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Primary prevention of diabetes is a public health priority for a number of good reasons: (i) the overall burden of diabetes justifies strategies at a population level: (ii) current treatments are costly, confer risks of serious adverse events (e.g. hypoglycaemia) and often have limited efficacy on key clinical outcomes; (iii) access to, and adherence to, diabetes treatments is still a challenge for many patients; and (iv) prevention of type 2 diabetes through lifestyle modification is likely to confer added benefits in terms of reducing the risks of hypertension, hyperlipidaemia, heart disease, and certain cancers.

Thus, assessing an individual’s diabetes risk status, discussing the risk and, referring the patient to a proven community‐based diabetes prevention program is an important role for the primary care practitioner. RCTs of structured lifestyle modification have consistently demonstrated that caloric reduction plus increased physical activity leading to modest weight loss reduces the risk of incident type 2 diabetes in adults at high risk by 50–70%.

Figure 4.3 An alarming trend in the USA with increasing numbers of patients. CDC’s Division of Diabetes Translation. United States Diabetes Surveillance System.

Figure 4.4 Mortality rates due to diabetes‐related complications. IDF Atlas, 2017.

The Diabetes Prevention program (DPP) recruited 3234 middle‐aged overweight or obese adults with impaired glucose tolerance, who were then randomised to one of three treatment groups: (i) a lifestyle intervention that employed behavioural counselling to promote caloric reduction and physical activity; (ii) metformin therapy; or (iii) placebo metformin therapy. The lifestyle intervention group achieved an initial weight loss of ∼6% of body weight after 12 months, reducing to ∼4% after 3 years, and an increase in self‐reported physical activity (equivalent to brisk walking) from 100 to 190 minutes per week. Compared to their counterparts in the control group, participants in the lifestyle intervention group showed a 58% reduction in incident diabetes over 4 years. This benefit was evident in men and women across different ethnic groups and it was even greater among older age participants (Figure 4.10).

The intensive and quite costly lifestyle intervention used in the DPP trial was designed to give maximum efficacy with limited consideration for the ease or sustainability of delivering the program in a real world community setting. Thus, two barriers have hampered the widespread implementation of the DPP findings to the growing population of people who might benefit: (i) the cost of the one‐to‐one lifestyle coaching and intervention format; and (ii) limitations in the practicalities of identifying suitable patients, optimising referral pathways and maintaining patient participation.

In the UK, the ambition is to achieve a country‐wide, evidence‐based type 2 diabetes prevention program, known as ‘The Healthier You’ programme, to prevent or delay diabetes in those identified to be at high risk. The scheme was rolled out in 2016, and participants undergo an intensive 9‐month programme that includes at least 13 face‐to‐face interactions and at least 16 hours of contact time. So far, >50,000 referrals have been made with attendance rates over 40% across diverse socio‐economic groups (Figure 4.11).