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ECHO 4: Managing Pre-Diabetes

Learning Objectives
1. Review the evidence and guidelines related to identifying and managing prediabetes
2. Determine clinical best practices and quality improvement approaches that support diabetes prevention in FQHC populations
1 Credit CME

This is part 4 of Project ECHO: Prevention and Management of Diabetes and Cardiometabolic Disorders in Community Health Centers. This series explores diabetes and cardiometabolic care from the endocrine perspective and the factors unique to the health center community, such as the need for clinical care integration and mindfulness towards health disparities. This 6-ECHO series will focus on approaches to cardiometabolic care and management in the primary care, and typically rural, setting and how to bring best practices to this unique arena. The ECHOs will incorporate endocrinologists and FQHC staff, such as certified diabetes educators, nurses, and behavioral health specialists, as they explore the many ways to manage diabetes and its comorbidities (such as depression, cardiovascular disease, hypertension, etc.) as well as considerations when working with the special populations FQHCs serve. This series will bridge the gap between specialty endocrine care and the primary care setting by focusing on FQHCs and their unique placement within these special populations.

This presentation reviews the evidence and guidelines related to identifying and managing prediabetes and identifies the appropriate methods to determine clinical best practices and quality improvement approaches that support diabetes prevention in FQHC populations.

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Video Transcript

Andrea Quiles-Sanchez: [00:00] Hello, everyone and thank you for joining us today. As you know, my name is Andrea, and I'm so excited to welcome you to our fourth ECHO Diabetes Care Starts with Diabetes Prevention: Managing Diabetes. Endocrine Society is excited to continue with Project ECHO Prevention and Management of Diabetes and Cardiometabolic Disorders and Community Health Centers, which is funded by Abbott Diabetes Care. This program is designed for FQHC care providers and teams and is intended to bridge the gap between endocrinologist and primary care providers to benefit your patients. As a reminder, these sessions are designed to be highly interactive, and we ask that you keep your cameras on and participate in the discussion with our facilitator. Everyone in this room has something to teach so we invite you to share your experiences and expertise. But please try to remain muted if you're not actively speaking. Also, feel free to send chat through the chat box. Today I am pleased to welcome Dr Kate Kirley. Dr Kirley is the director of chronic disease prevention and programs in the improving health outcomes group at the American Medical Association. She serves as a clinical lead on AMA's Chronic Disease Prevention Initiatives and leads efforts to advance chronic disease prevention via the utilization of digital health solutions and improving medical education. Prior to joining the AMA, she was a practicing family physician and health services researcher at North Shore University Health System and a clinical assistant professor in the Department of Family Medicine at the University of Chicago. And with that, I will turn things over to Dr Kirley.

Kate Kirley, MD, MS: [01:40] Thanks so much, Andrea! We don't have a huge group, let's do another round of intros. I know we did last time, I think you got everybody talking a little bit more. Andrea already introduced me, so, why don't we try to get through our hub first and Liz, I'm seeing you, go ahead.

Liz A. Beverly, PhD: [01:57] Hi, everyone, I'm Liz Beverly. I'm at Ohio University, which is in southeastern Ohio. I do a lot with diabetes, and I specialize in behavioral diabetes work. So I really focus on psychosocial issues and diabetes in this region. I'm going to pass it to Rayan because I see you.

Rayhan A. Lal, MD: [02:17] Hey there guys, Rayhan, med peds endocrinologist here at Stanford, one of the chairs for the program. I will pass it on to Nick.

Nicolas Cuttriss, MD, MPH, FAAP: [02:33] Nick Cuttriss, pediatric endocrinologist. Public health professional by training and founding director ECHO Diabetes Action Network. Thanks for joining everyone. Jay.

Jay H. Shubrook, DO: [02:45] Hi, everybody, Jay Shubrook, primary care diabetologist for University California. So glad you're here, and I look forward to seeing everyone today and work with you. Sorry! I gotta pass along to Chris.

Christopher West, PhD: [02:58] Hi, I'm Chris. I'm a nurse practitioner at a rural federally qualified health center in northern California. And let's see, is there anybody else to pass it along to?

Kate Kirley, MD, MS: [03:09] I think we got our hub? Did we get our hub? Alright, I'm going to run down my participant list. And so that means I'll miss people. Let's try it. Debbie.

Debbie Lucus, RD: [03:24] Hi, I'm Debbie, I work in Sacramento for a cardiovascular wellness program run through Sac State. I work with Linda Paumer, who I think will be on soon. I'm a dietitian and a diabetes educator.

Kirley: [03:38] Antonio.

Antonio Olea, PharmD, AAHIVP: 03:41 Hi, everyone. My name is Antonio Olea. I am a clinical pharmacist in Napa, California, for an FQHC.

Kirley: [03:47] Great, and I think I see Colleen next.

Colleen Hough, RDN: [03:55] Hi, I'm Colleen, I am a dietitian and FQHC not too terribly far from where Chris is. And I work very part time and have a privilege from working from home. And that way I can talk to people about what's in their refrigerators and cupboards. And that gets interesting.

Kirley: [04:12] Wonderful. And let's see who do I see next? I think Cyd?

Cyd Bernstein, LCSW: [04:18] Hi, I work in Anderson Valley, which is a tiny town in northern California and an FQHC. I'm on a diabetes care team and a medical social worker by training.

Kirley: [04:32] Awesome. And James.

James Pecard, PA: [04:37] Hi, my name is James Pecard. I'm a PA over at IWS Family Health Center, an FQHC lookalike in Chicago. Do a bit of everybody from kids to adults and everything in between.

Kirley: [04:53] Go family medicine! Let's see who is next on my list. Pasia-Leigh? I think I probably pronounced your name wrong, please correct me.

Pasia-Leigh Daum, RDN: [05:04] Hi, no worries. It's pronounced like pay-juh leigh, and I also work at an FQHC as a registered dietitian, and I have the pleasure of working with Colleen and Chris that are also on here.

Kirley: [05:18] Wonderful. And I think I see Sandra next.

Sandy Frank: [05:27] Hi, I'm Sandra Frank. I'm a family nurse practitioner. I'm a colleague of James's as well. We work in the inner city in Chicago. FHCQ lookalike, same thing caring for womb to tomb, lots of folks with diabetes and prediabetes in our practice.

Kirley: [05:46] And then I see Shirley.

Shirley Wong, PharmD: [05:49] Hi, everyone, my name Shirley. I'm one of the pharmacy residence at Touro University California, I work with Dr Shubrook in the Solano County clinics.

Kirley: [05:58] Thank you. All right, who did I miss? Did I miss anybody? I probably did. Oh, are we good? Okay, let's dive in. You want to go to the next slide, Andrea? We have already spent a lot of time together talking about some of our most difficult to manage, difficult to figure out, most complicated patients with diabetes, and now we're going to look at the other end of the spectrum. We're going to talk about people who don't have diabetes yet, and we're going to focus on prediabetes right now.

The reason I'm talking about this is because AMA has a pretty large strategic initiative around preventing Type 2 diabetes. In my seven years with AMA, have spent a lot of time working with health care delivery organizations of all shapes and sizes, on planning and implementing diabetes prevention strategies. I also work really closely with the CDC, federal government on different types of initiatives to try to promote the prevention of Type 2 diabetes, so this is one of my favorite topics, I'm really happy to get to talk about it and talk with you all about it. If you go on to our next slide. Learning objectives for today are to do a hopefully pretty quick review of the evidence and the guidelines that relate to identifying people with prediabetes and managing these people. We'll talk about some best practices and how to think about quality improvement that can support diabetes prevention at FQHCs. Next slide.

First, getting into the evidence and the guidelines. Next slide. Prediabetes. Really, really, really common. I think the latest estimate is that about 96 million American adults have it, so it's over a third of the adult population. Sometimes I spend time talking to people about whether the name "prediabetes" is really the best name for this condition, because it's by no means a guarantee that someone is going to go on to develop Type 2 diabetes. But, it's still the single most predictive risk factor that somebody will develop Type 2 diabetes, so I still believe it's very, very crucial to identify and manage. Also, people with prediabetes are at elevated risk of cardiovascular disease, even if they don't go on to develop Type 2 diabetes, so a very, very important condition to be aware of. Next slide.

We do have guidelines, and we have recommendations that touch on this topic. So this is the thumbnail summary of what USPSTF says, so they updated their recommendation that relates to prediabetes last year. They talk about both screening and management and this recommendation. They tell us that we should be screening for prediabetes as well as undiagnosed Type 2 diabetes in adults between the ages of 35 and 70, who also have overweight or obesity. And then they don't stop at the screening, they do touch on the intervention, and I think that's a piece that sometimes gets glossed over with this recommendation, but to me, it's actually the most important piece. They tell us that we should offer or refer our patients with prediabetes to effective preventive interventions, and we'll talk a little bit more about what some of those options are in a few minutes. So next slide.

To go into some of the finer points of the USPSTF recommendation as it relates to screening: In addition to thinking about those people between the ages of 35 and 70 with overweight and obesity, we do want to consider screening patients at an earlier age if they have that family history of Type 2 diabetes, if they have past medical history of gestational diabetes or PCOS. I do want to point out GDM is a really, really crucial risk factor for developing Type 2 diabetes. Very high risk of developing Type 2 diabetes later in life, so a really important group to think about. The recommendation also says that we can consider screening at a younger age for people who identify as certain races or ethnicities. Because of systemic racism, we do see a higher incidence, higher prevalence of Type 2 diabetes at a younger age in many different groups of people, and so they do suggest we consider screening at that younger age. Next slide.

A couple of additional points they talk about considering screening at a lower BMI, so a cutoff of 23 or higher. If a patient identifies as Asian American, they do tell us that we can use any of three screening tests to do our screening. It can be a hemoglobin A1C, it can be a fasting plasma glucose, or it can be a two-hour glucose tolerance test, which, we tend to not see very often, but we can use any of those options. There's not a ton of evidence about how often we should screen people. Expert opinion is to screen people who have had normal results every three years, but there's room for clinical judgment there for sure. They do, as I said, they talk about effective preventive interventions. According to USPSTF, what rose to the top and their evidence review was both lifestyle interventions, particularly intensive lifestyle interventions, and also Metformin. Both of these are pretty well studied in terms of their ability to prevent or delay the onset of Type 2 diabetes among people who have prediabetes. I should point out Metformin is not FDA approved for this indication, it does have some solid effectiveness and safety data here. Next slide.

Let's talk about some of that evidence-based, the original DPP study, the Diabetes Prevention Program Study is the cornerstone of the evidence base for diabetes prevention and thinking about prediabetes. This was a three-arm randomized control trial. It's been actually over 20 years now, since this trial started. People are still followed in the DPPOS study the outcome years later. They took more than 3000 people with either impaired fasting glucose or impaired glucose tolerance and they randomized them into one of three treatment arms. They either received Metformin, so they received 850 milligrams b.i.d., or they participated in this intensive lifestyle counseling intervention that we now generally refer to as the DPP, the Diabetes Prevention Program, or they participated in sort of a placebo standard-of-care arm. And what we saw in this study was that at an average follow up of three years, the group that participated in the lifestyle intervention had a reduced incidence of Type 2 diabetes of 58% compared to the placebo group. A really substantial reduction in the incidence of Type 2 diabetes.

Metformin was also effective. Metformin reduced the incidence by 31%, three years out, compared to placebo, so it wasn't as effective as the lifestyle change program, but it was effective. Then, when you start to look further out, as they follow people longer over time, you start to see those two interventions maybe come together a little bit more in terms of their long-term effectiveness, and there probably are some groups of people for which Metformin might be a little bit more appropriate, particularly women with a history of GDM. Metformin and lifestyle change are probably pretty comparable there. Let's go on to the next slide.

Just a quick reminder: our anti-obesity medications, I think, can be on the table too. Particularly if we look at liraglutide semaglutide. They've had these FDA approved indications for treating obesity and overweight. As we've talked about and in some of our other sessions so far, with liraglutide, the scale trial is really what we're thinking about here. You can see there, what the dosing was. When we look at the weight outcomes at week 56 in their trial, the mean change in body weight that they saw was a loss of 8% of body weight for people on liraglutide versus a loss of 2.6% of body weight for people using the placebo. Very effective in terms of weight management, weight loss, which is clearly tied to prevention of Type 2 diabetes. In this study, they looked at diabetes risk as one of their outcomes. They looked at whether or not people subsequently developed Type 2 diabetes. What they saw was that three years out, the hazard ratio of developing Type 2 diabetes was 0.21 for the liraglutide group compared to placebo. So pretty effective in terms of the potential to prevent Type 2 diabetes.

Another way to look at it was the liraglutide group. They took 2.7 times longer to develop Type 2 diabetes on average compared to the placebo group. They did look at this sort of diabetes prevention outcome and did see some, I think, pretty significant results there. If we switch over to semaglutide, we're thinking about the STEP trials here. Again, you can see the dosing there. In terms of their weight outcomes at week 68, the main change in body weight was a loss of 14.9% of body weight on average, compared to a loss of 2.4% body weight with placebo. So again, really significant difference there. They did not exactly look at diabetes risk as one of their outcomes, but they looked at something very similar to it. Among their patients that were included with prediabetes, they looked at the rate at which people reverted to normoglycemia from their prediabetes. And what they saw was that the likelihood of reverting to normal glycemia was much higher in this magnetized group. 84% of that group reverted to normal glycemia—this was at week 68—compared to 47.8% in the placebo group.

Again, not exactly looking at a diabetes risk outcome, but we're seeing an indication there that this may be useful for the purposes of preventing Type 2 diabetes. Neither of these meds have that FDA approval for preventing Type 2 diabetes specifically, but they do have, of course, that really important obesity overweight indication, and we know that weight loss among people with prediabetes is a real significant predictor of who is likely to go on to develop Type 2 diabetes. So there's that connection there. Okay, let's go to the next slide. That was a big dump of evidence. Maybe I actually will pause for one second, Liz. I'm not monitoring the chat anything in the chat about questions for this piece so far, before I talk a little bit about best practices and QI?

Beverly: [17:19] No questions as of yet.

Kirley: [17:21] Okay, thank you, we can go on to our next slide. Let's talk a little bit more about making this real life—making this, hopefully, pragmatic. So what should you do? We'll talk more about this as we go through the case, I think, but diabetes prevention, we've seen, doesn't do well as a topic if it's an individual responsibility. We do much better with diabetes prevention if we can build infrastructure within our clinics to support it, and if we can systematize things wherever possible. In terms of what we're systematizing, we want to think about how we identify our patients with prediabetes—having a systematic way to do that. We want to think about how we offer treatment to our patients and connect patients to evidence-based treatment, particularly the National DPP Lifestyle Change Program, and then we also want to think about how we support patients long term in terms of regular monitoring and follow up with them. Next slide.

In terms of what the physician or the providers role is, in the identifying patients piece, positions can be helpful in determining which patients actually need testing—that's, of course, something that can be turned into an algorithm as well—or actually ordering the appropriate tests, but that can also be facilitated through order sets, standing orders. Really, really crucial is this last piece here that often gets glossed over is actually making the diagnosis and documenting the diagnosis. People with prediabetes, only about 20% of them—actually, less than 20%—of them know that they have prediabetes, even though they have oftentimes a lab result out there, indicating that they have prediabetes, so we tend to skip this step. Really important to make the diagnosis, document the diagnosis and communicate the diagnosis to our patients. Next slide.

In terms of making that diagnosis, just one quick slide here about the lab results that you're looking for, for each and like I said earlier, any of these three tests is generally considered acceptable for making this diagnosis. There are different considerations with each, of course, but any three really are okay, and you can see there the ranges for making that prediabetes diagnosis. Next slide.

Let's talk more about the DPP. Let's talk more about the Lifestyle Change Program. So sure, it was it was studied in this randomized control trial, but what one of the best kept secrets, I think, in prevention is that it's actually an intervention to which we can connect our patients. It is a thing that is available out in the real world. The DPP is really about helping people make sustainable, healthy lifestyle changes with a goal of becoming more physically active, eating a healthier diet, achieving weight loss, and lowering the risk of Type 2 diabetes. It is intensive. The first six months of the program, participants usually will attend about 16 sessions on a mostly weekly basis. Then there's a follow up, or a maintenance phase, of the program, which lasts for the second six months, and usually participants will attend monthly sessions during that phase—minimum of six sessions there. Next slide.

There are a lot of components to the DPP. It's led by a trained lifestyle coach. That coach can be anybody, so it doesn't have to be a licensed health care professional. The key is that the person is trained to deliver the DPP program and curriculum. These sessions are usually done in a group format—they don't have to be but oftentimes group format. It's really about offering that peer-to-peer support for people, so it's not just a didactic experience. It's peer-to-peer, it's skills building, it's problem solving, it's a really great program overall. Emphasis is really on empowering people through developing their own personal action plan. The organizations that offer the DPP do still need to deliver, though, the CDC approved curriculum and CDC really oversees this whole initiative nationally. They provide quality assurance for these programs, so any organization that is offering a DPP Lifestyle Change Program is required to submit their data to CDC and CDC is monitoring for outcomes like weight loss and A1C stabilization or reduction, physical activity minutes that people achieve, things like that, so they really provide the quality assurance there. Next slide.

Who can go to a DPP? Probably the most important thing is who wants to go to a DPP, but there are also specific eligibility criteria: You have to be an adult—everything on the left is required—need to be an adult, need to have an elevated BMI, need to not yet be diagnosed with diabetes, and each not currently be pregnant. Then people need to have one of the following on the right hand side there: they either need that blood test that's consistent with prediabetes, or they need to have a history of gestational diabetes—remember, I said that that alone is very high risk—so history of GDM gets a person in. Or they can have an elevated score on a prediabetes risk screener. For example, the ADA has a risk screener that's validated. With any one of those following, a person is eligible to participate in the DPP. Now, there are some slight modifications for Medicare. Medicare does cover this as a benefit. They do require that there's a blood test result, and they have a slightly different fasting blood glucose result, they say you have to be between 110 and 125. They do require that blood test, but it's important to know that it is available for Medicare. Next slide.

I think with our case, we'll spend a lot more time thinking about how do we identify the best treatment options for patients with patients? And how do we get patients connected to that treatment? And that's honestly where a lot of the magic is. And so I'm going to jump ahead now and I'm going to talk about how do we monitor and support people with prediabetes in the long term. We want to stay connected with them, we want to explore how and whether they're adhering to their chosen treatment, which could change over time. We want to determine whether their treatment that they're using is effective. And really with anybody with prediabetes, we really should be monitoring them annually with blood tests to monitor for progression towards Type 2 diabetes. Those are the things, again, we talked about, systematizing stuff, we want to think about how do we make all of these pieces systematic within our practices. Next slide. I'm wrapping up here.

In terms of ways you can again systematize leverage QI approaches to support prevention. Lots of things you can do with your EHR, of course: create alerts for providers to ignore, generate reports that really identify your key groups of patients that you want to intervene upon, order set standing orders. Seeing some interesting work with people using Patient Portal to send out that patient risk questionnaire for their patients. It's also useful patient engagement tool. This is definitely a team sport. The physician, provider is just one piece of the puzzle, and in many ways, the less we ask them to do, the better sometimes. You think about how you engage all of your care team members and ensure that everybody's properly trained on this topic, and it's a topic that many of us didn't get a lot of training on along the way through our training, so oftentimes, there's a important education component, as you really work on diabetes prevention at your sites. You can definitely leverage previsit planning and labs. This is not a pitch for the AMA, but because we work on this topic, we do have a website that has a pile of tools and resources, amapreventdiabetes.org. It's free, no need to be an AMA member, and for organizations that want to do a deep dive on this topic, it's almost a project management tool to help you plan and implement your strategy. It guides you through that whole process. If you want more tools on this, check out amapreventdiabetes.org, and I can recommend others as well. There's lots of stuff out there. I think that is it. If we go on to the next slide.

Beverly: [26:22] Can I have a question? How do you find some of these DPP programs based off where we are all from?

Kirley: [26:31] Great question. Where I would start is going to the CDC website, which I'll see if I can manage to find and pop into this, I should have put a link in earlier. CDC does have a DPP program finder. Sometimes it's really helpful. Sometimes it's not super helpful. Other places that you can look: There are virtual programs—I didn't even talk about it—but there are virtual programs, those are listed on CDC's finder. Many health care organizations offer programs and oftentimes accept referrals even from outside health care organizations. And there are a lot of community-based organizations that offer these programs. Check in if you're local Y offers the program—the Y is one of the biggest providers of the DPP nationwide, so there are community based organizations that offer the programs. I see Jay.

Shubrook: [27:23] You mentioned that about the virtual programs. I think it's important. That's one thing that's happened from COVID. So we offer DPP and we have people from all over the country that participate in our DPP. And we also provide training for coaches. So no longer is geography a limiting factor.

Kirley: [27:40] Right. Right. Payment—How does somebody pay for this? Oftentimes it's actually not a limiting factor either. If they have some kind of commercial insurance, they have some form of coverage. Many state Medicaid programs cover it now, but not all of them. Medicare has coverage and a lot of these programs offer their services free of charge, because they are grant-funded, or they are using community benefit dollars that their health care organization or whatever it is—so most people can find a DPP that they don't necessarily have to pay out of pocket for. But it takes a little work.

Beverly: [28:23] I located the DPP finder for the CDC, so thanks. It's in the chat for everyone.

Bernstein: [28:33] I have two questions. The first question is as part of our QI project this past month, we were looking at increasing screenings and I had some pushback from providers that they were reluctant to do them because they thought insurance wouldn't cover them, you know, starting screenings at 35 versus what we're doing, which is 45. So I'm curious about your experience of that. Then the other question is just part of my role here as is as a health coach, and we've tried to offer groups before, for whatever reason, it's really tough to get them off the ground. I'm wondering if you've seen DPP rolled out in a more individualized... the health coach media meets with a person kind of as they come into the clinic and moves through it in a more individual way.

Kirley: [29:25] Yeah. Yeah. Both good questions. In terms of insurance coverage: It's it is a bit of a local question. I have yet to see people have problems with fasting glucose coverage. A1C is a little bit more of a mixed picture. At this point, most places and people I talked to seem to have coverage, so Medicare is a big outlier there. Medicare still does not cover a A1C for screening purposes—something I lobby about—but most commercial plans do. I think most Medicaid will, it is a little bit of a local question, and oftentimes a little bit of research that you've got to do just to kind of understand what coverage is like by you. Fasting glucose is usually not an issue, though. I don't know if other members have seen anything different.

Your other question was about sort of more individualized programs instead of group programs. So probably the most common way that this happens, honestly, is the virtual programs. So a lot of the virtual programs do more of an individualized coaching approach, and then oftentimes offer some kind of group interaction as well, but you can kind of do one or the other or both. Also, I didn't talk about this, but I think currently ADA and some others suggest DSMES as a potential, other relatively intensive intervention that is lifestyle focused for people with prediabetes. Oftentimes it's done more on an individual basis. Medical nutrition therapy, I will say, as a different intervention that's more individualized is also really reasonable to offer people with prediabetes as well, so it has a decent evidence base. I haven't seen a lot of organizations offer in person DPP on a one-on-one basis. And at this point, CDC has really kind of structured their guidance and curriculum to be more group oriented.

Yeah. I think we can go into the case, and probably that will also bring up more questions as well, that we can talk through. Full disclosure: I made this case up. We didn't get any case submissions, so I made this up based off of lots of different things I've seen with my own patients, but also talking with lots of care teams over the years. So if you ask me questions about him, I may not necessarily answer with direct answers and I may ask you things like, "Why do you want to do that? What are you thinking about?" Again, full disclosure. Let's talk about our patient who's a 55-year-old man. He's relatively new to our health center, he started coming in in the past year. He initially established care six months ago, after he lost his insurance after being laid off from his job about a year ago. At his initial appointment, he wanted refills on his blood pressure meds, and he also had some complaints about low back pain and some right knee pain. He did get some refills of his medications at that time. He was asked to come back a month later, to follow up on these things and also to begin to address some health maintenance issues that he might be due for.

The clinic was really good about ordering some previsit labs for him to try to get done before he comes back for his next appointment, but he didn't have his labs drawn and then we see him back about six months later for some more refills. He doesn't really have any new complaints this visit, he does agree to do his health maintenance bloodwork today, he's going do it right after the appointment. His comorbidities are obesity, hypertension, hyperlipidemia—the knee pain in the back pain. He does not have any chronic kidney disease, no history of ASCVD, no heart failure. He does have a family history of Type 2 diabetes and hypertension, no family history of early CVD. In terms of what we know about him from a social history standpoint: former plant worker laid off from his position a year ago and he's doing some intermittent handyman work with his brother. He's uninsured. He lives with his wife and his teenage son, and he has an adult daughter who's no longer at home, used to smoke—he quit 10 years ago—he drinks about four to six beers per week, he says, no other substance use. You can see there his meds and his recent labs with an AAMC of 6%, and you can see his vitals there. So that's him. Let people stare at him for minutes and off the bat, is there anything else? What questions are popping into your mind about him just off the bat as you start to think about him?

Frank: [34:42] I'm thinking about social stuff: he was laid off from his job, he didn't show up—he clearly lives with some family, so what their social support is like—didn't show up for his... has been a while since he returned and didn't do his labs, so what else is going on his in his life as barriers to access.

Kirley: [35:06] I think all great questions.

Frank: [35:10] Also: food security and access to healthy foods.

Kirley: [35:16] These are all great questions, they're exactly what I'd be thinking, too. Why do those things matter as we think about this case? What are your trade offs? What are your things that are running through your head that you're thinking about what you might want to do with him at this point?

Pecard: [35:35] Or has he been counseled on weight loss? 10%?

Kirley: [35:39] Good question, let's say no. Why 10%?

Pecard: [35:47] I think the goal of losing some of this body weight to see if it makes a difference with his other risk factors.

Kirley: [35:55] Yeah, one thing we've seen, you know, working with a lot of different providers is both skipping over the diagnosis piece, like I talked about before, and skipping over the goal-setting piece. Some of the researchers I work with have done some really interesting work, and what they showed is that patients really expect the physician or provider to do goal-setting with them, they expect them to address this issue, and if we leave it out, if we don't talk about it, then we're not necessarily meeting their expectation. Goal setting can be approached in a lot of different ways. By the way, if you do share decision making with your patients on this topic, they are actually much more likely to follow through with a preventive intervention of some sort. Usually, they pick the DPP, so doing that conversation about what's happening here, and determining individual goals for a person before you launch into, sort of, "What's the treatment going to be?" is really really crucial. But also being really clear about what reasonable goals are. A lot of people who have thought about their weight, struggled with their weight for a long time, do not always have a realistic expectation for what goal weight loss should look like, so you'll hear lots of people saying, "I need to lose 50 pounds" and it's kind of nice as a provider to be able to say, "Actually, if you set a goal of 5 to 7%, that is more achievable and actually impactful from a health standpoint. So, 5 to 7% is really what we shoot for with DPP, the goal setting piece I think, is really helpful. Hub team, any other comments on you know, as you're trying to understand him a little bit more, things you want to know?

Martha Vallin, MS, CHW/I: [37:53] Does he want to find a job? Is he happy being a handyman?

Hough: [37:59] I think I would also wonder if he has got issues with depression, because that's going to affect a whole lot of things, including whether or not he even wants to participate in treatment.

Kirley: [38:12] Absolutely.

West: [38:13] I want to know a little bit more about his day-to-day routine, is he active? What does he like to do?

Lal: [38:25] I'd love to get more information about what happened with his parents, you know, there may be a lot of avoidance of the topic of diabetes if they had deaths secondary to diabetes?

Kirley: [38:39] Yep. How would his responses to his feelings about his parents, his family history of diabetes, how would that change the way you talk to him about things?

Lal: [39:04] Providing a sense of self efficacy, and potentially saying, "Hey, we can prevent this even before it starts.

Kirley: [39:15] If we think about both motivational interviewing and shared decision making, really understanding what matters to him, it's pretty clear that there's a whole group of patients—and it depends on the topic—where talking about risk and disease terms is really scary and more of a turn off, or wants to make somebody avoid the topic altogether. Then there's other people where that actually is really meaningful to them. Other people, we're going to see that they really want to focus on their functional status and things that they can do in their day-to-day life and what would make things easier for them to function? Is that the tact that we take with them? There's I think there's a lot The possibilities, we see a lot, which is providers like we tend to go to this, like gloom and doom picture really quickly about risk. And that may not always be, you know, our most effective path forward to having a conversation with him about this, Jay, what are you going to say?

Shubrook: [40:18] Yeah, I love that I think you know, often is trying to find the slant that's meaningful to the patient. And, you know, maybe he cares a lot that his back and his knee pain might get better if he's able to do things to prevent his diabetes. And so it may not be his most important thing. But often, if you can find the thing that's meaningful home and meaningful for him, and then tie it into a shared goal, it can help quite a bit.

Kirley: [40:46] So we have a lot of things we want to know about him. And I agree with, I think everything that everybody has said, like, these are all questions, I'm asking myself about him. And so then we run into this challenge here of recognizing we want to sort of individualize the way we approach things with him. But we also, you know, I was saying before, if we systematize things, and we standardize things that also makes us more likely to actually succeed with diabetes prevention. How can you systematize learning more about him or getting the picture that you need about him?

Shubrook: [41:49] Tough one

Kirley: [41:56] I think one of the things I see people jump to, which I think has value, and I think it has its pluses and minuses is social determinants of health screening, other types of screening questionnaires, things we have patients fill out right before they see us. I have seen sites that have a dedicated team member, to actually have this shared decision-making conversation with a patient about this specific topic. And they've deployed different kinds of team members to do this. MAs can be trained to do this, certainly health coaches, I've seen clinical pharmacists trained to have this shared decision making conversation with patients. So dedicating someone who's trained on this topic to talk with patients about it is an approach that I've seen it a few different places that's been deployed pretty effectively. It does require assigning resources to it. So what do we think about treatment for him? What do you want to offer him?

Anastasia: [43:04] I think talking to him about where he's at, in terms of wanting to focus on—what lifestyle change that he wants to and choosing something that aligns with something that he's chosen to work on, that he feels self-efficacious about or motivated towards. I think it also depends on whether his partner somebody put him in a shot Do you know who's making the meals? If he shows up with his wife and his wife also has diabetes or prediabetes, maybe focusing on meal prep making more sense then having him talking about exercise or weight loss, but if he has depression and exercise is going to help with his depression, you know that. For me to be more about what he's open to and feeling good about.

Shubrook: [44:19] Comment in the chat as well. Yeah, go ahead Chris.

West: [44:21] Okay, it says "Don't you need to see his new labs before making some of the treatment decisions?" so she wants to gather some more information.

Kirley: [44:30] Maybe I should clarify. Those labs on the slide are the ones that you just got for him, but what else would you want to see? Maybe nothing, now that I said that.

Shubrook: [44:51] You know, some people actually like to have two results separated by time for confirmation of prediabetes or diabetes. Most of these tests are pretty accurate on the lower end, but it's not 100%. I don't know if that's where Linda was going, but I think that that's sometimes prudent. I would just balance that with that we want to take the opportunity that this guy has high risk, even if his A1C was 5.7. So it wouldn't change my approach to him.

Kirley: [45:21] Agree.

West: [45:23] I do also think you probably got a glucose level when you got the creatinine, so that could also improve things a little bit.

Kirley: [45:29] Yeah, good point.

Beverly: [45:32] I wanted to bring up something that I don't think has come up yet: geography. We have some people who are in very rural parts of the country, and some people were in more urban parts, we have some people who are on the West Coast, and then a few of us in the Midwest. I do think that plays a role. For example, if this patient was in a very rural town in the Midwest, would you approach it differently than if this was a gentleman in an urban region on the on the West Coast? And vice versa? That's my question I pose to you.

Kirley: [46:16] Any anybody have any thoughts on that? Obviously, I do. I think a lot of people tend to say, "Virtual programs for reaching those tough to reach geographies." There's something to be said for that, but the truth is virtual programs are not right for everybody. Medication is on the table, and we've also seen some success with programs that are structured a little more as "distance learning" than then truly virtual. so having a little bit of a hub site where there may be a coach reaching everyone via Zoom, or what have you. So you still kind of get this live synchronous interaction, and can let people not worry about traveling geographically to get to a place, but then that requires some technology pieces as well. There's always troubleshooting to be done when you're thinking about crossing a wider geography.

Beverly: [47:27] And reading the social history, I mean, the first thing that pops off: former plant worker to me, that makes me think of a different type of location, it makes me wonder about his educational background, it's another social determinants of health. So what is his background? And then what is his health literacy, if we factor that in? And then even talking about the digital divide. There are a lot of people who are not comfortable doing anything on computers, and they might have a smartphone. But even then to do some of these programs online, it's very challenging. So it's just factoring all of those types of things,

Kirley: [48:12] Agree. COVID, of course, has been fascinating with this particular topic too. A lot of organizations went from being in person to virtual or distance learning—in terms of organizations offering DPP. My to take away from it is it went better than everyone expected it to, like much of virtual stuff with COVID. So I think some of the lessons learned was: you can't jump right into a regular session in the first session, you need to spend some time with people kind of onboarding them to the technology before you can have effective group sessions with people, but that organizations, were really creative about that and found good ways to do that. Lots of different ways that they kind of approached that, but he definitely can't ignore the technology piece. Ooh, Shirly, as a DPP coach, if you have if you have any comments you want to make to definitely welcome them.

Shubrook: [49:16] Yeah, sorry. I called out Shirley. Shirley was an experienced cohorts.

Shirly: [49:23] I haven't actually taught a cohort in a while. It's been a few years. When I taught it as in person, and I think traveling was an issue for a lot of the participants I had, I remember, vividly a participant was on oxygen. They lived in a trailer. It was just transportation so that could apply for this gentleman here. I don't know how he gets to his appointments, too, so even if we had a live program in his area, is it easily accessible? A lot of times, it can be overwhelming. Even if you're in a tight cohort, when you're learning about so many different things and—especially with prediabetes—if he doesn't have the knowledge to even understand. I remember a couple months ago, I had a patient who speaks another language, and we try to explain to him what prediabetes is, what does A1C means. In their culture, there's no such thing, there's no term. Even the translator said, "I don't know how to translate this. There's no such term for prediabetes." That was also a barrier if they'd never heard the term.

Kirley: [50:28] Absolutely, yeah, and you're reminding me... Everyone is talking about so many important factors to take into consideration when we're thinking about how we're going to approach treatment with him. His understanding of his condition, what his values are, what he wants out of treatment, what his goals are for his health, in general, and what would really motivate him? Really getting an understanding of a lot of different potential barriers to participating in a preventive intervention. I think we've heard about a lot of different things here: the geography and potential transportation limitations. Really good point, I think, Anastasia, you made about who's preparing food at home? How much control does he actually have over that piece? Is this really more of a family intervention than an individual intervention? And how do we think about that? What are other reasons that he just hasn't been as engaged with his health care? We're thinking, what could be getting in the way of that? His mental health—how is that going to intersect with all of this?

All really complicated questions to figure out how we want to approach treatment with him. We have a handful of options: DPP, maybe some medical nutrition therapy, maybe DSMES, if that's something that he might have easier access to. Medication: totally fair game. We do see a lot of providers who, for whatever reasons, really don't want to pursue that. But I would argue that it is an important option to think about for people and let people choose for themselves what they want to achieve here, and what sort of burdens they want to deal with and risks they want to take on and what level of effectiveness is important for them. Lots of different pieces for sure. Any other like burning questions, or just thoughts about him right now?

Bernstein: [52:37] I was going to say, Kate, the part that jumped out at me most was that he's uninsured. And it's tough to do much while he's uninsured. I think on the medication piece, we our providers have been getting more bold about prescribing semaglutide or saxenda liraglutide, but insurance coverages still a major problem there. So until he has some kind of insurance, it's going to be difficult. And, likewise, why isn't he coming in for visit? Probably because he has to pay for them.

Kirley: [53:14] Yep, absolutely. Excellent points. Andrea timewise, anything that I should be doing right now or anyone else should be doing?

Quiles-Sanchez: [53:26] I was going to suggest closing out soon, I believe Jay may need to summarize some of what we covered.

Shubrook: [53:33] I've got the summary. I would just add one thing, and there is evidence that when you segment prediabetes, those with an A1C of six or greater actually do better with both lifestyle and medications. And those with an A1C less than six do just as well with DPP program, so there's a little bit more urgency above 6%. The summaries, and let's get some insight on the patient's concerns about social and financial resources, see if there's any mood disorders, get a handle on their daily routines. What we can do treatment-wise is recommend helping the patient with goal setting which is something often missing, certainly helping the patient set realistic weight loss goals— because we overestimate often—and then try to systemize systematize our approach to assessing risk and giving treatments. Then when you have treatments, we've shared a number of options: Let your patient be involved and so you can do shared decision making to see what's going to fit them the best. Kate, do you want to add anything to that? I think I tried to hit them all.

Kirley: [54:40] I think that was a very nice summary. Thank you.

Shubrook: [54:49] Other questions?

Kirley: [54:50] I think we covered a lot of ground.

Shubrook: [54:59] What happens next time?

Quiles-Sanchez: [55:06] Well, I guess that's me. Let me stop sharing my screen for a moment. Thank you all so much for today, and thank you Dr Kirley for that incredible presentation and thank you all for participating in the case discussion today. A recording of today's session will be made available next week and be on the lookout for emails regarding our next session on October 12, where Dr Elizabeth Beverley will be discussing diabetes, depression, and behavioral health. And I will be sending out reminders about submitting cases. We would love to hear from you all and I hope to see you all there. Have a great rest of your day. Bye everyone!

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The faculty, committee members, and staff who are in position to control the content of this activity are required to disclose to the Endocrine Society and to learners any relevant financial relationship(s) of the individual or spouse/partner that have occurred within the last 24 months with any commercial interest(s) whose products or services are related to the content. Financial relationships are defined by remuneration in any amount from the commercial interest(s) in the form of grants; research support; consulting fees; salary; ownership interest (e.g., stocks, stock options, or ownership interest excluding diversified mutual funds); honoraria or other payments for participation in speakers' bureaus, advisory boards, or boards of directors; or other financial benefits. The intent of this disclosure is not to prevent planners with relevant financial relationships from planning or delivery of content, but rather to provide learners with information that allows them to make their own judgments of whether these financial relationships may have influenced the educational activity with regard to exposition or conclusion.

The Endocrine Society has reviewed these relationships to determine which are relevant to the content of this activity and resolved any identified conflicts of interest for these individuals.

The following faculty reported relevant financial relationships: Elizabeth Beverly, PhD - Journal of Osteopathic Medicine, Section Editor. Nicolas Cuttriss, MD - ENDO Diabetes & Wellness, Employer; ECHO Diabetes Action Network, Employer; The Leona M. and Harry B. Helmsley Charitable Trust, Consultant; Cecelia Health; Consultant; American Youth Understanding Diabetes Abroad, Board. Kate Kirley, MD - American Medical Association, Employer. Rayhan Lal, MD - Abbott Diabetes Care, Consultant; Biolinq, Consultant; Capillary Biomedical, DSMB; Deep Valley Labs, Consultant; Gluroo, Consultant; Provention Bio, Advisory Board; Tidepool, Consultant. Jay Shubrook, DO - Abbott Diabetes Care, Consultant and Advisor; NovoNordisk, Consultant; Astra Zeneca, Advisor; Bayer, Advisor; Eli Lilly, Advisor; Nevro and Nevro, Advisor.

The following faculty reported no relevant financial relationships: Christopher E. West, PhD, A-GNP-C

Endocrine Society staff associated with the development of content for this activity reported no relevant financial relationships.

The Endocrine Society has reviewed all disclosures and resolved or managed all identified conflicts of interest, as applicable.


This educational activity is supported by an independent medical educational grant from Abbott Diabetes Care Inc.

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