Evidence-Based Approaches to Diabetes Prevention

An estimated one-third of Americans have prediabetes, a condition that puts someone at high risk for developing type 2 diabetes. It is characterized by blood glucose levels that are above normal, but not high enough to qualify as diabetes. People with prediabetes have no significant symptoms.

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An estimated one-third of Americans have prediabetes, a condition that puts someone at high risk for developing type 2 diabetes. It is characterized by blood glucose levels that are above normal, but not high enough to qualify as diabetes. People with prediabetes have no significant symptoms.

Prediabetes Sounds like a Dubious Diagnosis. Why Should I Care?

There are two major reasons benefit managers should care about the burden of prediabetes in their covered population.

  1. Prediabetes itself can lead to hypertension, heart disease and stroke.

    In addition to being a precursor to type 2 diabetes, people with prediabetes also have an increased likelihood of developing heart disease, hypertension and stroke. Therefore, although there are no symptoms related to prediabetes, it is best to avoid it.
  2. This population is on the verge of developing diabetes, a condition that is bad for health and costly to treat. People with type 1 and type 2 diabetes rack up an estimated $7,900 in medical expenses per year due to their condition and related complications, and their expenditures are 2.3 times higher than if they did not have diabetes.2 Workers with diabetes miss an average of two days more per year than their colleagues without this condition, require more time to heal after surgeries and are 5% to 6% more likely to have workplace limitations than coworkers without diabetes.3 About 15% to 30% of people with prediabetes develop diabetes, so it is in an employer’s best interest to target this population to help them avoid progressing to full-blown diabetes.

What is Prediabetes?

Individuals are diagnosed with prediabetes if their fasting blood glucose level is between 100mg/dL and 125mg/dL or their HbA1C is between 5.7 and 6.4. Numbers above those ranges generally result in a diagnosis of diabetes. Prediabetes itself doesn’t generally cause symptoms the way diabetes does, but it does mean that individuals are more likely to develop the disease if they don’t make significant lifestyle changes. The Centers for Disease Control and Prevention (CDC) estimate that 15%-30% of people with prediabetes will progress to diabetes within five years.

Some people have criticized the term prediabetes because it “medicalizes” an asymptomatic state that approximately one-third of Americans have. While over-diagnosis is a concern, identifying people with prediabetes and engaging them in better health practices are good ways to promote health and support interventions that are largely lifestyle-focused and relatively inexpensive.

Risk Factors for Developing Prediabetes

There are several modifiable and non-modifiable risk factors for developing prediabetes, including:

  • High body mass index (BMI) and waist size;
  • Sedentary and inactive lifestyle;
  • Smoking;
  • Over 45 years of age;
  • History of cardiovascular disease; and
  • History of gestational diabetes.

As people grow older, they’re more likely to develop prediabetes. Family history of diabetes is another risk factor. Unfortunately, there are no evidence-based treatments to address these facts of life over which we have no control.

What’s the Difference Between a Diabetes and Prediabetes Strategy?

Many of the medical interventions and workplace solutions for encouraging healthy behaviors will be the same for people with diabetes and prediabetes. Employer strategies for prediabetes differ largely in that they focus on screening for prediabetes (see below) and increasing awareness about the need for healthy behaviors among a population that may not think they need to make such changes. There are also a few evidence-based programs addressing prediabetes that employers should promote, like the National Diabetes Prevention Program (NDPP).

Preventing and Treating Prediabete

The most effective strategies for reversing prediabetes are dietary counseling for healthy eating, physical activity, weight loss, adequate sleep, smoking cessation and stress reduction. Where appropriate, these lifestyle changes can be supplemented with prescription medications that help keep blood sugar levels in check. Individuals with prediabetes generally need to lose 5%-10% of their body weight to prevent progression to type 2 diabetes.5

Spreading the Word in the Workplace and with Spouses/Partners

Employers can use ongoing communication campaigns to encourage employees and their dependents to educate themselves about prediabetes. Part of that process could be asking their doctor if they might be at risk and encouraging their spouses/partners to do the same. The American Diabetes Association, the American Medical Association and the CDC teamed up to create a website called doihaveprediabetes.org. It features an interactive test to assess risk of prediabetes and several printable materials available to the public to spread the word.

Screening and Education

Ninety percent of people with prediabetes don’t know they have it.6 The U.S. Preventive Services Task Force (USPSTF) recommends screening for prediabetes and type 2 diabetes every three years, or more often for people with risk factors like a family history of diabetes.7 Given that prediabetes is asymptomatic, screening and education are necessary to reversing its effects. Employers can encourage screening most directly by providing incentives to complete wellness exams that include blood work with their doctors. Online wellness assessments used in conjunction with biometric screenings can help refer participants with prediabetes to educational information at the work site and through third-party programs.

Comprehensive Lifestyle Strategies

There are several lifestyle changes that will help prevent progression from prediabetes to full-on diabetes. By making these changes, it is even possible to reverse prediabetes completely. Addressing any one lifestyle change, like changing to a lower fat or sodium diet or engaging in more physical activity, can help reduce blood sugar levels, but a comprehensive approach is most likely to succeed in reversing prediabetes and preventing diabetes. Below are examples of comprehensive programs that, when implemented in partnership with employers, have been successful.

National Diabetes Prevention Program (NDPP)

The NDPP is a year-long program operated by a partnership of public and private organizations that seeks to reverse prediabetes and prevent diabetes. The program organizes a team based on the needs of individuals with prediabetes to improve their eating habits, and level of physical activity in order to reduce their weight and blood sugar levels. Members of the team typically include the YMCA, health care providers, patients’ families, peer support groups and lifestyle coaches. Many commercial insurers have begun reimbursing providers, including health coaches and community practitioners (e.g. YMCA), for delivering NDPP services; Medicare will do the same beginning in January, 2018.8

People who complete the program have experienced positive results. Research funded by the National Institutes of Health (NIH) has shown that the NDPP can cut their risk of developing type 2 diabetes by 58%.9 Remarkably, even 10 years after completing this program, participants are one-third less likely to develop diabetes than their peers who did not complete such a program.10 Medicare estimated a savings of $2,650 for each enrollee in NDPP over the first five quarters of pilot implementation.11

Digital Platforms Gaining Interest

Some employers are offering new digital platforms that have incorporated elements of the NDPP to help employees and their dependents reverse prediabetes. These digital platforms can increase patient engagement and be covered outside the medical benefit. Examples include:

Omada Health uses a wireless scale and mobile app to send personalized reminders about healthy

eating and physical activity. It also connects people to providers, health coaches and community resources that deliver the NDPP program.

Kurbo Health uses a digital platform to help children with prediabetes avoid progression to diabetes. While the program is focused on children, parents of those children engaging with the program often benefit, too. By modeling the targeted behaviors, the adults lose weight and improve their blood sugar levels.

The Business Group doesn’t endorse particular vendors. When making decisions about third-party vendors, employers should assess them for adherence to evidence-based protocols.

Prescription Medications

Metformin is an inexpensive medicine used to treat prediabetes, type 2 diabetes and gestational diabetes. Drug treatment isn’t necessary for prediabetes, but it can be an effective way to control blood sugar when used alongside healthy eating and increased physical activity. It shouldn’t replace comprehensive lifestyle changes; 2016 clinical guidelines from the American Diabetes Association recommend using metformin in conjunction with increased activity, smoking cessation and healthier eating to reverse prediabetes and prevent diabetes in high-risk individuals (e.g., those who are morbidly obese.)12

Employer Recommendations

  1. Identify areas in your population where the prevalence of prediabetes is highest. 

    Employers should work with their health plans to determine the burden of prediabetes across their population and identify locations where targeted communication may be most effective in reaching employees in need of company resources. For example, the burden of prediabetes is the highest in the southern part of the U.S. Additionally, people of some ethnicities are at increased risk (e.g., African-Americans, Native Americans, and Latinos.) Employers can use this information to target communications effectively.

  2. Provide incentives for employees and dependents to receive screening for prediabetes.

    Identifying prediabetes requires a hemoglobin A1c, fasting glucose level or oral glucose tolerance test. The USPSTF recommends that adults aged 40 to 70 years old who are overweight or obese be screened every three years. People with a family history of diabetes should be screened more often.6 Offering incentives (e.g., health account contributions, raffles, gift cards, company swag) to employees as a reward for completing an annual checkup will increase the number who know they have prediabetes.

  3. Provide regular communications to employees about the risk of prediabetes and how they can address this condition before it progresses to diabetes.

    Third-party vendors should leverage employees’ well-being data to target proactive, personalized communications to employees with prediabetes. These communications should connect employees and their dependents to resources that can help them address their condition and avoid diabetes. If an employer does not have access to comprehensive well-being data, it can work with its health plan to target communications to populations that are most at risk for prediabetes, including older people, those who live in the South and industrial Midwest, African Americans, Native Americans and Latinos.13

  4. Provide coverage for NDPP through either the well-being program or through the medical benefit, with little or no cost sharing.

    NDPP is the most effective long-term approach to reversing prediabetes, in part because it is comprehensive in the way it encourages healthy behaviors. The NDPP does not use piecemeal strategies that address only one risk factor for prediabetes, but rather addresses multiple risk factors simultaneously. Employers should consider providing coverage for NDPP under the medical benefit or as an element of their well-being program. As a preventive service, this benefit can be covered with no cost sharing for patients, even if they are in health savings account (HSA)-eligible plans. Employers should only pay claims to practitioners or organizations that are recognized by the Centers for Disease Control and Prevention (CDC) Diabetes Prevention Program17. Employers will need to work with their health plans to adjudicate claims to eligible providers, and the plans can help identify opportunities to communicate and integrate NDPP resources into other health program offerings. Alternatively, some employers have implemented their own diabetes prevention programs at the work site that incorporate elements of NDPP but use their health and wellness centers.14

  5. Consider partnering with vendors that use digital platforms to deliver evidence-based supports to people with prediabetes.

    Employers should consider partnering with vendors that promote health behaviors to reverse prediabetes through digital platforms. These are relatively new solutions, but some employers have seen positive results in partnership with vendors that promote evidence-based approaches predicated on NDPP.15,16 Employers implementing solutions should continually monitor program effectiveness; for instance, any vendor should report on rates of engagement among target populations and impact on blood sugar levels. For programs that have shown high levels of engagement and clinical effectiveness, consider reducing cost barriers to program participation for eligible participants with prediabetes. See the adjacent text box for tips on how to assess whether a vendor is evidence-based.

  6. Consider covering metformin as a preventive medication at zero cost sharing for people with prediabetes

    Metformin is a relatively inexpensive drug, but eliminating financial barriers to accessing it may increase the likelihood that people fill their prescriptions and are adherent to the medication. Several large employers have used this strategy, and it complies with rules limiting pre-deductible coverage in HSA-eligible plans. Communication campaigns focused on prediabetes should note that drugs are not necessary for treatment and should only be used in conjunction with lifestyle changes for high-risk individuals.

Assessing Evidence-Based Vendors

There are dozens of vendors that help employers address the health behaviors of their population. Naturally, some vendors’ approaches are better rooted in evidence for what truly creates behavior change and positive results. When considering a vendor partnership, employers should assess key criteria for whether a vendor follows evidence-based principles. These criteria include:

  • Adherence to evidence-based protocols with regular clinical review;
  • Ability to share data across vendor platforms; and
  • A strong customer service record for patients and employer clients.

Conclusion

The burden of diabetes across the U.S. is significant and growing, but for many people it can be prevented. Employers can and should partner with on-site fitness center providers, health plans, community providers and others to screen for prediabetes and deliver programs to help keep individuals from progressing to diabetes. This is an effective mid- and long-term strategy to improve health and control costs for employer plans.

  • 1 | The Ad Council. So… do I have prediabetes? https://doihaveprediabetes.org/index.html. Accessed February 1, 2017.
  • 2 | American Diabetes Association. The cost of diabetes. https://www.diabetes.org/resources/statistics/cost-diabetes. Accessed February 1, 2017.
  • 3 | Tunceli K, et al. The impact of diabetes on employment and work productivity. Diabetes Care. 2005;28(11):26622667
  • 4 | Mayo Clinic. Prediabetes symptoms and causes. https://www.mayoclinic.org/diseases-conditions/prediabetes/symptoms-causes/syc-20355278. Accessed February 1, 2017.
  • 5 | Winters C. Got prediabetes? What to do now. Consumer Reports. 2015. https://www.consumerreports.org/blood-glucose-meters/got-prediabetes-what-to-do-now/. Accessed March 1, 2017.
  • 6 | American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2012;35(1): S11-S6
  • 7 | Laiteerapong N, Cifu A. Screening for prediabetes and type 2 diabetes mellitus. Journal of the American Medical Association. 2016;315(7):697-698.
  • 8 | Centers for Medicare and Medicaid. Medicare diabetes prevention program (MDPP) expanded model. https://innovation.cms.gov/innovation-models/medicare-diabetes-prevention-program. Accessed February 1, 2017.
  • 9 | U.S. Department of Health & Human Services. Diabetes prevention program. National Diabetes Information Clearinghouse. https://www.niddk.nih.gov/-/media/Files/Research-Areas/DPP_508.pdf. Accessed February 1, 2017.
  • 10 | Diabetes Prevention Program Coordinating Center. 10-year follow-up of diabetes incidence and weight loss in diabetes prevention program outcomes study. George Washington University Biostatistics Center.
  • 11 | Centers for Medicare & Medicaid Services. Diabetes prevention program independent evaluation report summary. https://www.cms.gov/newsroom/fact-sheets/diabetes-prevention-program-independent-evaluation-report-summary. Accessed February 1, 2017.
  • 12 | Cefalu W, et al. Standards of medical care in diabetes – 2016. American Diabetes Association. Page 44. https://care.diabetesjournals.org/content/suppl/2015/12/21/39.Supplement_1.DC2/2016-Standards-of-Care.pdf. Accessed February 1, 2017.
  • 13 | Menke A, Casagrande S, and Geiss L. Prevalence of and trends in diabetes among adults in the United States, 1988-2012. Journal of the American Medical Association. 2015;314(10):1021-1029
  • 14 | Burton W, et al. A worksite occupational health clinic-based diabetes mellitus management program. Population Health Management. 2015 Dec;18(6):429-36.
  • 15 | Omada Health. Success stories, Costco. https://www.omadahealth.com/donna-sexton. Accessed February 1, 2017.
  • 16 | Omada Health. Success stories, Costco. https://www.omadahealth.com/donna-sexton. Accessed February 1, 2017.
  • 17 | Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/prevention/pdf/dprp-standards.pdf

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