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Among U.S. adults at high risk for type 2 diabetes, participation in prevention programs was “exceedingly low,” according to authors of a large, population-based survey study.
Additionally, healthcare professionals commonly failed to refer high-risk individuals to such programs or to advise lifestyle modifications to prevent diabetes, researchers led by Mohammed Ali, MD, of the CDC’s National Center for Chronic Disease Prevention and Health Promotion in Atlanta, reported online in JAMA Network Open.
Ali and colleagues analyzed data from the 2016 and 2017 National Health Interview Survey (NHIS), the largest nationally-representative cross-sectional survey of non-institutionalized U.S. civilians. The study included more than 50,000 overweight or obese respondents with diagnosed prediabetes or an elevated American Diabetes Association (ADA) risk score.
Of those with prediabetes, 73.5% (95% CI 71.6%-75.3%) reported receiving any guidance in the past year from healthcare professionals about activities or programs to lower diabetes risk. Specifically, 63.0% (95% CI 60.9%-65.1%) reported receiving advice to increase physical activity, 59.2% (95% CI 57.0%-61.3%) to reduce fat or caloric intake, and 21.3% (95% CI 19.6%-23.2%) to participate in a weight loss program. In addition, 4.9% (95% CI 4.1%-6.0%) reported receiving a referral to a diabetes prevention program (DPP).
For those with an elevated ADA risk score, those figures were lower. Just half reported receiving any diabetes risk–reduction advice or referral (50.6%, 95% CI 49.5%-51.8%). Specifically, 42.3% (95% CI 41.2%-43.4%) were advised to be more physically active, 35.6% (95% CI 34.4%-36.7%) to reduce fat or caloric intake, 10.7% (95% CI 10.0%-11.4%), to participate in weight loss programs, and 0.4% (95% CI 0.3%-0.5%) to join a DPP.
Among patients who did get advice, the fraction actually following it was roughly the same for both groups. Approximately 70% of those advised engaged in more physical activity, three-quarters changed their diet, and one-third participated in a weight loss program. Of those referred to a DPP, approximately 40% joined.
“Among adults at high risk for diabetes, major gaps in receiving advice and/or referrals and engaging in diabetes risk-reduction activities and/or programs were noted,” the study authors said. “These data provide, to our knowledge, the most comprehensive assessment of the degree to which U.S. adults who are likely to benefit from diabetes prevention services are undergoing testing, counseling, and actual engagement in risk-reduction activities and/or programs.”
Guillermo Umpierrez, MD, of Emory University in Atlanta, who was not involved in the study, told MedPage Today in an email, “This is an important epidemiological study that reports on the state of patient participation and physician referral to [a] diabetes prevention program. It is not surprising that the overall referral and advice numbers are remarkably low in patients at risk of developing diabetes. Despite extensive evidence from randomized control trials indicating the success of diabetes prevention programs, translation to different communities [has] been slow and poor.”
Barriers and Recommendations
One reason for the lack of counseling and referrals may be the lack of formal prediabetes diagnoses, Ali and colleagues said. Although up to 90% of high-risk individuals reported having a blood glucose test, only 20% reported a prediabetes diagnosis.
“[P]eople at high risk may not meet biochemical prediabetes thresholds, or factors involving the test (e.g., inaccuracy of laboratory findings), healthcare professional (e.g., poor recognition, poor communication, or inaction), respondent (e.g., recall bias), or some combination of these may be at play,” the group wrote. “This is important because our data suggest that prediabetes diagnoses may lead to a higher likelihood of counseling or referral by healthcare professionals.”
Additionally, healthcare professionals appear to be reluctant to refer patients to prevention programs. They were much more likely to give patients with prediabetes general advice about risk reduction (60%) than to refer them to a weight loss program (20%) or a diabetes prevention program (5%). “Healthcare professionals may not believe in the effectiveness and cost-benefit of diabetes prevention programs, may be less aware of these programs, or may believe their patients would have less accessibility to [these] programs,” Ali and colleagues said.
Umpierrez agreed with that assessment. “Based on my clinical practice, lack of physician awareness of diabetes prevention programs, as well as concerns about patient accessibility to the programs, are major limiting factors for referrals. Many DPP sites are at private medical practices so there is potential for limited patient access based on insurance coverage. Other programs such as those at YMCA centers, with an out of pocket cost of $329 to $429 depending on membership, limit access to these programs.”
Ali and colleagues made some recommendations. “Given that barriers associated with these gaps are likely multifactorial, a variety of concurrent implementation processes and supportive policies may increase the supply and coverage of programs, awareness (among those at risk and healthcare professionals), initial engagement, and retention,” they said. “Investments in each of these areas (e.g., Ad Council campaigns, the American Medical Association’s efforts to increase awareness among healthcare professionals, and others) may increase awareness.”
Decision-support technologies might also boost referrals, the researchers suggested. Umpierrez endorsed that strategy as well. “There are multiple systematic tiers through which we can improve the frequency of screening for prediabetes and provide appropriate referrals to DPP or similar programs,” Umpierrez said. “From a provider level, automated prompts through electronic health record systems to 1) screen for prediabetes (for high risk patients) and 2) refer to a local DPP may improve provider awareness and efficiency.”
In addition, “Insurance companies, medical groups, and reimbursement plans must acknowledge the importance (and cost effectiveness) of prevention efforts to provide further incentives for screening, referring to lifestyle management programs, and achieving goal targets in preventing diabetes,” Umpierrez said. “And finally, there is a need to improve affordability and public awareness of DPP and similar programs for broader and more effective utilization.”
Limitations of the study, the authors noted, included its reliance on self-reported data. In addition, patients were only asked about their participation in prevention programs and not the extent of that participation. There was no distinction between those who may have attended only one or two sessions and those that actually completed a program, they said.
The study was supported in part by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases.
No study authors reported conflicts of interest.
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