Emerging Issues

Major challenges exist to both the public health and clinical implementation of lifestyle intervention for preventing type 2 diabetes. For a serious commitment to primary prevention, four areas need to be addressed: identification of candidates for diabetes prevention, delivery of lifestyle interventions, economics, and ethics.

Although an estimated 54 million people have prediabetes in the United States, how best to identify persons at high risk for diabetes is not clear.²⁴ One approach is to identify candidates for primary prevention in the clinical care system at an opportunistic encounter (that is, during a visit by patients to their health care providers for conditions unrelated to diabetes prevention). Limitations to opportunistic screening exist because persons with limited or no access to health care will be overlooked. Persons who have health insurance and persons who are more likely to use the health care system will be preferentially identified. Screening for diabetes outside of the opportunistic clinical setting raises the issues of how programs can ensure that persons with positive results are referred and receive the necessary clinical care and how patients will receive access to appropriate interventions if prediabetes or diabetes is diagnosed. The responsibility of clinical followup is equally challenging.

At present, evidence is not clear whether lifestyle intervention from the Diabetes Prevention Program (DPP) can be delivered with similar efficacy through integration into health care systems or in the community. Physicians may not have the means to deliver these interventions and may have little or no resources necessary to support them. It is also unclear whether other practicing professionals will be able to match the success of the DPP interventionists who were trained in counseling on nutrition, exercise, and behavior modification.²² Furthermore, it is not certain who will be responsible for the administration of lifestyle interventions, how quality will be assessed and ensured, or how these services will be covered. Economic studies may help to address these issues. For example, the DPP included a prospective economic evaluation to address two issues about the interventions to prevent type 2 diabetes: the cost of interventions to prevent type 2 diabetes and whether these interventions are a good value. According to the results, on balance, primary prevention is a good investment for health insurers and society.²⁵ While health insurers may be primarily responsible for reimbursement of the interventions' direct medical costs, including the costs of delivering the interventions and the costs of treating adverse effects of the interventions, other sectors of society will be responsible for the patient-specific direct medical costs, including deductibles and copayments, direct nonmedical costs, and time off from work.

The ethical implications of translating diabetes prevention by lifestyle interventions into public health and clinical practice are complex and challenging. According to results of the DPP, some experts assert that the health promotion activities and drug interventions should be widely applied because the results are obviously beneficial and without substantial adverse effect.

Diabetes prevention science has evolved over the past two decades, with major breakthroughs in controlling complications and now in preventing the disease's onset. Continuing efforts are needed as more Americans develop type 2 diabetes and spend increasing periods of time living with the complications of the disease.

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