Intervention for Diabetes Prevention

Dennis P. Scanlon, PhD: Welcome to The American Journal of Managed Care^® Peer Exchange^®, “Technology in Diabetes Care: From Prevention to Disease Management.” My name is Dr Dennis Scanlon, and I’m a professor of health policy and administration, and director for the Center for Healthcare Policy and Research, in the College of Health and Human Development, at the Pennsylvania State University.

In today’s discussion, the panel of experts will discuss the ever-increasing role that technology plays in both preventing and managing diabetes, as well as the challenges for payers, providers, and patients.

Before we begin, let me briefly introduce our panelists: Dr Robert Gabbay is senior vice president and chief medical officer of Joslin Diabetes Center in Boston, and associate professor at the Harvard Medical School; Mary Ann Hodorowicz is a Chicago-based dietitian, certified diabetes educator, consultant to physicians and health systems, and certified endocrinology coder; Dr Neal Kaufman, founder and chief medical officer for Canary Health, a board member with the Council for Diabetes Prevention, and adjunct professor of medicine and public health at the University of California, Los Angeles; and finally, Dr Kenneth Snow, a medical director for Aetna. Thank you all for joining us. Why don’t we begin?

Bob, maybe I can start with you. We talk a lot about diabetes and diabetes treatment. Today, we’re going to talk about diabetes prevention. I guess maybe a starting point is, what evidence is there for prevention and whether prevention works?

Robert Gabbay, MD, PhD, FACP: It’s a great question. Really, the landmark study was a study from the National Institutes of Health—the Diabetes Prevention Program (DPP). What they did was test, fundamentally, if you can prevent the development of diabetes. They took 2 different approaches: one was lifestyle intervention under very controlled rigorous conditions, and the other was medication. And the medication, initially, had 2 arms. One was a thiazolidinedione, and that was stopped because of the liver injury with troglitazone back in the day. But the arm that continued was with metformin (as a medication to prevent diabetes development).

The remarkable results were that the lifestyle intervention reduced the development of diabetes by almost two-thirds, and worked twice as good as metformin did. And so, lifestyle was very effective. The challenge of that study was that it was done in a very rigorous and resource-intensive way to ensure that people adhered to their lifestyle. And the challenge has been, now, how do you apply that to the broader population?

Dennis P. Scanlon, PhD: Anyone else have any thoughts about that? How do you take what was done in a controlled setting and work in prevention in the real-world?

Kenneth Snow, MD, MBA: That’s always one of the concerns for a payer—whether something that has been accomplished in a very well controlled clinical trial is actually going to show the same type of results when you bring it out into real-world experience. And certainly, with the DPP, I think everybody is hopeful that that is the type of results that we will continue to see.

Mary Ann Hodorowicz, RDN, MBA, CDE: I’d like to comment about how we define lifestyle intervention. What the trial showed is that weight-loss was one of the key factors in the prevention of full-blown type 2 diabetes—5% to 7% of weight loss from baseline and then a lower-fat eating style and exercise, 150 minutes per week of aerobic exercise, and then some stress management. Those are really the elements of the lifestyle intervention.

Neal Kaufman, MD: We found, with this theoretical approach, it is highly resource-intense. One individual could, maybe, help 30 or 40 people over a year. It was 16 weekly sessions, and monthly sessions thereafter. It was an hour each week, one-on-one in-person, and that worked. The CDC [Centers for Disease Control & Prevention] recognized that that was not a scalable or sustainable model and began looking to how to provide it in other ways.

There’s been 2 screens (or 2 threads) of approaches. The one that’s the dominant one uses groups. So instead of one-on-one, it was one with 10 or 15 people, and highly trained individuals to provide it. The paradigm for that was done most effectively in YMCA, where they did a pilot study and then got CMMI (Center for Medicare and Medicaid Innovation) funding to do to a major study to look at outcomes.

The second approach was technological. And the question was, could you take the program delivered in-person, and provide it in a technological format using the Internet, cell phone, etcetera? Our company was involved. I was very much involved, back in 2006, to create a digital version of that program. At that time, we didn’t know if it was going to work. We didn’t know if people would accept it, but we recognized that people need choice, and that having the ability to take in-person and digital as a way (by their choice) would make perfect sense. And so, we, and now a number of other companies, have been able to demonstrate that you can take an in-person program and use great design and great approaches to make technology work and have individuals use it effectively.

Dennis P. Scanlon, PhD: I want to get into that technology piece a little bit more. Before we do though, you mentioned the YMCA study, and I was wondering if one of you might talk a little bit about that study, sort of expanding from the earlier one that Bob mentioned.

Mary Ann Hodorowicz, RDN, MBA, CDE: One thing I would like to say about the YMCA study relates to what I just defined about lifestyle intervention. Self-monitoring the patients and participants, self-monitoring their eating, their exercise, their weight-loss on a regular basis, and reporting that to their lifestyle coach—that element of self-monitoring, I think all the physicians would agree, increases motivation and that stick-to-it attitude to keep going with the program.

Dennis P. Scanlon, PhD: I believe there are also a number of session requirements, and some particulars around that, as well.

Neal Kaufman, MD: Basically, the YMCA study, which has then led to part of the regulations and requirements that the CDC puts out, requires 16-weekly sessions. They have to be offered to the person no less than over 16 weeks, and no more than 26 weeks. There have to be additional sessions, at least once a month. The sessions have certain content that have to be there. They have to be full-setting tracking, and they need to get feedback on it, and create action plans of what they’re going to do between sessions. Whether it’s in-person or digital, those same requirements are there.