Two decades of diabetes prevention efforts: A call to innovate and revitalize our approach to lifestyle change

Abstract

The impact of global diabetes prevention efforts has been modest despite the promise of landmark diabetes prevention trials nearly twenty years ago. While national and regional initiatives show potential, challenges remain to adapt large-scale strategies in the real-world that fits individuals and their communities. Additionally, the sedentary lifestyle changes during the COVID-19 pandemic and guidelines that now call for earlier screening (e.g., US Preventative Task Force) will increase the pool of eligible adults worldwide. Thus, a more adaptable, person-centered approach that expands the current toolkit is urgently needed to innovate and revitalize our approach to diabetes prevention. This review identifies key priorities to optimize the population-level delivery of diabetes prevention based on a consensus-based evaluation of the current evidence among experts in global translational programs; key priorities identified include (1) participant eligibility, (2) intervention intensity, (3) delivery components, (4) behavioral economics, (5) technology, and (6) the role of pharmacotherapy. We offer a conceptual framework for a broader, person-centered approach to better address an individual's risk, readiness, barriers, and digital competency.

Keywords: Diabetes prevention program; Implementation science; Intensive lifestyle intervention; Intensive lifestyle program; Lifestyle change; Translation research.

Figure 1:. Key Components of Diabetes Prevention Service Delivery

Four key components to optimize the delivery of diabetes preventative services. 1) The ‘who’ revisits risk and readiness for program eligibility; 2) the ‘what’ considers how the program content can be curtailed to the individual; 3) the ‘when’ compliments existing lifestyle change programming with alternate, less intense programming and medications; 4) the ‘where’ addresses how to leverage technology. Addressing these four key areas will better adapt current programming to individuals’ risks, preferences, comorbidities, and settings and broaden the impact of current diabetes prevention efforts.

Figure 2:. Essential Elements for Person-Centered Diabetes Prevention Programming

IFG: Impaired Fasting Glucose IGT: Impaired Glucose Tolerance GDM: Gestational Diabetes Mellitus DPP: Diabetes Prevention Program MNT: Medical Nutrition Therapy CGM: Continuous Glucose Monitoring HRSN: Health-related Social Needs ^a Risk assessment tools include Centers for Disease Control/American Diabetes Association in the US; AUSDRISK in Australia, FINDRISC in Finland and IDRS in India A conceptual model of the essential elements to optimize diabetes prevention services with an evidence-based, person-centered approach. This model is based on the conceptual framework used by the International AIDS Society’s HIV Differentiated Care, with illustrative examples as references. Responding to the call for national programs to adapt to individual factors, ^, this model offers a guide for programs to better match to an individual’s risk, readiness and setting based on key elements of service delivery (eligibility, content delivery, intensity, and technology). For example, a highly motivated 53-year-old woman living with obesity, PTSD and a HbA1c of 6.3% who works shiftwork as a paramedic would be high-risk and ideally matched to an online or remote-based traditional lifestyle change program. She declines given time-constraints (‘When’) and preference (‘Who’) and requests options that more closely fit her schedule (‘Where’) and her background (‘What’). She may be receptive to nutritional counseling and life skills training (‘variable intensity’) with self-directed telephone and app-based approaches (technology) with other female veterans living with PTSD (‘group-aligned’ content delivery).