Summary and Conclusions

We are currently in the midst of a global epidemic of type 2 diabetes, which may well reverse the downward trend in CVD mortality seen in recent decades. The epidemic is being driven by the increasing prevalence of 'unhealthy lifestyle' involving a combination of obesity, physical inactivity and a diet high in saturated fat and refined carbohydrate. While established diabetes has long been regarded as an important cardiovascular risk factor, and hyperglycaemia has been shown to promote vascular dysfunction by a variety of mechanisms, there is increasing awareness that by the time a typical obese middle-aged subject is diagnosed with type 2 diabetes, he has already accrued significant cardiovascular risk in terms of hypertension, endothelial dysfunction, coagulopathy, atherogenic lipid profile and circulating pro-inflammatory adipocytokines. Indeed, there is now evidence that the overlapping conditions of pre-diabetes (encompassing both IFG and IGT) and the metabolic syndrome confer significant risk not only for development of diabetes but also of CVD. In recognition of the need to prevent these serious diseases, a number of trials have been designed to demonstrate delay or prevention of type 2 diabetes in high-risk groups (predominantly obese middle-aged subjects with IGT).

Convincing evidence has now been published for beneficial effects of intensive diet and exercise counselling as well as pharmacological agents such as metformin, rosiglitazone, acarbose and orlistat, although, as yet, the evidence that improvement of glucose dysregulation will translate into cardiovascular benefit is less robust. Interpretation of results from these diabetes prevention studies is complicated by the fact that both lifestyle and drug interventions have beneficial physiological effects not directly related to glucose handling, and it seems likely that they will prevent cardiovascular events more than would be expected by their effect on blood glucose alone. Now that effective interventions have been proven in the prolonged preclinical phase of these common diseases, there is a strong case for screening programmes to identify and target those at high risk. As yet, there is no clear consensus on screening criteria, partly because of the paucity of cost-benefit analyses in this area. However, common sense dictates that much would be gained by a population approach, warning of the future dangers of an unhealthy lifestyle and providing positive incentives for healthy eating and participation in regular physical activity. Governments must be persuaded of the importance of this approach to prevent widespread premature morbidity and mortality in future decades.

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