Latest news with #AnnePeters
Medscape
20-05-2025
- Health
- Medscape
Optimizing Prediabetes Care in Primary Care Settings
Around 98 million US adults — more than 1 in 3 people — have prediabetes. The condition often presents with no symptoms — 80% of people are unaware they have it — yet, it's not to be taken lightly: Untreated over the course of 5 years, many with prediabetes go on to develop type 2 diabetes. 'Cellular changes are already happening in prediabetes,' explained Kevin Miller, DO, board-certified family physician and member of the American Diabetes Association's Primary Care Committee, 'but I often tell patients that they are still in my 'prevention club.' I'm trying to protect the cells from further damage and progression.' Mihail Zilbermint, MD, an associate professor of clinical medicine in the Division of Endocrinology, Diabetes, and Metabolism at Johns Hopkins Medicine, Baltimore, said that 'we need to treat prediabetes as an actual diagnosis — not just a warning sign.' The condition, he said, marks a critical window for primary care physicians to intervene to improve health. There are no US Food and Drug Administration (FDA)–approved medications specifically for prediabetes, and due to systemic barriers, prediabetes can be overlooked. With the right tools and systems in place, however, it can be properly addressed to prevent disease progression and improve health. Early Intervention Matters Anne Peters, MD, director of the University of Southern California Clinical Diabetes Programs, Los Angeles, noted that early intervention with prediabetes is key. The landmark Diabetes Prevention Program (DPP) trial demonstrated that intensive lifestyle interventions — including diet, exercise, and weight loss — reduced type 2 diabetes incidence by 58%. In patients older than 60 years, these interventions lowered disease incidence by 71%. In comparison, metformin therapy reduced type 2 diabetes incidence by 31%. Even delaying diabetes onset by just 4 years is linked with significantly fewer complications, including heart attack and nephropathy. 'It wasn't until the DPP that we really showed that if you have a healthy lifestyle and/or take metformin, we can help you not progress to diabetes,' said Peters. 'In many cases, people would go back to more normal glucose tolerance.' Prediabetes is also independently associated with increased risk for all-cause mortality and both macro- and microvascular disease risk, including cardiovascular disease and chronic kidney disease. 'Microvascular complications really begin long before diabetes is diagnosed,' said Zilbermint. People with prediabetes often have other coexisting health concerns, including hypertension, abnormal cholesterol levels, sleep apnea, or gout — all worth treating, said Peters. Barriers in Primary Care Intervention Research suggested primary care physicians recognize the importance of highlighting prediabetes but face many systemic barriers, including time limitations, low reimbursement for preventive health counseling, a lack of FDA-approved drugs specifically targeting prediabetes, and more. 'My heart goes out to the primary care physicians; we know they don't have enough time to address all the problems,' said Zilbermint. Peters added that patient adherence to lifestyle interventions has always been difficult. 'It's hard to get patients motivated to adopt healthy habits, and until the recent advent of the GLP-1 [glucagon-like peptide 1] receptor agonists, it's been hard to get people to lose weight.' Yet even in constrained clinical environments, small interventions — such as timely screening, structured referrals, and judicious pharmacotherapy — can translate into long-term reductions in morbidity. Implement Screening and Make a Clear Diagnosis The US Preventive Services Task Force recommended screening for prediabetes and type 2 diabetes in adults aged 35 to 70 years who are overweight or obese; about half of eligible patients are screened in primary care settings. Results indicating prediabetes are a fasting blood glucose of 100-125 mg/dL, a glycated hemoglobin of 5.7%-6.4%, or an oral glucose tolerance test 2-hour blood glucose of 140-199 mg/dL. Peters said that too often, small elevations in glucose — say, a fasting blood glucose of 110 mg/dL — can get written off in primary care settings as 'nothing to worry about.' However, she stressed the need to act. Effective Counseling Techniques Even brief conversations can prompt lifestyle changes. Miller educated patients on some of the 'ominous octet,' or disruptions in normal bodily processes that contribute to the development and progression of type 2 diabetes. He used numbers as a gauge and explained prediabetes as a yellow zone. 'I often tell my patients, 'Let's take the car in to get some work done,'' he said. Peters encouraged providers to frame conversations about change around the present and future, noting that modest changes make an impact. For those with prediabetes, a 7% weight loss reduced the risk of developing type 2 diabetes by 58%, per the DPP. 'The more someone can shift to a healthier place, the healthier they'll be,' she said. Electronic medical record system prompts can also help flag candidates for counseling, said Zilbermint. Bringing Compassion to Conversations A prediabetes diagnosis can be overwhelming. Patients may have fears around family history or a resistance to change. Approaching conversations with kindness and empathy is important. 'There's a whole psychology to diabetes,' said Peters. 'Diabetes isn't about shame or blame. Some people are genetically prone to have prediabetes, and this is a manageable issue.' Miller tried to answer patients' questions to steer a personalized treatment plan for long-term, sustained results. Connecting Patients to Proven Programs Despite evidence of their effectiveness, only 36% of primary care physicians refer patients to a diabetes prevention lifestyle change program (findable here) as their initial management approach, according to one national survey. Miller often referred patients to DPP and encouraged a follow-up visit. Zilbermint noted that health coaches offer another potential solution. Consider Medication The American Diabetes Association recommended considering metformin to prevent type 2 diabetes in high-risk patients with prediabetes, yet less than half of primary care physicians (43%) reported prescribing it. Weight loss medications — such as GLP-1 receptor agonists or sodium-glucose cotransporter 2 inhibitors — can treat prediabetes, too, said Peters, who noted that they can improve blood sugars and overall health.
Medscape
14-05-2025
- Health
- Medscape
Primary Care's Evolving Role in Diabetes Technology
It's been more than a century since insulin was discovered, radically changing the course of diabetes treatment. Research continues to yield advances in treatments to help people better manage their diabetes and live healthier, longer lives. Newer medications, like glucagon-like peptide 1 receptor agonists, tend to get all the press, but technology also fosters innovation. This is good news for every healthcare professional caring for patients with diabetes, including primary care providers, as the number of people with diabetes continues to rise. 'I think it's important to be aware of what is available, so we can steer our patients in the right direction,' said Sos Mboijana, MD, a primary care physician and assistant chief medical information officer at Mid-Atlantic Permanente Medical Group in Washington, DC. Continuous Glucose Monitoring (CGM) As a Game Changer Insulin discovery was only the first step. Over the years, scientists continued to explore new treatments and devices that could help people manage their diabetes, including the first blood glucose test strip in 1965, followed by the first electronic meter for self-monitoring of blood glucose in 1970. The introduction of the CGM system proved to be one of the biggest game changers. 'As a diabetes doctor, I can't imagine managing a patient with diabetes without it,' said Anne Peters, MD, professor of medicine at the Keck School of Medicine of University of Southern California in Los Angeles. First approved by the US Food and Drug Administration in 1999, CGM allowed people with diabetes to forgo the multiple daily finger pricks to measure their blood glucose levels. As one of its 'Standards of Care in Diabetes,' the American Diabetes Association now recommends offering CGM to patients at the outset of a diabetes diagnosis that requires insulin. 'Continuous glucose sensors have changed the world of diabetes — absolutely,' said Natalie J. Bellini, DNP, assistant professor of medicine at Case Western Reserve University (CWRU) in Cleveland. Even people with diabetes who do not require insulin therapy now use a CGM device. Some use them all the time, while others use intermittently, according to Bellini, who also serves as a program director for diabetes technology at CWRU's Case Center for Diabetes, Obesity and Metabolism. Because CGM also allows patients to watch their blood sugar levels rise and fall in real time, it can inspire quicker behavioral changes. People can now obtain a CGM device over the counter on their own, which may also prompt people with prediabetes to make positive lifestyle shifts. 'The rise of continuous glucose monitoring has been great for those who are diabetic, and even those who are not, because it gives patients real-time data into their blood sugars and how certain foods can affect it,' said Neal Patel, DO, a family medicine physician with Providence St. Joseph Hospital Orange, Orange, California. 'For example, an apple may only mildly increase sugar levels in one person, whereas it might spike it in others.' Patients frequently tell Sarah Tucker Marrison, MD, a primary care physician in Charleston, South Carolina, that they've made changes to their diet based on noticing how certain food choices affected their blood sugar levels. 'I just appreciate when patients are proactive in terms of making changes and responding to some of the information that's available to them to best support their own health,' she said. Said Mboijana, 'It gets us over the hill with patient engagement.' More Advancements and Challenges As technology has evolved, more options have opened for patients with diabetes, especially those who need insulin. For example, the advent of the automated insulin delivery (AID) system — which is also called a 'bionic pancreas' — uses CGM-informed algorithms to communicate with a CGM device and automatically guides the delivery of insulin. With this type of a device, a patient with type 1 diabetes no longer has to make all the decisions about giving themselves insulin, removing a significant burden from the patient, said Boris Kovatchev, PhD, director of the Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia. The center conducted research that led to the creation of an artificial pancreas system called Control-IQ. 'This is the best therapy of the moment,' he said of the artificial pancreas technology. The authors of a recent study in The New England Journal of Medicine suggested AID systems could also be beneficial for patients with type 2 diabetes who need insulin. Their research showed that patients who used AID systems experienced a larger drop in their A1c levels than patients who only used CGM systems. Currently, many primary care providers say they don't typically manage insulin pumps, including those used as part of an AID system, choosing instead to refer those patients to endocrinologists. 'Those are better suited by practices that are constantly using this kind of resource,' said David Baidal, MD, an endocrinologist with University of Miami Health System and an assistant professor of medicine in the Division of Endocrinology, Diabetes and Metabolism at the University of Miami Miller School of Medicine. He noted that primary care providers are already strapped for time; managing multiple devices — including downloading the data and using it to make adjustments during clinical visits — may not be feasible for them. But primary care providers do care for many patients who use CGM devices, and one of the biggest challenges for providers is dealing with the amount of data they now have access to, said Mboijana. 'How do you manage that data?' he said. 'What do you do with it? A fire hydrant of data doesn't really help you unless you have a system to deal with it.' Not every primary care practice has the resources — including the time or dedicated staff — to download and pore over the data, agreed Bellini. 'It's a little more hit or miss,' she said. On the Horizon While many physicians say they're grateful for the advances that are already in use, they also look forward to the future, when cost is no longer a barrier for current technologies. The ADA reported that CGM is still less accessible for certain groups of people, including older patients, Black patients, and patients with Medicaid. Hybrid closed-loop AID systems are increasingly being integrated into clinical practice, but cost is still an issue for many patients who could benefit from using this technology. Physicians and other diabetes specialists also anticipate even better technologies that may become available. For instance, each year, the International Conference on Advanced Technologies & Treatments for Diabetes brings together experts focused on pioneering efforts in the field. The 2025 conference in March included sessions on innovative technologies and research, such as a session that spotlighted research on thioredoxin-interacting protein in pancreatic islet biology and the investigational novel oral therapy TIX100 that's currently in clinical trials. Baidal suggested that newer algorithms for AID systems may also be able to provide more precise insulin adjustments and help patients spend more time in their target blood glucose range. Glucose-sensitive insulin, or glucose-responsive insulin, could also improve glycemic control and reduce the incidence of hypoglycemia. Mboijana said he's looking forward to seeing how artificial intelligence may contribute in the future. 'Embrace the technology that's coming down the pike,' he said. 'Be aware of what's happening.'
