By Maggie Powers, PhD, RD, CDE; Teresa Pearson, MS, RN, CDE, FAADE;
and Rita Mays, MS, RD, LN
[Copyright 2011, Minnesota Physician Publishing. This article originally appeared in
Minnesota Physician 25(9): 30–31, 36, and is published with permission.]
The American Diabetes Association’s (ADA) slogan is “Stop Diabetes.” If this
is really possible, why is the prevalence of diabetes increasing at epidemic
proportions? The number of people with diabetes in the United States
increased by 17 million people from 1958 to 2010, according to the U.S.
Department of Health and Human Services; more than 8 percent of the
American population has type 2 diabetes now, and one in three children born
after 2000 will develop diabetes unless strong preventive steps are taken.
Furthermore, due to the insidious nature of the disease, by the time the
diagnosis is made, many people have had the disease for anywhere from nine
to 12 years, resulting in the presence of complications in as many as 39 percent
of those with newly diagnosed diabetes. And we know that those who are at
risk for diabetes are at similar risk for cardiovascular disease and peripheral
vascular disease as those who have diabetes.
The Minnesota Department of Health (MDH) reports that every year 20,000
Minnesotans are newly diagnosed with diabetes. Our goal is to bend the curve
on the rising incidence of diabetes.
There are a number of reasons to work hard at preventing diabetes. One
important reason is the cost of having diabetes, including the cost of health
care visits and tests, diabetes medications, and supplies.
Additionally, people with diabetes often have more health problems than those without diabetes. Other health problems associated with the disease increase the cost of health care, as they may require more expensive tests, medications, and hospitalizations. In Minnesota, diabetes costs almost $3 billion a year—about $12,000 for every person with diabetes. According to the ADA, health care costs for people with diabetes are three to four times higher than the costs for people without diabetes.
There are also emotional costs associated with diabetes. In fact, 20 percent of
Minnesotans who have diabetes also have depression, which can negatively
influence diabetes management and self-care behaviors.
Health professionals
Health professionals who care for people with diabetes understand the harm
and costs of diabetes. At the same time they may be frustrated that they have
little time to spend on diabetes care when patients present with multiple
health issues. Identifying people at risk of developing diabetes—i.e., those
with prediabetes—and knowing what resources are available can help
physicians work with patients before the most serious complications of the
disease develop.
Warning signs of type 2 diabetes and prediabetes
There is strong evidence that type 2 diabetes can be prevented or delayed. The
warning signs of diabetes listed in the patient handout (at the end of the
article) help identify which adults and children are at risk.
In Minnesota, the most frequent risk factor is being overweight. More than 1
million people in Minnesota have prediabetes, but only 20 percent know they
have it. That means 80 percent do not know that they have this health
problem, are not addressing it, and are at increased risk of developing type 2
diabetes. Table 1 lists the latest criteria for diagnosing diabetes and
prediabetes.
Evidence for preventing diabetes
The National Institutes of Health-sponsored Diabetes Prevention Program
(DPP) was stopped early because the results in one of the treatment groups
were so dramatic that it would be irresponsible if the successful intervention
was not offered to all study participants. The intervention that decreased
participants’ risk of developing type 2 diabetes by 58 percent was a 16-session
lifestyle education/support program. The primary goals were for participants
to:
• lose 5 to 7 percent of current body weight—about 10 pounds
• moderately exercise for a total of 30 minutes a day, five days a week
Some people think this is easy, but for most people it is not easy. Structured programs that guide and support individuals have proven to be very helpful.
Patients’ perspectives
A 2009 ADA survey showed that people at high risk of developing diabetes
report they follow a poor diet (67 percent), maintain an unhealthy weight (62
percent), and avoid doctors’ visits (50 percent). Admittedly, changing
unhealthy behaviors is not easy for many people, yet research shows that
change can occur when knowledge and barriers are addressed. In the 2009
survey, more than half of the responders mistakenly stated that “eating too
much sugar” is a risk factor for diabetes. On their own, patients may try to
eliminate sugar yet end up consuming more calories because they consume
more high-fat foods. Others may mistakenly replace sugary soda pop with
fruit juice, unaware that regular juice is very high in sugar, and thus achieve
no reduction in sugar, carbohydrate, or caloric intake.
If losing body weight was easy, two-thirds of the American population would
not be overweight or obese. Providing accurate information and support can
help patients develop healthier eating and activity patterns that can reduce
their risk—and physicians do not need to do all of this themselves.
Minnesota action
The Minnesota Diabetes Plan 2015 focuses on stemming the tide of the
diabetes epidemic and improving diabetes care. The plan encompasses
expanding and easing access to care, education, and food, and increasing
accountability for care coordination, referring patients to appropriate
resources, supporting diabetes self-management skills in prevention of type 2
diabetes, and making effective diabetes prevention programs (DPPs) available
statewide.
Minnesota has been a leader in piloting prevention programs. The state is now
facilitating access to these programs while also actively supporting additional
programs so all Minnesotans have easy access to diabetes prevention services.
The Diabetes Program at the MDH provides a current listing of group diabetes
prevention programs in Minnesota, including contacts, dates, locations, and
costs of participation (go to www.icanpreventdiabetes.org/groups.html).
Three 16-week DPP programs currently are offered in Minnesota:
• Lifestyle Balance for American Indians (offered through the Indian
Health Board in Minneapolis and tribal communities)
• I CAN Prevent Diabetes (offered throughout the state with coordination
by MDH)
• Y-DPP (offered by the metro-area, Willmar, and Alexandria YMCAs)
• The I CAN Prevent Diabetes program has demonstrated that people
who attend 80 percent or more of the 16-week session are more
successful than those that don’t. The average weight loss for people
who attend 13 or more sessions has been 6 percent but only 4 percent
for those attending 12 or fewer sessions.
Other prevention programs are available in Minnesota and may be offered by
registered dietitians, diabetes education programs, or community groups.
Although the effectiveness of these programs may be untested or less
vigorously tested, many have been successful.
Action steps for physicians
Behavior change is a long-term process and physician engagement in setting
expectations, making a referral, providing support and monitoring attendance,
process and outcomes is key to success. Here are steps physicians and their
staffs can take to help patients with prediabetes or diabetes achieve desired
outcomes.
1. Identify patients who have risk factors for diabetes and/or pre-diabetes.
2. Set clear expectations for patients with prediabetes based on the DPP
recommendations to:
a. lose 5 to 7 percent of body weight and
b. be active 30 minutes, five days a week.
3. Provide patients with resources to make healthy lifestyle choices to reach
their goals and help patients address barriers.
a. Ask patients what would most help them be successful; what support/
resources previously resulted in behavior change.
b. Refer patients to a registered dietitian for medical nutrition therapy or to
attend a group DPP lifestyle intervention program. If these resources are
not available in your clinic or community, consider collaborating with
others to make needed resources available.
c. Offer encouragement!
4. Establish a system to check in with patients between physician visits.
5. Celebrate successes, large and small.
Maggie Powers, PhD, RD, CDE, is a research scientist at the International
Diabetes Center at Park Nicollet, Minneapolis. Teresa Pearson, MS, RN, CDE,
FAADE, is a health care and clinical consultant with Halleland Habicht
Consulting, LLC, Minneapolis. Rita Mays, MS, RD, LN, is a diabetes
prevention planner at the Minnesota Department of Health.
