Discussion
This study reports three major findings. First, more than 75% of adults who were overweight or obese and reported pre-diabetes received a provider’s advice to reduce the risk for diabetes through lifestyle change, much higher than the prevalence (23%) reported in a general pre-diabetes population not limited to overweight or obesity status.9 Second, a disparity between Hispanics and non-Hispanic whites was identified in this study’s population in regard to receiving provider’s advice about lifestyle management. Finally, receiving advice from a provider significantly increased the likelihood of lifestyle change. Over 70% of those who received lifestyle advice in the study reported that they followed the provider’s advice.
Lifestyle interventions have been shown to be effective in reducing the risk of diabetes.4 8 19 20 However, a previous study indicated that less than 25% of a general adult population of pre-diabetes patients received provider’s advice about lifestyle change during office visits.9 This study found a much higher prevalence for receiving lifestyle management from health providers (76.5%) when the population of interest was limited to those who were overweight and obese. The results suggest that the gap between pre-diabetes treatment guidelines and clinical practice was reduced in people who were overweight or obese. Health professionals might pay more attention to reduce the risk of diabetes in a high-risk population. However, in this study, one quarter of adults with a BMI ≥25 kg/m2 and pre-diabetes did not receive provider’s advice about lifestyle change, a finding that becomes more concerning when the prevalence of diabetes screening in ambulatory care is considered. A study using the US National Ambulatory Medical Care Survey from years 2012–2015 reported that fewer than 15% of adults with BMI ≥25 kg/m2 and pre-diabetes indicators were screened for diabetes.10 With the growth of pre-diabetes prevalence in the USA, efforts have been made to increase the awareness of pre-diabetes through treatment guidelines1 and the National Diabetes Education Programme.21 However, screening for pre-diabetes and delivering pre-diabetes management are still a challenge in clinical practice for the entire US population.9 10
This study identified a racial disparity between Hispanics and non-Hispanic whites with pre-diabetes related to receiving provider advice about lifestyle change. Overall, Hispanic Americans were more likely to receive lifestyle management advice from their providers. The subgroup analysis indicated that the biggest difference occurred in the advice on diet change, where 66% of Hispanic adults received advice to reduce fat or calories intake vs 46% of non-Hispanic whites (p<0.001). In the USA, the prevalence of diabetes in Hispanic Americans is 17%, higher than non-Hispanic whites (8%).22 The higher prevalence of diabetes in Hispanic population might make health professionals more likely to address lifestyle change management to this population with high risk of developing diabetes. Research regarding Western diet acculturation and traditional Hispanic food choices may have influenced the increased likelihood to discuss dietary factors with Hispanic patients.23 24 The increased focus on lifestyle advice compared with non-Hispanic white adults may be influenced by provider’s perceptions about reported low levels of physical activity in Hispanic Americans.25
This study found that those receiving the provider’s advice were more likely to report reducing fat or calories intake and increasing exercise than those without provider advice. The results suggest providers advice would influence pre-diabetes lifestyle management. Providers often serve as a major resource to help patients learn about diabetes management.26 Patients may view the communication from their provider as a more trusted, reliable and effective source of information to address their specific health concerns.27 Patients may be more inclined to engage in lifestyle change after getting instructions from their provider than from developing self-awareness about pre-diabetes or knowledge obtained from other sources. However, more studies are needed to examine the long-term effect of health provider’s advice on quality, engagement and outcomes associated with pre-diabetes management in the overweight and obese population.
Whether patients follow a provider’s advice after an office visit is another concern in pre-diabetes management. Adherence to lifestyle change is critical to reduce the risk of type 2 diabetes. The results showed that after receiving a provider’s advice, over 80% of people reported reducing fat or calories intake and controlling or losing weight, and 70% reported increasing physical activity or exercise. The provider’s advice or the person’s perceived diabetes risk could contribute to the lifestyle change behaviour. Abel et al’s study indicated that supportive factors would help patients with pre-diabetes to make dietary changes, such as determination not to develop diabetes, clear information and manageable strategies and supportive relationship.28 Additional nutrition care is important to support dietary change in pre-diabetes management.29 Further studies are needed to examine the long-term adherence to lifestyle management to determine factors that sustain lifestyle change to reduce the risk of diabetes in overweight and obese populations.
This study provides important implications for pre-diabetes management in primary care. Compared with previous research assessing the general adult population, the gap between clinical guidelines regarding lifestyle style change in pre-diabetes treatment and real-world practice was reduced significantly in the overweight and obese population. However, inequitable access to diabetes care presents a major barrier to getting advice about diabetes disease management from a primary care provider.30 Addressing access to care may improve the dissemination of important lifestyle, diet and disease management information to vulnerable populations with type 2 diabetes. Delivering equitable population-based lifestyle interventions remains challenging in preventing and controlling type 2 diabetes. Primary care providers play an essential role in motivating patients to change their lifestyle to manage pre-diabetes. Patient-centred care has been proposed as a successful approach in diabetes management.31 32 Primary care providers should take the opportunity to understand their patients’ behaviour and identify barriers to pre-diabetes management. This would help personalise lifestyle intervention delivery, improve the quality of health advice and achieve desired treatment goals.
Limitations
First, all eligible respondents included in this study represented US adults who self-reported they were aware of having pre-diabetes. The findings of this study may not be generalised to the US population whose pre-diabetes diagnosis was determined by laboratory test values.33 Second, the results from NHANES data reflected a snapshot in time of participants’ behaviour to prevent or delay type 2 diabetes. It is unknown whether receiving a provider’s advice translated into actual behavioural change or long-term adherence to improved approaches to healthy lifestyle choices. The results should be interpreted with some caution as there may be discrepancies between what the respondent reported versus how well they followed the provider’s advice. Also, this study did not imply any causal relationships between a provider’s lifestyle management advice and adopting all or portions of that advice or between a provider’s advice and successful prevention of pre-diabetes disease progression. Third, the details of providers’ advice, such as duration and intensity, were not available in the NHANES. Variations in delivering lifestyle management advice might exist among the providers; however, this study could not measure the quality of the providers’ advice about lifestyle factors on pre-diabetes management. Additionally, the providers’ specialties were unknown, so the differences in lifestyle management delivery patterns among health providers with various specialties were not examined. Finally, the effects of the providers’ advice on treatment outcomes (eg, glucose control) were not assessed. This study suggests that the providers’ advice increased the likelihood of implementing lifestyle change to manage pre-diabetes; however, further research is needed to compare the health outcomes associated with lifestyle changes in those receiving a provider’s advice vs those who did not receive advice.