YES!!!! The cost of DM in the US in 2007 was $174 billion, an - PDF document

5/28/2010 Jennifer Janetski, MS RD CDE Is there a need for Diabetes Prevention? � 2007 obesity prevalence ≥ 25% in 30 states � World’s fifth leading cause of death in 2000. and ≥ 20% in 49 states � Diabetes Care, 2005 � Risk is 27% for a wt. increase of ≥ 5 kg Risk is 27% for a wt. increase of ≥ 5 kg � 24.1 million Americans have diabetes and it � 1 kg increase in wt=risk of diabetes is projected to double by 2050. increased by 4.5% � 57 million Americans have pre diabetes � Practical Diabetology, 2009 � Reviews in Cardiovascular Medicine, 2009 YES!!!! � The cost of DM in the US in 2007 was $174 billion, an increase from $23 billion in 1969. � For every 1 kg decreases in weight, risk of diabetes is � Forecasted expenditure for diabetes in 2010, lowered by 16% approach 2020 estimates of $192 billion. � Half of all direct medical costs in the United Half of all direct medical costs in the United States were from inpatient care of DM complications. � The indirect costs from obesity were $47.6 billion in 1995, comparable to the economic costs of cigarette smoking. � Gend Medicine, 2009 1

5/28/2010 WHAT IS PREDIABETES? � Increased risk for diabetes Patients with Pre diabetes should be referred to an effective ongoing support � IFG (Impaired Fasting Glucose) and (IGT) Impaired Glucose Tolerance p program for weight loss of 5 ‐ 10% of body g f g f 5 f y � IFG=Fasting Plasma Glucose of 100 ‐ 125 mg/dl weight and an increase in physical activity � IGT=2 hr OGTT values of 140 ‐ 199 mg/dl of at least 150 min/week of moderate � Dyslipidemia with high TG and/or low HDL, activity such as walking. abdominal obesity and HTN ADA position statement � A1C of 5.7 ‐ 6.4% � ADA clinical practice recommendations Mean Weight Change: Diabetes Prevention Program (DPP) � Diabetes Prevention Program (DPP) 1 0 � Goals=weight loss of 7% and 150 minutes of Placebo -1 Metformin walking/week -2 (kg) � Achieved a 58% risk reduction in progression -3 Lifestyle Lifestyle to diabetes after 2.8 years Weight Change -4 � Cardiometabolic syndrome was reduced by -5 41% -6 -7 -8 0 6 12 18 24 30 36 42 48 Months in Study Diabetes Prevention Program Research Group. N Engl J Med 2002; 346: 393-403. I ncidence of Type 2 Diabetes: Diabetes I ncidence of Type 2 Diabetes: Diabetes Prevention Program ( DPP) Prevention Program ( DPP) p< 0 .0 0 1 for com parison betw een each group p< 0 .0 0 1 for com parison betw een each group 40 40 ncidence of ncidence of Placebo Placebo � Finnish Diabetes Prevention Study 30 30 Metform in Metform in � After 3.2 years, 58% risk reduction in ( – – 3 1 % ) 3 1 % ) progression to diabetes 20 20 I ntensive I ntensive Cumulative in Cumulative in diabetes (% ) diabetes (% ) lifestyle lifestyle m odification m odification 10 10 ( – – 5 8 % ) 5 8 % ) 0 0 1 1 2 2 3 3 4 4 Years from randomization Years from randomization Diabetes Prevention Program Research Group. N Engl J Med 2002; 346: 393-403. 2

5/28/2010 DPPOS : The Bottom Line N=2766 …. “Compared with the placebo group, the incidence of diabetes mellitus in the 10 years since the initial DPP randomization was reduced by 34% in the lifestyle group and 18% in the metformin group. … 8% i th tf i Lifestyle ….With such an approach, we can no doubt RX N= achieve healthier communities across the globe DPP DPPOS and do so at less cost than it takes to care for those who develop overt diabetes mellitus.” Years since Randomization Robertson Nature 2010 Lancet 2009 � Given a one month � Cost: $100.00 ‐ $200.00 Marketing membership to the � 10% discount if paid first Summit (Health club) day � Pre diabetes patients ‐ database � One hour exercise � Hospital employees – email, employee mailings � Payment arrangements appt. made, if needed � Community – ads placed in local paper � Supervised exercise p � Physician offices – stuffed mail boxes, mailed or hand � Self pay/patient turned twice/week for that delivered fliers to offices into insurance month � If chose to join after � Instructors: RD/CDE the first month, and Exercise registration fee was Physiologist waived 3

5/28/2010 Week 1 � Initial Month � Follow ups � Measurements taken: Weight, BP, Waist/hip, body fat � 4 classes � Monthly for 11 months � Ice breaker � 1 hr 30 min RD/CDE � 45 min RD/15 min EP � Taught definition and diagnosis of pre diabetes � 30 min Exercised i E i d � Reviewed the DPP, expectations/contract Physioligist (EP) � Introduced to the concept of self monitoring � Given a weight goal – 7% � Session 1 and 2 in Lifestyle Balance � www.bsc.gwu.edu/dpp/manuals.htmlvdoc � Exercise Week 2 � Weigh in � Fat gram goal – 25% � Session 3 in LB � Gi � Given Fat counter F t t � Heart Healthy education � Destination Heart Healthy Eating, Bell Institute � Medications used to prevent � Exercise ‐ Pedometers Week 3 � Weigh in � Healthy eating/Food Guide Pyramid � Session 6 in LB � Given a calorie goal and taught calorie counting g g g � Session 7 in LB � Self Monitoring of Blood Glucose � Donated meters � Given goals for pre diabetes: � <100 Fasting, � <140 2 hours pp � Exercise 4

5/28/2010 FAT GRAM AND CALORIE GOALS Week 4 � Weigh in Weight Fat goal Calorie goal � Taught carbohydrate counting and given goals 120 ‐ 174 lb. 33 grams* 1200 kcal � 3 ‐ 4 choices/meal for women 175 ‐ 219 lb. 42 grams* g 1500 kcal � 4 ‐ 5 for men 220 ‐ 249 lb. 50 grams* 1800 kcal � My Food Plan from IDC > 250 55 grams* 2000 kcal � Reviewed fiber recommendations and how to increase * =25% of calories from fat � General Mills Fiber HO � Geared participants for the next 11 months � Exercise Living on the Edge of One year Diabetes � 37% remained in the program � Average wt. loss was 19.83 lbs/person � Waist circ. decreased 2.79” and hip 3.42”. � 3% decrease in body fat on avg/person � Diastolic BP decreased 27.5mmHg and systolic 13 mmHg on avg Montana CVD and DM Pr evention Pr ogr am L ocations � November 2008 – $25,000 grant from MDPHHS � Marketed to employees, current database of pre diabetes patients, physicians via practice meetings, office and mailboxes and community via newspaper. � Pre qualification meetings in January, 2009 � Enrolled 42 participants (40 required) E ll d i i ( i d) � $50.00 commitment in the form of a refundable deposit � Participants received a Summit membership for $10.00/month for the 10 month program. Started in 2008 Started in 2009 MONTANA DIABETES PROGRAM 5

5/28/2010 Partic ipatio n Criteria Pro gram E valuatio n Medical Readiness Baseline End of 16 weeks End of 6 months Clearance Assessment Height Overweight 18 years and Weight Weight Weight (BMI ≥ 25kg/m2) older Blood Pressure Blood Pressure Blood Pressure And one or more of the following risk factors for diabetes or Glucose/lab values Glucose/lab values Glucose/lab values cardiovascular disease Diagnosis of High BP IGT of IFG Weekly Pre ‐ diabetes ( ≥ 130/85 or tx) Participant SM data Dyslipidemia or History of GDM Baby >9lbs treatment CORE CLASSES MEASUREMENTS � Began in February, 2009. � Weekly: Wt and BMI � Weekly meetings and weigh ins for 16 weeks � Initial, 4 months and 10 � Followed Core curriculum months: BP, FBG, Total � Food and exercise diaries Chol, LDL, HDL and TG Ch l LDL HDL d TG � Class 1 met on Mondays � Initial and 10 months: 4:30 ‐ 5:30 PM BF%, WC, RMR, HR and � Class 2 met on Tuesdays O2 Sats noon to 1:00 PM � Individual meetings with coaches CORE CLASSES � Exercise sessions at the Summit required � First two months: Twice/week � Second two months: Once/week � All received an individual exercise plan/meeting � Coaches: RD/CDE and exercise physiologist 6

5/28/2010 CORE TOPICS COVERED PROGRAM GOALS � Nutrition � Behavior change � Lose 7% of body weight and maintain � Keeping a food diary � Handling Stress � Exercise at least 150 minutes/week � Reducing fat and � Problem Solving � Keep food and exercise diary calories calories � Preventing relapse � Preventing relapse � Consumed 25% of calories from fat � Healthy Eating � Staying motivated � Prevent diabetes � Exercise � Sustaining for a lifetime AFTER CORE � July 2009 – December 2009 � Monthly meetings with weekly weigh ins � Door prizes � Diaries optional � Individual support available AFTER CORE TOPICS EXERCISE IN AFTER CORE � SMBG � Summit was not required � Preventing CVD � 150 minutes/week or more � Exercise � Individual appointments I di id l i � Mindless Eating were offered with � Holidays Exercise Physiologist � Making time for Health 7