Pre- DiabetesProject ECHO

Veronica Brady, PhD, FNP-BC, BC-ADM, CDEApril 18, 2019

Objectives

• Define pre-diabetes• The facts about pre-diabetes• Diagnosis and Screening• Management of pre-diabetes

Adapted from: American Diabetes Association. Diabetes Care. 2014;37 Suppl 1:S81-90.

Normal

Diabetes Mellitus

PrediabetesImpaired Glucose

Tolerance

Fasting PlasmaGlucose

126 mg/dL

2-hour Plasma Glucose On OGTT

200 mg/dL

140 mg/dL

Any abnormality must be repeated and confirmed on a separate day The diagnosis of diabetes can also be made based on unequivocal symptoms and a random glucose >200 mg/dL

100 mg/dL

PrediabetesImpaired Fasting

Glucose

What is Prediabetes?

Normal

Diabetes Mellitus

Hemoglobin A1C

6.5%

5.7%

Prediabetes

Normal

Diabetes Mellitus

Pre-Diabetes

• No clear symptoms

• Labs: • A1c– 5.7-6.4%• FBS– 100-125mg/dL• OGTT– 2 hour 140-199mg/dL

Prediabetes

● An important risk factor for future diabetes and CV disease• Risk for prediabetes is a continuum• Important to identify early and begin intervention

immediately• Interventions can reduce the rate of progression from

prediabetes to diabetes• Healthy diet• Physical activity• Weight loss

American Diabetes Association. Diabetes Care. 2014:37 Suppl 1:S81-90.

Prediabetes• Long-term consequences include

• Hypertension1• Cancer2

• Risk increased by 15%• Stomach/colorectal, liver, pancreas,

breast, endometrium • Alzheimer’s disease3

1. American Diabetes Association. Diabetes Care. 2014:37 Suppl 1:S81-90.2. Baker LD, et al. Arch Neurol. 2011;68:51-57.3. Huang Y, et al. Diabetologia. 2014 Sep 11. [Epub ahead of print]

PrediabetesCenters for Disease Control, 2012

• 37% (86 million) U.S. adults aged 20 years or older have prediabetes1• Percentage was similar by race

• 51% aged ≥65 years• Only 11% were aware they had it2

● In adolescents aged 12 to 19 years, prevalence of prediabetes and diabetes increased from 9% to 23%3

1. National Diabetes Statistics Report. Available at: cdc.gov/diabetes/pubs/statsreport14.htm. 2. CDC. MMWR Morb Mortal Wkly Rep. 2013;62:209-212.3. May AL, et al. Pediatrics. 2012;129:1035–1041.

35%39% 38%

Non-Hispanic Whites Non-Hispanic Blacks Hispanics

Chart1

Non-Hispanic Whites

Non-Hispanic Blacks

Hispanics

Series 1

35%

39%

38%

35

39

38

Sheet1

Series 1

Non-Hispanic Whites35

Non-Hispanic Blacks39

Hispanics38

To resize chart data range, drag lower right corner of range.

Adapted from:Boyle JP, et al. Popul Health Metr. 2010;8:1-12.

Projecting the Future Diabetes Population:It Is Growing

Chart1

2020

2025

2030

2035

2040

2045

2050

Column2

U.S. Population withDiabetes (%)

20.4444444444

23.2108317215

25.6065696155

28.7468400144

29.5971978984

31.4100375555

32.7456741756

Sheet1

DiabetesColumn1Column2

202050.6247.520.4

202560.0258.523.2

203068.6267.925.6

203579.6276.928.7

204084.5285.529.6

204592.0292.931.4

2050100.3306.332.7

Sheet2

Risk of Prediabetes in Adolescent Offspring of Mothers with GDM

Adapted from:Holder T, et al. Diabetologia. 2014; DOI 10.1007/s00125-014-3345-2.

Obese adolescents with normal glucose tolerant (NGT) (N=255)

No Exposure to GDM(n=210; 82.3%)

Exposure to GDM(n=45; 17.7%)

Approx 5.75 times increase in risk; p < .001

Chart1

NGT

IGT/T2DM

0

NGT

IGT/T2DM

Series 1

Percentage (%)

91.4%

8.6%

68.9%

31.1%

91.4

8.6

68.9

31.1

Sheet1

Series 1

NGT91.4

IGT/T2DM8.6

0

NGT68.9

IGT/T2DM31.1

Modifiable Risk Factors of Diabetes/Prediabetes for CV Disease

American Diabetes Association. Diabetes Care. 2014:37:S14-80.

Non-modifiable

Age

Race/Ethnicity

Gender

Family history

Modifiable

Physical inactivity

Overweight/Obesity

Hypertension

Smoking

Abnormal lipid metabolism

High plasma glucose levels

The Cost of Prediabetes• National annual medical costs of prediabetes exceeded $25 billion;

an excess of $443 per person (average)

Adapted from:Zhang Y, et al. Popul Health Manag. 2009;12:157–163.

Per Capita Ambulatory Medical Costs, Adult Population, 2007

Cost Component US Average Excess Associated with PrediabetesBy Service Type $1,296 $443

Outpatient visit $215 $67Physician office visit $553 $183Medications $528 $194

By Complication Group $1,296 $443Neurological symptoms $16 $5Cardiovascular disease $49 $5Hypertension $74 $57Endocrine/metabolic complications $16 $11

All other medical conditions $1,017 $355

Diagnosis and Screening

MYTH:Borderline diabetes means you do not have diabetes yet.

FACT:Just like ‘borderline’ pregnancy, there is no such thing as ‘borderline diabetes’ –you either have it or you don’t!

Screening for Pre-DM

Screening• Risk based screening for diabetes/pre-diabetes is

recommended after onset of puberty or > age 10 in overweight/obese children (BMI ≥ 85th percentile) with one or more risk factors:

• Maternal diabetes/GDM• Signs of insulin resistance• 1st or 2nd degree relative with DM• Race/ethnicity

ADA standards of care, 2019, diabetes.org

Change in criteria for diagnosis

• Can have two abnormal tests from the “same” specimen. If 2ndtest needed-- do without delay. If close to threshold repeat in 3-6 months.

• If normal repeat testing at a minimum of 3 year intervals

Prevention or Delay of T2DM(Management of Pre-diabetes)

Diabetes Prevention Program• What: CDC recognized lifestyle change program for people with pre-diabetes.

• Format: Year-long program. During the first 6 months, participants meet about once a week. Participants meet about twice a month for the last 6 months. Incorporates weekly action plans and group sharing and problem solving.

• Topics Discussed: Healthy eating and tracking food intake, physical activity, managing stress, getting enough sleep, coping with triggers

• Qualifications: 18 and up and screening positive for pre-diabetes via CDC pre-diabetes screening (gender, age, history of gestational diabetes, high blood pressure), or having A1C levels between 5.7%- 6.4% tested by a medical professional

Herman WH, et al for the Diabetes Prevention Program Research Group.Ann Intern Med. 2005:142:323-332.

DM delay & prevention

• Recommend DPP • Weight loss 7%• Dietary modification– diet high in nuts, yogurt, berries, coffee & tea risk of T2DM

• Exercise 150 min/week• Consider use of Metformin

• BMI >35 kg/m2• < 60 years• h/o GDM

• Screen and treat for modifiable risk factors of CVD

RESOURCES

Prediabetes Materials for Patients

● Patient Handouts-diabetes.org/toolkit• Diabetes Risk Test-diabetes.org/risktest

• National Diabetes Prevention Program-www.cdc.gov/diabetes/prevention/

• My Health Advisor-diabetes.org/mha• CheckUp America-checkupamerica.org

• Internet-based and cell phone apps for weight loss-Various websites

Prediabetes Materials for Professionals

• ADA Clinical Practice Recommendations• Professional.diabetes.org/cpr

• On-line self-assessment programs• Cardiometabolic Risk• Diagnosing Prediabetes and Lifestyle Modification• professional.diabetes.org/ce

• ADA Diabetes is Primary webcasts• Professional.diabetes.org/primary

Prediabetes Conclusions

As a member of the healthcare team, YOU can make a difference •Only 11% of people with prediabetes are aware they have it•Identify those at risk for developing diabetes: be SAFE

• Proactively Screen/rescreen• Assess/advise with management strategies• Continually Follow-up and Evaluate

•Provide educational tools for success•Collaborate with other members of the healthcare team

Questions???

Pre- DiabetesSlide Number 2ObjectivesWhat is Prediabetes?Pre-DiabetesPrediabetesPrediabetesPrediabetes�Centers for Disease Control, 2012Projecting the Future Diabetes Population:�It Is GrowingRisk of Prediabetes in Adolescent Offspring of Mothers with GDMModifiable Risk Factors of Diabetes/Prediabetes for CV DiseaseThe Cost of PrediabetesDiagnosis and ScreeningSlide Number 14Screening for Pre-DMScreeningChange in criteria for diagnosisPrevention or Delay of T2DM�(Management of Pre-diabetes)Diabetes Prevention Program Slide Number 20DM delay & preventionRESOURCESPrediabetes Materials for PatientsPrediabetes Materials for ProfessionalsPrediabetes ConclusionsQuestions???