Oakland University

Alternative Care Options for

Diabetic and Prediabetic Patients:

A Systematic Review and Policy Analysis of Lifestyle Interventions

Jordan Shotwell

PS 472, Public Policy and Health Care

Professor Gary Petroni

Shotwell 2

Alternative Care Options for Diabetic and Prediabetic Patients:

A Systematic Review and Policy Analysis of Lifestyle Interventions

The United States’ health care system is one of the largest in the world, and has intricate

governmental systems regulating the ways and means in which care is provided to patients.

While the U.S. health care system is quite advanced and has been for decades, there are many

methods of health care practice prevalent in the United States health system that can be

detrimental to patient needs and are often less than helpful in providing positive patient

outcomes. One such area that could use vast improvement is in diabetes and prediabetes care and

prevention. Diabetes is a condition that in most cases is developed through unhealthy habits over

a long period of time. To be clear, our focus in this analysis will focus on type 2 diabetes, rather

than type 1 (which is more often diagnosed during childhood and is less often related to long-

term unhealthy habits) – type 2 diabetes more often affects those who are overweight, obese, or

have maintained unhealthy dietary and lifestyle habits for a number of years, and thus is more

often considered to be preventable.

While much of the public eye is focused on rare illnesses and diseases that affect a very

low percentage of the U.S. population (such as Ebola, avian influenza, etc.) because there exists

an “unknown” element or scariness to them, the statistics behind diabetes can be much more

frightening. As of 2012, over 75% of adults aged 65 or older have either been diagnosed with

diabetes or are considered prediabetic (or “at-risk” for diabetes) (Anderson, 2012). This statistic

represents a much greater portion of the population than most other illnesses, and thus should be

taken seriously – in the worst cases, diabetes can result in loss of limbs and even life. Diabetes is

one of the leading preventable causes of death in the United States, second only to heart disease;

Shotwell 3

the only other diseases with more deaths are cancer, respiratory diseases, strokes, accidents, and

Alzheimer’s.

To build on the effects of diabetes, in 2012 the United States spent a collective $147

billion on diabetes care and related costs for diabetes treatment. Out of that amount, over 60%

was paid for by government insurance – primarily Medicare – and the majority of the remainder

through private insurance (American Diabetes Association, 2013). The cost of care for diabetes

patients is extremely high, and only rises as patients’ conditions become more serious or as they

age. For this reason, more should be done to combat the effects of diabetes and to help

prediabetes patients in the U.S. population. In addition, more can be done to reduce costs on the

U.S. health care system in order to provide better and more efficient care for all. As addressed

above, the current health care system in the United States is inadequate for dealing with the

current diabetes crisis. In order to repair the system and to address needs for future diabetes

patients, health care practices in the U.S. should be amended and changed to address needs early-

on for diabetic and prediabetic patients.

Similar to heart disease and cardiovascular conditions, diabetes is an illness that in many

cases can be prevented or slowed greatly by making healthy lifestyle changes over a number of

years. Many studies have shown recently that lifestyle interventions can slow and even reverse

the effects of diabetes, and thus can lower the total cost of health care for diabetes patients over

their lifetimes. A multitude of authors – as discussed further below – have shown in their

research on lifestyle interventions that using these nonconventional methods of treatment for

diabetes and prediabetes patients can slow and even reverse the effects of the disease.

Throughout the rest of this analysis, we will discuss the ways in which alternative methods of

treatment – such as lifestyle interventions – can help to mitigate the health care costs currently

Shotwell 4

associated with diabetes and prediabetes treatment, in order to propose better solutions for

diabetes health care delivery and management in the United States.

Evaluation Criteria

In order to discuss alternative treatments as a solution to issues for care delivery in

diabetes, we’ll first have to understand the standards by which we’ll measure our findings. The

following section will explain the criteria set forth to measure patient outcomes, costs of care,

and other factors involved in the delivery of health care to diabetes patients.

Our research question asks specifically “Can lifestyle interventions help to mitigate

health care costs and improve care outcomes in diabetes and prediabetes patients?” and thus

“Should government insurance programs support lifestyle interventions as an alternative to

current methods of treatment?” We’ll use previous research from experts in public health,

medicine, and health care administration to come to a conclusive answer on these questions.

Their research involves these primary factors in measuring outcomes: the cost of care in both

current care options and in lifestyle interventions; patient care outcomes in both current methods

and in lifestyle interventions; and the effectiveness of different lengths of intervention programs.

The cost of care is a primary factor in understanding the effectiveness of care, both in

current methods of health care delivery and in alternative lifestyle interventions. It is especially

important to understand the cost of care between different courses of action, so that the most cost

effective option can be prescribed to the patient, saving them and their insurance provider

capital. However, one prohibitive factor to lower costs of care is fee-for-service health providers.

Many health care providers (physicians) are paid based on the services they perform, and part of

Shotwell 5

the reason that current methods of care are so prevalent (rather than alternative methods like

lifestyle interventions) is because they have a higher cost for the patient and the insurer, and thus

a larger payment to the health care provider. For example, a physician may make significantly

more money from performing gastrointestinal bypass surgery than by providing regular check-

ups and advice to a patient on healthy eating habits; most physicians in the United States fall into

this fee-for-service category, and are paid based on the work they perform rather than on

individual outcomes.

Patient care outcomes are also imperative to analyze in our studies, to understand which

course of care will provide the best long-term solution for the patient’s health. The reasons why

improved outcomes are better seem to be obvious, but oftentimes both physicians and patients

opt to take the quick and easy route, choosing to prescribe and take medication rather than to

make healthier diet and exercise choices. It’s easy to see why so many patients and physicians

are interested in instant gratification, rather than long-term strategies – on the part of the

physician, this also relates to the cost of care (a physician sees much quicker cash influx from

short-term solutions rather than building long-term solutions, like maintaining a healthy diet and

promoting exercise).

Finally, we’ll analyze the different lengths of lifestyle intervention programs and the

effects that they have on patient outcomes and costs of care. Whether it’s a three-year, six-year,

ten-year, or a lifetime intervention program, different lengths can have different impacts on the

effectiveness and costs of the programs, and these should be studied to understand the best

solution for patients and for the U.S. health care system.

Combining these three major factors (cost of care, patient outcomes, and program

lengths) will allow us to gain a broader understanding of the current predicament in the United

Shotwell 6

States’ health care system with relation to diabetes treatment. By analyzing each of these factors

in the following sections, we will be able to understand how and why alternative methods of

treatment may be beneficial for both diabetes patients and for the U.S. health care system.

Review of Previous Research

Previously published literature will provide the basis for our analysis of lifestyle

interventions and their effects on diabetes treatment. The list of authors cited includes

physicians, public health experts, statisticians, and health care analysts. By combining their

works and their published results, we can decide for ourselves the best course of action in

relation to current health care practices in the United States.

First, Jennifer Anderson discusses in the Journal of the Academy of Nutrition and

Dietetics the economic impacts of current U.S. health care practices (specifically among the 65-

and-older population) and the potential cost-saving measures found in implementing lifestyle

interventions and medical nutrition therapy (Anderson, 2012). She begins by explaining her

objectives, outlining that she aims to focus on cost-saving thresholds for lifestyle intervention

programs, in order to determine their effectiveness. Anderson directly relates this information in

her study to single-payer insurance providers, such as Medicare, as a majority of diabetes care

spending in the United States is spent by government insurance (American Diabetes Association,

2013; Anderson, 2012). Continuing, Anderson compiled her data from Kaiser-Permanente, the

American Diabetes Association, and with data from the Medical Expenditure Panel Survey.

Picking least and most conservative scenarios for annual per capita spending on diabetes

patients, Anderson found that nearly all lifestyle intervention programs and medical nutrition

Shotwell 7

therapy programs are effective at cost-saving and are much more cost effective than standard

methods of treatment. The only exception to this came with the longest lifestyle interventions

(those in the ten-year program) combined with the least conservative estimates for annual

spending. Anderson’s research provides a solid base of information to use in understanding the

cost-effectiveness and cost-savings associated with intervention programs, rather than more

prevalent forms of diabetes treatment in the United States.

A second major source on the effects of lifestyle interventions was from the Annals of

Internal Medicine, and was written by William Herman from the University of Michigan, along

with ten other coauthors for the Diabetes Prevention Program. Their essay on lifestyle

modifications studied the effects of the National Diabetes Prevention Program (DPP) – a

coalition of health care providers and federal agencies – and used outside information from

published reports to verify their results. Their research studied individuals with glucose

intolerances (those over the age of 25), and the effects that lifestyle interventions, metformin,

and placebo medications had on the program participants. Their research concluded that lifestyle

interventions and metformin regimens reduced the development “of type 2 diabetes by 11 and 3

years, respectively, and [reduced] the absolute incidence of diabetes by 20% and 8%,

respectively” (Herman et al., 2005). This information is crucial to our analysis of lifestyle

interventions and their effectiveness in delaying type 2 diabetes development, and will be used

extensively in our discussion below.

Further research on the topic from Peter Schwarz, in “Preventing type 2 diabetes – how to

proceed?” discusses the impact of previous studies on lifestyle interventions for type 2 diabetes

patients. Schwarz discusses the previous research by randomized controlled trials (RCTs), and

explains that these trials need to be effectively translated into clinical results. The primary focus

Shotwell 8

of his article is on the need for clinical testing of lifestyle interventions, and a major concern for

him is that the previous research on lifestyle interventions for diabetes patients must be

substantiated with clinical evidence of successful interventions (Schwarz, 2011).

Continuing, thorough research done by Schellenberg, Dryden, Vandermeer, Ha, and

Koronwnyk provides a stronger basis for our analysis. Where Peter Schwarz’s article stressed the

need for clinical trials of lifestyle interventions for diabetes patients, this article from the Annals

of Internal Medicine fills that gap, showing the positive results from clinical trials of lifestyle

interventions. Schellenberg and her coauthors synthesized information from multiple electronic

databases of clinical trials – from 1980 to 2013 – and chose multiple incidences of lifestyle

interventions programs with durations longer than three months each, including changes in

“exercise, diet, and at least one other component.” Their control during these RCTs was a

standard level of care, without a lifestyle intervention. To be accurate, the researchers chose a

total of 20 unique studies, 9 of which had patients at-risk for type 2 diabetes, and 11 of which

had patients already diagnosed with type 2 diabetes. Their research concluded that lifestyle

interventions effectively decrease the rate of development and delay diagnosis for at-risk

patients, but that they don’t necessarily decrease mortality rates for already diagnosed patients

(this could be due to insufficient information; further study is required to reach a conclusive

answer on this) (Schellenberg et al., 2013). This article is particularly important in reinforcing

the other research introduced above, from Anderson, Herman, Schwarz, and other coauthors.

The last major article used in our analysis is from authors Tuomilehto, Schwarz, and

Lindström, and they study the combined results of several important works in lifestyle

interventions for diabetes and prediabetes patients. The authors first look at the Finnish Diabetes

Prevention Study (DPS), in order to understand a baseline for the rest of their work. The DPS

Shotwell 9

used five predefined targets for high-risk participants in their study, which were “weight loss

>5%, intake of fat <30% energy, intake of saturated fats <10% energy, increase of dietary fiber

to ≥15 g/1,000 kcal, and increase of physical activity to at least 4 hours/week.” The study found

that none of the participants who met at least four of those five categories developed type 2

diabetes during the trial period (Lindström et al., 2003; Tuomilehto, Schwarz, & Lindström,

2011).

In addition, the authors used research from the Cardiovascular Health Study, written by

Dariush Mozaffarian and coauthored by five other writers. The study focused on the impact of

lifestyle interventions on the U.S. population (rather than European populations, like in the

Finnish DPS), and focused on six different factors hypothesized to reduce the incidence of

diabetes diagnosis in high-risk patients: physical activity, dietary score (as measured by higher

fiber intake, fat ratios, low trans-fat intake, and a lower glycemic index), never smoked (or

smoked more than 20 years ago), alcohol use, body mass index (BMI), and waist circumference

(Mozaffarian et al., 2009). Concluding their study, the researchers found incidences of type 2

diabetes at a rate of 9.8 per 1,000 person-years. Participants in the study who met the standards

for physical activity, diet, smoking, and alcohol habits had an “82% lower incidence of diabetes”

and those who also met either the BMI or waist circumference standards had an 89% lower

incidence of diabetes. Overall, the research showed that adherence to these lifestyle

modifications can help to delay or prevent diabetes diagnoses, and are an effective measure for

living a diabetes-free lifestyle (Mozaffarian et al., 2009).

Tuomilehto, Schwarz, and Lindström go on to discuss the long-term effects of lifestyle

interventions for diabetes and prediabetes patients, and cite the Malmö Feasibility Study. The

study shows that in two different groups of patients – both at-risk for type 2 diabetes – the group

Shotwell 10

that chose lifestyle modification programs had an 11% rate of diagnosis, versus the group that

chose traditional treatment which had a 29% rate of diagnosis; interestingly, the rate of those

participating in the lifestyle modification programs were actually very similar to those with a

normal glucose tolerance (those not at-risk for diabetes) (Eriksson & Lindgärde, 1991;

Tuomilehto, Schwarz, & Lindström, 2011). The original authors - Tuomilehto, Schwarz, and

Lindström – close their article by summarizing the cases presented above and concluding that

lifestyle intervention programs have a significant impact on the incidence of diabetes diagnoses

in at-risk patients, and thus should be promoted as an accepted form of treatment for at-risk

patients.

The major articles already discussed do not comprise an exhaustive list of work used in

this analysis, but will serve to provide the basis for this paper and its conclusions. All of the

previous work presented above will be used in our analysis below, and will serve to provide

insight on the different aspects of diabetes treatment: cost-effectiveness, outcomes, and the

length of treatment.

Existing Policies for Type 2 Diabetes Treatment and Prevention

When proposing new or amended policies, it’s important to also discuss the current

situation in order to better understand the existing framework and propose changes. To better

understand the topic of lifestyle interventions and their effectiveness at cost-saving and improved

patient outcomes, it’s necessary to also look at the existing policies set up by the United States

federal government and health care agencies, with respect to current policies and coverages for

diabetes and prediabetes treatment. In the following section, we’ll delve into the ways in which

Shotwell 11

the current United States health care system operates in regard to diabetes care, and aim to

explain the operations of government health programs like Medicare so as to propose effective

changes to the current systems of treatment.

The Centers for Medicare and Medicaid Services’s (CMS) instructional guide on diabetes

care and services explains that “original Medicare is fee-for-service coverage under which the

government pays your health care providers directly for your Medicare Part A (Hospital

Insurance) and/or Part B (Medical Insurance) benefits” (CMS, 2013). These policies are laid out

in the Social Security Act of 1965, Title XVIII, which details the explicit coverages and non-

coverages for the aged and disabled of the U.S. population. Outside of Medicaid and military

insurance, Medicare is the largest facet of government insurance programs. Government

insurance systems, including Medicare, are the largest payers of diabetes care costs at 64% of an

estimated $176 billion spent in 2012. Of those costs, the largest spending categories for diabetes

care are as follows:

Hospital inpatient care (43%)

Prescription medications to treat diabetes complications (18%)

Anti-diabetic agents and diabetes supplies (12%)

Physician office visits (9%)

Nursing/residential facility stays (8%)

The American Diabetes Association also explains that “one out of every five dollars” spent on

health care in the United States is spent on patients with diabetes, and over half of that money is

spent directly on care for diabetes or stemming from diabetes. The fact that Medicare pays for a

large portion of this amount shows that U.S. taxpayers foot the bill for an exorbitant amount of

health care spending related to a preventable disease. Diabetes costs present a “substantial

Shotwell 12

burden” to society and have a large impact not only on Americans’ health but also on the

American economy (American Diabetes Association, 2013).

As previously discussed, the standard care practices for diabetes and prediabetes patients

in the United States tend to focus on health maintenance and management, rather than

prevention. This is evident in reviewing Medicare and the CMS’s policies for diabetes care and

prevention, contained in their guide entitled “Medicare’s Coverage of Diabetes Supplies and

Services.” This guide details the simple facts and details of diabetes care coverage by Medicare,

and lists fairly extensively what is and isn’t covered by Medicare parts A, B, C, and D. Diabetes

services that are currently covered by Medicare include screenings, self-management training,

medical nutrition therapy, foot tests and treatment, hemoglobin and glaucoma tests, and

preventive yearly visits (CMS, 2013). However, the most concerning part of the current

regulations on diabetes treatment has to do with one specific aspect of coverages: medical

nutrition therapy.

As the CMS states, medical nutrition therapy programs are “covered for people with

diabetes or renal disease,” they must be prescribed, and they must be administered by a

registered dietician. These coverage specifics are taken directly from the Social Security Act of

1965, which outlines coverages for Medicare and details diabetes care practices (Health

Insurance for the Aged and Disabled, 1965). Due to the nature of this antiquated statute, only

those with already-diagnosed diabetes are eligible for medical nutrition therapy, which is a type

of lifestyle intervention involving intensive dietary management and consultations with

dieticians or nutritionists. This poses a major problem for those with prediabetes or those at-risk

for type 2 diabetes, who are thus currently ineligible for medical nutrition therapy coverage from

Medicare; their only other options are to opt for private insurance that may cover the program, or

Shotwell 13

choose to pay out of pocket for the program, both of which will likely cause the patient to incur

much larger personal expenses.

Another widespread issue in the current U.S. health care system is the prevalence of fee-

for-service based organizations and physicians. These systems charge their fees to patients and

insurance providers based on the work performed, rather than on the outcomes of the individual

patients. Extensive studies have shown that fee-for-service payment systems tend to raise overall

health care costs (not just individually, but on a national level), and often encourage wasteful

spending, often on “high-cost items and services” as Maura Calsyn describes. Calsyn’s article on

fee-for-service systems explains that fee-for-service is still the predominant health care payment

system in the United States, with “78% of employer-sponsored health insurance [being] fee-for

service” (Calsyn, 2012). However, as she continues to explain, programs like the Patient

Protection and Affordable Care Act, signed into law in 2010, are beginning to buck the trend and

promote positive, patient-oriented change in the U.S. health care industry.

The Patient Protection and Affordable Care Act (PPACA) has done much in recent years

to alleviate the pains of patients in the U.S. health care system, and these reforms have done

much to help diabetes patients as well. Robert Ratner expounds upon the implications of the

PPACA for individuals with diabetes or prediabetes – those with diabetes will no longer be

denied by insurance providers due to preexisting conditions; the creation of an “Innovation

Center” in the CMS will allow for improved methods of care delivery for those with diabetes and

prediabetes; and over $1.1 billion has been allocated to fund research that targets diabetes and

obesity-related health issues (Ratner, 2011). These measures from the PPACA have already

significantly impacted the health care climate in the United States, and further reforms to be

Shotwell 14

implemented by the PPACA will only continue to improve upon the current health care situation

in the United States.

Another facet of the PPACA was the tasking of the National Prevention, Health

Promotion and Public Health Council to “improve America's health with a major focus on

obesity, nutrition, and exercise.” In addition, the PPACA will provide for wellness and risk

assessments, and prevention plans for those deemed at-risk for diabetes. As Ratner suggests,

“diabetes care planning…should be easily integrated into this paradigm” of preventative

planning, and these reforms will be fundamental in improving diabetes care management and

prevention in the United States (Ratner, 2011).

The PPACA also provides for an extensive Community-based Collaborative Care

Network program, which will encourage health professionals and organizations to provide more

encompassing primary coverage to patients, and will create a “consortium of health care

providers that [provide] comprehensive coordinated and integrated health services” (Patient

Protection and Affordable Care Act, 2010; Ratner, 2011). These collaborative care networks will

encourage patients to more actively seek out primary care and will make primary care more

available, thus increasing the access that diabetic or prediabetic patients have to primary care.

These patients using primary care for their prevention and treatment needs will hopefully serve

to reduce rates of diabetes diagnosis due to early prevention, and will help to mitigate the high

costs of treatment down the road for those patients.

While there are reforms being put in place in the United States health care system – most

notably from the PPACA – there is still much to be done. New reforms, introduced since 2010,

have allowed patients greater access to health care resources, they have increased coverages for

those already with insurance, and they have expanded coverage options for uninsured patients.

Shotwell 15

All of the reforms described above will help to achieve cost-saving results and greater efficiency

in the U.S. health care system, especially for diabetes patients. But moving forward, more needs

to be done in order to allow diabetes and prediabetes patients access to efficient and affordable

preventative care.

Solutions for Greater Cost Savings and Efficiency in Diabetes Care

The policies laid out in the previous section are representative of the current state of the

health care system in the United States, and we should build upon those policies in order to

provide more extensive and efficient health care, and to reduce costs for future treatment and

prevention.

William Herman and his coauthors outlined in their article, detailed above, that lifestyle

interventions and metformin prescriptions reduced the absolute incidences of diabetes diagnosis

by 20% and 8%, respectively, in comparison to placebo treatments given to other participants.

The 12% gap between metformin and the lifestyle intervention participants shows a clear

difference in the effectiveness of lifestyle interventions, and these results are only further

reinforced by subsequent studies. Schellenberg, Dryden, Vandermeer, Ha, and Koronwnyk also

found in their research that lifestyle interventions effectively reduced the rate of diabetes

diagnosis, and their research included information from over 30 years of previous studies,

synthesizing multiple randomized controlled trials that all came to nearly the same conclusion

(Schellenberg et al., 2013). In addition, Tuomilehto, Schwarz, and Lindström wrote one of the

most comprehensive articles on lifestyle interventions and their effects on the outcomes of

diabetes and prediabetes patients. They compiled information from multiple studies, including

Shotwell 16

the Finnish Diabetes Prevention Study, the Cardiovascular Health Study, and the Malmö

Feasibility Study. Their analysis of the Finnish DPS and the Cardiovascular Health Study –

which analyze diabetes outcomes in the Finnish population and the U.S. population, respectively

– used multiple variables to determine risk categories for diabetes and prediabetes patients.

These variables included: physical activity, dietary habits, weight and BMI, body size and

circumference, and smoking and drinking habits (Lindström et al., 2003; Mozaffarian et al.,

2009; Tuomilehto, Schwarz, & Lindström, 2011). In both studies, the researchers definitively

concluded that lifestyle interventions are successful at reducing the incidence of diabetes

diagnosis, when a majority of those variables are followed; the more the participants adhered to

the standards set by each variable, the less likely the participant was to be diagnosed with

diabetes.

On top of studies that showed the effectiveness of lifestyle interventions in providing

positive care outcomes for patients, further research also showed the cost-saving abilities of

lifestyle interventions in comparison to standard methods of diabetes care. Anderson’s article,

discussed at the beginning of this analysis, dug deep into the costs of administering lifestyle and

medical nutrition therapy programs, over the course of three years, six years, and ten years.

Anderson found in her research that nearly all lifestyle intervention and MNT programs

administered were likely to be more cost-effective than standard treatment and prevention

procedures, except in the least-conservative intervention scenarios over the longest periods of

time (ten years) (Anderson, 2012).

The implications of the analyses studied in this paper are that lifestyle intervention and

modification programs are extremely effective at reducing and delaying the onset of type 2

Shotwell 17

diabetes for at-risk individuals. It is also evident that these programs are cost-effective and can

be cost-saving in comparison to standard treatment methods for type 2 diabetes.

Above, we analyzed the current climate in the United States health care system, with

regard to diabetes care and prevention. Up until recently, few options were available for diabetes

care that were covered by Medicare. With the introduction of the Patient Protection and

Affordable Care Act, more options are available now for coverage by both government insurance

plans and by private insurance plans, and these have been crucial to expanding coverage for

diabetes patients. From improved care delivery options, to the expansion of primary care

facilities, the PPACA is providing new options for diabetes and prediabetes patients to gain

access to more extensive care and prevention options (Patient Protection and Affordable Care

Act, 2010; Ratner, 2011).

However, the federal government still does not provide coverage for lifestyle intervention

and modification programs for all diabetes and prediabetes patients. As the Social Security Act

of 1965 stipulates, only those with already-diagnosed diabetes are eligible for medical nutrition

therapy programs, which aim to promote a healthy lifestyle by creating dietary programs

conducive to combating the effects of diabetes. This creates an enormous gap where prediabetes

and at-risk patients are not given coverage for necessary preventative options, and this is just one

step in major reforms that should be introduced in order to promote healthy living for diabetic

and prediabetic individuals.

Lifestyle intervention programs are effective at producing positive outcomes, both for

diabetic and prediabetic patients. They promote healthy living and encourage behaviors that

reduce the incidence of diabetes diagnosis. Furthermore, a very large majority of lifestyle

intervention programs are actually much more cost-effective and cost-saving than standard care

Shotwell 18

practices that are prevalent in the United States today. For these reasons, the federal government

should expand Medicare and endorse health reforms aimed at promoting lifestyle interventions

as an accepted method of treatment for diabetes and prediabetes conditions. It would be cost-

effective and socially responsible for the United States to provide government insurance

coverage for lifestyle intervention programs, and would help promote a culture of prevention

rather than management in the United States health care system.

Shotwell 19

References

American Academy of Family Physicians (AAFP) (2013). Lifestyle interventions can reduce

progression to diabetes in at-risk patients. AAFP News. Retrieved from

http://www.aafp.org/news/health-of-the-public/20131024diabetesintervene.html

American Diabetes Association. (2013). Economic costs of diabetes in the U.S. in 2012.

Diabetes Care. http://dx.doi.org/10.2337/dc12-2625

Anderson, J. M. (2012). Achievable cost saving and cost-effective thresholds for diabetes

prevention lifestyle interventions in people aged 65 years and older: a single-payer

perspective. Journal of the Academy of Nutrition and Dietetics, 112, 1747-54.

http://dx.doi.org/10.1016/j.jand.2012.08.033

Calsyn, Maura. (2012). Alternatives to fee-for-service payments in health care: moving from

volume to value. Center for American Progress. Retrieved from

https://www.americanprogress.org/issues/healthcare/report/2012/09/18/38320/alternative

s-to-fee-for-service-payments-in-health-care/

Centers for Disease Control and Prevention (CDC) (2010). Leading causes of death. U.S.

Department of Health and Human Services. Retrieved from

http://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm

Centers for Medicare and Medicaid Services (CMS) (2013). Medicare’s coverage of diabetes

supplies and services. U.S. Department of Health and Human Services. Retrieved from

http://www.medicare.gov/Pubs/pdf/11022.pdf

Shotwell 20

Eriksson K. F., Lindgärde F. (1991). Prevention of type 2 (non-insulin-dependent) diabetes

mellitus by diet and physical exercise: the 6-year Malmö feasibility study. Diabetologia,

34, 891–898. http://dx.doi.org/ 10.1007/BF00400196

Health Insurance for the Aged and Disabled, Social Security Act of 1965, Title XVIII. (1965).

Retrieved from http://www.healthinfolaw.org/federal-law/medicare-title-xviii-social-

security-act

Herman, W. H., Hoerger, T. J., Brandle, M., Hicks, K., Sorenson, S., Zhang, P., . . . Ratner, R. E.

(2005). The cost-effectiveness of lifestyle modification or metformin in preventing type 2

diabetes in adults with impaired glucose intolerance. Annals of Internal Medicine, 142,

323-332. http://dx.doi.org/ 10.7326/0003-4819-142-5-200503010-00007

Lindström, J., Louheranta, A., Mannelin, M., Rastas, M., Salminen, V., Eriksson, J., . . .

Tuomilehto, J. (2003). Lifestyle intervention and 3-year results on diet and physical

activity. Diabetes Care, 26, 3230-3236. http://dx.doi.org/ 10.2337/diacare.26.12.3230

Mozaffarian D, Kamineni A, Carnethon M, Djoussé L, Mukamal KJ, Siscovick D. (2009).

Lifestyle risk factors and new-onset diabetes mellitus in older adults. Arch Intern Med

169, 798–807. http://dx.doi.org/ 10.1001/archinternmed.2009.21

Pastors, J. C., Warshaw, H., and Daly, A. (2002). The evidence for the effectiveness of medical

nutrition therapy in diabetes management. Diabetes Care, 25, 608-613.

http://dx.doi.org/10.2337/diacare.25.3.608

Patient Protection and Affordable Care Act of 2010, Pub. L. 113-185, 42 USC § 256i. Retrieved

from http://www.law.cornell.edu/uscode/text/42/256i

Shotwell 21

Preventing Diabetes in Medicare Act of 2013, H.R. 1257, 113th Cong. (2013). Retrieved from

https://www.congress.gov/bill/113th-congress/house-bill/1257

Ratner, Robert E. (2011). Diabetes management in the age of national health reform. Diabetes

Care, 34, 1054-1057. http://dx.doi.org/ 10.2337/dc10-1987

Schellenberg, E.S., Dryden, D. M., Vandermeer, B., Ha, C., Korownyk, C. (2013). Lifestyle

interventions for patients with and at risk for type 2 diabetes: a systematic review and

meta-analysis. Annals of Internal Medicine, 159, 543-551. http://dx.doi.org/

10.7326/0003-4819-159-8-20131015000007

Schwarz, P. (2011). Preventing type 2 diabetes – how to proceed?. British Journal of Diabetes

and Vascular Disease, 11 (4), 158-160. http://dx.doi.org/10.1177/1474651411418152

Tuomilehto, J., Schwarz, P. E., and Lindström, J. (2011). Long-term benefits from lifestyle

interventions for type 2 diabetes prevention: time to expand the efforts. Diabetes Care,

34, S210-S214. http://dx.doi.org/10.2337/dc11-s222