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PCPs Lack Knowledge of Prediabetes Risk

Recent published study showed that health care providers may lack the knowledge to diagnose and even treat prediabetes.

Prediabetes can be diagnosed when the fasting blood glucose level is between 100 and 125 mg/dL, the glycated hemoglobin (HbA1c) level is between 5.7% and 6.4%, or a 2-hour postprandial glucose level is between 140 and 190 mg/dL. Approximately 70% of individuals with prediabetes will go on to have overt diabetes. However, in a major clinical trial, lifestyle intervention was associated with a 27% reduction in the progression of prediabetes to diabetes, and treatment with metformin reduced the risk for overt diabetes by 18%.  Yet, the medical professionals may not be getting the message.  We now know that even when a patient has prediabetes at any level their risk for CVD and other complications increases. So telling them to watch what they eat and exercise more, has been shown not to be very successful. Eventually they will get diagnosed with diabetes, so why not help them with a prescription for metformin which could do the following:

  • Lower mortality in type 2 patients with comorbidities as chronic kidney disease, congestive heart failure and chronic liver disease.
  • Reduce cardiovascular risk factors.
  • Enhance cellular insulin sensitivity.
  • Inhibit excess intestinal absorption of sugar.
  • Reduce excess liver production of glucose.
  • Reduce appetite, weight, and body fat content.
  • Metformin has been found to suppress the growth of some tumors and enhance the activity of anti-cancer drugs.
    • Has a mild effect on weight loss.
    • Increases insulin sensitivity.
    • Reduces or lowers the chances of developing atherosclerosis.
    • Does not cause hypoglycemia.
    • Can help decrease FBG 60-70 mg/dL.
    • Increases hypothalamo-pituitary sensitivity that declines with age.
    • Shown to reduce Cholesterol and triglycerides.
    • Reduces risk for polycystic ovarian syndrome.
    • Cost 3 dollars or even free
    • Main Side Effect: Abdominal distress

In the current study, researchers found that few primary care providers know when to screen their patients for prediabetes.  With 70% of those with prediabetes progressing to diabetes, our whole medical system would be in a difficult place, even though we know that lifestyle changes could prevent this progression, but most people with the condition are not aware they have it, and only one-quarter report receiving relevant lifestyle recommendations, the researchers wrote.

Only 6% of the 140 primary care providers surveyed at a medical conference identified 11 risk factors that should prompt screening under the guidelines of the ADA. To find out whether the problem could stem from a lack of knowledge among primary care physicians, the researchers asked attendees at a 2015 primary care retreat for practices associated with Johns Hopkins to take a survey. Most participants were physicians trained in internal medicine, family medicine, or internal medicine-pediatrics. There were 9 nurse practitioners and 1 physician assistant. Almost three-quarters were women, 55% were white, 23% Asian, and 14% African-American. More than half (59%) had been in practice at least 10 years.

Participants were asked to identify 11 risk factors for prediabetes:

  • age 45 years and older,
  • body mass index of 25 kg/m2 or higher,
  • hypertension,
  • dyslipidemia,
  • heart disease,
  • family history of diabetes in a first-degree relative,
  • sedentary lifestyle,
  • African-American race,
  • Asian-American race,
  • Latino ethnicity, and
  • history of gestational diabetes.

Seventeen percent correctly identified the fasting glucose (100-125 mg/dL) and HbA1c (5.7%-6.4%) laboratory values for diagnosing prediabetes.  Of the medicine-pediatrics providers, 43% picked the correct HbA1c values compared with 20% of family medicine and 12% of internal medicine specialists, a statistically significant difference (P =.02).

One-quarter of the participants correctly identified weight loss of 5% to 7% as the recommended target for people diagnosed with prediabetes, and 45% correctly identified 150 minutes per week as the recommended minimal amount of physical activity.

The survey also asked participants about their approach to managing prediabetes. Nine of 10 used fasting blood glucose and HbA1c levels as screening tools.  Almost all (99%) identified counseling on diet and physical activity as their initial management strategy, with 12% referring patients to behavioral weight loss programs.

One-quarter never prescribed metformin for prediabetes, and 36% prescribed it for no more than 5% of their patients. The respondents were more likely to prescribe metformin for patients who had high body mass index measurements or for patients who did not respond to lifestyle recommendations.

Practice Pearls:

  • The study shows that we need to do more in preventing diabetes
  • Although metformin is not recommended by the FDA for prediabetes, it should be seriously considered.
  • New guidelines are needed for the treatment of prediabetes

Reference:

J Gen Intern Med. Published online July 20, 2017.