'Encouraging' Latest Results from NHS England Diabetes Prevention Programme

Prof Jonathan Valabhji OBE MD FRCP

Disclosures

March 07, 2019

I'm Professor Jonathan Valabhji, National Clinical Director for Diabetes and Obesity at NHS England. I'm also a consultant diabetologist at Imperial in West London.

What's the latest progress for the National Diabetes Prevention Programme?

We're now in the third year of national rollout. As of this summer just gone, we became the first country in the world to achieve universal coverage across the country with a type 2 diabetes prevention programme. It means that people already identified to be at high risk - what we're currently describing as non-diabetic hypoglycaemia - for people in that category this affords them empowerment to beneficially modify that risk. So it provides them with access to a behaviour change programme: a lifestyle intervention that focuses on weight loss, more physical activity, and better quality nutrition.

How convincing is the data that this is working?

The evidence on which the programme is based is really very strong now. We've had data going back almost 20 years from well-conducted randomised controlled trials showing that if you provide access to the sort of intervention that we're providing here, that you can reduce the cumulative incidence of type 2 diabetes. Classically, in the original trials over a 3-year period, you could reduce that cumulative instance by up to 60%. Now, in the real world, it's not quite as big an effect, but at least 30% reduction has been shown in sort of real world translations thereof. And what we have is an intervention based on that best evidence.

Now, it'll be another couple of years, probably, until we have sufficient information on type 2 diabetes incidence to tell us if the programme really is doing what's written on the tin - in other words, preventing or delaying onset of type 2 diabetes. But in the interim, we can use surrogate markers. And what I did today in my presentation was present the two really important surrogate markers of weight change as a result of the programme, number one, and HbA1c changes, as a result of the programme, number two.

Both those parameters are looking highly encouraging. Before we set out on this journey we had commissioned a systematic review and meta-analysis of what had already taken place. And certainly the HbA1c changes and the weight loss that we're seeing is in excess of what was predicted in that original systematic review and meta-analysis. So that is certainly very encouraging. Obviously we have to await our type 2 diabetes incidence data but in terms of what indication the surrogates can give us, it's good news to date.

So today is a very much a good news story. And I'm relieved to see that data. The other encouraging thing is that when we landed this across the country, we didn't really know how enthusiastic people would be to take up the offer of an intervention. So if an individual has been told that are at high-risk that they have pre-diabetes, or non-diabetic hypoglycaemia, or whichever descriptor has been used to explain to them what their situation is, we had no idea really how enthusiastically they'd take up the offer.

We also didn't really know how enthusiastically our healthcare professionals would embrace the opportunity. But in both aspects, we've been really pleasantly surprised. So our referral rates (that when we publish data on this, this isn't from today, this is from a year ago, actually) we published data to show that our referral rates are a good 15% in excess of that which we had predicted. Our conversion of referral to attendance is greater than we have modelled. And as we've also shown today, for those that start one of the group-based sessions, we're seeing completion rates in excess of 50% - 53% actually - which again, is really encouraging.

And what we have also shown today is a very good dose-response relationship. So those that attend more sessions achieve more weight loss, and achieve greater reduction in HbA1c. So those high, pleasantly surprisingly good figures around referral retention, completion and of course around weight loss and HbA1c, we're really pleased with right now.

What were the headline figures for weight loss and HbA1c?

The mean weight loss of those that have completed the program was 3.4kg, and the mean HbA1c change was 2.0 mmol/mol.

Now in the meta-analysis and systematic review, the studies that provided that information, suggested a little smaller weight change than that. So what we are showing is about a kilogram in excess of what that meta-analysis and systematic review suggested we might expect.

And also we're seeing a bigger reduction in HbA1c than that meta-analysis and systematic review suggested we might see, despite in that meta-analysis, fairly modest reductions in HbA1c and weight, they saw quite marked reductions in type 2 diabetes incidence.

So from our perspective obviously if we're seeing slightly more weight loss and the bigger reduction in HbA1c, one might hope that in the fullness of time that might translate into a significantly greater effect size when it comes to preventing or delaying onset of type 2 diabetes in these high risk individuals.

What about patient groups that have been harder to reach?

We looked at our first year cohort and published [results] a year ago showing good equity of access in terms of people from the most deprived quintile of socio-economic status - [they] were just as likely to be a first attendee on the programme as those from the least deprived [quintile]. And we were seeing a significant excess of people from ethnic groups that we know carry higher risk of type 2 diabetes, so people of South Asian [and] African-Caribbean origin, were significantly more likely to pitch up as a first attendee. The data [presented] today shows that the retention of such individuals isn't quite as good. That said, if you take account for the excess initial attendance of those of South Asian, African-Caribbean ethnicity, although we see greater fall off, we're still seeing completion rates representative of the entire cohort because we have more to start with.

And so while we're seeing greater drop-off in terms of the proportion of completers, they are quite representative of the prevalence of South Asian, African-Caribbean ethnicity at population level in England. So it's not all bad news.

And what we are seeing though is a little bit greater fall off from of those from more deprived areas. And that is something we are actively looking to tackle through our new modes of delivery. What we are doing from the next financial year is introducing a pay-for-performance aspect for our providers such that they will be selectively incentivised through financial levers to address retention of those from more deprived socio-economic status groups, from black and minority ethnic groups, and those who are more obese actually. So I think we always said the programme would be iterative. And indeed that's what we're doing. We're taking the learning from the data we've presented today and moving forward looking how we tweak the programme to try and address the signals that have been sent up by the data.

Is the latest DiRECT study data on type 2 diabetes remission having an impact on your planning?

Absolutely right. So this is a different cohort. The Diabetes Prevention Programme addresses those who are at high-risk of developing to type 2 diabetes. The DiRECT study, and a similar study called the DROPLET study actually, looked to take people with recently-diagnosed type 2 diabetes to see if a specific lifestyle intervention could put those individuals into remission of their type 2 diabetes.

The results presented last year actually were really encouraging in that regard. So people put on a low calorie diet of just over 800 calories per day for a 3-month period achieved substantial weight loss in that time: between 10 and 11kg on average, and just less than half of the cohort with type 2 diabetes that went through that study achieved remission, which of course is really exciting, something that we in the NHS and in NHS England are particularly interested to see if we can reproduce in live environments. And indeed, articulated in our long-term plan for the NHS in England moving forward, we will be piloting the interventions described by Roy Taylor and his team, and by Susan Jebb and Paul Aveyard in their study called the DROPLET study. So both the DROPLET and the DiRECT study have really shown proof of concept that this can work, and does work in randomised controlled trial settings. We will look to pilot in live environments to see if we can realise the same benefit for our fairly recently-diagnosed individuals with type 2 diabetes. So exciting times.

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