Prediabetes Risk Unrecognized by Many PCPs

Laird Harrison

July 26, 2017

Few primary care practitioners know when to screen their patients for prediabetes, researchers say.

"We think the findings are a wake-up call for all primary care providers to better recognize the risk factors for prediabetes, which is a major public health issue," Eva Tseng, MD, an assistant professor at the Johns Hopkins University School of Medicine in Baltimore, Maryland, said in a news release.

Only 6% of the 140 primary care providers surveyed at a medical conference identified 11 risk factors that should prompt screening under the guidelines of the American Diabetes Association (ADA).

Dr Tseng and colleagues published their findings online July 20 in the Journal of General Internal Medicine.

Eighty-six million adults have prediabetes, and 70% will go on to develop diabetes. Lifestyle changes could prevent this progression, but most people with the condition are not aware they have it, and only a quarter report receiving relevant lifestyle recommendations, the researchers write.

To find out whether the problem could stem from a lack of knowledge among primary care physicians, the researchers asked attendees at a 2015 primary care retreat for practices associated with Johns Hopkins to take a survey. The survey respondents received $10 gift cards in exchange.

Most participants were physicians trained in internal medicine, family medicine, or internal medicine-pediatrics. There were nine nurse practitioners and one physician assistant. Almost three quarters were female, 55% were white, 23% Asian, and 14% African American. More than half (59%) had been in practice at least 10 years.

Participants were asked to identify 11 risk factors for prediabetes:

  • age ≥45 years,

  • body mass index ≥25 kg/m2,

  • hypertension,

  • dyslipidemia,

  • heart disease,

  • family history of diabetes in a first-degree relative,

  • sedentary lifestyle,

  • African-American race,

  • Asian-American race,

  • Latino ethnicity, and

  • history of gestational diabetes,

The researchers culled the list from ADA guidelines. On average, the participants identified eight of these factors. They were most likely to miss Asian race and Hispanic ethnicity.

Seventeen percent correctly identified the fasting glucose (100 - 125 mg/dL) and HbA1c (5.7% - 6.4%) laboratory values for diagnosing prediabetes.

Of the medicine-pediatrics providers, 43% picked the correct HbA1c values compared with 20% of family medicine and 12% of internal medicine specialists, a statistically significant difference (P = .02).

A quarter of the participants correctly identified weight loss of 5% to 7% as the recommended target for people diagnosed with prediabetes, and 45% correctly identified 150 minutes per week as the recommended minimum amount of physical activity.

The survey also asked participants about their approach to managing prediabetes. Nine of 10 used fasting blood glucose and HbA1c as screening tools.

Almost all (99%) identified counseling on diet and physical activity as their initial management strategy, with 12% referring patients to behavioral weight loss programs.

A quarter never prescribed metformin for prediabetes, and 36% prescribed it for no more than 5% of their patients. The respondents were more likely to prescribe metformin for patients who had high body mass index measurements or for patients who did not respond to lifestyle recommendations.

In its 2017 guidelines, the ADA recommends that metformin be considered in patients with prediabetes who have failed to decrease their risk for diabetes through lifestyle change.

Although 42% of the respondents found the ADA guidelines helpful, 30% were unfamiliar with them.

One limitation of the study is that the participants were all associated with Johns Hopkins and might not be representative of practitioners across the country, Dr Tseng acknowledged in the news release. But she said it was valuable because she did not know of any other survey of primary care physicians' approach to prediabetes.</p p>

"Primary care providers play a vital role in screening and identifying patients at risk for developing diabetes," coauthor Nisa Maruthur, MD, an assistant professor of medicine at the Johns Hopkins University School of Medicine, said in the news release. "This study highlights the importance of increasing provider knowledge and availability of resources to help patients reduce their risk of diabetes."

The study received funding from the National Institutes of Health. The authors have disclosed no relevant financial relationships.

J Gen Intern Med. Published online July 20, 2017. Abstract

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