International Diabetes Federation 2017

More than 8000 delegates from 165 countries gathered in Abu Dhabi, United Arab Emirates, for the International Diabetes Federation's 2017 Congress. Dr Mike Lean (University of Glasgow, Glasgow, UK) presented 1-year data from the DiRECT trial,1 which randomized 298 participants (recently diagnosed adults with type 2 diabetes (T2D; not on insulin) to intensive weight loss intervention (withdrawal of antidiabetic or antihypertensive drugs, total diet replacement with approximately 800 calories/day for 3–5 months, stepped food reintroduction for 2–8 weeks, and structured support for long-term weight maintenance) or to standard of care for the UK. Dr Lean reported that 24% of participants receiving intensive weight loss intervention (36/149) achieved ≥15 kg (~33 lb) weight loss, and that 46% of this treatment arm (68 individuals) achieved diabetes remission. Mean weight loss for the intervention group was 14.5 kg (~30 lb) after meal replacement, and mean weight regain at 12 months was 2 kg (~4.4 lb). In those losing ≥15 kg, 86% achieved diabetes remission, and Dr Lean thus underscored the apparent relationship between magnitude of weight loss and likelihood of diabetes remission. No member of the control group experienced ≥15 kg weight loss (P < 0.0001 for comparison), although 4% (6/149) did achieve diabetes remission with a mean 5% body weight reduction (P < 0.0001 for comparison). Dr Lean announced that economic analyses are underway to determine the cost-effectiveness of delivering the intensive weight loss intervention (in DiRECT, the treatment was implemented by modestly trained usual care providers). He shared that 32 participants dropped out of the treatment arm due to the intervention's demands or lack of appeal. Dr Roy Taylor (Newcastle University, Newcastle, UK) shared in discussion that shorter duration of diabetes predicted responders versus non-responders in a subgroup of DiRECT, and Dr Lean later clarified that people with longer duration of diabetes who lose a substantial amount of body weight can achieve diabetes remission, although the best results appear in individuals with shorter disease duration; 2- and 3-year data from DiRECT are still being collected.

During the same symposium, researchers presented findings from the DISCOVER study,2 a large-scale effort in real-world data collection spanning 38 countries and enrolling 15 992 patients with T2D, about to initiate second-line therapy. The primary objective of the program, as presented by Dr Linong Ji (Peking University Diabetes Center, Beijing, China), is to describe diabetes management patterns and disease evolution over 3 years for people initiating a second-line glucose-lowering therapy. Dr Mikhail Kosiborod (University of Missouri, Kansas City, MO, USA) presented key findings from the program so far (the 3 years of planned follow-up is ongoing): <80% of participants had a recorded HbA1c assessment, revealing gaps in screening and monitoring. The HbA1c screening rate was lowest in Africa, at 57%, followed by Southeast Asia (61%), ranging up to the Eastern Mediterranean (94%). When screening was defined as HbA1c or fasting plasma glucose evaluations, the rate increased, but was still <90% globally. Mean HbA1c across the entire global study population was 8.4%, from a high of 8.7% in the Eastern Mediterranean to a low of 8.1% in Europe. Nearly one-third of the population initiating a second-line therapy had HbA1c ≥9%, whereas 55% had HbA1c ≥8% and only 15% met an HbA1c target <7%. The prevalence of microvascular complications (chronic kidney disease, albuminuria, retinopathy, retinal laser photocoagulation, autonomic neuropathy, peripheral neuropathy, or erectile dysfunction) was 18% globally, ranging from 13% in the Americas to 22% in Southeast Asia. Macrovascular complications (coronary artery disease, stroke, transient ischemic attack, carotid artery stenting, carotid endarterectomy, peripheral artery disease, diabetic foot, amputation, defibrillator use, or heart failure) appeared in 13% of the overall study population, ranging from 10% in Africa and the Americas to 18% in Europe. Dr Kosiborod's main takeaway from these data was that a large proportion of patients relatively early in the course of diabetes (mean diabetes duration 5.6 years, range 4–7 years) present with microvascular disease, macrovascular disease, or a combination of both. He listed four correlates for both micro- and macrovascular complications: (i) male gender; (ii) older age; (iii) smoking; and (iv) a history of hypoglycemia. He also emphasized that mean worldwide HbA1c for the T2D population is far above goal, and suggested that DISCOVER provides evidence for broad treatment inertia, given that people starting a second diabetes drug exhibited high HbA1c and frequent complications.