Cardiologists could and should take more action in guiding their patients to interventions aimed at delaying, and even preventing, diabetes, USF Health faculty proposed last month in a review published  in the American Journal of Cardiology.

“We propose cardiologists can play a key role in preventing diabetes and aligning practice patterns with guideline recommendations among endocrinology, cardiology, and primary care stakeholders,” wrote Nicholas W. Carris, PharmD, assistant professor in the USF Health College of Pharmacy.

The review article, which summarizes previously published studies on the topic, presents cohesively for the first time the specific factors contributing to an apparent lack of action by clinicians, and suggests an approach that might better encourage cardiologists to proactively engage their patients who have prediabetes.

“The prediabetes timeframe is an opportunity to act and significantly reduce the likelihood of someone progressing to diabetes,” Dr. Carris said. “It’s an opportune time to help patients at considerable cardiometabolic risk and to have a significant impact on the current diabetes epidemic.”

“Eighty-four million patients in the United States have prediabetes and at least 70 percent will develop diabetes unless they receive an intervention,” he said. “Most of these patients have or are at risk for cardiovascular disease, with recent reports describing significantly increased microvascular and macrovascular risks among patients with prediabetes.”

Central to what Dr. Carris and authors suggest is for cardiologists to actively engage their patients with prediabetes and implement evidence-based methods of diabetes prevention.

“For several key reasons, we believe cardiologists have a responsibility and opportunity to improve the health of their patients with prediabetes by making it a very high priority to prevent progression to diabetes,” Dr. Carris said. “First, we must recognize that multiple cardiovascular medications may increase risk for new-onset diabetes. Second, avoiding or delaying diabetes’ onset can improve quality of life and decrease health-system cost. And third, because heart disease and stroke are the most common causes of death in people with diabetes, we expect that preventing diabetes will improve long term health.”

The authors go on to note how strong an influence cardiologists could have on shifting the diabetes epidemic.

“Cardiologists are increasingly being asked to weigh in on diabetes management as select agents demonstrate cardiovascular benefit… as the mortality risk of patients with a history of myocardial infarction and diabetes is almost double that of patients with a history of myocardial infarction who are free of diabetes, there is even more potential benefit in delaying/avoiding diabetes in patients with cardiovascular disease.”

Current methods of intervention show an impact in reversing prediabetes or slowing progression to diabetes, Dr. Carris said.

“Cardiologists are centrally positioned to help patients adopt a healthier lifestyle and prescribe therapeutic and preventive medications when appropriate,” he said. “Studies have shown that intensive lifestyle intervention, metformin, and other medications reduce the progression to diabetes.

“The bottom line is, it cannot be ignored that avoiding diabetes is an important outcome – at the very least from a humanistic perspective – and cardiologists are pivotal to helping patients avoid diabetes.”

More than 80 million Americans have prediabetes, increasing their chances of developing type 2 diabetes and cardiovascular disease, according to the Centers for Disease Control and Prevention.

USF College of Public Health’s Dr. Janice Zgibor, associate professor in the Department of Epidemiology and Biostatistics, and research colleagues set out to determine if weight loss and cardiovascular risk reduction was maintained following a lifestyle intervention.

Self-selection of a lifestyle intervention may be the key to reducing a patient’s risk of developing diabetes and its associated health complications, according to results. Their study, “Influence of Patient-Centered Decision Making on Sustained Weight Loss and Risk Reduction Following Lifestyle Intervention Efforts in Rural Pennsylvania,” is published in the March 2016 issue of The Diabetes Educator.

Zgibor and colleagues examined eight rural Pennsylvania communities, focusing on individuals who were obese, but did not yet have diabetes.

Individuals were split into groups based on three different types of lifestyle interventions: a face-to-face meeting, instructional DVD or internet-based intervention. A fourth group was allowed to self-select, choosing one of the three intervention modalities of their preference.

Participants made in-person visits at three, six, 12 and 18 months after enrolling in the study to get their height, weight, blood pressure and waist circumference measured. Blood samples were also collected for analysis of cardiovascular risk reduction changes, including changes in glucose and triglycerides. (Photo courtesy of Dr. Gretchen Piatt)

“We cast the net broad and looked at the comparative effectiveness of different ways to deliver a diabetes prevention curriculum,” Zgibor said.

The study reached a total of 434 participants who were assigned to one of the four lifestyle intervention modality groups.

Despite the modality, all content for the intervention was the same, according to Zgibor.

Participants were asked to lose at least five percent of their body weight and to decrease at least one cardiovascular disease risk factor following the intervention.

Training for the intervention was provided by the University of Pittsburgh Diabetes Prevention Support Center and consisted of a 12-week comprehensive lifestyle behavior change program adapted from the lifestyle intervention used in the national Diabetes Prevention Program.

More than half of all participants in each intervention group lost at least five percent of their total body weight following the intervention and maintained that loss at their 18-month follow-up meeting, losing an average of 20 pounds.

Trained community preventionists delivered all interventions and community peer leaders provided informational and emotional support to participants. (Photo courtesy of Dr. Gretchen Piatt)

The group with the largest achievement and maintenance of weight loss was the self-selection group, according to Zgibor.   They were more than twice as likely to maintain that weight loss at 18 months.

They found the key to not only reducing diabetes and cardiovascular risk, but also sustained reduction of that risk, is self-selection of the modality in which the lifestyle intervention was delivered.

“That’s where we found the most impact, when people can decide what they want do to, it tends to be most effective,” Zgibor said.

The study, called REACT, is one of the first to compare the long-term effectiveness of different modalities of delivering lifestyle interventions in multiple, underserved, rural communities.

“This is the first of its kind to look at people out in the community, in the real world, and what helps them to sustain weight loss,” Zgibor said.

Dr. Gretchen A. Piatt, assistant professor at the University of Michigan School of Public Health and principal investigator for the REACT study, said this research added to an area in need of illustrating how lifestyle intervention self-section works at the community level.

“We were able to take an intervention that was shown to be effective in large clinical trials and effectively translate it in a community setting for people who were struggling with their weight and diabetes risk on a daily basis,” Piatt said.

Zgibor, who joined the COPH in late 2015, hopes to expand upon this research in Tampa to examine hypertension and obesity in low-income minority women of childbearing age.

“We want people from those communities to tell us what they need and have them be part of the development process,” she said.

She will be holding focus groups with members of the community to determine intervention possibilities.

She appreciated being part of the REACT study because it provided her proof that lifestyle interventions play an important role in overall health and can be sustained.

“Given the huge problem that obesity is in this country, this tells us that something can be done,” she said. “There is a lot of awareness around healthy eating and chronic conditions that go along with obesity, but there is not enough awareness of things that can work, so understanding the challenges and meeting the needs is the message and this was the first step at getting at that.”

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Piatt, G.A., Seidel, M.C., Powell, R.O., Zgibor, J.C. Influence of Patient-Centered Decision Making on Sustained Weight Loss and Risk Reduction Following Lifestyle Intervention Efforts in Rural Pennsylvania. The Diabetes Educator [Internet]. 2016 Mar 8 [cited 2016 May 5]; Available from: http://tde.sagepub.com/cgi/doi/10.1177/0145721716636962

Story by Anna Mayor, USF College of Public Health