Diabetes Prevention Program Guide

Your Diabetes Prevention Guide

A diagnosis of prediabetes can fill you with worry, since it means that you are at higher risk for developing type 2 diabetes. You may have memories of a grandparent or parent who struggled with it, or you may even have a sibling or friend who is currently managing diabetes.

On a day-to-day basis, diabetes often means taking medications, often including injectable insulin, and often taking more than one medication. It means testing blood sugar multiple times a day. It means going to the doctor to take blood sugar tests, and tests for cholesterol and blood pressure. It means planning your day to avoid scary bouts of hypoglycemia, or low blood sugar.

When thinking about health and medical care, diabetes means a higher risk for complications such as blindness, kidney disease, neuropathy, and heart disease. It is listed as the seventh-leading cause of death in the U.S., but it plays a role in many cases of heart disease (top cause of death), stroke (fifth), and kidney disease (ninth).

Type 2 diabetes certainly sounds like a condition you want to prevent, and the great news is that, in many cases, it is preventable. If you have prediabetes, you can lower your risk of developing diabetes by over 50%, without medications, just by following a lifestyle program that includes diet and exercise changes.  

Lark's Diabetes Prevention Program (DPP) is a Centers for Disease Control and Prevention (CDC)-cerified program to prevent or delay type 2 diabetes. It involves education and support for healthy lifestyle changes through your Lark Health Coach using your smartphone. With it, you could lower your risk for type 2 diabetes and feel healthier than ever!

History of Diabetes and Its Discovery

The recognition of diabetes has been documented for nearly 4,000 years, since the ancient Egyptians noticed a classic symptom of excessive urination, which a symptom of diabetes resulting from excessive thirst, which in turn results from a high amount of sugar in the bloodstream. The ancient Indians, ancient Greeks, and ancient Persians also recognized diabetes and its link to sugar. In fact, the term "diabetes mellitus" reflects the "sweet" nature of urine due to sugar excretion.

More recently, in 1869, Paul Langerhans identified specific cells, later termed the islets of Langerhans, in the pancreas. In 1889, scientists discovered that removing the pancreas led to diabetes in dogs. Soon after came the discovery of a substance, termed "insulin," which was excreted from the islets of Langerhans, and required to prevent diabetes mellitus.

By the 1960s, blood sugar monitoring, including monitoring using home test strips, was common. The glycated hemoglobin, or A1C, measurement, eventually became the gold standard of monitoring. It indicated blood sugar control over the past three months, and is a good predictor of the development of complications.

Early treatment for diabetes included remedies such as rose oil, nettle flowers, and "jelly of viper's flesh," and some approaches still have merit today. For example, calorie restriction and exercise were prescribed before the twentieth century, and lifestyle changes are increasingly recognized as effective in improving blood sugar control and preventing diabetes.

In the twentieth century, the use of insulin as a medication immediately meant millions of lives could be saved, and improvements in delivery methods continue to improve health and satisfaction with treatment. Sulfonylureas, to increase insulin production, and metformin (Glucophage), to increase insulin sensitivity, also became standard treatments for diabetes.

Diabetes Statistics in the U.S.

Something you may realize once you start thinking about prediabetes and diabetes is how widespread they are. If it is not yourself, you are almost sure to know one or more people who are affected by diabetes or prediabetes.

Who Has Diabetes in the U.S.?

According to the National Center for Health Statistics (NCHS) within the CDC, 30 million Americans have diabetes. This is up over 50% from 1988, and includes 12.6%, or 1 out of 8, of Americans 20 years of age or older. Of those, nearly 1 out of 4 do not know it. Your chances of having diabetes are higher if you have certain characteristics.

• 16.6%, or 1 in 6, chance of diabetes if your age is 45 to 64 years.
• 26.3%, or more than 1 in 4, chance of diabetes if your age is over 65 years.
• 14.3%, or 1 in 7, if you are of Mexican origin.
• 15.1%, or over 1 in 7, if you are Asian.
• 17.5%, or more than 1 in 6, if you are black/African-American.

The risk of complications for adults with type 2 diabetes is higher for patients with poor glycemic control, defined as A1C over 9%. Overall, 15.6% of diabetes patients in the U.S. have poor control, and the following subgroups are more likely than average to have poor glycemic control:

• Adults aged 25-44 (26.2%)
• Hispanic or Latino (25.5%)
• African American or Black (19.0%)

What Are the Effects of Diabetes?

Patients with diabetes have a 15% higher risk of early death than healthy adults – it is often from direct diabetes causes or from cardiovascular diseases. The risk of complications for adults with type 2 diabetes increases with poorer glycemic control. Overall:

• 18.9% have eye damage, or retinopathy
• 22.9% have foot problems, such as numbness or amputations
• 6.6% have a stroke
• 9.8% have a heart attack
• 27.8% develop chronic kidney disease.

Economically, diabetes also has a severe impact, hitting $825 billion worldwide in 2014. The disease cost the country $327 billion in 2017, up from $245 billion in 2012 and $174 billion in 2007. Direct medical costs account for $237 billion of that, while reduced productivity accounts for $90 billion. About 1 in 7 healthcare dollars pay for diabetes-related costs.

What about Prediabetes?

Prediabetes has nowhere near the visible impact of diabetes in terms of complications and direct medical costs, but it affects far more people. The CDC estimates that 84 million American adults, or 1 in 3, have prediabetes, and fewer than 1 in 10 know about it. Nearly 1 in 2, or 48.3%, of adults over 65 years have prediabetes, and only 1 in 7 know it.

Link between Prediabetes and Diabetes

Most people who are diagnosed with prediabetes develop diabetes, but that fact does not have to get you down. It could be stressful if you interpret it as a warning that diabetes is coming soon, but you can decide how to handle your diagnosis of prediabetes.

The CDC suggests looking at your "prediabetes as a fork in the road." You can either take the fast path to diabetes by ignoring it, or you can work to delay and possibly prevent diabetes by taking charge. Since fewer than 1 out of 10 people with prediabetes know that they have it, you can consider yourself one of the lucky few who even know that they are at the fork in the road.

Consequences of Not Treating Prediabetes

Prediabetes rarely has symptoms, so it can seem easy to ignore it. People might choose not to treat their prediabetes because:

• They do not want to act "sick."
• "I don't have a health problem"
• "You cannot prevent diabetes"
• They do not know how to treat it without medications.

The actual numbers can vary, but an article in "Lancet" estimates about 10 to 15% of people with prediabetes develop diabetes each year. That value was 11% in the follow-up to the original DPP study. Eventually, about 70% of patients with prediabetes eventually develop diabetes – but reversal is possible for many people with proper treatment. The bottom line is that not treating prediabetes is almost sure to lead to diabetes, and the timeline is about 10 years. However, treating prediabetes can prevent or delay type 2 diabetes.

Why Diabetes Should Be Prevented Now

Preventing diabetes now is urgent. The urgency on a population level comes from the high and growing number of people with prediabetes and diabetes. The epidemic is growing, and leading to more complications and lower quality of life.

On a personal level, delaying or preventing diabetes is urgent for two reasons.

1. Because it is possible. Lifestyle changes among people with prediabetes can delay the onset of type 2 diabetes, and lower risk for diabetes by over 50%.
2. Because your body has known about your insulin resistance for years already. Your doctor does not find out about your prediabetes until you get high blood sugar reading or your A1C is over 5.7%. By that time, your body has been developing insulin resistance for a decade or more.

Easy Step to Prevent Diabetes via Your Smartphone

The urgency is clear, and help is one click away as soon as you are ready to act to prevent diabetes. Lark Diabetes Prevention Program can be with you every step of the way to establish healthy habits, lose weight, and fight prediabetes. Your Lark coach never judges you; instead, you get support, encouragement, and smart strategies in a text messaging-based program.  

How Does Lark Help Prevent Diabetes?

Lark helps prevent diabetes by empowering you to take charge of your health. Lark DPP provides coaching on healthy behaviors that are known to reduce diabetes risk. These include:

• Losing weight if you have extra pounds.
• Increasing your physical activity levels.
• Choosing healthier foods.
• Managing stress.
• Getting enough sleep.

Lark DPP helps prevent diabetes using the CDC curriculum. The weekly lessons are delivered to you via the app in friendly and relatable messages, so you can learn about healthy eating, physical activity, and stress management using strategies that fit into your life.

Your Lark experience may include a standardized curriculum shown to lower diabetes risk, but your program is customized for you. The app learns your habits, helps you set your own goals, and provides coaching whenever you need it – including at 11:00 p.m. when you need a quick alternative for a late-night ice cream run. Diabetes prevention starts now, and Lark is ready to journey with you.

Warning Signs of Diabetes Onset

Prediabetes has few signs, but some people may notice early signs of diabetes onset. These are related to high levels of sugar in the blood and trouble processing it.

• Being hungrier than usual even though you are eating normally. This happens because the sugar that your body makes from food stays in your blood instead of getting to the cells where it is needed. You may feel tired, too.
• Increased urination. Your kidneys have trouble reabsorbing the water that they filter because of the high amount of sugar in your blood. The result is that you excrete more water in the form of urine.
• Increased thirst. This results from the water you lose from increased urination. You might have dry mouth and itchy skin.
• Poorer vision. The changes in water retention in your body can alter pressure in your lenses.
• Signs of nerve damage. Nerve damage can lead to tingling or pain in your feet, and to reduced blood flow and slow-healing wounds.

It is important to be aware that not everyone who develops type 2 diabetes will notice warning signs of its onset. That makes it even more important to keep checking your blood glucose and/or A1C levels as your doctor recommends, even if you have no symptoms.

How to Prevent Diabetes Naturally

While nobody actually wants prediabetes, the good news is that having it often means that you can prevent or delay diabetes naturally. Eating better, exercising, losing weight, managing stress, and sleeping well can all have a significant impact on delaying or preventing diabetes.

There is even more good news when it comes to preventing diabetes naturally. First, small changes add up, so there is no need to get discouraged or overwhelmed. Just focus on small, doable, changes. Second, help is available. Lark DPP can work with you on all of those areas.

Diet

If you eat better, your insulin sensitivity and blood sugar control may increase, which means your risk for diabetes decrease. A good diet for prediabetes depends on unprocessed foods, with plenty of vegetables, lean proteins such as fish, legumes, and low-fat dairy products, whole grains, fruit, and water.

• Soft drinks – having them daily can bump your diabetes risk by 26%.
• Saturated and trans fats – They have extra calories, but worse, they can directly lower insulin sensitivity. They are in fried foods and fatty red meats. Plus, they're often in low-nutrient foods with extra calories, such as snack cookies and crackers or processed meats.
• Red meat – as little as a moderate 3-ounce serving per day can increase your risk by 19%. Choose fish or skinless poultry instead.
• Fried foods – along with trans fats, they have extra calories and often extra carbs – think about doughnuts, fried potatoes, and fried breaded chicken.
• Sugary foods – the sugar is a source of extra calories, and it bumps up blood sugar just as you might expect.
• Alcoholic beverages – mixed drinks especially are high in calories, including frequently from sugar, and can also lower your inhibition so you eat more.

How much can dietary changes lower your risk? One review article found that a Mediterranean-style diet pattern could lower risk by 19%. The diet is flexible, but includes choosing fish, olive oil, whole grains, fruits and vegetables, beans, and low-fat dairy products more often, and limiting processed foods, sweets, and red meat.

Another study estimated that those who ate the healthiest diets had a 51% lower risk of diabetes. If that is not convincing enough, what about this finding, published in the "European Journal of Nutrition?" Eating high amounts of junk food – think chips, soft drinks, and French fries, for example – was linked to a 70% greater risk of type 2 diabetes among over 200,000 participants.

Once you decide to make healthier diet choices, you may come across periodic challenges. Lark DPP includes lessons some of the most common challenges to healthy eating, and your Lark coach can guide you. Examples include:

• Shopping and cooking to prevent type 2 diabetes. Making a shopping list, putting the right things on it, and preparing them to have maximum nutrition can all have an impact.
• Eating well away from home. Eating at restaurants can be hard because of oversized portions and lack of healthy menu items. Learn what you can do to reduce your restaurant meals, and what to order when you do find yourself at a restaurant.
• Coping with triggers. Come into the Lark app when you feel a craving coming on to chat with your coach about healthier options! What about a square of unsweetened chocolate instead of a bowl of sugary chocolate ice cream? Whether you are craving a soft drink or salty snack, healthier options are possible, and can have a big impact on your diabetes risk.

Exercise

DPP: achieve or maintain 150 minutes per week of moderate physical activity

Exercise can lower your risk for diabetes independently of your body weight.  The DPP study found 44% reduction in diabetes risk for participants who achieved their exercise goals, even if they did not lose the amount of weight they had hoped.

In another study, normal-weight individuals with a normal BMI who exercised for an average of at least 1 hour per day (over 7 hours per week) had a 50% lower risk of developing diabetes compared to people whose weekly exercise totaled under 30 minutes. Among individuals who were obese in that study, the higher level of exercise was linked to a 26% lower risk. If an hour a day seems unattainable, feel better knowing the study results suggested that bumping your exercise up to 30 to 60 minutes weekly could lower your risk by 17 to 26% compared to under 30 minutes a week. That's the amount of a single walk!

Once you decide to get active to prevent type 2 diabetes, you can take steps to make it happen. For example:

• Set a goal. You might set your long-term goal at 150 minutes a week, or 30 minutes most days of the week, but a shorter-term goal if you have not exercised much recently might be 10 minutes most days.
• See your doctor. If you have any health conditions or have not exercised recently, check with your doctor before starting.
• Use a tracking program to stay motivated. Lark DPP reminds you to get active and helps you set goals, as well.
• Time is often a barrier to getting active. Between work, housecleaning, taking care of the family, and all the other obligations you may have, the day can slip by before you get a change to exercise if you are not careful. These tips can help you make exercise a regular part of your life.
• Make it a priority. Schedule it in your planner, just like you schedule other important appointments, so you are sure to block off the time.
• Break it up. You may not have 30 minutes at once, but you could squeeze in 10 minutes here and there. If not, take a 1-minute break each half-hour to stretch, march in place, or do squats.
• Multi-task. Integrate exercise into your life. Walk instead of drive to nearby stores, or replace your family time in front of the TV with family time outside. Or, walk around the field while your kids are at soccer practice.

Losing Weight

Losing weight if you are overweight is another impactful change you can make to lower diabetes risk. It may seem daunting if you have 30, 50, or 100 lb. to lose to achieve a "normal" body mass index (BMI), but you do not have to lose that much weight just to lower your risk for diabetes.

Losing 5 to 10% of your body weight can lower your diabetes risk quite a bit. That is 10 to 20 lb. if you weigh 200 lb., or 8 to 16 lb. if you weigh 160 lb. If that amount seems like a lot to lose, here is another statistic: each kilogram (2.2 lb.) of body weight that you lose can lower your risk by 16%. So, keep at it! The effort is worthwhile.

Weight loss plateaus are challenge that come up for many people when they are trying to lose weight. They can happen for many reasons: because your body is catching up with your weight loss, because your body needs a change, or because you have lost focus without realizing it.

These stalls, or plateaus, can be frustrating, but take heart in knowing that they are quite common, and you can overcome them. You can take this approach.

• Track your food intake carefully. Sometimes, extra foods creep in without being noticed unless you are very careful to count every bite. Those extra foods can lead a weight loss stall.
• Try something different. That could mean adding in a different kind of workout or trying six smaller meals instead of three larger ones. Sometimes, your body just needs a change.
• Have patience. Sometimes, your body needs some time to catch up. When it is ready, you will start losing weight again.

Stress Management

Stress is a reaction to certain situations in your environment. Some stress is good, because it prepares your mind and body to rise to the challenge. However, too much stress is unhealthy, and it can raise your risk for type 2 diabetes.

The stress response in your body includes increases in the hormones epinephrine (also known as adrenaline) and cortisol, along with a reduction in insulin. The goal is to prepare your body for fight or flight, and the result is an increase in blood sugar levels – not what you are looking for when trying to prevent diabetes! Worse, cortisol increases insulin resistance. Over time, too much stress can increase diabetes risk.

Stress can come from work, home, relationships, your health, and worries about your family. While you cannot eliminate all stress, you can work to manage it better. Lark DPP coaches you on strategies for that. Examples include:

• Accepting what you cannot change
• Talking to a friend
• Taking a walk
• Meditating or deep breathing 

Sleep

Sleep can make you feel so good, and it does wonders for your health. Specific to diabetes, too little sleep can have the following effects:

• Altering hormone levels, including of leptin, cortisol and ghrelin.
• Increasing insulin resistance.
• Lowering daytime energy levels so you are less likely to exercise.
• Increasing cravings for sweet foods.

Lark DPP tracks sleep and coaches you on achieving and/or maintaining healthy levels.

Getting Tested

Getting tested can help keep you motivated and on track. Get your blood glucose levels tested as often as your doctor recommends; this might be every three or six months if you have prediabetes. Your blood test could be:

• Fasting blood glucose: 100 to 125 mg/dl for prediabetes; lower is normal, and higher means diabetes.
• Oral glucose tolerance test: 140 to 199 mg/dl for prediabetes; lower is normal, and higher means diabetes.
• Hemoglobin A1C: 5.7 to 6.4% if you have prediabetes; lower is normal, and higher means diabetes.

Type 1 Diabetes Prevention

Type 1 diabetes is considered to be largely genetic, and prevention is not currently possible. You are at higher risk if you have a family member with the condition. The condition may be triggered when you develop a disease that ends up leading to damage to your pancreas and a loss of ability to make insulin.

Type 2 Diabetes Prevention

Type 2 diabetes has a genetic component, but is largely related to factors that are modifiable. In many cases, you can lower your risk with certain healthy behavior changes, and that is the focus of Lark DPP. The program supports you in:

• Eating better.
• Losing and/or maintaining a healthy weight.
• Exercising more.
• Managing stress.
• Getting enough sleep.

How to Reverse Prediabetes

Often, prediabetes is reversible. Many patients who adapt a healthier lifestyle can return their fasting blood sugar and A1C levels back to normal levels. This can often happen without any medications, although metformin can be necessary. The steps to lower are the same healthy behavior changes as described above.

Reversing prediabetes does not happen overnight. Detecting even a small change in A1C takes about 3 months. Instead of rushing it, take a long-term view for reversing prediabetes. Small but consistent changes might help you reverse it in a few years. These tips may help.

• Work closely with your healthcare provider or team. They can help you get the blood tests you need, keep you accountable and motivated, and connect you to any resources you may need.
• Join a DPP program, which takes a year to complete and focuses on gradual healthy changes that work for your lifestyle. A digital one, such as Lark DPP, lets you access all the material without needing to attend possibly inconvenient meetings each week.
• Ask friends and family for support. This can include moral support, such as encouragement, and physical support, such as helping you cook healthy meals or walking with you.

Diabetes Prevention Program

The Diabetes Prevention Program (DPP) was a 27-site clinical trial led by the Centers for Disease Control and Prevention (CDC) to prevent diabetes. It compared the effects of an intensive lifestyle intervention with the effects of medication with the effects of a placebo among participants with prediabetes.

• Intensive lifestyle intervention: specific weight loss and healthy eating goals, plus a goal to exercise at least 150 minutes per week, plus 16 weekly lessons given in one-on-one sessions covering diet, exercise, and other healthy behavior change materials, with subsequent group lessons.
• Medication: a glucose-lowering drug (metformin/Glucophage) plus standard lifestyle recommendations, such as losing weight, exercising more, and following a balanced diet.
• Placebo: standard lifestyle recommendations plus a placebo.

The DPP study was so successful that it remains the leading program for diabetes prevention around the country. Many insurance plans cover it, and offer it to members who have prediabetes. Other eligibility criteria may include being overweight (BMI over 25, which is 164 lb. for someone who is 5'8" tall) and being over 18 years old.

Diabetes Prevention Program Results

The DPP trial results showed that lifestyle changes work! Overall, there was a 58% reduction in diabetes risk among people in the intensive lifestyle group compared to the placebo, while the metformin group had their risk of developing diabetes decrease by 31% compared to placebo. Among individuals over 60 years old, the lifestyle group had a reduced risk of 71%!

To put in another way, 11% of people in the placebo group got diabetes, while only 4.8% of the participants in the lifestyle group and 7.8% metformin did in the first 2.8 years of the study. Over 10 years, there was a 34% lower incidence of diabetes among the lifestyle participants, and an 18% lower incidence of diabetes in the metformin group.

Program Curriculum

The CDC-approved DPP curriculum has 26 modules that focus on behavior change and achieving goals of losing 5 to 7% of body weight (for perspective, that is 9 to 13 lb. for someone who weighs 180 lb.) and increasing physical activity. The program encourages weighing yourself at each session and logging your exercise and what you eat.

The curriculum is designed to take a year to complete. The first 16 modules are presented during the first six months of the program. These are the topics that you will cover in any CDC-approved DPP, along with the description provided by the CDC.

During the final six months of the program, you will complete at least 6 of these 10 modules.

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Diabetes Prevention Program Options

You can check the CDC's website for a list of programs. There are in-person options, as well as virtual or online possibilities. As you choose, consider a variety of factors.

• Your own preferences and personality – do you want to meet in a large group or complete the curriculum in private?
• Your availability – does your schedule allow for in-person meetings each week at a specific time, or are you best off completing the program at times you can choose, which may or may not change with your schedule?
• Your hopes for the program – are you there just for the CDC-developed curriculum, or do you want extra support, such as for dealing with cravings or setting acti