Joanne Mizell: Lifestyle Modification Programs Take Holistic Aim at Metabolic Disease

Joanne Mizell

For decades, rates of metabolic diseases have been on the uptick with no sign of slowing down.¹ Diabetes and its associated health complications carry a significant financial burden for both individuals and society, a trend that is expected to continue.²

In this written interview with The American Journal of Managed Care^® (AJMC^®), Joanne Mizell, chief operating officer of Banner|Aetna, shares strategies insurers are using to address escalating rates of metabolic diseases, why traditional approaches centered primarily on pharmacologic management fall short, and the importance of holistic treatment methods, like lifestyle modification programs. She also previews what to expect from the future of metabolic disorder management and prevention efforts.

AJMC: How have you observed the prevalence of metabolic diseases, such as diabetes, evolve over recent years?

Mizell: The prevalence of metabolic disease has significantly increased over the last two decades. Finding solutions and ways to combat this trend has been a key focus area for our chief medical officer at Banner|Aetna, Robert Groves, MD. Before we dive into some of his insight—when we talk about metabolic disease, we’re using an umbrella term that covers the following:

• Hypertension
• Type 2 diabetes mellitus
• Hyperlipidemia
• Obesity
• Non-alcoholic fatty liver disease

Much of Groves’ work over the years has centered around the fact that these diseases share common risk factors and often co-occur. For instance, the steady rise in obesity in both children and adults is a major contributing risk factor for the development of type 2 diabetes, which often starts as prediabetes. Today, prediabetes affects 1 in 3 people, and the majority of those who have it don’t realize that they do.³ Because they don’t know they are prediabetic, they are unlikely to make the changes necessary to delay or prevent the onset of the full-blown disease.

This is a big deal because, in 90% of cases, type 2 diabetes is preventable with lifestyle modification.⁴ So, we expect to see rates continue to climb unless effective preventive and therapeutic strategies are implemented. Studies estimate that the number of people living with the disease will more than double by 2050. And that’s driven almost entirely by type 2 diabetes.⁵

AJMC: What are the limitations of current clinical and care management approaches in addressing metabolic disorders like diabetes? How can a more holistic approach, considering social determinants of health, improve outcomes for individuals with these conditions?

Mizell: Traditional approaches to treating diabetes and other metabolic diseases have centered on pharmacologic management. And for good reason—diabetes medications are lifesaving for certain people. But now, we understand that medication is only a piece of the puzzle.

That’s because there is such a wide range of clinical manifestations and treatment responses that characterize these disorders. Often, a traditional, one-size-fits-all treatment approach, like prescription management, doesn’t adequately address those nuances.

So, we reimagine what clinical and care management looks like for diabetes and other metabolic conditions when it’s multidisciplinary and focuses on whole-person health while incorporating behavior modification strategies.

What we found is that research-based population health strategies can significantly help people with a high or rising risk of metabolic disease change their behavior. That means holistic programs work to improve health outcomes and treat disease while addressing root-cause elements like diet, exercise, nutrition, and more.

The latest American Diabetes Association guidance supports this approach.²

AJMC: Can you share insights into the lifestyle modification programs offered by health insurers? What are the key components of these programs, and how do they differ from traditional approaches to managing metabolic disorders?

Mizell: The payer space is starting to recognize the value of lifestyle modification programs in managing and preventing metabolic disorders. Many are putting focus on member-centered services that take into account each person’s circumstances, desires, needs, and social determinants of health.

But while nearly every insurer has some type of lifestyle modification offering, they don’t always take a truly holistic approach. For example, it’s common to see separate point solutions for weight loss, nutrition, physical activity, and behavioral changes. Putting yourself in the members’ shoes could easily become overwhelming and unsustainable. I think it’s a key reason people find it difficult to be successful with these programs.

Banner|Aetna looked at all these challenges and developed a comprehensive approach to lifestyle modification programming, which we call “The Eco” (short for the Banner|Aetna Ecosystem). What sets our method apart is the way the suite of support aims to address the root cause of diseases and foster lasting health improvements. Importantly, we’re also able to provide consultative, concierge care management, virtual disease management, and wellness support to members.

Nested under this umbrella of The Eco, we have a unique hands-on nutrition education program. It’s a schedule of community-based dinner parties with a professional chef and a nutritionist. During the cooking-show-style classes, members prepare and enjoy a meal together while sharing in a guided conversation about topics like practical nutrition and how to stay physically active. It’s made a big impact on people who participate—data shows 75% adopt regular exercise routines, and 92% see benefits like weight loss or improved blood glucose.

Another core offering is our type 2 diabetes reversal program which helps members manage their condition and get off expensive medications. We’ve seen remarkable results. At the 12-month mark, participants experienced a 66% reduction in diabetes-related medication use, with some even reversing their disease entirely.

There’s also a fitness component that guides members through staying active year-round. We facilitate group activities like hikes and other fun outings.

AJMC: How do you ensure the engagement and sustained participation of individuals enrolled in these lifestyle modification programs? What strategies have been effective in motivating behavior change and adherence to healthy habits that other health insurers can replicate?

Mizell: It's extremely difficult to make lasting lifestyle changes. Having the right support can make all the difference in keeping people engaged.

We’ve zeroed in on several strategies that help people maintain momentum when they’re adopting healthy behaviors.

• Connect face-to-face, when possible. A lot of health, wellness, and lifestyle programming is now virtual, but most of our programs take place in person.
• Tap the power of community. Working with community partners allows us to glean their expertise and embed our programs into the geographic areas with the highest need.
• Build in peer-to-peer relationships. Connecting members with others in similar positions is part of the reason our programs have been so successful. We’ve even won over skeptical members who haven’t found other lifestyle modification programs helpful in the past.
• Support the whole person. Programs should be high-touch and take each participant into account. This includes their unique circumstances, culture, stigmas, motivations, commitments, and life complexities. Once a member is part of The Eco, they can more easily move into other programs, guided by the support of our coordinators.

Finally, we formed The Eco with sustainable growth and long-term participation in mind. Members who complete their first program are welcome to participate in any other offerings for as long as they have health insurance through Banner|Aetna. The idea is that members who have already demonstrated motivation are likely to stay engaged and leverage that momentum to achieve lasting health improvements. In fact, many participants want to become ambassadors. These individuals remain involved and offer support to others who are just starting their journey.

AJMC: Looking ahead, what do you see as the future direction of metabolic disorder management and prevention efforts? How can payers, providers, and policymakers work together to make health care supportive and equitable for individuals with these conditions?

Mizell: This is another area where we lean on the expertise of our chief medical officer, Dr. Groves, to help guide our organization’s efforts.

In our current fee-for-service environment, we’re doing and paying for “rescue medicine” which has a minority influence on health and life span. While it’s not trivial, if we want to dramatically improve metabolic disorder management, we have to invest in social determinants of health.

Through the years, we’ve seen many different approaches to treating metabolic disease. They often incorporate medication management and some form of dietary, behavioral, or lifestyle change programming. On the dietary front, low-carbohydrate strategies have staying power and will continue to grow in popularity, especially when combined with holistic lifestyle modification support. Ketosis interrupts the progression of the disease, members lose weight and improve their lab results. Most of them no longer need insulin. In fact, efficacy studies are backing this up. A recent assessment found that only those management programs that centered on nutritional ketosis have achieved clinically significant results.

The diabetes reversal program we offer Banner|Aetna members is an example of this approach. It’s completely in contrast with the historically downhill course of diabetes and metabolic disease. And it’s sustainable because the behavioral modification support reinforces that members can and do get better, spurring motivation for more positive progress.

We also expect to see more in-person programs and experiences offered. The demand is there as many people are looking to reestablish community and connection following the pandemic. Additionally, programs conducted face-to-face have the advantage of providing experiential and participatory learning, which tends to be more durable than education via lectures or videos. Our in-person programs take this into account, and we hope we can even put a dent in the epidemic of loneliness by bringing people together with a shared purpose.

The market—insurers, clinicians, and the industry at large, including policymakers—is beginning to respond to the growing demand for programs like these. And going forward, working together to meet the unique needs of this population with metabolic disease will prove worthwhile.

But to do so effectively, we must change the incentives and move away from a fee-for-service system. Our job is to serve patients, not industries. This means investing in social determinants of health as a society, at all levels of government, local, state, and national. Setting a new trajectory for individuals with metabolic disease will require us to make bold shifts in the status quo.

References

1. Chew NW, Ng CH, Tan DJH, et al. The global burden of metabolic disease: Data from 2000 to 2019. Cell Metabolism. 2023;35(3):414-428.e3.

2. ElSayed NA, Aleppo G, Bannuru RR, et al. 1. Improving care and promoting health in populations: Standards of Care in Diabetes—2024. Diabetes Care. 2024;47(Supplement_1):S11-S19.

3. The surprising truth about prediabetes. CDC. Accessed April 2024. https://www.cdc.gov/diabetes/library/features/truth-about-prediabetes.html

4. Simple steps to preventing diabetes. Harvard School of Public Health. Accessed April 2024. https://www.hsph.harvard.edu/nutritionsource/disease-prevention/diabetes-prevention/preventing-diabetes-full-story/#:~:text=About%209%20in%2010%20cases%20in%20the%20U.S.%20can%20be%20avoided%20by%20making%20lifestyle%20changes.

5. Ong KL, Stafford LK, McLaughlin SA, et al. Global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the Global Burden of Disease Study 2021. The Lancet. 2023;402(10397):203-34.