The prevalence of diabetes is increasing in epidemic proportion worldwide. Because of the morbidity and mortality associated with the disease, it is becoming a major burden for the health care system. With a better understanding of the pathogenesis of
type 2 diabetes, the concept of primary prevention has emerged. A number of studies demonstrated that both lifestyle modification program and pharmacological interventions in subjects with
impaired glucose tolerance (IGT) can prevent or delay the progression to diabetes. The Diabetes Prevention Study (DPS) and the Diabetes Prevention Program (DPP) convincingly showed that an intensive lifestyle modification program is highly effective in decreasing the risk of diabetes in a high risk population (risk reduction of 58%). Four other smaller studies have made similar observations. The DPP study showed that
metformin can reduced the risk of diabetes by 31% in subjects with IGT. The STOP-
NIDDM trial confirmed the efficacy of
acarbose in decreasing the risk of diabetes by 36% in similar high risk population. The TRIPOD study showed that
troglitazone can reduce the incidence of diabetes by 55% in Hispanic women with a history of
gestational diabetes. And more recently, the XENDOS study showed that in very obese population on intensive lifestyle modification program,
xenical treatment was associated with a 37% reduced incidence of diabetes compared to placebo. Three studies suggested that
bariatric surgery in morbidly obese subjects with or without IGT can reduce the incidence of diabetes to near zero. Eight of 10 studies showed that treatment with inhibitors of the renin-angiotensin aldosterone system in high risk population for
cardiovascular disease (CVD) were associated with a significant reduction in the subsequent development of diabetes as a secondary outcome. The WOSCOPS study and the HERS study examined the effect of
pravastatin and
estrogen/
progestin respectively on cardiovascular events and observed that these pharmacological interventions were associated with a 30% and 35% reduction in the incidence of diabetes as secondary outcome. There are 3 major trials currently in progress examining the effect of
rosiglitazone/
ramipril (the DREAM study),
nateglinide/
valsartan (the NAVIGATOR study) and
pioglitazone (the ACT NOW study) on the development of diabetes in IGT subjects as a primary outcome. We also have 3 studies studying the prevention of diabetes as secondary outcomes: the ONTARGET-TRANSCEND study examining
telmisartan with or without
ramipril, and the ORIGIN study testing
glargine insulin/omega 3. The evidence is overwelming-diabetes can be prevented or delayed in high risk population through lifestyle modification or pharmacological interventions. This new information now has to be translated in the real world into well defined strategies for screening and treating high risk population. Prevention of the disease is our only chance to alleviate the ever growing burden of
diabetes mellitus in the world.