Lifestyle modifications and its effects on prevention

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Multiple clinical trials have tested lifestyle modification to prevent type 2 diabetes. The inclusion criteria for all trials were impaired glucose tolerance based on two blood glucose measurements: a fasting value of less than 126 mg/dL, and a glucose value of 140 to 200 mg/dL 2 hours after consumption of 75 g of glucose. In the United Kingdom, Jarrett et al in the Borderline Diabetes Study and Keen et al in the Bedford Survey found no effect of dietary modification on preventing diabetes [12]. A Swedish study, however, found that diabetes counseling and tolbutamide reduced the incidence of diabetes, although intention-to-treat analysis was not performed [13]. More recently, the three studies of primary prevention that used lifestyle intervention have shown significant results. The Finnish Diabetes Prevention Study, the Da Qing Imaired Glucose Tolerance and Diabetes Study, and the Diabetes Prevention Program revealed that aggressive dietary intervention and an exercise program reduced the incidence of diabetes by 58%, 42%, and 58%, respectively, compared with controls [14-16]. The details are shown in Table 2.

Implementing lifestyle intervention at an individual level, especially in obese persons and those at high risk, is challenging. It is accompanied by deficiencies, primarily in motivation, both at the physician and patient level. Changes in health behavior have always been associated with efforts that are ephemeral, leading to a rebound increase in body weight. This increase, in turn, leads to loss of benefits that may have been accrued [17-18]. In addition, patients and providers encounter barriers in the health care system that make it difficult to translate results from the research setting into clinical practice. Many studies have assessed delivery of multifaceted, system-oriented, and integrated approaches aimed at primary prevention of type 2 diabetes [17-19]. Unfortunately, the long-term success of these programs has been disenchanting. Reductions in cardiovascular risk were suboptimal, without any overall reduction in mortality [20,21].

In addition, lifestyle changes are expensive. The most recent analysis from the Diabetes Prevention Program showed that in clinical practice the cost per case of diabetes delayed or prevented was similar for metformin ($14,300) and lifestyle interventions ($13,200) [22]. Hence it is important to consider all means available, including phar-macologic interventions, to prevent the development of diabetes. Prevention of diabetes by use of metformin, acarbose, and thiazolidinediones has been described elsewhere. This article focuses on RAAS inhibition as a therapeutic model to prevent diabetes.

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