Lifestyle Intervention for Prediabetes Treatment in the Elderly

Using prediabetes definitions, the Diabetes Prevention Program (DPP) trial showed that lifestyle intervention could delay or prevent diabetes for those persons experiencing prediabetes. While the primary outcome of the trial was diabetes and not a reduction of cardiovascular risk, cardiovascular risk factors such as high blood pressure and high cholesterol were monitored.  However, a recent study did shed light on the effect of lifestyle intervention on cardiovascular risk for older persons.

Indeed, one of the primary goals of the study was to determine if reversion to normal glucose from prediabetes could reduce cardiovascular risk in older people. The study was done by investigators in Germany. The investigators used results from the KORA S4 study which was a population-based health survey. The age range of the participants in the study was 55 to 74 years of age.

To determine prediabetes, the investigators used the following definitions of prediabetes: For HbA1c, they used a range of 5.7 to 6.4 percent. For oral glucose tolerance tests, the investigators used a range of 140 to 199 mg/dl. The investigators found that by lowering the weight and waist circumference, an older person could increase his or her “probabilities of returning to” normal blood glucose and maintaining normal blood glucose.

The investigators concluded that “in older adults, even moderate weight reduction contributes to reversion from prediabetes to normoglycaemia and to maintaining normoglycaemia." This conclusion supports the results from the original DPP trial. In fact, the results from the trial indicated that lifestyle intervention is, in general, more effective in prediabetes treatment for persons over 60 years of age than for younger persons.

Healthcare providers should consider these results and use the results in consultations with older patients who are diagnosed with prediabetes. The efforts could be beneficial to the patients, and the effort might even improve an organization’s financial position by giving the healthcare organization a strong platform for negotiating contracts with insurers.

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The Mediterranean Diet May Slow the Progression of Chronic Kidney Disease

It is estimated that chronic kidney disease (CKD) is experienced by 15% of the US adult population. The disease is serious and can lead to kidney failure and death. And approximately 90% of those who have CKD don’t even know they have the disease. It has been suggested by some that diet and exercise can be important elements in CKD treatment.

Estimated glomerular filtration rate or eGFR is a frequently used measurement in diagnosing CKD. Lower than normal eGFR measurements often indicate some reduction in kidney function. And one study has shown that the Mediterranean diet and increased physical activity can be effective in slowing the decline of eGFR and, thus, kidney function degradation.

Researchers in the study looked at 6719 overweight or obese subjects. The subjects ranged in age from 55 to 75 years of age. And each subject had metabolic syndrome, which is defined by a set of conditions, happening together, that can increase a person’s risk of heart disease, stroke and type 2 diabetes. The set of conditions typically include “increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels.”

The subjects in the above-mentioned study were randomly assigned to one of two groups. Some subjects were randomized to the group receiving an intensive weight loss intervention consisting of a Mediterranean diet and increase physical activity. And the other subjects were randomized to a group receiving normal care. The primary outcome was the change in eGFR after one year. The study was called the “PREvencion con Dieta MEDiterrianea-PLUS” or PREDIMED-PLUS trial.

At one year, there was a 40% lower degradation in eGFR for the intervention group compared to the group receiving usual care. These results showed that diet and exercise are important in CKD treatment. The researchers concluded that “the PREDIMED-Plus lifestyle intervention approach may preserve renal function and delaying CKD progression and overweight/obese adults.”

So, healthcare providers should consider counseling patients on the benefits of diet and exercise in the treatment of CKD. The providers should give specific advice on the kind of diets and exercise that are conducive to slowing the progression of CKD.

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Laparoscopic Roux-En-Y Gastric Bypass vs Laparoscopic Sleeve Gastrectomy for Weight Loss, Type 2 Diabetes and Comorbidities

More and more U.S. citizens are obese, and many U.S. citizens have been diagnosed with type 2 diabetes. In general, bariatric surgery is used to treat obesity. However, some forms of bariatric surgery can lead to type 2 diabetes remission. Two types of bariatric surgical methods in use for weight loss are laparoscopic roux-en-y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). These two surgical methods are often considered to be treatment options for type 2 diabetes. And while LRYGB may be the most effective treatment for weight loss, a recent study indicates that LSG is as effective as LRYGB for type 2 diabetes treatment.

LRYGB and LSG are similar in some ways: For example, both surgeries "modify the upper gastrointestinal tract anatomy." And this characteristic may make LRYGB and LSG more effective at weight loss and type 2 diabetes management than some other forms of bariatric surgery. However, depending on the disease condition, there are differences in the outcomes associated with the two surgical methods.

The study, mentioned above, showed that both LRYGB and LSG were equally effective in type 2 diabetes remission, obstructive sleep apnoea and quality of life (QoL) improvement. However, LRYGB produced better remission in hypertension, but was associated with a higher complication rate.

Specifically, the researchers concluded that "Although LRYGB induced greater weight loss and better amelioration  of hypertension than LSG, there was no difference in remission of T2DM,  obstructive sleep apnoea, or QoL at 5 years. There were more complications after  LRYGB, but the individual burden for patients with complications was similar  after both operations."

It is also important to remember that there may be contraindications and other potential issues to consider when deciding on the appropriate form of bariatric surgery. The possibility of reintervention should be kept in mind, for example. Indeed, one study demonstrated that "[LSG] has significantly lower risk of reintervention in all categories studied when compared with RYGB at 5-year follow-up."

So, depending on the desired treatment outcome, the healthcare provider and the patient should work together to make the appropriate decision when it comes to bariatric surgery. 

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A Need for a More Restrictive Diabetes Prevention Program Inclusion Criteria

Prediabetes affects approximately 88 million adults in the U.S. And most of these people don’t know they have the condition. So, to some extent, there is a lack of treatment for prediabetes because of a lack of knowledge. Further, the inclusion criteria used to refer individuals to a National Diabetes Prevention Program (National DPP) may need some modification. The current National DPP inclusion criteria may not be restrictive enough to realize the optimum value from the prediabetes treatment.

A recent study, using simulation methods, looked at how placing restrictions in the National DPP inclusion criteria, similar to those used in the DPP trial, may improve the value of the DPP services.

The researchers, performing the study, concluded that the three-year risk of developing type 2 diabetes in the National DPP eligible population ranges from 1% to more than 90%. This means that the National DPP treats individuals who have very little risk of progressing to type 2 diabetes.

The researchers suggested that comparing the original DPP trial inclusion criteria with the National DPP inclusion criteria shows a loosening of National DPP restrictions. For example, in the DPP trial, the criteria did not include HbA1c measurements, whereas the National DPP does. The National DPP also allows participation from individuals starting at 18 years of age, where the DPP trial's starting age was 25. The National DPP allows participation by persons who had gestational diabetes, where the DPP trial did not.

To be included in the DPP trial, an individual had to have "Impaired glucose tolerance (fasting plasma glucose 95-125 mg/dL and 2hr plasma glucose 140-199 mg/dL)" These criteria are more restrictive than the criteria used by the National DPP.

The researchers determined that being more restrictive in the National DPP selection process would be more beneficial. Specifically, the researchers concluded that “Targeting active diabetes prevention to patients at highest risk could improve health outcomes and reduce costs compared to providing the same intervention to a similar number of patients with pre-diabetes without targeted selection."

Primary care organizations, offering Diabetes Prevention Programs, might want to place more restrictions on candidates for DPP programs. This might improve outcomes and lower cost.

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HbA1c May be Superior to FBG in Diagnosing Prediabetes

 FPG (fasting plasma glucose), HbA1c, and the OGTT (oral glucose tolerance test) are used in determining if someone has prediabetes or diabetes. Indeed, all three measures are employed by the National Diabetes Prevention Program (National DPP) to determine eligibility for the National DPP. So, these blood based tests are important, and understanding which one of the three measurements is the most valid in assessing prediabetes and diabetes is a worthwhile undertaking. One recent study has focused on determining the validity of the measurements.

The OGTT is considered by some to be the gold standard for diagnosing diabetes and prediabetes. However, it is not always practical to perform the test, and results are not always reproducible. Therefore, while the OGTT is considered to be more accurate for some high risk patients than the HbA1c test, the HbA1c test is widely used since it is more practical and it is considered to be a valid test. So, determining how the test stacks up against the FPG test is high on the priority list.

In the above mentioned study, 201 patients were looked at. And the investigators concluded that “HbA1c is a more sensitive test compared to FPG in the diagnosis of DM. Prospective studies with broad participation at national and international levels are needed to redefine HbA1c cut-off points for the diagnosis of DM and prediabetes." When this is done, "it will be possible to revise the diagnostic guidelines accordingly.”

While work needs to be done in the area of defining the cut-off points for HbA1c to improve the diagnostic value of the measurement, the above study does seem to indicate that engaging in additional research to define the Hba1c cut-off points is worth the effort.

Healthcare providers should pay attention to this study and other studies related to diabetes and prediabetes measurements. If we can increase the validity of the measurements already in place, this will lead to improved assessment of prediabetes and diabetes. This endeavor will help providers deliver more accurate assessments to patients, enabling patients to take the appropriate actions.

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The Green Mediterranean Diet

During the 1960s, countries such as Italy and Greece followed the diet that has become known as the Mediterranean diet. And people in Mediterranean countries that followed the diet were very healthy compared to Americans who follow common American diets. The Mediterranean diet has been found to improve health and lower premature death. Further, a recent study found that a modified version of the diet, called the green Mediterranean diet, may be healthier.

The Mediterranean diet consists mostly of fruits, vegetables, whole foods, and a moderate amount of meat products, including cheese, poultry and eggs. There is also very infrequent use of red meat, and no use of sugar sweetened beverages or processed foods.

The green Mediterranean diet is not substantially different from the original Mediterranean diet. It essentially replaces the red meat with plant protein, and reduces the amount of all animal protein. A person replaces the animal protein with things like quinoa, soy milk and other sources of protein.

In the study mentioned above, participants were assigned to three groups. One of the groups was the healthy diet guidance (HDG) group; another group was the Mediterranean diet group, and the other group was the green Mediterranean diet group. In the study, all three of the diets were combined with physical activity. After six months, participants in the Mediterranean and the green Mediterranean diet groups had similar weight loss.

However, participants in the green Mediterranean group had greater improvement in the cholesterol, diastolic blood pressure, insulin resistance, and other metabolic parameters. The researchers concluded that “the green MED diet, supplemented with walnuts, green tea and Mankai and lower [helpings of meat and poultry] may amplify the beneficial cardio metabolic effects of Mediterranean diet.”

It appears that while the Mediterranean diet is a very healthy diet, the green Mediterranean diet, which is more plant-based with increased intake of plants that are heavy in protein, may be even healthier. Healthcare providers should consider the green Mediterranean diet when counseling patients.

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Superiority of Lifestyle Intervention for Weight Loss in a Group Setting

The CDC’s National Diabetes Prevention Program (DPP) uses group sessions to deliver the prevention program. The primary goal of the group sessions is weight loss. The desired outcome is delaying or preventing diabetes. The National DPP is based on the diabetes prevention study in which the coaches met one-on-one with each study participant. The results were that intensive lifestyle intervention, focusing on weight loss, lowered the risk of diabetes by 58%.

However, researchers felt that the program was not sustainable, because the cost to deliver the program was too high. So, the program was modified so that it could be delivered in a group setting, which is how the current National DPP is delivered. But some may still question the group delivery approach.

The original Diabetes Prevention Program study ended in 2001. And for several years after the end of the study, translational research was done to determine if the original DPP study's one-on-one lifestyle intervention could be effective in a group setting. One of the translational investigations was done by researchers at the Indiana University School of Medicine.

The researchers concluded that using weight loss as the goal in lifestyle intervention could indeed be effective in a group setting. Participants in the lifestyle intervention group lost 6% of their weight compared to 2% for the participants in the control group.

And a more recent study has, again, demonstrated the effectiveness of lifestyle intervention in a group setting. In fact, the researchers suggested that group lifestyle intervention is actually superior to one-on-one delivery for weight loss. According to the researchers, “Group multi-component lifestyle interventions are superior for weight loss compared to one-to-one interventions with respect to adult weight management.”

So, providers should consider group settings for weight loss and weight maintenance. The providers should also consider group settings for other chronic disease treatments. The actions could increase patient health. 

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