Sunday, March 17, 2019

We Know How to Prevent Diabetes, So Why Don’t We?

Back in 1996, Microsoft was promoting Windows 95 "Chicago." The Summer Olympics opened in Atlanta. General Motors released the EV1, the first production electric car. Our knowledge of Diabetes was expanding. 

Scientists with The Diabetes Prevention Program Research Group set out to answer two basic questions: 

          Does lifestyle intervention or treatment with metformin prevent or delay the onset of
     Type II Diabetes?

          Do these interventions differ in effectiveness, and does it differ with age, sex, or ethnicity?

A total of 3,234 patients at 26 centers at risk for but without diabetes were randomized to three groups: a Metformin Goup, an Intensive Lifestyle Intervention Group, and a Control Group.

         The Metformin Goup received standard lifestyle recommendations (NCEP Step 1 diet) and   meformin 850mg twice daily. 

         The Control Group received the same standard lifestyle recommendations and placebo.

         The Intensive Lifestyle Intervention Group received a 16 lesson curriculum covering diet, activity, and behavioral modification – NOT traditionally part of the standard lifestyle recommendations. It included goals of 7% weight loss and 150 minutes a week of physical activity.

The ground breaking results published in The New England Jounal of Medicine February 7, 2002 demonstrated that both Intensive Lifestyle Intervention and Metformin reduced the incidence of Diabetes in persons at risk. Interestingly, The Intensive Lifestyle Intervention was found more effective than Metformin and Standard lifestyle recommendations.

The breakdown was as follows:
11 new cases of Diabetes per 100 person years in the Control/Placebo Group.
7.8 new cases of Diabetes per 100 person years in the Metformin Group.
4.8 new cases of Diabetes per 100 person years in the Intensive Lifestyle Group.

Put another way, the number of people needed to treat to prevent one new case of Diabetes was 6.9 for the Intensive Lifestyle Group and 13.9 for the Metformin Group. For every 7 people who engaged in the Intensive Lifestyle program one person would NOT develop Diabetes. For every 14 people who took metformin one person would NOT develop Diabetes.

Intensive Lifestyle Intervention was more effective in older people, people with lower baseline glucose, and those with lower BMI. Metformin was more effective in younger people, people with higher baseline glucose, and those with higher BMI.

Much more data confirming the findings were published in the years after publication. Yet, seventeen years later it appears much of what we learned has only been slowly adopted by public health policy and primary care medicine.

The Centers for Medicare & Medicaid Services offered a glimmer of hope in March 2016. The Office of The Actuary issued a report stating expansion of the YMCA's Diabetes Prevention Program as a covered benefit WOULD NOT result in an increase in Medicare spending but would actually save money. Today, Medicare recipients can enroll with a CDC certified program.

Is it enough? Sadly – NO. In spite of reams of evidence based medicine published over the last 20 years only a minority of at risk people are aware of or encouraged to partake in such proven interventions.

It is time for change.

Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.
Knowler WC1, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, Nathan DM; Diabetes Prevention Program Research Group.
2002 Feb 7;346(6):393-403.

Recertification of the Medicare Diabetes Prevention Program Expansion

Medicare Diabetes Prevention Program (MDPP) Expanded Model

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