What’s Next for Diabetes Prevention?

Recent estimates of the prevalenceof diabetes and prediabetes under-score that no community is being spared from this ever-advancing, non-communicable disease (1). Given that many individuals with these conditions are going to experience the long-term, ravaging outcomes of hyperglycemia, there is a continued and pressing need to develop approaches that will prevent the development and progression of di-abetes as well as its micro- and macro-vascular complications. The last two decades have witnessed the introduction of a number of new classes of medications to treat diabetes and the refinement of others. We have also learned the benefits of more aggres-sive glucose lowering so that today in-terventions are frequently commenced earlier, and many patients are rapidly placed on more than a single agent. The focus on earlier intervention has also grown out of the recognition that the glucose elevation characterizing type 2 diabetes does not occur suddenly, but rather is a slow and progressive process with the pathophysiology well estab-lished at a time when the glucose levels have not yet reached the diagnostic thresh-olds (2). Thus, impaired glucose metabo-lism and diabetes represent a continuum and both are amenable to therapy. Intervening to prevent the develop-ment of diabetes has been a focus of a number of studies over the last decade. In these, both lifestyle modification and medications have been used and have, in general, been successful in delaying the onset of the disease. Lifestyle modifi-cation reduces the risk of developing diabetes by over 50 % (3,4), with different classes of medications having more vari-able impact (4–8). The greatest benefit from pharmacological intervention oc-curs with the thiazolidinediones (6–8), which have been shown to be as good, if not better, than lifestyle intervention. In this issue of Diabetes Care, Retnakaran et al. (9) provide additional information about the effectiveness of pharmacologic intervention to prevent progression to diabetes from the Canadia