Diabetes Prevention. UCSF Internal Medicine Updates San Francisco May, 2018

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1 Diabetes Prevention UCSF Internal Medicine Updates San Francisco May, 2018 Elizabeth J. Murphy, MD, DPhil Professor of Clinical Medicine Deborah Cowan Endowed Professorship in Endocrinology University of California, San Francisco Chief, Division of Endocrinology San Francisco General Hospital Nothing to Disclose 1

2 1 in every 3 adults in the U.S. will have diabetes by Diabetes in America million Americans (9.4%) have diabetes 25.2% of Americans > 65 have diabetes 84.1 million adult Americans (34%) have prediabetes 2

3 What is the only safe way to cure and treat DM2 long-term? Don t develop it in the first place. Basic Assumptions for today Weight loss will prevent/delay diabetes Increased activity will prevent/delay diabetes Eating less leads to weight loss Weight loss and increased activity are good no matter what Harms associated with behavioral interventions to promote weight loss are minimal to non-existent 3

4 Discrepancy Between Reported and Actual Energy Intake and Expenditure Energy Intake * Activity Energy Expenditure Kcal/d * 0 Reported Actual Reported Actual *P<0.05 vs reported. Lichtman et al. N Engl J Med 1992;327:1893. Slide Source: My Assumptions Intensive lifestyle methods are beneficial for everyone and we should not just focus on those at highest immediate risk We should focus lifestyle interventions on patients who are motivated Widespread lifestyle change will have spill over effects 4

5 Key Questions Who is at highest risk of diabetes and how do we easily identify them? What does the evidence show about success of interventions? What options are available for Diabetes Prevention? What about cost and what will get paid for? ADA/AMA/CDC National Ad Campaign Ad Council Push for self testing of diabetes risk In English, Spanish With hedgehogs, disco goats or puppies 5

6 What was your score? BMI cut points were roughly = 1 point = 2 points >= 5 High Diabetes Risk >40 = 3 points Audience Response A = 0 4 points B = 5 6 points C = 7 or more points D = I have diabetes Who is at Highest Risk for DM? History of gestational diabetes Family history of diabetes Age Overweight and obese Sedentary High risk ethnic group Impaired glucose metabolism High waist to hip ratio 6

7 Diabetes Prevalence by Ethnicity Northern California Karter et al, Diabetes Care year old sedentary Asian woman, BMI 29.5 history of GDM with a brother, mother and father with diabetes. 7

8 5 or more at increased risk BMI >40 Do I have diabetes.org (ADA/AMA/CDC/Ad Council) 8

9 = 13 9 or more, high risk BMI >27 35 year old sedentary Asian woman, BMI 29.5 history of GDM with a brother, mother and father with diabetes. TV screen 3 points (5) low risk ADA paper screen 4 points (5) low risk Doihaveprediabetes.org 4 points (5) low risk National Diabetes Prevention Program Screen 13 points (9) High risk 9

10 Includes questions on smoking, eating fruits and vegetables, waist circumference 10

11 Conclusions Who to Screen? Use a screening tool that will capture the largest number of people Use tools that include Asian specific BMI cutoff As with screening for gestational diabetes, perhaps easiest to screen widely Prediabetes Fasting glucose 100 or mg/dl A1C % 2h glucose post 75 OGTT mg/dl 11

12 Laboratory Screening Recommendations CDC DPP Positive on high risk on screening tools AND BMI 24 kg/m 2 or 22 kg/m 2 in Asian Americans OR History of GDM ADA Everyone over age 45 Adults who are overweight or obese and an additional risk factor (BMI 25 kg/m 2 or 23 kg/m 2 in Asian Americans) USPSTF Age with BMI 25 kg/m 2 USPSTF Recommendations No ethnicity appropriate BMI cut offs Doesn t allow for screening of < 40 Poor sensitivity (45%) and may detect only 25% of dysglycemic patients in 3 year f/u 1 1 O Brien MJ, Lee JY, Carnethon MR, Ackermann RT, Vargas MC, et al. (2016) Detecting Dysglycemia Using the 2015 United States Preventive Services Task Force Screening Criteria: A Cohort Analysis of Community Health Center Patients. PLoS Med 13(7): e

13 % Dysglycemic Patients Captured by USPSTF Screening Guideline 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% White African American Latino O Brien MJ, Lee JY, Carnethon MR, Ackermann RT, Vargas MC, et al. (2016) Detecting Dysglycemia Using the 2015 United States Preventive Services Task Force Screening Criteria: A Cohort Analysis of Community Health Center Patients. PLoS Med 13(7): e doi: /journal.pmed USPSTF Weight Loss to Prevent Obesity Related Morbidity and Mortality in Adults: Behavioral Interventions 13

14 Key Questions Who is at highest risk of diabetes and how do we easily identify them? What does the evidence show about success of interventions? What options are available for Diabetes Prevention? What about cost and what will get paid for? Diabetes Prevention Program 3234 Participants Good diversity 19% African American 16% Hispanic 5% American Indian 4% Asian and Pacific Islanders High Risk: 25 years or older BMI 24 kg/m 2 or 22 kg/m 2 in Asian Americans Fasting glucose mg/dl and OGTT glucose 140 to 199 mg/dl Randomized metformin (850 mg BID) OR extensive, individual lifestyle intervention NEJM 346:393, 2002; Lancet 374:1677,

15 Lifestyle Intervention 16 week curriculum with individual sessions over 24 weeks After 24 weeks follow up individual and group sessions for reinforcement Healthy low fat, low calorie diet 150 minutes of moderate-intensity physical activity per week 15

16 Lifestyle Group 7% weight loss at one year 4% weight loss at 4 years 150 minutes of moderate-intensity physical activity per week Diabetes Prevention Program Research Group. N Engl J Med 2002;346: Reduction in Diabetes by Weight Loss NEJM 346:393,

17 Metformin Sub Group Findings most effective in < 60 years old and BMI > 35 or if a history of gestational diabetes As effective as lifestyle in that group Least effective in lower fasting glucose and lower BMI Lifestyle more effective with lower base-line OGTT glucose. No significant differences based on sex, race or ethnic group DPP- Outcomes Study All subjects offered lifestyle intervention in a group format for one year Everyone offered maintenance group sessions quarterly Lifestyle group offered further supplementary group programs and an individual lifestyle check in twice a year 88% of DPP enrolled 17

18 Lancet. 2009; 374: DPP 15 years Risk Reduction 18% with metformin 34% with Lifestyle Microvascular Outcomes Followed for Microvascular Outcomes Nephropathy Retinopathy Neuropathy Lower prevalence in those who did not develop diabetes No significant treatment effect (yet) 18

19 Finnish Diabetes Prevention Study 500+ Finnish participants, Abnl OGTT; Ave BMI 31 Diabetes diagnosed as FBG>140 or OGTT>200 Lifestyle intervention Exercise = Gardening, snow shoveling, berry picking, gathering mushrooms, rowing, forest work Weight loss 5% ~3 years follow up NEJM 2001;344: Finnish DPP Results 58% reduction in incidence of diabetes Diabetes developed in 6% vs. 14% As with US DPP, success was dependent on achieving the goals NEJM 2001;344:

20 Finnish DPP 7 years Lancet 2006; 368: Da Qing Study 577 participants with IGT in China Control vs. Diet, Exercise, or Diet AND Exercise 6 year follow up 30 45% reduction in incidence of diabetes in intervention groups Different interventions were comparable Diabetes Care (4):

21 Da Qing Study 20 and 23 years 43% reduction in incidence of DM over 20 years No difference in rate of CV events or CVD death at 20yr At 23 years, CV and all cause mortality were reduced HR 0.59 and 0.71 CV mortality All-cause mortality Lancet 2008; 371: Lancet Diabetes & Endocrinology, 2014, 2(6): DPP Translational Studies Focus on more cost efficient delivery Focused on weight loss All achieve early weight loss Long term durability of weight loss not as clear Don t yet have diabetes prevention data for translational programs Other potential benefits Lipids HTN Depression 21

22 The Future of Type 2 Diabetes Care Key Questions Who is at highest risk of diabetes and how do we easily identify them? What does the evidence show about success of interventions? What options are available for Diabetes Prevention? What about cost and what will get paid for? 22

23 To Qualify For CDC Recognized Program Be at least 18 years old and Be overweight (body mass index 25; 23 if Asian) and Have no previous diagnosis of type 1 or type 2 diabetes and Have a blood test result in the prediabetes range within the past year: Hemoglobin A1C: 5.7% 6.4% or Fasting plasma glucose: mg/dl or Two hour plasma glucose (after a 75 gm glucose load): mg/dl OR Be previously diagnosed with gestational diabetes 23

24 CDC DPP Certification Requirements CDC approved curriculum promoting 5 7% weight loss and increased physical activity A lifestyle coach A peer support group of program participants Submit annual data on weight loss, activity, class participation Enroll > 50% of patients based on lab tests In person Hands on demonstrations with a coach who provides handouts and practice activities. Most in person sessions have three parts: Review and check in on weekly progress Group discussion about the week s topic Wrap up with a to do list and handouts to reinforce what was learned Advantages Easier group bonding and peer support More personal Disadvantages Need to be available at a given place and time 24

25 In Person Programs YMCA Weight watchers Kaiser DPP Small individual DPP Online Programs 100% online delivery of sessions Multiple opportunities for live lifestyle coach interaction individually and with a group Include online tracking programs to help log food and physical activity. Typically get things like a digital scale, pedometer and a stretch band Advantages Can do anywhere anytime Good for folks who don t like in person groups Disadvantages Need smartphone (or computer) Need to be tech savvy and typically high literacy 25

26 Distance Learning Yearlong programs delivered 100% by trained Lifestyle Coaches via remote classroom or telehealth (i.e., conference call or Skype). Good for participants who want group interaction, but live in remote areas and cannot attend an in person program. CDC Program Registration 1744 registered programs across the US 164 have full CDC program recognition 293 programs with preliminary status 1287 programs pending recognition 26

27 CDC Registered Online 57 Online programs registered 3 full recognition 6 preliminary 48 pending recognition Key Questions Who is at highest risk of diabetes and how do we easily identify them? What does the evidence show about success of interventions? What options are available for Diabetes Prevention? What about cost and what will get paid for? 27

28 Medicare Pilot Program Pilot program with YMCA in patients with Medicare Savings of $2650 per person enrolled CMS plan for diabetes prevention coverage Lead to Medicare covering DPP with patients able to enroll as of April 1,

29 Medicare Diabetes Prevention Program (MDPP) Medicare Part B enrollees BMI of at least 25 kg/m 2 (or 23 kg/m 2 Asian) AND one of FPG mg/dl OGTT of mg/dl HbA1c between 5.7% and 6.4%. No previous dx of DM1 or DM2 and no ESRD Medicare Diabetes Prevention Program (MDPP) Medicare Part B enrollees BMI of at least 25 kg/m 2 (or 23 kg/m 2 Asian) AND one of FPG mg/dl OGTT of mg/dl HbA1c between 5.7% and 6.4%. No previous dx of DM1 or DM2 and no ESRD 29

30 Solera 4 Me For Medicare Patients Four questions Age Gender Ethnicity BMI Excludes folks with diabetes or ESRD Links you with programs approved by your health plan Asks about online versus in person preferences 30

31 Medicaid Coverage Montana Medicaid covers everyone CDC/Medicaid Pilot Projects Maryland Oregon July 2017, Medi Cal announces coverage plan DHCS 1/2/2018 posted initial implementation information Will include 22 peer coaching sessions over 12 months, provided regardless of weight loss Participants who achieve and maintain a minimum weight loss of 5 percent by 12 months period will can receive ongoing maintenance sessions Programs must comply with CDC guidelines and obtain recognition To start 1/1/2019 Payments Many programs with a fixed fee of around $450 Increasingly programs are paid on a pay for performance basis Medicare 2018 payment notice $125 for < 5% weight loss $810 maximum pay for performance 31

32 Unanswered Questions Roll of maintenance programs Effectiveness in specific vulnerable populations Programs for kids and adolescents? Other Methods of Diabetes Prevention Metformin As effective as lifestyle in folks with BMI 35 Less effective than lifestyle overall Not effective if > 60 years old Cost saving over 10 years Other medications Bariatric surgery 32

33 Medication for DM Prevention Diabet. Med. 28, (2011) DM Trends in US Age 20-79; Geiss et al, JAMA. 2014;312(12):

34 SOME ONLINE DIABETES PREVENTION RESOURCES Some Online Risk Calculators Ada Link Nice for patients to do and includes Asian specific BMI you at risk/diabetes risk test/ Do I have diabetes.org (ADA/AMA/CDC/Ad Council) UK Risk Calculator (includes waist circumference) Printable PDF for clinic 5 point ADA and CDC d atwork/diabetes risk test poster english 11x17.pdf 9 point CDC Link To CDC Diabetes Prevention Resources How to find a CDC registered program How to convince a payor to cover DPP with savings calculators Program Finder for Covered Programs for Medicare Patients (commercial program)

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