Improving health outcomes of people with diabetes: target setting for the WHO Global Diabetes Compact.

The Global Diabetes Compact is a WHO-driven initiative uniting stakeholders around goals of reducing diabetes risk and ensuring that people with diabetes have equitable access to comprehensive, affordable care and prevention. In this report we describe the development and scientific basis for key health metrics, coverage, and treatment targets accompanying the Compact. We considered metrics across four domains: factors at a structural, system, or policy level; processes of care; behaviours and biomarkers such as glycated haemoglobin (HbA1c); and health events and outcomes; and three risk tiers (diagnosed diabetes, high risk, or whole population), and reviewed and prioritised them according to their health importance, modifiability, data availability, and global inequality. We reviewed the global distribution of each metric to set targets for future attainment. This process led to five core national metrics and target levels for UN member states: (1) of all people with diabetes, at least 80% have been clinically diagnosed; and, for people with diagnosed diabetes, (2) 80% have HbA1c concentrations below 8·0% (63·9 mmol/mol); (3) 80% have blood pressure lower than 140/90 mm Hg; (4) at least 60% of people 40 years or older are receiving therapy with statins; and (5) each person with type 1 diabetes has continuous access to insulin, blood glucose meters, and test strips. We also propose several complementary metrics that currently have limited global coverage, but warrant scale-up in population-based surveillance systems. These include estimation of cause-specific mortality, and incidence of end-stage kidney disease, lower-extremity amputations, and incidence of diabetes. Primary prevention of diabetes and integrated care to prevent long-term complications remain important areas for the development of new metrics and targets. These metrics and targets are intended to drive multisectoral action applied to individuals, health systems, policies, and national health-care access to achieve the goals of the Global Diabetes Compact. Although ambitious, their achievement can result in broad health benefits for people with diabetes.

Type 1 diabetes in 2017: global estimates of incident and prevalent cases in children and adults.

AIMS/HYPOTHESIS: Data on type 1 diabetes incidence and prevalence are limited, particularly for adults. This study aims to estimate global numbers of incident and prevalent cases of type 1 diabetes in 2017 for all age groups, by country and areas defined by income and region. METHODS: Incidence rates of type 1 diabetes in children (available from 94 countries) from the IDF Atlas were used and extrapolated to countries without data. Age-specific incidence rates in adults (only known across full age range for fewer than ten countries) were obtained by applying scaling ratios for each adult age group relative to the incidence rate in children. Age-specific incidence rates were applied to population estimates to obtain incident case numbers. Duration of diabetes was estimated from available data and adjusted using differences in childhood mortality rate between countries from United Nations demographic data. Prevalent case numbers were derived by modelling the relationship between prevalence, incidence and disease duration. Sensitivity analyses were performed to quantify the impact of alternative assumptions and model inputs. RESULTS: Global numbers of incident and prevalent cases of type 1 diabetes were estimated to be 234,710 and 9,004,610, respectively, in 2017. High-income countries, with 17% of the global population, accounted for 49% of global incident cases and 52% of prevalent cases. Asia, which has the largest proportion of the world's population (60%), had the largest number of incident (32%) and prevalent (31%) cases of type 1 diabetes. Globally, 6%, 35%, 43% and 16% of prevalent cases were in the age groups 0-14, 15-39, 40-64 and 65+ years, respectively. Based on sensitivity analyses, the estimates could deviate by ±15%. CONCLUSIONS/INTERPRETATION: Globally, type 1 diabetes represents about 2% of the estimated total cases of diabetes, ranging from less than 1% in certain Pacific countries to more than 15% in Northern European populations in 2017. This study provides information for the development of healthcare and policy approaches to manage type 1 diabetes. The estimates need further validation due to limitations and assumptions related to data availability and estimation methods.

Development of a target product profile for a point-of-care cardiometabolic device.

INTRODUCTION: Multi-parameter diagnostic devices can simplify cardiometabolic disease diagnosis. However, existing devices may not be suitable for use in low-resource settings, where the burden of non-communicable diseases is high. Here we describe the development of a target product profile (TPP) for a point-of-care multi-parameter device for detection of biomarkers for cardiovascular disease and metabolic disorders, including diabetes, in primary care settings in low- and middle-income countries (LMICs). METHODS: A draft TPP developed by an expert group was reviewed through an online survey and semi-structured expert interviews to identify device characteristics requiring refinement. The draft TPP included 41 characteristics with minimal and optimal requirements; characteristics with an agreement level for either requirement of ≤ 85% in either the survey or among interviewees were further discussed by the expert group and amended as appropriate. RESULTS: Twenty people responded to the online survey and 18 experts participated in the interviews. Twenty-two characteristics had an agreement level of ≤ 85% in either the online survey or interviews. The final TPP defines the device as intended to be used for basic diagnosis and management of cardiometabolic disorders (lipids, glucose, HbA1c, and creatinine) as minimal requirement, and offering an expanded test menu for wider cardiometabolic disease management as optimal requirement. To be suitable, the device should be intended for level 1 healthcare settings or lower, used by minimally trained healthcare workers and allow testing using self-contained cartridges or strips without the need for additional reagents. Throughput should be one sample at a time in a single or multi-analyte cartridge, or optimally enable testing of several samples and analytes in parallel with random access. CONCLUSION: This TPP will inform developers of cardiometabolic multi-parameter devices for LMIC settings, and will support decision makers in the evaluation of existing and future devices.

Medicines for Treatment Intensification in Type 2 Diabetes and Type of Insulin in Type 1 and Type 2 Diabetes in Low-Resource Settings: Synopsis of the World Health Organization Guidelines on Second- and Third-Line Medicines and Type of Insulin for the Control of Blood Glucose Levels in Nonpregnant Adults With Diabetes Mellitus.

Description: The World Health Organization developed these guidelines to provide guidance on selection of medicines for treatment intensification in type 2 diabetes and on use of insulin (human or analogue) in type 1 and 2 diabetes. The target audience includes clinicians, policymakers, national diabetes program managers, and medicine procurement officers. The target population is adults with type 1 or 2 diabetes in low-resource settings in low- or high-income countries. The guidelines also apply to disadvantaged populations in high-income countries. Methods: The recommendations were formulated by a 12-member guideline development group and are based on high-quality systematic reviews identified via a search of several bibliographic databases from 1 January 2007 to 1 March 2017. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to assess the quality of the evidence and the strength of the recommendations. The guideline was peer-reviewed by 6 external reviewers. Recommendation 1: Give a sulfonylurea to patients with type 2 diabetes who do not achieve glycemic control with metformin alone or who have contraindications to metformin (strong recommendation, moderate-quality evidence). Recommendation 2: Introduce human insulin treatment to patients with type 2 diabetes who do not achieve glycemic control with metformin and/or a sulfonylurea (strong recommendation, very-low-quality evidence). Recommendation 3: If insulin is unsuitable, a dipeptidyl peptidase-4 (DPP-4) inhibitor, a sodium-glucose cotransporter-2 (SGLT-2) inhibitor, or a thiazolidinedione (TZD) may be added (weak recommendation, very-low-quality evidence). Recommendation 4: Use human insulin to manage blood glucose in adults with type 1 diabetes and in adults with type 2 diabetes for whom insulin is indicated (strong recommendation, low-quality evidence). Recommendation 5: Consider long-acting insulin analogues to manage blood glucose in adults with type 1 or type 2 diabetes who have frequent severe hypoglycemia with human insulin (weak recommendation, moderate-quality evidence for severe hypoglycemia).

Investigation of 2 models to set and evaluate quality targets for hb a1c: biological variation and sigma-metrics.

BACKGROUND: A major objective of the IFCC Task Force on Implementation of HbA1c Standardization is to develop a model to define quality targets for glycated hemoglobin (Hb A1c). METHODS: Two generic models, biological variation and sigma-metrics, are investigated. We selected variables in the models for Hb A1c and used data of external quality assurance/proficiency testing programs to evaluate the suitability of the models to set and evaluate quality targets within and between laboratories. RESULTS: In the biological variation model, 48% of individual laboratories and none of the 26 instrument groups met the minimum performance criterion. In the sigma-metrics model, with a total allowable error (TAE) set at 5 mmol/mol (0.46% NGSP), 77% of the individual laboratories and 12 of 26 instrument groups met the 2σ criterion. CONCLUSIONS: The biological variation and sigma-metrics models were demonstrated to be suitable for setting and evaluating quality targets within and between laboratories. The sigma-metrics model is more flexible, as both the TAE and the risk of failure can be adjusted to the situation-for example, requirements related to diagnosis/monitoring or international authorities. With the aim of reaching (inter)national consensus on advice regarding quality targets for Hb A1c, the Task Force suggests the sigma-metrics model as the model of choice, with default values of 5 mmol/mol (0.46%) for TAE and risk levels of 2σ and 4σ for routine laboratories and laboratories performing clinical trials, respectively. These goals should serve as a starting point for discussion with international stakeholders in the field of diabetes.

Defining the research agenda to reduce the joint burden of disease from diabetes mellitus and tuberculosis.

The steadily growing epidemic of diabetes mellitus poses a threat for global tuberculosis (TB) control. Previous studies have identified an important association between diabetes mellitus and TB. However, these studies have limitations: very few were carried out in low-income countries, with none in Africa, raising uncertainty about the strength of the diabetes mellitus-TB association in these settings, and many critical questions remain unanswered. An expert meeting was held in November 2009 to discuss where there was sufficient evidence to make firm recommendations about joint management of both diseases, to address research gaps and to develop a research agenda. Ten key research questions were identified, of which 4 were selected as high priority: (i) whether, when and how to screen for TB in patients with diabetes mellitus and vice versa; (ii) the impact of diabetes mellitus and non-diabetes mellitus hyperglycaemia on TB treatment outcomes and deaths, and the development of strategies to improve outcomes; (iii) implementation and evaluation of the tuberculosis 'DOTS' model for diabetes mellitus management; and (iv) the development and evaluation of better point-of-care diagnostic and monitoring tests, including measurements of blood glucose and glycated haemoglobin A(1c) (HbA(1c)) for patients with diabetes mellitus. Implementation of this research agenda will benefit the control of both diseases.

The long-term effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a 20-year follow-up study.

BACKGROUND: Intensive lifestyle interventions can reduce the incidence of type 2 diabetes in people with impaired glucose tolerance, but how long these benefits extend beyond the period of active intervention, and whether such interventions reduce the risk of cardiovascular disease (CVD) and mortality, is unclear. We aimed to assess whether intensive lifestyle interventions have a long-term effect on the risk of diabetes, diabetes-related macrovascular and microvascular complications, and mortality. METHODS: In 1986, 577 adults with impaired glucose tolerance from 33 clinics in China were randomly assigned to either the control group or to one of three lifestyle intervention groups (diet, exercise, or diet plus exercise). Active intervention took place over 6 years until 1992. In 2006, study participants were followed-up to assess the long-term effect of the interventions. The primary outcomes were diabetes incidence, CVD incidence and mortality, and all-cause mortality. FINDINGS: Compared with control participants, those in the combined lifestyle intervention groups had a 51% lower incidence of diabetes (hazard rate ratio [HRR] 0.49; 95% CI 0.33-0.73) during the active intervention period and a 43% lower incidence (0.57; 0.41-0.81) over the 20 year period, controlled for age and clustering by clinic. The average annual incidence of diabetes was 7% for intervention participants versus 11% in control participants, with 20-year cumulative incidence of 80% in the intervention groups and 93% in the control group. Participants in the intervention group spent an average of 3.6 fewer years with diabetes than those in the control group. There was no significant difference between the intervention and control groups in the rate of first CVD events (HRR 0.98; 95% CI 0.71-1.37), CVD mortality (0.83; 0.48-1.40), and all-cause mortality (0.96; 0.65-1.41), but our study had limited statistical power to detect differences for these outcomes. INTERPRETATION: Group-based lifestyle interventions over 6 years can prevent or delay diabetes for up to 14 years after the active intervention. However, whether lifestyle intervention also leads to reduced CVD and mortality remains unclear.

Implications of the growing burden of diabetes for premature cardiovascular disease mortality and the attainment of the Sustainable Development Goal target 3.4.

Non-communicable diseases (NCDs) are a major cause of deaths globally, and cardiovascular disease (CVD) is the leading cause of these deaths. 42% of NCD deaths are premature (occurring before the age of 70 years). As part of the United Nations 3rd Sustainable Development Goal (SDG) on health and wellbeing, target 3.4 is to reduce premature mortality from NCDs by one third between 2015 and 2030. This target adds to the World Health Organization (WHO) target of reducing premature deaths from NCDs by 25% between 2010 and 2025. As diabetes is a major risk factor for CVD, it is important to account for the trends in diabetes when considering premature CVD mortality. We aimed to describe the global trends in diabetes prevalence and mortality, critically review the literature on the estimated attainability of the WHO and SDG targets, and determine if and how these studies accounted for trends in diabetes. Worldwide, the prevalence of diabetes is rising, with an estimated 9.0% global prevalence in adults aged 20-69 by 2030, and low- and middle-income countries (LMICs) having the largest increase of the burden in absolute numbers and age-standardized prevalence. There is a lack of data from most LMICs on the excess CVD mortality associated with diabetes and therefore no consensus on the global risk of CVD mortality in people with diabetes. Where data do exist, there are discrepancies between studies on the direction of mortality trends from diabetes over time. We reviewed 12 studies that estimated the attainability of the WHO or SDG targets for premature NCD mortality. Seven of these considered the potential impacts of achieving the 2025 WHO risk factor targets. Six studies modelled the impact of current trends in risk factors, including diabetes, continuing toward the target dates. Four studies compared this 'business as usual' model with the attainment of the risk factor targets for the world as whole and individual regions, 2 studies for NCD mortality overall, and 2 specifically for CVD mortality. On the impact of diabetes with regards to attainment of the WHO or SDG targets for premature CVD mortality, the overall results were inconclusive. Some concluded that none of the countries or regions considered would meet the targets, and others predicted that in some areas, the targets would be met. Examining the potential impact of trends in diabetes on future CVD mortality rates in LMICs is limited by a relative lack of high quality studies, including on the age specific excess mortality associated with diabetes. Filling these data gaps will enable better estimates of the potential impacts on future CVD mortality of the rapidly increasing prevalence of diabetes in LMICs and help to better inform health policy and the attainment of SDG target 3.4.

Diabetes and tuberculosis: the impact of the diabetes epidemic on tuberculosis incidence.

BACKGROUND: Tuberculosis (TB) remains a major cause of mortality in developing countries, and in these countries diabetes prevalence is increasing rapidly. Diabetes increases the risk of TB. Our aim was to assess the potential impact of diabetes as a risk factor for incident pulmonary tuberculosis, using India as an example. METHODS: We constructed an epidemiological model using data on tuberculosis incidence, diabetes prevalence, population structure, and relative risk of tuberculosis associated with diabetes. We evaluated the contribution made by diabetes to both tuberculosis incidence, and to the difference between tuberculosis incidence in urban and rural areas. RESULTS: In India in 2000 there were an estimated 20.7 million adults with diabetes, and 900,000 incident adult cases of pulmonary tuberculosis. Our calculations suggest that diabetes accounts for 14.8% (uncertainty range 7.1% to 23.8%) of pulmonary tuberculosis and 20.2% (8.3% to 41.9%) of smear-positive (i.e. infectious) tuberculosis. We estimate that the increased diabetes prevalence in urban areas is associated with a 15.2% greater smear-positive tuberculosis incidence in urban than rural areas - over a fifth of the estimated total difference. CONCLUSION: Diabetes makes a substantial contribution to the burden of incident tuberculosis in India, and the association is particularly strong for the infectious form of tuberculosis. The current diabetes epidemic may lead to a resurgence of tuberculosis in endemic regions, especially in urban areas. This potentially carries a risk of global spread with serious implications for tuberculosis control and the achievement of the United Nations Millennium Development Goals.

Diabetes and associated disorders in Cambodia: two epidemiological surveys.

BACKGROUND: The Asia-Pacific region is thought to be severely affected by diabetes. However, reliable, standardised data on prevalence and characteristics of glucose intolerance in Asian populations remain sparse. We describe the results of two field surveys undertaken in Cambodia in 2004. METHODS: 2246 randomly selected adults aged 25 years and older were examined in two communities, one rural (Siemreap) and one semi-urban (Kampong Cham). The diagnosis of diabetes and impaired glucose tolerance was based on 2-h blood glucose estimation using criteria recommended by the latest report of a WHO Expert Group. Blood pressure, anthropometry, habitual diet, and other relevant characteristics were also recorded. FINDINGS: Prevalence of diabetes was 5% in Siemreap and 11% in Kampong Cham. Prevalence of impaired glucose tolerance was 10% in Siemreap and 15% in Kampong Cham. About two-thirds of all cases of diabetes were undiagnosed before the survey. Prevalence of hypertension was 12% at Siemreap and 25% at Kampong Cham. People in Kampong Cham had higher estimates of central obesity than those in Siemreap. INTERPRETATION: Diabetes and hypertension are not uncommon in Cambodia. A quarter of all adults in the chosen suburban community had some degree of glucose intolerance. Since Cambodian society is relatively poor, and lifestyle is fairly traditional by international standards, these findings are unexpected.

The burden of mortality attributable to diabetes: realistic estimates for the year 2000.

OBJECTIVE: To estimate the global number of excess deaths due to diabetes in the year 2000. RESEARCH DESIGN AND METHODS: We used a computerized generic formal disease model (DisMod II), used by the World Health Organization to assess disease burden through modeling the relationships between incidence, prevalence, and disease-specific mortality. Baseline input data included population structure, age- and sex-specific estimates of diabetes prevalence, and available published estimates of relative risk of death for people with diabetes compared with people without diabetes. The results were validated with population-based observations and independent estimates of relative risk of death. RESULTS: The excess global mortality attributable to diabetes in the year 2000 was estimated to be 2.9 million deaths, equivalent to 5.2% of all deaths. Excess mortality attributable to diabetes accounted for 2-3% of deaths in poorest countries and over 8% in the U.S., Canada, and the Middle East. In people 35-64 years old, 6-27% of deaths were attributable to diabetes. CONCLUSIONS: These are the first global estimates of mortality attributable to diabetes. Globally, diabetes is likely to be the fifth leading cause of death.

Global prevalence of diabetes: estimates for the year 2000 and projections for 2030.

OBJECTIVE: The goal of this study was to estimate the prevalence of diabetes and the number of people of all ages with diabetes for years 2000 and 2030. RESEARCH DESIGN AND METHODS: Data on diabetes prevalence by age and sex from a limited number of countries were extrapolated to all 191 World Health Organization member states and applied to United Nations' population estimates for 2000 and 2030. Urban and rural populations were considered separately for developing countries. RESULTS: The prevalence of diabetes for all age-groups worldwide was estimated to be 2.8% in 2000 and 4.4% in 2030. The total number of people with diabetes is projected to rise from 171 million in 2000 to 366 million in 2030. The prevalence of diabetes is higher in men than women, but there are more women with diabetes than men. The urban population in developing countries is projected to double between 2000 and 2030. The most important demographic change to diabetes prevalence across the world appears to be the increase in the proportion of people >65 years of age. CONCLUSIONS: These findings indicate that the "diabetes epidemic" will continue even if levels of obesity remain constant. Given the increasing prevalence of obesity, it is likely that these figures provide an underestimate of future diabetes prevalence.

Diagnosis of GDM: a suggested consensus.

Despite recent attempts at building consensus, an internationally consistent definition of gestational diabetes mellitus (GDM) remains elusive. Within and between countries, there is disagreement between obstetric, medical, and endocrine groups as to the diagnosis and management of GDM. The current article aims to discuss the background to the controversy of GDM diagnosis and to address issues related to the detection and treatment of GDM in low-, middle-, and high-resource settings. The criteria recommended by the International Association of the Diabetes and Pregnancy Study Groups (IADPSG), the American Diabetes Association (ADA), and the World Health Organization (WHO) are endorsed. We also wish to put into perspective the importance of GDM, both during and after pregnancy, in terms of its relationship to overall women's health.

Improving tuberculosis prevention and care through addressing the global diabetes epidemic: from evidence to policy and practice.

Diabetes triples the risk of tuberculosis and is also a risk factor for adverse tuberculosis treatment outcomes, including death. Prevalence of diabetes is increasing globally, but most rapidly in low-income and middle-income countries where tuberculosis is a grave public health problem. Growth in this double disease burden creates additional obstacles for tuberculosis care and prevention. We review how the evolution of evidence on the link between tuberculosis and diabetes has informed global policy on collaborative activities, and how practice is starting to change as a consequence. We conclude that coordinated planning and service delivery across communicable and non-communicable disease programmes is necessary, feasible, and creates synergies that will help to reduce the burden of both tuberculosis and diabetes.

Cardiovascular mortality, all-cause mortality, and diabetes incidence after lifestyle intervention for people with impaired glucose tolerance in the Da Qing Diabetes Prevention Study: a 23-year follow-up study.

BACKGROUND: Lifestyle interventions among people with impaired glucose tolerance reduce the incidence of diabetes, but their effect on all-cause and cardiovascular disease mortality is unclear. We assessed the long-term effect of lifestyle intervention on long-term outcomes among adults with impaired glucose tolerance who participated in the Da Qing Diabetes Prevention Study. METHODS: The study was a cluster randomised trial in which 33 clinics in Da Qing, China-serving 577 adults with impaired glucose tolerance-were randomised (1:1:1:1) to a control group or lifestyle intervention groups (diet or exercise or both). Patients were enrolled in 1986 and the intervention phase lasted for 6 years. In 2009, we followed up participants to assess the primary outcomes of cardiovascular mortality, all-cause mortality, and incidence of diabetes in the intention-to-treat population. FINDINGS: Of the 577 patients, 439 were assigned to the intervention group and 138 were assigned to the control group (one refused baseline examination). 542 (94%) of 576 participants had complete data for mortality and 568 (99%) contributed data to the analysis. 174 participants died during the 23 years of follow-up (121 in the intervention group vs 53 in the control group). Cumulative incidence of cardiovascular disease mortality was 11.9% (95% CI 8.8-15.0) in the intervention group versus 19.6% (12.9-26.3) in the control group (hazard ratio [HR] 0.59, 95% CI 0.36-0.96; p=0.033). All-cause mortality was 28.1% (95% CI 23.9-32.4) versus 38.4% (30.3-46.5; HR 0.71, 95% CI 0.51-0.99; p=0.049). Incidence of diabetes was 72.6% (68.4-76.8) versus 89.9% (84.9-94.9; HR 0.55, 95% CI 0.40-0.76; p=0.001). INTERPRETATION: A 6-year lifestyle intervention programme for Chinese people with impaired glucose tolerance can reduce incidence of cardiovascular and all-cause mortality and diabetes. These findings emphasise the long-term clinical benefits of lifestyle intervention for patients with impaired glucose tolerance and provide further justification for adoption of lifestyle interventions as public health measures to control the consequences of diabetes. FUNDING: Centers for Disease Control and Prevention, WHO, the China-Japan Friendship Hospital, Da Qing First Hospital.

Impact of gestational diabetes mellitus screening strategies on perinatal outcomes: a simulation study.

AIMS: To evaluate the impact on perinatal outcomes of universal gestational diabetes (GDM) screening based on 1999 WHO and IADPSG diagnostic criteria; to assess the quality of the evidence (GRADE) to support GDM screening. METHODS: Simulation of a hypothetical cohort of community-based pregnant women with 10% GDM prevalence (1999 WHO). Most parameters were obtained from recent systematic reviews. RESULTS: Compared to no screening, screening based on 1999 WHO criteria (followed by treatment) reduced the incidence of large for gestational age (LGA) neonates by 0.53% (95% CI 0.37-0.74%; NNS=189) and of preeclampsia by 0.27% (0.10-0.45%; NNS=376). Screening based on IADPSG criteria reduced incidences by 0.85% (0.54-1.29%; NNS=117) and by 0.39% (0.15-0.65%; NNS=257), respectively. Compared to screening based on 1999 WHO criteria, screening with IADPSG criteria reduced the incidence of LGA by 0.32% (0.09-0.63%; NNS=309) and of preeclampsia by 0.12% (0.01-0.25; NNS=808). The quality of evidence for both screening approaches is very low. CONCLUSIONS: Universal screening for GDM has only a modest impact on pregnancy outcomes. The impact of screening based on IADPSG (vs. WHO, 1999) criteria is slightly larger. However, costs and resources should also be considered in local selection of a screening approach.

Cardiovascular risk reduction following diagnosis of diabetes by screening: 1-year results from the ADDITION-Cambridge trial cohort.

BACKGROUND: Uncertainties persist concerning the effects of early intensive management of type 2 diabetes and which patients benefit most from such an approach. AIM: To describe change in modelled cardiovascular risk in the 14 months following diagnosis, and to examine which baseline patient characteristics and treatment components are associated with risk reduction. DESIGN AND SETTING: A cohort of individuals from a pragmatic, single-blind, cluster-randomised controlled trial of 236 females and 361 males with screen-detected type 2 diabetes and without prior cardiovascular disease (CVD), from 49 GP surgeries in eastern England, examined at baseline (2002-2006) and after 14-months' follow-up. METHOD: Multiple linear regression was used to quantify the association between baseline patient characteristics, treatment components, and change in modelled 10-year cardiovascular risk (UK Prospective Diabetes Study [UKPDS] [version 3] risk engine). RESULTS: There was a downward shift in the distribution of modelled CVD risk over 14 months mean 31% (standard deviation [SD] = 14%) to 26% [SD = 13%]). Older individuals, males, and those with a larger waist circumference at baseline exhibited smaller risk reductions. Individuals prescribed higher numbers of drugs over the follow-up period, and those who decreased their energy intake or reduced their weight, demonstrated larger reductions in modelled risk. CONCLUSION: It is possible to achieve significant reductions in modelled CVD risk over 14 months following diagnosis of diabetes by screening. Risk reduction appeared to be driven mainly by prescription of higher numbers of drugs, decreased energy intake, and weight reduction. There was room for further risk reduction, as many patients were not prescribed recommended treatments.