Type 2 diabetes can be prevented in your patients
Did you know that more than a third of your adult patients have prediabetes and there is something you can do to prevent the disease in more than half of them ?
Currently, 86 million American adults have prediabetes and nearly 90% are unaware of their disease status. In people over the age of 60 years, nearly half have prediabetes , approximately 11% of whom will progress to type 2 diabetes if nothing is done . The main risk factors for type 2 diabetes are also increasingly common, including obesity, hypertension, dyslipidemia, and advancing age. There is an evidence-based national program that can reduce this progression to type 2 diabetes and can substantially reduce morbidity, mortality, and national healthcare expenditure. This program, called the National Diabetes Prevention Program (NDPP), is an intensive lifestyle intervention based upon the Diabetes Prevention Program (DPP) study.
The Diabetes Prevention Program study
The DPP study, published in 2002, took more than 3000 Americans who had prediabetes or gestational diabetes and looked at interventions to prevent new-onset type 2 diabetes. The three arms included routine care, metformin, and an intensive lifestyle intervention . The lifestyle intervention of the DPP focused on improving diet choices, increasing physical activity to a minimum of 150 minutes per week, and a 7% weight-loss goal by the end of the program. The lifestyle intervention group had a reduced incidence of type 2 diabetes by 58% and metformin reduced new-onset diabetes by 31% after an average of 2.8 years. A 10-year follow-up study of this cohort showed that the original DPP lifestyle group still had a decreased incidence of diabetes by 34% and the metformin group had an 18% decreased incidence of new-onset type 2 diabetes .
What is the National Diabetes Prevention Program?
With the significant results of the DPP, the Centers for Disease Control and Prevention (CDC) instituted the NDPP to make this intervention community based and translatable to the general public. The NDPP curriculum is a year-long program consisting of 16 weekly hour-long sessions over the first 6 months followed by six monthly sessions in the second half of the year . Participants gain insight on preventing stress, making healthier food choices, and rethinking the complexity of cues that led to their original lifestyle habits. The NDPP is required to be led by a certified lifestyle coach and follow the CDC-approved curriculum. The mainstays of the program are achieving a minimum 7% weight loss goal by reducing caloric and fat intake and increasing physical activity to at least 150 minutes per week.
How do I find eligible patients?
Your practice is full of them. In fact, odds are one in three adult patients in your practice would qualify for this program. As most individuals with prediabetes are not aware of the diagnosis, you cannot count on specific signs or symptoms to announce that someone has prediabetes. This means that screening those at risk is crucial to halt the progression to type 2 diabetes, which can occur in as little as 5 years.
A number of methods can be employed to assess patients during or after office visits to determine if they are eligible to participate in the NDPP. The American Diabetes Association recommends that all people with a body mass index (BMI) >25 kg/m2 and at least one risk factor be screened for prediabetes/diabetes. Further, all adults above the age of 45 years should be screened. Additionally, the CDC provides a free risk questionnaire that can be answered by your patients to quickly determine their risk .
To help systematically find patients in your practice, an electronic health record query for patients with a BMI greater than 24 kg/m2 and with a blood glucose level in the prediabetic range can quickly draw up a list of at-risk patients [7, 8].
Patients should be counseled during the visit if they are at high risk for prediabetes. Informing your patients about prediabetes and the risk of progression to type 2 diabetes is the first, most important step. Further, let your patients know about the NDPP and help them find the program. There is a national registry of NDPP programs at the CDC website . While a referral to NDPP is not necessary, patients are more likely to enroll in healthy habits and programs when recommended by their healthcare provider.
How can I refer patients to the National Diabetes Prevention Program?
Many insurance companies already cover the NDPP, but individual copays and deductibles may still apply. Starting in January 2018, NDPP will be a required benefit for Medicare. To qualify for participation in the program, participants must have the following:
- BMI of at least 24 kg/m2 (or at least 22 kg/m2 if self-identified as Asian);
- Presence of one of three of the following blood glucose tests:
- Hemoglobin A1c test with a value between 5.7% and 6.4%;
- Fasting plasma glucose of 100–125 mg/dL;
- 2-hour post glucose of 140–199 mg/dL (after 75 g glucose load).
Commonly used Current Procedural Terminology and International Classification of Diseases, Tenth Revision codes to qualify individuals for DPP are listed . If weight-loss goals are achieved, the patient may qualify for ongoing maintenance sessions of DPP based on their insurance.
Engagement with the local NDPP is crucial to enlist feedback regarding the patient’s participation to ensure the program is being utilized to its full potential. Locations of the NDPP can be within local community centers, YMCAs or faith-based organizations, or healthcare systems. Physicians can help reinforce the necessary healthy habits while participating in NDPP. With the right engagement and support, this can help not only the health of your patients, but also their families and even their communities.
High levels of prediabetes unawareness and rapid progression to type 2 diabetes are only a couple of reasons why it is so important to be proactive in managing the health of at-risk patients. Helping our patients to live healthy lives is a core part of all of our practices, but the time and skills for coaching our patients about exercise and dietary habits can be challenging. However, there is an evidence-based program in your area with skilled coaches that can cut your patients’ risk of getting diabetes by 50%. Instilling healthy habits as early on as possible is key to improving our patients’ quality of life and reducing the occurrence of type 2 diabetes, and the NDPP is one way to effectively do just that.
- Center for Disease Control and Prevention. A Snapshot: Diabetes in the United States. 2014. Available at www.cdc.gov/diabetes/pubs/images/diabetes-infographic.jpg. [Accessed March 21, 2017].
- Haas L. Being Active: Older Adults with Diabetes and Prediabetes, 2014. Available at http://diabetesstopshere.org/2014/05/01/being-active-older-adults-with-diabetes-and-prediabetes. [Accessed April 10, 2017].
- Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002; 346: 393–403.
- Diabetes Prevention Program Research Group, Knowler WC, Fowler SE et al. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet 2009; 374: 1677–1686.
- Center for Disease Control and Prevention. National Diabetes Prevention Program: Lifestyle Change Program Details. 2016. Available at www.cdc.gov/diabetes/prevention/lifestyle-program/experience/index.html. [Accessed February 4, 2017].
- American Medical Association. Preventing Type 2 Diabetes. Available at www.cdc.gov/diabetes/prevention/pdf/STAT_toolkit.pdf. [Accessed February 4, 2017].
- Center for Disease Control and Prevention. National Diabetes Prevention Program. Available at www.cdc.gov/prediabetes. [Accessed April 10, 2017].
- Center for Disease Control and Prevention. National Diabetes Prevention Program: Program Eligibility. Available at www.cdc.gov/diabetes/prevention/lifestyle-program/deliverers/eligibility.html. [Accessed February 4, 2017].