COMMENTARY

Diabetes Prevention in the COVID-19 Era

Prof Kamlesh Khunti 

Disclosures

August 21, 2020

This transcript has been edited for clarity.

Hello, my name is Kamlesh Khunti. I'm professor of primary care diabetes and vascular medicine at the University of Leicester.

Thank you for joining me on this video regarding prevention of diabetes.

As you all know the prevalence of type 2 diabetes is a serious threat to sustainability of health systems internationally. But there is good quality evidence from randomised controlled trials that behavioural interventions that support people who are at high risk, such as those with impaired glucose tolerance (IGT), to lose weight, or to develop a healthy dietary lifestyle, and increasing physical activity, can reduce the risk of type 2 diabetes.

There've been a number of studies, including systematic reviews, that have shown that it doesn't matter which country the study has come from, the risk reduction is about 50% in those people who are at high risk and given intensive lifestyle interventions to prevent diabetes.

There are differences in terms of the risk reductions because the progression rates by IFG and IGT combined, IGT or IFT on its own, or HbA1c, are slightly different. But no matter what the criteria used to diagnose diabetes, we know that all these intensive lifestyle interventions can lead to weight loss, and which would subsequently lead to prevention of diabetes.

Evidence

The longest running study is the Da Qing study, which showed that at 6 years there was a 50% reduction in risk of developing diabetes in those with the IGT. And the 20 year follow up showed that there was still a 43% reduction in the incidence of developing type 2 diabetes. These were all efficacy trials where the participants had volunteered to go into a trial, and they had very, very intensive lifestyle interventions, which are not really applicable, or even sustainable, in a real-world setting.

So there's been a number of what we call effectiveness studies that have been conducted to reduce the incidence of diabetes and those at high risk. And again, a number of studies have been carried out – what we call translational studies - and all of them have showed that we can improve risk factors in terms of developing diabetes.

And also, some studies, meta analyses, are showing that we can reduce the risk of diabetes in a real- world setting, and more data, even more data, for reductions in weight.

Guidelines

So on the basis of this a number of guidelines have been published. In the UK we have the National Institute for Health and Care Excellence (NICE) guidelines for England, which have said that we should be using some form of a risk score to identify those people who are at high risk.

And then those who are high on the risk score would have a blood test to see if they're high in terms of the blood test, and this could be a fasting glucose, or glucose tolerance test, or HbA1c.

Since the HbA1c criteria have come out, the majority of people are opting for an HbA1c. And people with an HbA1c of anything from 6% to 6.4% would be classed as being at high risk of diabetes, and they would be appropriately referred to a national Diabetes Prevention Programme. That started in England many years ago.

And this has led to a number of benefits over the years which I'll come to shortly.

In terms of the NICE guidance, NICE guidance showed that it was cost effective to identify people using the two-step approach where one would use a risk score and then refer patients to a diabetes prevention programme.

And indeed, they showed that in certain populations, such as those of ethnic minority populations, not just referring patients from age 40 to 74 as is the case in England, but referring patients from 25 to 39 of Black and Minority Ethnic (BAME) health groups would not only be cost effective, but also cost saving as well.

Recently, there's been a publication of the national programme. England has had the only national programme for diabetes prevention, and this showed that by December 2018 over 150,000 people have been referred and attended the initial assessment, of which 96,000 have attended at least one of the 13 group-based intervention sessions.

And intention to treat analysis within this observational study showed there was a 2.3 kg reduction in weight, and a 1.26 mmol/mol reduction in HbA1c. In terms of complete case analysis, there was about a 3.3 kg reduction in weight.

COVID-19

However, in view of COVID there's been a lot of debate - what should we be doing in terms of the prevention programme? Because first of all, it's been difficult to see these patients in clinical practice to have their blood tests done, HbA1c, for example, and then having the face-to-face group face education programmes.

Diabetes has really been heightened in the era of COVID because we know diabetes is one of the strong risk factors for severe COVID and hospitalisation. There's been a number of meta-analyses that have been done, all of them showing that people with diabetes have a two-fold increased risk of being hospitalised with COVID, and a two-fold increased risk of dying from COVID as well.

There's also now some good quality data showing that glycaemic control is associated with severe COVID and mortality. So, well-controlled people have a lower risk of mortality in those people who have diabetes. Whether the risk in people with pre-diabetes holds, we are still awaiting some results.

However, glucose does seem to be a risk factor for people with COVID and severe COVID.

So, our inclination would be to try and prevent diabetes. Also, physical fitness is important, so losing weight would be also beneficial in terms of contracting COVID and the risk associated with COVID.

In view of COVID, those people at high risk are now being given advice that they can have a risk score done. This is the Leicester Diabetes Risk Score, that is an online risk score available on the Diabetes UK website. Patients can assess their risk and those who are at high risk can enrol themselves to a risk reduction programme, the diabetes prevention programme, which is again an online programme.

This is a major announcement that was made by Sir Simon Stephens [NHS England chief executive], that the programme was now rolled out, all virtually, both in terms of risk assessment and for the prevention programme.

Unprecedented Times

This is exciting times, worrying times, but at the same time exciting times, because we do now work in an era of virtual consultations, and now also virtual programmes.

And we know that there are a number of digital support programmes globally that can be available, including wearable technologies. In the longer term, we will need to see if these programmes are effective, but we are working in unprecedented times.

We know diabetes is a risk factor for COVID severity and mortality, and whether people with diabetes in the pre-diabetes range are at high risk is to be asserted. But current data are showing that hyperglycaemia is a risk factor, and we need to continue all the efforts to reduce the risk of people developing diabetes, and hopefully reduce their risk of getting COVID, and severe outcomes from COVID.

Thank you very much for listening.

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