Quasi-experimental evaluation of a nationwide diabetes prevention programme.

Diabetes is a leading cause of morbidity, mortality and cost of illness1,2. Health behaviours, particularly those related to nutrition and physical activity, play a key role in the development of type 2 diabetes mellitus3. Whereas behaviour change programmes (also known as lifestyle interventions or similar) have been found efficacious in controlled clinical trials4,5, there remains controversy about whether targeting health behaviours at the individual level is an effective preventive strategy for type 2 diabetes mellitus6 and doubt among clinicians that lifestyle advice and counselling provided in the routine health system can achieve improvements in health7-9. Here we show that being referred to the largest behaviour change programme for prediabetes globally (the English Diabetes Prevention Programme) is effective in improving key cardiovascular risk factors, including glycated haemoglobin (HbA1c), excess body weight and serum lipid levels. We do so by using a regression discontinuity design10, which uses the eligibility threshold in HbA1c for referral to the behaviour change programme, in electronic health data from about one-fifth of all primary care practices in England. We confirm our main finding, the improvement of HbA1c, using two other quasi-experimental approaches: difference-in-differences analysis exploiting the phased roll-out of the programme and instrumental variable estimation exploiting regional variation in programme coverage. This analysis provides causal, rather than associational, evidence that lifestyle advice and counselling implemented at scale in a national health system can achieve important health improvements.

Pasifika Prediabetes Youth Empowerment Programme: learnings from a youth-led community-based intervention study.

AIM: Using a co-design approach, we describe exploratory findings of a community-based intervention to mobilise Pasifika communities into action, with the intent of reducing the risk factors of prediabetes. METHOD: A group of 25 Pasifika youth aged 15-24 years from two distinctive Pasifika communities in New Zealand were trained to lead a small-scale, community-based intervention programme (among 29 participants) over the course of eight weeks. The intervention, which targeted adults aged 25-44 years who were overweight or obese, employed both an empowerment-based programme and a co-design approach to motivate community members to participate in a physical-activity-based intervention programme. RESULTS: Findings show significant reductions in total body weight and waist circumference, as well as improved physical activity. CONCLUSIONS: The strength of this intervention was evident in the innovative approach of utilising Pasifika-youth-led and co-designed approaches to motivate communities into healthier lifestyles. The approaches used in this project could be utilised in a primary healthcare setting as a community-wide strategy to reduce diabetes risk, particularly among Pasifika peoples.

A simulation study of the economic and health impact of a diabetes prevention programme in Ireland.

AIMS: Type 2 diabetes is a major public health issue that has a large effect on society including its health and social services. The aims of this paper are to generate a projection of the number of cases and explore the potential impact of a preventive intervention targeted at people with pre-diabetes on disease prevalence, complications, mortality and cost. METHODS: A Markov simulation model of diabetes and pre-diabetes in Ireland, for the period 1991 to 2036, was generated based on international epidemiological data. The simulation was calibrated with the available Irish data on the prevalence of pre-diabetes, diabetes and diabetic complications. The economic and health impact of a hypothetical nationwide preventive intervention programme, which reduces the incidence by a factor consistent with the international literature, was estimated under three scenarios of alternative effectiveness and uptake. RESULTS: The estimated number of people over 40 years of age with type 2 diabetes in Ireland is projected to increase from 216,000 in 2020 to 414,000 in 2036. A prevention programme, based on the NHS Diabetes Prevention Programme, is estimated to result in a reduction of between 2000 (0.5%) and 19,000 (4.6%) in the number of prevalent cases of diabetes in 2036 resulting in substantial health and quality of life benefits. CONCLUSIONS: A wide range of initiatives with uncertain outcomes will be required to reduce the impact of obesity and type 2 diabetes. A diabetes prevention programme seems likely to be worth pursuing as one element of this set of initiatives.

Participant food and activity costs in a translational Diabetes Prevention Program.

The Diabetes Prevention Program (DPP) and its translational adaptations have been shown to be effective. However, individual-level economic impacts, such as the out-of-pocket costs borne by participants due to involvement in these programs have not been consistently and thoroughly evaluated. As cost is an important consideration that will impact the willingness of individuals to participate in such programs, this study examined direct monetary costs to participants in the Group Lifestyle Balance (GLB) DPP. Older adults (n = 134, mean age 62.8 years) with body mass index (BMI) ≥24 kg/m2 and prediabetes and/or metabolic syndrome participated in this GLB intervention, with two-thirds randomized to begin the intervention immediately and one-third functioning as a control for 6 months before receiving the entire intervention. Food and activity time and costs borne by participants were measured by self-report at baseline and after 6 months. Significant improvements in clinical metabolic measures, weight, and physical activity levels were achieved after 6 months in the intervention group compared both with baseline and the controls. Food costs did not increase among intervention participants. Costs related to physical activity did not change consistently over the course of the intervention. This DPP-GLB lifestyle intervention was effective in reducing risk factors for Type 2 diabetes mellitus among a diverse group of older participants without significantly increasing their out-of-pocket costs for food or physical activity over the course of the intervention. These results should help reduce concerns of individuals who are hesitant to participate in similar programs due to costs. The clinical trial registration number of this study is NCT01050205.

Medicare Diabetes Prevention Program: where are the suppliers?

OBJECTIVES: The Medicare Diabetes Prevention Program (MDPP) launched in April 2018, offering an unprecedented opportunity to reach the estimated 48.3% of older adults with prediabetes. Success of the innovative policy is likely to depend on adequate supplier availability. We examined supplier data from CMS to assess beneficiaries' potential access to MDPP services. STUDY DESIGN: We conducted a descriptive analysis of MDPP suppliers using data extracted from the CMS registry of suppliers as of July 2019 and data about beneficiary populations. METHODS: Identifying the location, type, and number of MDPP suppliers and their respective sites, including within states, US territories, and the District of Columbia (hereafter, states), we mapped geographic coverage of MDPP access. RESULTS: There are 126 unique supplier organizations that offer the MDPP across 601 sites, equating to only 1 site per 100,000 Medicare beneficiaries. Seventy-five percent of states have no MDPP sites, fewer than 1 site per 100,000 beneficiaries, and/or availability limited to a single municipality. Although only 10.3% of MDPP suppliers are community-based organizations, they represent more than half (55.7%) of sites where beneficiaries can access the program. CONCLUSIONS: Findings show inadequate MDPP access, with relatively few suppliers and locations where beneficiaries can receive services. Insufficient reimbursement relative to costs for suppliers may largely account for limited availability. Strategies to facilitate access are urgently needed, which may include partnering with large organizations for greater per capita reach and rural organizations for broader geographic coverage, along with setting fiscally sustainable rates based on refined program implementation and cost analysis.

Evidence and Challenges for Translation and Population Impact of the Diabetes Prevention Program.

PURPOSE OF REVIEW: Type 2 diabetes is common, burdensome, and preventable. Landmark trials such as the Diabetes Prevention Program (DPP) demonstrated that resource-intensive lifestyle support interventions resulting in modest weight loss via healthy diet changes and physical activity can lower the rate of diabetes development by 58%. We performed a review of efforts to translate and implement DPP-like programs throughout the USA to identify challenges and opportunities for improvement. RECENT FINDINGS: For more than a decade, multiple stakeholders have worked to translate evidence-based principles of diabetes prevention to reach 84 million Americans with prediabetes. DPP-like programs have been delivered by over 1500 organizations, reaching almost 300,000 people, but this number represents less than 1% of the target population. Research has uncovered large gaps in efforts to diagnose, raise awareness, and provide access to DPP-like programs for adults with prediabetes, requiring further stakeholder engagement and coordination to resolve. Efforts to address prevailing gaps in diabetes prevention must address distinct and sometimes conflicting priorities and concerns of stakeholders. Our review recommends several areas of further research and action to improve type 2 diabetes prevention on a population scale.

Health education and communication needs among primary care patients with prediabetes in Singapore: A mixed methods approach.

AIMS: To assess factors associated with ever receiving prediabetes education, and to explore the health education and communication needs among primary care patients with prediabetes in Singapore. METHODS: A mixed methods study, consisting of a cross-sectional survey involving 433 patients with prediabetes aged 21-79, and in-depth interviews (IDIs) with 48. Multivariable regression was used to analyse the survey results, while thematic analysis was used to analyse the IDIs. RESULTS: The prevalence of ever receiving prediabetes education was 26.6%. This was positively associated with school education, impaired glucose tolerance, number of co-morbidities, having family or peer with diabetes, having support to reduce diabetes risk, confidence to self-manage prediabetes, and negatively associated with age. A common reason among those not receiving such education was not being referred by doctors. The preferred content of health communication messages were to focus on risk and prevention of diabetes, health and family, and to avoid the term 'prediabetes' in messages. The top 2 preferred education components were healthy eating and physical activity, and the most desired setting was the community centre. CONCLUSIONS: More efforts are needed to increase the take-up rate of prediabetes education. Polyclinic healthcare professionals could provide preliminary advice, and subsequently refer patients to community-based programmes or resources.

[Possible to prevent prediabetes from progressing to manifest type 2 diabetes]. / Prediabetes ­ mål för intervention.

Different prediabetic states precede overt type 2 diabetes. Prediabetes also carries an increased cardiovascular risk per seand may be divided into fasting hyperglycemia, impaired glucose tolerance and intermediate hyperglycemia. Mixed forms of these are very common. Prediabetes develops insidiously for many years and usually produces no symptoms until very late. It is possible to prevent prediabetes from progressing to manifest type 2 diabetes and it can also be made to revert to normoglycemia. The importance of lifestyle interventions, pharmacological treatment, surgical treatment and community efforts is discussed.

Preventing Diabetes in the Workplace: Effects of Coaching and Monetary Incentives.

OBJECTIVE: Prevention of diabetes demonstrated in the diabetes prevention program has not been thoroughly evaluated in workplace settings. METHODS: Glycemic control was assessed by glycated hemoglobin (HbA1c) and its impact on 5-year incidence of diabetes and prediabetes prevalence, in wellness program participants (WPP) of (Group A, with) or (Group B, without) health coaching and monetary incentives. RESULTS: HbA1c fell in Group A WPP (5.52 ±â€Š0.60 vs 5.58 ±â€Š0.36 SD, P = 0.04) as did prediabetes. Incident diabetes was less than expected (24 vs 74, P < 0.001). HbA1c increased in Group B WPP (5.37 ±â€Š0.40 SD vs 5.58 ±â€Š0.54, P < 0.001) and prediabetes increased from 28 to 36 (P < 0.001). CONCLUSIONS: Health coaching and monetary incentives improved glycemic control over 5 years, an improvement not observed in WPP without these interventions.

Evidence for the Prevention of Type 2 Diabetes Mellitus.

Type 2 diabetes mellitus (T2DM) is a common chronic metabolic condition. Before receiving this diagnosis, persons typically have a long period of prediabetes. There is good evidence that T2DM can often be prevented or delayed by means of lifestyle interventions (39%-71%), medications (28%-79%), or metabolic surgery (75%). However, despite consistent data demonstrating their efficacy, these tools are underused, and knowledge about them among primary care physicians is limited. In an effort to engage physicians in addressing this public health crisis more effectively, the authors reviewed the evidence that T2DM can be prevented or delayed in persons at risk.

Practical Tips for Implementing the Diabetes Prevention Program in Clinical Practice.

PURPOSE OF REVIEW: The Diabetes Prevention Program (DPP) is an evidence-based lifestyle change program for prediabetes that is associated with a 58% reduction in 3-year diabetes incidence, and it has been supported by the American Medical Association and the Centers for Disease Control and Prevention. However, 9 in 10 patients are unaware they have the condition. RECENT FINDINGS: With the passage of the Affordable Care Act (ACA) and broadened coverage for preventive services, the DPP has emerged as an accessible intervention in patients at risk. In 2018, Medicare began to cover the DPP, making it widely available for the first time to any patient over the age of 65 meeting eligibility criteria. The DPP is an evidence-based, widely available, frequently covered benefit, for lifestyle change for patients with prediabetes. To take advantage of this intervention, providers need to develop prediabetes screening and DPP referral workflows.

The Impact of a Novel Structured Health Intervention for Truckers (SHIFT) on Physical Activity and Cardiometabolic Risk Factors.

OBJECTIVE: The aim of this study was to examine the effects of implementing a lifestyle health behavior intervention on cardiovascular risk markers in a sample of lorry drivers. METHODS: Fifty-seven males participated in the pre-post evaluation of a multicomponent 12-week intervention. RESULTS: Favorable changes in several cardiovascular health indicators were observed, including fasting blood glucose (-0.6 mmol/L), LDL-Cholesterol (-0.7 mmol/L), total cholesterol (-0.7 mmol/L), waist-hip ratio (-0.10), and waist circumference (-2.5 cm) (P < 0.01). The proportion of participants with a more than 10% risk of a cardiovascular event in the next 10 years was reduced by 12% (P < 0.05). A 21%, 12%, and 7.5% reduction in drivers with pre-diabetes (P < 0.001), undiagnosed diabetes (P < 0.05), and the metabolic syndrome (P < 0.05), respectively, was observed. CONCLUSION: This study highlights the feasibility of implementing a multicomponent health intervention within the transport setting and provides preliminary evidence of its beneficial effects on some markers of health.

Position of the Academy of Nutrition and Dietetics: The Role of Medical Nutrition Therapy and Registered Dietitian Nutritionists in the Prevention and Treatment of Prediabetes and Type 2 Diabetes.

It is the position of the Academy of Nutrition and Dietetics that for adults with prediabetes or type 2 diabetes, medical nutrition therapy (MNT) provided by registered dietitian nutritionists (RDNs) is effective in improving medical outcomes and quality of life, and is cost-effective. MNT provided by RDNs is also successful and essential to preventing progression of prediabetes and obesity to type 2 diabetes. It is essential that MNT provided by RDNs be integrated into health care systems and public health programs and be adequately reimbursed. The Academy's evidence-based nutrition practice guidelines for the prevention of diabetes and the management of diabetes document strong evidence supporting the clinical effectiveness of MNT provided by RDNs. Cost-effectiveness has also been documented. The nutrition practice guidelines recommend that as part of evidence-based health care, providers caring for individuals with prediabetes or type 2 diabetes should be referred to an RDN for individualized MNT upon diagnosis and at regular intervals throughout the lifespan as part of their treatment regimen. Standards of care for three levels of diabetes practice have been published by the Diabetes Care and Education Practice Group. RDNs are also qualified to provide additional services beyond MNT in diabetes care and management. Unfortunately, barriers to accessing RDN services exist. Reimbursement for services is essential. Major medical and health organizations have provided support for the essential role of MNT and RDNs for the prevention and treatment of type 2 diabetes.

A Preliminary Study of the Effects of a Multitheory-Driven Intervention in Adults With Prediabetes Mellitus.

BACKGROUND: Prediabetes mellitus (pre-DM) is an important predictive indicator of Type 2 diabetes. A person with pre-DM is eight times more likely to develop diabetes than a person without pre-DM. Prior research suggests that proactive interventions may delay the progression of this disease and reduce the rate of disease development. PURPOSE: The purposes of this preliminary study were to develop a multitheory-driven lifestyle intervention protocol for adults with pre-DM and to evaluate its feasibility and impacts on knowledge regarding pre-DM, dietary behaviors, and physical activity (primary outcomes) as well as to describe the disease progression indicators (secondary outcomes). METHODS: A single-group, longitudinal study design was used. Thirty-nine participants were included in the analysis. A generalized estimating equation model was used to determine the trends in changes in the outcomes. All of the participants underwent testing at baseline (T0) and at 3 (T1), 6 (T2), and 12 (T3) months after the 4-week lifestyle intervention. RESULTS: There were significantly increasing trends for each study parameter (Pre-DM Knowledge Assessment Form-12, p < .01; Dietary Behavior Scale, p < .01) and significantly positive changes in body weight (p < .01), body mass index (p < .01), fasting glucose level (p < .01), and glycated hemoglobin level (p < .01) over the 12-month study period. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: This study supports the feasibility of the developed multitheory-driven lifestyle intervention protocol and suggests that its application may improve the effectiveness of diabetes prevention programs in clinical settings. Further randomized controlled trials are needed.

Effect of Health Plan Financial Incentive Offering on Employees with Prediabetes.

BACKGROUND: Prediabetes may be improved or reversed with lifestyle interventions. A worksite wellness program offering financial incentives for participation may be effective in improving the health of employees with prediabetes. We studied the effect of employee health plan financial incentives on health outcomes for employees with prediabetes. METHODS: We conducted a retrospective cohort study using electronic medical record data from January 2008 to December 2012. Our study participants were employees with prediabetes and propensity-matched non-employees with prediabetes and commercial health insurance, all receiving care within one health system. Exposures included fixed annual financial incentives for program participation and later a premium discount divided between program participation and achievement of goals. We used longitudinal linear mixed models to assess yearly changes in glycosylated hemoglobin (HbA1c), weight, and low-density lipoprotein cholesterol in employees versus non-employees. We also compared outcomes of employees by ever- versus never- program participant status. RESULTS: Our study population included 1005 employees and 1005 matched non-employees. The yearly reduction in HbA1c for employees versus matched non-employees did not differ in 2008-2010 but was greater in 2010-2012, when incentives were tied to program participation as well as achievement of goals (-0.10% vs -0.08 %, respectively; P for difference in change [DIC] = .01 from 2010 to 2012). Analyses from both periods showed that employees lost more weight per year than matched non-employees (-1.85 vs -0.21 lb [1 lb=0.45 kg] from 2008 to 2010; P for DIC < .001 and -2.35 vs -0.65 lb from 2010 to 2012; P for DIC < .001). Employees who participated in disease management lost more weight than those who did not (-2.14 vs 0.79 lb yearly before 2010 and -2.82 vs -0.91 after January 1, 2010, P for DIC < .01 and < .001, respectively). CONCLUSION: A worksite wellness program offering health plan financial incentives for participation and outcomes was associated with improvements in weight and HbA1c.

Computer simulation models of pre-diabetes populations: a systematic review protocol.

INTRODUCTION: Diabetes is a major public health problem and prediabetes (intermediate hyperglycaemia) is associated with a high risk of developing diabetes. With evidence supporting the use of preventive interventions for prediabetes populations and the discovery of novel biomarkers stratifying the risk of progression, there is a need to evaluate their cost-effectiveness across jurisdictions. In diabetes and prediabetes, it is relevant to inform cost-effectiveness analysis using decision models due to their ability to forecast long-term health outcomes and costs beyond the time frame of clinical trials. To support good implementation and reimbursement decisions of interventions in these populations, models should be clinically credible, based on best available evidence, reproducible and validated against clinical data. Our aim is to identify recent studies on computer simulation models and model-based economic evaluations of populations of individuals with prediabetes, qualify them and discuss the knowledge gaps, challenges and opportunities that need to be addressed for future evaluations. METHODS AND ANALYSIS: A systematic review will be conducted in MEDLINE, Embase, EconLit and National Health Service Economic Evaluation Database. We will extract peer-reviewed studies published between 2000 and 2016 that describe computer simulation models of the natural history of individuals with prediabetes and/or decision models to evaluate the impact of interventions, risk stratification and/or screening on these populations. Two reviewers will independently assess each study for inclusion. Data will be extracted using a predefined pro forma developed using best practice. Study quality will be assessed using a modelling checklist. A narrative synthesis of all studies will be presented, focussing on model structure, quality of models and input data, and validation status. ETHICS AND DISSEMINATION: This systematic review is exempt from ethics approval because the work is carried out on published documents. The findings of the review will be disseminated in a related peer-reviewed journal and presented at conferences. REVIEWREGISTRATION NUMBER: CRD42016047228.

Simulated Effects of Policies to Reduce Diabetes Risk Among Adults With Schizophrenia Receiving Antipsychotics.

OBJECTIVE: Second-generation antipsychotics increase the risk of diabetes and other metabolic conditions among individuals with schizophrenia. Although metabolic testing is recommended to reduce this risk, low testing rates have prompted concerns about negative health consequences and downstream medical costs. This study simulated the effect of increasing metabolic testing rates on ten-year prevalence rates of prediabetes and diabetes (diabetes conditions) and their associated health care costs. METHODS: A microsimulation model (N=21,491 beneficiaries) with a ten-year time horizon was used to quantify the impacts of policies that increased annual testing rates in a Medicaid population with schizophrenia. Data sources included California Medicaid data, National Health and Nutrition Examination Survey data, and the literature. In the model, metabolic testing increased diagnosis of diabetes conditions and diagnosis prompted prescribers to switch patients to lower-risk antipsychotics. Key inputs included observed diagnoses, prescribing rates, annual testing rates, imputed rates of undiagnosed diabetes conditions, and literature-based estimates of policy effectiveness. RESULTS: Compared with 2009 annual testing rates, ten-year outcomes for policies that achieved universal testing reduced exposure to higher-risk antipsychotics by 14%, time to diabetes diagnosis by 57%, and diabetes prevalence by .6%. These policies were associated with higher spending because of testing and earlier treatment. CONCLUSIONS: The model showed that policies promoting metabolic testing provided an effective approach to improve the safety of second-generation antipsychotic prescribing in a Medicaid population with schizophrenia; however, the policies led to additional costs at ten years. Simulation studies are a useful source of information on the potential impacts of these policies.

Family-centered prevention ameliorates the association between adverse childhood experiences and prediabetes status in young black adults.

Individuals exposed to adverse childhood experiences (ACEs) are vulnerable to various health problems later in life. This study was designed to determine whether participation in an efficacious program to enhance supportive parenting would ameliorate the association between ACEs and prediabetes status at age 25. Rural African American parents and their 11-year-old children (N=390) participated in the Strong African American Families (SAAF) program or a control condition. Each youth at age 25 provided a total ACEs score and a blood sample from which overnight fasting glucose was assayed. Logistic regression equations were used to test the hypotheses. The logistic regression analyses revealed a significant interaction between total ACEs and random assignment to SAAF or control, OR=0.56, 95% CI [0.36, 0.88]. Follow-up analyses indicated that, for participants in the control condition, a 1-point increase in ACEs was associated with a 37.3% increase in risk of having prediabetes. ACEs were not associated with the likelihood of having prediabetes among participants in the SAAF condition. Control participants with high total ACEs scores were 3.54 times more likely to have prediabetes than were SAAF participants with similar scores. This study indicated that participation at age 11 in a randomized controlled trial designed to enhance supportive parenting ameliorated the association of ACEs with prediabetes at age 25. If substantiated, these findings may provide a strategy for preventing negative health consequences of ACEs.

Pre-diabetes tsunami: incidence rates and risk factors of pre-diabetes and its different phenotypes over 9 years of follow-up.

AIMS: To investigate the incidence of pre-diabetes and its different phenotypes and the related risk factors during 9 years of follow-up. METHODS: A total of 5879 people (2597 men and 3282 women) aged ≥ 20 years, free of diabetes and pre-diabetes, took part in the study. Multivariable Cox proportional hazard models were used to evaluate hazard ratios (HR) and 95% confidence intervals (CI) for all potential risk factors. RESULTS: Overall, 853 men and 902 women developed pre-diabetes. Incidence rates of pre-diabetes were 46.1 per 1000 person-years in men and 36.8 per 1000 person-years in women, while isolated impaired fasting glucose had the highest incidence rate among all pre-diabetes phenotypes. In both sexes, age, family history of diabetes, fasting plasma glucose and 2-hour post-challenge plasma glucose were related to incident pre-diabetes. Among women, waist-to-height ratio [HR: 1.02 (1.00-1.03)] and being divorced/widowed compared with married [HR: 0.67 (0.52-0.87)] were significant predictors of pre-diabetes; whereas among men, community-based intervention [HR: 0.79 (0.68-0.90)], higher level of education and being single [HR: 0.77 (0.6-0.97)] were protective against progression to pre-diabetes. Moreover, hip circumference among women [HR: 0.95 (0.93-0.98)] and current smoking among men [HR: 1.69 (1.15-2.48)] were related to incident combined impaired fasting glucose and impaired glucose tolerance. CONCLUSION: More than 4% of the Iranian population develop pre-diabetes each year, emphasizing the important role of socio-economic factors (marital status, education and smoking habits) and community-based intervention in progression to impaired glucose regulations. Thus, emergent intervention is necessary to halt the tsunami of pre-diabetes among the Iranian population.