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Prediabetes: How Often is the Opportunity to Intervene Missed?

Study finds less than one quarter of patients categorized as prediabetic received prediabetes treatment from their healthcare provider.

Diabetes currently has no cure. Diagnosis with prediabetes is a last call for patients to act and take control of their own health to prevent a lifetime battle with diabetes. The diagnosis of prediabetes is as simple as determining a patient’s A1C. According to the ADA, if A1C is between 5.7-6.4%, the patient is considered prediabetic and should be treated with lifestyle modifications and possibly metformin therapy.

A new article published in Journal of the American Board of Family Medicine (JABFM) states that only 23% of prediabetes patients were diagnosed by their healthcare providers and started on appropriate therapy. Researchers looked at the data from the 2012 National Ambulatory Medical Care Survey, which included adults over 45 years of age with no diabetes and their A1C tested within the last 90 days.  A1C results were categorized as normal, prediabetes, or diabetes and were broken down based on age, sex, race, payer type, body mass index, and prediabetes treatment.

The totals of 518 visits were analyzed. The survey found that 54.6% of participants had a normal A1C, 33.6% had prediabetes, and 11.9% had diabetes. Only 23.0% of patients categorized as having prediabetes received treatment; the most common was counseling on lifestyle modifications. Rates of prediabetes were similar between men (36.5%) and women (40.0%) The most frequent primary diagnosis was hypertensive disease (16.3%). There were no noticeable differences in applied treatments based on HbA1c level range whether patients had an HbA1c level of 5.7% or 6.4%,

Even though the number of patients who received a diagnosis of prediabetes was too small to allow reliable estimates to be produced (the estimate was 0.92%), the collected data indicates the need to educate healthcare providers about how important it is to utilize the narrow window of opportunity they have when patients present with elevated HbA1c. It is possible that some healthcare providers did not make the diagnosis of prediabetes because of lack of knowledge to recognize it, or awareness of the importance to appropriately address it. In some cases, physicians might have even intentionally kept the patients from using metformin to prevent over medicating a condition that is not considered by some to be a true disease.  It could also happen if they are missing resources to help patients, like clinical pharmacists, dietitians, or exercise professionals who would guide patients and follow up with them. Finally, physicians may have been restricted in some cases by the medical form they were filling out to include only three disease states patients had.

The power to prevent diabetes by lifestyle modifications in patients at high risk for developing diabetes was proven in a study conducted by Saila Koivusalo and colleagues. They assessed whether gestational diabetes mellitus (GDM) can be prevented by a moderate lifestyle intervention in pregnant women who were at high risk for the disease. They looked at 293 females with a history of GDM and/or a prepregnancy BMI of ≥30 kg/m2.  In the randomized controlled trial, there were 155 women in the intervention group and 138 in the control group. Women in the intervention group received individualized counseling on diet, physical activity, and weight control from trained study nurses, and had one group meeting with a dietitian. The control group received standard antenatal care.

Based on 269 women analyzed, the incidence of GDM (based on a 75-g, 2-h oral glucose tolerance test at 24–28 weeks of gestation) was 13.9% in the intervention group and 21.6% in the control group ([95% CI 0.40–0.98%]; P = 0.044 (after adjustment for age, pre-pregnancy BMI, previous GDM status, and the number of weeks of gestation). Moreover, gestational weight gain was lower in the intervention group (−0.58 kg [95% CI −1.12 to −0.04 kg]; adjusted P = 0.037). Women in the intervention group had more physical activity and a better diet as compared to women in the control group.

By adapting lifestyle changes, participants in the intervention group reduced the incidence of GDM by 39% in high-risk pregnant women.

Primary care providers should play an active role in the lives of patients who have diabetes. The increasing prevalence of diabetes is a major health problem and the American Diabetes Association recommends screening for prediabetes in all individuals over 44 years of age and children who are obese. When patients do have elevated A1C, healthcare providers must intervene. By providing them counseling and medication therapy, and following up with them, healthcare providers can influence patients’ lives by delaying the onset of diabetes, or perhaps even preventing patients from transitioning to diabetes. Prevention is the most effective strategy to treat diabetes that we have so far, and can greatly improve the overall quality of life of an affected patient as well as help lower the total cost of healthcare for all of us.

Practice Pearls:

  • Appropriate prediabetes treatment can delay or even prevent development of diabetes.
  • Many healthcare providers may need more education on the importance of diagnosing and treating prediabetes.
  • Supporting patients with prediabetes through counseling and guidance on lifestyle modifications is a key component of treatment.

Researched and prepared by Renata Kulawik, Doctor of Pharmacy Candidate LECOM College of Pharmacy, reviewed by Dave Joffe, BSPharm, CDE

 

Mainous, Arch G., Rebecca J. Tanner, and Richard Baker. “Prediabetes Diagnosis and Treatment in Primary Care.” The Journal of the American Board of Family Medicine 29.2 (2016): 283-285.

Koivusalo, Saila B., et al. “Gestational Diabetes Mellitus Can Be Prevented by Lifestyle Intervention: The Finnish Gestational Diabetes Prevention Study (RADIEL) A Randomized Controlled Trial.” Diabetes care 39.1 (2016): 24-30.