As the number of U.S. patients diagnosed with type 2 diabetes surges to new levels, researchers know interventions that could delay or prevent the disease are underused.
A paper outlining that argument titled "Evidence for the Prevention of Type 2 Diabetes Mellitus,"(jaoa.org) was published in the November issue of The Journal of the American Osteopathic Association.
Corresponding author and family physician Jay Shubrook, D.O., of Fairfield, Calif., told AAFP News that his professional work centers on diabetes.
"My research is focused on early intervention in prediabetes and new onset type 2 diabetes," said Shubrook. "My clinical practice (Solano County Family Health Services) is running a consultant team service for people with diabetes and its related disorders."
Shubrook is also a professor in the Primary Care Department at Touro University California College of Osteopathic Medicine and the director of clinical research and diabetes services there.
- Authors of a new evidence-review paper say there is strong evidence that type 2 diabetes can be largely prevented, or at least delayed.
- They found that the best consistent results came from long-term lifestyle intervention programs such as the Diabetes Prevention Program (DPP).
- A cost-effectiveness modeling study of widespread implementation of the National DPP for Medicare beneficiaries showed a 37 percent reduction in new-onset diabetes at a cost savings of $1.3 billion over 10 years.
He and his co-authors noted that obesity and obesity-related diseases in the United States have reached "epidemic proportions" with no end in sight. And they said that because type 2 diabetes is a common metabolic complication of obesity, it's no surprise that in 2016, one in 10 U.S. adults had been diagnosed with the disease.
The numbers were even worse for prediabetes, which affects one in three adults and one in two adults older than 65.
"There are simple and affordable tests that can be used for screening, and there is enough time between the appearance of risk factors and disease development to make such screening an effective tool for prevention," they wrote.
Shubrook said in an interview that the paper was the culmination of an evidence-based review. "There is very strong evidence that type 2 diabetes can be largely prevented or at least delayed. The best consistent results came from long-term lifestyle intervention programs such as the Diabetes Prevention Program (DPP).
"However, metabolic surgery is also a potent intervention to reduce risk of progressing to type 2 diabetes, and there are medications -- some for diabetes and some for general weight loss -- that also reduce diabetes risk," he added.
"Family physicians are already overwhelmed with patients with diabetes in our practices, and it is going to get a lot worse if we do not act now. We need to use those programs that have been shown to provide both short- and long-term benefit in reducing type 2 diabetes risk.
"This is good for our patients, but also good for the health of our nation. Physicians do not need to tackle this pandemic alone -- we can get help," said Shubrook.
Shubrook and his co-authors reviewed literature on the effects of lifestyle interventions on preventing or delaying the onset of type 2 diabetes; they also investigated pharmacologic and surgical approaches.
Lifestyle interventions center on improving nutrition and increasing activity levels to achieve weight loss. The authors cited evidence from the U.S. National Diabetes Prevention Program(www.cdc.gov) that involved 3,200 participants randomly assigned to routine care, metformin treatment or an intensive lifestyle intervention.
Participants in the latter group focused on reducing their total calories by reducing their fat intake; they also engaged in physical activity for at least 150 minutes per week to achieve a mean goal of 7 percent weight loss.
After a little more than 2.5 years, authors found the incidence of type 2 diabetes was reduced by
- 58 percent in the lifestyle intervention group,
- 31 percent in the metformin group and
- 17 percent in the routine care group.
Regarding medications, authors noted that metformin "has been the most-studied medication for at-risk populations," and said that even though it was less effective than lifestyle interventions, metformin provided a substantial decrease in the incidence of type 2 diabetes -- 18 percent at 10 years compared with placebo.
In reviewing the effectiveness of weight-loss interventions to slow or prevent the onset of type 2 diabetes, authors said some physicians have been reluctant to prescribe weight loss medications because they are expensive, often are not covered by insurance and can cause side effects that are troublesome for patients with diabetes.
Authors called metabolic surgery "the most effective way" to prevent type 2 diabetes in patients at risk but noted the danger of serious adverse events and the requirement of long-term followup for nutritional maintenance and observation for nutritional deficiencies.
Notably, results of a cost-effectiveness modeling study of the National DPP showed that implementing the program broadly among the Medicare population would have a striking positive effect. In short, the study showed a 37 percent reduction in new-onset diabetes at a cost savings of $1.3 billion over 10 years.
The results led CMS to make the Medicare DPP(innovation.cms.gov) a mandated covered benefit for Medicare beneficiaries with a confirmed prediabetes diagnosis.
Family Physician Perspective
In contemplating the underuse of diabetes prevention interventions, Shubrook said it was difficult to pinpoint the cause. He assumed a major driver was lack of insurance coverage until Medicare embraced the Medicare DPP as a covered benefit and many private insurers followed suit. As of Jan. 1, 2019, California Medicaid will also provide full coverage for the program, he added.
Shubrook now has another theory. "Very few clinicians know about this program, and those that know do not refer."
He urged family physicians to locate DPPs(nccd.cdc.gov) in their communities and have those resources handy when counseling patients. "The DPP is a serious commitment -- so it's important to make that DPP recommendation when a person is truly ready," added Shubrook.
He stressed that physicians must have honest discussions with patients about the best treatment options to allow for an informed choice. In his experience, patients are receptive to the idea of preventing the onset of diabetes, but each patient needs to consider his or her own ability to stay the course in a program that requires ongoing hard work.
"I think we need to support and believe in our patients. They are much more likely to try something if we recommend it to them personally," said Shubrook.
As always, treatment recommendations are based on each patient's circumstances.
"Time is not our friend with type 2 diabetes. So, if a person is extremely heavy, lifestyle alone may take too long," said Shubrook. He urged family physicians to "get comfortable working with a bariatric surgeon who can help with those patients who need metabolic surgery."
Lastly, when asked to share a patient success story, Shubrook didn't hesitate; there are many to choose from, he noted.
He recalled a patient with a recent diabetes diagnosis who was adamant about avoiding medication. "With an A1c of 6.7 percent, I told her that we would need to make a plan to address lifestyle and to add a medication. We discussed options, and even though she already had the disease, she enrolled in the community DPP," said Shubrook.
And here's the best part.
"This patient was able to lose 10 percent of her body weight and lower her A1c to 5.5 percent. She went on to become a DPP lifestyle coach and recently completed her first 5K race," he added.
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