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Small Steps. Big Rewards. Your GAME PLAN to Prevent Type 2 Diabetes Health Care Provider Toolkit

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Small Steps. Big Rewards. Your GAME PLAN to Prevent Type 2 Diabetes Health Care Provider Toolkit

This toolkit contains a decision pathway to diagnose and treat prediabetes, proven strategies to counsel and motivate patients, an office poster, and copier-ready patient education materials. These materials help people to take steps to prevent or delay diabetes.

Last reviewed: 09/01/2011


The Small Steps. Big Rewards. GAME PLAN toolkit is based on the lifestyle modification strategies used in the Diabetes Prevention Program (DPP), sponsored by the National Institutes of Health. All of the DPP resources are available on the Internet at www.bsc.gwu.edu/dpp/manuals.htmlvdoc. The Walking section was adapted from a brochure produced by the Weight-Control Information Network, NIH Publication No. 01-4155.

All of the materials in this kit may be reproduced without permission and shared with colleagues and patients. Feel free to duplicate the copier-ready masters for your practice.

For more information about diabetes prevention and control, call the National Diabetes Education Program at 1-800-438-5383 or visit our web site at www.ndep.nih.gov on the Internet.

Toolkit Contents

Health Care Provider Toolkit

Acknowledgments, References and Resources

 


Preface

In August 2001, U.S. Department of Health and Human Services Secretary Tommy G. Thompson announced that the National Institutes of Health’s Diabetes Prevention Program (DPP) clinical trial—a multi-year study with more than 3,000 participants—was concluding early because of its tremendous success. The DPP, together with studies in Finland and Asia, demonstrated that TYPE 2 DIABETES CAN BE DELAYED OR PREVENTED.

The DPP showed that only seven patients needed to be treated to prevent one case of diabetes.

This is very good news for your patients at risk. There are now 17 million Americans with diabetes and each year there are about one million new cases. The DPP study showed that it is possible to prevent or delay the onset of type 2 diabetes in a group of research participants at risk. Importantly, the participants were representative of the racial and ethnic diversity of the United States and of the groups at highest risk for diabetes.

Diabetes incidence was reduced substantially—58 percent in the lifestyle group and 31 percent in those taking metformin compared with the placebo group. What’s more, the DPP demonstrated that only seven patients needed to be treated to prevent one case of diabetes.

If we can apply the lessons learned from the DPP to patients who are at risk for diabetes, this will result in significantly fewer new cases of diabetes each year.

The National Diabetes Education Program (NDEP)—a joint program of the National Institutes of Health and the Centers for Disease Control and Prevention—is pleased to provide you with this Small Steps. Big Rewards. Your GAME PLAN for Preventing Type 2 Diabetes toolkit. This kit will help you apply the lessons learned from the DPP to your patients.

The risk is great.
The goals are important.
The changes are modest.
The action steps are clear.
That doesn’t make it easy for you or your patients, but the DPP demonstrated that it can be done.

Please join with us!

Sincerely,

James R. Gavin III, MD, PhD
Chair, NDEP Steering Committee

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Executive Summary: Identifying and Treating Prediabetes

  1. Identification of High-Risk Patients
    Identify high-risk patients based upon these risk factors:

    • Age—The risk of prediabetes increases with age.
    • Overweight—Defined as a body mass index (BMI) ≥25 (≥23 if Asian American or ≥26 if Pacific Islander).

    In addition to age and weight, these factors increase risk for prediabetes:

    • Blood pressure—> 140/90 mm/Hg
    • Abnormal lipid levels—HDL cholesterol < 40 mg/dL for men and < 50 mg/dL for women; triglyceride level ≥250 mg/dL
    • Family History—Parent, brother, or sister with diabetes.
    • Ethnicity—African American, American Indian, Asian American, Hispanic/Latino, or Pacific Islander heritage.
    • History of gestational diabetes— Or gave birth to at least one baby weighing 9 pounds or more.
    • Inactive lifestyle—exercises less than three times a week.
  2. Blood Glucose Testing & Diagnosis of Prediabetes

    • Age 45 or older and overweight, testing for diabetes and prediabetes is strongly recommended.
    • Age 45 or older without any other risk factors, consider the risks and discuss with your patient before deciding on testing.
    • Younger than 45, overweight, and have checked any other items above, consider the risks and discuss with patient before deciding on testing.

    Perform FPG or 2-hour OGTT test (defined throughout this document as a single 2-hour post challenge glucose level after drinking or ingesting a 75-gram glucose solution after an overnight fast of 8 to 12 hours). See page 13 for a discussion of the relative merits of the two tests.

  3. Determine Patient’s Readiness to Initiate GAME PLAN
    The GAME PLAN (Goals, Accountability, Monitoring, and Effectiveness: Prevention through a Lifestyle of Activity and Nutrition) builds upon proven behavioral strategies used in the DPP to help patients successfully initiate lifestyle changes. Pages 4–6 outline the GAME PLAN and how to use the toolkit materials.

  4. Initiate Appropriate Intervention and Follow-up Based Upon Readiness
    This kit includes materials for you to share with patients to help develop an intervention that is effective for their individual needs. Pages 7–10 offer strategies health care providers can employ to engage patients and create accountability for their actions.

Decision Pathway Diagram - read Executive Summer: Identifying and Treating Prediabetes for diagram description
Based on “The Prevention or Delay of Type 2 Diabetes,” Diabetes Care, April 2002

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How To Use The Game Plan Kit

Woman exercizing on the floor

The good news is that we have definitive proof that type 2 diabetes can be delayed or prevented through moderate changes in lifestyle.

The Good News About Diabetes

You might be wondering: What’s the “good” news about diabetes, the sixth leading cause of death that has reached epidemic proportions in the United States in the past 10 years? The good news is that we now have definitive proof that type 2 diabetes can be delayed or prevented in persons at risk for the disease. How—through moderate changes in lifestyle.

The Diabetes Prevention Program (DPP) was a large, multi-site clinical trial that proved that type 2 diabetes can be prevented or delayed through modest weight loss (5 to 7 percent of initial body weight) and regular physical activity. In fact, these modest changes resulted in a 58 percent reduction in the development of diabetes in persons at increased risk for the disease. Moreover, these impressive results were obtained in all ethnic and age groups and especially in those over age 60.

You’re probably saying to yourself…

“Every time I try to get my overweight patients to lose weight, I fail.” We recognize how difficult it is to get patients to lose weight. Aggressive (and sometimes unrealistic) goals often lead to failure and frustration for both patient and health care provider. Again, the good news is that significant risk reduction can be achieved through modest weight loss. In the DPP, a man who weighed 290 pounds and lost 7 percent of his body weight would still weigh 270 pounds, but have the potential for significant risk reduction for developing diabetes.

Realistically, you have two options for helping your patients lose weight:

  1. You can refer them to weight loss pro- grams and health care professionals in your area who specialize in nutrition and weight management.
  2. You can provide your patients with the basic tools to enable them to make appropriate lifestyle changes to help reduce their risk for developing diabetes.

The materials included in this package are designed to help you with Option 2. They are adapted from those used in the DPP and have been proven essential and effective in helping patients make the changes in their life that can delay or prevent diabetes.

We have incorporated these materials into a comprehensive program called the “GAME PLAN:”

Goals, Accountability, Monitoring, and Effectiveness: Prevention through a Lifestyle of Activity and Nutrition.

We call it the Small Steps. Big Rewards. Your GAME PLAN for Preventing type 2 Diabetes. to tie in with the National Diabetes Education Program’s mass media public awareness campaign on diabetes prevention.

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What's Included in This Package

All of the GAME PLAN materials may be reproduced without permission for your practice.

  • Health care provider materials:

    • A “how to” guide that provides suggestions for helping your patients to initiate and maintain risk-reducing behaviors.

    • A Q & A about diabetes prevention, including strategies for identifying your patients at increased risk.

    • A Poster for your office to encourage your patients who may be at risk for diabetes to ask you about starting the GAME PLAN.

  • Patient GAME PLAN booklets (3 sets):

    • Small Steps. Big Rewards. Your GAME PLAN for Preventing type 2 Diabetes Introduces and explains the tools your patients can use to assess their risk for diabetes, set goals, and start a walking program to prevent or delay the onset of the disease. It also lists organizations and web sites with a wealth of additional weight loss and physical activity information.

    • Am I at Risk for Type 2 Diabetes? Provides basic information about diabetes and prediabetes and includes a checklist of the factors that increase risk. The BMI charts will help your patients determine if they are overweight.

    • Food and Activity Tracker Enables patients to monitor and record their food intake and physical activity. This log is vital because most patients are unaware of their total daily calories and dietary fat consumption. We’ve provided a master copy so your patients can reproduce and make their own pocket diaries.

    • Small Steps. Big Rewards. Fat and Calorie Counter Provides calorie and fat gram values to help your patients record their food and drink intake. (This is provided only as a patient booklet.)

  • Copier-ready versions of the GAME PLAN booklets:

    • Small Steps. Big Rewards. Your GAME PLAN for Preventing Type 2 Diabetes

    • Who Is at Risk for Type 2 Diabetes and Prediabetes?

    • Walking…A Step in the Right Direction

    • Food and Activity Tracker

Feel free to photocopy and distribute these materials when needed.

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How To Use These Materials…

Help your patients set realistic goals.

  1. Identify patients who would benefit most from lifestyle intervention. Use the risk factors discussed on page 2 to identify your patients who are at increased risk for type 2 diabetes. As indicated on the Decision Pathway (page 3), patients who meet one or more of these criteria should be tested for prediabetes — Impaired Fasting Glucose (IFG) and Impaired Glucose Tolerance (IGT).

  2. Discuss the importance of lifestyle modification for reducing diabetes risk. You can provide your patients with the Am I at Risk for Type 2 Diabetes? booklet or the copier-ready version to communicate basic information about diabetes, diabetes risk reduction, and prediabetes and to initiate dialogue about lifestyle modification.

  3. Use the chart on page 7 to determine each patient’s readiness to initiate lifestyle changes. The chart suggests ways to approach patients along the full continuum of readiness to begin the GAME PLAN.

  4. Talk to your patients about initiating the GAME PLAN. “How to” information on pages 8–10 suggests ways you can explain this program to your patients, help them set realistic goals, and introduce them to the patient materials in the kit. Consider if a physical exam is appropriate before counseling your patients to begin an activity program.

  5. Provide patients with the GAME PLAN tools to help them begin making lifestyle changes. Reinforce the importance of setting goals, documenting their daily physical activity and dietary intake, and the impact of reducing dietary fat grams. This is also explained in the GAME PLAN patient booklet.

  6. Follow up with your GAME PLAN patients. It’s important for you or someone from your office to review your patients’ progress in achieving their risk reduction goals. This does not have to involve a lot of time, but it must be consistent.

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Determine Patient Readiness to Initiate the GAME PLAN

If the Answer is “NO”

  • Use motivational strategies:

    • *Avoid argument. Say:“ I have some information I want to share with you …” or “I want you to know that it is your choice…”
    • Acknowledge that “there are good things and bad things about making lifestyle changes.”
    • Elicit patient’s view of the pros and cons of making lifestyle changes.(Consider having patient list his/her pros and cons.)
    • Educate patient about health risks of prediabetes and the process of preventing diabetes.
    • Reinforce “small steps, big rewards” in preventing/avoiding future complications.
    • Reinforce that “the window of opportunity is now” to initiate changes.
  • OFFER TO HELP YOUR PATIENT WHEN HE/SHE IS READY TO BEGIN THE GAME PLAN.

IF THE ANSWER IS “YES” BUT NOT AT THIS TIME

  • Identify and address barriers to initiating the GAME PLAN:
    • Lack of knowledge of lifestyle change principles/strategies
    • Discouraged or hopeless because past attempts were unsuccessful
    • Lack of social support
    • Lack of environmental support (access to safe exercise areas, foods)
    • Life events or emotional issues that absorb most of patient’s time and energy—chronic and acute.
  • Identify reasons to lose weight or engage in physical activity:
    • Health-related
    • Emotional, social, financial, relationships &other— be sensitive to cross-cultural body image differences.
  • Work with patient to start thinking about a personal plan:
    • Discuss setting a realistic long- term goal (5–10% weight loss and/or exercise 150 minutes per week over next 12 months).
    • Discuss realistic short-term objectives (e.g., 30 minutes of exercise per week for next 30 days and/or reduce total daily fat consumption by 10%).
  • THIS DISCUSSION MAY PROMPT YOUR PATIENT TO COMMIT TO THE GAME PLAN.

IF THE ANSWER IS “YES” WITHIN THE NEXT 30 DAYS

  • Ask patient to set a starting date for initiating the GAME PLAN.
  • Assess prior efforts:
    • “What have you tried?”
    • “What worked?”
    • “What didn’t work?”
  • Work with patient to develop a personal plan.
  • Set a realistic long-term goal (5–10% weight loss and/or 150 minutes of exercise per week over next 12 months).
  • Set a realistic short-term objective (e.g., 30 minutes of exercise per week for next 30 days and/or reduce total daily fat consumption by 10%).
  • Consider pharmacotherapy.
  • Offer behavioral support:
  • GAME PLAN tools or other booklets
    • Referral to RD, counseling program, telephone counseling, on-line resources
  • EXPRESS CONFIDENCE IN YOUR PATIENT’S ABILITY TO MAKE LIFESTYLE CHANGES.

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How To Talk With Your Patients About Starting The Game Plan

Elderly couple dancing

Patients who achieve short-term successes are more inclined to stay with the program. Have your patients select something they enjoy doing.

These guidelines are meant to help you talk with your patients about the GAME PLAN, specifically those patients who have indicated a willingness to take action within the next 30 days. We urge you to use these guidelines to discuss key aspects of the program.

  1. Explain the GAME PLAN to your patients.

    The acronym is designed to communicate the key components of an effective diabetes prevention regimen: Goals, Accountability, Monitoring, and Effectiveness: Prevention through a Lifestyle of Activity and Nutrition.

    • Goals should be simple, realistic, and incremental. For example, the program goal may be losing 5 to 10 percent of current body weight; a short-term goal may be something as simple as walking briskly for 10 minutes a day, at least 3 days this week. Patients who achieve short-term successes are more inclined to stay with the program.
    • Accountability means having your patients identify an individual (or individuals) to whom they can report their progress. You can help your patients identify a coach or refer your patients to other health professionals and/or resources in your community. It is much easier for your patients to stay on their program when they know someone is working with them.
    • Monitoring progress means keeping track of nutrition, physical activity, and weight loss. This requires patients to keep daily logs of their exercise and food and drink intake using the Food and Activity Tracker provided in this kit. The DPP study showed that patient monitoring and documentation of food intake was the single most effective strategy for successful weight loss.
    • Effectiveness is tracked using the Food and Activity Tracker. Patients should be encouraged to utilize and review this important tool. Download additional copies.
  2. Help your patient set goals.

    Work with your patients to set short-term goals. Short-term goals will provide the motivation and positive reinforcement needed to meet their long-term goals. The GAME PLAN patient materials, especially the Food and Activity Tracker, include blank spaces for your patients to write in both their short-term and long-term goals.

    Here are some ways to help your patients set their physical activity goals and GAME PLAN…

    • Have your patients select something they enjoy doing. Most patients choose walking because it doesn’t require any special equipment, and they can do it anywhere—parks, neighborhoods, downtown, even shopping malls.

    • Urge your patients to start slowly. “Walking…A Step in the Right Direction” provides information about initiating a safe, gradual walking program. If your patients never had a regular exercise routine, they should start with 10 minutes of brisk walking 3 to 5 days a week. Then they can increase their walking to 30 minutes per day, 5 days a week. The frequency and intensity of physical activity can be increased gradually.

    • Remind patients to keep track of their physical activity. The best way to stay motivated is for your patients to record when and how long they are active in their Food and Activity Tracker. The more often they are physically active, the more it will become part of their routine.

    Here are some ways to help your patients set their nutrition goals and GAME PLAN…

    • Explain that healthy eating involves eating less fat and fewer calories. Eating too much fat causes weight gain and is related to heart disease and diabetes. Eating too many calories from any type of food is fattening.

    • The first step to eating less fat and fewer calories is to become a “fat detective.” Show your patients how to figure out how many fat grams and calories they are eating by using the Fat and Calorie Counter. Explain how to record everything they eat and drink in the Food and Activity Tracker.

    • Help your patients set their fat and calorie goals using the chart below. Explain that it may be hard to reach their fat gram and calorie goals at first. They should try to get as close to their goals as they can, first focusing on fat grams and then on calories.

    Fat and Calorie Goal Chart
    WEIGHT (POUNDS)FAT GOAL (GRAMS)CALORIE GOAL
    120-174331,200
    175-219421,500
    220-249501,800
    250+552,000
  3. Explain how to use the Food and Activity Tracker.

    The purpose of the Food and Activity Tracker is to provide patients with a tool to reach daily adherence to nutrition and activity goals. Explain that spelling and grammar are not important; honesty and self-awareness are what really matter.

    Each set of patient booklets includes one seven-day tracker. For more copies, your patients either can reproduce the copier-ready master provided in their GAME PLAN booklet or  print or order additional copies.

    Patients should be instructed:

    • How to record their daily and weekly activity, calorie, and fat gram goals on the Food and Activity Tracker.
    • How to use the Fat and Calorie Counter to look up the fat and calorie content of the foods they eat.
    • How to record the type and amount of food and drink they consume on the tracker.
    • How to add up the total fat grams, calories, and minutes of activity in the tracker.
    • How to enter their weight each day and their weekly weight loss in the tracker.
  4. Reinforce and encourage.

    It is important to remind your patients that small steps in improving their eating and activity habits can lead to big rewards in improving their health and quality of life. Explain to your patients that:

    • Initiating lifestyle change is difficult, even for the most disciplined individuals. It is very easy for patients to get discouraged when results don’t appear quickly or when they “skip” a day (or two) of exercise and/or proper nutrition.

    • They shouldn’t quit the program if they miss a few days. They just need to start again and keep going. It takes time and often several attempts to make long-lasting lifestyle changes.

    • They need to be patient with themselves and their progress. There are no “quick fixes” when it comes to weight loss. If they follow their GAME PLAN, they will eventually lose weight and improve their overall health.

Finally, remember to ask your patients how they are doing with the GAME PLAN at every visit. Your ongoing interest and reinforcement of their efforts is essential to your patients’ long-term success.

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Q & A: Translating Diabetes Prevention Research Into Clinical Practice

Q: What is the evidence that diabetes mellitus can be prevented?

A: The Diabetes Prevention Program, sponsored by the National Institutes of Health, was a randomized clinical trial testing whether lifestyle modification or medication could prevent or delay the development of type 2 diabetes in high-risk individuals with fasting plasma glucose values greater than 95 and impaired glucose tolerance. The 27 clinical centers in the U.S. that participated in the study recruited 3,234 participants of both sexes, approximately 50 percent of whom were minority patients and 20 percent of whom were 60 years of age or older.

Participants were randomized to one of three intervention groups: an intensive lifestyle intervention focusing on a healthy diet and exercise and two masked medication treatment groups—metformin or placebo—combined with standard diet and exercise recommendations. Participants were asked to lower fat to less than 25 percent of caloric intake. If reducing fat did not result in weight loss, a reduced calorie goal was added. The primary outcome was the development of diabetes, diagnosed by fasting or post-challenge plasma glucose concentrations meeting the 1997 American Diabetes Association criteria.

The study demonstrated that the lifestyle intervention resulted in a 58 percent reduction and the metformin intervention a 31 percent reduction in the risk of developing diabetes.

Chart of the Incidence of Diabetes - read the answer of What is the evidence that diabetes mellitus can be prevented? for chart's description
* Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin. N Engl J Med 2002; 346:393-403

Several studies in other countries have examined the effects of intensive changes in diet and exercise in people at risk for type 2 diabetes. For example, a study in Finland showed that diet and exercise resulted in a risk reduction similar to that shown in the DPP.

Q: What is “prediabetes?”

A: Prediabetes is the term that has been adopted to describe those states that occur when a person’s blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes. Prediabetes includes impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) and is a significant risk factor for type 2 diabetes. In fact, before people develop type 2 diabetes, they almost always have prediabetes. Studies show that most people with prediabetes develop type 2 diabetes within 10 years.

The good news from the Diabetes Prevention Program (DPP) is that people with prediabetes can delay or prevent the onset of type 2 diabetes through modest lifestyle changes. Therefore, screening for and treatment of prediabetes should be a priority for all health care professionals. Importantly, prediabetes is not simply an “early warning” of diabetes. For example, individuals with IGT have a 1.5 times greater risk of cardiovascular disease compared to people with normal blood glucose. This risk remains high even if they never go on to develop diabetes. Therefore, these patients should have screening for and appropriate treatment of other cardiovascular risk factors, especially hypertension and dyslipidemia.

Q: Who is most likely to be at risk for diabetes and prediabetes?

A: According to the National Health and Nutrition Examination Survey III (NHANES III), at least 16 million people in the U.S. have IGT, the closest match we have for identifying the number of people with prediabetes. In addition to the metabolic defect identified by elevated fasting and/or 2-hour OGTT mentioned above, the risk factor chart on page 2 details additional areas of concern.

Q: How do I diagnose prediabetes?

A: In 2002, a group of diabetes experts (The Prevention or Delay of Type 2 Diabetes, Diabetes Care, April 2002) decided either impaired fasting glucose or impaired glucose tolerance levels could be used to determine if a patient could potentially benefit from DPP-like interventions. Prediabetes, then, can be diagnosed using either the fasting plasma glucose test (FPG) or the 2-hour oral glucose tolerance test (2-hour OGTT).

FPG is performed by measuring a person’s blood glucose after an overnight fast (8 to 12 hours). The 2-hour OGTT is performed after an overnight fast (8 to 12 hours) by measuring a person’s blood glucose immediately before and 2 hours after drinking a 75-gram glucose solution.

Diagnostic Criteria
TESTVALUEDIAGNOSIS
FPG110-125 mg/dlPrediabetes (IFG)
FPG≥126 mg/dLDiabetes
OGTT2-hour value
140-199 mg/dL
Prediabetes (IGT)
OGTT2-hour value
≥ 200 mg/dL
Diabetes

Although the 2-hour OGTT is a more sensitive test for diagnosing prediabetes, it is not always practical. Therefore, you may decide to use the FPG. If you choose to use the FPG test alone, however, it is important to note that because it is less sensitive than the 2-hour test, some patients who have IGT or diabetes will be missed.

Data collected from the NHANES III illustrate this point:

Diagnosis Missed By FPG
FASTING PLASMA GLUCOSE mg/dLPERCENTAGE (%)
MISSED BY FPG ALONE*
IGTDIABETES
< 807.21.5
81-10914.31.6
110-126N/A prediabetes diagnosed17.6

*Based on U.S. population 40 t0 74 years of age.

These data show that if you rely solely on a FPG value, a percentage of persons with IGT and/or diabetes that would have been identified with a 2-hour OGTT will be missed. Recognizing the issues involved in conducting timed glucose tests, you may want to consider how many of the other prediabetes risk factors are present in deciding which test is appropriate. In addition, you may want to discuss the benefits and limitations of both testing methods with your patients in determining which testing procedure should be used.

Q: What is the treatment for prediabetes?

A: The DPP and other studies have definitively shown that type 2 diabetes can be delayed or prevented by modest weight loss (5 to 7 percent of total body weight) through diet modification and moderate exercise such as walking, 30 minutes a day, 5 days a week. Other studies also suggest that metformin and acarbose reduced the incidence of diabetes in individuals at risk. However, these medications have not yet been approved for preventing diabetes.

Because individuals with IGT are at a 1.5 times greater risk for heart disease, it is advisable to counsel patients with prediabetes about cardiovascular risk factors such as tobacco use, high blood pressure, and high cholesterol. Hypertension and dyslipidemia also should be treated aggressively and are responsive to lifestyle modification and pharmacologic therapy.

Referral is advisable to a registered dietitian or credible weight loss program/service for counseling in calorie-reduction strategies, low-fat meal planning and lifestyle modification. Reimbursement of nutrition counseling is available for diabetes. It also may be available for hypertension and/or dyslipidemia.

Q: Will insurance cover testing and treatment?

A: All insurance plans are different. Medicare and most insurance plans cover testing for people suspected of having diabetes. Individuals at risk for diabetes are also at risk for prediabetes. Since the test is the same and the risk factors are the same for both conditions, a prediabetes test may be covered.

Q: Should children be screened for prediabetes?

A: The DPP and other studies focused on diabetes prevention in adults. We do not have firm evidence that type 2 diabetes can be prevented or delayed in children at risk for the disease. However, a study of extremely obese youth (with a body mass index greater than the 95th percentile for age and sex) found that 25 percent of the 55 children and 21 percent of the 112 adolescents studied had IGT.* Given the significant increase in obesity and sedentary lifestyle among American children and adolescents (especially in high-risk ethnic populations), it may be reasonable to begin identifying children at risk for developing diabetes and initiating the appropriate therapy (lifestyle changes and counseling with parents).

*Sinha R, Fisch G, Teague B, et al. Prevalence of impaired glucose tolerance among children and adolescents with marked obesity. N Engl J Med 2002; 346:802-10.

Q: Lifestyle intervention more effectively reduced diabetes risk than metformin. Within each arm, did certain groups of DPP participants benefit more from the intervention than other groups?

A: Lifestyle intervention worked in all of the groups, but it was extremely effective in people aged 60 and older, reducing the development of diabetes by 71 percent. This is an important and heartening discovery because as many as 20 percent of people aged 60 and older develop diabetes. Among those taking metformin, its effect in reducing diabetes risk was most pronounced in younger, heavier people—those 25 to 40 years old with a body mass index of36 (about 50 to 80 pounds overweight).

Q. For a person with IGT, what is the risk of developing type 2 diabetes?

A: As few as one, to as many as 10, of every 100 persons with IGT will develop diabetes per year. The risk of getting diabetes rises as people become more overweight and more sedentary, have a stronger family history of diabetes, and belong to a racial or ethnic minority group. In the DPP, about 10 percent of participants in the placebo or standard group developed diabetes per year. The DPP interventions decreased the development of diabetes by 58 percent with intensive lifestyle intervention and by 31 percent with metformin.

Q: Are diet and exercise beneficial even after diabetes develops?

A: Research has clearly shown that diet and exercise help people with type 2 diabetes control their blood glucose, blood pressure, and blood lipids in the short term. Although diet and exercise should lower the risk of developing cardiovascular disease and the other complications of diabetes, no long-term clinical trials have addressed this question. A recently launched trial, the Look AHEAD study, will examine how diet and exercise affect heart attack,stroke, and cardiovascular-related death in overweight people with type 2 diabetes.

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Acknowledgments

Many National Diabetes Education Program (NDEP) partners contributed to the development of this toolkit. Members of the NDEP’s Lifestyle Tools Work Group and Executive Committee translated the lessons learned from the Diabetes Prevention Program clinical trial to help health care providers and their patients initiate steps to prevent type 2 diabetes. Their dedication and hard work were invaluable.

Lawrence Blonde, MD, FACP
American College of Physicians

Janet O. Brown, MSN, MPH, RN
Albert Einstein College of Medicine

Charles M. Clark, Jr., MD
Indiana University School of Medicine

Judith E. Fradkin, MD
National Institute of Diabetes and Digestive and Kidney Diseases/NIH

Wilfred Y. Fujimoto, MD
University of Washington

Joanne Gallivan, MS, RD
National Institute of Diabetes and Digestive and Kidney Diseases/NIH

Sanford Garfield, PhD
National Institute of Diabetes and Digestive and Kidney Diseases/NIH

James R. Gavin, III MD, PhD
Morehouse School of Medicine

Rita Goodman, MS, RNC
Bureau of Primary Health Care

Mary Hoskin, MS, RD
National Institute of Diabetes and Digestive and Kidney Diseases/NIH

Jane Kelly, MD
Centers for Disease Control and Prevention

Andrea M. Kriska
University of Pittsburgh

Carolyn Leontos, MS, RD, CDE
Academy of Nutrition and Dietetics

David Marrero, PhD
Indiana University Diabetes Research and Training Center

Saul Malozowski, MD, PhD, MBA
National Institute of Diabetes and Digestive and Kidney Diseases/NIH

Maria G. Montez, MSHP, RN, CDE
University of Texas, Health Science Center at San Antonio

Brenda Montgomery, RN, BSN, CDE
University of Washington

Christopher G. Parkin, MA
CG Parkin Communications

Kellie Smith, MSN, RN
Thomas Jefferson University

Lorraine Valdez, MPA, RN, CDE
Indian Health Service

Elizabeth M. Venditti, PhD
University of Pittsburgh

Frank Vinicor, MD, MPH
Centers for Disease Control and Prevention

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References

American Diabetes Association. Type 2 diabetes in children and adolescents. Diabetes Care 2000; 23:381-9.

American Diabetes Association and National Institute of Diabetes and Digestive and Kidney Diseases. The prevention or delay of type 2 diabetes. Diabetes Care 2002; 25:742-9.

Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults—The Evidence Report. National Institutes of Health. Obes Res 1998; 6 Suppl 2:51S-209S.

Eriksson KF, Lindgarde F. Prevention of type 2 (non-insulin-dependent) diabetes mellitus by diet and physical exercise. The 6-year Malmo feasibility study. Diabetologia 1991; 34:891-8.

Harris MI, Flegal KM, Cowie CC, et al. Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in U.S. adults. The Third National Health and Nutrition Examination Survey, 1988–1994. Diabetes Care 1998; 21:518-24.

Hernan WH, Brandle M, Zhang P, et al. Costs associated with the primary prevention of type 2 diabetes mellitus in the diabetes prevention program. Diabetes Care 2003; 26:36-47.

Pan XR, Li GW, Hu YH, et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study. Diabetes Care 1997; 20:537-44.

Sinha R, Fisch G, Teague B, et al. Prevalence of impaired glucose tolerance among children and adolescents with marked obesity. N Engl J Med 2002; 346:802-10.

The Diabetes Prevention Program (DPP) Research Group. Cost associated with the primary prevention of type 2 Diabetes Mellitus in the Diabetes Prevention Program. Diabetes Care 2002; 26(1):36-47.

The Diabetes Prevention Program (DPP) Research Group. The Diabetes Prevention Program (DPP): Description of lifestyle intervention. Diabetes Care. 2002 Dec;25(12):2165-2171.

The Diabetes Prevention Program (DPP) Research Group. (Knowler WC, Barrett-Connor E, Fowler SE, et al.) Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002; 346:393-403.

The Diabetes Prevention Program (DPP) Research Group. The Diabetes Prevention Program: Baseline characteristics of the randomized cohort. Diabetes Care 2000; 23:1619-29.

The Diabetes Prevention Program. Design and methods for a clinical trial in the prevention of type 2 diabetes. Diabetes Care 1999; 22:623-34.

Tuomilehto J, Lindstrom J, Eriksson JG, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001; 344:1343-50.

Wing RR, Goldstein MG, Acton KJ, et al. Behavioral science research in diabetes: lifestyle changes related to obesity, eating behavior, and physical activity. Diabetes Care 2001; 24:117-23.

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Resources

Centers for Disease Control and Prevention
www.cdc.gov/diabetes

Diabetes Prevention Program web site for materials:
www.bsc.gwu.edu/dpp/manuals.htmlvdoc

National Diabetes Education Program
www.ndep.nih.gov

National Diabetes Information Clearinghouse
diabetes.niddk.nih.gov

National Heart, Lung, and Blood Institute
www.nhlbi.nih.gov

National Institutes of Diabetes and Digestive and Kidney Diseases
www.niddk.nih.gov

United States Department of Agriculture
www.usda.gov

Weight-Control Information Network
win.niddk.nih.gov

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