Pre-Diabetes: Using Diabetes Self-Management Education/Training to Prevent Diabetes Onset

Overview: 57 million Americans are estimated to have pre-diabetes, a condition in which a person’s blood sugar (glucose) level is above normal but below a level that indicates diabetes. Pre-diabetes may have no outward symptoms, and is diagnosed with a blood glucose test.

It is well-accepted that pre-diabetes and diabetes are on a continuum; left untreated, pre-diabetes will almost always become type 2 diabetes within a few years. In addition to serving as a definitive precursor to the onset of diabetes, individuals with pre-diabetes are at increased risk for a variety of cardiovascular problems, high cholesterol, and polycystic ovarian syndrome for women.


The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003expanded diabetic services covered by Medicare to include diabetes screening for beneficiaries at risk for diabetes or those diagnosed with pre-diabetes. However, while the screening is an extremely positive step in order to help diagnose pre-diabetes, Medicare does not cover diabetes Self-Management Training (DSMT) for this patient group. While Diabetes Self-Management Education/Training (DSME/T) is a crucial tool that can be used to prevent the actual onset of diabetes and its severe complications, DSME/T is currently covered as a Medicare benefit only for those who have already been diagnosed with diabetes.

The prevalence of type2 diabetes is at epidemic proportions in the U.S. at present, and most health policy experts believe this trend is expected to double over the next 30 years. The most practical and cost effective step that should be incorporated into any health legislation to reverse this devastating trend is the inclusion of DSME/T as a covered benefit for those with pre-diabetes, in order to prevent the onset of full scale diabetes.

Preventing the Onset of Diabetes:

Numerous studies support the fact that it is possible to stop or reverse the progression of diabetes, or at least substantially delay its onset. The objective of pre-diabetes treatment is to bring blood sugar levels back to normal and to sustain those blood sugar levels in the normal range. Specific strategies to achieve this objective most commonly involve educating an individual with pre-diabetes how to make healthy lifestyle changes, such as those embodied in DSME/T programs and taught by professionally qualified diabetes educators.

In practical terms, professionally qualified diabetes educators teach individuals with diabetes the essential tools needed to control their diabetes, for example: accurately monitoring blood glucose levels, adopting healthy eating habits, engaging in appropriate exercise, and coping with specific diabetes-related emotional and physical challenges. Professionally qualified diabetes educators are state licensed or registered health care professionals, most commonly nurses or advanced practitioners, dietitians, pharmacists, or podiatrists.

Cost of Pre-Diabetes:

Diabetes is widely recognized as a top public health threat today, affecting 24 million people, or 8% of the population. At the same time, what is far less commonly understood is the impact that the 57 million Americans with pre-diabetes have on our nation’s health care system and resources.

A 2009 study commissioned by the National Changing Diabetes Program, published in the peer-reviewed Population Health Management, quantified these costs and provides a comprehensive estimate of costs for people with pre-diabetes, those with pregnancy related gestational diabetes, and those who are as yet undiagnosed:

  • Undiagnosed ($18 billion);
  • Gestational diabetes ($636 million, or $3,305 per pregnancy plus $209 in the newborn’s first year of life. More than a third of these costs are carried by government programs such as Medicaid.); and
  • Pre-diabetes ($25 billion, including 34% more ambulatory visits than the population at large; 92% more physician visits for hypertension, and 9% more visits for cardiovascular disease)

Bending the Cost Curve:

DSME/T programs taught by a professionally qualified diabetes educator reduce health costs for those diagnosed with diabetes and for those at high risk of diabetes (Costs and Benefits Associated with Diabetes Education in the January/February, 2009 issue of The Diabetes Educator):

  • In a study of over 32,500 high risk pregnant women with gestational diabetes, DSMT reduced overall pregnancy related health costs by an average of $13,000 per pregnancy;
  • A three year retroactive claims analysis of 4 million covered lives, including 250,000 Medicare beneficiaries, showed an average Medicare cost savings per month/per patient of $135 for those individuals who complete a DSMT program, and inpatient hospital cost savings of $160 per month/per patient.
  • A study of over 3,200 overweight or obese pre-diabetes adults found that lifestyle intervention techniques, such as those taught in DSMT programs, reduced the incidence of diabetes by 58 % overall, and 71% for older adults.


As Congress looks to address the rising prevalence of type 2 diabetes and its associated costs, we believe that attention must be paid to incorporating DSME/T for those with pre-diabetes to help bend the health care cost curve and reverse the skyrocketing costs associated with diabetes. We recommend that Congress take steps to include DSME/T as a Medicare benefit for those who are diagnosed with pre-diabetes, according to medically accepted screening guidelines adopted by the Centers for Disease Control (CDC).

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AADE public policy brief

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