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. 

Friday, September 20, 2019

Lifestyle Habits and Alzheimer's Disease

According to the Centers for Disease and Control and Prevention (CDC), the chief causes of chronic diseases are smoking, overuse of alcohol, poor diet, and lack of physical activity. Among the chronic diseases that the CDC lists are heart disease, stroke, cancer, diabetes, obesity and Alzheimer’s disease. And a recent study shows that lifestyle habits can lower the risks of Alzheimer’s disease a greater amount than the researchers had anticipated.

The study was described at the Alzheimer’s Association international conference in Los Angeles. The researchers concluded that if a person employs a healthy diet, engages in physical activity, stops smoking, does not overindulge in alcohol use, and participates in “cognitive stimulation activities,” the individual could lower his or her risk of Alzheimer’s disease by 60%.

The study included 2765 participants who were tracked over a ten-year period. There were two parts of the study: one part was called the Chicago Health and Aging Project (CHAP), and the other was called the Rush Memory and Aging Project (MAP). The study consisted of older adults with an average age of the CHAP participants being 73 years and the average age of the MAP participants being 81 years. The participants were both male and female, who were either black or non-Hispanic whites.

The participants evaluated the behavior of the participants using a scoring method involving healthy habits. The researchers gave the participants a "0" if they did not engage in one of the five above mentioned healthy habits or a "1" if the participants did engage in the one of the healthy habits. And it was concluded that if an individual earned four or five in the rating system, that individual’s risk of Alzheimer’s was lowered by 60% compared to subjects in the study who earned a total score of "0" or "1".

Further, another study presented at the conference indicated that healthy lifestyle choices could even lower the risk of Alzheimer’s for people who are genetically predispositioned for the disease. The investigators concluded that “people with a high genetic risk of Alzheimer’s are less likely to develop the disease if they pursue a healthy lifestyle.”

The above-referenced studies confirm what research continues to show: A healthy lifestyle is one of the best ways to reduce the risk of chronic illnesses. So healthcare providers ought to work to induce patients to embrace healthy living. It could lower our healthcare costs while improving population health.

Thursday, August 29, 2019

Personalizing the Treatment for Patients with Type 2 Diabetes

Personalized medicine is something that's being talked about a lot today. In personalized medicine, a provider customizes a patient's treatment, based on a specific set of characteristics associated with the patient. Customization can be used when it comes to type 2 diabetes. To customize the treatment, the provider should have knowledge of different type 2 diabetes treatment options. For example, for some individuals, focusing on excess body weight may be the best approach in the diabetes treatment. And for others, high intensity interval training (HIIT), as a key tool in the treatment of type 2 diabetes, may make the most sense.

A study done in Japan indicated that when men or women gain weight, there is an increase in type 2 diabetes and prediabetes. And when there is a decrease in weight, there is an associated decrease in type 2 diabetes and prediabetes. The investigators therefore concluded that “the BMI level was likely to contribute to trends in the prevalence of T2DM, and thus the management of obesity may be important to reduce the prevalence of T2DM.”

HIIT “is a training technique in which you give all-out, one hundred percent effort through quick, intense bursts of exercise, followed by short, sometimes active, recovery periods. This type of training gets and keeps your heart rate up and burns more fat in less time.”

And according to one study, for obese persons, HIIT can increase hormones, like ghrelin, that lead to weight gain, and HIIT can decrease hormones, such as GLP-1(Glucagon-like peptide-1), that lead to weight loss .

The investigators concluded that “appetite hormones differ between lean and obesity participants. The finding also suggested HIIT is more likely to elicit appetite hormones responses in obesity than in lean individuals with type 2 diabetes. Therefore, with caution, it is recommended that the high intensity interval training can be beneficial for these patients.”

Therefore, viewing the patient as an individual is worth the effort. If the patient with type 2 diabetes is obese, treat the obesity as well as the diabetes. And consider HIIT for those obese patients with type 2 diabetes who might benefit from the more intense physical activity.

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