《中西论防-糖尿病预防，西方经验的思考与展望（英文版）》经典培训课件

Diabetes Prevention Program: US Experience,Marinella Temprosa, PhDGeorge Washington University,Merck ForumApril 22, 2017Dalian, China,Global Diabetes Pandemic,IDF 2015,Global Diabetes Pandemic,IDF 2015,The prevalence of both type 1 and type 2 diabetes is increasing, despite the fact that many cases of type 2 diabetes can be delayed or prevented. Professor Nam Han Cho, Chair, IDF Atlas Committee, 7th Edition,Age-adjusted Percentage of Adults in the United States Who Were Obese or Diagnosed with Diabetes,Edelstein SL, et al. Diabetes 1997; 46: 701-710,Incidence of NIDDM based on:,What we knew about risk of diabetes before the DPP,IFG/IGT Type 2 DM Early Complications Morbidity/Mortality,10 20 30 Prevention Intervention Intervention,Dysglycemia:Potential for Intervention,Can we prevent or delay the development of type 2 diabetes in persons at high risk (impaired glucose tolerance, elevated fasting glucose levels, and overweight or obese)?,DPP Goals: Primary,High-risk individuals 2 hour glucose 140 - 199 mg/dl and Fasting glucose 95 - 125 mg/dl (American Indians 1phone contact between visits 3 group “courses” per year,Caucasian55% (n=1768),AfricanAmerican20% (n=645),Hispanic 16% (n=508),Asian/Pacific Islander 4% (n=142),American Indian5% (n=171),Study Population,25-44 yrs 31% (n=1000),60 yrs 20%(n=648),45-59 yrs 49% (n=1586),Age and Race/Ethnicity Distribution,DPP Recruitment 1996-1999,Study Population,Baseline Characteristics,Recruited 1996-1999,Mean Weight Change from Baseline,Years from Randomization,Lifestyle,Metformin,Placebo,7.2%,4.2%,NEJM 2002;346: 393-403,0,1,2,3,4,0,10,20,30,40,Placebo Annual incidence = 11.0%,Metformin Annual incidence= 7.8%,Lifestyle Annual incidence = 4.8%,Percent Developing Diabetes,All participants,Years from Randomization,Cumulative incidence (%),NEJM 2002;346: 393-403,Trial stopped one year ahead of schedule,after an average follow-up of 2.8 years, at recommendation of DSMB because “of proved efficacy”,Diabetes Incidence Rates by Sex,NEJM 2002;346: 393-403,Annual Incidence Rate (%),Diabetes Incidence Rates by Ethnicity,NEJM 2002;346: 393-403,Annual Incidence Rate (%),Diabetes Incidence Rates by Age,Effects of Age on Treatment Response,Age,25-44 45-59 60 (n=1000) (n=1586) (n=648) Age at Baseline,44% reduction,11% reduction,Annual Incidence Rate (%),(n=1045) (n=995) (n=1194),Diabetes Incidence Rates by BMI,Body Mass Index (kg/m2),NEJM 2002;346:393-403,65% reduction,51% reduction,3% reduction,53% reduction,Annual Incidence Rate (%),Placebo,Gestational Diabetes,JCEM 2008;93:4774,Met vs PLBO= 51%, P0.001,Reduction in Incidence ILS vs PLBO= 53%, P0.001,Reduction in Incidence ILS vs PLBO= 49%, P 15 years) randomized metformin trial, DPP/DPPOS is uniquely positioned to address the long-term benefits and risks of this widely used drug.Evidence suggests that metformin may have important extra-glycemic effects (e.g., CVD, cancer).Metformin treatment in DPP/DPPOS is largely in a non-diabetic population, thus may provide valuable insights to these non-glycemic effects.,Background,The epidemic continues in the US with an estimated 27 million with T2DM and another 86 million at high risk.Understanding how to prevent or delay T2DM and when to intervene, with the goal of reducing long-term morbidity and mortality in a cost-effective manner, is perhaps the most important public health question in diabetes.,Public Health Significance,National Diabetes Education Program/HHS,State Programs,CMS,ADA Consensus,Workplace InterventionPrograms,Health System Programs,Indian Health Service,Community Programs(e.g. Y-DPP; United Health Group),US Department ofVeterans Affairs,Translational Impact of DPP in US,Congressionally-establishedNational Diabetes Prevention Program,InternationalPrograms,CDC,Guidelines for US Diabetes Prevention,American Diabetes AssociationAmerican Medical AssociationUS Preventative Services Task Force,Programs forUS Diabetes Prevention Program,NIDDK: Small Steps Big Rewards (2002)US CDC: National Diabetes Prevention Program Coverage for Intensive Behavioral Therapy for Obesity by Medicare (2011) and National DPP (2017),ADA Strength of Evidence,Timeline for US Diabetes Prevention,1996,ADA: Although screening may identify IGT as a risk factor, screening for IGT alone is not justified.” Diab Care 1996;19(Suppl1):S5,DPP Start,2001,DPP end,2003,1 yr post DPP,DPP demonstrated powerful effects of lifestyle and metformin to delay diabetes in persons at high risk.DPP Research Group NEJM 2002;346:393-403,ADA: In those with prediabetes (IFG/IGT), lifestyle modification should be strongly recommended (A),2002,-1 mon NEJM,ADA: Screen for diabetes in high-risk, asymptomatic, undiagnosed adults within the health care setting. (E) In those with IFG/IGT, lifestyle modification should be considered (A),2007,ADA Consensus Statement on IFG and IGT,5 y post DPP,2008,6 y post DPP,2018,16 y post DPP,ADA: In addition to lifestyle counseling, metformin may be considered in those who are at very high risk (combined IFG and IGT plus other risk factors) and who are obese and under 60 years of age. (E),Medicare Diabetes Prevention Program Starts,USPSTF: Screening for diabetes in asymptomatic adults with hypertension (B)National DPP established via ACA (Obamacare),ADA Guidelines 2003,ADA Guidelines 2017 - Screening,ADA Guidelines 2017 - Interventions,Medicare Diabetes Prevention Program,Have We Turned the Corner?,L Geiss et alJAMA 2014;312:1218,Prevalence and Incidence Trends for Diagnosed Diabetes Among Adults Aged 20 to 79 Years, United States, 1980-2012,Prevalence Annual Change1980s 1990-2008 2008-12 0.2% 4.5% 0