SCREEN, COUNSEL, REFER AND FOLLOW-UP FOR DIABETES AND PREDIABETES J. Michael Gonzalez-Campoy, MD, PhD, FACE [email protected] Teresa Pearson, MS, RN, CDE, FAADE [email protected].
Download ReportTranscript SCREEN, COUNSEL, REFER AND FOLLOW-UP FOR DIABETES AND PREDIABETES J. Michael Gonzalez-Campoy, MD, PhD, FACE [email protected] Teresa Pearson, MS, RN, CDE, FAADE [email protected].
SCREEN, COUNSEL, REFER AND FOLLOW-UP FOR DIABETES AND PREDIABETES J. Michael Gonzalez-Campoy, MD, PhD, FACE [email protected] Teresa Pearson, MS, RN, CDE, FAADE [email protected] Sponsored by Minnesota Department of Health Diabetes Program With funds from the National Association of Chronic Disease Directors State Diabetes Prevention Program 2013 grant Thanks to the Institute for Clinical Systems Improvement for hosting this webinar Program Objectives Define the problem of prediabetes and diabetes Describe the progression, screening, diagnosis and treatment of diabetes Describe how to apply the Screen, Counsel, Refer and Follow-up Model to diabetes Identify National Diabetes Prevention Program sites in Minnesota and how to access them Present the Provider’s Toolkit Why Do We Care About Prediabetes? We first need to understand the big picture The Progression to Diabetes Slide 5 Adiposopathy -- shades of red DM-2 Dyslipidemia Hypertension Dysmetabolic Syndrome Overweight & Obesity IFG Primary PreDiabetes Vascular Event CV Risk Factors Secondary Tertiary Primary Secondary PREVENTION Primary Quaternary Tertiary Secondary Bays H, Rodbard HW, Schorr AB, González-Campoy JM, Adiposopathy: Treating Pathogenic Adipose Tissue to Reduce Cardiovascular Disease Risk. Prevention. 259-271. Bays H González-Campoy JM, Henry RR, , Bergman DA, Kitabchi,SAE, Schorr AB, Rodbard, HW, The Adiposopathy Working Group. Int J Clin Pract, October 2008, 62, 10, 1474–1483. Diabetes Definitions Normal Fasting 2 hours post challenge ** A1C PreDiabetes Diabetes 100-125 mg/dl 126 mg/dl or more Impaired Fasting Glucose 140 mg/dl or 141-199 mg/dl less 200 mg/dl or more Impaired Glucose Tolerance < 5.7% ≥6.5% 65-99 mg/dl 5.7–6.4% ** 75 grams glucose American Diabetes Association Standards of Medical Care. Diabetes Care, Volume 36, S1. January 2013 What is Behind the Epidemic Of DIABETES? Approximately 80%-90% of people with type 2 diabetes are overweight or obese In the United States, approximately 68% of adults are considered overweight or obese Obesity is the primary risk factor for developing type 2 diabetes. MN Adult Prediabetes and Diabetes Algorithm 2013 AACE guidelines Slide 11 Complications-Centric Model For Care of the Overweight/Obese Patient Prediabetes Algorithm IFG (100-125) | IGT (140-199) | Metabolic Syndrome (NCEP 2005) The Burden of Diabetes Slide 14 The Burden of Diabetes in the United States In the United States nearly 26 million people have diabetes (2010) • 11.3 % of the U.S. adult population • More than 1 out of 4 of these 26 million people (7 million) do not know they have the disease An estimated 79 million U.S. adults have prediabetes • 35% of U.S. adults • 5-15% develop diabetes each year The CDC projects that as many as one in three adults in the U.S. could have diabetes by 2050 if current trends continue. CDC. National Diabetes Fact Sheet 2011 Boyle et al. 2010 Population Health Metrics 8:29 Economic Impact of Diabetes Annual cost of diabetes in US is an estimated $245 billion (2012) • • • • Direct and indirect medical costs, disability, lost work, and premature death Annual 2009 Cost of Care • General Population, No Diabetes - $4,400 • All Persons with Diabetes (average) - $11,700 Persons with Diabetes only - $7,800 Persons with Diabetes and Complications - $20,700 ADA. 2013. Economic Costs of Diabetes in the U.S. in 2012. Diabetes Care 36:1033-1046 http://www.health.state.mn.us/diabetes/pdf/DiabetesPrediabetesMinnesotaFactSheet2012.pdf The Burden of Diabetes in Minnesota An estimated 300,000 adults have diabetes (2012) • 7.3 % of the adult population • This number does not include those who do not know they have the disease (1 in 4 from National data) As many as 1.4 million adults have prediabetes • Using national estimates of 35% of U.S. adults having prediabetes Annual cost of diabetes is an estimated $3.1 billion (2012) Percentage of Minnesota Adults Prevalence is increasing in Minnesota, just like the rest of the nation 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0 Year*,** *Note: Percentages are age-adjusted to account for any changes in age distribution in the MN population over time and represent only non-institutionalized adults. **Percentages reflect an average of 2-3 years of data. Source: Centers for Disease Control and Prevention: National Diabetes Surveillance System. http://apps.nccd.cdc.gov/DDTSTRS/default.aspx Diabetes Risk is Not Equal Across the Population Slide 19 Diabetes Risk Increases with Age Percentage of Adults with Diagnosed Diabetes 20 18 64-74 years 16 75+ years 14 12 10 45-64 years 8 6 4 2 18-44 years 0 1994 1996 1998 2000 2002 2004 2006 2008 2010 CDC, National Diabetes Surveillance System, www.cdc.gov/diabetes/statistics Retrieved 4/18/2013 Diabetes Rates Vary by Race/Ethnicity http://www.cdc.gov/features/hispanichealth/graph.html Additional Diabetes Risk Factors Being overweight/obese Low levels of physical activity Family history History of gestational diabetes Adults with hypertension and other cardiovascular risk factors Prediabetes The Challenge of Prediabetes in Minnesota Many Minnesotans, as many as 1.4 million adults, likely have prediabetes • In 2012 only 6% of Minnesota adults or ~210,000 people reported that they had prediabetes Most adults with prediabetes don’t know they have it. MDH, Diabetes Program Analyses 2012 BRFSS data; CDC National Diabetes Fact Sheet 2011 Why Focus on Prediabetes? High risk group Great time to intervene Effective intervention in the NDPP But lack of awareness What can you do? Slide 24 Diabetes Can Be Prevented Among Those With Prediabetes The Diabetes Prevention Program trial showed that the onset of diabetes can be prevented or delayed among people with prediabetes over a 3-year period • 58% among all participants • 71% among those 65 years and older Key to reduction in risk was a lifestyle change program that changed modifiable risk factors for diabetes: • Healthy eating • Increased physical activity • That lead to weight-loss Tabák et al. 2012. Lancet 379:2279-2290. CDC, DDT http://www.cdc.gov/diabetes/consumer/prediabetes.htm Original Diabetes Prevention Research Study Goal: to find out whether losing modest amounts of weight through improving diet and increasing physical activity, or taking the diabetes drug metformin, could prevent or delay type 2 diabetes in people at high risk for developing the disease. Major multicenter clinical research study – 3,234 participants – 27 clinical centers in U.S. – Funded primarily by NIH 26 Diabetes Prevention Program (DPP) Screened 158,177 OGTT, then randomize 3819 randomized Lifestyle 1079 Metformin 1073 5% Wt loss 3% Wt loss 58 % Risk Reduction 31% Risk Reduction Placebo 1082 Thiazolidinedione 585 ~10 month followup Diabetes Rate 11 % per year 24 % Risk Reduction Diabetes Prevention Program Research Gp, NEJM 346(6): 393-403, 2002. Lifestyle Intervention of the Original Diabetes Prevention Research Study • • • • One-on-one instruction Healthcare professional Toolbox of incentives Program structure – Primary goals: • 7% weight loss • 150 minutes/week physical activity – 16 core sessions – Maintenance phase Diabetes Prevention Research Study Original DPP: Type 2 diabetes risk reduction at 3 years Population Overall Seniors (over 60) White African American Hispanic American Indian Asian Lifestyle Intervention vs. Placebo 58% 71% 51% 61% 66% 65% 71% Metformin vs. Placebo 31% 11% 24% 44% 31% 25% 38% Diabetes Prevention Program Research Group NEJM 2002; 346, No. 6: 393-403 29 Diabetes Prevention Research Study Original DPP: Type 2 diabetes risk reduction at 10 years Original DPP Follow-Up DPP after 10 Years Lifestyle Intervention vs. Placebo 58% 34% Metformin vs. Placebo 31% 18% Diabetes Prevention Program Research Group The Lancet 2009; 374: 1677-86 The DPP in Practice Slide 31 Translating the DPP to Groups in Community Settings Similar levels of weight-loss have been obtained in community based programs that deliver curriculum in a group setting: • Deploy Research Study • Special Diabetes Program for American Indians Diabetes Prevention Demonstration Project • Montana Diabetes Prevention Program • I CAN Prevent Diabetes Sites in Minnesota Lancet, 2009 374:1677-1686 • YMCA-led classes with DPCA Amer J Prev Med 2008 35(4):357-63 Diabetes Educator, 2009 35:209-223 Diabetes Care 2013 – online (AI/AN reference) Amer J Prev Med 2013 44(4):S301-S306 On the Cutting Edge 2013 33(4): From DPP to NDPP CDC’s vision is for this to be a program available nationally: National Diabetes Prevention Program (NDPP) NDPP is based on curriculum of the original DPP and modifications from translational studies The Diabetes Prevention Recognition Program requires data submission from NDPP program to CDC. • CDC will “recognize” those programs meeting CDC standards. Goals for the NDPP? The DPP curriculum delivered in a group Following Standards set by CDC Goals of the NDPP • Lose 7% weight • Increase activity to 150 minutes per week Implementing a Prediabetes Screening Program in Your Practice Screen Counsel Refer Follow-up Provider's Prediabetes Toolkit http://www.icanpreventdiabetes.org/hptoolkit.html CDC Risk Test NDPP Referral Form NDPP awareness materials • Flyer • Patient Brochure • Provider Brochure List of NDPP in Minnesota Screen Slide 37 Define a Process for Screening Identify who to screen Discuss how to screen Identify who does the screening Identify who will interpret the screening Decide how and where to document and who will do it CDC Prediabetes Screening Test Interpreting the Score Counsel Who does the counseling? What to talk about? What if They Have a High Risk Level But Not Yet Prediabetes: A CDC Risk Test score of 3-8 Points or A1c < 5.7 Probably not at high risk for having prediabetes now. To keep risk level below high risk: • • • • If overweight, lose weight Be active most days Don’t use tobacco Eat low-fat meals including fruits, vegetables, and whole-grain foods • If high cholesterol or high blood pressure, talk to health care provider about risk for type 2 diabetes What If They Have Diabetes? Provide survival skills training Provide basic lifestyle recommendations Resources for Managing Diabetes • ADA Clinical Recommendations -- 2013 • ICSI Guideline for Diagnosis and Management of Type 2 Diabetes in Adults • ADA/ESAD Clinical Algorithm for Managing Type 2 diabetes 2012 • AACE Comprehensive Management of Diabetes 2013 Basic Lifestyle Recommendations For All Slide 44 For All: Recommend Healthy Eating • Enjoy food, eat less, watch portion size • Make ½ plate fruits and vegetables • Switch to fat-free or low-fat (1%) milk • Drink water instead of sugary drinks • Compare food labels and choose foods lower in sodium U.S. Department of Agriculture and U.S. Department of Health and HumanServices. Dietary Guidelines for Americans, 2010. 7th Edition, Washington, DC: U.S. Government Printing Office, December 2010. AW3075641B Recommend Physical Activity Be active together as a family; Eat meals together as a family whenever possible Walk and take the stairs; Park in distant spots and walk farther when shopping Try new activities that increase physical activity Limit screen time (TV, computer, video games) to < 2 hours/day Suggest community programs at YMCA, YWCA, Park & Recreation Centers Participant Poster Slide 48 Slide 49 Refer For those who qualify, refer to a National Diabetes Prevention Program near you… Who is Eligible to Participate in the NDPP? 18+ years old Overweight • BMI greater than 24 for most people • BMI greater than 22 for those of Asian descent Diagnosis of prediabetes OR History of gestational diabetes 51 NDPP Referral Form How To Find A NDPP Group In Minnesota CDC’s National Recognition Program: http://www.cdc.gov/diabetes/prevention/ Minnesota’s List of NDPP Sites: http://www.icanpreventdiabetes.org/groups.html Provider’s Prediabetes Toolkit: http://www.icanpreventdiabetes.org/hptoolkit.html All Sites in Minnesota Offering National Diabetes Prevention Programs in 2013 Listed on CDC national registry of recognized diabetes prevention programs What topics are covered in the National Diabetes Prevention Program Slide 55 The National Diabetes Prevention Program Core Curriculum Skills Controlling the external environment Psychological and emotional 1. 2. 3. 4. 5. 6. 7. Welcome Be a Fat and Calorie Detective Three Ways to Eat Less Fat and Fewer Calories Healthy Eating Move Those Muscles Being Active: A Way of Life Tip the Calorie Balance 8. Take Charge of What’s Around You 9. Problem Solving 10. Four Keys to Healthy Eating Out 11. 12. 13. 14. 15. 16. Talk Back to Negative Thoughts The Slippery Slope of Lifestyle Change Jump Start Your Activity Plan Make Social Cues Work for You You Can Manage Stress Ways to Stay Motivated Skills and Tools: Sessions 1-7 Self-monitoring skills and tools: • • • • Food intake Fat grams Weight Physical activity (Session 5) Knowledge Increased awareness of eating habits Tools Techniques to replace unhealthy behaviors with healthy ones Controlling the External Environment: Sessions 8-10 Contextual factors Ways to deal with elements in one’s environment that can influence food and physical activity habits • Eating out • Food and activity cues Identify problems, develop effective coping strategies Psychological and Emotional: Sessions 11-16 Internal and external influences related to emotions, stress, and motivation • Negative thoughts • Overcoming slips • Prevention and coping How to make these influences support lifestyle change Follow-up Adults Continue to screen every three years or more frequently with risk factors Kids 10-17 Re-test FPG and A1C every 4 months Follow-up for People with Prediabetes For those with prediabetes, return for followup in 3 months to review goals If tests were normal on screen, repeat at least at 3-year intervals Repeat tests annually for conversion to diabetes Continue lifestyle counseling and recommendations – best defense: • Managing weight • Physical activity In Summary: What You Can Do For Your Patients Ask patients to complete a risk assessment Obtain A1C, FPG or OGTT to confirm diagnosis For prediabetes: • • • • Encourage lifestyle change & refer to a National DPP 5-7% weight loss if overweight 150 min/wk physical activity Consider medications or other treatment as appropriate If diabetes: refer to an accredited DSME program • Encourage weight management and 150 min/wk physical activity • Consider medications or other treatment as appropriate Return for follow-up in 3 months to review goals Resources MN Dept of Health – I CAN Prevent Diabetes • http://www.icanpreventdiabetes.org/hptoolkit.html National Diabetes Education Program (NDEP) • www.YourDiabetesInfo.org http://ndep.nih.gov/ Medicare Diabetes Screening Program • http://www.screenfordiabetes.org/ Centers for Disease Control • http://www.cdc.gov/diabetes/pubs/factsheet11.htm American Diabetes Association • http://www.diabetes.org/diabetes-basics/prevention/ • http://professional.diabetes.org/CPR_search.aspx