Saturday, December 21, 2019

Prediabetes Plus Other Conditions as Risk Factors for Other Chronic Conditions

Because prediabetes is a risk factor for type 2 diabetes, the condition is gaining in importance in healthcare. Prediabetes is an abnormally high blood glucose condition, but not high enough to be called diabetes. And this abnormally high glucose state, along with other disorders, can raise the risk for other diseases. In fact, when a person has prediabetes, plus overweight, obesity, or central obesity, the risk for cardiovascular diseases and other morbidities can be heightened. Therefore, gaining more insight into ailments that can combine with prediabetes to increase the risk for diabetes and other morbidities becomes extremely important.

The CDC offers a program called the National Diabetes Prevention Program or NDPP. And Medicare offers the Medicare DPP, which is built on the NDPP. In both programs, individuals must have a BMI greater than or equal to 25 (greater than or equal to 23 for Asians) as part of the eligibility requirements, again, because excess body fat increases the risk for type 2 diabetes.

One study has shown that for men, having prediabetes plus a high BMI and belly fat can raise the risk of cardiovascular (CV) disease. The investigators concluded that “Among men with prediabetes, both BMI and waist circumference should be included when evaluating the risks of major CV events and mortality. Measurement of adiposity constitutes a simple and cost-effective strategy to identify those at high-risk population in prediabetes.”

Another study has shown that the hormone, cortisol, can be an important marker for a person with prediabetes. Cortisol is called the stress hormone, because the level of cortisol typically rises in our body during stressful situations. And this rise can lead to glucose elevation in our blood stream. While more glucose in our blood stream can be helpful in stressful situations -- giving us focus and energy -- too much glucose in the blood stream, for too long, can be harmful. Since a high level of cortisol can lead to an increase in glucose in the blood stream, being able to evaluate the cortisol in our body could be helpful.
And in the above referenced study, it was found that the cortisol in the saliva for persons who are prediabetic is not as high as the cortisol in the saliva for people with type 2 diabetes. So looking at the cortisol level in saliva for persons with prediabetes, and taking actions to lower the cortisol, like lowering the stress, may one day be helpful in delaying or preventing type 2 diabetes.

At any rate, evaluating a person for prediabetes is beneficial. And healthcare providers should make a point of including prediabetes considerations in patient evaluations. Further, the providers should include, risk-increasing conditions in the  evaluations. These inclusions may help prevent or delay type 2 diabetes and other chronic conditions.
 

Friday, December 20, 2019

The Combination Drug Phentermine-Topiramate May be Useful in Treating Childhood Obesity

The weight loss drug, Qsymia, is one of the five anti-obesity drugs approved by the Federal Drug Administration or the FDA for long term use. The other drugs given FDA approval are Xenical, Saxenda, Contrave and Belviq. Qsymia was developed by a company based in California called Vivus. The anti-obesity drug gained FDA approval in 2012. Qsymia is a combination of two other drugs. They are phentermine and topiramate.
The combination-drug is approved for adults with a BMI greater than or equal to 30, or for adults with a BMI greater than or equal to 27, when the adults have at least one comorbidity such as high blood pressure type 2 diabetes or high cholesterol. However, at least one study indicates that the combination of phentermine and topiramate may be appropriate for the treatment of childhood obesity.

The study was a multicenter randomized control study consisting of obese adolescents 12 to 17 years of age. For the study, 42 adolescents were randomly assigned to a placebo group and two other phentermine-topiramate groups. One of the phentermine-topiramate groups was given a low dose of the phentermine-topiramate combination. The dose was 7.5 mg of phentermine and 46 mg of topiramate. The other phentermine-topiramate group was given 15 mg of phentermine and 92 mg of topiramate for the combination dose.

The investigators concluded that: "Treatment of adolescents with obesity using a fixed-dose combination of phentermine/topiramate for 8 weeks resulted in exposure to [phentermine and topiramate] that was comparable to that observed in adults, statistically significant weight loss, and a tolerable safety profile. These data indicate that both mid- and top-doses  are appropriate for longer term safety and efficacy studies in adolescents.”

Since obesity is a problem for children as well as adults, perhaps some consideration should be given to making the combination drug, phentermine-topiramate, available for adolescent use. The drug could only add to the arsenal of tools that are now being used to fight childhood obesity.
 

Friday, November 29, 2019

The Potential Positive Impact of Lifestyle Coaches

Lifestyle coaches are an essential part of the CDC’s Diabetes Prevention Program (DPP). And while the CDC places an emphasis on getting community organizations to offer the DPP, the program can also be implemented in a primary care setting. Since lifestyle coaches facilitate the DPP in the setting, lifestyle coaches become part of the setting. And in one study, researchers in the Netherlands found that lifestyle coaches can be quite useful in a health care setting.

The DPP is a CDC program that was put in place to prevent or delay type 2 diabetes via weight loss, physical activity, a  healthy diet, and lifestyle modification. The program is a year-long program. The first six months consist of sixteen core sessions, where a lifestyle coach facilitates group learning. Through group interaction, the participants learn to eat healthy, engage in physical activity, reduce stress, and change behavior to improve health. And the last six months of the year-long program consist of at least six core maintenance sessions where topics from the first six months are reinforced.

In the above mentioned Netherlands study, the investigators set out to evaluate the implementation of lifestyle coaches in a health care setting. The investigators called the lifestyle coaches program  “coaching on lifestyle” or CooL. The investigators indicated that "Lifestyle coaches play a crucial role in ensuring the impact of CooL by actively networking, using clear communication materials and creating stakeholders’ support and understanding."

But the investigators also concluded that “the dissemination process of CooL still needs to be improved further." And that "It will take time before the lifestyle coaches have become accepted as valuable professionals who bridge the gap between the public health sector and health care settings.”

The CDC is trying to bridge the gap between the public health sector and health care settings in the U.S. with its DPP. The CDC quality-assures organization in the DPP via its recognition program. And primary care organizations are advised to send their patients to DPP recognized organizations in a health care setting or in a community setting.  Hopefully, the CDC will succeed at bridging the gap between the public health sector and healthcare settings in the U.S. This could improve health and lower health care cost.

Tuesday, November 19, 2019

Adapting the Diabetes Prevention Program Protocol to Intensive Behavioral Treatment

In 2011, Medicare started covering intensive behavioral therapy for the treatment of obesity. The treatment was part of Medicare’s preventive services. Therefore, an obese Medicare beneficiary would not have to pay for the treatment – no copay, no coinsurance and no deductible. As part of Medicare’s guidelines for delivering the Intensive Behavioral Treatment (IBT) services, it was recommended that providers use the 5 As counseling framework. However, Medicare recommended no specific protocol for the framework. So, the CDC’s Diabetes Prevention Program (DPP) protocol has been recommended for the IBT framework.

Medicare based its IBT coverage on the United States Preventive Services Task Force (USPSTF) evaluation. The USPSTF is an independent organization that evaluates preventive services, and rates the services with a letter grade of A, B, C, D of I. And the USPSTF gave IBT treatment service a grade of B. Specifically, “The USPSTF… found fair to good evidence that high intensity counseling combined with behavioral interventions in obese adults (as defined by a BMI ≥30 kg/m2) “produces modest, sustained weight loss.”

And the IBT should be consistent with the 5 As counseling framework. While there are variations of the 5 As framework, the framework shown on Medicare’s website may be summarized as follows: Acting within the framework, the provider should: Ask about and Assess a patient’s health risks; 2. Advise the patient; 3. Agree or collaborate with the patient; 4. Assist the patient in making healthy changes; and 5. Arrange to work with the patient in the future in support of the patient healthy activities.

The Diabetes Prevention Program, or DPP, is a patient-centered, value-based, evidence-based protocol. The DPP protocol consists of a one-year set of group sessions where a lifestyle coach delivers the sessions. The coach acts as a facilitator. The participants learn to follow a healthy eating pattern, increase physical activity, and modify behavior. The most important outcome is weight loss, since weight loss can lead to preventing or delaying type 2 diabetes in individuals with prediabetes.

Because weight loss is the most important outcome for both the DPP, and the IBT, using the DPP protocol within the IBT framework is a good approach. 

Monday, October 28, 2019

Body Fat Percentage May Be Better in Identifying Prediabetes and Diabetes

Obesity is viewed as a “major risk factor for the development of prediabetes and type 2 diabetes.” Body mass index or BMI is probably the most frequently used measurement of obesity. However, BMI is also viewed as an imperfect measurement of excess body fat. Based on BMI, an individual may appear to have a normal weight -- a BMI < 25 -- but actually have a body fat percentage (BF%) that raises the individual’s risk for prediabetes and type 2 diabetes.

Therefore, accurate measurements of BF% are sought. One of the more accurate methods may be the air-displacement plethysmography, or ADP. Further, it appears that ADP for BF% may be better at identifying those with a high risk of prediabetes and diabetes.

Air-displacement plethysmography (ADP) is defined as “A technique for measuring body composition (body volume and percentage of body fat) that relies on the relative volume and pressure of gas displaced by the body when it is placed inside a plethysmograph.” A plethysmograph is “a device for measuring and recording changes in the volume of the body or of a body part or organ.”

One study looked at a total of 4,828 participants to determine the effectiveness of ADP in measuring body fat percentage for the diagnosis of diabetes and prediabetes. Three groups were created using BMI classifications for normal weight, overweight and obesity. These groups were described as follows: 587 lean participants, 1,320 overweight participants, and 2,921 obese participants.

The investigators concluded that there was “a higher than expected number of subjects with prediabetes or type 2 diabetes” in the lean and obese groups, using BF% cutoff points, than what would be expected using BMI cutoff points. The most often used cutoff points for BF% are as follows: overweight men, 20.1-24.9%; overweight women, 30.1-34.9%; obese men, >= 25% and obese women, >= 35%.

At any rate, BF% does a better job of identifying subjects with a high risk of prediabetes or type 2 diabetes than BMI.

Wednesday, October 23, 2019

The Metabolically Healthy Obese and Diabetes

Past research has shown that there are obese people who are metabolically healthy. And while the idea that one can be obese and healthy is counterintuitive, apparently, these people exist. They are referred to as metabolically healthy obese or MHO. Although MHOs do exist, there are reasons to believe that the healthy state may not be long-lasting. And recent research has shown that metabolically healthy obese individuals have a higher risk of diabetes compared to normal weight individuals.

One scientist at the Jean Mayer USDA Human Nutrition Research Center on Aging suggested that MHOs may be healthier than one might expect because they have a healthier level of inflammation. And that this healthier level of inflammation may actually protect the MHOs from disease. This is an interesting conclusion, since one of the problems with excess body fat is inflammation. Inflammation appears to play a role in insulin resistance which can lead to type 2 diabetes.

The connection between excess body fat and diabetes was highlighted in a recent study done in China. The investigators looked at the connection between MHOs and diabetes incidence in middle-aged and elderly people. They were also interested in knowing whether or not nonalcoholic fatty liver disease (NAFLD) played a role in that Association.

The investigators looked at over 17,000 individuals who did not have diabetes at the beginning of the study. The investigators defined metabolically healthy individuals as those with a BMI of 28 and zero or one of four metabolic comorbidities. These comorbidities were high blood pressure, increased triglycerides, hyperglycemia and low-cholesterol. The healthy MHOs were compared to metabolically healthy normal weight persons.

The investigators concluded that the MHO condition “was associated with increased incidence of diabetes in a middle-aged and elderly population, and the association did not differ by the presence or absence of NAFLD.” And in another study, researchers concluded that the MHO state is relatively unstable.

So, while some obese individuals may be healthy, in general, the healthy state may not last as long as a person of normal weight. The excess, harmful body fat may be detrimental in the long run.

Wednesday, September 25, 2019

Primary Care Organizations Are Not Paying Enough Attention to Prediabetes

Having prediabetes puts a person at a high risk for type 2 diabetes. Type 2 diabetes can lead to kidney problems, heart problems, strokes and other comorbidities. Thus, both healthcare and community organizations are offering programs to combat prediabetes so that type 2 diabetes may be delayed or prevented. However, primary care organizations need to play a bigger role in prediabetes treatment. And currently, these organizations are not participating as much as they could in the treatment.

One study concludes “that few patients with undiagnosed prediabetes are even told that they are at high risk for diabetes.” Further, the study indicates “that diabetes prevention requires improved patient-centered care, which likely begins with the delivery of adequate information to patients.” There are reasons, however, why primary care organizations are reluctant to give a diagnosis and treatment for prediabetes. There is, at most, vague agreement on what prediabetes is, and some don’t think it is really a disease. And some feel that since there are other health conditions that are known to be serious, it is not a good idea to overburden the patient with more to worry about.

There are other reasons why primary care organizations are not participating in prediabetes treatment. A recent study suggested that providers may not be aware of how effective interventions are in reducing the risk of diabetes. And there may be a “lack of access to providers of dietary and exercise advice.”

At any rate, the study concluded: “most patients with confirmed prediabetes do not receive appropriate care.” And “that the approach of primary care toward prediabetes needs to change if we are to effectively prevent diabetes.”

More attention should be given to the diagnosis and treatment of prediabetes in order to prevent or delay type 2 diabetes. And the Centers for Disease Control and Prevention’s Diabetes Prevention Program (DPP), or National DPP, is a good place to start. 

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