Is the Current Lifestyle Modification Approach to Diabetes Prevention in the U.S. a Success?

Abstract

Prediabetes is an intermediate stage between normal glycemia and diabetes and is highly prevalent, especially in adults, but is also increasingly common in young individuals. Randomized clinical trials have demonstrated that lifestyle modification is cost-effective in preventing diabetes. Implementation studies showed the feasibility of delivering real-world structured lifestyle modification programs adapted from the U.S. Diabetes Prevention Program trial. However, the current approach to diabetes prevention in the U.S. has been largely inadequate thus far, as evidenced by the stagnant numbers of people with prediabetes and the growing number of those with diabetes. The many gaps in the implementation of the National Diabetes Prevention Program (NDPP) can be characterized as due to macro-level barriers (failures of pay-for-performance reimbursement, an undersupply of lifestyle change programs), micro-level barriers (low and disparate reach, low referral and retention rates in the program), variable fidelity in implementation, and limitations of a one-size-fits-all intervention. All of these issues point to a need for reexamining strategies for diabetes prevention in the U.S., which is yet to show benefits or value at the population level. This article details how prediabetes is currently suboptimally addressed in clinical practice and communities in the U.S. and articulates why there is an urgent need to rethink our approach to addressing prediabetes, possibly through integration of synergistic individual- and societal-levels approaches.