Better Than Drugs: A Diabetes Prevention Program That Works

Diabetes Prevention at the 'Y'

Laurie Scudder, DNP, NP: Welcome to a conversation about diabetes prevention programs (DPPs). In March 2016, federal officials proposed the expansion of a Medicare DPP funded by the Affordable Care Act and modeled on a pilot program that was developed and administered by the YMCA. That program has helped Medicare enrollees at high risk for type 2 diabetes to improve their diets, increase their exercise, and lose about 5% of their body weight.

We are here today to talk about this program with Dr Matt Longjohn. Dr Longjohn is an assistant professor of preventive medicine and pediatrics at the Northwestern University Feinberg School of Medicine and the National Health Officer at YMCA of the United States.

Let us begin by having you describe the key elements of this nationwide DPP. What makes this effort more successful than other interventions that have been attempted previously? Can you speak to the evidence base that supports wider implementation of this program?

Matthew M. Longjohn, MD, MPH: Absolutely. There is quite a robust background of research and data behind this intervention. The research began in the late 1990s when the National Institutes of Health (NIH) funded a three-arm, randomized controlled multicenter trial^[1] demonstrating that lifestyle interventions (which we have now scaled through the YMCA and worked with Medicare to deliver cost savings) outperformed our best drugs for people with prediabetes in preventing them from becoming diabetic. In fact, in the NIH trial of the late 1990s and early 2000s, there was a 58% reduction in new cases of diabetes in that at-risk population that was attributed to the effectiveness of this intervention.

Dr Scudder: Lifestyle change is something we often talk about but perhaps are a little less successful in actually doing. Do the programs offered at the YMCA rely on in-person services to reinforce lifestyle changes? Do they use technology, such as smartphone apps, telemedicine, or wearable devices? What specifically made this lifestyle intervention work?

Dr Longjohn: At the YMCA for over 160 years, we have been bringing people together in person to address community issues. Through our programs over that long history, we promote healthy spirit, mind, and body through programs that bring people together in groups. That is really the secret sauce of this intervention. It is bringing groups of people together who have similar risk profiles who are struggling every day with the same things, such as how to get more physically active and how to eat healthier. They support one another through this process. It is a year-long intervention and the curriculum follows a strict routine. That is what was tested by the NIH, but by bringing people as a group through that process, we help them achieve self-efficacy, and they are ultimately able to lose an average of 5% of their weight. Dozens of studies and several meta-analyses have shown that the 5% weight loss is what triggers that 58%-71% reduction in new cases of diabetes.

Who Has Prediabetes?

Dr Scudder: Your program, in measuring outcomes, uses fairly rigorous criteria for patient selection. What were those criteria? How was risk for type 2 diabetes defined?

Dr Longjohn: Under the Affordable Care Act, the Centers for Disease Control and Prevention (CDC) set up the National DPP. For the past 4 or 5 years, any person who has been coming to a DPP, whether it is the YMCA's program or another organization's DPP, has had to meet the same criteria. A person can become eligible for the program by demonstrating elevated risk through a validated risk assessment tool promulgated by the CDC and the American Diabetes Association, blood tests that support prediabetes (fasting plasma glucose, 2-hour plasma glucose or A1c levels), a diagnostic history recorded by a primary care provider, or a diagnosis of gestational diabetes at any time in the past. Those are the criteria that determine eligibility for the intervention.

Dr Scudder: You mentioned that some participants are identified by their primary care providers. How do these programs integrate with care provided in a primary care setting? Will providers be involved in monitoring the program? Will referral be necessary? How is it going to roll out logistically?

Dr Longjohn: In the past 5 years, there has not necessarily been a requirement for that, but the YMCA and other providers have been lucky to work with great partners like the American Medical Association (AMA), the American College of Preventive Medicine, and other societies, who have helped by holding continuing medical education courses and discussing the value of this intervention with the healthcare community. They are educating healthcare providers across the country who are dealing with prediabetes epidemics in their patient populations to refer these patients to this low-cost and extremely effective intervention.

In our pilot project with Medicare, we partnered very closely with the AMA. In multiple communities, they went into healthcare systems and helped by doing chart reviews and querying electronic medical records to come up with ways to identify participants for this program and make referrals from those healthcare systems to the YMCA's program. The participants who were identified by a primary care provider, and gave consent for the YMCA to share their information with their primary care providers, do better in the program. They attend more sessions and lose more weight. There is a virtuous cycle that we are aiming for at the YMCA to be integrated into these care teams. We have gone so far as establishing a CPT code—the first-ever CPT code for community-based organizations, nonlicensed providers to use, in providing a preventive service. Another historical moment was when Medicare was able to certify cost savings. We are now in a place where YMCAs are obtaining national provider identification numbers. In the past month, we retained Athena Health as our electronic medical record, because our goal is to make sure that this program is clinically integrated. We know that we are a new piece of the puzzle and must have, for the benefit of our program participants, very solid linkages to the clinical system.

Have Scale, Will Travel

Dr Scudder: Cost is an obvious barrier to the kind of services that you have been describing and is resolved to a certain extent with Medicare certification of cost savings. What about other barriers? This is an older population, by definition, with Medicare. What about such issues as transportation, cultural differences, and language barriers? What other barriers do you anticipate, and what are your plans for addressing them?

Dr Longjohn: In the Medicare beneficiary population, it appears that some of those barriers are less significant than in other segments of our population. The attendance rates are higher among the Medicare population compared with the general population. They achieve better outcomes because they are getting higher doses of the intervention. But still, your points are valid. One of the beautiful things about this program is that it is delivered wherever anyone is willing to attend sessions. YMCA staff—and we have thousands of them now trained to deliver this program in nearly 250 cities—are trained to take a scale and a laptop, put them in their backpack, and go to wherever participants need them to go. We deliver this program, the majority of the time, outside of YMCAs. We deliver it in senior centers, in libraries, in employee break rooms, and in conference rooms. We have even delivered the program in an auto dealership. There are many different ways in which we can address that location barrier. From a health-equity standpoint, another thing that you mentioned was cultural or language issues that might pop up. We have been able to translate the program into Spanish and Mandarin. We have actually delivered the program in Portuguese, Somali, and Hmong. We have recorded it for people with visual impairments and have delivered it in American Sign Language to folks who have auditory impairments. We can address some of those issues as one of the nation's largest and oldest charities, but certainly they are still real issues when you think about national implementation.

Dr Scudder: What happens when the program ends? How does the DPP prevent folks from slipping back into old habits? At that point, what is the role of the primary care setting in furthering the initiative?

Dr Longjohn: The way the Medicare certification cost savings was conducted and how Medicare anticipates that the rulemaking process will produce the coverage plan, there may be multiyear coverage for the program, so that maintenance sessions in years 2 and beyond would be available through the DPP providers to help support groups in an ongoing way. That is consistent with the science going back to the NIH trial, but in most cases, especially in the commercial sector, it is an annual benefit. About 10% of people have gone through the program a second time if they feel that they need a booster or more support. One of the most exciting things for us at the YMCA is that although only 30% of program participants (and we have had about 45,000) began the program as YMCA members, more than 50% of them are becoming YMCA members. As they become accustomed to physical activity, they are looking for other program opportunities, whether it is a swim lesson or a group exercise class.

Dr Scudder: Matt, thank you for providing such great information for our audience.

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