A modern integrated approach to prediabetes management
Controversies in prediabetes management
“T2DM is associated with complications such as diabetic nephropathy and retinopathy. Prevention of diabetes is an effective approach to prevent these debilitating complications,” commented Yuen.
“In the absence of a structured programme, however, patients are often at loss as to the approach they should take in achieving a healthy lifestyle and weight loss,” noted Yuen.
Lifestyle intervention: Key to prediabetes management
Results from the 2.8-year DPP study showed that compared with placebo, intensive lifestyle intervention (aimed at achieving and maintaining 7 percent weight loss, with ≥150 minutes per week of moderate-intensity physical activity) and metformin (850 mg twice daily) reduced the incidence of diabetes in high-risk adults by 58 percent and 31 percent, respectively. (Figure) [N Engl J Med 2002;346:393-403]
“Since then, structured lifestyle interventions have been proposed as the key in prediabetes management, followed closely by metformin,” pointed out Yuen.
App-based lifestyle transformation programme for diabetes prevention
The Transform programme, a commercial version of DPP, supports individuals in reducing body weight by 5–7 percent and in increasing moderate physical activity to 150 minutes/week. [Diabetes Care 2002;25:2165-2171] Transform was developed in the US, and is the first and only structured lifestyle modification programme available in Hong Kong that has gained full recognition from the US Centers for Disease Control and Prevention (CDC). One major hurdle to full participation in the original DPP is schedule conflicts, resulting in difficulty in complying with appointments. With the advent of technology, the DPP programme has been digitalized and offered through app-based formats with comparable efficacy as the original programme. [JMIR Diabetes 2019;4: e13904] Participants can follow the programme with greater flexibility.
“The goal is to encourage positive and sustainable lifestyle changes through a series of small, successive steps, so that weight loss and benefits would be sustained even after DPP completion,” explained Yuen.
According to the DPPOS study (Diabetes Prevention Program Outcomes Study), a 15-year follow-up of DPP, benefits gained from the initial intervention period, in terms of reduction of diabetes incidence and maintenance of body weight, were sustained for at least 15 years. (Figure) [Lancet Diabetes Endocrinol 2015;3:866-875]
“Individuals who would benefit the most from the Transform programme are those with prediabetes and those with early diabetes who are free from end-stage renal disease, heart disease and liver problems. Individuals who are overweight or obese would also benefit the most, since the programme prevents diabetes through an element of weight reduction,” said Yuen.
“The first requirements from potential participants of the app-based DPP programme are definitely commitment and readiness for change,” stressed Yuen. “In terms of practicality, an ability to utilize smartphones or tablets with Internet access are further prerequisites.”
The app-based DPP programme was recently introduced into Hong Kong. The programme, with a focus on diet, exercise and stress management, runs for 12 months and is organized into a 4-month core module and an 8-month maintenance module. Body weight and physical activity levels are tracked from a bathroom scale and a digital watch. Real-time information is made available on a dashboard and to health coaches for setting goals, monitoring progress and supporting behavioural changes. In addition, health coaches are available to offer feedback and suggestions for healthier choices through food tracking and sharing of recipes.
“Frequent communication and interactions with dedicated certified health coaches are made possible. It is hoped that individuals with busy schedules or those who are unable to attend health appointments would also be able to benefit from the original DPP,” commented Yuen.
In addition, culturally-adapted diabetes prevention strategies have been shown to have a positive impact on effectiveness. [Diabetes Educ 2017;43:54-77] The local app-based DPP programme will provide participants with one-to-one coaching and support from local Cantonese-speaking health coaches. Health advice is customized to the local cultural environment, with understanding of the specific challenges and requirements of participants. Meanwhile, peer support through an online community enables participants to inspire and be inspired to make lifestyle changes.
Metformin: Role in prediabetes management
Metformin, with its long-standing history in diabetes treatment, also plays a role in prediabetes management. [Diabetologia 2017;60:1561-1565] It has the strongest evidence base with demonstrated long-term safety as pharmacologic therapy for diabetes prevention. [Diabetes Care 2019;42:S29-S33]
Metformin reduces the risk of T2DM in high-risk individuals by preventing or reversing progressive insulin resistance and/or β-cell dysfunction. [Drugs 2015;75:1071-1094]
In 2018, metformin, in its extended-release (XR) form, was licensed in Hong Kong for reducing the risk or delaying the onset of T2DM in overweight and obese adults with prediabetes. [Metfomin XR Prescribing Information]
“The use of medication should not be regarded as a form of failure, but rather a strategy to prevent the onset of diabetes,” stressed Yuen.
Common gastrointestinal (GI) side effects associated with metformin can be minimized by switching to its XR formulation. [Diabetologia 2017;60:1561-1565] Results of a recent retrospective cohort study comparing the GI tolerability of metformin XR with metformin immediate-release (IR) showed significantly fewer GI adverse events with the XR vs IR formulation (9.23 percent vs 19.83 percent; p=0.0414). In particular, the rate of diarrhoea was significantly lower in the metformin XR group (3.08 percent vs 13.50 percent; p=0.0169). [Curr Med Res Opin 2004;20:565-572]
The improved GI tolerability of metformin XR is attributed to the use of the GelShield Diffusion System – a novel biphasic, controlled-release system that enables once-daily dosing. The system uses a heterogenous, two-phase approach composed of an inner polymer matrix containing individual metformin XR granules and an outer polymer matrix. On release from the inner phase, metformin diffuses gradually through the outer phase and is released for absorption. The rate of release of metformin XR is significantly reduced, allowing improved control of drug release with a lower potential for dose dumping. [Clin Pharmacokinet 2005;44:721-729]
When administrated with the evening meal, metformin XR works in accordance with the normal physiology of slowed GI emptying nocturnally, resulting in extended absorption and permitting once-daily dosing of metformin. [Clin Pharmacokinet 2005;44:721-729]
“Based on evidence, lifestyle modification with an emphasis on physical activity is more effective than metformin in reducing the risk of T2DM among individuals with prediabetes. However, for individuals who are unable to follow or have failed structured lifestyle intervention programmes, metformin offers an alternative in the management of prediabetes,” concluded Yuen.