A Randomized Controlled Clinical Trial of Lifestyle Intervention and Pioglitazone for Normalization of Glucose Status in Chinese with Prediabetes

Efficacy of lifestyle weight loss interventions on regression to normoglycemia and progression to type 2 diabetes in individuals with prediabetes: a systematic review and pairwise and dose-response meta-analyses

BACKGROUND

Current recommendations for weight loss in individuals with prediabetes come from individual trials and are derived from older data.

OBJECTIVES

To elucidate the dose-dependent impacts of weight loss on participants with prediabetes to determine the optimal magnitude of weight loss required for the implementation of the most effective diabetes prevention program.

METHODS

We searched PubMed, Scopus, CENTRAL, CINAHL, and gray literature sources to September 2023 for randomized trials ≥6 mo that evaluated the efficacy of a lifestyle weight loss intervention on participants with prediabetes. We conducted random-effects pairwise meta-analyses to calculate relative and absolute effects. We performed a 1-stage weighted mixed-effects meta-analysis to elucidate the dose-response curves.

RESULTS

Forty-four randomized trials with 14,742 participants with prediabetes [intervention duration range: 6-72 mo (median: 24 mo), mean weight loss range: 1%-9%] were included. Lifestyle weight loss interventions increased regression to normoglycemia by 11/100 participants (95% confidence interval [CI]: 8 more, 17 more; risk ratio: 1.51; 95% CI: 1.27, 1.80; n = 20 trials, grading of recommendations assessment, development, and evaluation = moderate], and reduced progression to type 2 diabetes by 8/100 participants (95% CI: 11 fewer, 6 fewer; risk ratio: 0.59; 95% CI: 0.51, 0.67; n = 37, grading of recommendations assessment, development, and evaluation = moderate). There were no significant or credible differences between subgroups categorized by the type and duration of intervention. Dose-response meta-analyses indicated that the risk of regression to normoglycemia increased, and the risk of progression to type 2 diabetes declined in a linear pattern within the range of weight loss from 1% to 9%.

CONCLUSIONS

Over a median duration of 24 mo, with weight loss ranging from 1% to 9%, the relationship between weight loss and the progression to type 2 diabetes, as well as the regression to normoglycemia, follows a linear pattern. Any form of lifestyle weight loss intervention, including diet, exercise, or a combination of both, can have beneficial impacts on participants with prediabetes. This trial was registered at PROSPERO as CRD42023465322.

Differential effect of interventions in patients with prediabetes stratified by a machine learning-based diabetes progression prediction model

AIM

To investigate whether stratifying participants with prediabetes according to their diabetes progression risks (PR) could affect their responses to interventions.

METHODS

We developed a machine learning-based model to predict the 1-year diabetes PR (ML-PR) with the least predictors. The model was developed and internally validated in participants with prediabetes in the Pinggu Study (a prospective population-based survey in suburban Beijing; n = 622). Patients from the Beijing Prediabetes Reversion Program cohort (a multicentre randomized control trial to evaluate the efficacy of lifestyle and/or pioglitazone on prediabetes reversion; n = 1936) were stratified to low-, medium- and high-risk groups using ML-PR. Different effect of four interventions within subgroups on prediabetes reversal and diabetes progression was assessed.

RESULTS

Using least predictors including fasting plasma glucose, 2-h postprandial glucose after 75 g glucose administration, glycated haemoglobin, high-density lipoprotein cholesterol and triglycerides, and the ML algorithm XGBoost, ML-PR successfully predicted the 1-year progression of participants with prediabetes in the Pinggu study [internal area under the curve of the receiver operating characteristic curve 0.80 (0.72-0.89)] and Beijing Prediabetes Reversion Program [external area under the curve of the receiver operating characteristic curve 0.80 (0.74-0.86)]. In the high-risk group pioglitazone plus intensive lifestyle therapy significantly reduced diabetes progression by about 50% at year l and the end of the trial in the high-risk group compared with conventional lifestyle therapy with placebo. In the medium- or low-risk group, intensified lifestyle therapy, pioglitazone or their combination did not show any benefit on diabetes progression and prediabetes reversion.

CONCLUSIONS

This study suggests personalized treatment for prediabetes according to their PR is necessary. ML-PR model with simple clinical variables may facilitate personal treatment strategies in participants with prediabetes.

The effectiveness of lifestyle interventions on type 2 diabetes and gestational diabetes incidence and cardiometabolic outcomes: A systematic review and meta-analysis of evidence from low- and middle-income countries

BACKGROUND

As lifestyle modification offers a unique strategy to prevent diabetes, we evaluated the effectiveness of lifestyle interventions in the prevention of type 2 diabetes and gestational diabetes in low- and middle-income countries (LMICs).

METHODS

We did a systematic literature review and meta-analysis. We searched MEDLINE, Embase, Web of Science, and Cochrane Library for randomised controlled trials published in English, Spanish, French, and Portuguese between 1 January 2000 and 15 June 2022, evaluating multi-target and multi-component lifestyle interventions in at-risk populations conducted in LMICs. The main outcomes were incidence of type 2 diabetes and gestational diabetes, and indicators of glycaemic control. We assessed the methodological quality of the studies using the Cochrane risk of bias tool. Inverse-variance random-effects meta-analyses estimated the overall effect sizes. Sources of heterogeneity and study bias were evaluated. The study protocol was registered in PROSPERO (CRD42021279174).

FINDINGS

From 14 330 abstracts, 48 (0·3%) studies with 50 interventions were eligible of which 56% were conducted in lower-middle-income countries, 44% in upper-middle, and none in low-income. 54% of the studies were assessed as moderate risk of bias and 14% as high risk. A median of 246 (IQR 137-511) individuals participated in the interventions with a median duration of 6 (3-12) months. Lifestyle interventions decreased the incidence risk ratio of type 2 diabetes by 25% (0·75 [95% CI 0·61 to 0·91]), and reduced the levels of HbA1c by 0·15% [-0·25 to -0·05], fasting plasma glucose by 3·44 mg/dL [-4·72 to -2·17], and 2-hr glucose tolerance by 4·18 mg/dL [-7·35 to -1·02]. No publication bias was suggested for these outcomes. High levels of heterogeneity (I²≥ 81%) were found in most meta-analyses. Exploration using meta-regressions could not identify any explanatory variable, except for fasting glucose for which the quality score of the articles seems to be an effect modifier decreasing slightly the heterogeneity (72%) in the low risk of bias pooled estimate. The effect on gestational diabetes could not be evaluated due to the scarcity of available studies.

INTERPRETATION

Comprehensive lifestyle interventions are effective strategies to prevent type 2 diabetes among at-risk populations in LMICs. The heterogeneity identified in our results should be considered when using these interventions to address the onset of type 2 diabetes.

FUNDING

None.