Title : Diabetes Prevention: More Than Just Screening and Lifestyle Changes
URL Link : Diabetes Prevention: More Than Just Screening and Lifestyle Changes
Diabetes Prevention: More Than Just Screening and Lifestyle Changes
In March 2016, the Centers for Medicare & Medicaid Services (CMS) proposed a national expansion of the Diabetes Prevention Program[1] (DPP), an extensive lifestyle change intervention modeled from a successful 2002 randomized trial[2] of patients at dangerous of developing diabetes. In the original trial, the life-style intervention outperformed both metformin and placebo in cutting the incidence of diabetes over four years. The Medicare DPP proposal is discussed in more detail in a webinar through the CMS Innovation Center[3] and was recently highlighted by Health and Human Services Secretary Sylvia Burwell[4] as being a cost-saving preventive health innovation originating through the Affordable Care Act.
To identify high-risk patients, the Centers for Disease Control and Prevention and also the American Medical Association are leading a campaign encouraging adults to get screened for prediabetes, which can be estimated to affect 1 in 3 Americans. Last year, the US Preventive Services Task Force (USPSTF) recommended that primary care clinicians screen overweight or obese adults between the ages of 40 and 70 years for abnormal blood sugar as part of the cardiovascular risk assessment, and this patients meeting criteria for prediabetes be provided or known as "intensive behavioral counseling interventions to enhance a healthful diet and training."[5]
However, I have some qualms about screening for prediabetes inside the name of diabetes prevention. Although you won't locate a more evidence-based guideline panel as opposed to USPSTF, existing evidence won't show that measuring blood sugar levels improves health outcomes, even during high-risk patients. According to the Task Force's own literature review, the most significant randomized controlled trial of screening for diabetes[6] found no mortality benefit after ten years compared with usual care.
Why wouldn't earlier detection of elevated blood sugar levels lead to longer life spans? The consensus diagnostic criteria for prediabetes and diabetes have both been lowered too many times over the years despite scant proof that life-style change or medications reduce cardiovascular events or deaths in patients diagnosed through screening.
My second issue is that screening for prediabetes will bring about overdiagnosis in primary care practices. If 33 of all the 100 adults have prediabetes and studies advise that less than half of those will develop diabetes within a decade, i will be giving 16 or 17 out of 100 adults a diagnosis it doesn't provide many benefits. Being labeled "prediabetic" could also result in harm through psychological stress or prescriptions for diabetes medications, a standard though unproven treatment strategy for patients with prediabetes who will be unable or unwilling to change their exercising or dietary patterns.
Finally, you will find disadvantages to taking anyone rather than a population health method of diabetes prevention. Sticking with change in lifestyle requires consistent effort for the patient and clinician, which enables it to be a never-ending struggle at home and in work environments that facilitate overeating and sedentary behavior. Noting that adults with lower socioeconomic status tend to be more likely than wealthy website visitors to suffer from diabetes, researchers on the Mayo Clinic have appropriately criticized the DPP's "prevent diabetes anyone at a time" approach as ignoring "the underlying conditions—poverty, income inequality, loneliness, and socioeconomic stress—that are conducive to more obesity plus much more cases of diabetes."[7]
Changing unhealthy environments can be considered a far more effective and long-lasting intervention than one-on-one clinical counseling. In the late 1990s, the US Department of Housing and Urban Development randomly assigned 4500 women with children in high-poverty towns to no housing vouchers, unrestricted traditional vouchers, or vouchers that might only be redeemed for housing in low-poverty areas. Ten to 15 years later, the group receiving traditional vouchers was no healthier compared to the control group, nevertheless the group receiving low-poverty vouchers had significantly lower body mass index and glycated hemoglobin levels.[8]
Although the Medicare DPP as proposed should increase the health of countless of our patients, in order to prevent diabetes without worsening health disparities, family physicians also require resources to handle social determinants of health. To this end, the American Academy of Family Physicians recently published a posture paper[9] describing techniques for collaborating effectively with public health partners to enjoy the prevention of chronic diseases within our communities.
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