Experts

Leadership Perspective: Prediabetes Tsunami — We Can’t Just Wait For It to Hit

Editor’s Note: This post is part of the “Leadership Perspectives” series on the Center for Total Health blog —  a collection of guest blog posts from Kaiser Permanente leaders all about why we need to take a Total Health approach.

Today’s guest author is Trina Histon, PhD, senior principal consultant with the Kaiser Permanente Care Management Institute, who shares her thoughts on prediabetes.

 

Few would deny the burden diabetes places on those who suffer from it and their loved ones who support them as they manage this disease. Estimates suggest that Americans with diabetes spend about $6,000 out of pocket per year managing their disease, monies that could be put to other use if we had more comprehensive ways implemented nationwide to prevent diabetes.

Trina Histon, PhD
Trina Histon, PhD

Many liken the next wave of diabetes as a tsunami that will hit the United States and its citizens, so let’s play that analogy through. Recent weather patterns have shown how devastating tsunamis are in the world, so much so, that efforts have been put in place to create sophisticated warning systems. So should another tsunami strike, countries will have advance warning so they are able to evacuate low-lying coastal areas and get people to safety.

In the U.S., the screening equivalent of that warning system for diabetes is an a1C test and the ADA has established a range of 5.7-6.4 as placing the individual in the “prediabetes” range. There are other tests, such as fasting blood sugar, but more and more health care is moving away from fasting blood work as it’s hard for people to fast for long periods of time. So this a1C range is our early warning system, and like most systems, it’s not perfect. In the literature this year, a few articles that discuss diabetes care and BMI have called into question the value of addressing prediabetes. These critiques are valid and perform an important function in both advancing the science and dialogue of where we want to spend our precious health care dollars.

Preparing for a Disaster We Know is on the Horizon

Kaiser Permanente today has 600,000 members with diabetes. We have also developed a cohort of just under one million members with lab values in the prediabetes range. Rather than wait for perfect science on exactly who needs an intervention, we feel ethically that if someone has a risk we should inform them and partner with them to address that risk, should they choose. One of the complexities of determining prediabetes risk is the prediabetes range has varying origins. For example, an a1C of 5.8 does not necessarily mean you will convert to diabetes, but you are at higher risk, and clearly are showing early signs of beta cell damage. What we do see is those with an a1C of 6.0 and higher and with BMIs in the obese range are most likely to convert. We are looking at our own data to see how we can further subtype the prediabetes risk spectrum and then subtype the interventions.

The Powerful Effect of Lifestyle Changes

The good news is lifestyle is the first line of treatment. The original diabetes prevention program (DPP) and subsequent translation trials show that those who lost 5 to 7 percent of their weight and increased their activity to 150 minutes/week prevented or delayed diabetes in 58 percent of participants over a three-year period – and 52 percent over 10 years. For most people, that translates to a 12- to 15-pound reduction, more attainable than the 30-40 percent of weight people might like to lose as reported on consumer surveys.

What Does Environmentally Sustainable Health Care Look Like?

It’s all you’ve ever wanted to know about the greening of health care!  In our earlier post, we told you about the recent publication of the book, Greening Health Care, by Kaiser Permanente’s Kathy Gerwig.  Today, we begin a series of excerpts from the book — and we start with an introduction and overview from the preface.

The very nature of health care is changing. Health care reform, clinical innovations, electronic medical records, social connectivity, technological advances, baby boomers’ expectations about quality of life, demands for price to align with value, and ways the environment contributes to disease are some of the factors behind the changes. These changes offer profound, new opportunities to address environmental issues across the health care sector and beyond.image

In this changing landscape, what does environmentally sustainable health care look like? Let’s take an imaginary visit to a hospital for a routine doctor visit. Approaching the medical facility, the first thing we notice is that the building is smaller than we expected. There is a convenient transit stop at the front entrance. And the parking lot pavement allows rainwater to filter through to be cleaned and returned to the aquifer. We notice that instead of lawns there are native plantings that minimize water and pesticide use.

There is a garden path that takes us by a stream that was brought back to life from where it was hidden in a concrete culvert decades ago. We enjoy the birds that have rediscovered this tranquil place. You notice a labyrinth and take a meditative respite.

Once inside, we’re walking on nonvinyl, nonpolluting material on the carpets and floors, and we notice how much natural light floods into the lobby and hallways from specially designed window glass, shades, and blinds that allow sunlight in while minimizing afternoon heat. The walls are painted in soothing colors and patterns that mimic the adjoining landscape. The energy efficient lighting fixtures glow with a pleasing hue. You see a plaque on the wall indicating that the building is carbon-neutral.

In the bathroom, the toilets and sinks are water-conserving, and the soap does not contain harmful anti-bacterial agents. The paper towels are made from 100 percent recycled, post- consumer waste, and the used towels go into a compost container. In the waiting room, the fabric on the chairs was selected to avoid harmful chemicals that can cause adverse health effects.

In the exam room, your temperature and blood pressure are taken with mercury-free devices. You notice the purple exam gloves used by the clinical staff. These are latex-safe for worker and patient safety, and they are environmentally preferable.

If you are here for a biopsy, your doctor will use a rigid endoscope (for minimally invasive surgery) which is steam sterilized to avoid the use of chemicals that are hazardous to the environment and to staff.

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