Lifestyle Interventions for Diabetes Prevention and Control

1
Lifestyle Interventions for Diabetes Prevention
and Control

• What does science tell us about potential Public
  Health strategies?

2
Diabetes A Public Health Problem

• High disease burden to individual and society
• Disproportionate burden to elderly and minorities
• Effective primary and secondary prevention
  strategies
• Systems approach
• Individual
• Family and friends
• Health care professionals
• Community
• Policy

3
Essential Public Health Strategies

• Monitor health status to identify problems
• Diagnose and investigate health problems
• Inform, educate, and empower people
• Mobilize community partnerships
• Develop policies and enforce regulations
• Evaluate effectiveness of health services
• Research innovative solutions to problems
• http//www.cdc.gov/od/ocphp/nphpdp/EssentialPHServ
  ices.htm

4
Essential Public Health Strategies

• Monitor health status to identify problems
• Diagnose and investigate health problems
• Inform, educate, and empower people
• Mobilize community partnerships
• Develop policies and enforce regulations
• Evaluate effectiveness of health services
• Research innovative solutions to problems

5
Monitor Health Status - Incidence

• MMWR Morbidity and Mortality Weekly Report
  200857(43)1169-1173

6
Incidence

• 50 of adult incident cases are between the ages
  of 45 and 59 years
• 10 diagnosed before age 35
• 2/3 of adult with diabetes reported having had
  diabetes for 10 years or less
• http//www.cdc.gov/diabetes/statistics/newDataTren
  ds.htm

7
Prevalence

• Americans with diabetes
• 1980 5.6 million
• 2005 16.8 million
• Increased prevalence due to
• Increased detection
• Decreased mortality
• Increased incidence
• WV prevalence in 2006 12.1
• MMWR Morbidity and Mortality Weekly Report
  200857(SS-7)1-192

8
Complications of Diabetes

• Increased risk of
• Blindness in adults (70/day)
• Stroke and death due to stroke
• Heart attack and death due to heart attack
• Lower limb amputation (150/day)
• Kidney failure (75/day)
• Glasgow et al Ann Behav Med 199921(2) 159-170

9
Age-adjusted all-cause mortality rates among the
U.S. population age 35 to 74 years with and
without diabetes, by cohort and sex
Gregg, E. W. et. al. Ann Intern Med
2007147149-155
10
Costs of Diabetes132 Billion

• Indirect 39.8 billion
• Estimates of lost work days, restricted activity
  days, prevalence of permanent disability, and
  mortality attributable to diabetes
• Direct - 91.8 billion
• 23.2 billion for diabetes care
• 24.6 billion for chronic complications
• 44.1 billion for excess prevalence of general
  medical conditions
• Diabetes Care 200326917-932

11
Per Capita Medical Expenditures

• With diabetes 13,243
• Without diabetes 2,560

12
Prevention of Complications

• Insulin resistance
• Causes impaired glucose tolerance
• No complications as long as B-cells function
• B-cell dysfunction (impaired insulin secretion)
• Strategies may address either
• Good medical care including self-management and
  prevention
• Outreach and education (population-based care)

13
Chronic Disease Self-Management

• Assess and specify
• problem/target behavior
• Provide follow-up Collaboratively
• support (and enhance set goals
• social resources) identify barriers
• and motivators
• Provide personalized
• coping skills
• Glasgow et al Ann Behav Med 199921(2) 159-170

14
Screening Options

• For type 2 diabetes
• For pre-diabetes estimated 21 of adults
• Impaired glucose tolerance (140 to 199 mg/dL)
• Impaired fasting glucose (100 to 125 mg/dL)
• Who?
• Ethnic minorities
• Obese
• Hypertension
• Crandall et al. Nat Clin Pract Endocrinol Metab
  20084(7)382-393

15
Prevent or Delay Type 2 Diabetes

• Chinese study
• Intervention in community health centers
• Diet, exercise, both or control
• No difference between intervention groups
• Finnish study
• Diet plus exercise to achieve 5 weight loss
• 4.2 kg weight loss, 58 reduction in risk over 4
  years
• 43 reduction at 7 years

16
Diabetes Prevention Program

• 3000 overweight adults with IGT
• Lifestyle, medication, or control
• Goal 7 weight loss over 24 weeks
• 150 minutes moderate physical activity per week

17
Lifestyle Interventions

• Clearly defined goals
• Individual case managers (lifestyle coaches)
• Intensive intervention
• 16-week core curriculum
• Supervised exercise sessions (2x/week)
• Maintenance program (individual and group)
• Individual adherence strategies
• Culturally competent materials and strategies
• Extensive network for training and support

18
Effectiveness

• Metformin 31 reduction in risk
• Lifestyle intervention 58 reduction in risk
• Greater weight loss
• Higher levels of physical activity
• Improved insulin sensitivity and B-cell function
• Lower average HbA1c from 6 months to 3 years, no
  difference at 4 years v. metformin
• 3-year follow-up showed improvements in BP,
  lipids, and C-reactive protein

19
Importance of Physical Activity

• 24 of US adults and 31 of adults with diabetes
  report no regular physical activity
• Decrease body weight and body fat
• Improve sense of well-being
• Reduce functional decline with aging
• Improve lipid profile, lower blood pressure,
  decrease risk for blood clots

20
Role in Diabetes Prevention and Management

• Increases insulin sensitivity in contracting
  muscles for 24 to 72 hours
• Increases glucose uptake
• Increased muscle mass requires more glucose
• Metabolic adaptations enhance glucose use
• Contracting muscles use glucose without insulin
• Prevent or delay complications or slow
  progression of existing complications

21
Food Patterns

• Lower Risk

• Greater Risk

• Whole grains
• Fruits, nuts, seeds
• Green leafy vegetables
• Low-fat dairy
• Mediterranean-style diet

• Red meat
• Low-fiber grains
• Cheese
• Tomato products
• Eggs
• Potatoes

22
Nutrients Associated with Lower Risk

• Fiber
• Soluble decreased glucose spikes
• Insoluble lower risk for T2DM
• Monounsaturated and omega-3 fatty acids increase
  insulin sensitivity
• Vitamin C plasma levels inversely related to
  risk of diabetes
• Magnesium - intake inversely related to risk
• Vitamin D blood levels inversely related to
  risk

23
Coffee and Tea

• Coffee lower risk with 2 or more cups per day
• Tea - lower risk in some studies, but not others
• Polyphenols associated with lower risk of chronic
  disease

24
Red Wine

• 1 or more times per week 16 lower risk in
  postmenopausal women
• High intake may increase risk in men
• Meta analysis U-shaped curve with more benefit
  for women

25
Cost Effectiveness DPPRG 2003

• Direct medical costs, direct nonmedical costs,
  and indirect costs from health system perspective
• Lifestyle - 13,200/case prevented27,100/QALY
• Metformin - 14,300/case prevented35,000/QALY
• Direct medical costs less in both interventions
  
• Direct nonmedical costs lifestyle higher
  (1445)
• Diabetes Care 2003262518-2523

26
Cost Effectiveness DPPRG 2003

• Indirect costs metformin 230, lifestyle 174
• Societal costs relative to placebo (3years)
• Metformin - 2,412
• Lifestyle - 3,540
• Diabetes Care 20032636-47

27
Cost Effectiveness Health Plan Perspective

• Expected 30y cost/QALY
• Lifestyle 143 000
• Metformin 35 400
• Lifestyle, delayed until diagnosis 24 500
• Lifestyle modification for high risk people can
  save costs if it can be delivered for 100 per
  year
• Conclusion Program used in DPP may be too
  expensive for 3rd party payers
• Eddy et al Ann Intern Med 2005 143 251-264

28
What we Know

• Interventions decrease incidence of diabetes,
  improve CV risk factors
• Lifestyle changes more effective than medications
• Interventions promote weight loss
• Lifestyle interventions are resource-intensive
• Is there a public health solution?

29
Prevention Strategies

• Targeted and opportunistic screening
• Improve care processes
• Nonphysician providers
• Care algorithms
• Electronic records
• Community health workers (peer-to-peer)

30
Translational Research

• Effective, sustainable, generalized, transferable
• Interventions
• Minimal level of intensity
• Note personal, social and economic costs
• Target Settings
• community-based participatory research
• Connect multiple levels of influence
• Research Design
• Qualitative and quantitative research

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• Thank you.