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Prediabetes

Frequently Asked Questions

December 3, 2008

Fast Facts

  • Prediabetes is a condition that raises the risk of developing type 2 diabetes, heart disease, stroke, and eye disease.1,2
  • People with prediabetes have impaired fasting glucose (IFG), impaired glucose tolerance (IGT), or both -- conditions where blood glucose levels are higher than normal but not high enough to be classified as diabetes.1,3
  • People with prediabetes are 5-15 times more likely to develop type 2 diabetes than are people with normal glucose values. 4
  • Progression to diabetes among those with prediabetes is not inevitable. Studies show that people with prediabetes who lose at least 7% of their body weight and engage in moderate physical activity at least 150 minutes per week can prevent or delay diabetes and even return their blood glucose levels to normal.1
  • Clinical research shows intensive lifestyle interventions are the most effective way to prevent or delay type 2 diabetes.5
  • About 54 million individuals in the United States aged 21 years and older have prediabetes2, 12 million of whom are overweight and between the ages of 45-74.6
  • In the United States, approximately one of every three persons born in 2000 will develop diabetes in his or her lifetime. The lifetime risk of developing diabetes is even greater for ethnic minorities: two of every five African Americans and Hispanics, and one of two Hispanic females, will develop the disease.3

What is prediabetes?

People with blood glucose levels that are higher than normal but not yet in the diabetic range have "prediabetes." Doctors sometimes call this condition impaired fasting glucose (IFG) or impaired glucose tolerance (IGT), depending on the test used to diagnose it. Insulin resistance and prediabetes usually have no symptoms. You may have one or both conditions for several years without noticing anything.

How is prediabetes detected?

At present, the fasting plasma glucose (FPG) and the 2-h oral glucose tolerance test (OGTT) are the tests of choice to identify all states of hyperglycemia. Either test is suitable, and each has advantages and disadvantages, such as convenience, cost, and reproducibility. Identification of individuals with IGT can be made only with a 2-hour OGTT; the fasting plasma glucose (FPG) alone will miss approximately 30% of patients with isolated IGT. A recent consensus statement issued by the American Diabetes Association has recommended that if pharmacotherapy is used, both IFG and IGT should be documented. If only lifestyle modification is planned, a confirmatory test is not required.5,4

  • IGT is detected when blood glucose levels are elevated (140-199 mg/dL) two hours after an Oral Glucose Tolerance Test is administered.
  • IFG is detected when blood glucose levels are elevated (100-125 mg/dL) after a fast of at least eight hours.

See Table 1 for the tests and corresponding glucose values used to identify IGT and IFG.

Table 1 -- Identifying Prediabetes: IGT and IFG7

Condition/Classification Test Used and Diagnostic Values
Impaired Glucose Tolerance (IGT)
  • Oral Glucose Tolerance Test (OGTT), 75 grams of glucose
  • 2-hour plasma glucose = 140?199 mg/dL
Impaired Fasting Glucose (IFG)
  • Fasting plasma glucose (FPG) after 8-hour fast
  • Fasting plasma glucose = 100?125mg/dL

How does prediabetes relate to the future diabetes burden?

About 54 million individuals in the United States aged 21 years and older have prediabetes,3 nearly 12 million of whom are overweight and between the ages of 45-74.6 In addition to the nearly 21 million individuals in the United States currently diagnosed with diabetes, the estimated number of diagnosed cases of diabetes will increase in the United States by 198% in the next 50 years?with the largest increase occurring among African Americans, American Indians, and Hispanic/Latino Americans.8

What are the guidelines for prediabetes screening?

Screening for prediabetes (IFG/IGT) is fundamentally no different from screening for diabetes because the same risk factors are associated with both conditions.5,9 See Table 2 for specific recommendations for prediabetes screening, as well as relevant prediabetes/type 2 diabetes risk factors.

Table 2 -- Prediabetes Screening Guidelines

Recommending Body Prediabetes risk factors and screening guidelines

American Diabetes Association (ADA)

Recommended tests: FPG or 2-h OGTT

1. All persons ≥45 years of age, particularly in those who are overweight (BMI>25kg/m2), and repeated every three years

2. Persons <45 years of age who are overweight (BMI>25kg/m2) with any one of the following risk factors:9

Habitually physically inactive

High-density lipoprotein (HDL) cholesterol < 35 mg/dl and/or triglyceride level > 250 mg/dl

First-degree relative with diabetes

Polycystic ovary syndrome (PCOS)

Member of high-risk ethnic population (e.g. African American, Latino, Native American, Asian American, Pacific Islander)

Impaired glucose tolerance (IGT) or impaired fasting glucose (IFG) on previous testing

Delivered a baby weighing >9lbs. or have been diagnosed with gestational diabetes

Other clinical conditions associated with insulin resistance (e.g., PCOS or acanthosis nigricans)

Hypertensive (blood pressure ≥140/90 mmHG)

History of vascular disease

Indian Health Services (IHS)

Recommended tests: FPG in the morning or 2-hr OGTT

1. Annual testing of American Indian and Alaska Native adults aged 19 years and older with any of the following risk factors for diabetes:7

BMI ≥25 kg/m2

Women with a history of gestational diabetes

Hypertension

Women with Polycystic Ovarian Syndrome (or Hyperandrogenic Chronic Anovulation)

High-density lipoprotein <40 mg/dl in men or <50mg/dl in women

Family history of type 2 diabetes

Triglycerides >150mg/dl

 

2. Testing every three years beginning at age 35 for those without the above risk-factors

The U.S Preventive Services Task Force also makes recommendations related to screening for diabetes and that recommendation can be found at: www.ahrq.gov/clinic/uspstf/uspsdiab.htm.

Do risk factors for prediabetes differ from type 2 diabetes?

No, risk factors for prediabetes do not differ from type 2 diabetes. Both conditions share the same risk factors, and prediabetes is itself a risk factor for type 2 diabetes.5,9 See Table 2 for prediabetes/type 2 diabetes risk factors.

While prediabetes and type 2 diabetes share the same risk factors, persons with prediabetes can reduce their blood glucose levels to normal values and reduce their risk for developing type 2 diabetes. Currently, there is not enough information to warrant distinguishing prediabetes and diabetes' risk factors. As we learn more about the differing pathophysiologies of IGT and IFG and their relation to the onset of type 2 diabetes, as well as preventive interventions, distinguishing prediabetes and type 2 diabetes risk factors might become possible.

What is the risk of a person's prediabetes converting into type 2 diabetes?

The risk of progressing to diabetes depends on the type of prediabetes that a person has (IFG only, IGT only, or both), as well as other diabetes risk factors. Individuals with prediabetes who are older, overweight, and have a family history of diabetes and gestational diabetes are more likely to progre-ss to diabetes.5 Individuals with prediabetes are 5-15 times more likely to develop type 2 diabetes than are people with normal glucose values.4 Individuals with both IFG and IGT develop diabetes approximately twice as often as individuals with just one of the two conditions.5

Annual progression to diabetes
Studies in the United States and abroad show that, for persons with IGT, between 2% and 34% will develop type 2 diabetes annually; for persons with IFG, between 1.5% and 23% will develop diabetes annually.4 Two randomized controlled trials of diabetes prevention, the Diabetes Prevention Program (DPP) and the Finish Diabetes Prevention Study, demonstrated that 3-5% of individuals with IGT who lost weight and engaged in moderate physical activity progressed to diabetes annually. For persons with prediabetes who did not lose weight and engage in moderate physical activity, 11% progressed to diabetes annually.10-11

Prolonged progression to diabetes
The natural history of prediabetes (both IGT and IFG) indicates that about 25% of persons with prediabetes progress to diabetes within three to five years. With longer observation, the majority of individuals with IFG or IGT go on to develop diabetes5 within about 10 years, unless they lose weight through moderate changes in diet and physical activity.12 Over the course of a lifetime, as many as 83% of persons with prediabetes (IGT) who neither lose weight nor engage in moderate physical activity will develop diabetes.13 Over the course of a lifetime, approximately 65% of persons with prediabetes who lose weight and engage in moderate physical activity will go on to develop diabetes13-14

Progression to diabetes among the general population in the United States
The annual risk of developing diabetes for the average person living in the United States with normal glucose levels is about 0.7% per year.15 For individuals born in the United States in 2000, the estimated lifetime risk of being diagnosed with diabetes is roughly 1 of 3 for males and 2 of 5 for females. The lifetime risk of diabetes is even greater for ethnic minorities: 2 of 5 African Americans and Hispanics, and 1 of 2 Hispanic females, will develop the disease.3 With lifestyle changes, this course can be changed.

Is conversion to type 2 diabetes inevitable? What are intervention strategies for preventing or delaying the conversion of prediabetes to diabetes?

Interventions to prevent or delay prediabetes from progressing to type 2 diabetes can be feasible and cost-effective, and many individuals in the United States could benefit from them, particularly those who are overweight or obese.16

Developing type 2 diabetes is not inevitable. A variety of clinical trials demonstrate that individuals with prediabetes can prevent or delay the progression to diabetes through lifestyle and some pharmaceutical interventions. These studies demonstrate that persons at risk for diabetes can be identified early in the disease progression, before exhibiting blood glucose values indicative of diabetes. Those individuals who lose weight and increase their physical activity can prevent or delay the development of diabetes. Moderate-intensity lifestyle interventions can delay development of type 2 diabetes by an average of 11 years and reduce the number of new cases of type 2 diabetes by 20%. Pharmacological interventions has shown to delay the onset of type 2 diabetes by an average of three years while reducing the number of new cases of type 2 diabetes by 8%.13

Lifestyle Intervention Strategies
Lifestyle changes can prevent or delay the onset of type 2 diabetes among high-risk adults. This has been shown in studies that included people with IGT and other high-risk characteristics for developing diabetes. Lifestyle interventions included low fat diet and moderate-intensity physical activity (such as walking for 2 1/2 hours each week). In the DPP, a large prevention study of people at high risk for diabetes, the development of diabetes was reduced by 58% over 3 years.17

See Table 3 for key aspects of the DPP lifestyle protocol. A comprehensive description of the DPP, including the lifestyle protocols, lifestyle manuals and an updated list of DPP-related publications can be found at www.bsc.gwu.edu/dpp/index.htmlvdoc.

Other studies have shown lifestyle education (dietary + exercise or dietary alone) can reduce 2-hour plasma glucose levels as well as the onset of type 2 diabetes among those at risk by as much as 50%.18 A listing of these lifestyle interventions can be found in Table 4.

Table 3 -- DPP Lifestyle Protocols19

Clearly defined weight loss and physical activity goals A flexible maintenance program
Individual case managers or "lifestyle coaches" Culturally-appropriate materials and strategies
Intensive, ongoing intervention Local and national network of training, feedback and clinical support
A core curriculum Supervised exercise sessions at least twice weekly

Table 4 -- Lifestyle education interventions for type 2 diabetes prevention18

Type of Intervention Dietary Education Exercise Education
Dietary + exercise Reducing energy intake Increase leisure physical exercise by one of more of the following examples: 30 extra minutes per day of slow walking; 20 extra minutes per day of brisk walking; 10 extra minutes per day of jogging; 5 extra minutes per day of jumping rope, playing basketball or swimming.
Dietary + exercise Standard diet advice sheet with telephone contact (three per month) Emphasizing need for regular exercise
Dietary + exercise Low-fat, high-fiber diet Regular exercise with a program implemented during a 1-month stay at a wellness center that included intense dietary learning sessions
Dietary + exercise Regular diet counseling from a dietician Physical activity counseling from a physiotherapist
Dietary + exercise Individualized dietary counseling from a nutritionist Circuit-type resistance training sessions and advice on increasing overall physical activity
Dietary + exercise Regular dietary advice Stimulated to lose weight and increase physical activity with visits scheduled at regular intervals
Dietary + exercise Weight-reduction through a healthy low-calorie, low-fat diet Engage in physical activity of moderate intensity by individualized curriculum by case managers
Dietary alone Reduced-fat diet and participation in monthly small-group education session for one year  
Dietary alone Reducing energy intake, especially at dinner  

Pharmacotherapy strategies
The drug metformin is effective in delaying or preventing conversion of prediabetes to diabetes. However, it is not as effective as the lifestyle intervention. While the lifestyle intervention reduced diabetes onset by 58%, metformin reduced onset by 31%.10

Several clinical trials have shown reductions in the incidence of diabetes with different pharmacotherapies, though their longer-term effectiveness remains unknown. For example, rosiglitazone is a newer drug that has been shown to reduce the incidence of diabetes in 60% of individuals with elevated blood glucose levels over the reduction observed in a placebo group.20 While this drug could be effective, the main clinical trial did not compare this treatment to lifestyle change or other drugs. Rosiglitazone can have side effects; these include headaches, back pain, fatigue, hypoglycemia, hyperglycemia, and upper respiratory tract infections. A major side effect of rosiglitazone was an increased incidence of cardiovascular events, including a 7-fold increase in heart failure over what was observed in those receiving a placebo.20 Also, acarbose (another drug) was shown to delay progression to type 2 diabetes in patients with IGT by 25% over 3.3 years.21 Researchers also observed a greater than 50% reduction in the incidence of type 2 diabetes in Hispanic women who were treated with troglitazone, an insulin-sensitizing drug. These women continued to experience the protective benefits from diabetes eight months after the drug was stopped.22 Troglitazone was removed from the market due to safety concerns. As questions remain regarding the long-term efficacy and cost-effectiveness of pharmaceutical interventions for prediabetes, experts continue to recommend diet and exercise as the most effective preventive approach for people with prediabetes.5,9,20,23

Are Prevention Interventions Cost-Effective?

Interventions to prevent or delay prediabetes from progressing to type 2 diabetes can be feasible and cost-effective. Many individuals in the United States, particularly those who are overweight or obese,16 could benefit from such interventions. As shown in Table 5, research from the DPP found that lifestyle interventions are more cost-effective than pharmacological agents.13,24

Table 5
DPP Findings on Cost-Effectiveness of Interventions

Lifestyle Intervention Strategies Pharmacological Agent (metformin)
  • Delayed development of type 2 diabetes by an average of 11 years
  • Reduced the number of new cases of type 2 diabetes by 20%
  • Over time could be predicted to result in cost per Quality Adjusted Life Year (QALY)a of approximately $1,100 from a health system perspectiveb and $8,800 from a societal perspectivec,13
  • During the DPP study period, direct medical cost for care received outside the study was $432 lower per participant after receiving the lifestyle change intervention than for a placebo group that did not receive any intervention.24 Within the trial period, the lifestyle change intervention cost $16,000 per case of diabetes prevented and $32,000 per QALY.13
  • Delayed onset of diabetes by an average of three years
  • Reduced the number of new cases of type 2 diabetes by 8%
  • Resulted in higher costs per Quality Adjusted Life Year (QALY)a than the lifestyle change intervention ? costs per QALY for individuals receiving metformin were approximately $31,300 from a health system perspectiveb and $29,900 from a societal perspectivec,13
  • During the program period, direct medical cost for care received outside the study for the metformin group was $272 lower per participant than a placebo group not receiving any intervention.24 Within the trial period, metformin cost $31,000 per case of diabetes prevented and $100,000 per QALY.13

a A QALY measures the cost to extend life by one healthy year. It measures not only years of life gained but also the quality of those life years.
b The health system perspective includes the cost of treatment (e.g., clinician time and medication cost).
c The societal perspective includes costs to society (e.g., indirect costs such as lost productivity and taxes paid for health care and disability, direct non-medical costs related to lifestyle changes).

The American Diabetes Association supports lifestyle modification as the best method of treating prediabetes because there is insufficient evidence to support the cost-effectiveness of medication interventions.9 The completed prevention trials indicate that an intensive lifestyle intervention provides the greatest reduction in the occurrence of diabetes, along with a modest reduction in cardiovascular disease risk factors.5

Assessing costs and savings can be a challenge in determining the best strategies for preventing diabetes among those with prediabetes. For example, lifestyle changes are usually paired with medical treatment, making it difficult to decipher which prevention strategy is most cost effective.25 Also, the brief duration of some trials limits the ability to determine long-term effects, such as morbidity (complications) or mortality.25-26

What are Current Reimbursement Strategies for Prediabetes Care?

Insurance plans differ in reimbursement for diabetes and prediabetes screening and treatment. Most insurance plans cover testing for people suspected of having diabetes. Becausethe tests and risk factors are the same for both conditions, a prediabetes test may be covered.

Medicare

As of 2005, the Centers for Medicare and Medicaid Services (CMS) cover screening tests for diabetes for those who have been diagnosed with prediabetes. The CMS policy covers the following:

  • Two diabetes screening tests per year for individuals with diagnosed prediabetes.
  • One diabetes screening test per year for individuals who were never tested or whose test results were negative for prediabetes.

Covered tests include the fasting blood glucose (FBG) test and the post-glucose challenge test (OGTT). Medicare-covered diabetes screening tests do not require co-payments, deductibles, or coinsurance from the Medicare member.27

Individuals who have any one of the following risk factors for diabetes are eligible for the CMS benefit:

  • Hypertension (high blood pressure)
  • Dyslipidemia (high cholesterol)
  • Obesity (a body mass index ≥30 kg/m2)
  • Elevated impaired fasting glucose intolerance

OR

Individuals who have at least two of the following characteristics:

  • Overweight (a body mass index of 25-29 kg/m2)
  • A family history of diabetes
  • Age 65 or older
  • A history of gestational diabetes
  • Delivery of a baby weighing >9 lbs

Medicaid

Medicaid, the combined federal and state health insurance program for the poor and disabled, has no national-level requirements around screening or treatment for diabetes or prediabetes, though all states and Medicaid plans must cover physician, hospital, and lab services. Generally, the Medicaid program covers most diabetes medications but may not always cover diabetes education services, insulin pumps or prediabetes screening.28 Medicaid coverage rules are set at the state level and vary from state to state.

Private Insurance

Private insurance generally consists of group (i.e., self-insured, employer-sponsored health insurance) and individual coverage. Individual coverage is subject to state insurance laws and mandates. As of December 2005, 46 states had laws requiring coverage of diabetes treatment in private insurance plans.29 Employer-sponsored health plans that are self-insured are exempt from these mandates through the Employee Retirement Income Security Act of 1974 (ERISA), so coverage of diabetes services varies greatly.

References

  1. Centers for Disease Control and Prevention. National Diabetes Fact Sheet, United States, 2005. [Cited 2006 Nov 3]. Available from: www.cdc.gov/diabetes/pubs/pdf/ndfs_2005.pdf. (PDF -- 54 KB)
  2. Diabetes Prevention Program Research Group. The prevalence of retinopathy in impaired glucose tolerance and recent-onset diabetes in the Diabetes Prevention Program Diabet. Med. 2007;24:137-144.
  3. Centers for Disease Control and Prevention Coordinating Center for Health Promotion. Diabetes: Disabling, Deadly, and on the Rise, 2007. [Cited 2007 April 2]. Available from: www.cdc.gov/nccdphp/publications/aag/ddt.htm.
  4. Santaguida PL, Balion C, Hunt D, et al. Diagnosis, prognosis, and treatment of impaired glucose tolerance and impaired fasting glucose. Summary, Evidence Report/Technology Assessment No. 128. (Prepared by the McMaster Evidence-based Practice Center under Contract No. 290-02-0020). AHRQ Pub. No. 05-E026-1. Rockville, MD: Agency for Healthcare Research and Quality. August 2005.
  5. Nathan DM, Davidson MB, Defronzo RA, Heine RJ, Henry RR, Pratley R, Zinman B. Impaired fasting glucose and impaired glucose tolerance. Diabetes Care. 2007;30:753?759.
  6. Benjamin SM, Valdez R, Geiss LS, et al. Estimated number of adults with pre-diabetes in the United States in 2000: Opportunities for prevention. Diabetes Care. 2003;26(3):645?9.
  7. Indian Health Service. IHS Guidelines for Care of Adults with Prediabetes and/or the Metabolic Syndrome in Clinical Settings. April 2005.
  8. Narayan VKM, Boyle JP, Geiss LS, Saaddine JB, Thompson TJ. Impact of recent increase in incidence on future diabetes burden. Diabetes Care. 2006;29:2114?2116.
  9. American Diabetes Association. Position statement: Standards of medical care in diabetes-2007. Diabetes Care. 2007;30(Suppl 1):S4?S40.
  10. Knowler WC, Barrett-Conner E, Fowler SE, Hammon RF, Lachin JM, Walker EA, Nathan DM, the Diabetes Prevention Program Research Group: Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. NEJM. 344:393?403, 2002
  11. Tuomilehto J, Lindstrom J, Eriksson JG, Valle TT, Hamalainen H, Ilanne-Parikka P, Keinanen-Kiukaanniemi S, Laasko M, Louheranta A, Rastas M, Salminen V, Uusituupa M, the Finnish Diabetes Prevention Study group; Prevention of type 2 diabetes with lifestyle intervention or metformin. NEJM. 2001;344:1343?1350.
  12. Centers for Disease Control and Prevention (CDC). Frequently Asked Questions: Preventing Diabetes. [Accessed 2007 Apr 19]. Available from: www.cdc.gov/diabetes/faq/preventing.htm#5.
  13. Herman WH, Hoerger TJ, Brandle M, et al. The cost-effectiveness of lifestyle modification or metformin in preventing type 2 diabetes in adults with impaired glucose tolerance. Annals of Internal Medicine 2005;142:323-332.
  14. DeVegt F, Dekker JM, JagerA, Hienkens E, Kostense PJ, Stehouwer CD, Nijpets G, Bouter LM, Heine RJ: Relations of impaired fasting and postload glucose with incident type 2 diabetes ina Dutch populations: the Hoorn Study. JAMA 2001;285:2109-2113.
  15. National Diabetes Surveillance System. Incidence of Diabetes: Crude and Age-Adjusted Incidence of Diagnosed Diabetes per 1000 Population Aged 18-79 Years, United States, 1997?2004, [Accessed 2007, April 17] www.cdc.gov/diabetes/statistics/incidence/fig2.htm.
  16. Kanaya AM, Narayan KM. Prevention of type 2 diabetes: data from recent trials. Primary Care 2003;30(3):511?26. Centers for Disease Control and Prevention (CDC). National Diabetes Fact Sheet. [Accessed 2007 Apr 19]. Available from: www.cdc.gov/diabetes/pubs/general.htm#impaired.
  17. Centers for Disease Control and Prevention (CDC). National Diabetes Fact Sheet. [Accessed 2007 Apr 19]. Available from: www.cdc.gov/diabetes/pubs/general.htm#impaired.
  18. Yamaoka K, Tango T. Efficacy of lifestyle education to prevent type 2 diabetes: a meta-analysis of randomized controlled trials. Diabetes Care. 2005; 28:2780-2786.
  19. Diabetes Prevention Program (DPP) Research Group. The diabetes prevention program (DPP): Description of lifestyle intervention. Diabetes Care. 2002; 25:2166.
  20. Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medication Trial Investigators. Effect of rosiglitazone on the frequency of diabetes in patients with impaired glucose tolerance or impaired fasting glucose: A randomized controlled trial. The Lancet 2006;368(9541):1096?1105.
  21. Chiasson JL, Josse RG, Gomis R, et al. Acarbose for prevention of type 2 diabetes mellitus: The STOP-NIDDM randomized trial. The Lancet 2002;359:2072?2077.
  22. Buchanan TA, Xiang AH, Peters RK, et al. Preservation of pancreatic beta cell function and prevention of type 2 diabetes by pharmacological treatment of insulin resistance in high-risk Hispanic women. Diabetes 2002;51:2796-2803.
  23. American Diabetes Association and National Institute of Diabetes, Digestive and Kidney Diseases. Position statement: The prevention or delay of type 2 diabetes. Diabetes Care. 2002;25(4):742?9.
  24. The Diabetes Prevention Program Research Group. Costs associated with the primary prevention of type 2 diabetes mellitus in the Diabetes Prevention Program. Diabetes Care. 2003;26:36?47.
  25. Thomas DE, Elliott EJ, Naughton GA. Exercise for type 2 diabetes mellitus. Oxford, UK: The Cochrane Collaboration. [Cited 2006 Sept 21]. Available from: www.cochrane.org/reviews/en/ab002968.html
  26. Satterfield DW, Volansky M, Caspersen CJ, et al. Community-based lifestyle interventions to prevent type 2 diabetes. Diabetes Care. 2003;26(9):2643?2652.
  27. Centers for Medicare and Medicaid Services Medicare Learning Network. MLN Matters, No. SE0660. [Cited 2006 Nov 14]. Available from: www.cms.hhs.gov/MLNMattersArticles/downloads/SE0660.pdf. (PDF -- 71 KB)
  28. National Diabetes Education Program. What we want to achieve through systems changes. Patient-centered care: Health insurance coverage for diabetes. [Cited 2006 Nov 13]. Available from: www.betterdiabetescare.nih.gov/WHATpatientcenteredcoverage.htm.
  29. National Conference of State Legislatures. State laws mandating diabetes health coverage. [Updated 2006 Sept; cited 2006 Nov 13]. Available from: www.ncsl.org/programs/health/diabetes.htm.


  
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