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Prediabetes Risk Unrecognized by Most PCPs

Only 6% of PCP’s were able to identify 11 prediabetes risk factors (there are actually 13) that would prompt them to screen patients under the ADA guidelines according to a new study. Are you any better?

The purpose of the study was to assess PCPs’ (1) knowledge of risk factors that should prompt prediabetes screening, laboratory criteria for diagnosing prediabetes and guidelines for management of prediabetes; (2) management practices around prediabetes; and (3) attitudes and beliefs about prediabetes.

Researchers surveyed 140 PCPs associated with Johns Hopkins in Baltimore and found the ADA guidelines were helpful for 42% of respondents, while 30% were unfamiliar with these guidelines.

Researchers say, “Few primary care practitioners know when to screen their patients for prediabetes….We think the findings are a wake-up call for all primary care providers to better recognize the risk factors for prediabetes, which is a major public health issue,” Eva Tseng, MD, an assistant professor at the Johns Hopkins University School of Medicine in Baltimore, Maryland, said in a news release.

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 American Diabetes Association (ADA). Dr Tseng and colleagues published their findings online July 20 in the Journal of General Internal Medicine.

Close to a million adults have prediabetes, and 70% will go on to develop diabetes. Simple lifestyle changes could prevent this progression, but most people with the condition are not aware they have it, and only a quarter report receiving relevant lifestyle recommendations, the researchers write.

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 nine nurse practitioners and one physician assistant. Almost three quarters were female, 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. [There are actually 13 risk factors for prediabetes.  Were you able to get them all?]

  1.      Body mass index ≥25 kg/m2
  2.      Age>45y/o
  3.      Hypertension (Part of the metabolic syndrome)
  4.      Dyslipidemia, (Part of the metabolic syndrome)
  5.      Heart disease
  6.      Family history of diabetes in a first-degree relative
  7.      Sedentary lifestyle
  8.      Races with darker skin as African-Americans, Asian-American, HIspanics, American Indian, Alaskan Natives, Chinese, Asian Indians, and Chinese
  9.      History of gestational diabetes or women who have had a baby that weighed more than 9 lb (4kg) at birth are at higher risk
  10.   Low birth weight; people who weighed less than 5.5 lb (2.5kg) at birth are more likely to get type 2 diabetes later in life
  11.   High visceral fat around the abdomen
  12.   Smoking
  13.   Polycystic ovary syndrome (PCOS)

The following risk factors are more for screening for diabetes:

  1.     Increased Urination
  2.     Increased Thirst
  3.     Increased Hunger
  4.     Fatigue

The researchers culled the list from ADA guidelines. On average, the participants identified eight of these factors. They were most likely to miss smoking, Asian race and Hispanic ethnicity.

From the results, it showed that six percent of PCPs correctly identified all of the risk factors that should prompt prediabetes screening. Only 17% of PCPs correctly identified the laboratory parameters for diagnosing prediabetes based on both fasting glucose and hemoglobin A1c. Nearly 90% of PCPs reported close follow-up (within 6 months) of patients with prediabetes. Few PCPs (11%) selected referral to a behavioral weight loss program as the recommended initial management approach to prediabetes. PCPs agreed that patient-related factors are important barriers to lifestyle change and metformin use. Provider characteristics were generally not associated with knowledge, management, attitudes and beliefs about prediabetes in multivariate analyses.

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).

A 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 minimum amount of physical activity.

The survey also asked participants about their approach to managing prediabetes. Nine of 10 used fasting blood glucose and HbA1c 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.

A 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.

In its 2017 guidelines, the ADA recommends that metformin be considered in patients with prediabetes who have failed to decrease their risk for diabetes through lifestyle change.

Although 42% of the respondents found the ADA guidelines helpful, 30% were unfamiliar with them.

Addressing gaps in knowledge and the underutilization of behavioral weight loss programs in prediabetes are two essential areas where PCPs could take a lead in curbing the diabetes epidemic.

One limitation of the study is that the participants were all associated with Johns Hopkins and might not be representative of practitioners across the country, Dr. Tseng acknowledged in the news release.

Practice Pearls:

  • Only 6% of PCP’s were able to identify 11 prediabetes risk factors that would prompt them to screen patients under the ADA guidelines.
  • Addressing gaps in knowledge and the underutilization of behavioral weight loss programs in prediabetes are two essential areas where PCPs could take a lead in curbing the diabetes epidemic.
  • Any patient with just one of the risk factors for prediabetes should be followed up with and an A1c test should be done.

J Gen Intern Med. Published online July 20, 2017. Abstract; CDC; American Diabetes Association