Vol. 5, No. 5 I May 2005
Certain facts about type 2 diabetes seem obvious: 1) the
condition is common, serious, and costly1; 2) its prevalence
is increasing throughout the world2; and 3) convincing sci-
entific and economic evidence supports primary prevention
for those at high risk of subsequently developing type 2 dia-
betes.3-5As reviewed by Angelo et al in this issue of
Advanced Studies in Medicine,6a consistent picture is
emerging indicating that relatively modest weight and activ-
ity improvements in people with “prediabetes” result in
impressive reductions in the incidence of type 2 diabetes,
regardless of age, race, ethnicity, or weight.3,4Similar
although somewhat less impressive results occur with a vari-
ety of medications.7Thus, it may appear that in terms of
prevention of type 2 diabetes, the answers are in, and that
the “epidemic” of type 2 diabetes has met its match.
Yet, real and important challenges remain. Just because
the science of prevention of type 2 diabetes says “yes” does
not mean that practitioners, patients, health systems, poli-
cies, and society also say “yes”—at least not yet! The issue of
translation of science remains and, in the diabetes world per-
haps more than ever, is a critical one.8-10
What are some of these challenges as they pertain to pri-
mary prevention of type 2 diabetes? First, to date, all the
clinical trials discussed by Angelo et al included people with
impaired glucose tolerance (IGT)—regardless of whether
they also were overweight, obese, or had a positive family
history of diabetes, etc. So, from a strict point of view, the
primary prevention science supports intervening only in
those individuals who have IGT and, in fact, only if they are
at least 18 years of age. Recently, the concept of prediabetes
has emerged with inclusion of both IGT and/or impaired
fasting glucose (IFG).11Further, the definition of IFG has
changed from values of 110-125 mg/dL to 100-125
mg/dL.11This simple and seemingly small reduction in the
lower range of IFG from 110 to 100 mg/dL has increased
the number of persons considered to have prediabetes to
approximately 40 million.12Thus, we must ask the ques-
tion of who should be the targets of primary prevention
programs for type 2 diabetes—those with IGT only (for
whom the science is strongest); those with prediabetes
(whether due to IFG and/or IGT); or perhaps all people
who already are, or are at risk for becoming, overweight,
obese, and physically inactive—regardless of glycemic sta-
tus—and for whom prediabetes will likely emerge?
Should we direct primary prevention programs at youth,
and, if so, based on what science? How far upstream
should we go to prevent type 2 diabetes, and who should
make these decisions?13These questions are not new, hav-
ing been articulated in a classic article by Geoffry Rose,
entitled “Sick Individuals and Sick Populations.”14
A second challenge is how to convert into the “real world”
the intensive effort to accomplish behavioral goals set by the
Finnish Diabetes Prevention Study and the Diabetes
Prevention Program.3,4,15Is it possible to move beyond the one-
on-one intensive behavioral interventions in these important
efficacy studies to a more practicable and affordable group
effort, without losing impact?5,16Further, how can we involve
the community (where people spend most of their time) as an
essential dimension to primary prevention programs? For
many individuals, the primary care clinician’s office will be a
site of initial contact, referral, and follow-up to offer encour-
agement and guidance. However, it is unlikely that the doc-
tor’s office will be the site for the actual implementation of
long-term preventive interventions.17
A third challenge, reflected again in the thoughts of Dr
Rose, is how to accept the “reality of limits,” that is, the need
to form explicit distinctions between focusing on improving
care among those with extant diabetes vs primary prevention
in those who are at risk. In regards to improved care (both sec-
ondary and tertiary prevention), clinical, health service, eco-
nomic, and public health research indicate the value of this
approach as well as the fact that improvements are indeed
occurring.18,19Still, the glass is not yet full, and more needs to
be done. How do we strike a balance between helping those
with extant diabetes and preventing the disease from occur-
ring? And who is responsible for striking this balance?
A fourth challenge in translating good science into reg-
ular clinical and public health practice is to ensure that poli-
cies are in place to facilitate essential components of
primary prevention science (eg, the need for prediabetes
screening and then initiation of behavioral programs).
While policies and reimbursement plans certainly are not
the only factors impacting health professionals, health sys-
tems, and private and public decisions, they do matter.20,21
Science must be more meaningfully integrated into practice
Primary Prevention of Type 2 Diabetes:
Are We There Yet?
Frank Vinicor, MD, MPH
Dr Vinicor is Director, Division of Diabetes Translation, Centers
for Disease Control and Prevention (K-10), Atlanta, Georgia.
See article on page 250.
Johns Hopkins Advanced Studies in Medicine
for most people at risk for subsequent diabetes22—through
policies, guidelines, and other care criteria. No one wants to
repeat the 264-year period between the science of scurvy
prevention to the actual adoption of British policy!9
A fifth challenge to the wide and active implementation of
primary prevention programs for type 2 diabetes is to recog-
nize and address “social determinants of health.”23It would be
nice if all the important factors that could sustain or improve
health occurred within existing healthcare systems. After all,
this is the world in which we were trained, and in which most
of us work. But this is not the reality we live in. Outside of the
office setting, many powerful and easily overlooked factors sig-
nificantly attenuate our ability to do “what is right.” We can-
not ignore the impact of these social factors.24Perhaps at that
top of our list of responsibilities as healthcare providers and
scientists we must be good “citizen leaders” if we really want to
make a difference in the lives of our patients.25
Experiences with successful antismoking programs indi-
cate that positive results do occur when—beyond the sci-
ence—multiple program components are combined,
coordinated, and sustained.26,27It also is clear that several dis-
crete steps beyond traditional science are involved in making
good science part of everyday health for all.28Thus, beyond the
impressive science of primary prevention of type 2 diabetes as
summarized by Angelo et al, multiple coordinated programs
to address nutrition, physical activity, and other preventive
strategies will be needed. We are seeing the beginnings of such
coordinated efforts. A very impressive and impactful media
program directed at the youth population, “VERB, It’s What
You Do,” demonstrates one dimension of this effort.29The
pending Medicare Modernization Act hopefully will enact a
reimbursement policy for prediabetes identification and
behavioral treatment.30However, any multidimensional strat-
egy will require considerable resources—a concern in the
United States, given the other federal priorities of the next few
years.31But, even if there were adequate resources, other pieces
of a prevention package for type 2 diabetes will still be needed
for a successful strategy beyond the convincing and exciting
science. And, until we successfully address these other neces-
sary steps, we are not there yet in terms of reducing the inci-
dence of type 2 diabetes.
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