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Few at-risk adults getting the diabetes prevention help they need

April 24, 2019

Using data from the 2016 National Health Interview Survey, Johns Hopkins researchers report that few American adults eligible for diabetes prevention programs are being referred to, or participating in, these programs.

Noting the high health and economic burden of type 2 diabetes in the U.S., the researchers called for efforts to enhance identification and recruitment of eligible adults from both clinical and community-based settings.

"For certain individuals, type 2 diabetes can be prevented or delayed through diet and exercise, and the National Diabetes Prevention Program's lifestyle intervention is one evidence-based method to help people at high-risk do so. But our research highlights the importance of continued efforts to enhance the reach of this program," says Maya Venkataramani, M.D., M.P.H., the study's lead author and assistant professor of medicine at the Johns Hopkins University School of Medicine.

The analysis was published in the March issue of the American Journal of Preventive Medicine.

According to the Centers for Disease Control and Prevention (CDC) and the American Diabetes Association, more than 30 million adults in the U.S. have type 2 diabetes, a chronic disease marked by the body's inability to process sugar properly. Diabetes is the seventh leading cause of death in the U.S., and it costs the country an estimated $327 billion each year. Complications include kidney damage, nerve damage, vision loss and limb amputations.

Prediabetes is marked by elevated blood sugar levels, even after fasting, between 100 and 125 milligrams per deciliter, or values of hemoglobin A1c--a hemoglobin with glucose attached--of 5.7 to 6.4. An estimated one out of three U.S. adults has prediabetes, according to the CDC, putting them at higher risk of developing diabetes. The CDC also estimates that only 11.6 percent of adults with prediabetes are aware of their condition.

In an effort to reduce the high prevalence of type 2 diabetes and prediabetes, the CDC established the National Diabetes Prevention Program in 2010. An important part of the program is enhancing access to an evidence-based, yearlong lifestyle intervention. This group-based effort, led by a lifestyle coach, teaches strategies and skills to make lifestyle changes with a weight loss goal of 5 percent and physical activity goal of 150 minutes per week. Programs can be provided in clinical or community settings. The Brancati Center for the Advancement of Community Care at Johns Hopkins (Venkataramani and study senior author Nisa Maruthur, M.D., M.H.S., are faculty members) has led efforts for community-based translation of the program to sites in East Baltimore. The Brancati Center is a CDC-recognized provider, one of over 1,500 established under the CDC model in the U.S.

To examine the reach of the CDC program, the Johns Hopkins researchers analyzed responses to Diabetes Primary Prevention Questions collected in the 2016 National Health Interview Survey from 28,354 adults living across the U.S. The data provided self-reported participant information on diabetes diagnoses, screening, risk factors and referrals, and participation and interest in diabetes prevention programming.

Specifically, the researchers examined responses of 2,341 survey participants who were likely to be eligible for the program because, although they didn't have a diagnosis of diabetes, they were considered at high risk for it. This was based on their body mass index and/or a history of self-reported diagnosis of prediabetes or gestational diabetes during pregnancy.

Among the 2,341 participants, 63 percent were female and almost 70 percent were over the age of 45. About 75 percent were white, 14.4 percent were black and 6.7 percent were Asian.

Although more than a quarter of these likely eligible adults said they were interested in participating in a diabetes prevention program, only 4.2 percent said clinicians referred them to one. More than one-third of the referred adults participated in the program, but overall, only 2.4 percent of eligible adults participated in a program either via physician referral or on their own.

Older adults and those with lower family incomes were two to three times more likely than younger and higher income people to participate. African American and Asian adults were more likely than white adults to report referral to a program. "In our analyses, racial minorities were more likely to be referred, and low-income adults were more likely to participate," says Venkataramani. "These are groups that historically have poorer access to preventive services. They have a higher burden of diabetes-related complications. It is thus important to confirm these trends, and if they hold, understand the reasons behind enhanced referral, participation and retention."

The overall low referral and participation rates, say the researchers, also point to the need to increase awareness both in clinical and in community settings of prediabetes and diabetes prevention programming.

The Brancati Center, Venkataramani says, works extensively with community-based partners and performs outreach to clinical providers to enhance awareness of the program.

For this study, the researchers acknowledge the limitations and biases of self-reported survey data, and they note that the findings may have underestimated the number of eligible adults and overestimated the prevalence of program referral and participation.

The researchers note future studies should further explore whether there are differences in trends in referral and participation based on race and ethnicity, and they should identify patient- and provider-related factors that drive program referral, participation and retention.
Other researchers involved in the study include Craig Pollack, and Hsin-Chieh Yeh from Johns Hopkins.

The researchers don't report specific funding that supported this work.

Pollack owns stock in Gilead Pharmaceuticals, which makes drugs used to treat type 2 diabetes.

Johns Hopkins Medicine

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