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Lifestyle Interventions for Diabetes Prevention and Control

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Title: Lifestyle Interventions for Diabetes Prevention and Control


1
Lifestyle Interventions for Diabetes Prevention
and Control
  • What does science tell us about potential Public
    Health strategies?

2
Diabetes A Public Health Problem
  • High disease burden to individual and society
  • Disproportionate burden to elderly and minorities
  • Effective primary and secondary prevention
    strategies
  • Systems approach
  • Individual
  • Family and friends
  • Health care professionals
  • Community
  • Policy

3
Essential Public Health Strategies
  • Monitor health status to identify problems
  • Diagnose and investigate health problems
  • Inform, educate, and empower people
  • Mobilize community partnerships
  • Develop policies and enforce regulations
  • Evaluate effectiveness of health services
  • Research innovative solutions to problems
  • http//www.cdc.gov/od/ocphp/nphpdp/EssentialPHServ
    ices.htm

4
Essential Public Health Strategies
  • Monitor health status to identify problems
  • Diagnose and investigate health problems
  • Inform, educate, and empower people
  • Mobilize community partnerships
  • Develop policies and enforce regulations
  • Evaluate effectiveness of health services
  • Research innovative solutions to problems

5
Monitor Health Status - Incidence
  • MMWR Morbidity and Mortality Weekly Report
    200857(43)1169-1173

6
Incidence
  • 50 of adult incident cases are between the ages
    of 45 and 59 years
  • 10 diagnosed before age 35
  • 2/3 of adult with diabetes reported having had
    diabetes for 10 years or less
  • http//www.cdc.gov/diabetes/statistics/newDataTren
    ds.htm

7
Prevalence
  • Americans with diabetes
  • 1980 5.6 million
  • 2005 16.8 million
  • Increased prevalence due to
  • Increased detection
  • Decreased mortality
  • Increased incidence
  • WV prevalence in 2006 12.1
  • MMWR Morbidity and Mortality Weekly Report
    200857(SS-7)1-192

8
Complications of Diabetes
  • Increased risk of
  • Blindness in adults (70/day)
  • Stroke and death due to stroke
  • Heart attack and death due to heart attack
  • Lower limb amputation (150/day)
  • Kidney failure (75/day)
  • Glasgow et al Ann Behav Med 199921(2) 159-170

9
Age-adjusted all-cause mortality rates among the
U.S. population age 35 to 74 years with and
without diabetes, by cohort and sex
Gregg, E. W. et. al. Ann Intern Med
2007147149-155
10
Costs of Diabetes132 Billion
  • Indirect 39.8 billion
  • Estimates of lost work days, restricted activity
    days, prevalence of permanent disability, and
    mortality attributable to diabetes
  • Direct - 91.8 billion
  • 23.2 billion for diabetes care
  • 24.6 billion for chronic complications
  • 44.1 billion for excess prevalence of general
    medical conditions
  • Diabetes Care 200326917-932

11
Per Capita Medical Expenditures
  • With diabetes 13,243
  • Without diabetes 2,560

12
Prevention of Complications
  • Insulin resistance
  • Causes impaired glucose tolerance
  • No complications as long as B-cells function
  • B-cell dysfunction (impaired insulin secretion)
  • Strategies may address either
  • Good medical care including self-management and
    prevention
  • Outreach and education (population-based care)

13
Chronic Disease Self-Management
  • Assess and specify
  • problem/target behavior
  • Provide follow-up Collaboratively
  • support (and enhance set goals
  • social resources) identify barriers
  • and motivators
  • Provide personalized
  • coping skills
  • Glasgow et al Ann Behav Med 199921(2) 159-170

14
Screening Options
  • For type 2 diabetes
  • For pre-diabetes estimated 21 of adults
  • Impaired glucose tolerance (140 to 199 mg/dL)
  • Impaired fasting glucose (100 to 125 mg/dL)
  • Who?
  • Ethnic minorities
  • Obese
  • Hypertension
  • Crandall et al. Nat Clin Pract Endocrinol Metab
    20084(7)382-393

15
Prevent or Delay Type 2 Diabetes
  • Chinese study
  • Intervention in community health centers
  • Diet, exercise, both or control
  • No difference between intervention groups
  • Finnish study
  • Diet plus exercise to achieve 5 weight loss
  • 4.2 kg weight loss, 58 reduction in risk over 4
    years
  • 43 reduction at 7 years

16
Diabetes Prevention Program
  • 3000 overweight adults with IGT
  • Lifestyle, medication, or control
  • Goal 7 weight loss over 24 weeks
  • 150 minutes moderate physical activity per week

17
Lifestyle Interventions
  • Clearly defined goals
  • Individual case managers (lifestyle coaches)
  • Intensive intervention
  • 16-week core curriculum
  • Supervised exercise sessions (2x/week)
  • Maintenance program (individual and group)
  • Individual adherence strategies
  • Culturally competent materials and strategies
  • Extensive network for training and support

18
Effectiveness
  • Metformin 31 reduction in risk
  • Lifestyle intervention 58 reduction in risk
  • Greater weight loss
  • Higher levels of physical activity
  • Improved insulin sensitivity and B-cell function
  • Lower average HbA1c from 6 months to 3 years, no
    difference at 4 years v. metformin
  • 3-year follow-up showed improvements in BP,
    lipids, and C-reactive protein

19
Importance of Physical Activity
  • 24 of US adults and 31 of adults with diabetes
    report no regular physical activity
  • Decrease body weight and body fat
  • Improve sense of well-being
  • Reduce functional decline with aging
  • Improve lipid profile, lower blood pressure,
    decrease risk for blood clots

20
Role in Diabetes Prevention and Management
  • Increases insulin sensitivity in contracting
    muscles for 24 to 72 hours
  • Increases glucose uptake
  • Increased muscle mass requires more glucose
  • Metabolic adaptations enhance glucose use
  • Contracting muscles use glucose without insulin
  • Prevent or delay complications or slow
    progression of existing complications

21
Food Patterns
  • Lower Risk
  • Greater Risk
  • Whole grains
  • Fruits, nuts, seeds
  • Green leafy vegetables
  • Low-fat dairy
  • Mediterranean-style diet
  • Red meat
  • Low-fiber grains
  • Cheese
  • Tomato products
  • Eggs
  • Potatoes

22
Nutrients Associated with Lower Risk
  • Fiber
  • Soluble decreased glucose spikes
  • Insoluble lower risk for T2DM
  • Monounsaturated and omega-3 fatty acids increase
    insulin sensitivity
  • Vitamin C plasma levels inversely related to
    risk of diabetes
  • Magnesium - intake inversely related to risk
  • Vitamin D blood levels inversely related to
    risk

23
Coffee and Tea
  • Coffee lower risk with 2 or more cups per day
  • Tea - lower risk in some studies, but not others
  • Polyphenols associated with lower risk of chronic
    disease

24
Red Wine
  • 1 or more times per week 16 lower risk in
    postmenopausal women
  • High intake may increase risk in men
  • Meta analysis U-shaped curve with more benefit
    for women

25
Cost Effectiveness DPPRG 2003
  • Direct medical costs, direct nonmedical costs,
    and indirect costs from health system perspective
  • Lifestyle - 13,200/case prevented27,100/QALY
  • Metformin - 14,300/case prevented35,000/QALY
  • Direct medical costs less in both interventions
  • Direct nonmedical costs lifestyle higher
    (1445)
  • Diabetes Care 2003262518-2523

26
Cost Effectiveness DPPRG 2003
  • Indirect costs metformin 230, lifestyle 174
  • Societal costs relative to placebo (3years)
  • Metformin - 2,412
  • Lifestyle - 3,540
  • Diabetes Care 20032636-47

27
Cost Effectiveness Health Plan Perspective
  • Expected 30y cost/QALY
  • Lifestyle 143 000
  • Metformin 35 400
  • Lifestyle, delayed until diagnosis 24 500
  • Lifestyle modification for high risk people can
    save costs if it can be delivered for 100 per
    year
  • Conclusion Program used in DPP may be too
    expensive for 3rd party payers
  • Eddy et al Ann Intern Med 2005 143 251-264

28
What we Know
  • Interventions decrease incidence of diabetes,
    improve CV risk factors
  • Lifestyle changes more effective than medications
  • Interventions promote weight loss
  • Lifestyle interventions are resource-intensive
  • Is there a public health solution?

29
Prevention Strategies
  • Targeted and opportunistic screening
  • Improve care processes
  • Nonphysician providers
  • Care algorithms
  • Electronic records
  • Community health workers (peer-to-peer)

30
Translational Research
  • Effective, sustainable, generalized, transferable
  • Interventions
  • Minimal level of intensity
  • Note personal, social and economic costs
  • Target Settings
  • community-based participatory research
  • Connect multiple levels of influence
  • Research Design
  • Qualitative and quantitative research

31
  • Thank you.
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