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© American Diabetes Association ®, Inc., 2001
Landmark Study |
Diabetes Prevention: How About NOW?1
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STUDY |
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Mokdad AH, Ford ES, Bowman BA, Nelson DE, Engelgau MM, Vinicor F, Marks JS: Diabetes trends in the U.S.: 1990-1998. Diabetes Care 23:1278–1283, 2000
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SUMMARY |
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TopSTUDYSUMMARYCOMMENTARYREFERENCES |
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Objective. The objective of this study was to evaluate trends in the prevalence of diabetes in the United States between 1990 and 1998.
Design and Methods. The Behavioral Risk Factor Surveillance System is a standardized telephone survey operated by state health agencies in collaboration with the Centers for Disease Control Prevention. A sample of adult residents (age 
18 years) with telephones from all states including the District of Columbia were asked standardized questions to provide data that could be compared across states. Diabetes status was assessed over the telephone by a trained interviewer who asked, "Have you been told by a doctor that you have diabetes?" Issues regarding gestational diabetes were coded separately. A total of 149,806 individuals were interviewed and completed the survey.
Results. The prevalence of diagnosed diabetes in the United States increased 33% between 1990 and 1998. This rise was seen across all ages, races, educational levels, and weight levels. There was a 70% increase in diagnosed diabetes among individuals aged 30–39 years. There were significant increases among Hispanics (38% increase), caucasians (29% increase), and African Americans (26% increase). For every 1-kg increase in self-reported weight, the risk of diabetes increased by 9%.
Conclusions. The prevalence of diabetes continues to rise. As the prevalence of obesity also continues to increase in the United States, diabetes will become an even greater health care problem, contributing to a worldwide diabetes epidemic that is largely preventable.
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COMMENTARY |
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"It is proper at the present time to devote time not alone to treatment but still more to prevention of diabetes. The results may not be so striking or immediate, but they are sure to come and to be important."
—Elliott P. Joslin, 1921
My how we have grown!
During the past several decades, we have rapidly grown in the areas of communication, technology, science, and medicine, and so, too, have we grown as individuals in our size and weight. Less than a century ago, there were no airplanes, no cars, and no fast food restaurants. Not surprisingly, this phenomenal technological growth has come at a price—an expanded girth that has extended not only to adults, but also to our children. This has resulted in a 70% rise in diabetes among 30- to 40-year-olds and a doubling in the number of children with type 2 diabetes in less than a decade.1
Since 1991, the number of obese Americans is up nearly 60%, and now nearly one in five of us are far overweight. It has been estimated that 31% of men and 35% of women are overweight.2–4 The highest incidence occurs in those aged 50–70 years, with 52% of women and 42% of men being overweight. Thirty-four percent of adults aged 20–70 years are overweight. Teens are also affected, with one in five teenagers considered overweight.3 Ironically, there are 58 million overweight adults in the United States—a number almost identical to that of Americans who eat at one of the 160,000 fast-food restaurants in the United States each day.5,6
Prevention holds the winning number, but no one will buy a ticket.
A computer analysis of the Diabetes Control and Complications Trial (DCCT) found that improved glycemic control results in a mean 7.7 additional years of sight, 5.8 additional years free from end-stage renal disease, 5.6 additional years free from lower-extremity amputation, and 15.3 additional years free from onset of substantial microvascular or neurological complications.7,8 Similar outcomes among individuals with type 2 diabetes were demonstrated by the United Kingdom Prospective Diabetes Study.9 Yet diabetes-related complications are on the rise in the United States.10 The prevalence of type 2 diabetes in children and adolescents is now as high as that of type 1 diabetes.
Unlike chronic diseases such as hypertension and coronary disease, for which medications-for-life is the rule, the cornerstones of care for diabetes—namely, medical nutrition therapy, exercise, and diabetes education—have never been considered to be a lifelong medical need. The recently published Healthy People 2010 reported that only half of all Americans with diabetes have received diabetes self-management training.10
To say that efforts to prevent complications in diabetes are cost-effective is extreme understatement. Yet few health care systems in the United States truly embrace the concept of comprehensive, preventive diabetes care "for life." In a technical review of diabetes self-management education for the American Diabetes Association, Clement noted that few "educational" programs extended even to 1 year.11 Perhaps when we place greater value on those who deliver preventive diabetes resources, including dietitians, certified diabetes educators, and the many other providers who are dedicated to the prevention of diabetes and its complications, self-management prevention will prevail over rising rates of diabetes and its associated complications.
Diets DO work.
Not surprisingly, more than 84% of Americans eat too much fat, whereas <30% eat the daily recommended five servings of fruits and vegetables. These factors contribute to the 800,000 new cases of diabetes that are diagnosed each year in the United States.12 In 1980, 1,000 new patients were diagnosed with diabetes each day in this country. By 1998, that number had more than doubled.13
In many cases, diet and exercise have controlled blood glucose levels to the normal range, reversed the course of the disease,14,15 and reduced the risk for accelerated vascular disease.16,17 Large studies have reinforced the efficacy of diet and exercise in preventing diabetes.14–29 Over a 6-year period, Pan and colleagues15 demonstrated a 31% reduction in the risk of developing diabetes among patients with impaired glucose tolerance (IGT), as compared to those who did not change their eating habits.
Other studies have clearly demonstrated that diet and exercise improve glycemic control. In a subset of patients with mild type 2 diabetes, 50% of patients treated with diet and exercise without concomitant medication entered a state of remission that was maintained for at least 5 years.14 Compliance with dietary recommendations has resulted in significant dose reductions in diabetes medications, including insulin, and insulin has been completely discontinued in many patients who have complied with prescribed diet and exercise regimens.30,31
Yes, you, too, can prevent diabetes.
Among 21,271 nondiabetic American male physicians participating in the Physicians’ Health Study, there was an inverse relationship between physical activity and the development of diabetes.18 The same result was found among 87,000 women in the Nurses Health Study.19 Both studies also found that all-cause mortality was significantly reduced among study participants whose body mass index was below the national average.
The 1990 National Health Interview Survey demonstrated that diabetic individuals across all age-groups were less likely to participate in regular physical exercise than were people without diabetes. Women with diabetes were significantly less likely to participate in regular exercise than were nondiabetic women and diabetic men, and African Americans with diabetes were less likely to exercise than caucasians with diabetes.32 Physical exercise is not only a critical factor in improving glucose control by increasing peripheral glucose uptake, but also can result in an improved sense of well-being among patients. Consistent with the recommendations of Healthy People 2010, technical reviews in the field of diabetes recommend aerobic exercise at 50–70% of maximum capacity three times per week for at least 20 min each.10
Let’s review the evidence for prevention of diabetes.
A landmark 6-year, randomized, prospective trial by Pan and colleagues,15 demonstrated that exercise resulted in a 46% reduction in the incidence of diabetes among patients with IGT. Similar reductions were found among those who dieted and/or exercised.
Tuomilehto25 found that type 2 diabetes could be effectively prevented by lifestyle interventions inclusive of a lowered-fat diet and exercise during the 4-year study. The incidence of diabetes was 10% in the intervention group, compared to 22% in the control group. The intervention group lost an average of 7.7 lb compared to 1.7 lb in the control group.
A similar trial, the Diabetes Prevention Program, is underway in the United States to evaluate the impact of diet, exercise, and medication on the progression to diabetes among patients with IGT. That study is scheduled to be completed in 2003.
Table 1 presents a summary of the major studies related to diabetes prevention.
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Many other studies have demonstrated the tremendous impact of dietary modification and exercise within weeks of initiating a fitness regimen. For example, Rogers and colleagues34 found significant improvements in glucose tolerance and reductions in insulin resistance within seven days of beginning a vigorous exercise program.33 Wing and colleagues found significant improvements in glycemic control when as little as 2.2 kg of weight were lost.
Diabetes preventive care pays, but few are collecting.
A 12-week study by Testa and Simonson35 demonstrated that improved glycemic control not only is beneficial in the long run, but also resulted in lower absenteeism from work, fewer days in bed, and a fourfold reduction in health care costs over the 3-month study period.
Sadur and colleagues36 demonstrated the benefits for adults with poorly controlled diabetes of outpatient diabetes education delivered by a diabetes nurse educator, a psychologist, a dietitian, and a pharmacist in cluster-visit settings of 10–18 patients/month for 6 months. This study demonstrated not only a significant decline in HbA1c levels in the intervention subjects, compared to a decline of 0.2% in control subjects, but also significant reductions in both hospitalizations (P = 0.04) and utilization of outpatient medical services (P < 0.01).
In a similar 6-month randomized intervention, my colleagues and I demonstrated that a computer-generated personalized diabetes education poster designed to be hung on a refrigerator and a personalized wallet card bearing the same information resulted in a decrease in HbA1c twice as large as the decrease for control subjects, who did not receive these materials.37 The poster and card stated the patient’s diabetes status, goals, and self-care recommendations.
Unfortunately, even after important studies such as these end and their results are published in peer-reviewed journals, there is often no preventive infrastructure to carry out the cost-effective strategies they recommend.
Talk is cheap, and it pays.
In 1969, the diabetes section at the Los Angeles County/University of Southern California Medical Center implemented a telephone-answering service for clinic patients with diabetes as an alternative entry point for patients who would ordinarily have gone directly to the emergency room.38 The phone line was staffed by a designated diabetes nurse practitioner or a diabetes-service resident who screened all patients being considered for hospital admission rather than having that decision made in the emergency room.
Within 1 year of initiation of the phone line, the diabetes population served increased by 50%, whereas emergency admissions decreased from 2,680 to 1,250, with a two-thirds reduction in diabetic ketoacidosis. But although the estimated cost savings of this program was $3.4 million, the minimal costs of such an advice line could not be absorbed by the health care system over the long run.
The value of a simple intervention such as telephone access to diabetes professionals has been lost in our current health care system. How many hospitalizations could be prevented if physicians and diabetes health care professionals were given the time to talk to patients? How many office visits could be avoided if time on the telephone was encouraged rather than discouraged by our current system of reimbursement?
The DCCT was successful in sustaining improved HbA1c results over a 10-year period in large part because of the regular telephone contact between members of the research team and patients.7 Patients in the intervention group received on average 32 phone calls per year, but the payoff in terms of additional years of complication-free living was staggering. The intensive services provided during the DCCT, including the phone calls) were well within cost-efficacy range for the current standards we provide for many other chronic diseases.
Who will pay for diabetes prevention?
Although we have the scientific know-how and data demonstrating our ability to reduce the rising rates of diabetes and its devastating complications, the current health care system in the United States provides a paucity of the preventive diabetes resources that are truly the lifelines for those with or at risk for this disease.
Not uncommonly, both physicians and patients are weighed down by conundrums posed by insurers, such as being denied reimbursement for diagnostic testing unless a patient already has a diagnosis of a disease when the disease cannot be diagnosed until a test is performed. We have yet to shift our focus to beginning prevention long before adulthood, when our formative habits develop.
By 2025, it is estimated that more than 300 million people throughout the world will have diabetes. The time has come for diabetes prevention, both in the United States and around the world. But the question remains: Who will pay this small price for prevention of diabetes? Perhaps a better question would be: Will our health care system continue to be a reactive one that would rather pay for costly procedures such as amputation or dialysis than cover the much lower costs of preventing complications?
As we think about new technological and pharmacological developments for combating disease, we need to take a few steps back and begin to value those health care systems that promote healthier lifestyles and provide more complex and ongoing care but reap much greater benefits in the long run. When we demonstrate to society that disease prevention is valued as much as medical and surgical treatment of a disease after preventable complications arise, then we will begin to prevent diabetes.
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Footnotes |
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1 Reviewed by Claresa Levetan, MD
Claresa Levetan, MD, is director of diabetes education at MedStar Research Institute in Washington, D.C. She is an associate editor of Clinical Diabetes.
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REFERENCES |
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TopSTUDYSUMMARYCOMMENTARYREFERENCES |
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1 Centers for Disease Control and Prevention National Center for Chronic Disease Prevention and Health Promotion: Diabetes threat on the rise among U.S. children. Chron Dis Notes Reports 12(2):1,10–12, 1999
2
Mokdad AH, Serdula MK, Dietz WH, Bowman BA, Marks JS, Koplan JP: The spread of the obesity epidemic in the United States, 1991–1998. JAMA 282:1519–1522, 1999
3 National Heart, Lung, and Blood Institute: Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Bethesda, MD, National Heart, Lung, and Blood Institute, 1998
4 Kuczmarski RJ, Flegal KM, Campbell SM, Johnson CL: Increasing prevalence of overweight among U.S. adults. JAMA 272:205-111, 1994[Abstract]
5 Food & Nutrition Resource Network: Food & Nutrition Resource Newsletter. March/April 1995
6 The American Forum for Global Education: Handout #4: McFast-food Conquers America. Global Perspectives on Fast-Food History. http://www.globaled.org/curriculum/ffood4.html
7 The DCCT Research Group: Lifetime benefits and costs of intensive therapy as practiced in the Diabetes Control and Complications Trial. JAMA 276:1409–1415, 1996[Abstract]
8
The DCCT Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 329:977–986, 1993
9
Gray A, Raikou M, McGuire A, Fenn P, Stevens R, Cull C, Stratton I, Adler A, Holman R, Turner R: The UKPDS Study Group: Cost effectiveness of an intensive blood glucose control policy in patients with type 2 diabetes: economic analysis alongside randomized controlled trial (UKPDS 41). BMJ 320:1373–1378, 2000
10 U.S. Department of Health and Human Services: Healthy People 2010. Washington, D.C., U.S. Government Printing Office, January 2000
11 Clement S: Diabetes self-management education. Diabetes Care 18:1204-1214, 1995[Medline]
12 Centers for Disease Control and Prevention: National Diabetes Fact Sheet: National Estimates and General Information on Diabetes in the United States. Revised edition. Atlanta, GA, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 1998
13 Trends in the prevalence and incidence of self-reported diabetes mellitus: United States, 1980–1994. Morb Mortal Wkly Rep 46:1014–1018, 1997[Medline]
14 Eriksson J, Lindstrom J, Valle T, Aunola S, Hamalainen H, Ilanne-Parikka P, Keinanen-Kiukaanniemi S, Laakso M, Lauhkonen M, Lehto P, Lehtonen A, Louheranta A, Mannelin M, Martikkala V, Rastas M, Sundvall J, Turpeinen A, Viljanen T, Uusitupa M, Tuomilehto J: Prevention of type 2 diabetes in subjects with impaired glucose tolerance: the Diabetes Prevention Study (DPS) in Finland: study design and 1-year interim report on the feasibility of the lifestyle intervention programme. Diabetologia 42:793–801, 1999[Medline]
15 Pan XR, Li GW, Hu YH, Wang JX, Yang WY, An ZX, Lin J, Xiao JZ, Cao HB, Liu PA, Jiang XG, Jiang YY, Wang JP, Zheng H, Zhang H, Bennett PH, Howard BV: Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance: the Da Qing IGT and Diabetes Study. Diabetes Care 20:537–544, 1997[Abstract]
16 Wannamethee SG, Shaper AG: Weight change and duration of overweight and obesity in the incidence of type 2 diabetes. Diabetes Care 22:1266–72, 1999[Abstract]
17 Salmeron J, Manson JE, Stampfer MJ, Solditz GA, Wing AL, Willett WC: Dietary fiber, glycemic load, and risk of non-insulin-dependent diabetes mellitus in women. JAMA 277:472–477, 1997[Abstract]
18 Manson JE, Nathan DM, Krolewski AS, Stampfer MJ, Willett WC, Hennekens CH: A prospective study of exercise and incidence of diabetes among U.S. male physicians. JAMA 268:63–67, 1992[Abstract]
19 Manson JE, Rimm EB, Stampfer MJ, Colditz GA, Willett WC, Krolewski AS, Rosner B, Hennekens CH, Speizer FE: A prospective study of physical activity and incidence of noninsulin-dependent diabetes mellitus in women. Lancet 338:774–778, 1991[Medline]
20
Hu FB, Sigal RJ, Rich-Edards JW, Colditz GA, Solomon CG, Willett WC, Spelzer FE, Manson JE: Walking compared with vigorous physical activity and risk of type 2 diabetes in women: a prospective study. JAMA 282:1433–1439, 1999
21
Folsom AR, Kushi LH, Hong CP: Physical activity and incident diabetes mellitus in postmenopausal women. Am J Public Health 90:134–138, 2000
22
Burchfiel CM, Sharp DS, Curb JD, Rodriguez BL, Hwang LJ, Marcus EB, Yano K: Physical activity and incidence of diabetes: the Honolulu Heart Program. Am J Epidemiol 141:360–368, 1995
23 Helmrich SP, Ragland DR, Leung RW, Paffenbarger RS Jr.: Physical activity and reduced occurrence of non-insulin-dependent diabetes mellitus. N Engl J Med 325:147–152, 1991[Abstract]
24 Uusitupa M, Louheranta A, Lindstrom J, Valle T, Sundvall J, Eriksson J, Tuomilehto J: The Finnish Diabetes Prevention Study. Br J Nutr (Suppl. 1):S137–S142, 2000
25 Tuomilehto J, Linstrom J, Erisson J, Valle T, Louheranta A, Ilanne-Parikka P, Salminen V, Hamalainen H, Aunola S, Keinanen-Kiukaanniemi S, Laasko M, Mannelin M, Sundvall J, Uusitupa M, DPS Study Group: Type 2 diabetes can be prevented by lifestyle intervention: the final results from the randomized Finnish Diabetes Prevention Trial (DPS) (Late-breaking abstract 12). American Diabetes Association 60th Scientific Sessions, San Antonio, TX. Alexandria, VA, American Diabetes Association, 2000
26 Bourn DM, Mann JI, McSkimming BJ, Waldron MA, Wishart JD: Impaired glucose tolerance and NIDDM: does a lifestyle intervention program have an effect? Diabetes Care 17:1311–1319, 1994[Abstract]
27 Wein P, Beischer N, Harris C, Permezel M: A trial of simple versus intensified dietary modification for prevention of progression to diabetes mellitus in women with impaired glucose tolerance. Diabetologia 34:891–898, 1991[Medline]
28 Lynch J, Helmrich SP, Lakka TA, Kaplan GA, Cohen RD, Salonen R, Salonen JT: Moderate intense physical activities and high levels of cardiorespiratory fitness reduce the risk of non-insulin-dependent diabetes mellitus in middle-age men. Arch Intern Med 156:1307–1314, 1996[Abstract]
29
Meigs JB, Nathan DM, Wilson PWF, Cupples LA, Singer DE: Metabolic risk factors worsen continuously across the spectrum of nondiabetic glucose tolerance Ann Intern Med 128:524–533, 1998
30 Davidson JK: Clinical Diabetes Mellitus: A Problem-Oriented Approach. 2nd ed. New York, Thieme Medical Publisher,
31
Savage PJ, Narayan KM: Reducing cardiovascular complications of type 2 diabetes: a complex but achievable and affordable task. Diabetes Care 22:1769–1770, 1999
32 U.S. Department of Health and Human Services: Healthy People 2000: Summary Report. Washington, D.C., U.S. Department of Health and Human Services (DHHS Publ. PHSSs 91-50213), 1992, p. 6–8, 55, 91–92.
33 Rogers MA, Yamamoto C, King DS, Hagberg JM, Ehsani AA, Holloszy JO: Improvement in glucose tolerance after 1 week of exercise in patients with mild NIDDM. Diabetes Care 11:613–618, 1988[Abstract]
34 Wing Rr, Koeske R, Epstein LH, Nowalk MP, Gooding W, Becker D: Long-term effects of modest weight loss in type II diabetic patients. Arch Intern Med 147:1749–1753, 1987[Abstract]
35
Testa MA, Simonson DC: Health economic benefits and quality of life during improved glycemic control in patients with type 2 diabetes mellitus. JAMA 280:1490–1496, 1998
36
Sadur CN, Moline N, Costa M, Michalik D, Mendlowitz D, Roller S, Watson R, Swain BE, Selby JV, Javorski WC: Diabetes management in a health maintenance organization: efficacy of care management using cluster visits. Diabetes Care 22:2011–2017, 1999
37 Levetan CS, Dawn KR, Robbins DC, Ratner RE: Impact of customized automation on hemoglobin A1c (Late-breaking abstract 11). American Diabetes Association 60th Scientific Sessions, San Antonio, TX. Alexandria, Va., American Diabetes Association, 2000
38 Miller LV, Goldstein BA: More efficient care of diabetic patients in a county-hospital setting. N Engl J Med 286:1388–1391, 1972
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