1、3. Prevention or Delay of Type 2Diabetes and AssociatedComorbidities:Standards ofMedical Care in Diabetes2022Diabetes Care 2022;45(Suppl. 1):S39S45 | https:/doi.org/10.2337/dc22-S003American Diabetes AssociationProfessional Practice Committee*The American Diabetes Association (ADA) “Standards of Med
2、ical Care in Dia-betes” includes the ADAs current clinical practice recommendations and isintended to provide the components of diabetes care, general treatment goalsand guidelines, and tools to evaluate quality of care. Members of the ADA Profes-sional Practice Committee, a multidisciplinary expert
3、 committee (https:/doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Careannually, or more frequently as warranted. For a detailed description of ADAstandards, statements, and reports, as well as the evidence-grading system forADAs clinical practice recommendations, please re
4、fer to the Standards of CareIntroduction (https:/doi.org/10.2337/dc22-SINT). Readers who wish to commenton the Standards of Care are invited to do so at professional.diabetes.org/SOC.For guidelines related to screening for increased risk for type 2 diabetes (prediabe-tes), please refer to Section 2,
5、 “Classification and Diagnosis of Diabetes” (https:/doi.org/10.2337/dc22-S002). For guidelines related to screening, diagnosis, andmanagement of type 2 diabetes in youth, please refer to Section 14, “Children andAdolescents” (https:/doi.org/10.2337/dc22-S014).Recommendation3.1 Monitor for the develo
6、pment of type 2 diabetes in those with prediabe-tes at least annually, modified based on individual risk/benefit assess-ment. EScreening for prediabetes and type 2 diabetes risk through an informal assessmentof risk factors (Table 2.3) or with an assessment tool, such as the American DiabetesAssocia
7、tion risk test (Fig. 2.1), is recommended to guide providers on whether per-forming a diagnostic test for prediabetes (Table 2.5) and previously undiagnosedtype 2 diabetes (Table 2.2) is appropriate (see Section 2, “Classification and Diagnosisof Diabetes,” https:/doi.org/10.2337/dc22-S002). Testing
8、 high-risk patients for predi-abetes is warranted because the laboratory assessment is safe and reasonable incost, substantial time exists before the development of type 2 diabetes and its com-plications during which one can intervene, and there is an effective means of pre-venting type 2 diabetes i
9、n those determined to have prediabetes with an A1C 5.76.4% (3947 mmol/mol), impaired glucose tolerance, or impaired fasting glucose.The utility of A1C screening for prediabetes and diabetes may be limited in the pres-ence of hemoglobinopathies and conditions that affect red blood cell turnover. See*
10、A complete list of members of the AmericanDiabetesAssociationProfessionalPracticeCommittee can be found at https:/doi.org/10.2337/dc22-SPPC.Suggested citation: American Diabetes Asso-ciationProfessionalPracticeCommittee.3.Prevention or delay of type 2 diabetes andassociated comorbidities: Standards
11、of MedicalCare in Diabetes2022. Diabetes Care 2022;45(Suppl. 1):S39S45 2021 by the American Diabetes Association.Readers may use this article as long as thework is properly cited, the use is educationaland not for profit, and the work is not altered.Moreinformationisavailableathttps:/diabetesjournal
12、s.org/journals/pages/license.3. PREVENTION OR DELAY OF TYPE 2 DIABETESDiabetes Care Volume 45, Supplement 1, January 2022S39Downloaded from http:/diabetesjournals.org/care/article-pdf/45/Supplement_1/S39/637518/dc22s003.pdf by guest on 10 July 2022Section 2, “Classification and DiagnosisofDiabetes”(
13、https:/doi.org/10.2337/dc22-S002), and Section 6, “GlycemicTargets”(https:/doi.org/10.2337/dc22-S006), for additional details on theappropriate use and limitations of A1Ctesting.LIFESTYLE BEHAVIOR CHANGEFOR DIABETES PREVENTIONRecommendations3.2 Refer adults with overweight/obesity at high risk of ty
14、pe 2diabetes, as typified by the Dia-betes Prevention Program (DPP),to an intensive lifestyle behaviorchange program consistent withthe DPP to achieve and maintain7% loss of initial body weight,and increase moderate-intensityphysical activity (such as briskwalking) to at least 150 min/week. A3.3 A v
15、ariety of eating patterns canbe considered to prevent diabe-tes in individuals with prediabe-tes. B3.4 Given the cost-effectiveness oflifestylebehaviormodificationprograms for diabetes preven-tion, such diabetes preventionprograms should be offered topatients. A Diabetes preventionprograms should be
16、 covered bythird-party payers and inconsis-tenciesinaccessshouldbeaddressed.3.5 Based on patient preference, cer-tified technology-assisted diabe-tespreventionprogramsmaybe effective in preventing type 2diabetes and should be consid-ered. BThe Diabetes Prevention ProgramSeveral major randomized cont
17、rolled tri-als, including the Diabetes PreventionProgram (DPP) (1), the Finnish DiabetesPrevention Study (DPS) (2), and the DaQing Diabetes Prevention Study (DaQing study) (3), demonstrate that life-style/behavioral therapy with individual-ized reduced-calorie meal plan is highlyeffective in prevent
18、ing or delaying type2 diabetes and improving other cardio-metabolic markers (such as blood pres-sure, lipids, and inflammation) (4). Thestrongest evidence for diabetes pre-vention in the U.S. comes from the DPPtrial (1). The DPP demonstrated thatintensivelifestyleinterventioncouldreduce the risk of
19、incident type 2 diabe-tes by 58% over 3 years. Follow-up ofthree large studies of lifestyle interven-tion for diabetes prevention has shownsustained reduction in the risk of pro-gression to type 2 diabetes: 39% reduc-tion at 30 years in the Da Qing study(5), 43% reduction at 7 years in theFinnish DP
20、S (2), and 34% reduction at10 years (6) and 27% reduction at 15years (7) in the U.S. Diabetes PreventionProgram Outcomes Study (DPPOS).The two major goals of the DPPintensive lifestyle intervention were toachieve and maintain a minimum of 7%weight loss and 150 min of physicalactivity per week simila
21、r in intensity tobrisk walking. The DPP lifestyle interven-tion was a goal-based intervention: allparticipantsweregiventhesameweight loss and physical activity goals,but individualization was permitted inthe specific methods used to achievethe goals (8). Although weight loss wasthe most important fa
22、ctor to reducethe risk of incident diabetes, it was alsofound that achieving the target behav-ioral goal of at least 150 min of physicalactivity per week, even without achiev-ing the weight loss goal, reduced theincidence of type 2 diabetes by 44% (9).The7%weightlossgoalwasselected because it was fe
23、asible toachieve and maintain and likely tolessen the risk of developing diabetes.Participants were encouraged to achievethe 7% weight loss during the first 6months of the intervention. Further anal-ysis suggests maximal prevention of dia-betes with at least 710% weight loss(9). The recommended pace
24、 of weightloss was 12 lb/week. Calorie goals werecalculated by estimating the daily calo-ries needed to maintain the participantsinitial weight and subtracting 5001,000calories/day (depending on initial bodyweight).The initial focus was on reducingtotal dietary fat. After several weeks, theconcept o
25、f calorie balance and the needto restrict calories as well as fat wasintroduced (8).The goal for physical activity wasselected to approximate at least 700kcal/week expenditure from physicalactivity. For ease of translation, this goalwas described as at least 150 min ofmoderate-intensity physical act
26、ivity perweek similar in intensity to brisk walk-ing. Participants were encouraged todistribute their activity throughout theweek with a minimum frequency ofthree times per week and at least 10min per session. A maximum of 75 minof strength training could be appliedtoward the total 150 min/week phys
27、icalactivity goal (8).To implement the weight loss andphysical activity goals, the DPP used anindividual model of treatment ratherthan a group-based approach.This choicewas based on a desire to intervenebefore participants had the possibility ofdeveloping diabetes or losing interest inthe program. T
28、he individual approachalso allowed for tailoring of interventionsto reflect the diversity of the population(8).The DPP intervention was adminis-tered as a structured core curriculumfollowed by a flexible maintenance pro-gram of individual counseling, groupsessions, motivational campaigns, andrestart
29、 opportunities. The 16-sessioncore curriculum was completed withinthe first 24 weeks of the program andincluded sessions on lowering calories,increasing physical activity, self-moni-toring, maintaining healthy lifestylebehaviors, and guidance on managingpsychological, social, and motivationalchallen
30、ges. Further details are avail-able regarding the core curriculumsessions (8).NutritionDietary counseling for weight loss in theDPP lifestyle intervention arm included areduction of total dietary fat and calories(1,8,9). However, evidence suggests thatthere is not an ideal percentage of calo-ries fr
31、om carbohydrate, protein, and fatfor all people to prevent diabetes; there-fore, macronutrient distribution shouldbe based on an individualized assess-ment of current eating patterns, prefer-ences, and metabolic goals (10). Basedon other intervention trials, a variety ofeating patterns characterized
32、 by thetotality of food and beverages habituallyconsumed (10,11) may also be appropri-ate for patients with prediabetes (10),including Mediterranean-style and low-carbohydrateeatingplans(1215).Observational studies have also shownthat vegetarian, plant-based (mayincludesomeanimalproducts),andS40Prev
33、ention or Delay of Type 2 Diabetes and Associated ComorbiditiesDiabetes Care Volume 45, Supplement 1, January 2022Downloaded from http:/diabetesjournals.org/care/article-pdf/45/Supplement_1/S39/637518/dc22s003.pdf by guest on 10 July 2022Dietary Approaches to Stop Hypertension(DASH) eating patterns
34、are associatedwith a lower risk of developing type 2diabetes (1619). Evidence suggests thatthe overall quality of food consumed (asmeasured by the Healthy Eating Index,Alternative Healthy Eating Index, andDASH score), with an emphasis on wholegrains, legumes, nuts, fruits, and vegeta-bles and minima
35、l refined and processedfoods, is also associated with a lower riskof type 2 diabetes (18,2022). As is thecase for those with diabetes, individual-ized medical nutrition therapy (see Sec-tion 5, “Facilitating Behavior Change andWell-being to Improve Health Outcomes,”https:/doi.org/10.2337/dc22-S005,f
36、ormore detailed information) is effective inlowering A1C in individuals diagnosedwith prediabetes (23).Physical ActivityJust as 150 min/week of moderate-intensity physical activity, such as briskwalking, showed beneficial effects inthose with prediabetes (1), moderate-intensityphysicalactivityhasbee
37、nshown to improve insulin sensitivity andreduce abdominal fat in children andyoung adults (24,25). On the basis ofthese findings, providers are encour-aged to promote a DPP-style program,including a focus on physical activity, toall individuals who have been identifiedto be at an increased risk of t
38、ype 2 dia-betes. In addition to aerobic activity, anexercise regimen designed to preventdiabetes may include resistance training(8,26,27). Breaking up prolonged seden-tary time may also be encouraged, as itis associated with moderately lowerpostprandial glucose levels (28,29). Thepreventive effects
39、of exercise appear toextend to the prevention of gestationaldiabetes mellitus (GDM) (30).Delivery and Dissemination ofLifestyle Behavior Change forDiabetes PreventionBecause the intensive lifestyle interven-tion in the DPP was effective in prevent-ing type 2 diabetes among those at highrisk for the
40、disease and lifestyle behaviorchange programs for diabetes preventionwere shown to be cost-effective, broaderefforts to disseminate scalable lifestylebehavior change programs for diabetesprevention with coverage by third-partypayers ensued (3135). Group delivery ofDPP content in community or primary
41、care settings has demonstrated thepotential to reduce overall program costswhile still producing weight loss and dia-betes risk reduction (3640).The Centers for Disease Control andPrevention (CDC) developed the NationalDiabetes Prevention Program (NationalDPP), a resource designed to bring suchevide
42、nce-based lifestyle change programsfor preventing type 2 diabetes to commu-nities (www.cdc.gov/diabetes/prevention/index.htm). This online resource includeslocations of CDC-recognized diabetes pre-vention lifestyle change programs (avail-able at www.cdc.gov/diabetes/prevention/find-a-program.html).T
43、o be eligible for thisprogram, patients must have a BMI in theoverweight range and be at risk for diabe-tes based on laboratory testing, a previousdiagnosis of GDM, or a positive risk test(availableatwww.cdc.gov/prediabetes/takethetest/).Resultsfrom the CDCsNational DPP during the first 4 years ofim
44、plementation are promising and dem-onstrate cost-efficacy (41). The CDC hasalso developed the Diabetes PreventionImpact Tool Kit (available at nccd.cdc.gov/toolkit/diabetesimpact) to help organiza-tions assess the economics of providingor covering the National DPP lifestylechange program (42). In an
45、 effort toexpand preventive services using a cost-effective model that began in April 2018,the Centers for Medicare & MedicaidServices expanded Medicare reimburse-ment coverage for the National DPPlifestyle intervention to organizationsrecognized by the CDC that becomeMedicare suppliers for this ser
46、vice (atinnovation.cms.gov/innovation-models/medicare-diabetes-prevention-program).The locations of Medicare DPPs areavailable online at innovation.cms.gov/innovation-models/medicare-diabetes-prevention-program/mdpp-map. To qual-ify for Medicare coverage, patients musthave BMI 25 kg/m2(or BMI 23 kg/
47、m2if self-identified as Asian) and laboratorytesting consistent with prediabetes in thelast year. Medicaid coverage of the DPPlifestyle intervention is also expanding ona state-by-state basis.While CDC-recognized behavioral coun-selingprograms,includingMedicareDPP services, have met minimum qual-ity
48、 standards and are reimbursed bymany payers, there have been lowerretention rates reported for youngeradults and racial/ethnic minority popu-lations (43). Therefore, other programsand modalities of behavioral counselingfor diabetes prevention may also beappropriate and efficacious based onpatient pr
49、eferences and availability. Theuse of community health workers tosupport DPP efforts has been shown tobe effective and cost-effective (44,45) (seeSection 1, “Improving Care and Promot-ing Health in Populations,” https:/doi.org/10.2337/dc22-S001, for more infor-mation). The use of community healthwor
50、kers may facilitate adoption of behav-ior changes for diabetes prevention whilebridging barriers related to social determi-nants of health, though coverage bythird-party payers remains problematic.Counseling by registered dietitians/regis-tered dietitian nutritionists (RDNs) hasbeen shown to help in
