifier in mortality risk among kidney transplant recipients with highest rates among people with T1D-related ESKD. Development of effective interventions that reduce excess mortality in transplant recipients with diabetes is needed, especially for T1D.

Although physical activity (PA) is a key element in the prevention and management of type 2 diabetes, many with this chronic disease do not become or remain regularly active. High-quality studies establishing the importance of exercise and fitness in diabetes were lacking until recently, but it is now well established that participation in regular PA improves blood glucose control and can prevent or delay type 2 diabetes, along with positively affecting lipids, blood pressure, cardiovascular events, mortality, and quality of life. Structured interventions combining PA and modest weight loss have been shown to lower type 2 diabetes risk by up to 58% in high-risk populations. Most benefits of PA on diabetes management are realized through acute and chronic improvements in insulin action, accomplished with both aerobic and resistance training. The benefits of physical training are discussed, along with recommendations for varying activities, PA-associated blood glucose management, diabetes prevention, gestational diabetes mellitus, and safe and effective practices for PA with diabetes-related complications.

According to the Centers for Disease Control and Prevention, in 2007 almost 24 million Americans had diabetes, with one-quarter of those, or six million, undiagnosed (1).

Background Although diabetes is one of the most costly and rapidly increasing serious chronic diseases worldwide, the optimal mix of strategies to reduce diabetes prevalence has not been determined. Methods Using a dynamic model that incorporates national data on diabetes prevalence and incidence, migration, mortality rates, and intervention effectiveness, we project the effect of five hypothetical prevention policies on future US diabetes rates through 2030: 1) no diabetes prevention strategy; 2) a “high-risk” strategy, wherein adults with both impaired fasting glucose (IFG) (fasting plasma glucose of 100–124 mg/dl) and impaired glucose tolerance (IGT) (2-hour post-load glucose of 141–199 mg/dl) receive structured lifestyle intervention; 3) a “moderate-risk” strategy, wherein only adults with IFG are offered structured lifestyle intervention; 4) a “population-wide” strategy, in which the entire population is exposed to broad risk reduction policies; and 5) a “combined” strategy, involving both the moderate-risk and population-wide strategies. We assumed that the moderate- and high-risk strategies reduce the annual diabetes incidence rate in the targeted subpopulations by 12.5% through 2030 and that the population-wide approach would reduce the projected annual diabetes incidence rate by 2% in the entire US population. Results We project that by the year 2030, the combined strategy would prevent 4.6 million incident cases and 3.6 million prevalent cases, attenuating the increase in diabetes prevalence by 14%. The moderate-risk approach is projected to prevent 4.0 million incident cases, 3.1 million prevalent cases, attenuating the increase in prevalence by 12%. The high-risk and population approaches attenuate the projected prevalence increases by 5% and 3%, respectively. Even if the most effective strategy is implemented (the combined strategy), our projections indicate that the diabetes prevalence rate would increase by about 65% over the 23 years (i.e., from 12.9% in 2010 to 21.3% in 2030). Conclusions While implementation of appropriate diabetes prevention strategies may slow the rate of increase of the prevalence of diabetes among US adults through 2030, the US diabetes prevalence rate is likely to increase dramatically over the next 20 years. Demand for health care services for people with diabetes complications and diabetes-related disability will continue to grow, and these services will need to be strengthened along with primary diabetes prevention efforts.

We examined ranges of A1C useful for identifying persons at high risk for diabetes prior to preventive intervention by conducting a systematic review. From 16 included studies, we found that annualized diabetes incidence ranged from 0.1% at A1C <5.0% to 54.1% at A1C >or=6.1%. Findings from 7 studies that examined incident diabetes across a broad range of A1C categories showed 1) risk of incident diabetes increased steeply with A1C across the range of 5.0 to 6.5%; 2) the A1C range of 6.0 to 6.5% was associated with a highly increased risk of incident diabetes, 25 to 50% incidence over 5 years; 3) the A1C range of 5.5 to 6.0% was associated with a moderately increased relative risk, 9 to 25% incidence over 5 years; and 4) the A1C range of 5.0 to 5.5% was associated with an increased incidence relative to those with A1C <5%, but the absolute incidence of diabetes was less than 9% over 5 years. Our systematic review demonstrated that A1C values between 5.5 and 6.5% were associated with a substantially increased risk for developing diabetes.

BackgroundDespite strong evidence and national policy supporting type 2 diabetes prevention, little is known about type 2 diabetes prevention in the primary care setting.ObjectiveOur objective was to assess primary care physicians’ knowledge and practice regarding perceived barriers and potential interventions to improving management of prediabetes.DesignCross-sectional mailed survey.ParticipantsNationally representative random sample of US primary care physicians (PCPs) identified from the American Medical Association Physician Masterfile.Main MeasuresWe assessed PCP knowledge, practice behaviors, and perceptions related to prediabetes. We performed chi-square and Fisher’s exact tests to evaluate the association between PCP characteristics and the main survey outcomes.Key ResultsIn total, 298 (33%) eligible participants returned the survey. PCPs had limited knowledge of risk factors for prediabetes screening, laboratory diagnostic criteria for prediabetes, and management recommendations for patients with prediabetes. Only 36% of PCPs refer patients to a diabetes prevention lifestyle change program as their initial management approach, while 43% discuss starting metformin for prediabetes. PCPs believed that barriers to type 2 diabetes prevention are both at the individual level (e.g., patients’ lack of motivation) and at the system level (e.g., lack of weight loss resources). PCPs reported that increased access to and insurance coverage of type 2 diabetes prevention programs and coordination of referral of patients to these resources would facilitate type 2 diabetes preventive efforts.ConclusionsAddressing gaps in PCP knowledge may improve the identification and management of people with prediabetes, but system-level changes are necessary to support type 2 diabetes prevention in the primary care setting.

Coordinated efforts by national organizations in the United States to implement evidence-based lifestyle modification programs are under way to reduce type 2 diabetes (hereinafter referred to as diabetes) and cardiovascular risks. To provide a status report on the reach and use of diabetes prevention services nationally. This nationally representative, population-based cross-sectional analysis of 2016 and 2017 National Health Interview Survey data was conducted from August 3, 2017, through November 15, 2018. Nonpregnant, noninstitutionalized, civilian respondents 18 years or older at high risk for diabetes, defined as those with no self-reported diabetes diagnosis but with diagnosed prediabetes or an elevated American Diabetes Association (ADA) risk score (>5), were included in the analysis. Analyses were conducted for adults with (and in sensitivity analyses, for those without) elevated body mass index. Absolute numbers and proportions of adults at high risk with elevated body mass index receiving advice about diet, physical activity guidance, referral to weight loss programs, referral to diabetes prevention programs, or any of these, and those affirming engagement in each (or any) activity in the past year were estimated. To identify where gaps exist, a prevention continuum diagram plotted existing vs desired goal achievement. Variation in risk-reducing activities by age, sex, race/ethnicity, educational attainment, insurance status, history of gestational diabetes mellitus, hypertension, or body mass index was also examined. This analysis included 50 912 respondents (representing 223.0 million adults nationally) 18 years or older (mean [SE] age, 46.1 [0.2] years; 48.1% [0.3%] male) with complete data and no self-reported diabetes diagnosis by their health care professional. Of the represented population, 36.0% (80.0 million) had either a physician diagnosis of prediabetes (17.9 million), an elevated ADA risk score (73.3 million), or both (11.3 million). Among those with diagnosed prediabetes, 73.5% (95% CI, 71.6%-75.3%) reported receiving advice and/or referrals for diabetes risk reduction from their health care professional, and, of those, 35.0% (95% CI, 30.5%-39.8%) to 75.8% (95% CI, 73.2%-78.3%) reported engaging in the respective activity or program in the past year. Half of adults with elevated ADA risk scores but no diagnosed prediabetes (50.6%; 95% CI, 49.5%-51.8%) reported receiving risk-reduction advice and/or referral, of whom 33.5% (95% CI, 30.1%-37.0%) to 75.2% (95% CI, 73.4%-76.9%) reported engaging in activities and/or programs. Participation in diabetes prevention programs was exceedingly low. Advice from a health care professional, age range from 45 to 64 years, higher educational attainment, health insurance status, gestational diabetes mellitus, hypertension, and obesity were associated with higher engagement in risk-reducing activities and/or programs. Among adults at high risk for diabetes, major gaps in receiving advice and/or referrals and engaging in diabetes risk-reduction activities and/or programs were noted. These results suggest that risk perception, health care professional referral and communication, and insurance coverage may be key levers to increase risk-reducing behaviors in US adults. These findings provide a benchmark from which to monitor future program availability and coverage, identification of prediabetes, and referral to and retention in programs.