Jennifer Janetski, MS RD CDE Is there a need for Diabetes Prevention? World s fifth leading cause of death in 2000. Diabetes Care, 2005 24.1 million Americans have diabetes and it is projected to double by 2050. 57 million Americans have pre diabetes Reviews in Cardiovascular Medicine, 2009 2007 obesity prevalence 25% in 30 states and 20% in 49 states Risk is 27% for a wt. increase of 5 kg 1 kg increase in wt=risk of diabetes increased by 4.5% Practical Diabetology, 2009 The cost of DM in the US in 2007 was $174 billion, an increase from $23 billion in 1969. Forecasted expenditure for diabetes in 2010, approach 2020 estimates of $192 billion. Half of all direct medical costs in the United States were from inpatient care of DM complications. The indirect costs from obesity were $47.6 billion in 1995, comparable to the economic costs of cigarette smoking. Gend Medicine, 2009 YES!!!! For every 1 kg decreases in weight, risk of diabetes is lowered by 16% 1
WHAT IS PREDIABETES? Increased risk for diabetes IFG (Impaired Fasting Glucose) and (IGT) Impaired Glucose Tolerance IFG=Fasting Plasma Glucose of 100 125 mg/dl IGT=2 hr OGTT values of 140 199 mg/dl Dyslipidemia with high TG and/or low HDL, abdominal obesity and HTN A1C of 5.7 6.4% ADA clinical practice recommendations Patients with Pre diabetes should be referred to an effective ongoing support program for weight loss of 5 10% of body weight and an increase in physical activity of at least 150 min/week of moderate activity such as walking. ADA position statement Diabetes Prevention Program (DPP) Goals=weight loss of 7% and 150 minutes of walking/week Achieved a 58% risk reduction in progression to diabetes after 2.8 years Cardiometabolic syndrome was reduced by 41% Mean Weight Change: Diabetes Prevention Program (DPP) (kg) Weight Change 1 0-1 -2-3 -4-5 -6-7 -8 0 6 12 18 24 30 36 42 48 Months in Study Diabetes Prevention Program Research Group. N Engl J Med 2002;346:393-403. Placebo Metformin Lifestyle Incidence of Type 2 Diabetes: Diabetes Prevention Program (DPP) Cumulative in ncidence of diabetes (%) 40 p<0.001 for comparison between each group Placebo 30 20 10 0 0 1 2 3 4 Years from randomization Metformin ( 31%) Intensive lifestyle modification ( 58%) Finnish Diabetes Prevention Study After 3.2 years, 58% risk reduction in progression to diabetes Diabetes Prevention Program Research Group. N Engl J Med 2002;346:393-403. 2
DPP N=2766 Lifestyle RX N= DPPOS Years since Randomization Lancet 2009 DPPOS : The Bottom Line. Compared with the placebo group, the incidence of diabetes mellitus in the 10 years since the initial DPP randomization was reduced by 34% in the lifestyle group and 18% in the metformin group..with such an approach, we can no doubt achieve healthier communities across the globe and do so at less cost than it takes to care for those who develop overt diabetes mellitus. Robertson Nature 2010 Cost: $100.00 $200.00 Given a one month 10% discount if paid first membership to the Summit (Health club) day One hour exercise Payment arrangements appt. made, if needed Self pay/patient turned into insurance Instructors: RD/CDE and Exercise Physiologist Supervised exercise twice/week for that month If chose to join after the first month, registration fee was waived Marketing Pre diabetes patients database Hospital employees email, employee mailings Community ads placed in local paper Physician offices stuffed mail boxes, mailed or hand delivered fliers to offices 3
Initial Month 4 classes 1 hr 30 min RD/CDE 30 min Exercised Physioligist (EP) Follow ups Monthly for 11 months 45 min RD/15 min EP Week 1 Measurements taken: Weight, BP, Waist/hip, body fat Ice breaker Taught definition and diagnosis of pre diabetes Reviewed the DPP, expectations/contract Introduced to the concept of self monitoring Given a weight goal 7% Session 1 and 2 in Lifestyle Balance www.bsc.gwu.edu/dpp/manuals.htmlvdoc Exercise Weigh in Fat gram goal 25% Session 3 in LB Given Fat counter Heart Healthy education Week 2 Destination Heart Healthy Eating, Bell Institute Medications used to prevent Exercise Pedometers Week 3 Weigh in Healthy eating/food Guide Pyramid Session 6 in LB Given a calorie goal and taught calorie counting Session 7 in LB Self Monitoring of Blood Glucose Donated meters Given goals for pre diabetes: <100 Fasting, <140 2 hours pp Exercise 4
FAT GRAM AND CALORIE GOALS Weight Fat goal Calorie goal 120 174 lb. 33 grams* 1200 kcal 175 219 lb. 42 grams* 1500 kcal 220 249 lb. 50 grams* 1800 kcal > 250 55 grams* 2000 kcal * =25% of calories from fat Weigh in Week 4 Taught carbohydrate counting and given goals 3 4 choices/meal for women 4 5 for men My Food Plan from IDC Reviewed fiber recommendations and how to increase General Mills Fiber HO Geared participants for the next 11 months Exercise One year 37% remained in the program Average wt. loss was 19.83 lbs/person Waist circ. decreased 2.79 and hip 3.42. 3% decrease in body fat on avg/person Diastolic BP decreased 27.5mmHg and systolic 13 mmhg on avg Living on the Edge of Diabetes November 2008 $25,000 grant from MDPHHS Marketed to employees, current database of pre diabetes patients, physicians via practice meetings, office and mailboxes and community via newspaper. Pre qualification meetings in January, 2009 Enrolled 42 participants ii (40 required) $50.00 commitment in the form of a refundable deposit Participants received a Summit membership for $10.00/month for the 10 month program. Montana CVD and DM Prevention Program Locations Started in 2008 Started in 2009 MONTANA DIABETES PROGRAM 5
Participation Criteria Program Evaluation Medical Clearance Overweight (BMI 25kg/m2) Readiness Assessment 18 years and older And one or more of the following risk factors for diabetes or cardiovascular disease Baseline Height Weight Blood Pressure Glucose/lab values End of 16 weeks Weight Blood Pressure Glucose/lab values End of 6 months Weight Blood Pressure Glucose/lab values Diagnosis of Pre diabetes Dyslipidemia or treatment IGT of IFG History of GDM High BP ( 130/85 or tx) Baby >9lbs Weekly Participant SM data Weekly: Wt and BMI Initial, 4 months and 10 months: BP, FBG, Total Chol, LDL, HDL and TG Initial and 10 months: BF%, WC, RMR, HR and O2 Sats MEASUREMENTS CORE CLASSES Began in February, 2009. Weekly meetings and weigh ins for 16 weeks Followed Core curriculum Food and exercise diaries Class 1 met on Mondays 4:30 5:30 PM Class 2 met on Tuesdays noon to 1:00 PM Individual meetings with coaches CORE CLASSES Exercise sessions at the Summit required First two months: Twice/week Second two months: Once/week All received an individual exercise plan/meeting Coaches: RD/CDE and exercise physiologist 6
PROGRAM GOALS Lose 7% of body weight and maintain Exercise at least 150 minutes/week Keep food and exercise diary Consumed 25% of calories from fat Prevent diabetes Nutrition CORE TOPICS COVERED Keeping a food diary Reducing fat and calories Healthy Eating Exercise Sustaining for a lifetime Behavior change Handling Stress Problem Solving Preventing relapse Staying motivated AFTER CORE July 2009 December 2009 Monthly meetings with weekly weigh ins Door prizes Diaries optional Individual support available SMBG Preventing CVD Exercise Mindless Eating Holidays Making time for Health AFTER CORE TOPICS EXERCISE IN AFTER CORE Summit was not required 150 minutes/week or more Individual id appointments were offered with Exercise Physiologist 7
RESULTS 93% of KRMC participants completed the core classes 90% completed the after core Total wt. loss at 16 weeks = 677 lbs. Total wt. loss at end of 10 months =711.4 lbs Average physical activity minutes 227+/ 93 Initial 10 mos Wt: 223.3 lbs 184.3 lbs BMI 31.2 BMI 26.4 BF %: 34.4% 22.4% RMR: 1805 kcal 1772 kcal WC: 43.5 39.5 BP: 138/86 150/60 Heart Rate: 96 82 O2 Sats: 69 97 MARV Initial lab work FBG: 124 TG: 255 Chol: 155 HDL: 38 LDL: 66 MARV 10 month lab work FBG: 78 TG: 85 Chol: 145 HDL: 50 LDL: 78 Medications Crestor 10 mg ASA 81 mg Niacin 500 mg BID Quinaprin 10mg Metoprolol 100 mg BID Furosemide 20 mg Allopurinol 100 mg MARV Medications: Crestor 5mg (cut in half) Metoprolol 50 mg (decreased d by 75%) Furosemide d/c d All other meds remained the same 8
5/28/2010 WEIGHT RESULTS 2010 PROGRAM y January 25, 2010 y Currently starting the 12th week of the Core y 47 Enrolled y As of 3/30/10: y 534.8 lbs lost y 12.73 lbs/person on avg y 42 participants remain y $50.00 refundable fee y Supervised exercise y Once/week y Summit membership not provided SUPERVISED EXERCISE y Mondays 4:00 8:00 PM y Tuesdays: 7:00 AM 3:00 PM y Thursdays: 5:00 5:00 8:00 8:00 PM y Saturdays: Aerobics DIABETES PREVENTION WORKS!! y Partnered with a medical fitness facility y The facility donated exercise time y Exercise physiologist involved with cardiac rehab y Set a break even point y Marketed the classes in the paper, paper to employees and physicians y Met our break even point within a few weeks of marketing y Catchy name y Competitive pricing 9
Catchy Name Visibility with administration Visibility with physicians Visibility with insurance board Partnership with the Summit Passionate instructors Money Accountability Keys to success Break even point TCOYD Marketing Grateful patients Foundation board presentations Lions club partnership Appropriate screening Volunteer MAKE IT FUN!!! http://www.youtube.com/watch?v=ieajjdrn_h0 Reimbursement FUTURE OF DPP Northwest Healthcare State employees covered Area insurance coverage $350.00 $400.00 cost/person Portion is the patient s responsibility Legislation, Franken Luker bill YMCA/ Partnership Washington 10