Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia.
Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia.
JAMA Netw Open. 2019 May 3;2(5):e193160. doi: 10.1001/jamanetworkopen.2019.3160.
Coordinated efforts by national organizations in the United States to implement evidence-based lifestyle modification programs are under way to reduce type 2 diabetes (hereinafter referred to as diabetes) and cardiovascular risks.
To provide a status report on the reach and use of diabetes prevention services nationally.
DESIGN, SETTING, AND PARTICIPANTS: This nationally representative, population-based cross-sectional analysis of 2016 and 2017 National Health Interview Survey data was conducted from August 3, 2017, through November 15, 2018. Nonpregnant, noninstitutionalized, civilian respondents 18 years or older at high risk for diabetes, defined as those with no self-reported diabetes diagnosis but with diagnosed prediabetes or an elevated American Diabetes Association (ADA) risk score (>5), were included in the analysis. Analyses were conducted for adults with (and in sensitivity analyses, for those without) elevated body mass index.
Absolute numbers and proportions of adults at high risk with elevated body mass index receiving advice about diet, physical activity guidance, referral to weight loss programs, referral to diabetes prevention programs, or any of these, and those affirming engagement in each (or any) activity in the past year were estimated. To identify where gaps exist, a prevention continuum diagram plotted existing vs desired goal achievement. Variation in risk-reducing activities by age, sex, race/ethnicity, educational attainment, insurance status, history of gestational diabetes mellitus, hypertension, or body mass index was also examined.
This analysis included 50 912 respondents (representing 223.0 million adults nationally) 18 years or older (mean [SE] age, 46.1 [0.2] years; 48.1% [0.3%] male) with complete data and no self-reported diabetes diagnosis by their health care professional. Of the represented population, 36.0% (80.0 million) had either a physician diagnosis of prediabetes (17.9 million), an elevated ADA risk score (73.3 million), or both (11.3 million). Among those with diagnosed prediabetes, 73.5% (95% CI, 71.6%-75.3%) reported receiving advice and/or referrals for diabetes risk reduction from their health care professional, and, of those, 35.0% (95% CI, 30.5%-39.8%) to 75.8% (95% CI, 73.2%-78.3%) reported engaging in the respective activity or program in the past year. Half of adults with elevated ADA risk scores but no diagnosed prediabetes (50.6%; 95% CI, 49.5%-51.8%) reported receiving risk-reduction advice and/or referral, of whom 33.5% (95% CI, 30.1%-37.0%) to 75.2% (95% CI, 73.4%-76.9%) reported engaging in activities and/or programs. Participation in diabetes prevention programs was exceedingly low. Advice from a health care professional, age range from 45 to 64 years, higher educational attainment, health insurance status, gestational diabetes mellitus, hypertension, and obesity were associated with higher engagement in risk-reducing activities and/or programs.
Among adults at high risk for diabetes, major gaps in receiving advice and/or referrals and engaging in diabetes risk-reduction activities and/or programs were noted. These results suggest that risk perception, health care professional referral and communication, and insurance coverage may be key levers to increase risk-reducing behaviors in US adults. These findings provide a benchmark from which to monitor future program availability and coverage, identification of prediabetes, and referral to and retention in programs.
重要性：美国国家组织正在共同努力实施基于证据的生活方式改变计划，以降低 2 型糖尿病（以下简称糖尿病）和心血管风险。
目的：提供全国范围内预防糖尿病服务的可及性和使用情况的现状报告。
设计、环境和参与者：这是一项全国代表性的基于人群的横断面分析，对 2016 年和 2017 年国家健康访谈调查数据进行了分析。调查于 2017 年 8 月 3 日至 2018 年 11 月 15 日进行。调查对象为患有糖尿病高风险（定义为没有自我报告的糖尿病诊断，但患有确诊的前期糖尿病或美国糖尿病协会（ADA）风险评分升高（>5）的非孕妇、非住院、非机构化的、18 岁及以上的平民受访者。分析包括（和在敏感性分析中，不包括）超重的成年人。
主要结果和措施：估计了具有升高体重指数的高风险成年人中接受关于饮食、体力活动指导、体重减轻计划转介、糖尿病预防计划转介或这些建议的任何建议的绝对人数和比例，以及那些在过去一年中肯定参与任何活动的人数和比例。为了确定存在哪些差距，绘制了现有的与预期目标达成情况的预防连续图。还检查了按年龄、性别、种族/族裔、教育程度、保险状况、妊娠糖尿病史、高血压或体重指数的风险降低活动的差异。
结论：在这项分析中，包括了 50912 名受访者（代表全国 22300 万成年人），年龄在 18 岁或以上（平均[标准差]年龄为 46.1[0.2]岁；48.1%[0.3%]为男性），有完整的数据且没有自我报告的由其保健专业人员诊断的糖尿病。在所代表的人群中，36.0%（8000 万人）有医生诊断的前期糖尿病（1790 万人）、升高的 ADA 风险评分（7330 万人）或两者兼有（1130 万人）。在患有确诊前期糖尿病的人群中，73.5%（95%可信区间，71.6%-75.3%）报告从他们的保健专业人员那里获得了糖尿病风险降低的建议和/或转介，其中 35.0%（95%可信区间，30.5%-39.8%）至 75.8%（95%可信区间，73.2%-78.3%）报告在过去一年中参与了各自的活动或计划。一半具有升高 ADA 风险评分但没有确诊前期糖尿病的成年人（50.6%；95%可信区间，49.5%-51.8%）报告接受了风险降低建议和/或转介，其中 33.5%（95%可信区间，30.1%-37.0%）至 75.2%（95%可信区间，73.4%-76.9%）报告在过去一年中参与了活动和/或计划。参与糖尿病预防计划的人数极低。来自保健专业人员的建议、45 岁至 64 岁年龄范围、较高的教育程度、医疗保险状况、妊娠糖尿病、高血压和肥胖与更高的风险降低活动和/或计划的参与度相关。
结论：在患有糖尿病高风险的成年人中，在接受建议和/或转介以及参与糖尿病风险降低活动和/或计划方面存在重大差距。这些结果表明，风险感知、保健专业人员的转介和沟通以及保险覆盖范围可能是增加美国成年人风险降低行为的关键杠杆。这些发现为监测未来的项目可用性和覆盖范围、识别前期糖尿病以及转介和保留在项目中提供了基准。
