Stepwise diabetes prevention effectively reduces diabetes incidence by one-third among patients with prediabetes, according to a study published in Diabetes Care.

The Diabetes Community Lifestyle Improvement Program (D-CLIP) trial included 578 overweight or obese Asian Indian adults identified through community-based recruitment. Mary Beth Weber, PhD, MPH, from the Emory Global Diabetes Research Center, Hubert Department of Global Health, Emory University in Atlanta, Georgia, and colleagues conducted the randomized controlled trial to examine stepwise diabetes prevention, defined as lifestyle modification plus metformin when required, in patients with prediabetes.

Participants had impaired glucose tolerance, isolated impaired fasting glucose, or a combination of both. They were randomly assigned to receive either standard lifestyle advice or a 6-month intervention lifestyle curriculum based on the U.S. Diabetes Prevention Program. Patients with the highest risk of conversion to diabetes after 4 months of follow-up also received stepwise addition of metformin (500 mg, twice daily). The researchers measured incidence of diabetes biannually across the study groups with intention-to-treat analysis.

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 The investigators found that 34.9% of participants receiving standard lifestyle advice developed diabetes, compared with 25.7% of participants from the intervention group (relative risk reduction [RRR], 32%).

The RRR was stronger among patients who were older than age 50 years, male, or obese. In addition, the RRRs also varied by prediabetes type (isolated impaired fasting glucose, 12%; isolated impaired glucose tolerance, 31%; combination, 36%). Overall, 72.0% of participants required metformin in addition to lifestyle intervention. However, this rate varied by prediabetes type (isolated impaired glucose tolerance, 51.3%; isolated impaired fasting glucose, 76.5%; combination, 83.0%).

The researchers reported no serious adverse events during the study. They also noted that the program appeared to be less effective among patients with isolated impaired fasting glucose, and a higher proportion of these individuals required metformin therapy, which suggests that lifestyle intervention failed to slow disease progression.

“In conclusion, the D-CLIP trial shows that expert recommendations of adding metformin in a stepwise manner to lifestyle education is an effective method for preventing or delaying diabetes in adults with prediabetes, even in a resource-challenged setting like a [low or middle income country],” the study authors concluded. “However, further research is needed to better understand diabetes prevention among people with ilFG [isolated impaired fasting glucose].”


  1. Weber MB, Ranjani H, Staimez LR, et al. The stepwise approach to diabetes prevention: results from the D-CLIP randomized controlled trial. Diabetes Care. 2016;39:1760-1767. doi: 10.2337/dc16-1241.