Diabetes Prevention and Control:
A Public Health Imperative

Prevention Opportunities

• Levels of Prevention
  
  
• Types of Strategies

There is a strong scientific basis for the primary, secondary, and tertiary prevention of diabetes. However, translating the science into effective interventions to lessen the burden of diabetes requires considerable resources and effort.

Levels of Prevention
Diabetes programs should address all three levels of diabetes prevention: primary, secondary, and tertiary.

Primary prevention interventions seek to delay or halt the development of diabetes. The most compelling evidence for the effectiveness of primary prevention is for interventions targeting people with impaired glucose tolerance,¹⁰ who are at highest risk of developing diabetes. Both drugs and lifestyle changes have proven effective in helping these people delay or prevent the development of diabetes, although lifestyle changes related to losing weight and increasing physical activity have been most effective.¹⁰ Primary prevention efforts in state diabetes programs cover a wide spectrum. At a minimum, diabetes programs should partner with other programs that assume responsibility for reducing risk factors in the population at large, such as those that provide broad nutrition and physical activity interventions. (See Chapter 4.) In such partnerships, diabetes programs play a supportive rather than a leadership role. For example, diabetes programs could participate in coalitions that seek broad environmental changes to support walking. These coalitions would typically be developed, sponsored, and led by state nutrition and physical activity programs. On the other hand, diabetes programs should play a leadership role in primary prevention interventions focused on ensuring that people at highest risk for diabetes have access to interventions that will delay or avert the development of the disease. The leadership role may entail aggressively soliciting partnerships with cardiovascular health, nutrition, and physical activity programs to develop lifestyle change interventions.

Secondary and tertiary prevention interventions focus on people with diabetes and seek to prevent (secondary) or control (tertiary) the devastating complications of this disease. More proven intervention models are available for both secondary and tertiary prevention than for primary prevention. For example, maintaining near normal glucose, blood pressure, and cholesterol levels has been shown repeatedly to reduce diabetes complications.^{10, 12} Additionally, routine preventive care practices such as foot exams, eye exams, and frequent A1C testing are well-established components of quality diabetes care.¹³ To ensure that these benefits reach the people who need them, programs should develop, implement, and coordinate multilevel interventions targeting people with diabetes, their families, their health care systems, and their communities.

All three types of prevention interventions rely on active stakeholder involvement and support. Stakeholders include people with diabetes, voluntary organizations that have an interest in diabetes or serve populations disproportionately affected by diabetes, health care providers (e.g., primary care providers, endocrinologists, diabetes educators, eye care specialists), and academic institutions. However, program planners are encouraged to explore partnerships with organizations (e.g., urban planning groups, restaurant associations) that may not traditionally work with the diabetes community but can assist in implementing interventions.

Achieving population-level impact in the primary, secondary, and tertiary prevention of diabetes is a complex task that requires resources, competent leadership, and a diverse staffing mix at the national, state, and provider levels. Diabetes programs should collaborate with a wide variety of partners to ensure an appropriate balance between efforts to prevent diabetes complications and efforts to prevent the onset of diabetes. The ability to capitalize on prevention opportunities requires a strong infrastructure to plan and support interventions, nurture partnerships, and monitor and evaluate progress.

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Types of Strategies
Diabetes programs should pursue three major types of strategies: health systems change, community intervention, and health communications. These three strategies should be implemented at multiple levels and in tandem with each other.

Health Systems Change
The U.S. Task Force for Community Preventive Services strongly recommends disease and case management to improve diabetes clinical outcomes.¹⁴ Programs should not only seek to improve preventive health care practices by providers and people with diabetes, but also seek to redesign health care processes related to diabetes care.

Strategies to improve health care systems and access to quality care can address either the primary, secondary, or tertiary prevention of diabetes. Such strategies addressing primary prevention might aim to identify more people with impaired glucose tolerance by increasing screening among populations at high risk, including obese people, people over age 45, and members of certain racial or ethnic groups. Health system change strategies addressing secondary and tertiary prevention might demonstrate the benefit of policy interventions that support self-management of diabetes (e.g., adding lay health workers to the staff of some medical practices, using information technology to communicate with people with diabetes outside of the provider’s office,¹⁵ expanding support for patients with diabetes as the source of control of diabetes care¹⁶).

Community Intervention
Community intervention strategies can combine aspects of primary, secondary, and tertiary prevention. Community intervention strategies aimed at the primary prevention of diabetes might include community-based exercise and healthy nutrition programs targeting people at high risk for diabetes. Community intervention strategies aimed at secondary and tertiary prevention might seek to increase the availability of influenza vaccinations or to provide diabetes education for people with diabetes in gathering places for adults.¹⁴ Initiatives can also mobilize community members to improve access to care for people with diabetes, such as by establishing community diabetes support groups or by holding routine diabetes question-and-answer sessions at local pharmacies.¹⁴ Other community intervention strategies might address broader issues that affect individuals with diabetes and their families and communities, such as the need for social support and stress reduction. For example, efforts could include advocacy for increasing the availability of diabetes education programs outside of normal working hours so that entire families are able to participate together.

Health Communications
Diabetes health communications interventions are based on consumer research and often involve raising awareness of diabetes and its complications by disseminating health information to targeted audiences. Health communications should be viewed as a complementary strategy tied to health systems change or community interventions. Health communications strategies are rarely effective as stand-alone activities.

Diabetes health communications strategies are appropriate for primary, secondary, and tertiary interventions. Possible primary prevention interventions include awareness campaigns targeting people with impaired glucose tolerance, as well as their health care providers and their employers. Secondary interventions include developing and disseminating targeted messages to address misconceptions about flu and pneumococcal immunizations. Tertiary interventions include developing and disseminating targeted messages to increase rates of foot examinations for special populations.

CDCynergy, a CDC-developed CD-ROM to help organizations plan health communications activities,¹⁷ suggests that the development of health communications initiatives include the following steps:

• Defining and describing the problem.
• Analyzing the problem.
• Identifying and profiling audiences.
• Developing a communication strategy and tactics.
• Developing an evaluation plan.
• Launching the initiative and gathering feedback from participants.

Program planners are encouraged to review the experience of programs in other states or communities. However, these programs should be viewed as guides and not templates, since interventions usually need to be tailored to a particular population.

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