A simulation model estimates lifetime health and economic outcomes of screening prediabetes using the 1-h plasma glucose

Screening for Type 2 Diabetes Mellitus: A Systematic Review of Recent Economic Evaluations

OBJECTIVES

To examine recent economic evaluations and understand whether any type 2 diabetes mellitus (T2DM) screening designs may represent better value for money and to rate their methodological qualities.

METHODS

We systematically searched 3 concepts (economic evaluations [EEs], T2DM, screening) in 5 databases (Medline, Embase, EconLit, Web of Science, and Cochrane) for EEs published between 2010 and 2023. Two independent reviewers screened for and rated their methodological quality (using the Consensus on Health Economics Criteria Checklist-Extended).

RESULTS

Of 32 EEs, a majority were from high-income countries (69%). Half used single biomarkers (50%) to screen adults ≥30 to <60 years old (60%) but did not report locations (69%), treatments for those diagnosed (66%), diagnostic methods (57%), or screening intervals (54%). Compared with no screening, T2DM screening using single biomarkers was found to be not cost-effective (23/54 comparisons), inconclusive (16/54), dominant (11/54), or cost-effective (4/54). Compared with no screening, screening with a risk score and single biomarkers was found to be cost-effective (21/40) or dominant (19/40). The risk score alone was mostly dominant (6/10). Compared with universal screening, targeted screening among obese, overweight, or older people may be cost-effective or dominant. Compared with fasting plasma glucose or fasting capillary glucose, screening using risk scores was found to be mostly dominant or cost-effective. Expanding screening locations or lowering HbA1c or fasting plasma glucose thresholds was found to be dominant or cost-effective. Each EE had 4 to 17 items (median 13/20) on Consensus on Health Economics Criteria Checklist-Extended rated "Yes/Rather Yes."

CONCLUSIONS

EE findings varied based on screening tools, intervals, locations, minimum screening age, diagnostic methods, and treatment. Future EEs should more comprehensively report screening designs and evaluate T2DM screening in low-income countries.

Performance of the 1 h oral glucose tolerance test in predicting type 2 diabetes and association with impaired β-cell function in Asians: a national prospective cohort study

Background

Postprandial glucose concentration 1-h (1 h-PG) after an oral glucose tolerance test (OGTT) has similar or superior performance to 2 h-PG in predicting type-2 diabetes mellitus (T2DM) in several populations, and is simpler to obtain in clinical practice. However, studies in Asians are scarce. We investigated the utility of elevated baseline 1 h-PG in predicting T2DM incidence within three years, and its relationship with β-cell function in 1250 non-diabetic Asian participants.

Methods

Participants underwent an OGTT, an intravenous glucose challenge and a hyperinsulinemic-euglycemic clamp to determine glucose tolerance, acute insulin response (AIR) and insulin sensitivity at baseline. OGTTs were repeated every six months until study completion to monitor T2DM conversion.

Findings

The area under the receiver operating characteristic curve of 1 h-PG was not significantly different from 2 h-PG (AUC1h-PG = 0.883 vs. AUC2h-PG = 0.907; ΔAUC = -0.024, P = 0.124) and the optimal 1 h-PG cut-off was ≥10.7 mmol/L. When groups of high/low 1 h-PG and 2 h-PG at baseline were compared, AIR and disposition index were significantly lower in groups with high 1 h-PG, and both had a stronger correlation with 1 h-PG, indicating that impaired β-cell function was more strongly associated with elevated 1 h-PG than 2 h-PG.

Interpretation

The ability of 1 h-PG to detect Asians at risk of developing T2DM within three years is on par with 2 h-PG and the optimal cut-off is 10.7 mmol/L. Elevated 1 h-PG is associated with β-cell dysfunction. We conclude that 1 h-PG can be considered as a primary OGTT time point to identify Asians at risk for T2DM, allowing for screening at a reduced time and cost, and with lower patient burden.

Funding

National Medical Research Council (NMRC), Ministry of Health (MOH; Singapore) Industry Alignment Fund [NMRC/MOHIAFCat1/0048/2016] and Janssen Pharmaceuticals Inc. (USA).

High one-hour plasma glucose is an intermediate risk state and an early predictor of type 2 diabetes in a longitudinal Korean cohort

AIMS

Because one-hour post-load plasma glucose (1h-PG) ≥ 155 mg/dL (8.6 mmol/L) has been proposed as an early marker for future diabetes but lacks sufficient longitudinal confirmation of its risk, we aimed to evaluate the risk of T2D based on 1h-PG and track changes of insulin sensitivity and β-cell function over time by 1h-PG in a longitudinal cohort.

METHODS

OGTTs were conducted every 2 years in the 10-year longitudinal Korean Genome Epidemiology study (n = 6144) with three groups characterized at baseline: Low 1h-PG (< 155 mg/dL) with Normal Glucose Tolerance (NGT), High 1h-PG (≥155 mg/dL) with NGT, and prediabetes (PreDM).

RESULTS

T2D risk was higher in people with High 1h-PG with NGT and PreDM than those with Low 1h-PG with NGT. Baseline insulin sensitivity in Low 1h-PG as measured by the insulin sensitivity and secretion (ISS) model and Matsuda insulin sensitivity index (ISI) was higher than in High 1h-PG, which was comparable to PreDM. β-cell function as assessed by ISS and the insulinogenic index decreased from Low 1h-PG to High 1h-PG to PreDM. Over time, insulin sensitivity decreased in the three groups. Time from High 1h-PG to T2D was 0.9 years shorter than from Low 1h-PG. All participants passed the 1h-PG threshold for T2D (209 mg/dL, 11.6 mmol/L) first, and 74 % passed the 1h-PG threshold for impaired glucose tolerance (IGT; 155 mg/dL) first.

CONCLUSIONS

High 1h-PG NGT is an intermediate risk category between Low 1h-PG NGT and PreDM and may provide an opportunity for early intervention to prese rve ß-cell function.

International Diabetes Federation Position Statement on the 1-hour post-load plasma glucose for the diagnosis of intermediate hyperglycaemia and type 2 diabetes

Many individuals with intermediate hyperglycaemia (IH), including impaired fasting glycaemia (IFG) and impaired glucose tolerance (IGT), as presently defined, will progress to type 2 diabetes (T2D). There is confirmatory evidence that T2D can be prevented by lifestyle modification and/or medications, in people with IGT diagnosed by 2-h plasma glucose (PG) during a 75-gram oral glucose tolerance test (OGTT). Over the last 40 years, a wealth of epidemiological data has confirmed the superior value of 1-h plasma glucose (PG) over fasting PG (FPG), glycated haemoglobin (HbA1c) and 2-h PG in populations of different ethnicity, sex and age in predicting diabetes and associated complications including death. Given the relentlessly rising prevalence of diabetes, a more sensitive, practical method is needed to detect people with IH and T2D for early prevention or treatment in the often lengthy trajectory to T2D and its complications. The International Diabetes Federation (IDF) Position Statement reviews findings that the 1-h post-load PG ≥ 155 mg/dL (8.6 mmol/L) in people with normal glucose tolerance (NGT) during an OGTT is highly predictive for detecting progression to T2D, micro- and macrovascular complications, obstructive sleep apnoea, cystic fibrosis-related diabetes mellitus, metabolic dysfunction-associated steatotic liver disease, and mortality in individuals with risk factors. The 1-h PG of 209 mg/dL (11.6 mmol/L) is also diagnostic of T2D. Importantly, the 1-h PG cut points for diagnosing IH and T2D can be detected earlier than the recommended 2-h PG thresholds. Taken together, the 1-h PG provides an opportunity to avoid misclassification of glycaemic status if FPG or HbA1c alone are used. The 1-h PG also allows early detection of high-risk people for intervention to prevent progression to T2D which will benefit the sizeable and growing population of individuals at increased risk of T2D. Using a 1-h OGTT, subsequent to screening with a non-laboratory diabetes risk tool, and intervening early will favourably impact the global diabetes epidemic. Health services should consider developing a policy for screening for IH based on local human and technical resources. People with a 1-h PG ≥ 155 mg/dL (8.6 mmol/L) are considered to have IH and should be prescribed lifestyle intervention and referred to a diabetes prevention program. People with a 1-h PG ≥ 209 mg/dL (11.6 mmol/L) are considered to have T2D and should have a repeat test to confirm the diagnosis of T2D and then referred for further evaluation and treatment. The substantive data presented in the Position Statement provides strong evidence for redefining current diagnostic criteria for IH and T2D by adding the 1-h PG.

Therapeutic potential of adiponectin in prediabetes: strategies, challenges, and future directions

Adiponectin, an adipose-derived hormone, plays a pivotal role in glucose regulation and lipid metabolism, with a decrease in circulating adiponectin levels being linked to insulin resistance and prediabetes. This review examines the therapeutic potential of adiponectin in managing prediabetes, elucidating on multiple aspects including its role in glucose and lipid metabolism, influence on insulin sensitivity, and anti-inflammatory properties. Moreover, the paper highlights the latest strategies to augment adiponectin levels, such as gene therapy, pharmacological interventions, dietary modifications, and lifestyle changes. It also addresses the challenges encountered in translating preclinical findings into clinical practice, primarily related to drug delivery, safety, and efficacy. Lastly, the review proposes future directions, underlining the need for large-scale human trials, novel adiponectin analogs, and personalized treatment strategies to harness adiponectin's full therapeutic potential in preventing the transition from prediabetes to diabetes.

High 1-h glucose in youths with obesity as marker of prediabetes and cardiovascular risk

PURPOSE

Testing 1-h glucose (1HG) concentration during oral glucose tolerance test is cost-effective to identify individuals at risk of incident type 2 diabetes. Aim of the study was to define 1HG cutoffs diagnostic of incident impaired glucose tolerance (IGT) in youths with obesity, and to evaluate prevalence and association of cutoffs identified in the cohort and from the literature (133 and 155 mg/dl) to cardiovascular disease (CVD) in a population of youths with obesity.

METHODS

This is a longitudinal study of 154 youths to identify 1HG cutoffs, and cross-sectional study of 2295 youths to estimate prevalence of high 1HG and association to CVD. Receiver-operating characteristic curves (ROC) were used to establish 1HG cutoffs, and univariate regression analyses to test association of 1HG to blood pressure, lipids and aminotransferases.

RESULTS

ROC analysis identified the 1HG cutoff of 159 mg/dl as having diagnostic accuracy of IGT with area under the ROC 0.82 (95% CI 0.66-0.98), sensitivity 0.86% and specificity 0.79%. In the cross-sectional population, prevalence of high 1HG was 36% and 15% for 133 and 155 mg/dl cutoffs, respectively, and 17% for the 159 mg/dl value. All the examined cutoffs were significantly associated with worse lipid profile, liver function test, reduced insulin sensitivity, secretion and disposition index.

CONCLUSION

High 1HG is marker of persistent IGT and increased risk of metabolic abnormalities in youths. The 155 mg/dl cutoff is a convenient estimate in young people but longitudinal studies with retinopathy and overt diabetes as end points are advised to verify the 1HG cutoff with the best diagnostic accuracy.

One-hour glucose is an earlier marker of dysglycemia than two-hour glucose

AIMS

The timing of increase in 1-hour PG and its utility as an earlier predictor of both prediabetes (PreDM) and type 2 diabetes (T2D) compared to 2-hour PG (2 h-PG) are unknown. To evaluate the timing of crossing of the 1 h-PG ≥ 155 mg/dl (8.6 mmol/L) for PreDM and 209 mg/dl (11.6 mmol/L) for T2D and respective current 2 h-PG thresholds of 140 mg/dl (7.8 mmol/L) and 200 mg/dl (11.1 mmol/L).

METHODS

Secondary analysis of 201 Southwest Native Americans who were followed longitudinally for 6-10 years and had at least 3 OGTTs.

RESULTS

We identified a subset of 43 individuals who first developed PreDM by both 1 h-PG and 2 h-PG criteria during the study. For most (32/43,74%), 1 h-PG ≥ 155 mg/dl was observed before 2 h-PG reached 140 mg/dl (median [IQR]: 1.7 [-0.25, 4.59] y; mean ± SEM: 5.3 ± 1.9 y). We also identified a subset of 33 individuals who first developed T2D during the study. For most (25/33, 75%), 1 h-PG reached 209 mg/dl earlier (median 1.0 [-0.56, 2.02] y; mean ± SEM: 1.6 ± 0.8 y) than 2 h-PG reached 200 mg/dl, diagnostic of T2D.

CONCLUSIONS

1 h-PG ≥ 155 mg/dl is an earlier marker of elevated risk for PreDM and T2D than 2 h-PG ≥ 140 mg/dl.

Two decades of diabetes prevention efforts: A call to innovate and revitalize our approach to lifestyle change

The impact of global diabetes prevention efforts has been modest despite the promise of landmark diabetes prevention trials nearly twenty years ago. While national and regional initiatives show potential, challenges remain to adapt large-scale strategies in the real-world that fits individuals and their communities. Additionally, the sedentary lifestyle changes during the COVID-19 pandemic and guidelines that now call for earlier screening (e.g., US Preventative Task Force) will increase the pool of eligible adults worldwide. Thus, a more adaptable, person-centered approach that expands the current toolkit is urgently needed to innovate and revitalize our approach to diabetes prevention. This review identifies key priorities to optimize the population-level delivery of diabetes prevention based on a consensus-based evaluation of the current evidence among experts in global translational programs; key priorities identified include (1) participant eligibility, (2) intervention intensity, (3) delivery components, (4) behavioral economics, (5) technology, and (6) the role of pharmacotherapy. We offer a conceptual framework for a broader, person-centered approach to better address an individual's risk, readiness, barriers, and digital competency.

From Metabolic Syndrome to Type 2 Diabetes in Youth

In the frame of metabolic syndrome, type 2 diabetes emerges along a continuum of the risk from the clustering of all its components, namely visceral obesity, high blood pressure and lipids, and impaired glucose homeostasis. Insulin resistance is the hallmark common to all the components and, in theory, is a reversible condition. Nevertheless, the load that this condition can exert on the β-cell function at the pubertal transition is such as to determine its rapid and irreversible deterioration leading to plain diabetes. The aim of this review is to highlight, in the context of metabolic syndrome, age-specific risk factors that lead to type 2 diabetes onset in youth; resume age specific screening and diagnostic criteria; and anticipate potential for treatment. Visceral obesity and altered lipid metabolism are robust grounds for the development of the disease. Genetic differences in susceptibility to hampered β-cell function in the setting of obesity and insulin resistance largely explain why some adolescents with obesity do develop diabetes at a young age and some others do not. Lifestyle intervention with a healthy diet and physical activity remains the pillar of the type 2 diabetes treatment in youth. As to the pharmacological management, metformin and insulin have failed to rescue β-cell function and to ensure long-lasting glycemic control in youth. A new era might start with the approval for use in pediatric age of drugs largely prescribed in adults, such as dipeptidyl peptidase-4 and sodium-dependent glucose transport inhibitors, and of new weight-lowering drugs in the pipeline such as single and multiple agonists of the glucagon-like peptide 1 receptor. The latter drugs can have tremendous impact on the natural history of the disease. By treating diabetes, they will reduce the burden of all the metabolic abnormalities belonging to the syndrome while causing a tremendous weight loss hitherto never seen before.