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

5/28/2010 1

Jennifer Janetski, MS RD CDE

Is there a need for Diabetes Prevention?

World’s fifth leading cause of death in 2000.

Diabetes Care, 2005

24.1 million Americans have diabetes and it is projected to double by 2050. 57 million Americans have pre diabetes

Reviews in Cardiovascular Medicine, 2009

2007 obesity prevalence ≥ 25% in 30 states and ≥ 20% in 49 states Risk is 27% for a wt. increase of ≥ 5 kg Risk is 27% for a wt. increase of ≥ 5 kg 1 kg increase in wt=risk of diabetes increased by 4.5%

Practical Diabetology, 2009

The cost of DM in the US in 2007 was $174 billion, an increase from $23 billion in 1969. Forecasted expenditure for diabetes in 2010, 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

YES!!!!

For every 1 kg decreases in weight, risk of diabetes is lowered by 16%

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WHAT IS PREDIABETES?

Increased risk for diabetes

IFG (Impaired Fasting Glucose) and (IGT)

Impaired Glucose Tolerance

IFG=Fasting Plasma Glucose of 100‐125 mg/dl IGT=2 hr OGTT values of 140‐199 mg/dl Dyslipidemia with high TG and/or low HDL,

abdominal obesity and HTN

A1C of 5.7‐6.4%

ADA clinical practice recommendations

Patients with Pre diabetes should be referred to an effective ongoing support program for weight loss of 5‐10% of body p g f g f 5 f y weight and an increase in physical activity

• f at least 150 min/week of moderate

activity such as walking.

ADA position statement

Diabetes Prevention Program (DPP)

Goals=weight loss of 7% and 150 minutes of

walking/week

Achieved a 58% risk reduction in progression

to diabetes after 2.8 years

Cardiometabolic syndrome was reduced by

41%

1

• 1
• 3
• 2

Mean Weight Change: Diabetes Prevention Program (DPP)

(kg) Placebo Metformin Lifestyle

• 5
• 7
• 8
• 6
• 4

Weight Change Months in Study Lifestyle

6 12 18 24 30 36 42 48

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)

ncidence of ncidence of

20 20 30 30 40 40 I ntensive I ntensive Metform in Metform in ( – – 3 1 % ) 3 1 % ) Placebo Placebo p< 0 .0 0 1 for com parison betw een each group p< 0 .0 0 1 for com parison betw een each group

Cumulative in Cumulative in diabetes (% ) diabetes (% )

10 10

Years from randomization Years from randomization

1 1 2 2 3 3 4 4 lifestyle lifestyle m odification m odification ( – – 5 8 % ) 5 8 % )

Diabetes Prevention Program Research Group. N Engl J Med 2002; 346: 393-403.

Finnish Diabetes Prevention Study

After 3.2 years, 58% risk reduction in

progression to diabetes

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N=2766 N= DPP DPPOS Years since Randomization Lancet 2009 Lifestyle RX

…. “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 8% i th tf i

DPPOS : The Bottom Line

18% in the metformin group. … ….With such an approach, we can no doubt achieve healthier communities across the globe and do so at less cost than it takes to care for those who develop overt diabetes mellitus.”

Robertson Nature 2010

Cost: $100.00‐$200.00 10% discount if paid first day Payment arrangements made, if needed Given a one month membership to the Summit (Health club) One hour exercise appt. Supervised exercise Self pay/patient turned into insurance Instructors: RD/CDE and Exercise Physiologist p twice/week for that month If chose to join after the first month, registration fee was waived

Marketing

Pre diabetes patients ‐ database Hospital employees – email, employee mailings Community – ads placed in local paper Physician offices – stuffed mail boxes, mailed or hand delivered fliers to offices

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Follow ups

Monthly for 11 months 45 min RD/15 min EP

Initial Month

4 classes 1 hr 30 min RD/CDE

i E i d

30 min Exercised

Physioligist (EP)

Week 1

Measurements taken: Weight, BP, Waist/hip, body fat Ice breaker Taught definition and diagnosis of pre diabetes Reviewed the DPP, expectations/contract 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 F t t Given Fat counter 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

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FAT GRAM AND CALORIE GOALS

Weight Fat goal Calorie goal 120‐174 lb. 33 grams* 1200 kcal 175‐219 lb. 42 grams* 1500 kcal g 220‐249 lb. 50 grams* 1800 kcal > 250 55 grams* 2000 kcal

* =25% of calories from fat

Week 4

Weigh in Taught carbohydrate counting and given goals

3‐4 choices/meal for women 4‐5 for men My Food Plan from IDC

Reviewed fiber recommendations and how to increase

General Mills Fiber HO

Geared participants for the next 11 months Exercise

One year

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

Living on the Edge of Diabetes

November 2008 – $25,000 grant from MDPHHS Marketed to employees, current database of pre diabetes patients, physicians via practice meetings,

• ffice and mailboxes and community via newspaper.

Pre qualification meetings in January, 2009 E ll d i i ( i d) Enrolled 42 participants (40 required) $50.00 commitment in the form of a refundable deposit Participants received a Summit membership for $10.00/month for the 10 month program.

Montana CVD and DM Pr evention Pr

• gr

am L

• cations

MONTANA DIABETES PROGRAM Started in 2008 Started in 2009

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Overweight (BMI ≥25kg/m2)

And one or more of the following risk factors for diabetes or cardiovascular disease

Medical Clearance 18 years and

• lder

Partic ipatio n Criteria

Readiness Assessment Diagnosis of Pre‐diabetes History of GDM IGT of IFG Dyslipidemia or treatment High BP (≥130/85 or tx) Baby >9lbs

Pro gram E valuatio n

Baseline Height Weight Blood Pressure Glucose/lab values End of 16 weeks Weight Blood Pressure Glucose/lab values End of 6 months Weight Blood Pressure Glucose/lab values Weekly Participant SM data

MEASUREMENTS

Weekly: Wt and BMI Initial, 4 months and 10 months: BP, FBG, Total Ch l LDL HDL d TG Chol, LDL, HDL and TG Initial and 10 months: BF%, WC, RMR, HR and O2 Sats

CORE CLASSES

Began in February, 2009.

Weekly meetings and weigh ins for 16 weeks Followed Core curriculum Food and exercise diaries Class 1 met on Mondays

4:30‐5:30 PM

Class 2 met on Tuesdays

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

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PROGRAM GOALS

Lose 7% of body weight and maintain Exercise at least 150 minutes/week Keep food and exercise diary Consumed 25% of calories from fat Prevent diabetes

CORE TOPICS COVERED

Nutrition

Keeping a food diary Reducing fat and

calories Behavior change

Handling Stress Problem Solving Preventing relapse

calories

Healthy Eating

Exercise

Sustaining for a lifetime Preventing relapse Staying motivated

AFTER CORE

July 2009 – December 2009 Monthly meetings with weekly weigh ins Door prizes Diaries optional Individual support available

AFTER CORE TOPICS

SMBG Preventing CVD Exercise Mindless Eating Holidays Making time for Health

EXERCISE IN AFTER CORE

Summit was not required 150 minutes/week or more I di id l i Individual appointments were offered with Exercise Physiologist

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RESULTS

93% of KRMC participants completed the core classes 90% completed the after core 90% completed the after core Total wt. loss at 16 weeks = 677 lbs. Total wt. loss at end of 10 months =711.4 lbs Average physical activity minutes 227+/‐ 93

MARV

Initial 10 mos Wt: 223.3 lbs 184.3 lbs

BMI 31.2 BMI 26.4

BF %: 34.4% 22.4% RMR: 1805 kcal 1772 kcal WC: 43.5” 39.5” BP: 138/86 150/60 Heart Rate: 96 82 O2 Sats: 69 97

MARV

Initial lab work

FBG: 124 TG: 255 Chol: 155

10 month lab work

FBG: 78 TG: 85 Chol: 145 Chol: 155 HDL: 38 LDL: 66

Chol: 145

HDL: 50 LDL: 78

MARV

Medications

Crestor 10 mg ASA 81 mg Niacin 500 mg BID

Medications:

Crestor 5mg (cut in

half)

Metoprolol 50 mg

(d d b ) Niacin 500 mg BID

Quinaprin 10mg Metoprolol 100 mg BID Furosemide 20 mg Allopurinol 100 mg

(decreased by 75%)

Furosemide d/c’d All other meds

remained the same

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WEIGHT RESULTS

Currently starting the 12th week of the Core As of 3/30/10:

534.8 lbs lost 12.73 lbs/person on avg 42 participants remain

2010 PROGRAM

January 25, 2010 47 Enrolled $50.00 refundable fee Supervised exercise

Once/week

Summit membership not provided

SUPERVISED EXERCISE

Mondays 4:00‐8:00 PM Tuesdays: 7:00 AM – 3:00 PM Thursdays: 5:00‐8:00 PM Thursdays: 5:00 8:00 PM Saturdays: Aerobics

DIABETES PREVENTION WORKS!!

Partnered with a medical fitness facility The facility donated exercise time Exercise physiologist involved with cardiac rehab Set a break‐even point Marketed the classes in the paper to employees Marketed the classes in the paper, to employees and physicians Met our break‐even point within a few weeks of marketing Catchy name Competitive pricing

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Keys to success

Catchy Name Visibility with administration Visibility with physicians Break‐even point TCOYD Marketing Grateful patients Visibility with insurance board Partnership with the Summit Passionate instructors Money Accountability G p Foundation board presentations Lions club partnership Appropriate screening Volunteer

MAKE IT FUN!!!

http://www.youtube.com/watch?v=IeAJJDRn_H0

FUTURE OF DPP

Reimbursement

Northwest Healthcare State employees covered

A i

Area insurance coverage $350.00‐$400.00 cost/person Portion is the patient’s responsibility

Legislation, Franken‐Luker bill YMCA/ Partnership Washington