1. What is the relationship between the Guide to Community Preventive Services and the Centers for Disease Control and Prevention's (CDC) and the Division of Diabetes Translation (DDT)?

The Guide to Community Preventive Services is a group of systematic reviews and evidence-based recommendations that summarize the scientific evidence on the effectiveness of interventions to reduce disease, illness, injury, and to promote health. These reviews are performed for the Task Force on Community Preventive Services, which is a 15-member group of national and regional experts in public health, clinical care, and health promotion who do not work for the federal government. CDC staff members, including those from the Division of Diabetes Translation, support the Task Force. The Task Force reviews the evidence on effectiveness, then formulates recommendations using an explicit process. These recommendations are thus independent of CDC. CDC's DDT health professionals review the evidence and recommendations from the Task Force and then provide guidance on their use.

2. How were the diabetes recommendations developed?

The Task Force on Community Preventive Services is an independent group of individuals with public health expertise who established the content and processes to be used in the Guide, and ultimately approved the recommendations in this document. CDC's DDT and Epidemiology Program Office (EPO) and the Task Force worked closely to systematically review the literature, synthesize the information, and make suggestions to the Task Force for recommendations. An external working group advised and guided CDC's DDT in all phases of this activity.

3. What "rules" were used to determine the diabetes recommendations?

The "rules" for systematic retrieval of relevant studies, quality assessment of studies, data synthesis, and the methods of formulating recommendations were developed under the direction of the Task Force. For a description of the process, visit the Internet at http://www.thecommunityguide.org.*

4. Who wrote this report?

This document was written by staff members of CDC's Division of Diabetes Translation and the Community Guide Branch of EPO. The conclusions in this report represent the evaluations and discussions of the entire 15-member Task Force on Community Preventive Services. Task Force member George Isham, MD, medical director and chief health officer for HealthPartners, Bloomington, Minnesota, represented the Task Force in the development of this report in coordination with a team of consultants.

5.Why does the Guide review interventions in both community settings and in health care systems?

The Guide reviews interventions that occur outside traditional clinical settings as well as interventions relevant to the health of populations. Thus, the Guide reviews the effectiveness of diabetes education in community settings, such as the home and faith institutions. The Guide also reviews health care system interventions that manage populations along with individual patients. The Guide examines the effectiveness of disease management, focusing on populations and individuals with diabetes, rather than one-on-one patient care. The latter area is the focus of the U.S. Preventive Services Task Force that examines issues of screening for various risk factors and diseases (including diabetes and gestational diabetes), and the effectiveness of patient counseling for health promotion. Although addressing the needs of individuals, case management was included in the Guide review because it involves health care system-level changes and uses population-based approaches.

6. The education interventions reviewed in the Guide are examined as single-component interventions. Diabetes education is often delivered as part of a set of interventions. How do you justify evaluating these interventions in isolation?

In evaluating the effectiveness of interventions, it is important to examine the parts of programs as single entities, in order to minimize the effects of other interventions. Otherwise, we can't clarify which interventions lead to positive outcomes. We realize that education is often delivered with other interventions, but in performing systematic reviews, it is important to isolate educational components when trying to answer questions on effectiveness. We recognize the limitations of this approach; further well designed studies are needed to examine the multicomponent approaches that are important in the care of people with diabetes. With limited public health resources, we need to be careful that our programs promote effective interventions without using extra ones that might not contribute to positive outcomes.

7. What does it mean when the recommendation for an intervention has "insufficient evidence"?

"Insufficient evidence" means that the Task Force was unable to issue a recommendation for the use of that intervention. It does not mean that the intervention is ineffective or that it should not be implemented. Rather, it means that at present, there were not enough "quality" studies — as defined by criteria established by the Task Force — that demonstrate effectiveness and that these are key areas for future research.

8. What is the value of this work? It seems to raise many questions?

The work of the Task Force on Community Preventive Services represents an important, evidence-based summary of the effectiveness of community and population-based interventions to prevent disease and injury. We agree that the Guide raises many questions. However, the Morbidity and Mortality Weekly Report Recommendations and Reports (MMWR/RR) and the American Journal of Preventive Medicine Supplement represent a "beginning," when it is not unusual for questions to outnumber answers regardless of the topic. With more experience and studies, and evolving methodology, more definite "answers" will become available. Nevertheless, the present recommendations reflect the state of knowledge of effectiveness of interventions in diabetes care. The Guide provides great insight into what we do not know and suggests many future research topics. The message is very clear after examining this literature: we must better evaluate many of the programs we currently implement and support.

9. What do CDC's health professionals think of these recommendations?

We support this work because this synthesis of existing evidence on the effectiveness of diabetes-related interventions can be used in many ways. Mainly, it can begin to direct our program and research efforts to prevent diabetes and promote health and quality of life among people with diabetes. This entire process, however, must be viewed as a "beginning." More studies are continuously being published and the methods of performing reviews and integrating data are evolving since this work on diabetes began almost three years ago.

10. How does CDC suggest using these recommendations?

The recommendations of the Guide to Community Preventive Services are useful to help prioritize potential programs for communities and health care systems. Many factors go into deciding whether to promote any program or intervention and the Guide is but one piece of evidence that might be useful in the decision making process. We do not recommend that current programs be changed based on the Guide's recommendations. Nor do we suggest that future programs necessarily revolve only on the Guide's recommendations. However, the systematic process involved in establishing the recommendations for diabetes should be applied to all our thinking when implementing any program. Further, when programs are completed, it is important to clearly describe the program and results in a published article, so that more evidence will be available for developing subsequent guidelines.

11. Does the Guide suggest that further research is needed?

The systematic evidence reviews on the effectiveness of the diabetes recommendations show that there are many unanswered questions. This publication represents an initial effort to carefully and systematically base program decisions on evidence, which will evolve over time, both in content and methodology. These are areas where further research is needed to make it clear which interventions are effective and to show how these can best be applied to certain populations. Research is particularly needed on the effectiveness of the interventions that did not yet have enough evidence to make a recommendation; these included diabetes self-management education in camps, the work site, and in the home for adults, as well as the education of school personnel about diabetes. The lack of evidence in these areas underscores the importance of publishing results of public health programs, so that more studies can be considered in determining recommendations.

12. Might not all this emphasis on evidence lead to a stifling of innovation, a hesitancy to tailor programs to individual and community needs, and an inability to identify programs that are based on solid evidence?

CDC's health professionals recognize the importance of innovation, creativity, and community and individual needs when developing and implementing programs. We advocate critical appraisal of existing knowledge to provide a solid base for innovation and creativity to flourish. As we develop programs, we must carefully evaluate them, so that we continually advance the knowledge base that helps improve the health and quality of life of people with diabetes.

13. How do the recommendations of the Guide relate to the primary prevention of diabetes?

The diabetes-related interventions reviewed to date address the needs of people with diagnosed diabetes. Primary prevention has clearly become a critical diabetes issue and community interventions to promote physical activity are addressed in the MMWR/Vol. 50, No. RR-16/September 28, 2001, as well as the American Journal of Preventive Medicine 2002;22(1 Suppl).

14. How do these recommendations apply to different settings and racial and ethnic groups?

The Guide process involves carefully examining existing data to see what racial and ethnic groups and settings they apply to and it comments on these issues. The recommendations for diabetes self-management education in the home for adolescents with type 1 diabetes and in community gathering places for adults with type 2 diabetes apply to people with a broad range of racial and ethnic backgrounds. Disease and case management can be used in managed care organizations and disease management can also be used in community clinics. These health care system interventions involved people with a range of racial and ethnic backgrounds, although in many of these studies, adequate demographic data were not provided.

15. What are the plans for CDC and future Guide reviews?

CDC supports the work of and concepts underlying the Guide and plans to continue this support. Further reviews are planned on other health care system interventions; the effectiveness of interventions in the families of people with diabetes; and public policies about diabetes. CDC's health professionals are very interested in the critical evidence appraisal of effective diabetes interventions and programs and they plan to evaluate other interventions using the methods of the Guide and other techniques for systematic reviews and summaries (for example, meta-analyses). The CDC plans to promote strategies based on evidence and to formulate research agendas based on thorough reviews of the literature that will help identify knowledge gaps.

16. Where can we get more information about these reviews?

The supplement to the American Journal of Preventive Medicine in May 2002 — Am Journal of Prev Med 2002;22(1 Suppl) — provides details on the recommendations of the Task Force and the supporting evidence for both diabetes and physical activity interventions. Further information on the Guide process and summaries of the diabetes recommendations and others are on the Guide's Web site at http://www.thecommunityguide.org.*

* Links to non-Federal organizations found at this site are provided solely as a service to our users. These links do not constitute an endorsement of these organizations or their programs by CDC or the Federal Government, and none should be inferred. The CDC is not responsible for the content of the individual organization Web pages found at these links.

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Page last modified: December 20, 2005
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