Diabetes has become a major threat throughout the world. Due to the size of the problem and the impact on health that this disease entails (it can cause blindness, kidney failure, heart attacks and strokes, among other things), the scientific community views the progress of this growing epidemic with concern.
The number of people with this disease has almost quadrupled in the last three decades, with 422 million afflicted by it in 2014, according to the World Health Organization. It is forecasted that, by 2030, the total number of people who have diabetes will reach 578 million, or 10% of the world’s adult population.
In a global context in which sedentary lifestyles, poor diets and obesity — all of which fuel the development of type 2 diabetes — continue to rise, experts are focused on finding ways to stop this condition, which is potentially preventable in many cases. A recent study published in the journal Nature confirms the real-life success of a tool that had already borne fruit in controlled clinical trial contexts. It has been proven that health programs designed to improve lifestyle habits can also stop the development of diabetes. The research — which evaluated the potential of an intervention program implemented by the U.K. National Health Service — demonstrated that the promotion of healthy habits improves cardiometabolic indicators in people with prediabetes.
Lifestyle habits are oftentimes key elements for the development of a disease. Smoking, for example, increases the risk of suffering from cancer, while a sedentary lifestyle and being overweight precipitate the appearance of cardiovascular problems. In these cases, a change in behavioral patterns can prevent some ailments, delay them, or overcome them for a time. Type 2 diabetes — the most common, as 95% of all cases are of this type — is also one of those pathologies associated with unhealthy habits. A behavioral change can prevent it from appearing, or help control it. In controlled clinical trials, behavior change programs have already demonstrated effective results to counteract this pathology. However, among the scientific community there was still “controversy” — as acknowledged by the authors of the Nature article — about whether these results could be extrapolated to everyday life, which is a less controlled environment than clinical trials, as well as one with more limited resources and support mechanisms in place.
“Our aim was to establish the transferability of behavior change programs to real-world settings. [We did this] by researching whether a referral to the British NHS Diabetes Prevention Programme — made by a clinician in primary care — leads to improvements in risk factors among patients. [We used methods] such as the glycosylated hemoglobin test (HbA1c), which measures the concentration of sugar in the blood over the last two or three months, or [by measuring] excess body weight,” explains Pascal Geldsetzer, a professor in the Division of Primary Care & Population Health at Stanford University. He’s one of the authors of the recent study.
Researchers also analyzed electronic medical records of more than two million patients and found “causal evidence that [showed how being referred] to the largest behavior change program for prediabetes globally led to better glycemic control and reductions in body mass index, weight, HDL (high-density lipoproteins, also called good cholesterol) and triglycerides,” as explained in the article.
People living with prediabetes — that is, individuals with above-average blood glucose levels, with a greater risk of developing the disease — are incorporated into an intensive intervention program to change their habits. For nine months, patients — organized in groups of no more than 20 people — participate in up to 13 sessions to improve diet, increase physical activity and facilitate weight loss. “Activities include a combination of education, group support, knowledge testing and interactive or visual activities. They’re based on behavior change theory (e.g., goal setting, problem-solving, planning, self-monitoring, individual adaptation and increased self-efficacy) rather than on activity and weight loss benchmarks alone,” Geldsetzer summarizes.
In controlled trials, the effects of this type of intervention were maintained over time. The Stanford researcher points out how glycemic levels don’t rebound as soon as the program is stopped. As an example, he points to an American study, in which it was found that people who participated in an intervention program, or those who were taking metformin — a drug used to control blood glucose — “continue to prevent or delay type 2 diabetes for at least 15 years.” The researcher clarifies, however, that “this intervention was carried out under highly-controlled conditions with extensive individual sessions.” He admits that “it’s not guaranteed that these effects can be transferred” to real life.
Regarding his research, Geldsetzer notes: “At this time, we cannot determine how long these benefits will be maintained and whether they will have subsequent effects on the incidence of diabetes or adverse cardiovascular complications [among the general population]. This still needs to be established in the future, once the British NHS Diabetes Prevention Programme has been implemented for a longer period of time.”
Promoting preventative measures
In their article, the authors affirm that “investments in structured and intensive health behavior change programs can help promote primary and secondary prevention of type 2 diabetes and reduce the risk of diabetes complications and cardiovascular events.” However, Geldsetzer clarifies that this disease is “multifactorial and complex” and requires “systemic interventions.”
“It’s important to remember that an individual’s lifestyle is determined by environmental and social factors that can make choosing a healthy lifestyle either more or less easy,” he cautions.
In fact, the scientist admits that, at this time, “given the magnitude of the diabetes epidemic and the number of people at risk, approaches aimed solely at changing individual behavior are unlikely to be sufficient” to effectively control diabetes at the population level. “Lifestyle interventions are just one tool in the prevention toolbox. Still, our study shows that investments in health systems are needed, for example, in the form of accessible programs. Diabetes prevention requires urgent and coordinated attention from policymakers, accompanied by infrastructural and environmental changes, sustainable funding and an experimental mindset that allows public health researchers to develop, implement and evaluate elements of successful lifestyle interventions,” he concludes.
In an accompanying article, Edward W. Gregg and Naomi Holman — researchers at the University of Medicine and Health Sciences in Dublin — highlight the importance of active participation in such programs to obtain better health results. “This cascade of risk reduction — which was greatest in those who actively participated in the program — reflects the [central challenge] facing individual-level prevention approaches. The success of these strategies depends largely on a strong commitment and [careful] adherence to the program… and perhaps the identification of people who will respond well to lifestyle interventions in the first place. It’s also a reminder that individual-targeted approaches cannot work alone: a combination of individual and population-based approaches that address a wide variety of risk factors are needed to change the course of the type 2 diabetes epidemic,” they reflect.
Antonio Pérez — director of the Endocrinology and Nutrition Unit at the Sant Pau Hospital in Barcelona — didn’t participate in the recently-published study, but highlights that the results contradict “the general idea” that patients don’t usually follow the recommendations, or that time is wasted in these interventions and it’s better to use medication. “There’s no drug as effective as these lifestyle tips. And if the intervention is done with changes in lifestyle, not only glucose levels improve, but also lipids, blood pressure, the impact on health is multiplied. It’s worth dedicating time and energy to programs like this. Of course, it’s not easy,” the doctor admits.
Albert Goday — head of the emeritus section of Endocrinology at the Hospital del Mar in Barcelona, who also didn’t participate in the study — emphasizes that the research conveys an “important” concept: “Prevention can happen. There’s no absolute determinism to developing diabetes. If people make changes in their lifestyle, this progression decreases.”
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