What is prediabetes?
Prediabetes is a condition in which blood glucose or hemoglobin A1C (HbA1C) levels are higher than normal but not high enough to be classified as diabetes.1 In the average primary care practice, up to one‑third of patients age 18 and above—and up to half age 65 and above—could have prediabetes.1
Five steps to help patients prevent diabetes
- Create awareness
- Identify patients with prediabetes
- Educate at‑risk patients
- Refer patients to an evidence‑based diabetes prevention program
- Follow‑up on weight loss progress
Hang educational posters and distribute informational handouts, such as “Are you at risk for prediabetes?,” in exam rooms or in waiting areas.
Use this handout to raise awareness among colleagues and clinicians about the evidence-based diabetes prevention program and why it makes sense to screen and refer.
Identify patients with prediabetes
The most common blood tests used to identify people with prediabetes include a fasting plasma glucose or hemoglobin A1C (HbA1C).
|HbA1C (%)||< 5.7||5.7‑6.4||≥ 6.5|
|Fasting plasma glucose (mg/dL)||< 100||100‑125||≥ 126|
Encourage patient to maintain a healthy lifestyle.
Continue with exam/consult. Retest within three years of last negative test.
Refer to diabetes prevention program, provide brochure.
Consider retesting annually to check for diabetes onset.
Confirm diagnosis; retest if necessary.
Counsel patient re: diagnosis.
Reprinted with permission from the American Medical Association.19
You can prospectively identify patients with prediabetes by having patients complete a diabetes risk assessment before their visit and by arranging for pre‑visit lab testing before a planned care appointment (see pre‑visit planning module). This will allow face‑to‑face engagement with the patient about the results at the visit.
You can also retrospectively identify patients by setting up a query in your electronic health record (EHR). Use the one‑page infographic – Retrospective prediabetes identification – to set up a prediabetes registry using your EHR. Your patients with a BMI ≥ 24 kg/m2 (≥ 22 for Asians) and blood glucose or HbA1C levels in the prediabetes range qualify for an evidence‑based diabetes prevention program. (Read on to learn more about referring patients to this program.)*
* These BMI levels reflect eligibility for the National DPP as noted in the CDC Diabetes Prevention Recognition Program Standards and Operating Procedures. The American Diabetes Association (ADA) encourages screening for diabetes at a BMI of ≥23 for Asian Americans and ≥25 for non-Asian Americans, and some programs may use the ADA screening criteria for program eligibility. Please check with your diabetes prevention program provider for their specific BMI eligibility requirements.
What are the features of a diabetes prevention program?
Diabetes prevention programs emphasize behavior modification, managing stress and peer support. Some of the components are:
- A structured program of at least 16 sessions in the first six months, followed by monthly sessions for the next six months
- Facilitation by a trained lifestyle coach
- Use of an evidence‑based curriculum
What is the evidence behind the diabetes prevention program?
The diabetes prevention program is a lifestyle intervention based on research funded by the National Institutes of Health that showed, among those with prediabetes, a 58 percent reduction in the number of new cases of diabetes overall, and a 71 percent reduction in new cases for those over age 60.2 Researchers published the findings of the Diabetes Prevention Program (DPP) study in the February 7, 2002, issue of the New England Journal of Medicine. Additional studies2‑17 have since been published showing the efficacy of the DPP.
Are diabetes prevention programs covered by insurance?
Currently, there is limited insurance coverage for diabetes prevention programs. However, coverage for diabetes prevention programs continues to grow. To determine if your patient has coverage for a diabetes prevention program, ask the patient to contact his or her insurance carrier.
Does metformin prevent diabetes in at-risk adults?
Pharmacological agents, such as metformin, a‑glucosidase inhibitors, orlistat, and thiazolidinediones, have each been shown to decrease incident diabetes to various degrees. Metformin has the strongest evidence base and demonstrated long‑term safety for diabetes prevention.20 Although metformin is less effective than lifestyle modification for diabetes prevention, the DPP study2,21 found that metformin can reduce the risk of developing diabetes by 31 percent over three years. Lifestyle modification with diet and exercise is approximately twice as effective as metformin for preventing diabetes, especially in older patients. Metformin was shown to be most effective in preventing or delaying the development of type 2 diabetes in younger, heavier people with prediabetes. Metformin was also effective for lowering the risk of diabetes in women who have had gestational diabetes. Clinical guidelines recommend that metformin can be considered for diabetes prevention in people younger than 60 years who are at very high risk for progressing to diabetes, such as women with a history of gestational diabetes or obese individuals.22
Educate patients at risk for diabetes
Focus your education on four key messages:
- Prediabetes is a serious condition: It raises your risk of heart attack and stroke and poses a very high risk of eventually progressing to full‑blown diabetes
- Prediabetes is treatable: The good news is that most patients with prediabetes can avoid or delay developing diabetes by losing weight, becoming more active and eating more healthfully
- Evidence-based diabetes prevention programs are available. These programs help people with prediabetes accomplish these healthy changes, lose weight and avoid developing diabetes
To have the diabetes prevention program available is something bigger that you can give them that's clinically proven, and available nation-wide, that is just unbelievable.
How much does it cost to participate in the diabetes prevention program?
While costs may vary, the average cost per participant is approximately $400 to $500 for the yearlong program.
How can I explain prediabetes to patients so they understand?
You might consider saying: “Your blood sugar is higher than normal, but not at a level of diabetes. We call this prediabetes. Prediabetes is serious because it increases your risk of getting type 2 diabetes. Prediabetes can also double your chances of suffering from heart disease or a stroke. The good news is that prediabetes is reversible. There are things you can do now to prevent prediabetes from progressing to diabetes. Studies show that you can cut your chance of developing diabetes in half by losing XX pounds (5‑7 percent of body weight), eating healthier and exercising regularly.”
Use a patient handout, such as “So you have prediabetes…now what?” to help you reinforce these messages.
What if my patient does not have access to a diabetes prevention program?
While few alternatives have been shown to be as effective, if a patient with prediabetes does not have access to an evidence-based diabetes prevention program, an alternative is to refer the patient for both nutrition and physical activity counseling. Both of these services will generally be covered by insurance for patients with obesity and prediabetes.
Refer patients to an evidence-based diabetes prevention program
If the patient is interested and ready to make healthy lifestyle changes, then refer him or her to an in‑person, virtual or online diabetes prevention program.
Locate diabetes prevention programs in your community by:
The YMCA is the largest U.S. provider of in-person diabetes prevention programs. The YMCA uses the CDC model for diabetes prevention and has been found to be as effective as the original diabetes prevention program when tested in clinical trials.
The AMA and CDC, along with physicians and care teams at multiple physician practices in communities within four states, have developed a step‑by‑step toolkit on how to screen, test and refer high‑risk patients to diabetes prevention programs in their communities. The toolkit includes multiple resources that practices can adapt to best meet their needs. Prevent Diabetes STAT: Screen, Test, Act - Today™.
I believe that physicians, nurse practitioners and physician assistants really need to send their patients so that they can get the benefit of this program. This program works. We saw it in our patients.
We don't have all that time to spend with them in classes and teach them about their eating habits and counting calories and sugar, so they actually go spend time with a person in a group session and they can get all that from them.
How can I get a diabetes prevention program in my community?
Physicians and members of their care teams can advocate for community organizations or their own health system to offer the diabetes prevention program. You may want to speak with the director of your local YMCA, hospital, state health department or other interested community organization about the need to address prediabetes locally and encourage them to offer in–person, virtual or online diabetes prevention programs. It’s important that they follow the CDC’s evidence-based curriculum, and become a CDC-recognized provider.
Follow‑up on weight loss progress
Plan a three‑ or six‑month follow‑up with patients to assess their progress towards their weight loss goals and to address barriers to weight loss and a healthy lifestyle.
How can I get feedback on my patient from a diabetes prevention program?
Most programs send reports of participant progress to referring clinicians after the eighth and 16th group sessions. In addition, participants in the program complete periodic self-evaluations that referring clinicians can request directly from patients. You can also contact the diabetes prevention program in the area and request to receive information about your patients' participation.
- How can I get feedback on my patient from a diabetes prevention program?
Check out tools to screen and refer patients with #prediabetes to a #diabetes prevention program. #STEPSforward
Prevention is a team sport
Diabetes prevention is a team sport. This one‑page document – M.A.P. (Measure, Act, Partner) – can help you and your team determine roles and responsibilities regarding diabetes prevention and your practice workflow.
Using the EHR to identify patients with prediabetes
You can use blood values you already have recorded in your EHR to identify patients with prediabetes. Use this one‑page infographic—Retrospective prediabetes identification—to set up a prediabetes registry using your EHR.
Receive performance improvement (PI-CME) credits
Integrate new diabetes prevention strategies, tools and resources into your practice workflow. Screen and test patients for prediabetes, and refer them to a diabetes prevention program that's part of the CDC's National Diabetes Prevention Program. The learnings in this module can help you create links between your clinic and evidence‑based community resources to reduce chronic illness and improve outcomes for your patients.
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- Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014. Atlanta, GA; 2014. http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf
- Knowler WC, Barrett-Connor E, Fowler SE, et al; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393-403.
- Tuomilehto J, Lindstom J, Eriksson J, et al; Finnish Diabetes Prevention Study Group. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med. 2001; 344:1343—50.
- Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HAW. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med. 2008;359:1577-89. doi:10.1056/NEJMoa0806470.
- Nathan DM, Cleary PA, Backlund JY, et al; Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Study Research Group. Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med. 2005;353(25):2643—53.
- The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329(14):977—86.
- UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352(9131):837—53.
- Herman WH, Hoerger TJ, Brandle M, et al; Diabetes Prevention Program Research Group. The cost-effectiveness of lifestyle modification or metformin in preventing type 2 diabetes in adults with impaired glucose tolerance. Ann Intern Med. 2005;142:323—32.
- Ratner R, Goldberg R, Haffner S, et al.; Diabetes Prevention Program Research Group. Impact of intensive lifestyle and metformin therapy on cardiovascular disease risk factors in the Diabetes Prevention Program. Diabetes Care. 2005;28:888—94.
- Jiang L, Manson SM, Beals J, et al; Special Diabetes Program for Indians Diabetes Prevention Demonstration Project. Translating the Diabetes Prevention Program into American Indian and Alaska Native communities: results from the Special Diabetes Program for Indians Diabetes Prevention demonstration project. Diabetes Care. 2013;36(7):2027-34. doi: 10.2337/dc12-1250.
- Gerstein HC, Santaguida P, Raina P, et al. Annual incidence and relative risk of diabetes in people with various categories of dysglycemia: a systematic overview and meta-analysis of prospective studies. Diabetes Res Clin Pract. 2007;78(3):305-12.
- Ackermann RT, Finch EA, Brizendine E, Zhou H, Marrero DG. Translating the Diabetes Prevention Program into the community. The DEPLOY Pilot Study. Am J Prev Med. 2008;35(4):357-63.
- Knowler WC, Fowler SE, Hamman RF, et al; Diabetes Prevention Program Research Group. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet. 2009;374(9702):1677-86.
- Whittemore R. A systematic review of the translational research on the Diabetes Prevention Program. Transl Behav Med. 2011;1(3):480-91. doi:10.1007/s13142-011-0062-y.
- Johnson M, Jones R, Freeman C, et al. Can diabetes prevention programmes be translated effectively into real-world settings and still deliver improved outcomes? A synthesis of evidence. Diabet Med. 2013;30(1):3-15.
- Ma J, Yank V, Xiao L, et al. Translating the Diabetes Prevention Program lifestyle intervention for weight loss into primary care: a randomized trial. JAMA Intern Med. 2013;173(2):113-21.
- Albright AL, Gregg EW. Preventing type 2 diabetes in communities across the U.S.: the National Diabetes Prevention Program. Am J Prev Med. 2013;44(4 Suppl 4):S346-51.
- PCMH recognition via Standard 4: Self-Care Support, B. Provide Referrals to Community Resources (3 points), NCQA Facilitating PCMH Recognition, 2011.
- American Medical Association. PREVENTING TYPE 2 DIABETES: A guide to refer patients to the YMCA's Diabetes Prevention Program. Chicago, IL: Improving Health Outcomes, American Medical Association; 2014.
- Diabetes Prevention Program Research Group. Long-term safety, tolerability, and weight loss associated with metformin in the Diabetes Prevention Program Outcomes Study. Diabetes Care. 2012;35:731—7.
- Lilly M, Godwin M. Treating prediabetes with metformin. Can Fam Physician. 2009;55:363-9.
- American Diabetes Association. Prevention or delay of type 2 diabetes. In: Standards of Medical Care in Diabetes. Diabetes Care. 2015;38(Suppl. 1):S31—S32. doi: 10.2337/dc15-S008
STEPS in practice
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Downloadable toolsGo to Resource Library
To help prevent type 2 diabetes, the Centers for Disease Control and Prevention (CDC) and the American Medical Association (AMA) have created a toolkit that health care teams can use as a guide to screen, test and act today by referring patients to in-person, virtual or online diabetes prevention programs.
Preventing type 2 diabetes in at-risk patients module
Download a printable PDF version of this module.
PDF, 683 KBPreview
Preventing type 2 diabetes in at-risk patients PowerPoint
Use this PowerPoint presentation to review this module with your team.
PPT, 39 MBPreview
Diabetes risk assessment
This handout offers an educational opportunity for patients to learn about their risk for prediabetes and help physicians and care teams identify their patients at great risk.
PDF, 527 KBPreview
Are you at risk for prediabetes?
This patient handout is for use in waiting areas to increase awareness and pave the way for conversations about screening, testing and referral.
PDF, 92 KBPreview
ICD and CPT codes for prediabetes and diabetes screening
Use a fasting plasma glucose or hemoglobin A1C (A1C) to identify people with prediabetes.
PDF, 2,856 KBPreview
M.A.P. to diabetes prevention for your practice
Offers a roadmap to applying the elements of the diabetes prevention identification and referral guide.
PDF, 67 KBPreview
Retrospective prediabetes identification algorithm
This infographic offers practices an option to adapt/incorporate an identification and referral process into their electronic health records and generate a registry of patients at risk for type 2 diabetes.
PDF, 88 KBPreview
So you have prediabetes…now what?
This patient handout is for use by physician practices in the exam room after screening has revealed that a patient has prediabetes. Helps the patient leave the office visit with concrete information for later reference.
PDF, 100 KBPreview
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Obtaining CME credits with STEPS Forward™
AMA PRA Category 1 Credit™ will be available for the activity. Physicians should claim only the credit commensurate with the extent of their participation in the activity. In order to claim AMA PRA Category 1 Credit™, you must: 1) view the module in its entirety, 2) successfully complete the quiz by answering 4 out of 5 questions correctly and 3) complete the evaluation.
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