Diabetes Care Volume 47, Supplement 1, January 2024 S43

3. Prevention or Delay of American Diabetes Association

Professional Practice Committee*
Diabetes and Associated
Comorbidities: Standards of Care
in Diabetes—2024

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Diabetes Care 2024;47(Suppl. 1):S43–S51 | https://doi.org/10.2337/dc24-S003

3. PREVENTION OR DELAY OF DIABETES

The American Diabetes Association (ADA) “Standards of Care in Diabetes” in-
cludes the ADA’s current clinical practice recommendations and is intended to
provide the components of diabetes care, general treatment goals and guide-
lines, and tools to evaluate quality of care. Members of the ADA Professional
Practice Committee, an interprofessional expert committee, are responsible for
updating the Standards of Care annually, or more frequently as warranted. For a
detailed description of ADA standards, statements, and reports, as well as the
evidence-grading system for ADA’s clinical practice recommendations and a full
list of Professional Practice Committee members, please refer to Introduction
and Methodology. Readers who wish to comment on 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, “Diagnosis and Classification and of Diabetes.” For
guidelines related to screening, diagnosis, and management of type 2 diabetes in
youth, please refer to Section 14, “Children and Adolescents.”

Recommendations
3.1 In people with prediabetes, monitor for the development of type 2 diabetes
at least annually; modify based on individual risk assessment. E
3.2 In people with preclinical type 1 diabetes, monitor for disease progression
using A1C approximately every 6 months and 75-g oral glucose tolerance test
(i.e., fasting and 2-h plasma glucose) annually; modify frequency of monitor-
*A complete list of members of the American
ing based on individual risk assessment based on age, number and type of
Diabetes Association Professional Practice Committee
autoantibodies, and glycemic metrics. E can be found at https://doi.org/10.2337/dc24-SINT.
Duality of interest information for each author is
available at https://doi.org/10.2337/dc24-SDIS.
Screening for prediabetes and type 2 diabetes risk through an assessment of risk factors
Suggested citation: American Diabetes Association
(Table 2.5) or with an assessment tool, such as the American Diabetes Association risk Professional Practice Committee. 3. Prevention or
test (Fig. 2.2), is recommended to guide whether to perform a diagnostic test for predi- delay of diabetes and associated comorbidities:
abetes (Table 2.2) and type 2 diabetes (Table 2.1) (see Section 2, “Diagnosis and Standards of Care in Diabetes—2024. Diabetes
Classification of Diabetes”). Testing high-risk adults for prediabetes is warranted be- Care 2024;47(Suppl. 1):S43–S51
cause the laboratory assessment is safe and reasonable in cost, substantial time exists © 2023 by the American Diabetes Association.
before the development of type 2 diabetes and its complications during which one can Readers may use this article as long as the
work is properly cited, the use is educational
intervene, and there are effective approaches delaying type 2 diabetes in those with and not for profit, and the work is not altered.
prediabetes with an A1C 5.7–6.4% (39–47 mmol/mol), impaired glucose tolerance More information is available at https://www
(IGT), or impaired fasting glucose (IFG). The utility of screening with A1C for prediabetes .diabetesjournals.org/journals/pages/license.
S44 Prevention or Delay of Diabetes Diabetes Care Volume 47, Supplement 1, January 2024

and diabetes may be limited in the pres- prevention programs may be effec- higher benefit for prevention of diabetes
ence of hemoglobinopathies and condi- tive in preventing type 2 diabetes and with at least 7–10% weight loss with life-
tions that affect red blood cell turnover. should be considered. B style interventions (12). The recommended
See Section 2, “Diagnosis and Classification pace of weight loss was 1–2 lb/week. Calo-
of Diabetes,” and Section 6, “Glycemic rie goals were calculated by estimating the
Goals and Hypoglycemia,” for additional The Diabetes Prevention Program daily calories needed to maintain the par-
details on the appropriate use and limita- Several major randomized controlled tri- ticipant’s initial weight and subtracting
tions of A1C testing. als, including the Diabetes Prevention 500–1,000 calories/day (depending on ini-
Three distinct stages of type 1 diabetes Program (DPP) trial (4), the Finnish Diabe- tial body weight). The initial focus of the di-
have been defined, with symptomatic tes Prevention Study (DPS) (5), and the etary intervention was on reducing total
type 1 diabetes being stage 3 (Table 2.3). Da Qing Diabetes Prevention Study (Da fat rather than calories. After several
In individuals at risk for development of Qing study) (6), demonstrate that life- weeks, the concept of calorie balance and
clinical type 1 diabetes, younger age of

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style/behavioral intervention with an indi- the need to restrict calories and fat was in-
seroconversion (particularly under age vidualized reduced-calorie meal plan is troduced (11).
3 years), the total number of diabetes re- highly effective in preventing or delaying The goal for physical activity was se-
lated autoantibodies (1), and the devel- type 2 diabetes and improving other car- lected to approximate at least 700 kcal/
opment of autoantibodies against islet diometabolic risk factors (such as blood week expenditure from physical activity.
antigen 2 (IA-2) have all been associated pressure, lipids, and inflammation) (7). For ease of translation, this goal was de-
with more rapid progression to clinical The strongest evidence for diabetes pre- scribed as at least 150 min of moderate-
type 1 diabetes. While continuous glucose vention in the U.S. comes from the DPP intensity physical activity per week, similar
monitoring can predict progression to trial (4). The DPP demonstrated that in- in intensity to brisk walking. Participants
overt diabetes in children with autoanti- tensive lifestyle intervention could reduce were encouraged to distribute their activ-
bodies (2), oral glucose tolerance testing– the risk of incident type 2 diabetes by ity throughout the week with a minimum
based metrics are superior in predicting
58% over 3 years. Follow-up of three large frequency of three times per week and at
progression compared with continuous
trials of lifestyle intervention for diabetes least 10 min per session. A maximum of
glucose monitoring (3). The decision to
prevention showed sustained reduction in 75 min of strength training could be ap-
perform an oral glucose tolerance test
the risk of progression to type 2 diabetes: plied toward the total 150 min/week
may depend on such factors as eligibility
39% reduction at 30 years in the Da Qing physical activity goal (11).
and interest for stage-specific treatments,
study (8), 43% reduction at 7 years in the To implement the weight loss and physi-
participation in clinical research, and avail-
Finnish DPS (5), and 34% reduction at cal activity goals, the DPP used an individ-
ability and burden of testing.
10 years (9) and 27% reduction at 15 years ual model of treatment rather than a
(10) in the U.S. Diabetes Prevention Pro- group-based approach. This choice was
LIFESTYLE BEHAVIOR CHANGE
gram Outcomes Study (DPPOS). based on a desire to intervene before par-
FOR DIABETES PREVENTION
The DPP lifestyle intervention was a ticipants had the possibility of developing
goal-based intervention. All participants diabetes or losing interest in the program.
Recommendations
were given the same weight loss and The individual approach also allowed for
3.3 Refer adults with overweight or
physical activity goals, but individualiza- the tailoring of interventions to reflect the
obesity at high risk of type 2 diabetes,
tion was permitted in the specific meth- diversity of the population (11).
as seen in the Diabetes Prevention
ods used to achieve the goals (11). The The DPP intervention was adminis-
Program (DPP), to an intensive life-
two major goals of the DPP intensive life- tered as a structured core curriculum fol-
style behavior change program to
style intervention were to achieve and lowed by a flexible maintenance program
achieve and maintain a weight reduc-
maintain a minimum of 7% weight loss of individual counseling, group sessions,
tion of at least 7% of initial body weight
and 150 min of moderate-intensity physi- motivational campaigns, and restart op-
through healthy reduced-calorie diet
cal activity per week, such as brisk walk- portunities. The 16-session core curricu-
and $150 min/week of moderate-
ing. Although weight loss was the most lum was completed within the first
intensity physical activity. A
important factor in reducing the risk of in- 24 weeks of the program. It included
3.4 A variety of eating patterns can be
cident diabetes, achieving the behavioral sessions on lowering calories, increasing
considered to prevent type 2 diabetes
goal of at least 150 min of physical activ- physical activity, self-monitoring, main-
in individuals with prediabetes. B
3.5 Given the cost-effectiveness of lifestyle ity per week, even without achieving the taining healthy lifestyle behaviors (such
behavior modification programs for diabe- weight loss goal, reduced the incidence as how to choose healthy food options
tes prevention, such diabetes prevention of type 2 diabetes by 44% (12). when eating out), and guidance on man-
programs should be offered to adults at The 7% weight loss goal was selected aging psychological, social, and motiva-
high risk of type 2 diabetes. A Diabetes because it was feasible to achieve and tional challenges. Further details are
prevention programs should be covered maintain and likely to lessen the risk of de- available regarding the core curriculum
by third-party payers, and inconsistencies veloping diabetes (as well as improve other sessions (11).
in access should be addressed. E cardiometabolic risk factors). Participants
3.6 Based on individual preference, were encouraged to achieve the $7% Nutrition
certified technology-assisted diabetes weight loss during the first 6 months of Nutrition counseling for weight loss in the
the intervention. Further analysis suggests DPP lifestyle intervention arm included a
diabetesjournals.org/care Prevention or Delay of Diabetes S45

reduction of total dietary fat and calories Delivery and Dissemination of DPP is also expanding on a state-by-state
(4,11,12). However, evidence suggests that Lifestyle Behavior Change for basis.
there is not an ideal percentage of calories Diabetes Prevention While CDC-recognized behavioral counsel-
from carbohydrate, protein, and fat for Because the intensive lifestyle interven- ing programs, including Medicare DPP
all people to prevent diabetes; therefore, tion in the DPP was effective in prevent- services, have met minimum quality
macronutrient distribution should be based ing type 2 diabetes among those at high standards and are reimbursed by many
on an individualized assessment of current risk for the disease and lifestyle behavior payers, lower retention rates have been
eating patterns, preferences, and meta- change programs for diabetes prevention reported for younger adults and racial
bolic goals (13). Based on other trials, a va- were shown to be cost-effective, broader and ethnic minority populations (46).
riety of eating patterns (13,14) may also be efforts to disseminate scalable lifestyle Therefore, other programs and modalities
behavior change programs for diabetes of behavioral counseling for diabetes pre-
appropriate for individuals with prediabe-
prevention with coverage by third-party vention may also be appropriate and effi-
tes (13), including Mediterranean-style and
payers ensued (34–38). Group delivery of cacious based on individual preferences

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low-carbohydrate eating plans (15–18). Ob-
DPP content in community or primary and availability. The use of community
servational studies have also shown that
care settings has demonstrated the po- health workers to support DPP-like inter-
vegetarian, plant-based (may include some
tential to reduce overall program costs ventions has been shown to be effective
animal products), and Dietary Approaches
while still producing weight loss and dia- and cost-effective (47,48) (see Section 1,
to Stop Hypertension (DASH) eating pat-
terns are associated with a lower risk of
betes risk reduction (39–43). “Improving Care and Promoting Health in
The Centers for Disease Control and Populations,” for more information). The
developing type 2 diabetes (19–22). Evi-
Prevention (CDC) developed the National use of community health workers may fa-
dence suggests that the overall quality of
Diabetes Prevention Program (National cilitate the adoption of behavior changes
food consumed (as measured by the
DPP), a resource designed to bring such for diabetes prevention while bridging
Healthy Eating Index, Alternative Healthy
evidence-based lifestyle change programs barriers related to social determinants of
Eating Index, and DASH score), with an
for preventing type 2 diabetes to commu- health. However, coverage by third-party
emphasis on whole grains, legumes, nuts,
nities (cdc.gov/diabetes/prevention/index payers remains limited. Counseling by a
fruits, and vegetables and minimal re- .htm). This online resource includes loca- registered dietitian nutritionist (RDN) has
fined and processed foods, is also associ- tions of CDC-recognized diabetes preven- been shown to help individuals with predi-
ated with a lower risk of type 2 diabetes tion lifestyle change programs (cdc.gov/ abetes improve eating habits, increase
(21,23–25). As is the case for those with diabetes/prevention/find-a-program.html). physical activity, and achieve 7–10% weight
diabetes, individualized medical nutrition To be eligible for this program, individuals loss (13,49–51). Individualized medical nu-
therapy (see Section 5, “Facilitating must have a BMI in the overweight range trition therapy (see Section 5, “Facilitating
Positive Health Behaviors and Well-being and be at risk for diabetes based on labo- Positive Health Behaviors and Well-being
to Improve Health Outcomes,” for more ratory testing, a previous diagnosis of to Improve Health Outcomes,” for more
detailed information) is effective in lower- GDM, or a positive risk test (cdc.gov/ detailed information) is also effective in im-
ing A1C in individuals diagnosed with pre- prediabetes/takethetest/). During the first proving glycemia in individuals diagnosed
diabetes (26). 4 years of implementation of the CDC’s with prediabetes (26,49). Furthermore, tri-
National DPP, 36% achieved the 5% weight als involving medical nutrition therapy for
Physical Activity loss goal (44). The CDC has also developed adults with prediabetes found significant
Moderate-intensity physical activity, such the Diabetes Prevention Impact Tool Kit reductions in weight, waist circumference,
as brisk walking for 150 min/week, has (nccd.cdc.gov/toolkit/diabetesimpact) to and glycemia. Individuals with prediabetes
shown beneficial effects in those with help organizations assess the economics can benefit from referral to an RDN for
prediabetes (4). Similarly, moderate- of providing or covering the National DPP individualized medical nutrition therapy
intensity physical activity has been shown (45). To expand preventive services using upon diagnosis and at regular intervals
to improve insulin sensitivity and reduce a cost-effective model, the Centers for throughout their treatment plan (50,52).
abdominal fat in children and young Medicare & Medicaid Services expanded Other health care professionals, such as
adults (27,28). Health care professionals Medicare reimbursement coverage for pharmacists and diabetes care and educa-
are encouraged to promote a DPP-style the National DPP to organizations recog- tion specialists, may be considered for dia-
program to all individuals who have been nized by the CDC that become Medicare betes prevention efforts (53,54).
identified to be at an increased risk of suppliers for this service (innovation Technology-assisted programs may ef-
type 2 diabetes. In addition to aerobic .cms.gov/innovation-models/medicare fectively deliver a DPP-like intervention
activity, a physical activity plan designed -diabetes-prevention-program). The loca- (55–60). A digital diabetes prevention
to prevent diabetes may include resis- tions of Medicare DPPs are available on- program improved cardiovascular risk at
tance training (11,29,30). Breaking up line at innovation.cms.gov/innovation 4 months but not at 12 months (61).
prolonged sedentary time may also be -models/medicare-diabetes-prevention Such technology-assisted programs may
encouraged, as it is associated with -program/mdpp-map. To qualify for Medi- deliver content through smartphones,
moderately lower postprandial glucose care coverage, individuals must have BMI web-based applications, and telehealth
levels (31,32). The effects of physical ac- >25 kg/m2 (or BMI >23 kg/m2 if self- and may be an acceptable and effica-
tivity appear to extend to the prevention identified as Asian) and glycemic testing cious option to bridge barriers, particu-
of gestational diabetes mellitus (GDM) consistent with prediabetes in the last larly for individuals with low income and
(33). year. Medicaid coverage of the National people in rural locations; however, not
S46 Prevention or Delay of Diabetes Diabetes Care Volume 47, Supplement 1, January 2024

all technology-assisted programs are ef- higher fasting plasma glucose (e.g., where vitamin D supplementation may be
fective (55,62–64). The CDC Diabetes $110 mg/dL [$6 mmol/L]), and higher of benefit (80).
Prevention Recognition Program (DPRP) A1C (e.g., $6.0% [$42 mmol/mol]), No pharmacologic agent has been ap-
(cdc.gov/diabetes/prevention/requirements proved by the U.S. Food and Drug Admin-
and in individuals with prior gestational
-recognition.htm) certifies technology- istration for prevention of type 2 diabetes.
diabetes mellitus. A
assisted modalities as effective vehicles The risk versus benefit of each medication
3.8 Long-term use of metformin
for DPP-based interventions; such pro- in support of person-centered goals must
may be associated with vitamin B12
grams must use an approved curriculum, be weighed in addition to cost and burden
include interaction with a coach, and at- deficiency; consider periodic assess-
of administration.
tain the DPP outcomes of participation, ment of vitamin B12 level in metfor-
Metformin has the most safety data as
physical activity reporting, and weight min-treated individuals, especially a pharmacologic therapy for diabetes pre-
loss. Health care professionals should con- in those with anemia or peripheral vention (90). Metformin was overall less
sider referring adults with prediabetes to neuropathy. B effective than lifestyle modification in the

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certified technology-assisted programs. DPP, though group differences attenuated
Because weight loss through behavior over time in the DPPOS (10), and metfor-
Lifestyle and Type 1 Diabetes changes in diet and physical activity can min may be cost-saving over a 10-year
Progression period (36). In the DPP, metformin was as
be difficult to maintain long term (9),
Observational studies suggest that in effective as lifestyle modification in par-
people at high risk of type 2 diabetes may
those with islet autoantibodies, factors
benefit from additional support and phar- ticipants with BMI $35 kg/m2 and in
that may increase b-cell demand includ- younger participants aged 25–44 years
macotherapeutic options, if needed. Vari-
ing less physical activity (65), higher die- (4). In individuals with a history of GDM
ous pharmacologic agents used to treat
tary glycemic index (66), and total sugar in the DPP, metformin and intensive life-
intake (67) are associated with progression diabetes have been evaluated for diabetes
prevention. Metformin, a-glucosidase in- style modification led to an equivalent
to clinical diabetes. Similar associations 50% reduction in diabetes risk (91). Both
have not been seen in the development of hibitors, incretin receptor agonists (e.g.,
interventions remained highly effective
autoantibodies. In The Environmental liraglutide and semaglutide), thiazolidine-
during a 10-year follow-up period (92). By
Determinants of Diabetes in the Young diones, and insulin have been shown
the time of the 15-year follow-up (DPPOS),
(TEDDY) longitudinal study, daily minutes to lower the incidence of diabetes in
exploratory analyses demonstrated that
spent in moderate to vigorous physical specific populations (69–74), whereas
participants with a higher baseline fasting
activity were associated with a reduced diabetes prevention was not seen with
glucose ($110 mg/dL [$6 mmol/L] vs.
risk of progression to type 1 diabetes in nateglinide (75).
95–109 mg/dL [5.3–5.9 mmol/L]), those with
children 5 to 15 years of age with multiple In the DPP, weight loss was an impor- a higher A1C (6.0–6.4% [42–46 mmol/mol]
islet autoantibodies (hazard ratio [HR] tant factor in reducing the risk of progres- vs. <6.0% [<42 mmol/mol]), and individ-
0.92 [95% CI 0.86–0.99] per 10-min in- sion, with every kilogram of weight loss uals with a history of GDM (vs. individuals
crease; P = 0.021) (65). In the Diabetes conferring a 16% reduction in risk of pro- without a history of GDM) experienced
Autoimmunity Study in the Young (DAISY), gression over 3.2 years (12). In individuals higher risk reductions with metformin,
in children with islet autoantibodies, pro- with previous history of GDM, the risk of identifying subgroups of participants that
gression to type 1 diabetes was associated type 2 diabetes increased by 18% for ev- may benefit the most from metformin
with higher dietary glycemic index (HR ery 1 unit BMI above the preconception (93). In the Indian Diabetes Prevention
2.20 [95% CI 1.17–4.15]) and total sugar baseline (76). Several medications evalu- Program (IDPP-1), metformin and lifestyle
intake (HR 1.75 [95% CI 1.07–2.85]) ated for weight loss (e.g., orlistat, phenter- intervention reduced diabetes risk simi-
(66,67). In nonobese diabetic mice, an ani- mine/topiramate, liraglutide, semaglutide, larly at 30 months; however, the lifestyle
mal model for the development of type 1 and tirzepatide) have been shown to de- intervention in IDPP-1 was less intensive
diabetes, sustained high glucose drinking crease the incidence of type 2 diabetes in than that in the DPP (94). Based on find-
significantly aggravated islet inflammation those with prediabetes (74,77–79). ings from the DPP, metformin should be
and accelerated the onset of type 1 diabe- Studies of other pharmacologic agents recommended as an option for high-risk
tes (68). Lifestyle interventions focusing on have shown some efficacy in diabetes individuals (e.g., younger individuals, those
such factors in those with stage 1 or prevention with valsartan or testosterone with history of GDM, or those with BMI
stage 2 type 1 diabetes have not yet (80,81), but no efficacy in preventing dia- $35 kg/m2). A recent Chinese open-label
been reported. betes with ramipril or anti-inflammatory randomized controlled trial showed that
drugs (81–84). Although the Vitamin D metformin combined with standard life-
PHARMACOLOGIC and Type 2 Diabetes (D2d) prospective style intervention further reduced the risk
INTERVENTIONS randomized controlled trial showed no of developing diabetes than lifestyle inter-
Recommendations
significant benefit of vitamin D versus pla- vention alone by 17% over 2 years (95).
3.7 Metformin for the prevention of cebo on the progression to type 2 diabe- Periodic assessment of vitamin B12 level
type 2 diabetes should be considered tes in individuals at high risk (85), post in those taking metformin chronically
in adults at high risk of type 2 diabetes, hoc analyses and meta-analyses suggest a should be considered to check for possible
as typified by the DPP, especially those potential benefit in specific populations deficiency, especially in those with anemia
aged 25–59 years with BMI $35 kg/m2, (85–89). Further research is needed to or peripheral neuropathy (96,97) (see
define characteristics and clinical indicators Section 9, “Pharmacologic Approaches to
diabetesjournals.org/care Prevention or Delay of Diabetes S47

Glycemic Treatment,” for more details). information. The lifestyle interventions and maintenance, minimizing the pro-
The effect of metformin on vitamin B12 in- for weight loss in study populations at gression of hyperglycemia, and atten-
creases with time (98), with a higher risk risk for type 2 diabetes have shown a re- tion to cardiovascular risk. B
for vitamin B12 deficiency (<150 pmol/L) duction in cardiovascular risk factors and 3.13 Pharmacotherapy (e.g., for weight
noted at 4–5 years. A person who has the need for medications used to treat
management, minimizing the progres-
been on metformin for more than 4 years these cardiovascular risk factors (106,107).
sion of hyperglycemia, and cardiovascu-
or is at risk for vitamin B12 deficiency for The lifestyle intervention in the Da Qing
lar risk reduction) may be considered to
other reasons (e.g., vegan, previous study was associated with lowering car-
support person-centered care goals. B
gastric/small bowel surgery) should be diovascular disease and mortality at 23 and
3.14 More intensive preventive ap-
monitored for vitamin B12 deficiency an- 30 years of observational follow-up (6,8).
Treatment goals and therapies for hyper- proaches should be considered in indi-
nually (99).
tension and dyslipidemia in the primary viduals who are at particularly high
and secondary prevention of cardiovas- risk of progression to diabetes, includ-

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PREVENTION OF VASCULAR
cular disease for people with prediabetes ing individuals with BMI $35 kg/m2,
DISEASE AND MORTALITY
should be based on their level of cardio- those at higher glucose levels (e.g.,
Recommendations vascular risk. Increased vigilance is war- fasting plasma glucose 110–125 mg/dL
3.9 Prediabetes is associated with ranted to identify and treat these and [6.1–6.9 mmol/L], 2–h postchallenge glu-
heightened cardiovascular risk; there- other cardiovascular diseases risk factors cose 173–199 mg/dL [9.6–11.0 mmol/L],
fore, screening for and treatment of (108). Statin use increases risk of diabetes and A1C $6.0% [$42 mmol/mol]),
modifiable risk factors for cardiovascu- (109–113). In the DPP, statin use was as- and individuals with a history of ges-
lar disease are suggested. B sociated with greater diabetes risk irre- tational diabetes mellitus. A
3.10 Statin therapy may increase the spective of the treatment group (pooled
risk of type 2 diabetes in people at HR [95% CI] for incident diabetes 1.36
[1.17–1.58]) (111). In trials of primary Individualized risk-to-benefit ratio should
high risk of developing type 2 diabe-
and secondary prevention of cardiovas- be considered in screening, intervention,
tes. In such individuals, glucose status
cular disease, cardiovascular and mortal- and monitoring to lower the risk of type 2
should be monitored regularly and di-
ity benefits of statin therapy exceed the diabetes and associated comorbidities.
abetes prevention approaches rein-
risk of diabetes (114,115), suggesting a Multiple factors, including age, BMI, and
forced. It is not recommended that
favorable benefit-to-harm balance with other comorbidities, may influence the
statins be discontinued for this ad-
statin therapy. Hence, discontinuation of risk of progression to diabetes and lifetime
verse effect. B
statins is not recommended in this popu- risk of complications (121,122). Prediabe-
3.11 In people with a history of stroke
lation due to concerns of diabetes risk. tes is associated with increased cardiovas-
and evidence of insulin resistance and
Cardiovascular outcome trials in people cular disease and mortality (102), which
prediabetes, pioglitazone may be con-
without diabetes also inform risk reduc- emphasizes the importance of attending
sidered to lower the risk of stroke or
tion potential in people without diabetes to cardiovascular risk in this population.
myocardial infarction. However, this
at increased cardiometabolic risk (see Sec- In the DPP, which enrolled high-risk indi-
benefit needs to be balanced with the
tion 10, “Cardiovascular Disease and Risk viduals with IGT, elevated fasting glucose,
increased risk of weight gain, edema,
Management,” for more details). The IRIS and elevated BMI, the crude incidence of
and fractures. A Lower doses may mit-
(Insulin Resistance Intervention after Stroke) diabetes within the placebo group was
igate the risk of adverse effects but
trial of people with a recent (<6 months) 11 cases per 100 person-years, with a cu-
may be less effective. C
stroke or transient ischemic attack, without mulative 3-year incidence of diabetes of
diabetes but with insulin resistance (as de- 29% (4). Characteristics of individuals in
People with prediabetes often have other fined by a HOMA of insulin resistance index the DPP/DPPOS who were at particularly
cardiovascular risk factors, including hy- of $3.0), evaluated pioglitazone (target high risk of progression to diabetes (crude
pertension and dyslipidemia (100), and dose of 45 mg daily) compared with pla- incidence of diabetes 14–22 cases per 100
are at increased risk for cardiovascular cebo. At 4.8 years, the risk of stroke or person-years) included BMI $35 kg/m2,
disease (101,102). Evaluation for tobacco myocardial infarction, as well as the risk higher glucose levels (e.g., fasting plasma
use and referral for tobacco cessation of diabetes, was lower in the pioglitazone glucose 110–125 mg/dL [6–6.9 mmol/L],
should be part of routine care for those group than with placebo; weight gain, 2–h postchallenge glucose 173–199 mg/dL
at risk for diabetes. Of note, the years edema, and fractures were higher in the [9.6–11.0 mmol/L], and A1C $6.0%
immediately following smoking cessation pioglitazone treatment group (116–119). [$42 mmol/mol]), and a history of GDM
may represent a time of increased risk Lower doses may mitigate the adverse ef- (4,91,92). In contrast, in the community-
for diabetes (103–105), and individuals fects but may also be less effective (120). based Atherosclerosis Risk in Communi-
should be monitored for diabetes devel- ties (ARIC) study, observational follow-up
opment and receive evidence-based PERSON-CENTERED CARE GOALS of adults with mean age 75 years with
lifestyle behavior change for diabetes Recommendations laboratory evidence of prediabetes
prevention described in this section. See 3.12 In adults with overweight or obe- (based on A1C 5.7–6.4% [39–47 mmol/mol]
Section 5, “Facilitating Positive Health sity at high risk of type 2 diabetes, and/or fasting glucose 100–125 mg/dL
Behaviors and Well-being to Improve care goals should include weight loss [5.6–6.9 mmol/L]), but not meeting specific
Health Outcomes,” for more detailed BMI criteria, found lower progression to
S48 Prevention or Delay of Diabetes Diabetes Care Volume 47, Supplement 1, January 2024

diabetes over 6 years: 9% of those with Teplizumab has been approved to delay with impaired glucose tolerance in the Da Qing
A1C-defined prediabetes, 8% with IFG (122). the onset of stage 3 type 1 diabetes in Diabetes Prevention Study: a 23-year follow-up
study. Lancet Diabetes Endocrinol 2014;2:474–
Thus, it is important to individualize the people 8 years of age and older with 480
risk-to-benefit ratio of intervention and stage 2 type 1 diabetes based in part on 7. Nathan DM, Bennett PH, Crandall JP, et al.;
consider person-centered goals. Risk mod- the results of a single trial in relatives of DPP Research Group. Does diabetes prevention
els have generally found higher benefit of people with type 1 diabetes (126). In translate into reduced long-term vascular
the intervention in those at highest risk this study, 44 individuals were random- complications of diabetes? Diabetologia 2019;62:
1319–1328
(12). Diabetes prevention trials and obser- ized to a 14-day course of teplizumab 8. Gong Q, Zhang P, Wang J, et al.; Da Qing
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