1. Evidence-based Diabetes Prevention – National Policy Considerations
Ronald T Ackermann, MD, MPH, FACP
Diabetes Translational Research Center
Indiana 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 Diabetes
Diabetes, Heart Disease, Stroke
Population-based Policies
(Social/Cultural Change)
Long-term Payoff
Resource 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 trial
3,200 overweight / obese adults with prediabetes
Compared 3 preventive interventions
Brief Education (usual care)
Diabetes Pill Metformin
Intensive Diet & Physical Activity Program
Lifestyle Program most effective
Prevented 58% of new diabetes cases
Worked for all age, gender, and race subgroups
Replicated 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 format
Goal to lose/maintain ≥7% of body weight
Cut down dietary calories & fat
≥150 min/week moderate physical activity
Education & 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 diabetes
This 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.
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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 Diabetes1
Prevents 162 missed work days2
Avoids the need for BP/Chol pills in 11 people3
Avoids $91,400 in healthcare costs4
Adds the equivalent of 20 perfect years of health5
1 DPP Research Group. N Engl J Med Feb 7;346(6):
2 DPP Research Group. Diabetes Care Sep;26(9):2693-4
3 Ratner, et al Diabetes Care 28 (4), pp
4 Ackermann, et al Am J Prev Med 35 (4), pp ; estimates scaled to 2008 $US
5 Herman, et al Ann Intern Med 142 (5), pp

7. DPP Dissemination Challenges
Too costly ($1,800+) in year 1 alone
Intense & long-term – skepticism over replication in the ‘real world’

8. IUSM’s Approach for DPP Translation
Stick to the DPP approach
Goal-oriented; weight loss through diet & exercise
Target adults at highest risk for diabetes now (prediabetes)
Adopt “practical” solutions for key barriers
Minimize intervention costs
Group-based delivery
Strong, not-for-profit community partner
Preserve effectiveness (weight maintenance)

9. DEPLOY1, DPP-LINC2, & RAPID3 Studies
Community comparative effectiveness trials
Group DPP at the YMCA vs. standard advice
~70% of high risk adults with pre-diabetes attend the YMCA at least once if referred4
Average weight loss among those attending YMCA at least once 5.0% to 6.8%5
Weight losses still 4.8% after 28 months6
Cost of YMCA DPP delivery ~$240 in year 1
1 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 07/2010
6 Long-term DEPLOY Extension Study results under review 07/2010

10. Recipe for Successful Scaling
Right People
Right Interventions
Scalable Delivery Model
Cost-Effective Population Based Prevention
High risk for short-term obesity-related problems
(Pre-Diabetes)
Intensive & ongoing (DPP)
Lifelong diet & activity changes
Achieves modest weight loss
Nationwide
Accessible
Coordinated with Medical Home
Valued Health Outcomes
Sustainable to Finance

11. Supportive Policy Actions Still Needed
Step in the Process
Target(s)
Supportive Policy
Whole population focus on better health
HHS; States; Others
New policies to make healthy eating & activity desired, normative, convenient, & feasible ($)
People seek testing/resources
CDC; ADA
Raise awareness of risk factors; how to be tested
Clinicians test & offer resources
CMS; NCHS
Revise ICD/HCPCS to easily document tests/counseling
USPSTF
Revisit recommendation for targeted screening
NCQA
Develop performance indicators for testing/referral
CMS; payers
New coverage policies to expand testing (A1c); payment policies to reward providers
Programs available
HHS; CDC
Develop workforce; recognize community programs that are ‘evidence-based’
Programs accessible
CPSTF
Review / recommend community-based DPP
Review coverage policies for community-based prevention services by recognized CBOs
Coordination with medical home
Review/recommend as part of PCMH Recognition
New payment policies for CBO referral/feedback