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June 24, 2010

On Health — Diabetes:

Focusing on prevention

applesThe need for prevention is the dominant theme when diabetes health care specialists discuss the disease.

Pitt is on the cutting edge of promoting prevention and training with its group lifestyle balance program (GLB) program, an adaption of the diabetes prevention program. DPP, a large clinical trial conducted in 27 centers across the United States, demonstrated that a healthy lifestyle, including changes in diet and physical activity leading to weight loss, is more effective than medication in reducing risk factors associated with diabetes and cardiovascular disease, as well as reducing the onset of diabetes in those with pre-diabetes (a condition where blood glucose levels are elevated but not high enough to be considered at the level for diabetes diagnosis).

Funded by the National Institute of Diabetes and Digestive and Kidney Diseases, DPP divided subjects into three groups: one received a placebo; one received the medication metformin, and one group received diet and lifestyle intervention techniques over 16 informational sessions and performed 150 minutes of physical activity weekly.

DPP researchers found a 31 percent reduction in the onset of diabetes for those who received the drug, but a 58 percent decrease for those in the lifestyle intervention group.

Members of Pitt's Diabetes Prevention Support Center training team, from left, M. Kaye Kramer, Linda Semler, Andrea Kriska and Elizabeth Venditti.

Members of Pitt's Diabetes Prevention Support Center training team, from left, M. Kaye Kramer, Linda Semler, Andrea Kriska and Elizabeth Venditti.

The clear message, researchers say, is: Get active and lose a little bit of weight. Losing as little as 7 percent of one’s body weight makes a significant difference for at-risk populations, researchers found.

Pitt researchers created the lifestyle intervention evaluated in the DPP study, then developed the Diabetes Prevention Support Center (DPSC), part of the University of Pittsburgh Diabetes Institute, and adapted the DPP intervention to its group lifestyle balance program for delivery in real-world settings. These DPSC researchers now travel all over the country and occasionally internationally, including to military bases via funding from the Department of Defense. They lead sessions for health care professionals on how to make healthy lifestyle changes to lower the risk for diabetes.

“We’re training health professionals in all settings — senior centers, churches, wherever we’re invited — and we’re training graduate students here at Pitt,” said Andrea Kriska, professor in the Department of Epidemiology and an investigator on the prevention project, who helped develop two new courses based on DPP training at the Graduate School of Public Health. “As we do that, more and more people will be offered these interventions,” Kriska said. But, unfortunately, remuneration for the trainers of these types of programs is lacking, she added.

Fellow researcher Elizabeth Venditti, assistant professor of psychiatry, added, “We need insurers, third-party payers that support this. There is one particular program that [insurers] United Health Care is putting in. But that’s just one. We need more inroads in medical settings, facilities, clinics, hospitals, work sites, senior centers, wherever people go for their medical care. I would hope that 10 years from now, there would be some type of a per-head package reimbursement rate.”

The team recently finished training employees of Sutter Medical Foundation in California, which will be implementing the prevention program at five of its clinical sites. “They were successful in getting their health insurer to buy in for half of it,” said M. Kaye Kramer, a visiting assistant professor in epidemiology who is part of the DPSC training team. She said the team’s latest undertaking was training Massachusetts state health department staff, who plan to implement the diabetes prevention program at various sites across the state.

Venditti said the DPSC researchers currently are in early stages of consultation with UPMC Health Plan about expanding diabetes prevention coverage for its members.

“With our government funding we can model implementation initiatives,” Venditti said. “But to make a true dent in the worldwide problem we need a whole health care industry behind it.”

So the question becomes: How do you achieve that?

Linda Semler, nutrition coordinator of DPP and a staff member in the Department of Health and Physical Activity, School of Education, said getting the message to a wider audience is the key. “I’m not sure we know the best model of health care delivery. We’re taking our message to people in various ways. For example, when we did the training sessions in Jamaica, it was done through churches there. We also are piloting a program for the Air Force to use DVDs for DPP training. We want to have programs reach as many people as possible, which is why we’re now training others in how to teach the DPP.”

Venditti said, “With health care reform, I think people see diabetes as the disease that can be a model of what preventive medicine would look like. My goal as a scientist is to work with someone like the health plan to make sure that the integrity of the DPP is maintained in this piece of translation. And since we’re next-door neighbors, we can be a training resource, we can actually point to personnel who are qualified. But there are a lot of different ways to model and I don’t know that we’ve figured all that out yet.”

One positive sign for expanding pre-diabetes care nationally is the recently introduced federal legislation called the Diabetes Prevention Act. Venditti said legislators who are pushing the act are evaluating the economic impact of diabetes prevention programs.

“They’re trying to say, ‘Let’s look at what it would cost to institutionalize diabetes prevention and treatment. How scalable is it and how are we going to do that?’” Venditti said. “And that’s why people continue to look to the commercial insurers, because they’re generating revenue,” she said. “I think that’s what the insurers themselves are wrestling with, because for a long time people felt that prevention didn’t really pay. That balance is tipping: The problem is getting big enough, the costs are getting big enough, the employers are getting hit enough by the costs of the premiums —  so everybody is saying, ‘C’mon, what’s the answer here?’”

Another issue is where to draw the treatment line, Kriska said. “The DPP used a high-risk population. But we’ve shown scientifically and published research that we’ve also helped people with metabolic syndrome,” Kriska said. Metabolic syndrome is a condition when a group of metabolic risk factors such as obesity, high LDL cholesterol and elevated blood pressure occur in one person. “So the issue becomes: Do you take only people who are sort of knocking on diabetes’ door, or do you step down a bit and take people with pre-diabetes and metabolic syndrome, or step down even further and take anyone who is overweight?”

Venditti said, “Probably the economic wisdom, at least in the present, is to stick to taking those who are high-risk. If you want to see an immediate pay-off, from an odds point of view, intervening with a group who has not yet become diabetic, but is older, is a way of getting at that risk. I think the medical community feels it’s got to go after this older high-risk group first to halt the runaway costs.”

Kramer added, “Part of that problem is that there are so many who fit that category. An estimated 57 million people have pre-diabetes and many, many of them don’t even know they have it.”

On the other hand, the researchers agreed, society should not ignore the fact that the diabetes epidemic increasingly is affecting younger people, partly due to a cultural de-emphasis on physical activity and a disregard for healthy eating.

Kramer said, “The two very most important things you could learn in school as a child are eating healthy and being physically active. Really, if you don’t have that through your life, you’ll be at risk.” But schools often do not provide wholesome foods and many are cutting out physical activity programs. “That is not a healthy combination,” Kramer said.

Semler said that offering healthy lifestyle programs throughout all levels of schooling could result in lifestyle changes that become permanent. “We could have programs in middle schools, for example, when young people are just becoming aware of the changes in their bodies,” Semler said. “We could go on up to college. There also should be more local and regional programs like America on the Move, to appeal to wider age groups. We really need to get the prevention message out to kids and families and schools.”

She added that Pitt’s prevention program showed that the post-60 age group usually is more successful than their younger at-risk counterparts in lowering their risk factors for diabetes by following the program. “Older people have more time if they’re retired to keep food diaries and stick to healthy food choices and weight-loss techniques,” Semler said. “They’re also more used to cooking. I heard one young person say, ‘I don’t cook. I assemble food, like using a taco mix package.’”

Venditti said the causes of the diabetes epidemic are deep-rooted, systemic and cultural. “Our advances in technology, obviously, have benefited a lot of people economically. But what price progress?” she said. “People for the most part have better standards of living but their health standards are going the other way.”

Parents need to play a major role in reversing these unhealthy trends, she said. They should teach their kids to be active, drive them around less, make sure they get enough sleep and limit the time spent on computers and other electronic gadgets, Venditti said.

Semler noted that younger people often want a quick fix, whereas making lifestyle changes, such as adopting a healthy diet or exercise regimen, takes a long-term commitment. “They have a microwave mentality, whereas making lifestyle changes is more like using a Crock-Pot: It requires planning and time.”

But the changes required go beyond an individual’s choices, the researchers pointed out.

Kramer said, “We also need to think through things like urban planning, realizing that when people are building a community, sidewalks are important.”

The role of government may need to be expanded, as well, Kramer maintained. “I think taxing soda is fine. I don’t think it’s socialism, I think it’s public health,” she said. “We have mandatory vaccinations. You might need government intervention to make physical activity and weight loss priorities.”

Kriska recalled Lady Bird Johnson’s 1960s Keep America Beautiful campaign against littering. “Now there’s a fine for littering, so it had a policy effect,” she said.

Like Linda Siminerio, Venditti is optimistic that attitudes are changing. “I feel like there’s movement now in ways there hadn’t been 10 years ago or even five years ago. It’s because the problem is big enough. Kids are getting sick enough, employers are angry, insurers are freaking out because employers are in a frenzy over premiums. So it’s come to a head.”

Kriska said she has worked for years in research trials attempting to verify the benefits of activity and weight loss.

“You’re at risk. You do the DPP and at the end it’s not just that it works, it’s that it works better than the meds,” Kriska said.

“This is the first time in the United States we prevented a disease with lifestyle changes. We also believe the DPP was shown to be cost-effective. There are a lot more benefits to a moderate diet and moderate activity than just preventing diabetes: lessening stroke and heart disease. So you’re getting a bigger bang for the buck. It just makes sense to expand it across the country and even globally.”

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