Health Dialog Connections

Population Health Management: 3 Steps for Getting the Word out About Pre-Diabetes

Two friends exercising together to prevent pre-diabetes

Did you know that over 9% of the US population  has been diagnosed with diabetes? This chronic disease is not just about glycemic control, but is a multifactorial metabolic imbalance that impacts the entire body system. Adults with diabetes experience macrovascular complications making them 1.8 times more likely to have a heart attack and 1.5 times more likely to have a stroke.

Microvascular complications of diabetes, such as retinopathy, nephropathy, sexual dysfunctions and other neuropathies, are often present prior to the onset of diabetes. Early detection of pre-diabetes and prompt lifestyle change modification can lower the risk of these complications. Today, 86 million people nationwide are at risk for diabetes and 90% of them don’t know they have pre-diabetes.  Evaluations of anthropometric measures have consistently shown that assessing risk can be as easy as looking at the person in front of you.

The American Medical Association (AMA) and the Centers for Disease Control and Prevention (CDC) have joined forces to create the Prevent Diabetes STAT (Screen, Test, Act-TodayTM) program.Additionally, the AMA and CDC partnered with the American Diabetes Association (ADA) and the Ad Council of America to launch a public service message campaign helping to increase consumer awareness of the risks of pre-diabetes by encouraging a simple test.

So how can you increase awareness across your population and help prevent diabetes? Follow these 3 steps that align with the Prevent Diabetes STAT toolkit:

1. Screen

  • Increase patient awareness and encourage self-screening, (with posters in waiting rooms, pre-appointment questionnaires, and quiz widgets on your office homepage).
  • Identify at-risk individuals:
    • Adult over the age of 18 with a BMI higher than 24 (greater than 22 if Asian).
    • Waist circumferences (larger than 40 inches in men, or 35 inches in women).
    • Other metabolic risk markers, such as history of gestational diabetes; pre-hypertension, or hyperlipidemia.

2. Test

  • Follow ADA recommendations for testing:
    • Test all adults over age 45 regardless of weight.
    • Test all adults over age 18 who have one or more risk factor in addition to being overweight or obese.
  • Use 1 of 3 blood tests.


Prediabetes Range

Hemoglobin A1C

5.7-6.4% mmol/mol

Fasting plasma glucose

100 mg/dL to 125 mg/dL

Oral glucose tolerance test

140 mg/dL to 199 mg/dL

  • Conduct a retrospective review of the patient’s medical record for risks noted above and test results within the last 6-12 months that meet pre-diabetes criteria. (See list of helpful CPT and IDC codes). This will help to identify people at risk who will need to be seen for prevention and treatment discussions.
  • If testing is normal, repeat at a minimum of 3 year intervals or more frequently depending on risk status. Patients identified with pre-diabetes should be tested annually to assess for diabetes onset.

3. Act

  • Reinforce with your population that early and intensive lifestyle intervention can prevent or delay diabetes in at-risk people.
  • Refer anyone at risk or confirmed to have pre-diabetes to a diabetes prevention program, or an online support for lifestyle changes.
  • Launch a chronic care management program and provide access to health coaches who can support lifestyle changes, medication management, and disease prevention.
  • Engage healthcare teams to help you reach out to your high-risk population identified through the retrospective review process.
  • Implement engagement, education and awareness technology. The 2016 ADA Standards of Medical Care guidelines recommend technology-assisted tools including internet-based social networks, distance learning, DVD-based content, and mobile applications to support lifestyle modifications to prevent diabetes. Providing access tools that lend a personalized experience, such as a health portal, can help individuals take an active part in their care.

A robust chronic care management program that stresses early identification and personalized engagement can go a long way towards improving the long range health of your population. What protocols do you have in place to align with the Prevent Diabetes STAT initiative? What areas could you improve?

For more insight into how to identify and reach your pre-diabetic population, watch our webinar: Are You Managing the Health of Your Silent Population?


View the Webinar


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