Population Approaches to Prevention of Type 2 Diabetes

Citation: White M (2016) Population Approaches to Prevention of Type 2 Diabetes. PLoS Med 13(7): e1002080. doi:10.1371/journal.pmed.1002080
Published: July 12, 2016

With the prevalence of Type 2 Diabetes Mellitus (T2DM) continuing to rise in most high-income, low-income, and middle-income countries [1], strategies to stem the emerging pandemic are urgently needed. To date, the best evidence for prevention of T2DM comes from randomized controlled trials of lifestyle interventions (e.g., to modify diet and physical activity and achieve weight loss) delivered to individuals at high risk, usually those with impaired glucose tolerance or prediabetes [2]. However, strategies that focus on changing individual behavior have limited reach due to the challenges of identifying at scale those in whom an intervention may be beneficial. Thus, while the behavioral interventions themselves have been shown to be meet acceptable cost-effectiveness thresholds, the cost-effectiveness of both identifying and intervening at the scale needed to achieve population impact remains less clear [3]. It is likely that, in the short term, such strategies will be unaffordable by all but the most affluent nations. Demonstration projects attempting to identify and deliver interventions to all those at high risk in the population (estimated to be >10% of adults in England, for example), such as the NHS Diabetes Prevention Programme, will therefore be watched with interest [4].

Behavioral interventions targeting individuals can also have variable effectiveness across population subgroups due to differential access, uptake, and compliance, resulting in lesser benefits in people from socioeconomically disadvantaged backgrounds [5]. Such interventions could therefore widen inequalities in incidence and prevalence of T2DM [6]. Such strategies will be of value to help stem the tide of new cases of T2DM but realistically need to be accompanied by more affordable and wider reaching population-level interventions to change diet and physical activity, reduce obesity, and thus reduce incidence of T2DM. Population intervention strategies will be particularly important for low-income and middle-income countries, for whom individual-level interventions may be unaffordable [7]. Such approaches have been advocated by WHO, which calls for “multisectoral action that simultaneously addresses different sectors that contribute to the production, distribution, and marketing of food, while concurrently shaping an environment that facilitates and promotes adequate levels of physical activity” [8].

Population approaches to prevention aim to reduce key risk factors for T2DM in the whole population, irrespective of individual level of risk. They achieve this by bringing about small changes in risk factor levels in the whole population, resulting in a shift in the population distribution of risk. Such shifts in the distribution of disease risk can theoretically lead to substantial population benefit [9], and the principle has been well demonstrated in relation to, for example, salt consumption and blood pressure [10]. Such approaches may not be entirely without harm, however. For example, not everyone in a population needs to reduce weight, reduce blood pressure, or become more active [11]. But given the small expected change in risk at an individual level, and their delivery in a societal context, population interventions are generally considered safe [9].

There are potential concerns also about the differential effectiveness of some population interventions. Not all population-level interventions are likely to have the same impact, and some may be less equitable than others. This is a particular concern for interventions that require a higher level of engagement by individuals, such as food labelling, which demands literacy and numeracy as well as an ability to process and apply the information presented in making healthy food choices, often from a bewildering array of available products [12]. Interventions requiring low levels of individual engagement, such as regulation of TV advertising of unhealthy foods, may be more equitable and offer greater overall health impacts. However, such policy interventions need to be formulated to ensure population benefit and be rigorously evaluated [13].

Simulation studies have modelled the potential impacts on T2DM incidence of small changes in risk factors for T2DM, such as physical activity at a population level, demonstrating significant potential benefits [14]. The challenge is to develop and deliver interventions that can bring about such small changes across the whole population cost-effectively. Is this achievable and, if so, how?
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