CDC-supported programs seek to halt prediabetes through coaching

Michael Dansinger

According to the CDC, 86 million U.S. adults, or more than 33%, currently have prediabetes. An even more alarming statistic is the number of those who are unaware of their condition: 90%.

“I call this a national epidemic of prediabetes,” Michael Dansinger, MD, medical director of patient wellness at Boston Heart Diagnostics and founding director of the Diabetes Reversal Program at Tufts Medical Center, told Endocrine Today. “There are more people with prediabetes than with diabetes. People who have prediabetes just don’t know it unless they’ve had a blood test looking for it. People with prediabetes don’t feel pain in their sick pancreas or their arteries. There are no symptoms.”

Although prediabetes is a mounting health concern in the United States, steps can be taken to stop the condition from progressing to diabetes.
his goal of reaching patients at the prediabetes stage, and equipping them with the tools to modify unhealthy habits, was what prompted Dansinger and colleagues to create the Boston Heart Diagnostics’ Personalized Diabetes Prevention Program. The CDC-supported program offers patients an effective step-by-step approach to decrease their risk for developing type 2 diabetes.

“We know that when people are trying to prevent type 2 diabetes, taking the extra weight off and keeping it off is critical, but it’s hard to do,” Dansinger said. “We have two special approaches to helping people stick to it.”

Dansinger spoke to Endocrine Today about the prevalence of prediabetes, the need for prevention programs, and the unique ways Boston Heart’s program addresses diabetes prevention.

What can be done to better identify people with prediabetes ?

Dansinger : There are two things. No. 1 is that people who are at risk for diabetes should be aware that they probably have prediabetes until proven otherwise. For example, if you’re older than 60 years, and you’re carrying extra weight, you should just assume that you have prediabetes until proven otherwise. No. 2 is that health care providers should be aware of the same thing, that most of their patients older than 50 years with extra weight probably have prediabetes or type 2 diabetes. People who are even younger might have prediabetes because there is a family history of type 2 diabetes or other risk factors, but carrying extra weight is by far the main risk factor. That’s the good news and the bad news: Body weight is something that can be decreased through the right strategy. Of course, it’s never easy to take weight off and keep it off, but people don’t have to lose all their excess weight. If they can lose between 5% and 10% of their body weight — 15 lb, for example — that can make all the difference between having prediabetes or not or going on to develop type 2 diabetes.

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How was the Personalized D iabetes Prevention P rogram developed?

Dansinger: First, we needed research studies to demonstrate just how well weight loss and coaching would work. The Diabetes Prevention Program (DPP) research study, which was published in 2002, proved that people with prediabetes could reduce their risk for progressing to type 2 diabetes by 58%, which astounded everyone. It was a nearly 60% reduced risk if you could participate in the lifestyle program, which focused on healthy eating, exercise and weight loss. People who were able to keep off 10 lb or 15 lb had dramatic results.

Similar results were found in Europe, which meant that throughout the world, in countries with high diabetes rates, there is a lot we can do about it. The U.S. Congress asked the CDC to sponsor the DPP, to ensure that physicians, health care systems and companies like Boston Heart Diagnostics get on board in this national effort to prevent or delay type 2 diabetes. When we learned that this program was available, we joined this national effort. It’s almost patriotic to participate as a provider, or as a patient or clinician, because when you show you can prevent diabetes, you’re affecting more than just the individual participant. You’re leading the way and contributing to the national proof that we can take back our health as a country, one individual at a time.

What does Boston Heart ’s program offer patients in terms of support and guidance?

Dansinger: We are part of a national effort where different versions of the DPP are being used, but our approach is unique in a couple of ways. No. 1 is that we have advantages in terms of helping people stick to the plan. We have a unique approach to “personalization.” We use specialized blood testing to uncover the abnormalities that could be missed by routine blood testing. We combine that with an understanding of patients’ relevant medical conditions: high blood pressure, heart disease, family history of diabetes and other conditions. Then we combine that with their food preferences to pinpoint the eating strategy in a scientifically based, scientifically designed prescription that we call the life plan. We figure out for each patient the optimum amount of carbohydrates, fats, saturated fats, protein, fiber, cholesterol, salt and several other factors, and we truly personalize a life plan based on their food preferences. No two life plans are the same, because no two people are the same.
measure not only how much good cholesterol a patient has, but we can also determine the amount and types of different variations of the good cholesterol. We can look at the types of bad cholesterol and a number of other important markers. In patients with high cholesterol, we can determine whether it’s coming from their liver or from their intestinal tract. We can gear the eating strategy to the person based on that information.

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So, rather than just giving general, one-size-fits-all advice to everyone, we can look at the specific blood test abnormalities and be much more precise. We believe, and our internal studies show, that providing the life plan gives better health improvements according to their blood tests.

How do you encourage patients to adhere to the program?

Dansinger: That is another important factor. Just because you give someone a personalized plan, that in itself doesn’t produce results. What really matters is when the patient forms a relationship with a coach, and we have coaching that is special. If patients have only a vague or loose relationship with a coach, the accountability and structure are not the same as when they identify closely with a coach. All of our coaches are registered dietitians trained in the methods recommended by the CDC. We have coaches throughout the country who are familiar with different regions. We have a Spanish-speaking coach. We have a broad diversity, so patients can choose a coach who is a good fit for them from a menu of coaches.

Most importantly, patients need to feel like that coach is part of their life. When they know that the coach can see what they’re eating from their food log, they know that every day when they’re eating, their coach is watching them. That’s when magic happens. Food logging and coaching together can result in better than a 58% reduction in prediabetes. I’m not satisfied with a 58% reduction — I want 80% or more, and that’s what I expect to see in my clinical practice.

We provide one-on-one coaching over the telephone, and I like that approach because there’s no hiding behind the anonymity of a group. I do think groups have certain advantages, but for clinically meaningful results, there’s no substitute for one-on-one interaction. It provides a level of accountability that is necessary. It’s never easy to be as strict as you want to be, or to exercise when you don’t feel like it. When you work with a coach on a weekly or biweekly basis, you can set specific goals that are right for you. The ideal goal is one that is ambitious enough to get good results, but not so ambitious that it’s unrealistic. Some of the goals are things that are directly in the patient’s control, such as strictness in eating and how much they exercise. Some of the goals are results of those behaviors, like specific weight-loss goals or improvements in blood glucose levels. If the patient doesn’t have the right attitude and make the right choices, they’re not set up to get results. Everyone has a reserve of strength that they’re trying to tap. Our coaches are experts at bringing that out.

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How are goals determined?

Dansinger: When a patient and a coach have their first conversation, they’re starting to get to know each other and building rapport, and it’s good for the coach to listen to the patient and understand what the patient wants. Then, together, they set a goal. For example, they might decide that in the next 2 weeks, they will focus on food logging and will review the patient’s progress at the next meeting. There are short-term week-by-week goals, but the coach and patient also establish larger goals, like “during the first 6 months in this program, we want to see 2 lb of weight loss per week,” or we want to reduce HbA1c from 6.4% to 6% at the next blood testing. Those larger goals are important, but the patient will never meet those larger goals unless they are making the progress week by week. That’s where coaching makes all the difference.

How many programs like yours have been adopted at other institutions across the country?

Dansinger: We got in early, but this is going to be a growing movement across the United States. I’m not sure exactly how many of these programs exist, but I think every state will have a handful of them. We’re expecting that there will be more and more each month. We see it as a team effort; we’re not competing with other programs. We’re confident our program will continue to stand out, but I would love to see other medical centers and other entities provide those kinds of services. I’d love to see it build month by month, and increase 10-fold.

I would like to add that Boston Heart just had more than 40,000 people participate in our Lifestyle program, which is focused on cardiovascular health. Not all of these patients have prediabetes, but a good number of them do. We have a peer-reviewed paper in press, demonstrating that people with prediabetes can achieve remission. People who participate in the Lifestyle program have less likelihood of progressing to diabetes, especially if they have coaching. What we’re doing now is adding the CDC component, including the information modules, which make it part of a national effort. But we’re not just speculating that this kind of program is going to work — we have data to back it up. – by Jennifer Byrne

Reference:

Diabetes Prevention Program Research Group. N Engl J Med. 2002;doi:10.1056/NEJMoa012512.

For more information:

Michael L. Dansinger, MD, can be reached at 175 Crossing Road, Framingham, MA 01702.

Disclosure: Dansinger is an employee of Boston Heart Diagnostics.