by Shared decision-making programs can help patients adjust their lifestyle choices to reach that goal…
Increasing physical activity and losing about 7% of body weight can decrease chances of being diagnosed with type 2 diabetes by 58%, according to nearly two decades of data collected through the Diabetes Prevention Program.
A low-cost medication called Metformin also can reduce diabetes risk by 31% — for the one in three Americans with pre-diabetes.
Yet only a tiny fraction of people actually become more active and lose the weight or take the drug, says Carol Mangione, MD, MSPH, division chief of general internal medicine and health services research at UCLA Health.
There are a number of barriers that prevent studies of these interventions from translating into real lifestyle changes, Dr. Mangione says — from a lack of health insurance to limited knowledge on the part of patients or physicians, along with doctor’s visits that seem to get shorter and shorter.
“One in two people in the U.S. either have type 2 diabetes or pre-diabetes,” Dr. Mangione says. “We haven’t been able to take the efficacy trial and get it into the hands of the people who need it the most.”
People with prediabetes have higher than normal blood sugar. About 70% of these cases develop into diabetes, according to the American Diabetes Association.
Reducing diabetes risk
Dr. Mangione and her team conducted studies looking into the hurdles people with prediabetes face related to proven diabetes prevention practices, such as losing a modest amount of weight (about 7%), walking five days a week for 30 minutes a day or taking Metformin. They found that every 2.2 pounds of weight lost reduced the risk of diabetes diagnosis by 16%.
Incorporating these kinds of lifestyle changes, however, can be challenging.
“Part of the problem, especially in Los Angeles, is safe places to exercise,” says Dr. Mangione, adding that L.A. ranks 71st out of 100 major cities when it comes to park space.
“We’ve known for decades that increased physical activity and healthy diet can prevent and/or decrease the severity of type 2 diabetes, but many neighborhoods lack the resources to support lifestyle changes,” she says. “Across Los Angeles, in our neighborhoods with the highest rates of pre-diabetes, 41 of the 262 neighborhoods have less than an acre of park space per 1,000 people.”
The median park space per 1,000 residents in other high-density U.S. cities is 6.8 acres, according to the Trust for Public Land.
“For years, we sat in the clinical encounter and said, ‘You’ve got to exercise more. You’ve got to get out there and walk,’” Dr. Mangione says. “But we didn’t ask the questions about neighborhood safety or whether there were pleasant and reliable places to actually exercise that were affordable.”
Finding healthy food nearby is another challenge for some Los Angeles residents. The U.S. Department of Agriculture considers South L.A. a “food desert,” Dr. Mangione says.
“The lack of access to fresh food and a drought of supermarkets result in an influx of fast-food restaurants, liquor stores and small convenience stores, making the healthy choice of what to eat the harder choice for those most in need of healthy food in our community,” she says.
Role of shared decision-making
Shared decision-making can help bridge the gap between study findings and lived behaviors, Dr. Mangione says: “Shared decision-making is a purposeful way of educating patients, assessing their values and preferences and helping them make informed decisions.”
Dr. Mangione and her research team studied whether shared decision-making could lead to increased adoption of healthy behaviors in people with pre-diabetes. They talked with patients about their options for diabetes prevention and discussed how they might go about incorporating these new behaviors into their lives.
“Making a choice to do something, if you’d had a shared decision-making session, went up to almost 40%,” Dr. Mangione says, adding that participation among the control group – those without decision-making partners – was about 4%.
People in the shared decision-making group were able to lose about five pounds and keep it off, she says, which is enough to significantly reduce their diabetes risk.
The patients involved in shared decision-making also reported enjoying the sessions: 82% said it improved their understanding of diabetes prevention; 39% said it taught them to do something new; 61% said it helped them make a decision to reduce their personal risk of developing diabetes; and 62% said it helped them take action and manage their own health problems.
“A formal, shared decision-making program led to significantly greater uptake of an intensive lifestyle program grounded in healthy eating, increased physical activity and/or using Metformin, with subsequent weight loss at a level that should prevent diabetes,” Dr. Mangione says.
“Shared decision-making needs to be available for all UCLA Health primary care patients who have pre-diabetes.”
