Peer-lead and Telemedicine Activated Care (PACT) in Diabetes Prevention and Management

The prevalence of obesity and diabetes in older adults has increased during the past 20 years and will increasingly affect medical and social services, as well as costs over time. Because older adults are often portrayed as less likely to change long-standing health behaviors, health promotion in this age group has lagged behind others. In fact, little attention has been given to the importance of diabetes prevention and management in community-dwelling older adults.

A recent report of obesity diagnosis and care practice in the Veterans Health Administration showed that elderly patients were less likely to receive obesity-related education or counseling [Noel 2010]. Intentional weight loss in obese older adults has not been widely advocated by health care providers due to the perceived uncertainty of whether the benefits outweigh the risks. There is also a need to overcome the barriers to provide appropriate interventions on blood pressure, glucose, and lipid management tailored to the functionality of older adults.

The Diabetes Prevention Program (DPP) demonstrated the benefit of modest weight loss, through diet and exercise, on the reduction of diabetes risk in participants from all race/ethnic groups (58% overall reduction with a 71% reduction in the older population), leading to a delay of 4 years over a 10-year period in the onset of diabetes among those that received lifestyle intervention [DPP 2002, DPP 2009]. The DPP is considered a landmark study in comparative effectiveness research (CER), but it has yet to be translated into widespread public health practice.

South Florida provides a unique setting to accelerate the adoption of this CER evidence into practice and address the obesity and diabetes challenges of the aging population. There are more than 800,000 multi-ethnic residents age 60 and over, many of whom have one or more chronic diseases [CDC 2008]. A large number of older veterans with or at high-risk of diabetes currently receive care in the Miami VA Healthcare System.

Compelling scientific evidence exists that lifestyle change delays the onset of type 2 diabetes in high-risk persons. Lifestyle intervention can also lead to a reduction in cardiovascular risk factors in individuals with type 2 diabetes [Look AHEAD research group 2007]. However, few older adults succeed in achieving intentional weight loss through healthy diet and increased physical activity. Furthermore, some have argued that the current US health system is not prepared to deliver lifestyle interventions [Narayan 2004].