Diabetes Prevention: A Unique Opportunity

Unlike type 1 diabetes, type 2 diabetes can be prevented or delayed. However, as we have already established, the prevalence of type 2 diabetes is rising. We have recognized that major contributors to this rise are overweight and obesity; one estimate is that 70% of the risk for type 2 diabetes can be attributed to overweight and obesity.^[1] The good news is that making even modest lifestyle changes in diet and exercise patterns can reduce risk significantly.^[2] Health plans and employers that explore and apply behavior modification strategies to help members/employees make these lifestyle changes can reap short- and long-term benefits.

Obesity is a major risk factor for prediabetes and diabetes as well as for other criteria of metabolic syndrome (hypertension and dyslipidemia).3 Each kilogram (2.2 pounds) of weight gain over 10 years can increase risk for developing diabetes by 4.5%.^[1] Obesity, especially in those exhibiting the manifestations of metabolic syndrome, is also a risk factor for other leading causes of death and disability, such as heart disease, stroke, and some forms of cancer.^[3]In patients with diabetes already at a higher risk for CVD, being overweight or obese and having metabolic syndrome significantly increase cardiovascular morbidity and mortality.^[4] Excess body weight also complicates the management of diabetes by worsening both hyperglycemia and hyperinsulinemia.^[5]

Body mass index (BMI) is one way to measure overweight and obesity (Table 1). It is worth emphasizing that BMI is not a measure of the amount of body fat, but rather is a ratio of weight to height. Therefore, the BMI ranges in Table 1 are not exact definitions of healthy versus unhealthy weights since some very muscular individuals may have a high BMI, but low body fat.^[6] Although being overweight or obese according to BMI values does increase health risks,^[6] research shows that the waist-to-hip ratio, or so-called^[6] abdominal obesity, may be a more accurate predictor for diabetes.^[7]

Employers Can Help Fight Obesity Obesity is a major and growing concern for employers in the United States. Obesity costs U.S. employers about $13 billion per year in medical expenses and lost productivity.[5] "Employers recognize that the only real way to control health care costs long-term is to adopt comprehensive health improvement programs that address the disease, lifestyle, and behavioral factors in a strategic framework based on sound epidemiology,” says Helen Darling, President of the National Business Group on Health (NBGH). In response to the increasing epidemic, the NBGH (formerly the Washington Business Group on Health) launched an obesity initiative in June 2003. The goals of the initiative are to: Increase awareness about why obesity is an issue in which employers should become involved Define specific steps employers can take to promote a healthy weight for their employees and dependents Encourage health plan and vendor efforts to implement effective interventions to address obesity NBGH uses a variety of methods to promote its undertaking, including educational summits and forums that bring together employers, scientists, health plans, and health care industry representatives to examine solutions that work; dissemination of issue briefs that provide information and solutions on weight-related topics; a communications tool kit to help employers effectively address this potentially sensitive issue with employees; a cost calculator that helps the employer estimate its costs from overweight and obesity; and return-on-investment (ROI) data to help make the business case for investing resources in promoting healthy weight. The obesity initiative encourages employers to address issues not previously considered related to health benefits, such as: Whether their facility promotes physical activity through walking paths and stairwell climbing programs The nutritional value of the foods offered in the onsite vending machines and the company cafeteria Employee knowledge and understanding about the definitions of healthy weight, overweight, and obesity; the impact of overweight and obesity on health; and how to interpret a BMI measurement All health care stakeholders need to participate to effectively address the obesity epidemic. Employers can take a number of actions with a demonstrated ROI to promote healthy weight for their employees and dependents.

Prediabetes is a condition in which a person has blood glucose levels higher than normal but not high enough to meet the accepted criteria for being diagnosed as having diabetes.^[9,10] A person with prediabetes has either impaired fasting glucose (IFG) or impaired glucose tolerance (IGT), or both.^[11]

In IFG, an individual’s blood glucose level is 100 to 125 mg/dL after overnight fasting. In IGT, the blood glucose level is 140 to 199 mg/dL after a two-hour oral glucose tolerance test. In either case, glucose levels are below those indicating full-blown diabetes.11 Prediabetes is a powerful predictor of future diabetes.^[12] In one study, about 11% of people with prediabetes developed type 2 diabetes during each ensuing year of the study. Other studies show that most people with prediabetes developed type 2 diabetes within 10 years.^[12]

Estimates of the prevalence of prediabetes among Americans aged 40 to 74 years range from 12 million to 41 million. There is little research that has examined this condition in those younger than 40 years, so we do not know its overall prevalence.^[12-14] A number of studies have demonstrated that lifestyle interventions or medication regimens can prevent or delay the progression from prediabetes to type 2 diabetes (Table 2). Perhaps the most significant finding is that modest changes in weight and physical activity can lead to major decreases in the development of diabetes from prediabetes.^[15] This provides significant benefits by also delaying or preventing the major complications of diabetes: heart disease and stroke, nephropathy, retinopathy, and neuropathy. Delaying or preventing diabetic complications by treating prediabetes can improve a person’s quality of life and may extend their lives. Further, preventing or delaying complications may also provide cost savings for employers and/or payers.^[15]

Metabolic syndrome is a group of related risk factors for kidney and cardiovascular disease (CVD), which include obesity and insulin resistance.^[20] Three different groups have proposed clinical criteria for metabolic syndrome: the National Cholesterol Education Program (NCEP), the World Health Organization (WHO), and the American Association of Clinical Endocrinologists (AACE) (Table 3).^[21]

Although the three sets of criteria differ somewhat, they have in common the following components ^[21]:

• Overweight or obesity
• Elevated triglycerides
• Low high-density lipoprotein (HDL) cholesterol
• High blood pressure
• IFG or IGT or both (prediabetes)

Metabolic syndrome is very common: one study found that 44% of Americans over 50 years of age met the NCEP criteria. In addition, 86% of people with diabetes have metabolic syndrome.4 A person who has one component of the syndrome is at increased risk for having one or more of the others.^[20]

Barrier-Based Diabetes Education Initiatives Improve HEDIS® Results A mid-sized health plan in the Northeast examined its HEDIS® results for diabetes testing and decided that it needed to improve existing efforts. In the past, the health plan employed newsletter mailings to educate members about the consequences of diabetes. High-risk members received case management services, but these services were limited to a small portion of the total diabetes population. The organization felt it was critical to provide information to members early in the course of their disease in order to prevent complications. The challenge was how to deliver the education in a manner that would make a difference. Initial Barriers The health plan wanted to understand the root causes for members failing to achieve optimal care outcomes. A telephone survey of 250 members with diabetes was conducted by diabetes nurses, and the results revealed: 85% performed self-monitoring of blood glucose levels; of those, 48% tested more than once per day. 43% had an A1c level drawn within the past one to three months; of those, 64% were not aware of their results 81% had their cholesterol measured within the past year. 46.5% had a dilated retinal eye examination in the past year. The health plan identified a need for: Member education about blood glucose and cholesterol testing Member education about the need for retinal eye examinations Member assistance with glucose self-monitoring and proper use of glucometers The plan decided that consistency and repetition would be integral to improving its diabetes education. Initial Interventions Prior to the initiation of interventions, the health plan developed the following: An Oracle database: The database allowed tracking of tests and their results for each member with diabetes. Barrier analysis: Phone calls to analyze members who were not receiving screening tests. The health plan then implemented the following interventions: Mailing of “Focus” eye care educational materials: Three mailings were sent during the year to members who had not received a retinal eye examination (see Appendix 4). These mailings included a reminder written partially in blurry text to encourage members to make an appointment,reinforcing the fact that eye exams are important. A glucose meter program: All members with diabetes received an expanded selection of equipment and accompanying education. Evaluation The health plan noted that the interventions were starting to positively impact testing outcomes for A1c and LDL-C, but that more time and effort were required to achieve significant gains. The rates for retinal eye examinations dropped from baseline, so the health plan reassessed this issue. Additional Barriers Identified In addition to barriers previously identified, the health plan recognized new ones through discussion with practitioners and members: Referral requirements for eye care created a delay in services in one portion of the practitioner network that used different utilization management procedures. Members were unaware of the seriousness of their condition due to the silent nature of diabetes early on in the course of the disease process. Based on feedback received from members and practitioners during barrier analysis, the health plan decided to expand educational efforts to include a broader pool of patients and to use different teaching modalities. Additional Interventions Implemented Member educational seminars Eating for Health” and “Cooking With a Diabetic Chef”: Conducted by a dietitian, the focus of these seminars is on proper meal planning and food selection. They include a healthy lunch to demonstrate the teaching content. Christmas party for children with diabetes: The plan supplied gifts and entertainment while educating parents and children about diabetes and strategies for managing the disease. The children met other kids with diabetes, and the parents had the opportunity to form a support network. Web site education: Members could interact with a nurse via the Internet. A “Nurse Care Call” educational program: Members who were not obtaining screening tests according to HEDIS® guidelines received calls from a nurse over an eight- week period. The nurse provided education and discussed issues or questions the member had about diabetes. Summer camp for children with diabetes: The health plan sponsored children’s attendance at a week-long camp offered by the ADA. The children are selected through a coloring contest, and so far the health plan has been able to sponsor all entrants. Reevaluation Results were statistically significant from baseline to final remeasurement for A1c and LDL-C screening. Diabetes eye examinations did not improve significantly but showed positive gains. Conclusions The health plan was able to improve HEDIS® screening results for diabetes by tracking members throughout the year who were not receiving services and by providing continuous reminders and education. The personal contact by nurses permitted the health plan to tailor education to member-identified needs. The health plan did not assume it knew the reasons for members’ nonadherence to treatment recommendations; instead it went directly to the source and learned firsthand the issues that were confronting patients with diabetes. This information proved instrumental in developing successful interventions and eventually resulted in measurable improvements in care.

Screening during routine doctor visits may be the most cost-effective way to find people at risk for diabetes. Screening will also detect people with undiagnosed diabetes and identify those with significant risk factors (prediabetes, metabolic syndrome) for developing diabetes.^[15] These people can then begin treatment.

Checking height and weight and calculating the BMI can identify those people with a high likelihood of having metabolic syndrome. Those identified as overweight or obese can then be screened for blood pressure, lipid abnormalities, and a fasting blood glucose (see Table 4). For detecting those with prediabetes who are not obese, but who have genetic or other risks, both the two-hour oral glucose tolerance test (OGTT) and the fasting plasma glucose (FPG) test can be used. The FPG test is more convenient for patients, easier to administer, less costly, and more reproducible.^[15] The ADA recommends that the FPG test be given in the morning because afternoon values tend to be lower and more variable.^[15]

The ADA also recommends screening adults who have an average risk for diabetes during each regular health care visit, starting at age 20 (Table 4).^[1] Research has shown that in addition to overweight and obese people, even those who are only slightly overweight according to BMI values have a higher risk for metabolic syndrome.^[22]

Candidates for screening who have a higher risk for prediabetes and diabetes include the following^[15]:

• People aged 45 years or older who are overweight
• People younger than 45 years old who are overweight and have another risk factor for diabetes, such as having a first-degree relative with diabetes or having hypertension or dyslipidemia

Efforts to prevent obesity, diabetes, and their sequelae have one major theme in common: lifestyle modification. Lifestyle modification requires permanent changes in behavior, including dietary changes and changes in the amount of physical activity.^[23]

Losing weight, changing nutritional habits, increasing physical activity, and quitting smoking are the most effective ways to reduce the risk of prediabetes and diabetes. These changes can also help to lower blood pressure and normalize blood lipid levels.^[20]

Preventing or reversing overweight and obesity is a formidable task in a culture where people need not expend much energy doing everyday activities and calorie-dense, inexpensive foods are both heavily advertised and readily available.23 In the United States, nearly half of all women and more than a third of all men have tried to lose weight, most unsuccessfully.^[3] Table 5 shows the recommendations of the National Institutes of Health for utilizing the different types of weight-loss treatment.

To lose weight, any low-calorie diet can work; remaining consistent with dietary changes is more important than the type of diet chosen.^[24] Research shows that behavioral therapy plus prescribed low-calorie meals work better than behavioral therapy alone.^[23]

Maintaining weight loss is more challenging than initial weight reduction, and it requires long-term behavioral treatment for many. Obesity, like diabetes, is a chronic condition.^[23] Strategies that are associated with successful long-term weight loss include^[25]:

• Eating a diet low in calories (~1400 kcal/day) and fat (24% of total energy intake)
• Monitoring body weight often
• Participating in regular physical activity (about one hour of moderate activity per day)
• Reducing both portion sizes and snacking
• Eating breakfast daily
• Eating meals away from home fewer than four times a week
• Watching television less than an average of three hours per week

Even when weight loss is not the goal of a change in diet, eating fewer fats, particularly saturated fats, and more whole grains and dietary fiber can lower lipid levels and reduce the risk of developing metabolic syndrome and type 2 diabetes.^[20,26,27]

The ADA and the American Heart Association (AHA) recommend the following nutritional guidelines^[25]:

• Consume a variety of fruits, vegetables, grains, low-fat or nonfat dairy products, fish, legumes, poultry, and lean meats
• Limit foods high in saturated fat, trans-fatty acids, and cholesterol; substitute unsaturated fat from vegetables, fish, legumes, and nuts
• Emphasize a diet rich in fruits, vegetables, and low-fat dairy products
• Limit salt to 6 g/day (2,400 mg sodium) by choosing foods low in salt and limiting the amount of salt added to food
• Limit alcohol intake to no more than two drinks per day (men) or one drink per day (women)

Recent diabetes prevention studies demonstrate that exercise is a major factor in preventing diabetes (see Table 2).^[28] Even low-intensity activities, such as walking, decreased the rate of diabetes.

Physical activity also makes maintaining weight loss easier.^[23] Most weight-loss studies suggest that maintenance requires daily activities representing 60 to 75 minutes of a moderately intense activity, such as walking, or 35 minutes of vigorous activity, such as jogging.^[25]

Physical activity need not be routine to be effective (e.g., planned, aerobic, completed in a single session). Lifestyle activities such as using stairs, parking at a distance from stores, and walking the dog are also effective.^[20] Changes in lifestyle activity may work better for people who say they hate to exercise.^[23]

Several studies have shown that cigarette smoking is a risk factor for type 2 diabetes and greatly increases the risk of ischemic vascular disease in patients with diabetes. In one study, men and women who smoked two packs a day had a 45% and 74% greater incidence of diabetes, respectively. Quitting smoking reduced the rate to that of nonsmokers after five years in women and 10 years in men.^[1] Data for 2003 show that about 22% of the U.S. population over age 18 smokes.^[29]

Smokers who are looking for help to quit have been shown to have better success with group therapy or individual counseling than with self-help methods.^[30] The addition of nicotine replacement therapy may increase the effectiveness of other interventions.^[30]

Nicotine replacement helps people to stop smoking, as found by the Cochrane review of over 90 trials. Overall, it increased the chances of quitting about one and a half to two times, regardless of the level of supplemental support and encouragement.^[30]

Medications that may help smokers quit include selected antidepressants (bupropion, nortriptyline, and fluoxetine) and clonidine. (Note that clonidine has side effects that limit its use.) It is unknown how antidepressants aid in smoking cessation. At this time there is insufficient information to know if it is a class effect or drug-specific.^[30]

Data from 31 trials that included over 26,000 smokers demonstrated that brief advice from doctors during routine care increases the rate of smoking cessation. More intensive advice is slightly more effective.30 Health care professionals should not fear that they will antagonize smokers if they bring up tobacco use, assess interest in smoking cessation, provide encouragement, and help smokers quit, according to one survey of 2,714 cigarette smokers. These smokers reported greater satisfaction with physicians and nurses who did offer smoking cessation advice during an encounter.^[31]

In summary, physician advice, counseling, and nicotine replacement therapy have demonstrated the most success in helping smokers quit.

Making long-term changes to eating and lifestyle behaviors is extremely difficult for most people.^[25] Health care professionals can help by first ensuring that their patients understand the risks caused by poor choices and then empowering them to make changes.

One factor that affects whether people will adopt a behavior to prevent obesity or diabetes is whether they understand the risk of not doing so.^[32] Research shows that many people have a bias toward optimism, which can lead them to downplay the possibility of developing a disease, despite knowing they have the risk factors for it.^[32] An awareness of this bias to dismiss the risk is important for health care workers to consider when developing their communication to patients. Other studies have shown differences between the genders and races in perceiving risk. White men score lower than all other categories of respondents on risk perception surveys, and women score higher than men, regardless of race.^[32]

Motivational interviewing is a successful method of interacting with patients who are at risk for obesity or diabetes.^[33] It is a client-centered approach that addresses ambivalence in people who need to make lifestyle changes. The basic principles include^[33]:

• Expressing empathy for how difficult change is
• Developing discrepancy between the person’s goals and behavior
• “Rolling with resistance” by restating the problem and asking the person to help brainstorm a solution
• Supporting self-efficacy by respecting autonomy and emphasizing personal control

To help people who are motivated to change their behaviors, health care workers can help the patient set specific, realistic goals. Setting small, achievable goals makes success more likely and provides a solid foundation for further changes.^[25]

Health care workers can suggest strategies for lifestyle modification, including^[25]:

• Self-monitoring—daily records of food intake, physical activity, smoking
• Stimulus control—avoiding triggers that prompt unwanted behaviors
• Problem-solving—identifying barriers and ways to overcome them

Physicians who find it difficult to apply behavior modification treatment can use the support of a nurse, medical assistant, or dietitian in the office or clinic for some aspects of treatment. Referring patients to a registered dietitian or a legitimate commercial or self-help program in the local community is also a practical option.^[25]

Although trials have shown drug therapy to be successful in preventing or delaying diabetes, it can be less beneficial than lifestyle change for a variety of reasons^[15]:

• Metformin and acarbose are considerably less effective than lifestyle modification, particularly in older or less overweight patients.
• Glucose-lowering drugs require monitoring, may have significant adverse side effects, and are contraindicated in some individuals
• Prescribing a medication to delay the onset of diabetes that is also used to treat diabetes increases a person’s total years of drug exposure. This may increase the likelihood of unwanted drug effects. When considering all factors, evidence does not support the use of drug therapy as a substitute for, or a routine addition to, lifestyle modification to prevent diabetes. As a result, the ADA does not currently support the routine use of drugs to delay or prevent diabetes.^[15]

Beyond the Barriers Identifying and understanding barriers is critical for developing interventions that will be effective in improving diabetes care. Collecting data for the sake of reporting results does little to improve care; likewise, actions that are not correlated to accurate interpretation of data often fail to achieve desired results. In 1999, one health plan found that 87% of its members with diabetes received one A1c test annually, while only 64% received two or more tests, and 30% had poorly controlled A1c levels. To interpret this data and identify why so many members with diabetes were not being tested for A1c levels, or had poor A1c control (as measured through HEDIS®), the organization researched its barriers to care. Barrier Analysis The health plan used four approaches to barrier analysis: A review of the literature, including citations from professional organizations, scientific journals, published studies, and government agencies, provided the health plan with information about complications of diabetes, clinical management recommendations and intervention strategies. The health plan concluded from the literature that managing A1c was critical to the overall health of its members with diabetes. A work group and committees composed of experts with knowledge of diabetes care, education, data analysis, billing and claims coding, and quality management assessed the health plan’s data, with the help of local practitioners, and determined that it needed to place more emphasis on self-management skills and on better coordination of services with plan practitioners. Health plan participation in a state diabetes advisory group that included state legislatures, health agencies, health care professionals, consumers, community health centers, and other health insurers provided insights into the plan’s outcomes. From this experience the health plan concluded that the physicians in its network were not complying with the ADA recommendations for diabetes care. Use of quality improvement tools, including brainstorming and fishbone diagrams, allowed the organization to dissect issues impeding care into distinct categories. A fishbone (or cause-and-effect) diagram is a graphic technique of identifying cause-and-effect relationships among factors in a given situation or problem. From this analysis process, the health plan concluded that its major barriers to diabetes care were: Lack of member education about the importance and need for recommended screening examinations Lack of physician awareness about the diabetes program and diabetes education network offered by the health plan Failure of physician to adhere to clinical practice guideline testing recommendations Limited physician knowledge regarding patients’ history of diabetes Interventions: To address these barriers, the health plan developed several approaches. Interventions Conclusion: By using a thorough barrier analysis, the health plan was able to identify key issues affecting care and driving performance down. Interventions specific to root causes were then developed and implemented. With each remeasurement, the health plan assessed the strength of interventions and identified any new barriers to care. In the first year following implementation of this initiative, the health plan was able to improve A1c screening from a baseline of 86.7% to 90.9% and A1c control from 30.7% to 21.4% (inverse measure). This health plan was successful in a short period of time as a result of the systematic barrier analysis and tailored interventions, a valuable approach that can be used in all quality improvement projects.

Evidence shows that lifestyle changes can prevent or delay prediabetes from progressing to type 2 diabetes. If health care organizations focus on the elements of metabolic syndrome, in particular overweight and obesity, lowering cholesterol, and control of hypertension, as well as on smoking cessation, millions of Americans are likely to benefit. The advantages of tackling these problems are not limited to diabetes prevention; the risks for cardiovascular disease, kidney disease, and some forms of cancer may also decrease. Health care organizations have an extraordinary opportunity to take the lead in addressing a national health crisis.

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26. McKeown NM, Meigs JB, Liu S, Saltzman E, Wilson PWF, Jacques PF. Carbohydrate nutrition, insulin resistance, and the prevalence of the metabolic syndrome in the Framingham Offspring Cohort. Diabetes Care. 2004;27:538-546.

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33. Carino JL, Coke L, Gulanick M. Using motivational interviewing to reduce diabetes risk. Prog Cardiovasc Nurs. 2004;19:149-154.