Lifestyle Modification in Prediabetes and Diabetes: A Large Population Analysis

Abstract

Background/Aims: Diabetes mellitus is a major cause of atherosclerotic cardiovascular disease (ASCVD). We examined a large population and tested the efficacy of a voluntary lifestyle program in prediabetic and diabetic subjects. Methods: Of 133,764 subjects, 56.3% were healthy, 36.2% were prediabetic, and 7.5% were diabetic. Fasting serum measurements of glucose, insulin, adiponectin, glycosylated hemoglobin (HbA1c), high-sensitivity C-reactive protein (hs-CRP), glycated serum protein (GSP), fibrinogen, myeloperoxidase (MPO), lipoprotein-associated phospholipase A₂ (LpPLA₂), as well as standard lipids, direct low-density lipoprotein cholesterol (LDL-C), and small dense LDL-C (sdLDL-C) were performed using standard automated assays. Follow-up sampling at 6-12 months occurred in 20.1% of the prediabetic and 22.2% of the diabetic subjects; of these, 12.2% of the prediabetic and 9.7% of the diabetic subjects participated in a voluntary, real-world, digital dietitian-directed lifestyle-modification program with a 10-year diabetes risk being calculated using a biochemical model (Framingham). Results: Prediabetic and diabetic subjects had significantly elevated triglycerides, sdLDL-C, and hs-CRP and decreased HDL-C. They were insulin resistant as compared to healthy subjects, but only diabetics had significant reductions in insulin production. Lifestyle modification significantly reduced diabetes risk by 45.6% in prediabetics and significantly increased (2.4-fold) the percentage of diabetics that were in remission at follow-up (8.2% versus 3.4%) with increased weight loss (6.5 versus 2.0 pounds). Lifestyle intervention resulted in significant favorable effects on many metabolic markers. Conclusions: The measurement of fasting glucose and insulin is essential for the detection of decreased insulin production in diabetics. A digital lifestyle program can have favorable effects on ASCVD risk factors and diabetic status.

Keywords: ASCVD risk; HOMAIR; diabetes; fasting glucose; insulin; lifestyle; prediabetes.

Figure 1

Insulin production and insulin sensitivity in healthy, prediabetic, and diabetic subjects. In this figure we have plotted data for the entire population of 133,764 subjects (56.3% healthy, 36.2% prediabetic, and 7.5% diabetic). Homeostasis assessment model assessment of insulin production, or HOMA_β, was calculated as equal to [360 × fasting insulin (µU/mL)]/[fasting plasma glucose (mg/dL) − 63] as previously described and plotted on the horizontal axis (22). The homeostasis model of insulin resistance, or HOMA_IR, was calculated as equal to [fasting insulin (µU/mL)] × [fasting plasma glucose (mg/dL)]/405 as previously described [22]. We then plotted the reciprocal of this value multiplied by 100, or as [(1/HOMA_IR) × 100], for the same subjects as a measure of insulin sensitivity (HOMA_S). What can be clearly seen on the graph is that diabetic subjects not infrequently have HOMA_β of <60 (the 25th percentile value in healthy subjects), as well as decreased insulin sensitivity as compared to healthy and prediabetic subjects, with clear lines of demarcation between diabetic, prediabetic, and healthy subjects.