Why Are We Still Failing to Prevent Diabetes?

Intuitively, it makes sense: Healthy living prevents disease. The Diabetes Prevention Program (DPP) provided the evidence in 2002. If patients at risk for developing diabetes make lifestyle changes, they can decrease their chance of progressing to diabetes by 58%.¹ As I was reading yet another report on the benefits of lifestyle interventions,² I experienced a wave of déjà vu: Hadn't I been here before?

The post-DPP excitement is reminiscent of reactions following the release of the Diabetes Control and Complications Trial (DCCT) findings in 1993, which showed that intensified therapy and blood glucose control prevent complications of the disease.³ Instinctively, we already knew that keeping glucose in tight control prevented complications, and the DCCT provided the science to back up our efforts. We were eager and ready to charge ahead.

Sadly, despite all the follow-up reports and promises, more than a decade later we still have not translated adequately the DCCT message from the ivory towers to our communities, resulting in enormous human and economic costs.

Although widespread implementation of the DCCT is lacking, we have begun to recognize the value of the team approach and the important roles of each team member. Prior to the DCCT, nurses' and dietitians' responsibilities largely were limited to skills demonstrations to teach patients how to administer an injection or test their blood.

We have since come to appreciate the essential roles of nurses and dietitians in providing intensified therapy through the DCCT,^4,5 in which they effectively provide counseling and management, adjust insulin doses, help troubleshoot problems, and develop strategies to support patients' efforts in achieving their glucose goals.

It didn't take rocket science to see that interactions with nurses and dietitians make a difference. Post-DCCT, nurses, dietitians, pharmacists, and psychologists finally gained their long-awaited and well-deserved respect and recognition from the diabetes community. Yet it took more than 10 years to establish mechanisms to obtain reimbursement for their education services, and we still have not developed delivery systems that provide education in the primary care setting, where 90% of diabetes patients are managed.

As the authors in the latest prevention report point out, physicians have limited time and expertise in educating patients about healthy lifestyles.² Physicians report inadequate support for the increased time and effort required for treating diabetes patients, and neither clinics nor patients can afford what is required for comprehensive care.

If this is the case in the care for those already diagnosed, one can only imagine the challenge in treating the patient who is at risk. It takes more than a 10-minute office visit to convince and motivate someone to make lifestyle changes when he or she does not have a defined diagnosis. It also takes time and skill to teach people good nutrition and to engage them in physical activity.

Dietitians and nurses, however, have the opportunity, training, and skills to provide these services, and they can do it at a substantially lower cost. Educators who provide diabetes self-management training in programs recognized by the American Diabetes Association (ADA) are required to substantiate their education on nutrition, physical activity principles, and behavior-change strategies.^4,5 Nurses and dietitians in these education programs already report receiving referrals from physicians to provide nutrition and physical-activity counseling to patients with pre-diabetes and metabolic syndrome. Unfortunately, most of our health care systems do not reimburse for these services, and patients at highest risk for diabetes also risk being ignored.

It is a sorry state of affairs when expensive interventions are reimbursed, while a visit with a dietitian at a nominal cost is not a covered benefit. One usually has to wait for a patient to develop diabetes or renal disease in order to justify reimbursement for a visit, although it is refreshing that some insurers are taking the lead and paying for lifestyle interventions.

After attending both the ADA and American Association of Diabetes Educators (AADE) annual meetings, it is apparent to me that educators are willing to expand their responsibilities to include lifestyle interventions for primary prevention of the disease. In fact, the AADE has added prevention efforts to its mission statement. Yet the reality is that reimbursement barriers preclude diabetes educators from actually providing preventive care. It is time we begin advocacy efforts to support reimbursement of these services.

We have an obesity epidemic that is causing the incidence of diabetes to skyrocket.² Employing inexpensive and proven strategies for prevention is critical. Health care systems must investigate innovative methods that support physicians and patients with other diabetes-care disciplines. And reimbursement for those services is vital. These professionals can no longer afford to provide their services free of charge. Health system stakeholders must continue to establish and evaluate programs and policies that will sustain the preventive-care process.

The DPP demonstrated the benefits of moderate weight loss and physical activity in 2002.¹ Let's not allow these findings to sit on a shelf. Forty-one million Americans with pre-diabetes need our attention. If we don't act now, we can expect a replay of the inadequate response to the DCCT message of a decade ago. When are we going to learn? ▪