A “Spoonful of Sugar” and the Realities of Diabetes Prevention!

Lifestyle Modification for the Management of Obesity

Reducing the Risk of Developing Diabetes

Treating Type 2 Diabetes Mellitus: A Growing Epidemic

The changing cost to prevent diabetes: A retrospective analysis of the Diabetes Prevention Program

Introduction and Objective: In 2010, the Centers for Disease Control and Prevention (CDC) established the National Diabetes Prevention Program (National DPP) to address the growing rate of type 2 diabetes (T2D) in the United States and the millions of adults at high risk for the disease. The National DPP supports a structured lifestyle change program (LCP) based on the Diabetes Prevention Program (DPP) research study and subsequent translation studies. Our objective is to compare outcomes from the lifestyle intervention arm of the DPP to that of the National DPP LCP using data from CDC’s Diabetes Prevention Recognition Program. Methods: This study compares participant outcomes from the DPP (n=1,079) to two groups from the National DPP LCP: all participants (n=634,545) and those who more closely matched criteria for DPP inclusion (n=116,330). Outcomes include weight loss at ~6 months and percentage who met the 150 minutes/week of physical activity (PA) goal at ~6 months. Analysis was done using SAS 9.4. Results: Median weight loss was higher for DPP participants (7.2%) than for the two groups of LCP participants: 4.3% (all) and 4.7% (matched). Weight loss in the 5-7% range, the goal of the LCP, was the same or better for those in the LCP, 14% (all) and 16% (matched), compared to the DPP (14%). DPP participants met the PA goal of 150 weekly minutes at a rate of 74%. Among LCP participants, the percentage reporting meeting the goal during the 6-month period was 56% (all) and 62% (matched). Conclusion: The National DPP LCP is offered by various organizations in real-world settings, whereas the DPP was conducted in a controlled environment that included individualized support. Despite this, LCP participants are meeting weight loss goals at similar rates and showing increases in PA. The National DPP shows promise as a model to scale a proven lifestyle intervention from research into widespread practice, helping adults with prediabetes lower their risk for T2D. Disclosure E. Ely: None. M. Bell: None.

In the current issue of Circulation , Philip Ades and his associates at the University of Vermont College of Medicine have provided us with an innovative and important article demonstrating the feasibility and benefits of an enhanced exercise option in cardiac rehabilitation.1 In this study, 74 patients were randomized to a standard cardiac rehabilitation exercise program versus a high-calorie-expenditure exercise program. All patients were provided with 16 hours of group dietary counseling and given a dietary target deficit of 500 calories per day. One group was given a standard exercise program typically used in cardiac rehabilitation (25 to 40 minutes, 3 times per week) and the other an enhanced program targeting 45 to 60 minutes, 5 to 7 times per week, or a total caloric expenditure of 3000 to 3500 kcal/week. The length of the intervention was 5 months, though 1-year data collection was also performed. Patients were of course followed up closely to promote compliance. Article see p 2671 The primary outcome of the study was weight loss. Subjects in the high-calorie-expenditure exercise program lost more than twice as much total body weight (8.2±4 versus 3.7±5 kg) and fat mass (5.9±4 versus 2.8±3 kg). Waist circumference also decreased by a greater amount (7±5 versus 5±5 cm). The enhanced exercise program was also associated with a greater benefit on a number of coronary risk factors including insulin resistance, total/high-density lipoprotein cholesterol ratio, and metabolic syndrome. Most of the weight loss and the difference between the groups were retained at 1-year, though some weight regain occurred (1.3 kg for the enhanced exercise group and 0.9 kg for the standard exercise group). Guidelines for the secondary prevention of coronary heart disease2 and for management of specific coronary risk factors3–4 emphasize the importance of lifestyle change, including weight loss, but …

ResultsLong-term remission occurred in 88% of the patients.Mean HbA1c fell from 9.7% -1.5% to 5.9% -0.1% ( p < 0.001).Weight loss failed to correlate with diabetes remission, suggesting an alternative method for diabetes resolution.There was also an increase in C-peptide, suggesting increased b-cell function.There were no mortalities or major surgical morbidities in the study.

UTILITY OF A LDL CHOLESTEROL GENETIC RISK SCORE TO PREDICT RECURRENT CARDIOVASCULAR EVENTS AFTER ACUTE CORONARY SYNDROME

Reducing the Risk of Developing Diabetes.

Hypertension is strongly influenced by genetic factors. Although hypertension prevalence in some Hispanic sub-populations is greater than in non-Hispanic whites, genetic studies on hypertension have focused primarily on samples of European descent. A recent meta-analysis of 200,000 individuals of European descent identified 29 common genetic variants that influence blood pressure, and a genetic risk score derived from the 29 variants has been proposed. We sought to evaluate the utility of this genetic risk score in Hispanics. The sample set consists of 1994 Hispanics from two cohorts: the Northern Manhattan Study (primarily Dominican/Puerto Rican) and the Miami Cardiovascular Registry (primarily Cuban/South American). Risk scores for systolic and diastolic blood pressure were computed as a weighted sum of the risk alleles, with the regression coefficients reported in the European meta-analysis used as weights. Association of risk score with blood pressure was tested within each cohort, adjusting for age, age squared, sex, and BMI. Results were combined using an inverse-variance meta-analysis. The risk score was significantly associated with blood pressure in our combined sample (p = 5.65 × 10−4 for systolic and p = 1.65 × 10−3 for diastolic) but the magnitude of the regression coefficients varied by degree of European, African, and Native American admixture. Further studies among other Hispanic sub-populations are needed to elucidate the role of these 29 variants and identify additional genetic and environmental factors contributing to blood pressure variability in Hispanics.

Reducing the rates of diabetes across the United States

SCREENING FOR DIABETES IN GENERAL PRACTICE

> It is not in the stars to hold our destiny but in ourselves > > —William Shakespeare The widespread availability and lower costs of genotyping and sequencing have resulted in the performance of a large number of genotype–phenotype association studies in cardiovascular medicine. The stringent requirements for correction for multiple testing and replication have particularly favored genotype–phenotype studies examining the association between genetic variation and quantitative traits that allows for greater statistical power. Multiple genome-wide association studies and a subsequent meta-analysis have identified >180 common and rare genetic variants associated with lipid traits.1,2 However, the effect size of these individual genetic variants is small, explaining only a small fraction of phenotypic variation prompting investigators to use genetic risk scores (GRS) that represent an aggregate of genetic risk to demonstrate clinical utility. Single-nucleotide polymorphisms (SNPs) and GRS have been used to predict cardiovascular disease such as coronary artery disease (CAD) and hypertension, surrogate markers of disease such as coronary calcium, cardiovascular outcomes such as myocardial infarction, and intermediate traits such as blood pressure and lipids.3 Article, see p 495 The Global Lipids Genetics Consortium has performed the largest genetic association study of lipid levels in 188 577 individuals from a total of 60 studies.1,2 There were 157 genetic loci that were identified, 95 were described previously and 62 were novel. The lipid level variance explained by the novel loci in this study ranged from 1.6% for high-density lipoprotein cholesterol (HDL-C) levels to 2.6% for total cholesterol levels. The total lipid variance explained by the previously described loci was 10% to 12%. The population studied was predominantly of European ancestry, and subjects on lipid-lowering therapy were excluded. The association of these genetic loci with lipid levels and a change in lipid levels with intervention in a prediabetic population …

Changes in the National Diabetes Prevention Program Present Opportunities for Registered Dietitian Nutritionists to Reduce the Prevalence of Diabetes

Glucose lowering and diabetes prevention: are they the same?