Presentation on theme: "Evidence-based Diabetes Prevention – National Policy Considerations"— Presentation transcript:
1 Evidence-based Diabetes Prevention – National Policy Considerations Ronald T Ackermann, MD, MPH, FACPDiabetes Translational Research CenterIndiana University School of Medicine
2 Continuum of Risk & Intervention 200 Million with Obesity Risk Factors?140 Million Overweight or Obese*85 Million High Risk for DiabetesDiabetes, Heart Disease, StrokePopulation-based Policies(Social/Cultural Change)Long-term PayoffResource Intensive Programs(Prevent Obesity-Related Risks)Shorter-term Payoff* Estimated from Flegal KM, et al. JAMA. 2010;303(3):† Using ADA prediabetes definition OR A1c %; Source: NHANES
3 U.S. Diabetes Prevention Program National comparative effectiveness trial3,200 overweight / obese adults with prediabetesCompared 3 preventive interventionsBrief Education (usual care)Diabetes Pill MetforminIntensive Diet & Physical Activity ProgramLifestyle Program most effectivePrevented 58% of new diabetes casesWorked for all age, gender, and race subgroupsReplicated worldwide – 6 studies; >5,400 total participants* DPP Research Group. N Eng J Med 2002;346(6):
4 DPP Lifestyle Program 16-session course over 24 weeks; then monthly One-on-one personal coach formatGoal to lose/maintain ≥7% of body weightCut down dietary calories & fat≥150 min/week moderate physical activityEducation & training in behavior modification (Self-monitoring; problem solving)Strong support structure (building self esteem, empowerment, social support; accountability)
5 DPP: Modest Weight Loss is the Goal In DPP… …every 1 kilogram of weight loss = 16% decrease in chances of getting diabetes …just 5 kg (11 pounds) of weight loss = 58% decrease in chances of diabetesThis analysis models the effect of weight change on the hazard, or incidence rate of diabetes. Among lifestyle participants, the weight change range shown is from the 5th to the 95th percentile. There is a strong relationship between weight loss and lower diabetes risk.<mouse>With NO weight loss, the incidence rate is estimated to be approximately 13% per year.At 7%, the average weight loss at one year in the lifestyle group, the incidence rate of diabetes is estimated at about 4.5%. For every Kg of weight loss, there was a 16% reduction in risk. Conversely, it appears from this model that weight gain from baseline also resulted in important increases in risk. It is also important to note that even small reductions in weight were associated with marked decreases in diabetes risk.As in the bariatric surgery study – there appears to be tight temporal coupling between weight change and glucose intolerance.+*Hamman, et al. Diabetes Care 2006; 29:2102–2107.
6 DPP Lifestyle Program Summary Treating 100 high risk adults (age 50) for 3 years…Prevents 15 new cases of Type 2 Diabetes1Prevents 162 missed work days2Avoids the need for BP/Chol pills in 11 people3Avoids $91,400 in healthcare costs4Adds the equivalent of 20 perfect years of health51 DPP Research Group. N Engl J Med Feb 7;346(6):2 DPP Research Group. Diabetes Care Sep;26(9):2693-43 Ratner, et al Diabetes Care 28 (4), pp4 Ackermann, et al Am J Prev Med 35 (4), pp ; estimates scaled to 2008 $US5 Herman, et al Ann Intern Med 142 (5), pp
7 DPP Dissemination Challenges Too costly ($1,800+) in year 1 aloneIntense & long-term – skepticism over replication in the ‘real world’
8 IUSM’s Approach for DPP Translation Stick to the DPP approachGoal-oriented; weight loss through diet & exerciseTarget adults at highest risk for diabetes now (prediabetes)Adopt “practical” solutions for key barriersMinimize intervention costsGroup-based deliveryStrong, not-for-profit community partnerPreserve effectiveness (weight maintenance)
9 DEPLOY1, DPP-LINC2, & RAPID3 Studies Community comparative effectiveness trialsGroup DPP at the YMCA vs. standard advice~70% of high risk adults with pre-diabetes attend the YMCA at least once if referred4Average weight loss among those attending YMCA at least once 5.0% to 6.8%5Weight losses still 4.8% after 28 months6Cost of YMCA DPP delivery ~$240 in year 11 R34-DK (NIH); 2 R34-DK (NIH); 3 R18-DK (NIH)4 Ackermann, et al. Am J Prev Med Oct;35(4):357-63; RAPID study ongoing (unpublished)5 Ackermann, et al. DPP-LINC Study Results, under review 07/20106 Long-term DEPLOY Extension Study results under review 07/2010
10 Recipe for Successful Scaling Right PeopleRight InterventionsScalable Delivery ModelCost-Effective Population Based PreventionHigh risk for short-term obesity-related problems(Pre-Diabetes)Intensive & ongoing (DPP)Lifelong diet & activity changesAchieves modest weight lossNationwideAccessibleCoordinated with Medical HomeValued Health OutcomesSustainable to Finance
11 Supportive Policy Actions Still Needed Step in the ProcessTarget(s)Supportive PolicyWhole population focus on better healthHHS; States; OthersNew policies to make healthy eating & activity desired, normative, convenient, & feasible ($)People seek testing/resourcesCDC; ADARaise awareness of risk factors; how to be testedClinicians test & offer resourcesCMS; NCHSRevise ICD/HCPCS to easily document tests/counselingUSPSTFRevisit recommendation for targeted screeningNCQADevelop performance indicators for testing/referralCMS; payersNew coverage policies to expand testing (A1c); payment policies to reward providersPrograms availableHHS; CDCDevelop workforce; recognize community programs that are ‘evidence-based’Programs accessibleCPSTFReview / recommend community-based DPPReview coverage policies for community-based prevention services by recognized CBOsCoordination with medical homeReview/recommend as part of PCMH RecognitionNew payment policies for CBO referral/feedback
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