Community Health Workers Can Deliver Patient-Centered, Evidence-Based, Value-Based Services

Today, healthcare is striving to practice medicine that is patient-centered, evidence-based, and value-based. What this means is that the patient is to be viewed as the most important person in the room, the providers are to use evidence-based medicine, and the patient gets a lot for his or her money. And it has been shown that community health workers (CHWs) can play an important role in delivering services associated with patient-centered, evidence-based, value-based medicine. A set of these services is related to the Centers for Disease Control and Prevention (CDC) sponsored Diabetes Prevention Program (DPP).

Patient-centered means providing medical care “that is focused on the patient or consumer of health care rather than on health care providers, financiers, insurers, or institutions.” “Evidence based medicine (EBM) is the conscientious, explicit, judicious and reasonable use of modern, best evidence in making decisions about the care of individual patients. EBM integrates clinical experience and patient values with the best available research information.” And value-based medicine is where “providers, including hospitals and physicians, are paid based on patient health outcomes.” One way of looking at value-based medicine is patient-outcomes divided by cost (patient-outcomes/cost).

According to the CDC, “a community health worker (CHW) is a frontline public health worker who is a trusted member or has a particularly good understanding of the community served.” CHWs may work as coaches in some community organizations. These organizations include YMCA’s, churches and other community groups that offer community services. One of the important services is the Diabetes Prevention Program or DPP.

The DPP is based on a study done between 1996 and 2001. In the study, it was concluded that type 2 diabetes can be avoided or delayed in an individual who follows a healthy diet, engages in purposeful physical activity, and changes his or her lifestyle to include healthy activities. After the completion of the study, it was determined that lifestyle CHWs working as coaches could successfully motivate individuals to engage in DPP related activities.

Furthermore, healthcare providers are encouraged to refer patients to DPP organizations that have satisfied DPP standards established by the CDC.

 

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Prediabetes Can Be Effectively Treated in a Primary Care Setting

According to the  Centers for Disease Control and Prevention (CDC), prediabetes is a chronic disease. The disease affects 88% of the adults in the U.S. And having prediabetes raises the risk for a number of diseases, including diabetes, heart disease, stroke, and other conditions. The CDC established the Diabetes Prevention Program (DPP) in 2012 to address prediabetes. The DPP is based on a study, funded by the National Institutes of Diabetes and Digestive and Kidney Disease (NIDDK). The study was done and reported on between 1996 and 2002. The services delivered in the DPP are being delivered in community organizations, including YMCAs and churches. And the DPP services can be delivered in a primary care setting.

A study was done in New Zealand using a nurse-led diabetes prevention program in a primary setting. One hundred fifty-seven patients with prediabetes were enrolled in the six month study. Two groups were formed for the study, where 85 of the participants comprised the intervention group and 72 participants were in the control group. HbA1c, BMI and waist circumference were analyzed, and it was found that these parameters decreased in the intervention group while they increased in the control group.

While the differences in outcomes between the intervention group and the control group were not statistically significant, the study showed that the DPP program can work well in a primary care setting. The program was acceptable to the patients and the nurses.

Another study confirmed the effectiveness of wellness coaching programs addressing prediabetes in a primary care setting. A survey was used to evaluate the experiences of participants in a 12 week prediabetes program in a primary care setting. Sixty-three percent of the participants completed the survey. And the participants were very satisfied with the program.

This means that primary care practices might want to focus on integrating prediabetes treatment procedures into the practices. The integration could reduce the number of patients who eventually experience type 2 diabetes. 

 

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Using Mobile Devices to Treat Prediabetes

Type 2 diabetes is a serious disease in today's society. And the disease is well known. A less well known disease in prediabetes. Prediabetes is a chronic disease that affects 84% of the adults in the U.S. Someone with prediabetes has a higher risk for diabetes heart disease, stroke and other conditions. The  Centers for Disease Control and Prevention (CDC) established the Diabetes Prevention Program (DPP) in 2012 to address prediabetes. The DPP program is based on a study, funded by the National Institutes of Diabetes and Digestive and Kidney Disease (NIDDK). The study was performed and reported on between 1996 and 2002. The services delivered in the DPP can potentially be replicated with the use of mobile devices.

For those with prediabetes, the DPP study demonstrated that lifestyle modification, diet and increased physical activity can reduce the risk of diabetes by 58%. The DPP study was done using highly trained individuals to deliver the one-on-one counseling. These highly trained individuals included registered dietitians, and healthcare workers with master's degrees. These trained individuals worked one-on-one with the DPP participants.

The one-on-one program was subsequently translated into a group based program. Delivering the program in a group-based setting was less costly than the one-on-one program. And delivering the program using mobile devices, such as smart phones, may be a way to make the program even less costly than the group-based program. A mobile-delivered DPP has been looked at in a study.

The study was a "24-week virtual DPP with human coaching through a mobile platform." The investigators concluded that "A fully mobile DPP intervention resulted in significant weight loss and high engagement during the maintenance phase, providing evidence for long-term potential as an alternative to in-person DPP by removing many of the barriers associated with in-person and other forms of virtual DPP."

Healthcare providers might want to take note of the mobile DPP study results. Treating prediabetes is important. And using the most cost efficient delivery method will benefit the patient.

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Lorcaserin, the Anti-Obesity Drug

Over the past several years, four anti-obesity drugs have been approved by the FDA. These drugs are: contrave, which is a combination of bupropion and naltrexone; qsymia, which is a combination of phentermine and topiramate; saxenda, which contains the active ingredient liraglutide that is used to treat type 2 diabetes; and lorcaserin which has the brand name Belviq. In this post, we are going to focus on lorcaserin.

In the past, some weight loss drugs were found to be harmful. Fen-phen was one of those drugs. Phentermine, which is one of the components of qsymia, was also one of the components of fen-phen. Fenfluramine was the other component drug. Fen-phen was taken off the market in the 1990s. While fen-phen was effective for weight loss, the drug was found to cause heart related problems. Fenfluramine was deemed the culprit in the combination, while phentermine was not. So fenfluramine was removed from the market.

To some extent, because of the problems fen-phen caused, all anti-obesity drugs are subjected to intense skepticism and research regarding their potential side effects. However, lorcaserin has been shown to lead to weight loss, while creating no cardiovascular safety issues. Further, the drug has been shown to have positive metabolic effects.

In a one year study of 12,000 overweight and obese subjects, a portion of the participants were randomly assigned to one group that was given a 10 mg dose of lorcaserin per day, while the other participants were assigned to a placebo group. And 38.7% of the participants in the lorcaserin group lost at least 5% of their body weight compared to 17.4% of the placebo group. The cardiovascular events in the lorcaserin group were no higher than the cardiovascular events in the placebo group.

Furthermore, when used in combination with phentermine, lorcaserin can lower food cravings during short-term energy restrictions, as shown in a study consisting of 235 participants during a 12 week treatment session.

Also, lorcaserin has been found to improve metabolic parameters. In one study, it was found that lorcaserin can lower fasting glucose and A1c with or without weight loss. And in another study, investigators concluded that lorcaserin "improved multiple cardio metabolic parameters through both weight loss dependent and independent mechanisms.”

Therefore, lorcaserin should be considered by practitioners when they are treating a patient who is overweight or obese, or who experiences overweight or obesity related metabolic diseases. 

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Confronting Prediabetes

Although not commonly listed as a chronic disease, prediabetes is a chronic disease that carries many risks. It raises the risk of type 2 diabetes, and it raises the risk of stroke and heart attack. According to the CDC, 84% of the adults in America have prediabetes. Further, most people who have prediabetes are not aware that they have the condition. It is estimated that 90% of people who have prediabetes don’t know they have prediabetes. The sooner prediabetes is diagnosed, the faster prediabetes treatment can start. So methods to predict prediabetes and to treat prediabetes can benefit at least 1/3 of the US adult population.

One study done in China indicated that it may be possible to isolate individuals in lean populations who may be at a high risk of prediabetes and diabetes. During a six year period, approximately 800 children and adults were studied who eventually developed prediabetes or diabetes. Seven hundred and thirty seven of the studied subjects were lean at baseline and during the follow-up phase.

The investigators concluded that even if they are lean, individuals whose fasting glucose is in the top tertile of the normal fasting glucose range have a higher risk of prediabetes and diabetes. And this is often overlooked because individuals are not overweight or obese.

Furthermore, when prediabetes is diagnosed in a patient, the condition is typically not addressed by the clinician. In one study, only 22.8% of patients with prediabetes between 2013 and 2015 indicated that they were treated for the disease. Treatment for prediabetes commonly includes lifestyle change. But patients with hyperlipidemia or obesity were more likely to be treated with lifestyle change than those with prediabetes.

Therefore, based on the above studies, physicians and other practitioners should pay more attention to patients who are close to the upper limits of the normal fasting glucose and other glucose measurement guidelines. Further, practitioners should treat prediabetes more aggressively in the future. By taking the appropriate actions, practitioners can do a lot to reduce the number of patients who eventually get type 2 diabetes.

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Insight into Glucose Metabolism May Lead to Personalized Nutrition

Macronutrients in our diet include proteins, carbohydrates and fats. It is often said that calories and not macronutrient combinations are what lead to weight loss. So, if you want to lose weight, you need to lower your calorie intake. And changing the macronutrient combination or content will not lead to weight loss. Indeed, with some qualifications, the above statements are probably true, in general. However, one study has indicated that fasting glucose and fasting insulin concentrations, combined with specific macronutrient compositions, may be good predictors of weight loss. Further, different concentrations can lead to different amounts of weight loss.

The participants in the study were randomized to an ad libitum low carbohydrate diet or low-fat diet where the calorie intake was 1200 hundred to 1800 calories per day. The study lasted 24 months. At the end of the study period, participants who had prediabetes and high fasting insulin lost more weight on the low-fat diet than on the low-carbohydrate diet, while participants who had prediabetes and low fasting insulin lost more weight on the low-carbohydrate diet than on the low-fat diet.  

The investigators concluded that “Fasting plasma glucose and insulin are strong predictors of the weight loss response to diets with different macronutrient composition and might be a useful approach for personalized weight management.”

We think these findings are important. The indications are that by gaining insight into a prediabetic patient's fasting glucose and fasting insulin concentrations, a practitioner can better personalize the patient’s diet.

And if the patient's diet can be personalized in a way that enables the patient to lose weight, the weight loss will likely have other benefits, such as resolving a person’s prediabetes, and lowering the risks for conditions associated with prediabetes. These conditions include type 2 diabetes, stroke and heart problems. Practitioners should attempt to embrace personalized medicine when it can be of use to patients.

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Mouth and Gut Bacteria May Aid in Overweight And Obesity Treatment

Studies done at The Washington University St. Louis Medical School have shown that trillions of bacteria live in our gut. These bacteria perform specific activities such as extracting calories from food we eat and managing nutrients. These bacteria are common to all of us, however, each individual has a unique set of the bacteria.  Studies at Washington University have shown that the composition of the bacteria plays an important role in weight control. A more recent study done at Penn State University is suggesting that mouth bacteria in infants may predict obesity later in life.

The researchers at Washington University studied mice, and concluded that obese mice had more of the bacteria called Firmicutes in their gut, and fewer of  the bacteria called Bacteroidetes.  Firmicutes are associated  with obesity and Bacteroidetes are associated with leanness. These same bacteria were found in the mouths of participants in the Penn State University study. The researchers indicated that an imbalance in these two sets of bacteria could lead to obesity.

The researchers concluded that “the children who had rapid weight gain as infants, which is a strong risk factor for childhood obesity, had fewer groups of bacteria or less diversity in their mouth bacteria. These children also had a higher ratio of Firmicutes to Bacteroidetes, two of the most common bacteria groups of the human microbiota.”
One of the study’s researchers indicated that “There's … a certain balance of these two common bacteria groups, Firmicutes and Bacteroidetes, that tends to work best under normal healthy conditions, and disruptions to that balance could lead to dysregulation in digestion,”

Of course researchers will need to determine the full effect of these two types of bacteria in the creation of fat tissue, and the value of the bacteria in the mouth for predicting obesity. And researchers need to determine what diets lead to the optimal composition of these bacteria. However, gaining knowledge about these bacteria may enable us to better fight, predict, and avoid obesity. 

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