Interagency Committee Explores Dissemination of Diabetes Prevention Programs
The Diabetes Mellitus Interagency Coordinating Committee (DMICC) met November 11, 2009, to discuss the dissemination and community-wide implementation of diabetes prevention programs aimed at the estimated 57 million U.S. residents with prediabetes, who are at risk of developing type 2 diabetes.
Prediabetes is characterized by blood glucose, also called blood sugar, that is higher than normal but not high enough to be considered diabetes. This condition substantially raises a person's risk of developing type 2 diabetes.
Congress formed the DMICC in 1974 to coordinate the federal response to the diabetes epidemic and avoid unnecessary duplication of activities aimed at studying, preventing, diagnosing, and treating diabetes. The DMICC meetings bring together top experts in the Federal Government and leaders from the community, academia, and the private sector to discuss current and future activities and to identify opportunities for collaboration.
"We've learned through the Diabetes Prevention Program and other trials that intensive lifestyle management reduces the incidence of type 2 diabetes," said Judith Fradkin, M.D., director of the Division of Diabetes, Endocrinology, and Metabolic Diseases at the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and chair of the DMICC. "The challenge now is to integrate what we've learned into cost-effective health programs." For more information about the Diabetes Prevention Program (DPP) and its continuation study, the Diabetes Prevention Program Outcomes Study (DPPOS), see "A Decade Later, Both Lifestyle Changes and Metformin Still Lower Type 2 Diabetes Risk" in this issue.
As compelling as the DPP data are, "study results are not necessarily reproducible in the real world," said Ronald Ackerman, M.D., M.P.H. He and David Marrero, Ph.D., both professors at the Indiana University School of Medicine, summarized the Diabetes Education and Prevention with a Lifestyle Intervention Offered at the YMCA (DEPLOY) Study, which aimed to determine if DPP methods could be applied in community-based settings by non-research personnel.
Funded by the NIDDK, DEPLOY compared the weight loss benefits of a brief one-time counseling session about steps to prevent diabetes with a 16-session, DPP-like intensive lifestyle management course taught by YMCA employees who were trained by DPP investigators. After 6 months in the study, participants who attended the lifestyle management course decreased theirbody weight an average of 6 percent, compared with an average of 2 percent among those who received only brief counseling. Those who attended the lifestyle management course also saw reductions in total cholesterol. On average, participants in the intensive lifestyle management group had kept the weight off when measured again at 12 months from the study's start. Building on DEPLOY's initial success in Indiana, the program is expanding to five new states.
Various other DMICC member organizations are actively translating DPP knowledge into community health programs.
Several states receive funds from the Centers for Disease Control and Prevention's (CDC's) Diabetes Prevention and Control Programs (DPCPs) to implement DPP-like pilot programs. The primary goal of the DPCPs, which are active in all 50 states and several U.S. territories, is to improve access to affordable high-quality diabetes care and services with the priority of reaching high-risk and disproportionately affected populations.
The Indian Health Service (IHS), through the Special Diabetes Program for Indians Diabetes Prevention Demonstration Project, is also implementing DPP-like programs. Funded by Congress, this program uses the DPP Lifestyle Change Program Manual of Operations adapted for American Indian and Alaska Native (AI/AN) communities and supports AI/AN communities in custom-tailoring programs to suit their unique needs.
"Involvement of tribal leaders has been essential to gaining community support," said Kelly Acton, M.D., M.P.H., director, Division of Diabetes Treatment and Prevention at the IHS. "While focusing on lessons learned from the DPP, each tribe participated in the process of building their program creatively." Acton said programs and many participants are meeting DPP goals.
DPP-like pilot programs are demonstrating their ability to turn back the clock on diabetes, but for health care insurers such as Medicare and private insurance companies to begin paying for them, DPP-like programs must also be cost-effective.
Analyses of the cost-effectiveness of the DPP interventions have found that its lifestyle intervention resulted in greater health benefits at lower cost than metformin treatment. Some private insurers are already putting DPP results to good use.
In early 2009, UnitedHealth Group, one of the United States' largest health and well-being companies, serving more than 70 million Americans and one in five Medicare beneficiaries, launched the Diabetes Health Plan pilot. Offered by employers as stand-alone plans or as an add-on feature to UnitedHealthcare benefit designs, the Diabetes Health Plan encourages participants to take an active role in their health. In exchange for adhering to the Plan's evidence-based preventive care guidelines, which include requirements for periodic health screenings and, if necessary, participation in weight-loss programs, participants receive free or discounted physician visits, medication, and supplies.
Because only 15 percent of Americans with prediabetes know they have it, UnitedHealthcare analyzes claims data and biometric information-within the bounds of privacy regulations-to identify candidates who would benefit from the plan.
"With over 40 percent of UnitedHealth Group's commercial expenditures being spent on people living with diabetes," said Deneen Vojta, M.D., senior vice president of UnitedHealth Group's Center for Health Reform and Modernization, "UnitedHealth Group is very interested in collaborating with CDC and other DMICC members on ways to prevent diabetes with evidence-based interventions such as the DPP."
But despite such potential savings, obstacles to broad implementation of DPP-like programs persist.
Medicare does not have the authority to cover diet and exercise programs like DEPLOY that are intended to prevent diabetes in people with prediabetes. Doing so would require statutory changes, according to Marc Hartstein, deputy director of the Hospital and Ambulatory Policy Group at the Centers for Medicare and Medicaid Services, which runs Medicare. Hartstein noted that Congress recently established new benefits for pulmonary and intensive cardiac rehabilitation that include diet and exercise, but the statute requires these programs to be under the direct supervision of a physician-meaning the physician does not have to be present when the services are provided but must be immediately available to assist the patient if there is a problem. Medicare does not pay for any DPP-like programs that would not be supervised by a physician.
The four key levers the CDC is actively putting in motion, as summarized by Ann Albright, Ph.D., R.N., director of the CDC's Division of Diabetes Translation, include the following:
- Training. The CDC will develop a trained work force of lifestyle interventionists through collaboration with Emory University's Diabetes Training and Technical Assistance Center.
- Recognition. The CDC will develop a Diabetes Prevention Program Recognition System to assure quality and fidelity of the lifestyle program and provide a registry to track and report data, performance, and outcomes of the national diabetes prevention program.
- Model sites. The YMCA is currently working with model sites that can deliver the translated DPP lifestyle program with funding provided by the CDC as well as other model sites supported by UnitedHealth Group. The CDC will provide funding for an additional five to seven model sites in 2010.
- Health marketing. The CDC is working with health marketing consultants to develop effective tools and programs to inform pulations at highest risk for diabetes about the dangers of prediabetes and raise awareness among both health care providers and high-risk populations to increase effective referral of people at high-risk to lifestyle intervention programs.
Going forward, the DMICC seeks to broaden its membership to increase opportunities for collaboration and bring new perspectives and expertise to DMICC member activities.
To learn more about the DMICC, read Diabetes Mellitus Interagency Coordinating Committee: Coordinating the Federal Investment in Diabetes Programs to Improve the Health of Americans, available at the DMICC website, www.diabetescommittee.gov.
The National Diabetes Information Clearinghouse has information about diabetes, including a fact sheet about the DPP. For more information or to obtain copies, visit www.diabetes.niddk.nih.gov.
NIH Publication No. 10-4562
Page last updated: December 5, 2011