Contributor: Despite Updated NCCC Guidelines, More Action Is Needed to Address Diabetes Care Equity

The National Clinical Care Commission (NCCC) recently published guidelines to improve the federal response to the diabetes epidemic,¹ which have been summarized elsewhere.² Briefly, the recommendations were updated for the first time in close to 50 years and identified 4 focus areas: foundational, population prevention and control, prevention in targeted populations, and treatment and complications, with action items in each focus area.

Many of the recommendations highlight the need for coordination across federal agencies and departments to address upstream contributors to the diabetes epidemic, including improving access to healthy environments and implementation of evidence-based prevention efforts while emphasizing health equity. Focusing on these social determinants of health (SDOH) has the potential to improve diabetes alongside other chronic conditions. Additional recommendations for treatment emphasize team-based, accessible care including expanding virtual care.

The NCCC guidelines represent a comprehensive call to action to numerous federal programs, agencies, and departments to focus on health equity in prevention and access to care. Population prevention and control guidelines specify key areas, including improving the availability and accessibility of healthy foods, especially for individuals and families utilizing federal nutrition assistance programs, as well as concerted efforts through changes in marketing and food labeling to discourage consumption of sugar-sweetened beverages and increase awareness of food nutritional value.

If upstream systematic changes such as these are indeed realized, they have the potential to change the course of the diabetes epidemic and improve the health of our nation while having a substantial impact on moving health equity forward.

In addition to these broader recommendations, the NCCC guidelines for Prevention in Targeted Populations focus on increasing access to the National Diabetes Prevention Program (DPP). Finally, guidelines for treatment and complications focus on improving access to efficacious treatment, including medications (ie, insulin), devices (ie, insulin pumps), and team-based care.

In addition to changing the built and food environments, the NCCC guidelines focus heavily on the continued uptake of the National DPP and access to medication (metformin) for diabetes prevention in targeted populations. The guidelines focus on improving coverage for behavioral health and preventative medication by insurance companies, improving coordination between Medicaid and Medicare to deliver the DPP, and expanding the reach of the DPP through telehealth and other evidence-supported delivery modalities, especially to rural communities.

These changes are necessities to overcome the quality gap in diabetes prevention. The call for metformin approval by the FDA for prevention of type 2 diabetes in those at high risk is long overdue. Despite the abundance of evidence-based lifestyle interventions, they are inaccessible to many Americans.

A final strength of the guidelines is the comprehensive, team-based approach to diabetes treatment. Improving access to diabetes self-management education alongside access to technologies (eg, continuous glucose monitoring) and medication (ie, insulin) are critical to avoid further complications. The US House of Representatives passed the Insulin Now Act on April 1, 2022, and it now waits ratification in the Senate. Passing this bill would create immediate and meaningful changes to the affordability of treating diabetes for millions of Americans.

While these guidelines suggest significant and substantial steps forward in the prevention and treatment of diabetes, there are additional areas of opportunity to consider.

First, many of the recommendations require coordination and action across multiple federal agencies on an unprecedented scale. Although the report recommends the creation of the Office of National Diabetes Policy (ONDP) as its first action item, there seems to be limited urgency to realize this recommendation and the ONDP would have limited power to implement its recommendations without large-scale support from numerous federal agencies.

In addition, this precedent of establishing a special office for a particular disease may meet resistance, as lawmakers and administrators consider the feasibility to scaling this approach to other disease conditions. Instead, an Office of Chronic Disease Policy may be better suited to address SDOH that impact numerous chronic diseases, recognizing that there are disease-specific issues (eg, medications specific to diabetes).

Second, although 3 of the 4 focus areas (population prevention and control, prevention in targeted populations, and treatment and complications) note the need for continued research support, a stronger message regarding the need for continued research is warranted. Specifically, an explicit emphasis on disseminating and implementing available knowledge was missing. The quality gap in medicine is well documented,³ and guidelines such as these are an opportunity to highlight the need for implementation-focused work to best connect effective strategies with populations who need them.

Finally, there was an opportunity missed to encourage person-centered care. Consideration is needed for developing culturally appropriate adaptations to the DPP for diverse populations and encouraging providers to adopt a personalized-medicine approach to treating diabetes, taking into consideration persons’ with diabetes individual contexts and goals in their health care.

The NCCC guidelines for diabetes prevention and care take a much-needed step forward in addressing the impact of upstream SDOH as they contribute to the diabetes epidemic. Although promising, these goals are lofty and will likely take years to be implemented and time beyond that to see the positive impact on communities.

In the meantime, continuing to focus on equitable access to prevention and care and bridging the gap through continuing to advance the science of implementation across contexts is critical in combating the diabetes epidemic.

References

1. National Clinical Care Commission. Report to Congress on leveraging federal programs to prevent and control diabetes and its complications. January 2022. Accessed April 5, 2022.https://health.gov/sites/default/files/2022-01/NCCC%20Report%20to%20Congress.pdf
2. The National Clinical Care Commission Writing Group. The National Clinical Care Commission report: improving federal programs that impact diabetes prevention and care. Ann Intern Med. 2022;175(4):594-597. doi:10.7326/M21-4175
3. Baker A. Crossing the Quality Chasm: A New Health System for the 21st Century. British Medical Journal Publishing Group. 2001.