Effect of Conventional Lifestyle Interventions on Type 2 Diabetes Incidence by Glucose-Defined Prediabetes Phenotype: An Individual Participant Data Meta-analysis of Randomized Controlled Trials

Excessive exposure to nitrate and nitrite boosts progression of isolated impaired fasting glucose to type 2 diabetes: a cohort study

Objectives

This cohort study investigated the possible association of dietary nitrate (NO3)/nitrite (NO2) intake and risk of progression to type 2 diabetes (T2D) across different phenotypes of prediabetes (Pre-DM).

Methods

A total of 1586 adults diagnosed with Pre-DM [i.e., 60.2% isolated impaired fasting glucose (iIFG), 21% isolated impaired glucose tolerance (iIGT), and 18.8% combined IFG-IGT] in the third (2006-2008) and fourth (2009-2011) examinations of the Tehran Lipid and Glucose Study, were assessed for dietary intake of NO3 and NO2 and were followed up to 2015-2017. Cox proportional hazard models, stratified by Pre-DM phenotypes, were used to plot cumulative hazard curve and calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for developing T2D across tertile categories and per every 100 mg/d NO3 and 2 mg/d NO2 intake exceeded the acceptable daily intake (ADI).

Results

The mean age of the participants was 47.2 ± 12.9 years at baseline, and 52.2% were men. Highest intake of NO3 (≥ 645 vs. < 451 mg/d) and NO2 (≥ 11.5 vs. <9.0 mg/d) increased risk of T2D among subjects with iIFG (HR = 1.69, 95% CI = 1.04-2.74 and HR = 2.07, 95% CI = 1.29-3.32). The cumulative hazards were higher in the highest compared to the lowest NO3 and NO2 intake in subjects with iIFG phenotype. Every 100 mg/d of NO3 and 2 mg/d NO2 intake exceeded ADI was associated with an increased risk of progression from iIFG to T2D by 13 and 25%, respectively.

Conclusion

High exposure to dietary NO3 and NO2 may be a risk factor for developing T2D in subjects with iIFG.

Vitamin D deficiency in relation to different phenotypes of prediabetes: a population-based study

PURPOSE

Vitamin D deficiency is implicated in the development of prediabetes. However, it is unclear whether vitamin D deficiency showed any relationship with different phenotypes of prediabetes. This study was designed to address this issue.

METHODS

We included participants from the National Health and Nutrition Examination Survey 2011-2016. Prediabetes is classified into the following phenotypes: an isolated defect (that is, impaired fasting glucose [IFG], impaired glucose tolerance [IGT], or impaired hemoglobin A1c[IA1c]), two defects (that is, IFG+IGT, IFG+IA1c, or IGT+IA1c), or three defects (that is, IFG+IGT+IA1c). Multivariate logistic regression analysis was used to obtain the odds ratio (OR) and 95% confidence intervals (CIs).

RESULTS

A total of 4126 participants (2332 with prediabetes and 1794 with normal glycemia) were included in this study. Multivariate logistic regression analysis showed that prediabetes was associated with an increased odds of vitamin D deficiency than normal glycemia (OR 1.216, 95% CI 1.023-1.444). Further analysis showed that prediabetes phenotypes of IGT+IFG (OR 1.549, 95% CI 1.050-2.283) and IFG+IGT + IA1c (OR 1.507, 95% CI 1.062-2.138) had an increased odds of vitamin D deficiency. The odds of vitamin D deficiency was higher in individuals with glucose-defined prediabetes, but not in those with HbA1c-defined prediabetes when compared with individuals with normal glycemia.

CONCLUSION

Prediabetes was associated with an increased odds of vitamin D deficiency, and glucose-defined prediabetes might be a better predictor of vitamin D deficiency.

Use of technology in prediabetes and precision prevention

Controlling the epidemic of diabetes is an urgent global healthcare challenge. The low uptake of diabetes prevention programs highlights difficulties in scalability, partly due to the need for intensive face-to-face contact and its impact on healthcare resource utilization. In this narrative review, we will summarize the latest evidence in technology-assisted lifestyle interventions. We will appraise evidence of digital diabetes prevention programs that use internet platforms or text messaging tools to support information delivery, lifestyle coaching, or peer support. We will also discuss the use of wearables, including physical activity trackers and continuous glucose monitoring (CGM) as part of lifestyle intervention. Experience from diabetes highlights the potential for CGM as a motivational tool to promote lifestyle change. The integration of digital data may facilitate earlier detection of prediabetes, sub-phenotyping, and personalized nutritional predictions. We will highlight major gaps in research and the need for rigorous clinical trials to evaluate the acceptability and cost-effectiveness of integrating technologies as part of a multicomponent strategy in diabetes prevention.

Differential effect of nonpharmacological interventions according to prediabetes phenotype: Systematic review and meta-analysis of randomized clinical trials

BACKGROUND AND AIMS

Impaired glucose intolerance (IGT) and impaired fasting glucose (IFG) are totally different. Lifestyle modification is effective in moving from prediabetes to normoglycaemia. There is a lack of information showing the effect of lifestyle modification according to each prediabetes and assessing its effect on the degree of reversibility to normoglycaemia and on cardiometabolic markers.

METHODS AND RESULTS

We searched for randomized controlled trials (RCT) that enrolled individuals with IGT or IFG. Meta-analysis was performed to compare the proportion of subjects progressing to type 2 diabetes mellitus (T2DM); proportion reversing to normoglycaemia and mean differences in glucose level and cardiometabolic parameters. Thirty-six RCTs were included. The proportion of subjects progressing from impaired glycaemia to T2DM was higher among those with IGT (16.3% vs. 10.9%), whereas reversion to normoglycaemia was higher in subjects with IFG (27.2% vs. 24.8%). The effect of lifestyle modification on glucose level was significant on those with IFG (mean difference [MD] = -1.56 mg/dL, 95% CI: -2.71, -0.40), but not on those with IGT of (MD = 1.47 mg/dL, 95% CI: -1.33, 4.28).

CONCLUSION

Diverse lifestyle modification interventions improved glucose levels in people with IFG, but not in those with IGT. Our findings imply that different non-pharmacological interventions are warranted for IGT and IFG.

Divergence in prediabetes guidelines - A global perspective

The global landscape of prediabetes diagnostic guidelines varies significantly, reflecting diverse healthcare priorities, population characteristics, and resource availability. Major international organisations, including the World Health Organisation (WHO), European Association for the Study of Diabetes (EASD), Italian Society of Diabetes (SID), American Diabetes Association (ADA), International Diabetes Federation (IDF), Diabetes UK, and Chinese Diabetes Society (CDS), adopt differing criteria for defining and diagnosing prediabetes. These discrepancies arise from variations in diagnostic tests-oral glucose tolerance test (OGTT), fasting plasma glucose (FPG), and glycated haemoglobin (HbA1c)-as well as differences in prevalence estimates, screening policies, and healthcare infrastructure. Ethnic variability in glucose metabolism further complicates standardisation, as some diagnostic tools, such as HbA1c, perform differently across populations. Additionally, individuals diagnosed via different criteria exhibit distinct metabolic risks and may respond differently to interventions. This heterogeneity poses challenges for global research, policy-making, and equitable access to care. While complete international harmonisation may be impractical, emerging diagnostic approaches, such as the 1-hour plasma glucose (1-h PG) test, offer a promising step toward improving diagnostic consistency. A hybrid model integrating universal standards with population-specific adaptations may offer a more effective global strategy for prediabetes identification and prevention.

Long-term effects and effect heterogeneity of lifestyle and metformin interventions on type 2 diabetes incidence over 21 years in the US Diabetes Prevention Program randomised clinical trial

BACKGROUND

In the US Diabetes Prevention Program (DPP), a 3-year randomised clinical trial in 3234 adults with prediabetes, type 2 diabetes incidence was reduced by 58% with intensive lifestyle intervention (ILS) and by 31% with metformin, compared with placebo. We sought to assess the long-term effects and potential heterogeneity of treatment effects over approximately 21 years of follow-up.

METHODS

The DPP trial was continued with protocol modifications as the DPP Outcomes Study (DPPOS). In the DPPOS, placebo was discontinued, metformin (850 mg twice a day as tolerated) was continued after unmasking, and group-based booster intervention classes were offered to the ILS group twice a year; additionally, all participants were offered group-based lifestyle intervention four times a year. The prespecified primary outcome during DPP and DPPOS was diabetes incidence defined by American Diabetes Association criteria. The DPPOS protocol specified continued diabetes incidence as an outcome; Feb 23, 2020, was chosen as the closing date for the present analysis, as a date prior to the COVID-19 pandemic, which caused major disruptions in clinic visits and complicated longitudinal data analyses. We assessed long-term persistence of intervention effects on diabetes incidence, and heterogeneity of effects in subgroups defined by baseline diabetes risk factors. Follow-up is reported for the combined study from July 31, 1996, to Feb 23, 2020, and analysis was by intention to treat. The trial is registered with ClinicalTrials.gov, NCT00004992 (DPP) and NCT00038727 (DPPOS); follow-up is ongoing but the trial is closed to enrolment except for previous DPP participants.

FINDINGS

3195 participants originally enrolled in the DPP were included in the present analyses. This population comprised 2171 (67·9%) female participants and 1024 (32·1%) male participants, with a mean baseline age of 50·6 years (SD 10·7). Individual follow-up times ranged from 0·2 to 23·2 years (median 8·0 years [IQR 3·0 to 18·0]); remaining numbers at risk decreased sharply after 21 years because of administrative censoring and thus follow-up was considered to represent a 21-year period. During follow-up, compared with placebo, diabetes incidence rate was reduced in the original ILS group (hazard ratio [HR] 0·76 [95% CI 0·68 to 0·85], rate difference [RD] -1·59 cases [95% CI -2·25 to -0·93] per 100 person-years) and in the original metformin group (HR 0·83 [0·74 to 0·93], RD -1·17 [-1·85 to -0·49]), with corresponding increases in median diabetes-free survival of 3·5 years and 2·5 years, and mean diabetes-free survival of 2·0 years (95% CI 1·2 to 2·8) and 1·2 years (0·4 to 2·0), respectively. The diabetes cumulative incidence curves separated early, especially in the first 3 years, with lower incidence rates in the metformin and ILS groups than in the placebo group. The metformin and ILS curves progressively converged with longer follow-up. The overall treatment effects appeared to result from large early effects during the DPP. Absolute intervention effects, measured as RDs versus placebo, were greater with ILS in participants with higher values for baseline fasting glucose, HbA1c, and multivariable clinical and physiological risk indices, and with metformin in younger participants.

INTERPRETATION

The large initial intervention effects seen in the DPP trial were followed by sustained reductions in cumulative diabetes incidence for 21 years. Intervention effects were heterogeneous according to some baseline variables. These findings could guide precision interventions to help address the current type 2 diabetes epidemic.

FUNDING

US National Institute of Diabetes and Digestive and Kidney Diseases and other agencies.

TRANSLATION

For the Spanish translation of the abstract see Supplementary Materials section.

The Unique Ethnicity-Specific Aspects of Burden, Pathogenesis and Management of Prediabetes: Insights from Africa

PURPOSEOF REVIEW

Prediabetes poses a significant risk of developing diabetes and it's complications. Africa faces specific challenges, hindering early recognition and management of prediabetes. We aimed to understand unique, ethnicity specific aspects of the burden, pathogenesis and management of prediabetes in Africa.

RECENT FINDINGS

The rate of progression from prediabetes to diabetes is higher in African, compared to European populations. Prediabetes in Africans is driven mainly by hyperinsulinemia and reduced hepatic clearance causing obesity and insulin resistance, rather than impaired insulin sensitivity. High risk, difficult to reach individuals in lower socioeconomic strata, benefited from community versus facility-based screening. Intensive lifestyle changes with low calorie or low fat-high fiber diet provide longer lasting effect versus drug monotherapy. Using structured community-based screening, early detection of prediabetes is achievable, requiring dedicated stakeholder engagement. Further research into the etiology and sequencing of pathogenetic anomalies and preventive strategies in African populations is needed.

Multi-omics approaches for biomarker discovery and precision diagnosis of prediabetes

Recent advancements in multi-omics technologies have provided unprecedented opportunities to identify biomarkers associated with prediabetes, offering novel insights into its diagnosis and management. This review synthesizes the latest findings on prediabetes from multiple omics domains, including genomics, epigenomics, transcriptomics, proteomics, metabolomics, microbiomics, and radiomics. We explore how these technologies elucidate the molecular and cellular mechanisms underlying prediabetes and analyze potential biomarkers with predictive value in disease progression. Integrating multi-omics data helps address the limitations of traditional diagnostic methods, enabling early detection, personalized interventions, and improved patient outcomes. However, challenges such as data integration, standardization, and clinical validation and translation remain to be resolved. Future research leveraging artificial intelligence and machine learning is expected to further enhance the predictive power of multi-omics technologies, contributing to the precision diagnosis and tailored management of prediabetes.

Call to action for clinicians in the South-East Asian regions on primary prevention of diabetes in people with prediabetes- A consensus statement

Primary prevention of diabetes still remains as an unmet challenge in a real world setting. While, translational programmes have been successful in the developed nations, the prevailing social and economic inequities in the low and middle income countries, fail to integrate diabetes prevention into their public health systems. The resulting exponential increase in the prevalence of diabetes and the cost of treatment has put primary prevention in the back seat. As a call to action, an expert group was formed to lay down practical guidelines for clinicians in the South East Asian regions to implement primary prevention programmes at an individual or at a community level. The guideline was developed based on the outcomes of the evidence based prevention programmes conducted in India. This decentralised self-guided approach for primary prevention of diabetes follows a three step implementation process of screening, diagnosis of intermediate hyperglycaemia and design and delivery of personalized interventions. Recommendations provided on dietary intake and physical activity can be tailored by the clinician to suit individual needs. Initiation of pharmacological treatment to achieve desired targets has also been addressed. A personalised approach by the clinician may be effective and offer a sustainable solution to curb the rising epidemic.

High-Intensity Interval Training for Individuals With Isolated Impaired Fasting Glucose: Protocol for a Proof-of-Concept Randomized Controlled Trial

BACKGROUND

Standard lifestyle interventions have shown limited efficacy in preventing type 2 diabetes among individuals with isolated impaired fasting glucose (i-IFG). Hence, tailored intervention approaches are necessary for this high-risk group.

OBJECTIVE

This study aims to (1) assess the feasibility of conducting a high-intensity interval training (HIIT) study and the intervention acceptability among individuals with i-IFG, and (2) investigate the preliminary efficacy of HIIT in reducing fasting plasma glucose levels and addressing the underlying pathophysiology of i-IFG.

METHODS

This study is a 1:1 proof-of-concept randomized controlled trial involving 34 physically inactive individuals (aged 35-65 years) who are overweight or obese and have i-IFG. Individuals will undergo a 3-step screening procedure to determine their eligibility: step 1 involves obtaining clinical information from electronic health records, step 2 consists of completing questionnaires, and step 3 includes blood tests. All participants will be fitted with continuous glucose monitoring devices for approximately 80 days, including 10 days prior to the intervention, the 8-week intervention period, and 10 days following the intervention. Intervention participants will engage in supervised HIIT sessions using stationary "spin" cycle ergometers in groups of 5 or fewer. The intervention will take place 3 times a week for 8 weeks at the Aerobic Exercise Laboratory in the Rehabilitation Hospital at Emory University. Control participants will be instructed to refrain from engaging in intense physical activities during the study period. All participants will receive instructions to maintain a eucaloric diet throughout the study. Baseline and 8-week assessments will include measurements of weight, blood pressure, body composition, waist and hip circumferences, as well as levels of fasting plasma glucose, 2-hour plasma glucose, and fasting insulin. Primary outcomes include feasibility parameters, intervention acceptability, and participants' experiences, perceptions, and satisfaction with the HIIT intervention, as well as facilitators and barriers to participation. Secondary outcomes comprise between-group differences in changes in clinical measures and continuous glucose monitoring metrics from baseline to 8 weeks. Quantitative data analysis will include descriptive statistics, correlation, and regression analyses. Qualitative data will be analyzed using framework-driven and thematic analyses.

RESULTS

Recruitment for the study is scheduled to begin in February 2025, with follow-up expected to be completed by the end of September 2025. We plan to publish the study findings by the end of 2025.

CONCLUSIONS

The study findings are expected to guide the design and execution of an adequately powered randomized controlled trial for evaluating HIIT efficacy in preventing type 2 diabetes among individuals with i-IFG.

TRIAL REGISTRATION

Clinicaltrials.gov NCT06143345; https://clinicaltrials.gov/study/NCT06143345.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/59842.

Total fat intake and fatty acid patterns and prediabetes regression: differential effects across phenotypes in a population-based cohort

BACKGROUND AND AIM

This cohort study investigated the potential association between dietary fat intakes and returning to normal glucose regulation (NGR) in different prediabetes (Pre-DM) phenotypes.

METHODS

A total of 1587 Pre-DM subjects consisting of 60.2% isolated impaired fasting glucose (iIFG), 21% isolated impaired glucose tolerance (iIGT), and 18.8% combined IFG-IGT, were recruited for baseline dietary assessment and were followed for changes in glycemic status (i.e., returned to NGR, remained Pre-DM, or progressed to diabetes) over 9 years. Cox proportional hazard models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for returning to NGR across categories of fat intake (< 20%, 20-30%, and > 30% of total energy intake), and tertiles of major fat patterns identified through principal component analysis (PCA).

RESULTS

The mean age of the participants was 47.2 ± 12.9 years, and 52.2% were men. Over a median of 5.8 years of follow-up, 46.8% of Pre-DM subjects regressed to NGR. Low-fat diet (LFD) was associated with an increased chance of returning to NGR in the iIGT phenotype (HR = 1.44, 95% CI 1.05-1.98). Two major dietary fat patterns, i.e., Mixed Fat Pattern (MFP, whit a higher load of saturated fat, cholesterol, oleic, linoleic, and trans fatty acids) and ω3FP (i.e., loaded heavily on docosahexaenoic, eicosapentaenoic, and α-linolenic acids), extracted by PCA, were corresponded to 58.4% of the total variance of fat intake. In both iIFG and iIGT phenotypes, highest MFP score was inversely associated with NGR (HR = 0.71, 95% CI 0.50-0.99 and HR = 0.60, 95% CI 0.37-0.97), while the highest ω3FP score was associated with an elevated incidence of NGR in subjects with combined IFG-IGT phenotype by twofold (HR = 2.29, 95% CI 1.00-5.29).

CONCLUSIONS

Subjects with iIGT phenotype may take more advantage from adhering a LFD. Dietary fat patterns may differentially affect chance of returning to NGR across Pre-DM phenotypes.

Lessons Learned From Epidemiology of Type 2 Diabetes in South Asians: Kelly West Award Lecture 2024

South Asia has high prevalence rates of type 2 diabetes (T2D). Until the 1990s, the prevalence of T2D within South Asia was low but much higher in the South Asian diaspora living abroad. Today, high prevalence rates of T2D are reported among those living in South Asia. T2D in South Asians presents with unique clinical features described as the "South Asian phenotype" that include younger age at onset of diabetes than in White Europeans, much lower BMI, hyperinsulinemia and greater insulin resistance, rapid decline in β-cell function resulting in low insulin reserve, low muscle mass, and greater ectopic fat deposition, especially in the liver. Also, prevalence of impaired fasting glucose is higher among South Asians than prevalence of impaired glucose tolerance. Genetic predisposition combined with intrauterine fetal programming (low vitamin B12 intake and high folate intake) increases susceptibility to T2D, from birth. In later life, overnutrition, especially a high carbohydrate intake with refined grains of higher glycemic index, coupled with low physical activity likely triggers the T2D epidemic in South Asians. Additionally, there are emerging risk factors like air pollution. Preventing T2D in South Asians requires a multifactorial approach, including improvements in maternal and fetal nutrition with special reference to vitamin B12 and folate intake, decreasing refined carbohydrate and increasing protein and fiber intake in the diet, increasing physical activity, and control of air pollution. Lessons learned from epidemiology of T2D in South Asians could be useful to other developing countries that are in earlier stages of epidemiological transition.

Responses to lifestyle interventions among individuals with distinct pre-diabetes phenotypes: A systematic review and Meta-Analysis

AIMS

To assess responses to lifestyle interventions (LIs) among individuals with distinct pre-diabetes phenotypes (isolated impaired fasting glucose [i-IFG], isolated impaired glucose tolerance [i-IGT], and combined IFG + IGT) for reducing diabetes incidence, reversing pre-diabetes, and improving glycemic control and insulin sensitivity.

METHODS

PubMed, Embase, Cochrane Library, and Web of Science were searched until December 6th, 2023. We included randomized controlled trials examining responses to LIs (including diet and/or physical activity) among adults with i-IFG, i-IGT, and IFG + IGT. Outcomes included diabetes incidence, normoglycemia incidence, fasting plasma glucose (FPG), 2-hour plasma glucose (2 h-PG), hemoglobin A1c, fasting insulin (FI), and homeostasis model assessment-insulin resistance (HOMA-IR). Random-effects meta-analyses were performed to estimate risk ratios (RRs) and mean differences.

RESULTS

Twenty-seven studies were included. Meta-analysis of 10 studies that performed stratified analyses by pre-diabetes phenotype found that LIs significantly reduced diabetes incidence in i-IGT (RR = 0.69 [0.56; 0.85], I2 = 14 %) and IFG + IGT (RR = 0.56 [0.48; 0.66], I2 = 0 %) but not in i-IFG (RR = 0.85 [0.66; 1.11], I2 = 0 %; psubgroup = 0.02). Meta-analysis of 20 studies using IGT for participant recruitment showed that LIs significantly decreased diabetes incidence, increased normoglycemia incidence, and improved FPG, 2 h-PG, FI and HOMA-IR.

CONCLUSIONS

LIs are effective for IGT (with or without IFG), but tailored LIs are needed for i-IFG to prevent diabetes.

Effects of lifestyle interventions on the prevention of type 2 diabetes and reversion to normoglycemia by prediabetes phenotype: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To explore the effects of lifestyle interventions on the prevention of type 2 diabetes (T2D) and reversion to normoglycemia by prediabetes phenotype.

METHODS

We searched MEDLINE, Embase, and the Cochrane Library for randomized controlled trials (RCTs) that evaluated the effects of lifestyle interventions in adults with prediabetes for a minimum duration of one year. Two reviewers independently screened articles, extracted data, and performed quality assessment. The relative effects were analyzed using a random-effects model, subgroup analysis was employed to explore the potential effects among subpopulations.

RESULTS

A total of 31 RCTs involving 23684 participants were analyzed. Compared with usual care, lifestyle interventions reduced the incident T2D by 41 % (RR 0.59 [95 % CI 0.52-0.68]) and increased the probability of reverting to normoglycemia by 44 % (RR 1.44 [95 % CI 1.15-1.81]) in adults with prediabetes. No significant difference was observed between the impaired fasting glucose (IFG5.6)/impaired glucose tolerance (IGT) and IFG6.1/IGT (P = 0.752). IGT + IFG benefited more than isolated IGT in prevention of T2D (RRIGT + IFG 0.47 [95 % CI 0.41-0.55]; RRisolatedIGT 0.77 [95 % CI 0.64-0.93]), whereas no benefit was found in isolated IFG (RR 0.77 [95 % CI 0.51-1.16]) or elevated HbA1c (RR 0.89 [95 % CI 0.74-1.07]).

CONCLUSIONS

Lifestyle intervention could help prevent T2D and revert to normoglycemia in adults with prediabetes, with significant benefit in people with IGT but not in those with isolated IFG or elevated HbA1c.

Risk factors for chronic kidney disease progression over 20 years for primary prevention in Japanese individuals at a preventive medicine research center: Focus on the influence of plasma glucose levels

AIMS/INTRODUCTION

Chronic kidney disease (CKD) is a very important issue globally because of the risk of its progressing to end-stage renal disease. We aimed to identify factors contributing to long-term estimated glomerular filtration rate (eGFR) decline to determine an early diagnosis and prevent CKD progression.

MATERIALS AND METHODS

From January 2003 to December 2006, 5,507 individuals underwent health checkups at our hospital's Preventive Medicine Research Center. We ultimately enrolled 2,175 individuals. The eGFR was ≥60 mL/min/1.73 m2 at the start of observation period, which was 20 years. The event onset time was the day that the eGFR became <30 mL/min during the 20-year period. Baseline risk factors - in particular, the effect of plasma glucose levels on the eGFR - were extracted and evaluated by using Fine and Gray analysis.

RESULTS

During the 20-year observation, the hazard ratio (HR) of CKD progression was examined. A fasting plasma glucose (FPG) level ≥105 mg/dL was significantly associated with the risk of CKD progressing to an eGFR <30 mL/min. This trend was similar in the slope of eGFR. An FPG ≥105 mg/dL or an glycated hemoglobin level ≥6.5% was useful for intervening in CKD progression. Multivariate analysis showed that independent risk factors were an FPG level ≥105 mg/dL (HR 1.9; P < 0.001), age ≥60 years (HR 3.86; P < 0.001), obesity (HR 1.61; P < 0.01) and urinary protein (HR 1.55; P < 0.01).

CONCLUSIONS

For early intervention against a reduction in the eGFR, detecting mild increases in FPG ≥105 mg/dL in patients with CKD with or without diabetes is useful.

The association of body weight change and regression to normoglycemia in different phenotypes of pre-diabetes: Findings of a longitudinal cohort study

AIM

We investigated the association of a 3-year change in body weight (BW) and regression to normal glucose regulation (NGR) among different phenotypes of pre-diabetes (Pre-DM), i.e., isolated impaired glucose tolerance (iIGT), isolated impaired fasting glucose (iIFG) and combined IFG-IGT.

RESEARCH DESIGN AND METHODS

1458 Pre-DM subjects (iIFG = 618, iIGT = 462, and IFG-IGT = 378) were assessed for 3-year change-percent in BW (2006-2008 to 2009-2011) and then followed up to 2015-2017, within the national cohort of Tehran Lipid and Glucose Study (TLGS). Binary logistic regression models were used to estimate the probability (odds ratio, ORs) of regression to NGR across categories of 3-year BW change (i.e., ≥5% BW loss, <5% BW loss, BW gain) in different phenotypes of Pre-DM.

RESULTS

The mean age of the participants was 53.0 ± 13.7, and 46.8% were men. Over a median of 6 years of follow-up, the rate of regression to normoglycemia was 50.6, 43.2, and 12.7% in iIGT, iIFG, and combined IFG-IGT, respectively. The baseline-adjusted mean of 3-year BW change was not significantly different across Pre-DM phenotypes (0.68 ± 0.19, 0.32 ± 0.22, and 0.23 ± 0.24 kg, in iIFG, iIGT, and IFG-IGT). Three-year BW loss ≥5% was associated with a greater NGR probability in iIGT than other phenotypes (OR = 4.29 vs. 3.90 and 2.84 in IFG-IGT and iIFG, respectively). A modest reduction (<5% of initial BW) resulted in an increased chance of Pre-DM regression among subjects with iIGT (OR = 1.61, 95% CI = 1.03-2.52) but not iIFG or IFG-IGT phenotypes.

CONCLUSION

Short-term intensive BW loss (≥5% of initial BW) increased NGR probability in all Pre-DM phenotypes, with an order of iIGT > combined IFG-IGT > iIFG. Only iIGT takes advantage of moderate BW loss (<5% of initial BW) to increase the chance of Pre-DM regression.

Call to action for a life course approach

Gestational diabetes remains the most common medical disorder in pregnancy, with short-term and long-term consequences for mothers and offspring. New insights into pathophysiology and management suggest that the current gestational diabetes treatment approach should expand from a focus on late gestational diabetes to a personalised, integrated life course approach from preconception to postpartum and beyond. Early pregnancy lifestyle intervention could prevent late gestational diabetes. Early gestational diabetes diagnosis and treatment has been shown to be beneficial, especially when identified before 14 weeks of gestation. Early gestational diabetes screening now requires strategies for integration into routine antenatal care, alongside efforts to reduce variation in gestational diabetes care, across settings that differ between, and within, countries. Following gestational diabetes, an oral glucose tolerance test should be performed 6-12 weeks postpartum to assess the glycaemic state. Subsequent regular screening for both dysglycaemia and cardiometabolic disease is recommended, which can be incorporated alongside other family health activities. Diabetes prevention programmes for women with previous gestational diabetes might be enhanced using shared decision making and precision medicine. At all stages in this life course approach, across both high-resource and low-resource settings, a more systematic process for identifying and overcoming barriers to preventative care and treatment is needed to reduce the current global burden of gestational diabetes.

One-hour post-load plasma glucose level predicts future type 2 diabetes in a community-based study of Hong Kong Chinese workforce

BACKGROUND

We compared performance of high 1-hour PG level, impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) in predicting type 2 diabetes in a longitudinal community-based cohort of Hong Kong Chinese.

METHODS

Between 2001 and 2003, 472 adults aged 18-55 years without diabetes underwent 75-gram oral glucose tolerance test (OGTT). Between 2012 and 2014, progression to diabetes was ascertained by reviewing medical records or repeating OGTT and HbA1c. We defined high 1-hour PG as PG ≥ 8.6 mmol/L at 1-hour.

RESULTS

In this cohort, 23.5% had normal glucose tolerance and high 1-hour PG, 10.0% had isolated IGT, 4.2% had isolated IFG. Over 12-year follow-up, 9.3% developed type 2 diabetes. In logistic regression, high 1-hour PG was associated with progression to type 2 diabetes with adjusted odds ratio (95% CI) of 4.20 (1.60, 12.40), independent of IFG, IGT and other clinical variables. Areas under ROC (95% CI) for type 2 diabetes were similar between 1-hour (0.84 [0.78, 0.89], 2-hour (0.79 [0.72, 0.86]) and fasting PG (0.79 [0.71, 0.86]).

CONCLUSION

High 1-hour PG identified young Chinese with 5-fold increased risk of type 2 diabetes independent of other intermediate hyperglycaemia status and clinical factors. 1-hour PG is similar to fasting and 2-hour PG in predicting type 2 diabetes.

Test and Treat for Prediabetes: A Review of the Health Effects of Prediabetes and the Role of Screening and Prevention

The term prediabetes describes blood glucose levels above the normal range but below the threshold to diagnose type 2 diabetes. Several population health initiatives encourage a test and treat approach for prediabetes. In this approach, screening and identification of individuals with prediabetes should be followed by prompt referral to structured lifestyle modification programs or pharmacologic interventions that have been shown to prevent or delay the progression to type 2 diabetes in clinical trials. Here we provide a critical review of evidence for this test and treat approach by examining health outcomes associated with prediabetes and the availability and effectiveness of lifestyle modification approaches that target prediabetes. We also describe current limitations to the reach and uptake of evidence-based treatment options for prediabetes. Finally, we highlight lessons learned from identifying and labeling other preconditions to consider challenges and opportunities that may arise with increasing awareness of prediabetes as part of routine preventive care.

Natural History of Type 2 Diabetes in Indians: Time to Progression

OBJECTIVE

To describe the natural history of diabetes in Indians.

RESEARCH DESIGN AND METHODS

Data are from participants older than 20 years in the Centre for Cardiometabolic Risk Reduction in South Asia longitudinal study. Glycemic states were defined per American Diabetes Association criteria. Markov models were used to estimate annual transition probabilities and sojourn time through states.

RESULTS

Among 2,714 diabetes-free participants, 641 had isolated impaired fasting glucose (iIFG), and 341 had impaired glucose tolerance (IGT). The annual transition to diabetes for those with IGT was 13.9% (95% CI 12.0, 15.9) versus 8.6% (7.3, 9.8) for iIFG. In the normoglycemia ↔ iIFG → diabetes model, mean sojourn time in normoglycemia was 40.3 (34.6, 48.2) years, and sojourn time in iIFG was 9.7 (8.4, 11.4) years. For the normoglycemia ↔ IGT → diabetes model, mean sojourn time in normoglycemia was 34.5 (29.5, 40.8) years, and sojourn time in IGT was 6.1 (5.3, 7.1) years.

CONCLUSIONS

Individuals reside in normoglycemia for 35-40 years; however, progression from prediabetes to diabetes is rapid.

Young-Onset Diabetes in East Asians: From Epidemiology to Precision Medicine

Precision diagnosis is the keystone of clinical medicine. In East Asians, classical type 1 diabetes is uncommon in patients with youngonset diabetes diagnosed before age of 40, in whom a family history, obesity, and beta-cell and kidney dysfunction are key features. Young-onset diabetes affects one in five Asian adults with diabetes in clinic settings; however, it is often misclassified, resulting in delayed or non-targeted treatment. Complex aetiologies, long disease duration, aggressive clinical course, and a lack of evidence-based guidelines have contributed to variable care standards and premature death in these young patients. The high burden of comorbidities, notably mental illness, highlights the numerous knowledge gaps related to this silent killer. The majority of adult patients with youngonset diabetes are managed as part of a heterogeneous population of patients with various ages of diagnosis. A multidisciplinary care team led by physicians with special interest in young-onset diabetes will help improve the precision of diagnosis and address their physical, mental, and behavioral health. To this end, payors, planners, and providers need to align and re-design the practice environment to gather data systematically during routine practice to elucidate the multicausality of young-onset diabetes, treat to multiple targets, and improve outcomes in these vulnerable individuals.

Effectiveness of a blended mobile-based lifestyle intervention in women with glucose intolerance after a recent history of gestational diabetes (MELINDA): a 1-year, prospective, multicentre, randomised controlled trial

Background

Women with glucose intolerance after gestational diabetes mellitus (GDM) are at high risk to develop type 2 diabetes. Traditional lifestyle interventions in early postpartum have limited impact. We investigated the efficacy of a blended mobile-based lifestyle intervention in women with glucose intolerance after a recent history of GDM.

Methods

Prospective, double-arm, non-masked, multicentre randomised controlled trial (RCT) in which women with glucose intolerance, diagnosed 6-16 weeks after a GDM-complicated pregnancy, were assigned 1:1 to a one-year blended-care, telephone- and mobile-based lifestyle program (intervention) or usual care (control). Primary endpoint was the proportion of women able to achieve their weight goal (≥5% weight loss if prepregnancy BMI ≥ 25 kg/m2 or return to prepregnancy weight if prepregnancy BMI < 25 kg/m2) in the intention-to-treat sample. Key secondary outcomes were frequency of glucose intolerance, diabetes and metabolic syndrome, and lifestyle-related outcomes assessed with self-administered questionnaires. The study was registered in ClinicalTrials.gov (NCT03559621).

Findings

Between April 10th 2019 and May 13th 2022, 240 participants were assigned to the intervention (n = 121) or control group (n = 119), of which 167 (n = 82 in intervention and n = 85 in control group) completed the study. Primary outcome was achieved by 46.3% (56) of intervention participants compared to 43.3% (52) in the control group [odds ratio (OR) 1.13, 95% confidence interval (CI) 0.63-2.03, p = 0.680; risk ratio 1.07, 95% CI (0.78-1.48)]. Women in the intervention group developed significantly less often metabolic syndrome compared to the control group [7.3% (6) vs. 16.5% (14), OR 0.40, CI (0.22-0.72), p = 0.002], reported less sedentary behaviour and higher motivation for continuing healthy behaviours. In the intervention group, 84.1% (69) attended at least eight telephone sessions and 70.7% (58) used the app at least once weekly.

Interpretation

A blended, mobile-based lifestyle intervention was not effective in achieving weight goals, but reduced the risk to develop metabolic syndrome.

Funding

Research fund of University Hospitals Leuven, Novo Nordisk, Sanofi, AstraZeneca, Boehringer-Ingelheim, Lilly.

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.

Low-calorie diets for people with isolated impaired fasting glucose

Thirunavukkarasu et al. discuss how standard lifestyle interventions prove ineffective in preventing type 2 diabetes in individuals with isolated impaired fasting glucose, a highly prevalent prediabetes phenotype globally. They propose low-calorie diets as a promising strategy for diabetes prevention in this high-risk population.

Prevention of Type 2 Diabetes with Lifestyle Interventions: Evidence vs. Reality

Type 2 diabetes is a serious global public health concern that affects every country in the world [...]

Postprandial Hyperlipidemia: Its Pathophysiology, Diagnosis, Atherogenesis, and Treatments

Postprandial hyperlipidemia showing postprandial increases in serum triglyceride (TG) is associated with the development of atherosclerotic cardiovascular disease (ASCVD). To diagnose postprandial hyperlipidemia, the oral fat loading test (OFLT) should be performed; however, this test is very time-consuming and is difficult to perform. Elevated serum TG levels reflect an increase in TG-rich lipoproteins (TRLs), such as chylomicrons (CM), very low-density lipoproteins (VLDL), and their remnants (CM remnants [CMRs] and VLDL remnants [VLDLRs]). Understanding of elevation in CMR and/or VLDLR can lead us to understand the existence of postprandial hyperlipidemia. The measurement of apo B48, which is a constituent of CM and CMR; non-fasting TG, which includes TG content in all lipoproteins including CM and CMR; non-high-density lipoprotein cholesterol (non-HDL-C), which includes TRLs and low-density lipoprotein; and remnant cholesterol are useful to reveal the existence of postprandial hyperlipidemia. Postprandial hyperlipidemia is observed in patients with familial type III hyperlipoproteinemia, familial combined hyperlipidemia, chronic kidney disease, metabolic syndrome and type 2 diabetes. Postprandial hyperlipidemia is closely related to postprandial hyperglycemia, and insulin resistance may be an inducing and enhancing factor for both postprandial hyperlipidemia and postprandial hyperglycemia. Remnant lipoproteins and metabolic disorders associated with postprandial hyperlipidemia have various atherogenic properties such as induction of inflammation and endothelial dysfunction. A healthy diet, calorie restriction, weight loss, and exercise positively impact postprandial hyperlipidemia. Anti-hyperlipidemic drugs such pemafibrate, fenofibrate, bezafibrate, ezetimibe, and eicosapentaenoic acid have been shown to improve postprandial hyperlipidemia. Anti-diabetic drugs including metformin, alpha-glucosidase inhibitors, pioglitazone, dipeptidyl-peptidase-4 inhibitors and glucagon-like peptide 1 analogues have been shown to ameliorate postprandial hyperlipidemia. Although sodium glucose cotransporter-2 inhibitors have not been proven to reduce postprandial hyperlipidemia, they reduced fasting apo B48 and remnant lipoprotein cholesterol. In conclusion, it is important to appropriately understand the existence of postprandial hyperlipidemia and to connect it to optimal treatments. However, there are some problems with the diagnosis for postprandial hyperlipidemia. Postprandial hyperlipidemia cannot be specifically defined by measures such as TG levels 2 h after a meal. To study interventions for postprandial hyperlipidemia with the outcome of preventing the onset of ASCVD, it is necessary to define postprandial hyperlipidemia using reference values such as IGT.