Thursday, October 15, 2020

White Coat Adherence and Glucose Control

 Upcoming visits to a healthcare provider can cause a person to respond in different ways. The response can be involuntary or on purpose. Many patients’ blood pressure will rise or decline as a result of contact with a healthcare provider. This rise or fall in blood pressure is called the white coat syndrome. The change in blood pressure is involuntary. On the other hand, patients may purposely increase their adherence to their healthcare providers’ instructions just before the healthcare visit. This adherence is called white coat adherence (WCA). And WCA can lead to errors in treatment, including diabetes treatment.

WCA may be defined as “an increased adherence to treatment regimens directly before a visit with a healthcare provider.” And when WCA is present while treating diabetes, the situation can negatively affect the diabetes treatment. So, a study was done to determine how to lessen the possibility of a misinterpretation of Glucose Control  Monitoring data that might be caused by WCA.

It is known that up to 50% of patients who have chronic conditions will increase the adherence to medical guidelines just before and just after a healthcare provider visit. Patients will be more likely to take prescribed medications as directed and to follow treatment guidelines as directed two to three days before the visit and two to three days after the visit.

The above-mentioned study was an observational study, consisting of 276 patients. The investigators looked at patients between January 2013 and July 2018 who were using continuous or intermittent scanning glucose monitoring (rtCGM or iscCGM). And the investigators looked at CGM-data over various periods of time before and after a healthcare visit.

The investigators concluded that the WCA effect was especially present during the three days before a healthcare visit. And that a more accurate assessment of the patient’s diabetic condition can be made by looking at GCM-data two weeks before the scheduled healthcare meeting. Specifically, the investigators indicated that “based on [their] findings, analysis of CGM data, particularly in adult patients non-optimal diabetes control, should encompass a period of adequate length (i.e. a minimum of one-two weeks) before consultation to avoid misinterpretation due to WCA.”

The study just confirms the existence of WCA in diabetes treatment. But more than that, it offers guidance that can be put in place to minimize the associated misinterpretations of the CGM results.


Tags: , , , , bariatric medicine, obesity medicine, medical practice start up, bariatric industry analysis, weight loss industry analysis, weight management industry analysis

Thursday, September 24, 2020

Increased Waist Circumference with Weight Loss Can Raise CVD Risks

The Diabetes Prevention Program (DPP) trials is a landmark study that proved that intensive lifestyle intervention (ILI) can delay or prevent type 2 diabetes. Because of the success of the DPP trials, another study called the Look AHEAD  study was carried out. The purpose of the Look AHEAD study was to determine if ILI could reduce "cardiovascular morbidity and mortality in overweight individuals with type 2 diabetes.” A secondary analysis of the study was also done to determine the relationship between cardiovascular disease (CVD), waist circumference (WC) and weight loss.

The Look AHEAD failed to conclusively show that ILI could reduce cardiovascular morbidity and mortality in overweight individuals with type 2 diabetes, however, the study was a useful study. In the secondary analysis, the investigators concluded that even with weight loss, an increase in waist circumstance can cause an increase in CVD risk.

The analysis consisted of 5,490 participants, where four groups were formed. One group consisted of participants that had lost weight and reduced WC, another group that had gained weight and increased WC, a group that had gained weight and reduced WC and a group that had lost weight and increased WC. All changes happened within one year of baseline.

The researchers performing the secondary analysis concluded that "increased WC during the first year of ILI, independent of weight change, was associated with higher risk for subsequent cardiovascular outcomes."

Still, it should be noted that, in general, weight loss via ILI is associated with a lowering of the risk of negative cardiovascular outcomes. Further, in one Look AHEAD follow-on study that used machine-learning methods to analyze the Look AHEAD data, the investigators concluded that 85% of the Look AHEAD subjects did, in fact, experience a significant reduction in cardiovascular events as a result of weight loss.

It is possible to have an increase in CVD risk with weight loss, if there is a rise in WC. And while providers should be aware of the possibility of increased CVD risk with a rise in WC, employing ILI for weight loss is still a prudent approach to possibly lower CVD risks.


Tags: , , , , bariatric medicine, obesity medicine, medical practice start up, bariatric industry analysis, weight loss industry analysis, weight management industry analysis

Tuesday, September 22, 2020

Less Stringent ADA Prediabetes Criteria vs More Stringent Criteria

The CDC’s diabetes prevention program (DPP) treats prediabetes to enable an individual to avoid or delay type 2 diabetes. The general definition of prediabetes is something like the following: prediabetes is where an individual has abnormally high blood glucose, but the blood glucose is not high enough to be called diabetes. The criteria used by the DPP to determine the abnormally high blood glucose is based on the criteria used by the American Diabetes Association (ADA) and the CDC. However, the criteria used by the ADA and the CDC differ from the criteria used by the World Health Organization (WHO), and the National Institute for Health and Care Excellence (NICE).

The prediabetes criteria used by WHO and NICE are more stringent than the prediabetes criteria used by the ADA and the CDC. So a study was done “to evaluate the associations between different definitions of prediabetes and the risk of cardiovascular disease and all cause mortality.”

The ADA uses the following criteria for prediabetes: a fasting plasma glucose (FPG) greater than or equal to 100 mg/dL and less than or equal to 125 mg/dL; an impaired glucose tolerance (IGT) where the glucose is greater than or equal to 140 mg/dL and less than or equal to 200 mg/dL; and hemoglobin A1c greater than or equal to 5.7% and less than or equal to 6.4%.

The WHO uses the following criteria for prediabetes: an FPG greater than or equal to 110 mg/dL and less than or equal to 125 mg/dL; an IGT where the glucose is greater than or equal to 140 mg/dL and less than or equal to 200 mg/dL. NICE uses a hemoglobin A1c of 6.0-6.4% as it's criteria.

The above referenced study took the form of a meta analysis where 53 studies were included. The studies consisted of 1,611,339 subjects. The subjects were looked at for a period of about 9 ½ years. The investigators concluded that individuals who satisfied the less stringent ADA prediabetes criteria experienced an increased risk of “cardiovascular events, coronary heart disease, stroke, and all cause mortality.”

Further, because prediabetes can increase the risk of metabolic problems, investigators suggested that “high risk populations with prediabetes, especially combined with other cardiovascular risk factors, should be selected for controlled trials of pharmacological treatment.”



Friday, August 28, 2020

Reimbursement for the Medicare Diabetes Prevention Program Should be Increased

Based on positive results from the Diabetes Prevention Program (DPP) study carried out between 1996 and 2002, Medicare started offering a version of the Diabetes Prevention Program to Medicare beneficiaries in April 2018. The program is called the Medicare Diabetes Prevention Program (MDPP). However, there are currently very few MDPP providers in the U.S. That means that many Medicare beneficiaries don’t have access to an MDPP. One reason for the limited number of MDPP providers is the cost of delivering the program. The cost is often more than the Medicare reimbursement. MDPP reimbursement should be increased to entice more providers to offer the MDPP.

The DPP study showed that the intensive lifestyle intervention (ILI) employed in the study could lower the risk of type 2 diabetes by 58% for people with prediabetes. But more importantly, the study showed that for persons over 60, the risk reduction was 71%. Because of the DPP study results, CMS carried out its own test.

The CMS investigators concluded that by using the DPP methodology, Medicare could save $278 per participant per quarter of each year. Because of the savings, Medicare started offering the MDPP in April of 2018. However, a study published on June 12, 2020, indicates that MDPP providers are in short supply. For example, In July 2019, it [was] estimated that there was one MDPP “site per 100,000 Medicare beneficiaries nationwide.”

One of the reasons for the lack of MDPP providers is the cost of delivering the program compared to the Medicare reimbursement. For example, in 2019 the maximum reimbursement was $470 per participant for the first MDPP year, while the cost of delivering the program was typically in excess of $500 per participant per year.

So adjustments should be made in the MDPP reimbursement to attract more MDPP suppliers. If adjustments are made in the reimbursement that improve return-on-investment (ROI), providers will see that they can improve the health of their patients while realizing a net income.


Tuesday, August 25, 2020

Counseling for Prediabetes Should be Heightened in Primary Care

Prediabetes is a condition where an individual’s blood glucose is abnormally high, but not high enough to be called type 2 diabetes. But prediabetes raises the risk of type 2 diabetes. Because of the nature of prediabetes, a healthcare provider -- especially one in a primary care setting -- can collaborate with the patient to determine if there is a need to treat the condition. Being over 40 years of age, overweight or obese, for example, can raise the risk of type 2 diabetes in a patient with prediabetes. If the patient is at high risk of getting type 2 diabetes, the provider should counsel the patient or make a referral.

The provider should counsel the patient on ways to make lifestyle changes to treat the prediabetes, or refer the patient to an organization that can provide the counseling. While the referral rate for prediabetes treatment is unknown, counseling for prediabetes in a primary care setting is relatively low. The level of counseling for prediabetes should be increased.

Approximately 88 million adults in the US have prediabetes. And the CDC’s Diabetes Prevention Program study has shown that addressing prediabetes using intensive lifestyle intervention (ILI) can reduce the incidence of type 2 diabetes. Based on the results of the Diabetes Prevention Program  study, the CDC established the Diabetes Prevention Program (DPP) to help individuals treat prediabetes.

Counseling high risk patients with prediabetes or referring the patients to an organization that offers prediabetes counseling is recommended by the US preventive services task force (USPSTF) . However, one study showed that only about 40% of patients with prediabetes were counseled by a healthcare provider to control or lose weight, increase physical activity, or decrease the fat or calories in the diet.

The investigators further stated that “participants who were counseled to adopt healthy lifestyle reported high adherence to weight control and diet modification.” So while ILI, used by the DPP, can reduce type 2 diabetes cases by treating prediabetes, providers often don’t counsel patients who have the condition.

Since patients are more often in a primary care setting than any other healthcare setting, primary care providers can be an important factor in helping to decrease the number of type 2 diabetes cases by counseling patients who have prediabetes.



Tuesday, July 21, 2020

The Benefits of a Plant-Based Diet in Combating Cardiovascular Disease

There is a lot of talk today about plant-based diets, and how they appear to be beneficial in combating many chronic diseases, including obesity, high blood pressure, chronic kidney disease, and cardiovascular disease (CVD). With respect to CVD, people following a plant-based diet may have less heart disease than those following a diet that includes animal products. Even people who have a high genetic risk of CVD can benefit from a plant-based diet.

First of all, what exactly is a plant-based diet? Depending on who you talk to, a plant-based diet can be anything from a semi-vegetarian diet, consisting of very small portions of animal products, to a vegan diet, consisting of absolutely no animal products. At any rate, compared to diets that include animal products, plant-based diets appear to be significantly helpful in the treatment of CVD, and for lowering a person's risk for high blood pressure, diabetes and other unhealthy conditions.

In another study, it was found that “high animal protein intake was positively associated with cardiovascular mortality and high plant protein intake was inversely associated with all-cause and cardiovascular mortality, especially among individuals with at least 1 lifestyle risk factor."

The benefits of a plant-based diet are even evident for those people who have a high genetic CVD risk profile. In a study consisting of 156,148 adult participants, who didn’t have CVD, it was found that adherence to a plant-based diet gradually decreased the risk of CVD even for those who had a high genetic risk of CVD. Indeed, investigators concluded that “adherence to healthy plant-based diets may be associated with a decreased incidence of CVD in the entire population, suggesting that plant-based diet patterns may modify the risk of CVD, regardless of genetic susceptibility.”

Indeed, there are indications that the use of a plant-based diet can improve health, in general, and CVD risk factors in particular. The evidence creates an opportunity for cardiologists and other healthcare providers. Therefore, healthcare providers should learn more about plant-based diets and how to counsel patients on the benefits to be gained from the diet.


Monday, July 20, 2020

The CDC's Diabetes Prevention Program Methods Can Treat Metabolic Syndrome

Approximately a third of Americans have prediabetes. Prediabetes is a condition where an individual has an abnormally high blood glucose that is not high enough to be called type 2 diabetes. And many experts agree that prediabetes is a predictor of type 2 diabetes.  Metabolic syndrome, which is a cluster of potentially unhealthy conditions that happen together, can also be a predictor of type 2 diabetes. It is estimated that about a third of Americans have metabolic syndrome. And just as with prediabetes, the CDC's Diabetes Prevention Program methods can be used to treat metabolic syndrome.

As was stated above, metabolic syndrome is a cluster of potentially unhealthy conditions. The cluster of conditions may typically include any three of the following: excess belly fat, abnormally high blood glucose (but not high enough to be called type 2 diabetes), hypertension, elevated triglyceride or elevated cholesterol levels. One study suggested that “metabolic syndrome was associated with an increased risk of type 2 diabetes.”

The conditions that usually form the metabolic syndrome cluster are, many times, associated with a lack of physical activity, overweight and an unhealthy lifestyle. Therefore, weight-loss related intensive lifestyle intervention (ILI) consisting of heightened physical activity, diet improvement, and behavioral change may be recommended as a treatment for metabolic syndrome.

This lifestyle treatment includes sessions, for participants, that highlight the importance of engaging in at least 150 minutes per week of physical activity, eating a healthy diet that includes whole-grains, vegetables, fruits, healthy protein and losing and maintaining a healthy weight.

The CDC’s Diabetes Prevention Program (DPP) was put in place to address prediabetes in an attempt to delay or prevent type 2 diabetes. The DPP uses the type of lifestyle sessions described above for treating prediabetes. And one report indicates that the DPP ILI sessions can be used to prevent or delay metabolic syndrome.

Metabolic syndrome and prediabetes can be predictors of type 2 diabetes. Therefore, it is incumbent on healthcare providers to pay close attention to metabolic syndrome and prediabetes. It may also be a good idea to learn how to employ the methods used in the CDC's DPP for possible metabolic and prediabetes treatment.


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