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Diabetes Prevention in the Community

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“Obesity-fueled diabetes becomes a national concern”, the headline says.  It is becoming clear that the so-called “obesity epidemic” is worsening.  A recent report by the Centers for Disease Control (CDC) estimates that by 2050, 1/3 of American adults could have type 2 diabetes (T2D).  People with T2D have medical costs two times those without the disease that could be catastrophic to an already burdened U.S. healthcare system.  One estimate states that the cost of treating both diabetes and pre-diabetes exceeds $200 billion a year.  Currently 25 million people in the U.S. live with diabetes; 6 million are unaware they have the disease and about 60 million people are pre-diabetic putting them at risk for developing the disease.

There are two screening tests for Diabetes: the Fasting Plasma Glucose (FPG) (shown on the right) and the Oral Glucose Tolerance Test (OGTT) (shown on the left).  Values are different for each of them.

Many cases of diabetes are preventable.  People have been told for years to lose weight, eat a balanced diet, and get enough exercise to prevent a variety of chronic diseases, including diabetes.  Adherence to this advice is another story; is it possible to prevent diabetes in the population to make a difference?  The research shows promise.

Major Clinical Trials

The Diabetes Prevention Program (DPP) was a large randomized controlled clinical trial conducted with 3234 U.S. adults with glucose intolerance. A lifestyle intervention  (healthy diet, moderate physical exercise of 30 minutes a day 5 days a week) was compared with a drug intervention (metformin) plus standard care and a placebo group plus standard care.  The duration of the study was 2.8 years.  Results showed that losing a modest amount of weight along with other changes in diet and exercise habits could delay diabetes type 2 by 58%.  These results were shown in all ages and ethnic groups.  The individuals in the methformin group plus usual care reduced their risk by 31%.  The Centers for Disease Control collaborated with the research team to develop, evaluate and fund the program.

The Finnish Diabetes Prevention Study (DPS) randomized 522 overweight/obese individuals with impaired glucose tolerance (IGT) to either a individualized lifestyle intervention of diet and exercise or a control group for 3.2 years.  The subjects in the control group were given only written information about diet and exercise, but no individualized program. At a 2 year follow-up, the incidence of T2D was less than half that observed in the control group and was maintained for at least 4 years after the intervention ended.

In the first year, the intervention group self-reported a higher degree of lifestyle change compared to the controls that included a decreased intake of fat, a change in the quality of fat (less saturated fat intake), an increased consumption of vegetables, a deceased consumption of sugar, salt, and alcohol, and Increased exercise.

In addition to improved glucose tolerance several cardiovascular risk factors improved including a modest weight loss, a decrease in waist circumference, an increase in high-density lipoprotein cholesterol, a decrease in triglycerides, and a decrease in blood pressure.

Presently, 5145 overweight or obese adults with type 2 diabetes are participating in the  (Look AHEAD (Action for Health in Diabetes) randomized clinical trial. This study is comparing the effects of an intensive lifestyle intervention (ILI) with diabetes support and education (DSE) groups for the prevention of major CVD events. Averaged across 4 years, ILI participants had a greater percentage of weight loss than the DSE group and greater improvements in treadmill fitness, hemoglobin A1c, systolic and diastolic blood pressure levels, high levels of high-density lipoprotein cholesterol, and triglycerides.  The study will continue for a total of 11.5 years.

Community-based Prevention Programs

Finland became the model of healthy eating when it improved the heart health of its population with the North Karelia Project of the 1970’s and 1980’s.  This community-based program reduced the incidence of heart-related deaths by 70% after Finland had experienced one of the highest rates of heart disease in the world. Diabetes type 2 became the next target due to an expenditure of 11% of its total healthcare on diabetes management.  Due to the tremendous success of the DPS, Finland wanted to extend the interventions used in the clinical trial to the population in general in a cost-effective manner. Therefore, FIN-D2D was established from 2003 to 2007.  The primary goal of FIN-D2D was to reduce the incidence of T2D in five hospital districts.  Thus, FIN-D2D is becoming a model for a countrywide diabetes prevention strategy.  As of this writing, evaluation of this program is ongoing.

Healthy-Living Partnerships to Prevent Diabetes (HELP-PD) is a community-based program that compared lifestyle and weight loss intervention with usual care in 301 overweight or obese individuals with prediabetes.  Lifestyle interventions were conducted by registered dietitians and lay community health workers at a diabetes care center.  The goals were to achieve at least 7% weight loss and increased physical activity for at least 180 minutes per week. The intervention consisted of an intensive phase (weekly group meetings) for 6 months  followed by  a maintenance phase with monthly group meetings with phone or personal contact.  The usual care group received two visits from a RD with a quarterly newsletter.

The intervention group reduced blood glucose levels from 105.5 mg/dL at baseline to 101.3 mg/dL compared with less than 0.3 mg/dL in the usual care group. Weight loss in the intervention group was 7.3 % of body weight compared to 1.3% of body weight in the usual care group.  The intervention group reduced their waist circumference by 5.9 cm vs. 0.8 cm in the usual care group along with improved fasting insulin due to insulin resistance.  Fewer cases of diabetes developed in the intervention group – two vs. seven in the usual care group although the sample size was small.  In a press conference, David Goff, PhD, chair of the department of epidemiology and prevention at Wake Forest University School of Medicine said: “We believe this approach is able to be readily disseminated to the more than 3,000 diabetes education centers in the United States”.

The YMCA, CDC and Diabetes Prevention Shows Promise

There are over 2500 YMCA facilities serving more than 10,000 rural, suburban and inner-city communities that are positioned to provide health promotion programs such as diabetes prevention.  57% of U.S. households are located within 3 miles of a YMCA.

A pilot study was conducted with about 350 participants in Indiana, Kentucky, and Minnesota. Using the DPP as a model, a 16-week course was provided that emphasized knowledge skills for goal setting, self-monitoring and problem solving along with the baseline educational materials for diabetes prevention.   At 4-6 months follow-up, mean weight loss of 5.7 kg (12.5 lbs) was achieved in the intervention group vs 1.8 kg (4.0 lbs) for controls.  Total cholesterol concentration showed a meaningful difference with a -21.6 mg/dL vs. +6 mg/dL in the intervention and control group, respectively.  These differences persisted at 12-14 month follow-ups.

Robert T. Ackerman, MD, MPH states: “This is the first study to demonstrate that the YMCA is promising vehicle for a the dissemination of the DPP lifestyle intervention into the community…”

Insurers such as the UnitedHealth Group are teaming up with the YMCA and retail pharmacies to keep people healthier to achieve lower costs and lower premiums.

The insurer will work with Y “lifestyle coaches” in seven cities presently to help people at high risk for diabetes reduces their risk with just a modest loss of weight.  An effort by the CDC to finance Y programs may be initiated in 10 additional locations around the country.  This is thought to offer a glimpse of the future of health insurance.

Prevention Tools

The National Diabetes Education Program (NDEP) along with the Centers for Disease Control and Prevention and the NIH has developed educational tools for health care providers who would like to implement the findings of the DPP in a real-life setting.  The NDEP GAMEPLAN (Goals, Accountability, Monitoring, Effectiveness, Prevention through a Lifestyle of Activity and Nutrition is divided into two parts: a healthcare provider toolkit and copier-ready tools for patient use.  All materials are copyright-free and can be downloaded. H  http;// website.

The FIN-D2D program to identify individuals at high risk for type 2 diabetes used a screening tool.  The Finnish Diabetes Risk Score (FINDRISC) can be a self-administered screening tool that contains 8 scored questions with the total test score estimating the probability of developing T2D.  People who score below 7 are given no prevention measures; those between 7-14 are given written information about health-enhancing lifestyles and diets and offered local physical exercise opportunities and nutrition education services.  Those who score above 15 or more are considered to be at high-risk and are referred to an intervention program after a health exam and appropriate treatment.

What Works?

Group interventions appear to be more effective than individual counseling and are cost effective and timesaving while providing more support, motivation, and positive feedback for success.  Referring back to the original highly successful North Karelia Project in Finland to prevent CVD, a community-based prevention program for chronic disease ideally should include the participation of many roles of primary healthcare voluntary organizations, the food industry and supermarkets, schools, and the local media.

Will prevention be cost-effective?

With its serious complications, diabetes has become the sixth leading cause of death in the U.S.  Adults with diabetes have heart disease death rates 2 to 4 times higher than adults without diabetes and their risk for stroke is 2 to 4 times higher. Diabetes is the leading  cause of blindness among adults age 20-74 and the leading cause of end-stage renal disease.  More than 60% of nontraumatic lower-limb amputations occur among people with diabetes.  Recent studies have found a possible links between diabetes and Alzheimer’s disease. This finding suggests that people may be able to prevent AD by working to prevent diabetes through exercise and eating habits.

Most prevention studies have been performed in research settings in populations with IFG and IGT (high-risk individuals).  Can the same results be obtained daily practice and in the community setting?  Presently, there are few studies that examine this issue. Diabetes affects less than 8% of the population presently, but diabetics represent nearly 20% of  U.S. hospitalizations in 2008 according to a report by the federal Agency for Healthcare Research and Quality. The Urban Institute has said that making the YMCA Prevention Program available nationwide could save our nation $191 billion over 10 years.

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