o Prevalence of prediabetes o Health care costs related to T2DM o The complications of T2DM o National Diabetes Prevention Program (NDPP)

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1 Preventing Diabetes in America What s Next Joyce B. Patterson, MPH, RDN, BC ADM University of Michigan Adult Diabetes Education Program and UM Diabetes Prevention Program Define the problem o Prevalence of prediabetes o Health care costs related to T2DM o The complications of T2DM Describe a solution o National Diabetes Prevention Program (NDPP) Discuss implementation o Identify patients at risk o Discuss role of the RDN o Discuss Medicare DPP expansion o Locate or develop NDPP programs in Michigan Objectives The Numbers { Prevalence, economic burden, individual costs 86,000, million adults have prediabetes. Source: Centers for Disease Control and Prevention 1

2 9 out of 10 people with prediabetes do not know they have it % with prediabetes will develop T2DM in 5 years.*????????? Source: Centers for Disease Control and Prevention *Without intervention. Source: Centers for Disease Control and Prevention Underreported Only 8.2% of adults in MI reported ever being told that they have prediabetes. Source: Michigan Department of Health and Human Services, Fact Sheet: Prediabetes in Michigan 2015 Note C: Due to the BRFSS methodology changes in 2011, estimates should only be compared to MiBRFS estimates from , and not years prior to 2011 Source: Michigan Department of Health and Human Services, Fact Sheet: Diabetes in Michigan Update

3 $245,000,000,000 $245 billion total cost of care for people with diabetes* $13,700 average cost per person The People { Who is at risk The complications of T2DM *Total cost in 2012, up 41% over 5 years Source: Centers for Disease Control and Prevention Who s at risk? 45 or older Certain Ethnicities Family History History of GDM Weight Diet and physical activity *Not reported due to relative error greater than 30.0% Source: MiBRFSS as reported in Michigan Department of Health and Human Services, Fact Sheet: Diabetes in Michigan Update 2015 Who s at risk? Source: MiBRFSS as reported in Michigan Department of Health and Human Services, Fact Sheet: Diabetes in Michigan Update

4 Complications Cardiovascular disease Stroke Kidney disease Retinopathy Neuropathy A Solution { Diabetes Prevention Source: USRDS as reported in Michigan Department of Health and Human Services, Fact Sheet: Diabetes in Michigan Update 2015 Randomized Controlled Methods n=3234 Diabetes Prevention Program Research Group Study ~Knowler, WC, et al, 2002 The Evidence Intensive Lifestyle change VS Metformin VS Standard care, nutrition counseling 4

5 Results 31% Reduced risk of DM taking Metformin compared to standard care 58% Reduced risk of DM from lifestyle change compared to standard care Conclusion Lifestyle change Can prevent or delay T2DM Prevention can reduce the individual and public health burden of diabetes National Initiative Diabetes Prevention Act of 2009 establish a national diabetes prevention program targeted at persons at high risk for diabetes National Diabetes Prevention Program { An Intensive Lifestyle Intervention The Solution 5

6 Intensive A one year program 16+ weekly group sessions in the first 6 months Plus 8 or more monthly maintenance sessions Intensive Goal 150 minutes physical activity per week 5 7% weight loss by 6 months and maintained by 12 months Supportive Comprehensive Led by a trained lifestyle coach Dietitian, health professional, community health worker, or lay person Weekly group discussion participants Meal Planning, shopping Problem solving/time management Stress management Holidays, vacations Social support Staying motivated and preventing relapse And much more! 6

7 Comprehensive Effective Effective Effective I visited my PCP today and he said these words: ʺCongratulations. Youʹve cured yourself of hypertensionʺ and took me off of blood pressure medicine. He also tested my A1C and it was 5.4. ~Winter 2016 Participant My HgBA1C is down to 4.6. Here is the trend of my results over the past few years: 2016: : : : : 5.0 ~Fall 2015 Participant 7

8 Effective I havenʹt felt this good in years. I have really enjoyed the class and I donʹt believe I could have made all the changes to my diet on my own. ~Fall 2016 Participant Implementation { Medicare Expansion Coming Soon! CMS to expand MDPP 1 Announced July 7, 2016 Starts January 1, 2018 st Preventive Service the first time a preventive service model from the CMS Innovation Center has been expanded. Source: Medicare Diabetes Prevention Program (MDPP) Expanded Model, diabetes prevention program/, accessed 4/9/

9 25% Diabetes effects more than 25% of people over age 65. $42,000,000 Medicare estimated to spend $42 billion more in 2016 due to diabetes. Source: Medicare Diabetes Prevention Program (MDPP) Expanded Model, diabetes prevention program/, accessed 4/9/2017. Source: Medicare Diabetes Prevention Program (MDPP) Expanded Model, diabetes prevention program/, accessed 4/9/2017. Eligibility Enrollees of Medicare Part B with: BMI 25 or higher (23 or higher for Asians) A1c % or FBG or 2 Hr OGTT No previous diagnosis of T2DM or ESRD (exception GDM) Benefit Coverage of 1 year program Recognized MDPP supplier Plus ongoing maintenance sessions after 1 year in 3 month intervals with 5% weight loss Source: Medicare Diabetes Prevention Program (MDPP) Expanded Model, diabetes prevention program/, accessed 4/9/2017. Source: Medicare Diabetes Prevention Program (MDPP) Expanded Model, diabetes prevention program/, accessed 4/9/

10 Dietitians vs other An opportunity for RDNs { Become a trained lifestyle coach Effect size of lifestyle intervention at 12 months delivered by dietitian or nondietitian during overall intervention: Outcome Dietitian Non Dietitian Weight % CI 0.40 to 0.21 FBG 0.42 (95% CI 0.70 to 0.14) HbA1c 0.43 (95% CI 0.70 to 0.16) 0.26 (95% CI 0.34 to 0.18) 0.17 (95% CI 0.37 to 0.04) Not significant 0.26 (95% CI 0.55 to 0.03) P<0.10 Source: Sun Y et al 2017 Coach Training American Association of Diabetes Educators, Diabetes Prevention Program Black Women s Health Imperative Center for Excellence in Aging & Community Wellness/Quality and Technical Assistance Center (QTAC) Diabetes Training and Technical Assistance Center, The Emory Centers for Training and Technical Assistance at Emory University Magnolia Medical Foundation Solera Health Inc State of Wellness University of Pittsburgh Diabetes Prevention Support Center, Department of Epidemiology at the Graduate School of Public Health Virginia Center for Diabetes Prevention & Education Become a MDPP provider { Develop a CDCrecognized DPP program Source: Centers for Disease Control and Prevention, National Diabetes Prevention Program, program/staffing training.html, accessed 4/13/

11 Develop a Program Become a CDC Recognized DPP Start today! Develop your 1 year program Apply for Pending Recognition status Use CDC approved curriculum* Recruit and train lifestyle coaches Recruit eligible participants Note: Eligibility is slightly different than MDPP Start collecting data * lifestyle program/curriculum.html Source: Centers for Disease Control and Prevention, National Diabetes Prevention Program, program/requirements.html, accessed 4/9/2017. Source: Centers for Disease Control and Prevention, National Diabetes Prevention Program, program/requirements.html, accessed 4/9/2017. Full Recognition Submit data 1 year after effective date of application. Weight Loss: average 5% at 6 and 12 months Attendance: average 9+ sessions in first 6 months plus 3+ sessions in months 6 12 Physical activity minutes recorded: 60% or more of all sessions Weight recorded: 80% or more of all sessions Medicare Coverage Full recognition is required to become an MDPP supplier. Maximum reimbursement for 1 st year per participant: $450 Maximum reimbursement for maintenance sessions after 1 st year: $180 Source: Centers for Disease Control and Prevention Diabetes Prevention Recognition Program: Standards and Operating Procedures, January 1, 2015, Source: Calendar Year 2017 Medicare Physician Fee Schedule (PFS) Final Rule, /medicare program revisions to paymentpolicies under the physician fee schedule and other revisions#h 321, accessed 4/9/

12 Refer your patients { Find programs around Michigan Find a program National Diabetes Prevention Program on CDC Web Site abetes/prevention/ index.html Michigan Online Programs Also available, online or combo In person/ online programs Source: Centers for Disease Control and Prevention, National Diabetes Prevention Program, accessed accessed 4/13/2017. Source: Centers for Disease Control and Prevention, National Diabetes Prevention Program, accessed accessed 4/13/

13 Online Programs Effect size of lifestyle intervention at 12 months delivered in person or via technology during overall intervention: Outcome In Person Technology Weight % CI 0.30 to 0.18 FBG 0.33 (95% CI 0.55 to 0.12) HbA1c 0.40 (95% CI 0.62 to 0.18) P< (95% CI 0.68 to 0.14) 0.33 (95% CI 0.58 to 0.08) P<0.05 Insufficient data Looking ahead Preventing Diabetes in Medicare Act of 2015 Introduced in House on 3/26/2015 Latest action: Referred to subcommittee on Health on 4/8/2015 A proposal to provide coverage for MNT for prediabetes. Source: Sun Y et al 2017 Source: H.R.1686 Preventing Diabetes in Medicare Act of 2015, bill/1686/all actions?overview=closed#tabs, accessed 4/13/2017 Summary Intensive lifestyle programs are recognized as an effective intervention for diabetes prevention. Insurance coverage is on the rise. A growing opportunity for RDNs. Centers for Disease Control and Prevention, National Diabetes Prevention program, Centers for Disease Control and Prevention Diabetes Prevention Recognition Program: Standards and Operating Procedures, January 1, 2015, CMS.gov, Medicare Diabetes Prevention Program (MDPP) Expanded Model, diabetes prevention program/ Congress.gov H.R.1686 Preventing Diabetes in Medicare Act of 2015, bill/1686/all actions?overview=closed#tabs H.R.4124 Diabetes Prevention Act of 2009, congress/housebill/4124 Federal Register: The Daily Journal of the United States Government. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2017; Medicare Advantage Bid Pricing Data Release; Medicare Advantage and Part D Medical Loss Ratio Data Release; Medicare Advantage Provider Network Requirements; Expansion of Medicare Diabetes Prevention Program Model; Medicare Shared Savings Program Requirements, /medicare program revisionsto payment policies under the physician fee schedule and other revisions#h 321. Knowler WC, Barrett ConnorE, Fowler SE, Hamman RF, Lachin JM, Walker EA, Nathan DM & Diabetes Prevention Program Research Group. (2002). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med, 346(6), doi: /nejmoa Michigan Department of Health and Human Services, Fact Sheet: Prediabetes in Michigan 2015 Fact Sheet: Diabetes in Michigan Update 2015 Sun Y, You W, Almeida F, Estabrooks P, Davy B. The Effectiveness and Cost of Lifestyle Interventions Including Nutrition Education for Diabetes Prevention: A Systematic Review and Meta Analysis. J Acad Nutr Diet 2017;117: Resources 13