SCREEN, COUNSEL, REFER AND FOLLOW-UP FOR DIABETES AND PREDIABETES J. Michael Gonzalez-Campoy, MD, PhD, FACE drmike@mncome.com Teresa Pearson, MS, RN, CDE, FAADE tpearson@hallelandhabicht.net
Sponsored by Minnesota Department of Health Diabetes Program With funds from the National Association of Chronic Disease Directors State Diabetes Prevention Program 2013 grant Thanks to the Institute for Clinical Systems Improvement for hosting this webinar
Program Objectives Define the problem of prediabetes and diabetes Describe the progression, screening, diagnosis and treatment of diabetes Describe how to apply the Screen, Counsel, Refer and Follow-up Model to diabetes Identify National Diabetes Prevention Program sites in Minnesota and how to access them Present the Provider s Toolkit
Why Do We Care About Prediabetes? We first need to understand the big picture
The Progression to Diabetes Slide 5 6/3/2016
Adiposopathy -- shades of red DM-2 Dyslipidemia Hypertension Overweight & Obesity IFG Pre- Diabetes Dysmetabolic Syndrome CV Risk Factors Vascular Event Primary Secondary Tertiary Quaternary Primary Secondary Tertiary PREVENTION Primary Bays H, Rodbard HW, Schorr AB, González-Campoy JM, Adiposopathy: Treating Pathogenic Adipose Tissue to Reduce Cardiovascular Disease Risk. Prevention. 259-271. Bays H González-Campoy JM, Henry RR,, Bergman DA, Kitabchi,SAE, Schorr AB, Rodbard, HW, The Adiposopathy Working Group. Int J Clin Pract, October 2008, 62, 10, 1474 1483. Secondary
Diabetes Definitions Normal PreDiabetes Diabetes Fasting 65-99 mg/dl 100-125 mg/dl 126 mg/dl or more Impaired Fasting Glucose 2 hours post challenge ** 140 mg/dl or less 141-199 mg/dl 200 mg/dl or more Impaired Glucose Tolerance A1C < 5.7% 5.7 6.4% 6.5% ** 75 grams glucose American Diabetes Association Standards of Medical Care. Diabetes Care, Volume 36, S1. January 2013
What is Behind the Epidemic Of DIABETES? Approximately 80%-90% of people with type 2 diabetes are overweight or obese In the United States, approximately 68% of adults are considered overweight or obese Obesity is the primary risk factor for developing type 2 diabetes.
MN Adult Prediabetes and Diabetes Algorithm
Slide 11 2013 AACE guidelines
Complications-Centric Model For Care of the Overweight/Obese Patient
Prediabetes Algorithm IFG (100-125) IGT (140-199) Metabolic Syndrome (NCEP 2005)
Slide 14 The Burden of Diabetes
The Burden of Diabetes in the United States In the United States nearly 26 million people have diabetes (2010) 11.3 % of the U.S. adult population More than 1 out of 4 of these 26 million people (7 million) do not know they have the disease An estimated 79 million U.S. adults have prediabetes 35% of U.S. adults 5-15% develop diabetes each year The CDC projects that as many as one in three adults in the U.S. could have diabetes by 2050 if current trends continue. CDC. National Diabetes Fact Sheet 2011 Boyle et al. 2010 Population Health Metrics 8:29
Economic Impact of Diabetes Annual cost of diabetes in US is an estimated $245 billion (2012) Direct and indirect medical costs, disability, lost work, and premature death Annual 2009 Cost of Care General Population, No Diabetes - $4,400 All Persons with Diabetes (average) - $11,700 Persons with Diabetes only - $7,800 Persons with Diabetes and Complications - $20,700 ADA. 2013. Economic Costs of Diabetes in the U.S. in 2012. Diabetes Care 36:1033-1046 http://www.health.state.mn.us/diabetes/pdf/diabetesprediabetesminnesotafactsheet2012.pdf
The Burden of Diabetes in Minnesota An estimated 300,000 adults have diabetes (2012) 7.3 % of the adult population This number does not include those who do not know they have the disease (1 in 4 from National data) As many as 1.4 million adults have prediabetes Using national estimates of 35% of U.S. adults having prediabetes Annual cost of diabetes is an estimated $3.1 billion (2012)
Percentage of Minnesota Adults Prevalence is increasing in Minnesota, just like the rest of the nation 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0 Year*, ** *Note: Percentages are age-adjusted to account for any changes in age distribution in the MN population over time and represent only non-institutionalized adults. **Percentages reflect an average of 2-3 years of data. Source: Centers for Disease Control and Prevention: National Diabetes Surveillance System. http://apps.nccd.cdc.gov/ddtstrs/default.aspx
Diabetes Risk is Not Equal Across the Population Slide 19
Percentage of Adults with Diagnosed Diabetes Diabetes Risk Increases with Age 20 18 16 14 12 10 8 6 4 2 0 64-74 years 75+ years 45-64 years 18-44 years 1994 1996 1998 2000 2002 2004 2006 2008 2010 CDC, National Diabetes Surveillance System, www.cdc.gov/diabetes/statistics Retrieved 4/18/2013
Diabetes Rates Vary by Race/Ethnicity http://www.cdc.gov/features/hispanichealth/graph.html
Additional Diabetes Risk Factors Being overweight/obese Low levels of physical activity Family history History of gestational diabetes Adults with hypertension and other cardiovascular risk factors Prediabetes
The Challenge of Prediabetes in Minnesota Many Minnesotans, as many as 1.4 million adults, likely have prediabetes In 2012 only 6% of Minnesota adults or ~210,000 people reported that they had prediabetes Most adults with prediabetes don t know they have it. MDH, Diabetes Program Analyses 2012 BRFSS data; CDC National Diabetes Fact Sheet 2011
Why Focus on Prediabetes? High risk group Great time to intervene Effective intervention in the NDPP But lack of awareness What can you do? Slide 24
Diabetes Can Be Prevented Among Those With Prediabetes The Diabetes Prevention Program trial showed that the onset of diabetes can be prevented or delayed among people with prediabetes over a 3-year period 58% among all participants 71% among those 65 years and older Key to reduction in risk was a lifestyle change program that changed modifiable risk factors for diabetes: Healthy eating Increased physical activity That lead to weight-loss Tabák et al. 2012. Lancet 379:2279-2290. CDC, DDT http://www.cdc.gov/diabetes/consumer/prediabetes.htm
Original Diabetes Prevention Research Study Goal: to find out whether losing modest amounts of weight through improving diet and increasing physical activity, or taking the diabetes drug metformin, could prevent or delay type 2 diabetes in people at high risk for developing the disease. Major multicenter clinical research study 3,234 participants 27 clinical centers in U.S. Funded primarily by NIH 26
Diabetes Prevention Program (DPP) Screened 158,177 OGTT, then randomize 3819 randomized Lifestyle 1079 Metformin 1073 Placebo 1082 Thiazolidinedione 585 5% Wt loss 3% Wt loss ~10 month followup 58 % Risk Reduction 31% Risk Reduction Diabetes Rate 11 % per year 24 % Risk Reduction Diabetes Prevention Program Research Gp, NEJM 346(6): 393-403, 2002.
Lifestyle Intervention of the Original Diabetes Prevention Research Study One-on-one instruction Healthcare professional Toolbox of incentives Program structure Primary goals: 7% weight loss 150 minutes/week physical activity 16 core sessions Maintenance phase
Diabetes Prevention Research Study Original DPP: Type 2 diabetes risk reduction at 3 years Population Lifestyle Metformin vs. Placebo Intervention vs. Placebo Overall 58% 31% Seniors (over 60) 71% 11% White 51% 24% African American 61% 44% Hispanic 66% 31% American Indian 65% 25% Asian 71% 38% Diabetes Prevention Program Research Group NEJM 2002; 346, No. 6: 393-403 29
Diabetes Prevention Research Study Original DPP: Type 2 diabetes risk reduction at 10 years Lifestyle Intervention vs. Placebo Metformin vs. Placebo Original DPP Follow-Up DPP after 10 Years 58% 34% 31% 18% Diabetes Prevention Program Research Group The Lancet 2009; 374: 1677-86
Slide 31 The DPP in Practice
Translating the DPP to Groups in Community Settings Similar levels of weight-loss have been obtained in community based programs that deliver curriculum in a group setting: Deploy Research Study Special Diabetes Program for American Indians Diabetes Prevention Demonstration Project Montana Diabetes Prevention Program I CAN Prevent Diabetes Sites in Minnesota YMCA-led classes with DPCA Lancet, 2009 374:1677-1686 Amer J Prev Med 2008 35(4):357-63 Diabetes Educator, 2009 35:209-223 Diabetes Care 2013 online (AI/AN reference) Amer J Prev Med 2013 44(4):S301-S306 On the Cutting Edge 2013 33(4):
From DPP to NDPP CDC s vision is for this to be a program available nationally: National Diabetes Prevention Program (NDPP) NDPP is based on curriculum of the original DPP and modifications from translational studies The Diabetes Prevention Recognition Program requires data submission from NDPP program to CDC. CDC will recognize those programs meeting CDC standards.
Goals for the NDPP? The DPP curriculum delivered in a group Following Standards set by CDC Goals of the NDPP Lose 7% weight Increase activity to 150 minutes per week
Implementing a Prediabetes Screening Program in Your Practice Screen Counsel Refer Follow-up
Provider's Prediabetes Toolkit http://www.icanpreventdiabetes.org/hptoolkit.html CDC Risk Test NDPP Referral Form NDPP awareness materials Flyer Patient Brochure Provider Brochure List of NDPP in Minnesota
Slide 37 Screen
Define a Process for Screening Identify who to screen Discuss how to screen Identify who does the screening Identify who will interpret the screening Decide how and where to document and who will do it
CDC Prediabetes Screening Test
Interpreting the Score
Counsel Who does the counseling? What to talk about?
What if They Have a High Risk Level But Not Yet Prediabetes: A CDC Risk Test score of 3-8 Points or A1c < 5.7 Probably not at high risk for having prediabetes now. To keep risk level below high risk: If overweight, lose weight Be active most days Don t use tobacco Eat low-fat meals including fruits, vegetables, and whole-grain foods If high cholesterol or high blood pressure, talk to health care provider about risk for type 2 diabetes
What If They Have Diabetes? Provide survival skills training Provide basic lifestyle recommendations Resources for Managing Diabetes ADA Clinical Recommendations -- 2013 ICSI Guideline for Diagnosis and Management of Type 2 Diabetes in Adults ADA/ESAD Clinical Algorithm for Managing Type 2 diabetes 2012 AACE Comprehensive Management of Diabetes 2013
Basic Lifestyle Recommendations For All Slide 44
For All: Recommend Healthy Eating Enjoy food, eat less, watch portion size Make ½ plate fruits and vegetables Switch to fat-free or low-fat (1%) milk Drink water instead of sugary drinks Compare food labels and choose foods lower in sodium U.S. Department of Agriculture and U.S. Department of Health and HumanServices. Dietary Guidelines for Americans, 2010. 7th Edition, Washington, DC: U.S. Government Printing Office, December 2010. AW3075641B
Recommend Physical Activity Be active together as a family; Eat meals together as a family whenever possible Walk and take the stairs; Park in distant spots and walk farther when shopping Try new activities that increase physical activity Limit screen time (TV, computer, video games) to < 2 hours/day Suggest community programs at YMCA, YWCA, Park & Recreation Centers
Participant Poster
Slide 48
Slide 49
Refer For those who qualify, refer to a National Diabetes Prevention Program near you
Who is Eligible to Participate in the NDPP? 18+ years old Overweight BMI greater than 24 for most people BMI greater than 22 for those of Asian descent Diagnosis of prediabetes OR History of gestational diabetes 51
NDPP Referral Form
How To Find A NDPP Group In Minnesota CDC s National Recognition Program: http://www.cdc.gov/diabetes/prevention/ Minnesota s List of NDPP Sites: http://www.icanpreventdiabetes.org/groups.html Provider s Prediabetes Toolkit: http://www.icanpreventdiabetes.org/hptoolkit.html
Listed on CDC national registry of recognized diabetes prevention programs All Sites in Minnesota Offering National Diabetes Prevention Programs in 2013
What topics are covered in the National Diabetes Prevention Program Slide 55
The National Diabetes Prevention Program Core Curriculum Skills 1. Welcome 2. Be a Fat and Calorie Detective 3. Three Ways to Eat Less Fat and Fewer Calories 4. Healthy Eating 5. Move Those Muscles 6. Being Active: A Way of Life 7. Tip the Calorie Balance Controlling the external environment 8. Take Charge of What s Around You 9. Problem Solving 10. Four Keys to Healthy Eating Out Psychological and emotional 11. Talk Back to Negative Thoughts 12. The Slippery Slope of Lifestyle Change 13. Jump Start Your Activity Plan 14. Make Social Cues Work for You 15. You Can Manage Stress 16. Ways to Stay Motivated
Skills and Tools: Sessions 1-7 Self-monitoring skills and tools: Food intake Fat grams Weight Physical activity (Session 5) Knowledge Increased awareness of eating habits Tools Techniques to replace unhealthy behaviors with healthy ones
Controlling the External Environment: Sessions 8-10 Contextual factors Ways to deal with elements in one s environment that can influence food and physical activity habits Eating out Food and activity cues Identify problems, develop effective coping strategies
Psychological and Emotional: Sessions 11-16 Internal and external influences related to emotions, stress, and motivation Negative thoughts Overcoming slips Prevention and coping How to make these influences support lifestyle change
Follow-up Adults Continue to screen every three years or more frequently with risk factors Kids 10-17 Re-test FPG and A1C every 4 months
Follow-up for People with Prediabetes For those with prediabetes, return for followup in 3 months to review goals If tests were normal on screen, repeat at least at 3-year intervals Repeat tests annually for conversion to diabetes Continue lifestyle counseling and recommendations best defense: Managing weight Physical activity
In Summary: What You Can Do For Your Patients Ask patients to complete a risk assessment Obtain A1C, FPG or OGTT to confirm diagnosis For prediabetes: Encourage lifestyle change & refer to a National DPP 5-7% weight loss if overweight 150 min/wk physical activity Consider medications or other treatment as appropriate If diabetes: refer to an accredited DSME program Encourage weight management and 150 min/wk physical activity Consider medications or other treatment as appropriate Return for follow-up in 3 months to review goals
Resources MN Dept of Health I CAN Prevent Diabetes http://www.icanpreventdiabetes.org/hptoolkit.html National Diabetes Education Program (NDEP) www.yourdiabetesinfo.org http://ndep.nih.gov/ Medicare Diabetes Screening Program http://www.screenfordiabetes.org/ Centers for Disease Control http://www.cdc.gov/diabetes/pubs/factsheet11.htm American Diabetes Association http://www.diabetes.org/diabetes-basics/prevention/ http://professional.diabetes.org/cpr_search.aspx