The Prevention of Type 2 Diabetes: From Theory to Practice

Transcription

1 The Prevention of Type 2 Diabetes: From Theory to Practice David G Marrero, Ph.D. J.O. Ritchey Professor of Medicine Diabetes Translational Research Center Indiana University School of Medicine

2 Diabetes: how serious is the problem? Diabetes cost the U.S. more than 245 billion dollars last year: $176 billion in direct medical costs $69 billion in lost productivity: increased absenteeism ($5 billion) reduced productivity while at work ($20.8 billion) for the employed population, reduced productivity for those not in the labor force ($2.7 billion), inability to work as a result of disease related disability ($21.6 billion) lost productive capacity due to early mortality ($18.5 billion).

3 2010 Leading Causes of Death in the United States 1. Heart disease 2. Cancer 3. Lower respiratory diseases 4. Stroke and related diseases 5. Accidents 6. Alzheimer s disease 7. Diabetes 8. Kidney diseases 9. Influenza, pneumonia 10. Suicide 11. Septicemia 12. Chronic liver disease and cirrhosis 13. Hypertension and related renal disease 14. Parkinson s disease 15. Pneumonitis CDC

4 1O most costly medical conditions National Condition Cost Heart disease $90.9 B Cancer 71.4 Trauma-related 67.3 Mental disorders 59.9 Osteoarthritis 56.2 Hypertension 47.3 Diabetes 45.5 COPD, Asthma 44.5 Hyperlipidemia 38.5 Back problems 34.6 Soni, A. Top 10 Most Costly Conditions among Men and Women, 2008: Statistical Brief #331. July AHRQ,.

5 OK Dave, I get it; diabetes is a costly disease and kills a lot of people, but so does cancer. Why should I worry?.

6 Diabetes in U.S. Tip of the Iceberg Diabetes 26 million Americans 8.3% U.S. population Pre diabetes: 79 million Americans 35% of all adults 50% of adults >65 Progression to diabetes 5 15% per year

7 The Problem of Diabetes is Growing.

8 Prevalence of Diagnosed Diabetes Among U.S. Adults Percent White men White women Black men Black women AI/AN men AI/AN women Source: National Health Interview Survey (NHIS) and 2004 Indian Health Service outpatient database. Age

9 Why is this happening?

10 Lewis Carroll: kids author or Public Health Prophet? But wait a bit, the Oysters cried, Before we have our chat; For some of us are out of breath, And all of us are fat! The Walrus and the Carpenter

11 Percentage of Obese and Diabetic U.S. Adults Obesity Diabetes (diagnosed) <14% % % % 26% <4.5% % % % 9.0%

12

13 Etiology of Obesity: Dietary Intake Pereira MA et al. The Lancet. 365(9453):36-42 Daily caloric intake increased dramatically in the past 30 years - Increased portion sizes Marketplace portions are 2-8 fold larger than FDA recommendations - Increased frequency of eating out/fast food consumption Fast food consumption has strong positive associations with weight gain and insulin resistance

14

15 WE HAVE CHANGED OUR CULTURE

16

17 The State Fair Food of our Youth

18

19

20

21

22 Building/Community Designs Discourage Walking

23

24

25

26

27

28

29 What Can We Do About it?

30 The Diabetes Prevention Program

31 Diabetes Prevention the DPP 3 arm nation wide RCT with >3,000 participants with pre diabetes (IGT) Intensive Lifestyle Intervention Metformin (Diabetes medication) Placebo (Basic advice)

32 Development of Diabetes Placebo Metformin Life-style Development of diabetes 11.0% 7.8% 4.8% (percent per year) Reduction of diabetes % 58% compared with placebo Number needed to treat to prevent 1 case in 3 yrs

33 DPP Lifestyle Intervention Worked for: All ethnic/racial groups Men and women, lean, plump or fat All adults, especially those over age 60

34 SO WHY DON T HE HAVE A DIABETES PREVENTION PROGRAM ON EVERY STREET CORNER?

35 Barriers to DPP for All Evidence only supports Pre Diabetes Requires a blood test Not a routine in primary care settings Need for Scalable Models Purchaser must believe a program has fidelity Programs must be widely available (meet demand) Must be cost effective What do we translate?

36 Partnered Approach for Prevention Healthcare Reciprocal Interactions Glucose testing Risk/benefit assessment (safe?) Prescriptive advice (role for meds?) Gateway to reimbursement Community Population Resources Environment Education by Schools & Media Lower intensity programs Risk assessment opportunities Formal Programs Personnel Experience Facilities Contact

37 A FEW EXAMPLES

38 Diabetes Education & Prevention with a Lifestyle Intervention Offered at the YMCA

39 Why the Y? Lower Cost Programs Lower cost lay group leaders Operate to achieve cost recovery only Policy to turn no person away for inability to pay Past experience with national program scaling

40 Availability and Penetration 2700 Y facilities 57% of U.S. households are located within 3 miles of a YMCA

41 DPP Lifestyle Intervention Delivered in the YMCA Study Design Comparative effectiveness trial Group based DPP at YMCA vs. brief education only 92 participants at risk for diabetes Study Questions Can the YMCA deliver group based DPP? Could it achieve similar weight loss to DPP? Would it be less costly? Ackermann, et al. Am J Prev Med Oct;35(4):357-63;

42 Results: Weight Loss & Maintenance Percent Weight Loss 10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% 16 weekly visits p< monthly visits p=0.008 NO VISITS! 12 visits in 8 mos Same intervention now offered to both groups 6 months 12 months 20 months 28 months Brief Advice YMCA Group DPP *p values comparing Group DPP to Brief Advice Ackermann, et al. Am J Prev Med Oct;35(4):357-63;

43 Minimizing Program Costs Cost Category Original DPP Group Format YMCA Instructor Personnel $794 $131 Supplies $11 $11 Incentives $123 $10 Overhead $548 $51 Total $1,476 $203

44 Costs and Cost effectiveness PRE Diabetes Treatment Cost per year $US /QALY Intensive Lifestyle $1,500 / $700 $11,000* Group Lifestyle at YMCA $240 Cost Saving * Ackermann, et al. Am J Prev Med Oct;35(4): Herman, et al Diabetes Care

45 Where DEPLOY evolved; New Initiatives The National YDPP program The United Health Group Project The CDC s National Diabetes Prevention Program

46 The National YMCA DPP Decision to ramp up DEPLOY to YMCAs across the country Standardize training Standardize program elements and adapt to Y culture.

47 THE NATIONAL YDPP PROGRAM From : From 2009 June 2010: 2011 At the end of 2013: 1 Y in Indianapolis Multiple Ys in Indianapolis and Kentucky 35 new Ys in 116 sites in 9 new states Trained 200+ Lifestyle Coaches 100 Y Associations with over 700 locations Over 14,000 participants Lots more in 2014

48 The United Health Group Project Collaboration between the YMCA and UHG First payer to cover the benefit for persons identified as high risk by providers and referred to YDPP sites Scaled payment based on performance

49 Public Health Impact: The National Diabetes Prevention Program 2011: Congressional legislation established the CDC led National Diabetes Prevention Program Establish local evidence based lifestyle change programs for people at high risk for type 2 diabetes Train workforce to implement cost effectively Recognition Program: Assure quality and (hopefully) lead to reimbursement Develop intervention sites Marketing to support program uptake Inaugural partners (YMCA and United Health Group) Already provided services to thousands of patients

50 THE WEIGHT WATCHERS STUDY

51 Weight Watchers Leading global provider of weight management services Teach people to lose weight and keep it off by adopting a healthier lifestyle Clinically proven lifestyle program promotes healthy habits, a supportive environment, exercise, and smarter food choices 51

52 Weight Watchers Reach U.S. Annually more than 1.7 million enrollments in Weight Watchers meetings and 1 million signups for WeightWatchers.com 25,000 meetings each week held in convenient times and locations (~5,000 in workplace) 75% of members live with a 12 minute drive to a meeting Open attendance no need to reserve or schedule ahead of time 20,000 field staff, all of whom are Lifetime Members LTMs attend meetings for free as a reward when 52 maintaining their weight goal

53 Weight Watchers Geographic Coverage. 53

54 The Study RCT with 250 subjects with diagnosed IGT Comparison of WW with the same self help program used in DEPLOY Data collected for 24 months At 6 months, 5.7% weight loss vs. 1% in controls. At 12 months, 6.1% vs. 2%

55 The Public Health Promise Weight Watchers is the only at scale provider of education behavior modification for weight management in the world, and the only potential DPP partner with Brand awareness, channel access and investment to drive demand for Diabetes Prevention Programs Infrastructure to fulfill demand at scale quickly Experience with recruitment, training and management to deliver consistent, high quality results A built in base of role model service providers A science based approach that mirrors that of the DPP 55

56 Thank You!