A ARP PUBLIC POLICY INSTITUTE NOVEMBER 2018 Fact Sheet The Facts about Prediabetes and Older Americans By Susan Reinhard, Lynda Flowers, Olivia Dean, Jennifer Peed, and Erwin Tan AARP Public Policy Institute Almost half (48.3 percent) of US adults ages 65 and older (23.1 million people) have prediabetes—blood sugar levels that are higher than normal but not high enough to be considered diabetes.1 Nine out of 10 (90 percent) of people with prediabetes do not even know they have the condition, and many do not realize that prediabetes is a serious health concern that increases risk for developing type 2 diabetes, heart disease, and stroke.2 Diabetes Explained Risk Factors for Prediabetes Diabetes is a disease in which blood sugar (glucose) Prediabetes has no signs or symptoms, so it levels are too high, which can lead to serious health often goes undetected. However, prediabetes can complications. The glucose (sugar) in a person’s progress to type 2 diabetes. Thus, it is important blood comes from the foods they eat. When some to understand risk factors for prediabetes when foods—like carbohydrates—are digested, glucose evaluating the likelihood that an individual may enters the bloodstream immediately. The pancreas have the condition. Factors that increase risk for is a gland within the body that produces a hormone prediabetes include the following:5 called insulin. Insulin circulates through the body, moving sugar from the bloodstream into the body’s xxWeight: Being overweight, as measured by body cells to produce energy. As glucose is moved into mass index cells, the amount of glucose in the blood decreases. xxInactivity: Not getting enough physical activity When a person has diabetes, either the pancreas to support weight control completely stops producing insulin or the body is xxWaist Size: Having a large waist size (over 40 unable to use the insulin that is produced.3 inches for men and over 35 inches for women) There are two types of diabetes: type 1 and type 2. xxDiet: Eating red and/or processed meat and With type 1 diabetes, the pancreas does not produce drinking sugar-sweetened beverages, instead of a enough insulin or stops producing insulin altogether. diet high in fruits, vegetables, whole grains, nuts, With type 2 diabetes—the more common type—the and olive oil body’s cells become resistant to the effects of insulin, resulting in glucose remaining in the blood instead of being moved into the cells to become energy.4 1 A ARP PUBLIC POLICY INSTITUTE NOVEMBER 2018 xxAge: Being age 45 or older 2 diabetes. These year-long classes focus on teaching xxGenetics and Family History: Having a parent people how to safely increase physical activity, or sibling with type 2 diabetes eat a healthier diet, and lose a modest amount of weight.12,13 For most people, certified classes can be xxRace: Being African American, Hispanic, Native taken online or in person (see below). American, or Asian American/Pacific Islander xxGestational Diabetes: Being a woman with Medicare Coverage for Prediabetes a history of pregnancy-related (gestational) Intervention Programs diabetes or delivering a baby weighing 9 pounds The cost of Lifestyle Change Programs varies or more depending on where they are being offered, the xxLack of Sleep: Having obstructive sleep apnea sponsoring organization, and whether they are or working a job with changing shifts or night offered online versus in person. Some employers shifts and health insurance companies will pay for the classes.14 Medicare pays for the in-person classes as The Centers for Disease Control and Prevention a covered Part B benefit—at no out-of-pocket cost to (CDC), The American Medical Association, and beneficiaries.15 The Medicare-covered classes are a the Ad Council have partnered on a risk test once-per-lifetime benefit, and online classes are not comprising seven simple questions that provide covered by Medicare. scores indicating low, medium, and high risk for prediabetes.6,7 The risk test is only a predictor of Medicare coverage of Lifestyle Change Programs— prediabetes. Individuals scoring in the high-risk called the Medicare Diabetes Prevention Program range8 on the test should have their blood tested (MDPP)—began in April 2018,16 but, to date, few by a health professional to determine whether they providers have signed up to provide the benefit. At least one study has found that low reimbursement actually have prediabetes.9 rates may be a deterrent to provider participation.17 It is unclear whether other factors are at play—like An Evidence-Based Intervention to Combat lack of Medicare coverage for online classes or Prediabetes difficulty getting beneficiaries to commit to taking Not everyone will be able to fully reverse prediabetes, classes that span several months. depending on their risk factors. However, most people will be able to combat prediabetes and Conclusion lower their risk for developing type 2 diabetes by Nearly half of adults ages 65 and older have modifying three factors: physical activity, eating prediabetes, putting them at high risk for habits, and weight loss. Several scientific studies developing type 2 diabetes and its associated have evaluated the effect of making small changes health problems.18 The high prevalence of to these lifestyle factors and have consistently prediabetes among older adults creates an shown such changes to be effective in preventing or imperative to intensify outreach and education delaying the onset of type 2 diabetes in people with about prediabetes among Medicare beneficiaries. prediabetes.10 These changes include losing between It is also important to educate beneficiaries about 5 to 7 percent of current body weight (10 to 14 the prediabetes risk test. Beneficiaries at high risk pounds for a 200-pound person) and getting regular for prediabetes should be encouraged to seek a physical activity—at least 150 minutes a week of definitive diagnosis from their health care provider brisk walking or a similar activity (30 minutes a day, and to enroll in the MDPP if diagnosed with 5 days a week).11 prediabetes. Efforts to enroll beneficiaries in MDPP Based on these promising research findings, the CDC are currently hampered by a critical shortage of now recognizes classes—called Lifestyle Change certified providers. Thus, it is important to better Programs—that are proven to help people reverse understand barriers to provider participation and prediabetes and prevent or forestall the onset of type implement policies to overcome them. 2 A ARP PUBLIC POLICY INSTITUTE NOVEMBER 2018 1 Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Division of Translation, National Diabetes Statistics Report, 2017: Estimates of Diabetes and Its Burden in the United States (Atlanta, GA, CDC, 2017) accessed at https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report. pdf. 2 Centers for sDisease Control and Prevention (CDC), Diabetes Home, Prediabetes, (CDC, Atlanta, GA, no date) accessed at https://www.cdc.gov/diabetes/basics/prediabetes.html. 3 Mayo Clinic, Prediabetes Risk Factors, accessed at https://www.mayoclinic.org/diseases-conditions/prediabetes/symptoms- causes/syc-20355278. 4 U.S. National Library of Medicine, Medline Plus, Diabetes Summary, (National Library of Medicine, Bethesda, MD, no date) accessed at https://medlineplus.gov/diabetes.html. 5 Mayo Clinic, Prediabetes Risk Factors, assessed at https://www.mayoclinic.org/diseases-conditions/prediabetes/symptoms- causes/syc-20355278. 6 The risk test can be accessed at Do I Have Prediabetes, About the Risk Test, American Medical Association (AMA), Centers for Disease Control and Prevention (CDC), and Ad Council, accessed at https://doihaveprediabetes.org/take-the-risk-test/#. 7 The American Diabetes Association launched its first risk test in 1993. The risk test was adapted by a published study and validated using data from the CDC. When developing the test, researchers looked for specific characteristics that made a person more likely than average to have undiagnosed type 2 diabetes. To make the tool as easy to use as possible, they considered only health characteristics that people would know about themselves without needing a blood test or other medical evaluation—such as age, height, and weight, but not including blood glucose or cholesterol levels. AMA, CDC, and Ad Council, Do I Have Prediabetes, About the Risk Test, accessed at https://doihaveprediabetes.org/take-the-risk-test/#/about. 8 A high score on the online risk test (5 or higher) means an individual has a significant risk for having undiagnosed prediabetes or type 2 diabetes; however, only a blood test can determine a diagnosis. AMA, CDC, and Ad Council, Do I Have Prediabetes. 9 Any of the following results will confirm a diagnosis of prediabetes: (a) Hemoglobin A1C (a blood test used to measure the average level of glucose in the blood over the last two to three months) of 5.7 percent to 6.4 percent; (b) fasting plasma glucose (a measurement of a person’s blood sugar level after fasting or not eating anything for at least 8 hours) of 100–125 mg/dL (impaired fasting glucose); or (c) two-hour post-75-gram oral glucose challenge (a fasting blood draw to test fasting glucose level followed by drinking 8 ounces glucose solution. Follow up blood is drawn to determine how well the body is producing insulin to metabolize the sugar in the body) of 140–199 mg/dL (impaired glucose tolerance). The A1C test offers advantages for patients and providers because it removes the burden of fasting and/or lengthy lab visits. Although the future development of type 2 diabetes is possible when blood test results are below these ranges, the risk for progression becomes higher for individuals with these more elevated test results. 10For a brief summary of the research, see American Medical Association (AMA), What Is the Evidence Base for the Prevention of Prediabetes through Lifestyle Change, (AMA, Chicago, Illinois, no date), accessed at https://assets.ama-assn.org/sub/prevent- diabetes-stat/downloads/AMA-evidence-supporting-dpp.pdf. 11Centers for Disease Control and Prevention (CDC), Prediabetes: Your Chance to Prevent Type 2 Diabetes: Preventing Type 2 Diabetes, (CDC, Atlanta, GA, no date), accessed at https://www.cdc.gov/diabetes/basics/prediabetes.html 12CDC-certified programs run for one year. During the first six months of the program, participants are required to meet once per week. During the second six months, participants meet once or twice a month. Centers for Disease Control and Prevention (CDC), National Diabetes Prevention Program: Key Components of a CDC-Recognized Lifestyle Change Program (CDC, Atlanta, GA, no date), accessed at https://www.cdc.gov/diabetes/prevention/lifestyle-program/experience/index.html. 13Centers for Disease Control and Prevention (CDC), National Diabetes Prevention Program: Lifestyle Change Program Details, Time Commitment (CDC, Atlanta, GA, no date), accessed at https://www.cdc.gov/diabetes/prevention/lifestyle-program/ experience/index.html. 14Centers for Disease Control and Prevention (CDC), National Diabetes Prevention Program: Lifestyle Change Program Details, The Cost (CDC, Atlanta, GA, no date), accessed at https://www.cdc.gov/diabetes/prevention/lifestyle-program/experience/ index.html. 15Medicare calls its benefit the Medicare Diabetes Prevent Program (MDPP). Medicare beneficiaries who are enrolled in Medicare Part B (medical insurance) are eligible for the MDPP benefit if they meet the following requirements: are overweight or obese; 3 A ARP PUBLIC POLICY INSTITUTE NOVEMBER 2018 have blood sugar laboratory values that indicate they have prediabetes; have no previous diagnosis of diabetes (except for gestational diabetes); and have not been diagnosed with end-stage renal disease. A lab value in the prediabetes range is determined by one of the following: a hemoglobin A1C test with a value between 5.7 and 6.4 percent; a fasting plasma glucose of 110–125 mg/dL; or a two-hour plasma glucose (glucose tolerance test) of 140–199 mg/dL. Centers for Medicare & Medicaid Services (CMS), Medicare Diabetes Prevention Program, Expanded Model Fact Sheet (CMS, Washington, DC, no date), accessed at https://innovation.cms.gov/Files/x/MDPP_Overview_Fact_Sheet.pdf. The core MDPP service consists of 16 sessions over a six-month period, during which program participants receive in-person practical training in long-term dietary change, increased physical activity, and problem-solving strategies for overcoming challenges to maintaining weight loss and a healthy lifestyle. The six-month core sessions are followed by another six months of in-person monthly maintenance sessions. Medicare beneficiaries who meet certain weight loss and attendance requirements are eligible a second year of in-person maintenance sessions 16On April 1, 2018, the Centers for Medicare & Medicaid Services began offering an evidence-based lifestyle change programs called the Medicare Diabetes Prevention Program. In addition to being offered as a fee-for-service benefit, all Medicare health plans—including Program of All-Inclusive Care for the Elderly (PACE) providers—are required to cover the service for eligible beneficiaries. 17Natalie D. Ritchie and Robert M. Gritz, “New Medicare Diabetes Prevention Coverage May Limit Beneficiary Access and Widen Disparities,” Medical Care 56, no. 11 (2018): 908–11. 18 Ibid. Fact Sheet 647, November 2018 © AARP PUBLIC POLICY INSTITUTE 601 E Street, NW Washington DC 20049 Follow us on Twitter @AARPpolicy on facebook.com/AARPpolicy www.aarp.org/ppi For more reports from the Public Policy Institute, visit http://www.aarp.org/ppi/. 4