Models for diabetes prevention go beyond traditional approach

DinenbergThe traditional solution for diabetes prevention is found in the traditional site for disease control and prevention: the doctor’s office. While the physician must play a central role in diabetes prevention, the increasing prevalence of diabetes requires an exploration of a new model.

- Currently, there are 26 million adults in the U.S. with diabetes and 79 million with prediabetes.

- Every year 5% to 10% of people with prediabetes convert to diabetes.

The Centers for Disease Control and Prevention (CDC) projection for diabetes trending in the U.S. is grim:

- In 2013, 1 in 9 adults have diabetes

- In 2025, 1 in 5 adults are projected to have diabetes

 - In 2050, 1 in 3 adults are projected to have diabetes

The total estimated cost of diabetes in 2007 was $174 billion, including $116 billion in excess medical expenditures. People with diagnosed diabetes incur average expenditures of $11,744 per year, of which $6,649 is attributed to diabetes. On average, medical expenses for a person with diabetes are double that of someone without diabetes. Diabetes prevention is the ultimate “low-hanging fruit” for decreasing healthcare costs. 

Missing links in the traditional model 

For the traditional physician approach to work, patients must:

1. Receive a diagnosis of prediabetes from their physician. 

2. Receive physician recommendations based on this diagnosis. 

Evidence shows that the traditional approach is not effective. A representative sample of the U.S. population was assessed to determine the proportion of adults with prediabetes who reported: receiving a diagnosis of prediabetes from their physicians, and being prescribed lifestyle modifications by their physicians. Of study subjects, 35% had prediabetes and of those:

- Only 4.8% reported having received a formal diagnosis of prediabetes from their physicians.

- Only 26% had received recommendations for exercise and healthy eating from their physicians.

The study concludes that the majority of people with prediabetes were undiagnosed and untreated. Physicians have cited low confidence and lack of knowledge and skills as major barriers to counseling patients on lifestyle interventions.

An evidence-based model for diabetes prevention has emerged. The National Institutes of Health (NIH) randomized clinical trial called the Diabetes Prevention Program (DPP) studied whether modest weight loss through dietary changes and increased physical activity could prevent or delay the onset of type 2 diabetes. 

All study participants where overweight and at risk for developing diabetes at the beginning of the study. The lifestyle intervention group had a goal of 7% reduction in starting weight and received a 16-week curriculum, motivational support on healthy eating, recommendations on physical activity (150 minutes/week) and behavioral modifications. The lifestyle intervention group reduced their risk of developing diabetes by 58%.

Real world translation

Studies that apply the findings of the DPP to real world settings demonstrate that diabetes prevention costs can be lowered through a group class format and by training lay educators to facilitate the classes without sacrificing effectiveness. The success of the DPP combined with the increasing prevalence of diabetes triggered the U.S. Congress to authorize the CDC to establish and lead the National Diabetes Prevention Program (National DPP) as a low-cost, scalable diabetes prevention intervention. The National DPP curriculum and methodology are rooted in the DPP and provide an evidence-based model for diabetes prevention. With health plans beginning to explore reimbursement for National DPP, delivery of the program at the doctor’s office, employer or other community site by allied health professionals or lay health workers is indeed an exciting new possibility to explore to address an increasing problem.

Robert Eric Dinenberg, MD, MPH is Chief Medical Officer at Viridian Health Management.