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Engaging Patients In Diabetes Management

How can diabetes progression be prevented in patients with nondiabetic hyperglycemia?

Diabetes management is a challenge. Various factors influence proper diabetes management, and hinder how patients respond to therapy, ultimately affecting their lifestyle and health outcomes. There is a constant battle when it comes to encouraging patients to take control over their disease states. Diet becomes of utmost concern due to patient inability to make changes, or simply confusion over the changes they’ve been asked to make. Proper diabetes management focuses on detecting the disease before it progresses any further. There is a large portion of the U.S. population that goes undiagnosed and/or suffers from metabolic syndrome, greatly predisposing them to diabetes and cardiovascular complications. Learning when and where to intervene is key to helping prevent these predispositions; early group interventions have shown to play an important role in diabetes management.

In the Let’s Prevent Diabetes trial, researchers looked at patients with nondiabetic hyperglycemia (NDH), also known as prediabetes, and the effect of participating in the Let’s Prevent Diabetes Program for a total of six years.  This diabetes program focuses on a group-based education program aiming to increase knowledge about the disease state. The main portion of the program focuses on promoting behaviors such as reducing weight, following a healthy diet, and increasing physical activity. Each patient’s NDH in the study was identified and confirmed utilizing the oral glucose tolerance test (OGTT). Those patients with confirmed diabetes per the WHO 1999 criteria/guidelines were excluded from the study. 880 patients participated in the study, out of which 447 were assigned to the group intervention, whereas the other 433 were offered standard of practice (i.e. information booklets). The primary outcome measure of the study focused on evaluating the progression of patients’ NDH to diabetes three years into the intervention. The secondary outcome measures focused on observing improvements in glucose levels, lipid levels, blood pressure, weight, waist circumference, and body mass index.

Findings from the trial show that from those patients in the intervention group, 346 patients were considered engagers based on their attendance at an initial 6-h education session. 130 patients were identified as retainers given their attendance to every session offered by the program. The remaining 248 only attended the initial 6-h session and one refresher thereafter; no description was assigned for this group. Based on these patterns, the results show dose-response relationship. Hence, greater reduction in diabetes incidence was observed with increasing retention. Therefore, those patients who participated in the initial session and every session offered had a decrease in the incidence of developing diabetes. When comparing the other two groups with those in the standard of care group, there was a significant association observed in the initial session and one refresher minimum [95% CI 0.236–0.62]) and in those considered retainers (HR 0.12 [95% CI 0.05–0.28]) compared to standard care. Additionally, those patients in the intervention group also showed an improvement in glucose, A1c, weight, waist circumference, anxiety, quality of life, and daily step count. It was concluded that the intervention group showed an overall 88% reduction in the incidence of T2DM.

Based on these findings, the implementation of a diabetes program can decrease the rates of progression into diabetes in those patients experiencing NDH (prediabetes). These programs have shown to improve patient outcomes and improve quality of life. However, certain challenges arise when engaging and maintaining patients in these programs. Factors such as education status, cultural competency, physical condition, and other psychological factors, affect patient retention in these programs. The use of Let’s Prevent Diabetes or similar programs needs to be further evaluated in patients from diverse backgrounds. The key in engaging and retaining patients relies on providing an interdisciplinary approach where patients receive education about the disease management, but are also actively engaged in their health decisions. An early jump start in advocating for these programs can help prevent life-threatening complications.

Practice Pearls:

  • The intervention group showed an overall 88% reduction in the incidence of T2DM.
  • More frequent meetings and follow-up in diabetes programs can improve glycemic levels and other metabolic factors.
  • Strategies should be implemented in order to identify patients who are at risk of not engaging or not retaining specific information on their disease management.

References:

Gray, Laura J., Thomas Yates, Jacqui Troughton, Kamlesh Khunti, and Melanie J. Davies. “Engagement, Retention, and Progression to Type 2 Diabetes: A Retrospective Analysis of the Cluster-Randomised “Let’s Prevent Diabetes” Trial.” PLoS Med PLOS Medicine 13.7 (2016): n. pag. Web.

Mcauley, Kirsten A., Rachael W. Taylor, Victoria L. Farmer, Paul Hansen, Sheila M. Williams, Chris S. Booker, and Jim I. Mann. “Economic Evaluation of a Community-based Obesity Prevention Program in Children: The APPLE Project.” Obesity 18.1 (2010): 131-36. Web.

Bowen, Michael E., Kerri L. Cavanaugh, Kathleen Wolff, Dianne Davis, Rebecca P. Gregory, Ayumi Shintani, Svetlana Eden, Ken Wallston, Tom Elasy, and Russell L. Rothman. “The Diabetes Nutrition Education Study Randomized Controlled Trial: A Comparative Effectiveness Study of Approaches to Nutrition in Diabetes Self-Management Education.” Patient Education and Counseling 99.8 (2016): 1368-376. Web.

Researched and prepared by Pablo A. Marrero-Núñez – USF College of Pharmacy Student Delegate – Doctor of Pharmacy Candidate 2017, reviewed by Dave Joffe, BSPharm, CDE