January 17, 2023
More than one in three adults in the United States have prediabetes, a preventable condition that puts someone at high risk for developing type 2 diabetes.1 Prediabetes is characterized by blood glucose levels that are above normal but not high enough to qualify as diabetes.1 People living with prediabetes often experience no significant symptoms, which results in most not knowing they are at risk and may need to take action.2
Diabetes is associated with numerous health risks and complications, resulting in significant health care costs and reduced productivity. The annual estimated cost of diabetes is $327 billion and accounts for more than $89.9 billion in indirect costs in the following ways: Increased absenteeism, reduced productivity, disability and premature mortality.3,4 Low-income individuals and certain racial and ethnic minorities are disproportionately impacted by this costly chronic condition— emphasizing the potential for employers to leverage targeted prevention and treatment approaches to counteract these disparities and mitigate downstream costs.5
People with prediabetes face as much as a 50% chance of developing type 2 diabetes over the next 5 to 10 years.2 A claims-based analysis conducted by economists at the American Medical Association (AMA) compared medical expenditures over a 3-year period for individuals with prediabetes who developed diabetes compared to individuals with prediabetes who did not develop diabetes.6 The study found that annual expenditures were nearly one-third higher for patients who developed diabetes in subsequent years—with an average difference of $2,671 per patient each year.6 In addition to being a precursor to type 2 diabetes, people with prediabetes have an increased likelihood of developing heart disease, hypertension and stroke.7 Once diagnosed with type 2 diabetes, people are at risk for many serious health problems, including amputation of limbs, blindness and kidney failure.7
The good news for employers is that prediabetes can be reversed through effective intervention and treatment, mitigating its impact on workforce health and overall health care cost.8 Evidence suggests that lifestyle modifications can reduce the relative risk for developing diabetes by 40%-70% among individuals with prediabetes.9 In contrast, once a person develops type 2 diabetes, it is generally considered irreversible (though some emerging research suggests that diabetes remission may be possible through lifestyle interventions).10
There are demonstrated simple interventions that can help with prediabetes reversal. Promoting early identification through primary care and testing in clinics in addition to offering access to various lifestyle programs designed to treat prediabetes will help prevent progression toward type 2 diabetes and improve population health.
What Is Prediabetes?
According to the American Diabetes Association (ADA), individuals are diagnosed with prediabetes if their fasting blood glucose level is between 100 mg/dL and 125 mg/dL or their HbA1C (A1C) is between 5.7 and 6.4.11 A1C numbers above those ranges generally result in a diagnosis of diabetes.11 As previously noted, prediabetes itself does not typically cause symptoms the way diabetes does, but it does mean that individuals are more likely to develop the disease if they do not make significant changes to their lifestyle.
Some researchers have criticized the term prediabetes because it “medicalizes” an asymptomatic state that approximately 96 million American adults have.1,12 While overdiagnosis may be a concern, identifying people with prediabetes and engaging them in better health practices are primary ways to promote health and prevent chronic disease. Interventions needed are largely lifestyle focused and cost effective.
Risk Factors for Developing Prediabetes
There are several modifiable and non-modifiable risk factors for developing prediabetes, including:
- Excess weight: A primary risk factor for prediabetes is being overweight. The more fatty tissue a person has — particularly when it is stored inside and between the skin and muscle around the abdomen (i.e., visceral fat)— the more resistant their cells become to insulin.13
- Large waist size: A larger waist circumference is associated with insulin resistance. The risk of insulin resistance increases with a waist measurement of 35 or more inches in women and 40 or more inches in men.13
- Sleep issues: Prediabetes is positively associated with poor quality sleep.14 Lack of sleep (i.e., consistently sleeping less than 7 hours per night) increases insulin resistance and makes it harder for the body to control blood sugar and appetite.15 Having obstructive sleep apnea — a condition that regularly disrupts sleep— is associated with an increased risk of insulin resistance. Moreover, people who are overweight or obese face a greater risk for developing obstructive sleep apnea.16
- Tobacco smoke: For people living with prediabetes, being a smoker might increase insulin resistance and the risk of type 2 diabetes.17 Smoking also raises the risk of complications from diabetes.18
- Poor nutrition: Eating an unhealthy diet is associated with an increased risk of prediabetes.2
- Sedentary lifestyle: The less active an individual is, the greater their risk for developing prediabetes.1
- Older age: Though prediabetes and type 2 diabetes can develop at any age, the risk of prediabetes increases for someone 45 years of age or older—especially in the absence of preventive treatment.1
- Family history of diabetes: The risk of prediabetes is greater for someone who has a sibling or parent with type 2 diabetes.1
- Ethnicity or race: People belonging to certain racial and ethnic populations, specifically Black, Indigenous and People of Color (BIPOC), are more likely to develop prediabetes and diabetes.19 Health equity research attributes racial disparities in the prevalence of prediabetes to Social Determinants of Health (SDOH) driving disproportionate levels of obesity.20,21
- Gestational diabetes: For mothers who develop diabetes while pregnant—known as gestational diabetes—their children will also be at high risk for developing diabetes and prediabetes.22
- Polycystic ovary syndrome (PCOS): Individuals diagnosed with PCOS—a common condition among women characterized by irregular menstrual periods, obesity and excess hair growth — are considered a high-risk population for prediabetes.23
Additional conditions associated with prediabetes include:
- High blood pressure: Elevated blood pressure, also known as hypertension or prehypertension, is a common condition strongly associated with prediabetes. Ideally, normal blood pressure is 120/80 mm Hg or lower.24
- Cholesterol levels: Prediabetes is linked to lower levels of high-density lipoprotein (HDL) cholesterol, the "good" cholesterol, and higher levels of low-density lipoprotein (LDL), the “bad" cholesterol.25 Moreover, evidence suggests high LDL:HDL ratios are associated with an increased risk of prediabetes in non-obese individuals, young adults, women and those with a family history of diabetes.26
- High triglycerides levels: Having high triglycerides levels— a type of fat in the blood— is associated with a greater risk of prediabetes.27
- Cardiovascular disease and death: Prediabetes is associated with an increased risk of cardiovascular disease, coronary heart disease, stroke and death.28
- Food insecurity: Findings from a 2019 study reveal that among adolescents in the U.S., food insecurity status results in higher odds of prediabetes and elevated blood pressure.29
For employers seeking to align their weight management strategy with the most recent evidence, access An Employer's Practical Playbook for Treating Obesity, which offers recommendations for creating a comprehensive benefits package to treat obesity, including behavior-based interventions and pharmacological and surgical treatment.
What’s the Difference Between a Diabetes and Prediabetes Strategy?
Many of the medical interventions and workplace solutions for encouraging healthy behaviors will be the same for people with diabetes and prediabetes. In an effort to improve care and outcomes for patients who have diabetes, many employers encourage them to enroll in a diabetes management program and promote medication adherence. However, employer strategies for prediabetes should primarily focus on screening and increasing awareness about the need for healthy behaviors in addition to offering targeted programs that address the needs of people with prediabetes. Opportunities exist to put more emphasis on the need for action at the prediabetes stage and strongly communicate or incentivize programs and behaviors that can reverse prediabetes.
Evidence-based Approaches to Preventing and Treating Prediabetes
More than eight in ten American adults are living unaware that they have prediabetes.8 Given that those living with prediabetes are asymptomatic, screening and education are pivotal to reversing its effects. The U.S. Preventive Services Task Force (USPSTF) recommends screening every 3 years for prediabetes and type 2 diabetes in adults aged 35 to 70 who are overweight or obese.30 An effective primary care strategy, coupled with holding providers accountable for glucose screening, can promote early detection.
There are several effective approaches for reversing prediabetes, including lifestyle change programs supporting healthy eating, physical activity, weight loss, adequate sleep, smoking cessation and stress reduction. Where appropriate, these lifestyle changes can be supplemented with prescription medications that help keep blood sugar levels in check for individuals with certain risk factors (i.e., high triglycerides, low levels of HDL cholesterol, a parent or sibling with diabetes, overweight). These approaches are explained in more detail below.
Comprehensive Lifestyle Strategies
One study showed that individuals with prediabetes who take part in a structured lifestyle change program and lose 5% to 7% of their body weight through healthier eating and completing 150 minutes of physical activity per week can cut their risk of developing type 2 diabetes by 58%.31,32 In addition, lifestyle change programs may reduce the risk of heart attack and stroke associated with prediabetes and improve participants’ overall health.33,34 There are several lifestyle changes that will help prevent progression from prediabetes to diabetes. By making lifestyle changes, it is possible for patients to reverse prediabetes completely. Addressing any one lifestyle change, like reducing percent of body fat, sodium consumption or engaging in more physical activity, can help reduce blood sugar levels, but a comprehensive approach is most likely to succeed in reversing prediabetes and preventing diabetes.
- The National Diabetes Prevention Program (NDPP) is a year-long program operated by a public-private partnership that seeks to address prediabetes and prevent diabetes.35,36 The program organizes a team based on the needs of individual participants and focuses on nutritional counseling, physical activity and reduction in weight and blood sugar levels. Members of the team typically include YMCA representatives, health care providers, patients’ families, peer support groups and lifestyle coaches.36 Many commercial insurers and private employers include the NDPP lifestyle change program as a covered benefit. This program is a year long and teaches participants lifestyle skills that they can implement after they complete the program.37
- The Department of Health and Human Services (HHS) announced on March 23, 2016 that the Centers for Medicare and Medicaid Services (CMS) Office of the Actuary (OACT) certified that the NDPP lifestyle change program would “reduce net-Medicare spending” and services started on April 1, 2018.38
- Evidence to support NDPP’s efficacy is grounded in findings from the Diabetes Prevention Program (DPP) Clinical Trial, a randomized clinical trial with 10-year and 15-year follow-up data. Remarkably, in the 10, 15 and 21 years after completing the DPP, participants remained less likely to develop diabetes than their peers who did not complete such a program.32,37,39,40 Medicare estimated a savings of $2,650 for each enrollee in NDPP over the first five quarters of pilot implementation.41
NDPP is an evidence-based lifestyle change program that partners with employers and has proven to:
- Decrease future health care cost;6,41
- Prevent or delay the onset of type 2 diabetes;37
- Increase productivity; 42 and
- Increase employee retention.42
Sufficient, Quality Sleep
Both the quantity and quality of sleep are important factors that influence a person’s physical health, blood sugar levels and their risk for prediabetes and developing type 2 diabetes. While additional research is needed to understand the connection between sleep and blood sugar, this linkage may indicate that restorative sleep might help lower unhealthy blood glucose levels by reinforcing healthy/functioning bodily systems.43
Evidence suggests that people who smoke nicotine have a higher chance of developing prediabetes. A 2022 analysis of data from a large, nationally representative survey of the U.S. adult population indicates that e-cigarette use is associated with greater odds of prediabetes.44
- Metformin: Metformin is an inexpensive medicine used to treat prediabetes, type 2 diabetes and gestational diabetes. Drug treatment is not necessary for prediabetes, but it can be an effective way to control blood sugar when used alongside healthy eating and increased physical activity. It should not replace comprehensive lifestyle changes; 2021 clinical guidelines from the ADA recommends metformin be considered as an option for people living with prediabetes and high-risk individuals (i.e., those with a history of gestational diabetes or a BMI > 35).45
- Glucagon-like peptide 1 (GLP-1): GLP-1 agonists are costly, yet effective, pharmaceutical drugs used to treat type 2 diabetes. GLP-1 drugs are increasingly recognized for their considerable clinical effects on weight loss and prediabetes.46 Growing evidence demonstrates that use of GLP-1s can improve cardiovascular disease risk, decrease mortality and provide other metabolic improvements.47 In recent years, the popularity of GLP-1s has skyrocketed along with utilization and demand from patients. The rise in use of GLP-1s has been accelerated by startups offering more direct access to these drugs, often prescribed alongside behavioral services—primarily marketing the drug as part of a weight loss program.48
The Role of Digital Health
Some employers are offering new digital platforms that have incorporated elements of the NDPP to help employees and their dependents reverse prediabetes. These digital platforms can increase patient engagement and be covered outside the medical benefit. Some of the eligibility criteria used by them include HbA1c levels and most recently reported BMI in the employee health record.49
Prediabetes digital programs can vary based on how they are designed to interact with the user. Some use a wireless scale and mobile app to send personalized reminders about healthy eating and physical activity. These tools also connect people to providers, health coaches and community resources that deliver the NDPP program. Typically, these platforms approach prediabetes treatment with either general weight loss programs or more tailored approaches like the use of medication-assisted treatment. Some programs utilize a combination of nutritional counseling paired with advanced telehealth coaching and remote patient monitoring tools. In a 2-year prediabetes study that utilized such combination, 97% of participants did not progress to type two diabetes, which was estimated to save employers up to $381 per patient per month on average.50 Alternatively, some platforms treat patients using medication-assisted therapy. A study of patients using a GLP-1 protocol demonstrated that participants showed a 15% loss in mean body weight as well as an 84% improvement in A1C levels.51
As virtual health continues to expand, so will opportunities, barriers and risks that need to be considered and addressed. Review the article Shaping the Future of Virtual Health: Creating Agile Solutions for more insights on how virtual health can shape the future of care and enhance patient experience.
- 1 | Identify areas in your population where risk is highest: Employers can work with their health plans to determine the burden of prediabetes across their population and identify locations where targeted communication may be most effective in reaching employees in need of resources. For example, the burden of prediabetes is the highest in southern parts of the U.S., and BIPOC populations are at increased risk.45,52 In addition, the Centers for Disease Control and Prevention (CDC) has a tool that employers can use to estimate annual risk for developing type 2 diabetes using various worker demographics. Employers can leverage this information to help tailor communications and establish effective support for their affected employee population.
- 2 | Provide incentives for employees and dependents to receive screening for prediabetes: Identifying prediabetes requires a hemoglobin A1C, fasting glucose level or oral glucose tolerance test. The USPSTF recommends that adults aged 35 to 70 years old who are overweight or obese be screened every 3 years. People with a family history of diabetes should be screened more often.30 Offering incentives to employees as a reward for completing an annual checkup will help identify prediabetes for those unaware of their condition and increase chances for timely intervention.
- 3 | Provide regular, targeted communications to employees about the risk of prediabetes and how they can address this condition before it progresses to diabetes: Third-party solutions can leverage employees’ well-being data to target proactive, personalized communications to employees with prediabetes. These communications should connect employees and their dependents to resources that can help them address their condition and avoid diabetes. If an employer does not have access to comprehensive well-being data, it can work with its health plan to target communications to populations that are most at risk for prediabetes, including older people, those who live in the South and industrial Midwest and BIPOC populations.19
- 4 | Spread the word in the workplace and with spouses/partners: Employers can use ongoing communication campaigns to encourage all employees and their dependents to educate themselves about prediabetes. Part of that process could be asking their doctor if they might be at risk and encouraging their spouses/partners to do the same. The American Diabetes Association (ADA), the American Medical Association (AMA) and the CDC teamed up to create a website called doihaveprediabetes.org. The website features an interactive test to assess risk of prediabetes and materials available to the public to spread awareness.
- 5 | Provide coverage for NDPP through a wellness program or medical benefit, with little or no cost sharing: NDPP is an effective approach to reversing prediabetes, in part because it is comprehensive in the way it encourages healthy behaviors. The NDPP does not use piecemeal strategies that address only one risk factor for prediabetes, but rather addresses multiple risk factors simultaneously. As a preventive service, this benefit can be covered with no cost sharing for patients even if they are in health savings account (HSA)-eligible plans. Employers should only pay claims to practitioners or organizations that are recognized by the CDC Diabetes Prevention Recognition Program. The health plans can help identify opportunities to communicate and integrate NDPP resources into other health program offerings. Alternatively, some employers have implemented on-site DPPs that incorporate elements of NDPP but leverage their own health and wellness centers.53
- 6 | Consider partnering with solutions that use digital platforms to deliver evidence-based supports to people living with prediabetes: Employers should assess key criteria for whether a solution that promotes healthy behaviors to reverse prediabetes adheres to evidence-based protocols. The criterion for solutions includes adherence to evidence-based protocols with regular clinical review, an ability to share data across different platforms and a strong customer service record for patients and employer clients. Employers have seen positive results in partnership with solutions that promote evidence-based approaches predicated on NDPP.54,55 Nevertheless, employers implementing solutions should continually monitor program effectiveness; for instance, any solution should report on rates of engagement among target populations and impact on blood sugar levels. For programs that have shown high levels of engagement and clinical effectiveness, consider reducing cost barriers to program participation for eligible participants with prediabetes.
- 7 | Consider covering metformin as a preventive medication at zero cost sharing for people with prediabetes: Although metformin is a relatively inexpensive drug, eliminating financial barriers to accessing it may increase the likelihood that people fill their prescriptions and are adherent to the medication. Several large employers have used this strategy, and it complies with rules limiting pre-deductible coverage in HSA-eligible plans. Communication campaigns focused on prediabetes should note that drugs are not necessary for treatment and should only be used in conjunction with lifestyle changes for high-risk individuals.
- 8 | Consider providing targeted coverage of GLP-1s alongside lifestyle intervention programs: Employers should assess the health of their workforce population and determine the need for coverage of other evidence-based nonpharmaceutical treatment approaches (e.g., behavioral change and lifestyle intervention programs). Additionally, understanding costs and utilization trends, including off-label prescribing of GLP-1s, may be helpful when considering current and future coverage, along with prior authorization criteria.
- 9 | Emphasize the importance of healthy sleeping habits: Regular lack of sleep can increase a person’s risk of prediabetes and make managing diabetes more difficult since it increases insulin resistance.56 Given this linkage between prediabetes risk and lack of quality sleep, employers can emphasize the importance of practicing healthy sleeping habits. Moreover, employers may also consider additional ways to support sleep for vulnerable workforce populations (i.e., frontline employees working long hours/overnight consistently such as health care workers).
- 10 | Promote smoking cessation programs: For individuals who are at risk or have already been diagnosed as insulin resistant, smoking cessation is a realistic solution to prevent disease progression, especially given the rising prevalence of prediabetes and diabetes. Thus, incorporating smoking cessation and/or reduction in any prediabetes prevention and/or treatment strategies is ideal.
- 11 | Acknowledge and address food insecurity: SDOH often contribute to food insecurity and can make it difficult for employees to maintain a healthy diet. Employers are well positioned to positively shape the food environment that surrounds employees, both on-site and at home, through a combination of benefits, programs, policies and structural changes. On-site, employers can promote access to healthy foods through corporate nutrition guidelines for dining facilities (for example, guidance on the placement, pricing and availability of healthy foods), access to on-site farmer’s markets or mobile markets, community-supported agriculture programs (CSA) and access to a company-sponsored food pantry stocked with healthy food bundles for food insecure colleagues. For hybrid workforces, employers can facilitate the home delivery of medically tailored meals or other nutritious meal kits, provide access to grocery discount programs and provide access to in-person or digital sessions with registered dieticians and nutritionists.
The burden of prediabetes across the U.S. is significant and growing: It is projected that over 470 million people will have prediabetes in 2030. For many people, however, prediabetes can be effectively treated to halt disease progression toward diabetes.9 To do so, employers can partner with on-site fitness center providers, health plans, community providers and others to screen for prediabetes and deliver programs that utilize some combination of lifestyle change, nutritional counseling and medication. This is an effective mid- and long-term strategy to improve health and mitigate downstream costs for employer-sponsored health and well-being plans.
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