Urgent need for diabetes prevention

In a 1921 issue of the Journal of American Medical Association, Elliott Joslin, a firm believer in the importance of patient education and the first American doctor to specialize in the treatment of diabetes, wrote: “It is proper at the present time to devote attention not alone to treatment, but still more, as in the campaign against the typhoid fever, to prevention.”

In 2010, Joslin's prescient words resonate more strongly than ever. Nearly 100 years after Joslin began his diabetes education campaign, we still are not as vigilant as we need to be in helping patients prevent diabetes before it creeps up on them. And equally important, patients need to recognize that preventing this devastating disease is largely within their control.

At least 57 million Americans—more than a quarter of the nation's adult population—have “prediabetes,” a condition that places them at high risk for developing type 2 diabetes, according to the Centers for Disease Control and Prevention. Even worse, approximately one-quarter of individuals suffering from diabetes, and nearly 90% of those at high risk of developing diabetes, remain undiagnosed. Translating those statistics into dollars and cents, $1 out of $5 spent on healthcare is spent caring for someone with diagnosed diabetes, a figure that has increased 32% since 2002, according to the American Diabetes Association. If current obesity trends continue, by 2018 some 103 million Americans will be considered obese—putting them at grave risk of diabetes—to the tune of an estimated $344 billion in treatment costs, according to a report by the American Public Health Association, and Partnership for Prevention and United Health Foundation.

The early identification and involvement of populations that are most at risk of developing diabetes and other obesity-related health complications should be our nation's top healthcare priority. In fact, most healthcare plans have insurance claims codes for prediabetes that could help facilitate physician work in this arena, and might provide a valuable resource to help track prediabetes trends and better identify at-risk individuals. For any number of reasons, however, few physicians make use of these insurance claims codes.

Much more is needed than greater use of prediabetes reimbursement claims codes, though. Because the increased prevalence of type 2 diabetes is largely attributable to repeated unhealthy behaviors that are arguably voluntary, efforts to reverse these trends will cut across a swath of complementary medical, social, cultural and environmental behavioral factors.

Fortunately, new, “partnered” approaches for preventing and managing diabetes offer proven solutions. Consider, for example, a series of research studies at Indiana University School of Medicine in Indianapolis over the last seven years. These studies have paired clinical and community resources toward the goal of preventing the development of diabetes among individuals with prediabetes. These studies were based on the U.S. Diabetes Prevention Program, a nationwide initiative funded by the National Institutes of Health and the CDC, which demonstrated that with lifestyle changes and modest weight reduction, prediabetic individuals can prevent or delay the onset of the disease by 58%.

Data from the original DPP study suggested that for every 100 high-risk adults who participate in the program, 15 cases of diabetes are avoided at a savings of more than $90,000 in healthcare costs over a three-year period, according to the NIH. According to the Urban Institute, implementing diabetes intervention programs in the community through the YMCA nationwide could save more than $190 billion over the next decade.

Unfortunately, the DPP as originally conceived was deemed too expensive to administer in most settings; the U.S. healthcare system generally lacked the personnel and facilities needed to offer intervention programs to millions of at-risk Americans. However, the Indiana University School of Medicine in partnership with the YMCA was able to pilot a lower-cost, group-based adaptation of the DPP lifestyle intervention model as a possible approach to achieve broader, national scalability.

How does it work? The DPP program uses a group-based lifestyle intervention designed especially for people with prediabetes. In a communal setting, a trained coach helps individuals address and begin to change certain lifestyle choices by teaching participants to eat healthier, increase their physical activity and learn about other behavior modifications over a 16-session program. After an initial 16 core sessions, participants meet monthly for added support to help them maintain their progress.

The results of the pilot program: At participating Indianapolis-area YMCAs, program participants shed 6% of their body weight within six months, compared with 2% in a control group, with recently completed analyses demonstrating that weight losses persist through almost 2 ½ years of follow-up.

Even better news, the Y teamed up with UnitedHealth Group to roll out the DPP program nationwide. This new diabetes prevention benefit will be offered to tens of thousands of at-risk people who are enrolled in UnitedHealthcare insurance plans in more than 20 U.S. cities over the next two years. It is the first time that an insurer is paying for this kind of service. With this stimulus, the YMCA also has begun partnering with local entities in other cities to offer the program as well.

The DPP does not strive to “medicalize” the management of obesity and other unhealthy behaviors or to curtail the need for social and environmental policies to support healthier lifestyle behaviors on a grand scale. Rather, the program seeks to capitalize on the strengths of both healthcare and community sectors in ways that achieve far more than either could alone.

In Joslin's 1916 monograph titled The Treatment of Diabetes Mellitus, which included the findings from 1,000 of his own case studies, the physician noted a 20% decrease in the mortality of patients after instituting a program of diet and exercise. Flash forward nearly a hundred years and the formula for diabetes prevention has little changed. As Joslin once remarked: “Teaching is cheaper than nursing.” We owe it to ourselves, our neighbors and the long-term viability of our straining healthcare system to make diabetes prevention a top priority. It is a hundred years' war we cannot afford to lose.

Ronald Ackermann is an associate professor of medicine at Indiana University School of Medicine, Indianapolis

http://www.modernhealthcare.com/article/20101206/NEWS/101209980/0

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