Diabetes Prevention with Dr. David Marrero

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Expanding the Reach of Diabetes Prevention: Challenges and Pitfalls of Community-based DPP Translation

Translational Clinical Researchto the Community in the Case of Diabetes PreventionDavid G Marrero, Ph.D.J.O. Ritchey Professor of Medicine Director, Diabetes Translational Research CenterIndiana University School of Medicine

The Problem

The Problem of Diabetes is Growing.

Pre-diabetes: 86 million Americans35% of all adults50% of adults >65Progression to diabetes 5 15% per yearDiabetes in U.S. Tip of the IcebergDiabetes 29 million Americans8.3% U.S. population

5This ok?

Why is this happening?

Age-adjusted Prevalence of Obesity and Diagnosed Diabetes Among US AdultsObesity (BMI 30 kg/m2)Diabetes




2000 No Data 26.0%

No Data 9.0%

CDCs Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics



Etiology of Obesity: Dietary IntakeDaily caloric intake increased dramatically in the past 30 yearsIncreased portion sizesMarketplace portions are 2-8 fold larger than FDA recommendationsIncreased frequency of eating out/fast food consumptionFast-food consumption has strong positive associations with weight gain and insulin resistance

Pereira MA et al. The Lancet. 365(9453):36-42


Building/Community Designs Discourage Walking

What can we do about it?

The Diabetes Prevention Program

Diabetes Prevention the DPP3-arm nation-wide RCT with >3,000 participants with pre-diabetes (IGT)Intensive Lifestyle InterventionMetformin (Diabetes medication)Placebo (Basic advice)

Development of Diabetes Placebo Metformin Life-styleDevelopment of diabetes 11.0% 7.8% 4.8% (percent per year)

Reduction of diabetes ---- 31% 58% compared with placebo

Number needed to treat---- 13.9 6.9 to prevent 1 case in 3 yrs


All ethnic/racial groupsMen and women, lean, plump or fatAll adults, especially those over age 60

DPP Lifestyle Intervention Worked for:

23The good news for us is that the DPP exercise and weight loss program worked well in every ethnic and racial group, in men and women, and for all adults. It worked especially well among those ages 60 and older, cutting their risk for diabetes by 71 percent.

So Why Dont He Have a Diabetes Prevention Program on Every Street Corner?


DPP Translation: Efficacy vs. Public HealthPopulation-Level Diabetes Prevention


Real-World ImplementationLinked to healthcareFeasible across settingsScalable nationallyWorth the investmentHealth PayersEmployersIndividualsMinimize Costs : Optimize Effectiveness


Barriers to DPP for AllEvidence only supports Pre-DiabetesRequires a blood testNot a routine in primary care settingsNot well understood by publicNeed for Scalable ModelsPurchaser must believe a program has fidelityPrograms must be widely available (meet demand)Must be cost effectiveWhat do we translate?


Goals for DPP TranslationMaintain fidelity to core evidencePaying for intensive lifestyle interventions is a value for the dollar in adults with PRE-DIABETESWe dont know if other strategies are cost effectiveLess intensive interventionsTargeting lower risk groups (e.g. all obesity)Adopt practical solutions for barriersSeek to demonstrate possible cost savingsMinimize intervention costsPreserve effectiveness (weight maintenance)


Developing a Scalable ModelSimplify testingLower intervention costsPartner with community to share resources


Partnered Approach for Prevention

HealthcareGlucose testingRisk/benefit assessment (safe?)Prescriptive advice (role for meds?)Gateway to reimbursement

Formal ProgramsCommunityPopulation ResourcesEnvironmentEducation by Schools & Media Lower intensity programsRisk assessment opportunities

Reciprocal InteractionsPersonnelExperienceFacilitiesContact


A few Examples from our center



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



Why the Y? Lower Cost ProgramsLower cost lay group leadersOperate to achieve cost recovery onlyPolicy to turn no person away for inability to pay

Past experience with national program scaling


Availability and Penetration

2700 Y facilities

57% of U.S. households are located within 3 miles of a YMCA

As you can see, there are a lot of YMCAs in the country.

And to be more precise [CLICK], there are more than 2,600 YMCAs in the U.S. and 57% of all US households are located within 3 miles of these YMCAs.

With this scale, I have come to believe that there are few organizations in the U.S. in as strong of a position as the Y to influence change in individuals and in communities to proactively address Americas health.

DPP Lifestyle Intervention Delivered in the YMCAGroup randomized pilot comparative effectiveness trialParticipants (N = 94)Overweight/obeseHigh random capillary glucose + T2DM risk factors*Allocated based on YMCA site for screeningIntervention Offered group-based DPP Control Given basic advice & other Y programsCan 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. 2008 Oct;35(4):357-63;


Results: Weight Loss & Maintenance*p-values comparing Group DPP to Brief AdviceAckermann, et al. Am J Prev Med. 2008 Oct;35(4):357-63; Same intervention now offered to both groups

Can the YMCA deliver group-based DPP?Could it achieve similar weight loss to DPP?

Answer to these first 2 questions is yes.6% vs. 2% weight loss maintainedweight loss comparable to those seen in DPP35

DEPLOY Cholesterol & Maintenance*p-values comparing Group DPP to Brief AdviceAckermann, et al. Am J Prev Med. 2008 Oct;35(4):357-63P=0.52P=0.003

Minimizing Program CostsCost CategoryOriginal DPPNo IncentivesGroup FormatGroup Format YMCA InstructorPersonnel$794$794$156$151Supplies$11$11$11$10Incentives$123$10$10$10Overhead$548$548$108$34Total$1,476$1,363$284$205


Where did this work go?


The National YMCA DPPDecision to ramp up DEPLOY to YMCAs across the countryStandardize training Standardize program elements and adapt to Y culture.


The National Diabetes Prevention Program2011: 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 diabetesTrain workforce to implement cost effectivelyRecognition Program: Assure quality and (hopefully) lead to reimbursementDevelop intervention sitesMarketing to support program uptake

Inaugural partners (YMCA and United Health Group)

Already provided services to thousands of patients

However, these results were a part of the impetus for legislation 2011 creating the CDC led National Diabetes Prevention Program

NDPP is a public-private partnership of community organizations, private insurers, employers, health care organizations, and government agencies

The inaugural partners of the National Diabetes Prevention Program were the YMCA and UnitedHealth Group.

The goal is build a network of evidence-based structured lifestyle programs across the nation to intervene with those individuals at high risk of developing type 2 diabetes.

This program has already provided evidence-based lifestyle intervention services to thousands of patients.


Getting it covered as a Benefit: The United Health Group ProjectCollaboration between the YMCA and UHGFirst payer to cover the benefit for persons identified as high risk by providers and referred to YDPP sites Scaled payment based on performance


The YDPP and the NDPP are good starts, but still fall far short of the scale we need to combat this epidemic.

Where can we go next? How can we expand reach and access?


Can a commercial program provide an alternative approach?


Weight WatchersLeading 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



Weight Watchers Reach U.S.Annually more than 1.7 million enrollments in Weight Watchers meetings and 1 million signups for WeightWatchers.com25,000 meetings each week held in convenient times and locations (~5,000 in workplace)75% of members live with a 12 minute drive to a meetingOpen attendance no need to reserve or schedule ahead of time25,000 field staff, all of whom are Lifetime MembersLTMs attend meetings for free as a reward when maintaining their weight goal




The StudyRCT with 250 subjects with diagnosed IGTWait list controlComparison of WW with the same self help program used in DEPLOYData collected at 6, 12, and 24 monthsAt 6 months, 5.7% weight loss vs. 1% in controls.At 12 months, 5.8% vs. 2%


The Public Health PromiseWeight 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 ProgramsInfrastructure to fulfill demand at scale quickly E