Patients Want a Lifestyle Program, but Where Are the Doctors?

Alicia Ault


August 19, 2019

Vicki Johnson, 67, was alarmed when she checked her doctor's patient portal and saw that her fasting plasma glucose was 110 mg/dL, which placed her in the "prediabetic" category. Along with her test results, her doctor had included a note: "Watch your carbs."

To Johnson, that admonition wasn't enough. She was overweight and not particularly active. Her father had diabetes and died of a heart attack at age 60. Her younger brother has diabetes and survived a heart attack at age 42. And her sister was recently diagnosed with prediabetes. Johnson's research told her she could be next. Her physician confirmed that she was "technically" prediabetic but gave no further instruction aside from telling her to curtail her carbohydrate intake.

Johnson recalled that her local YMCA in Columbus, Ohio, offered a program to help prevent diabetes. What she didn't know was that it was part of a nationwide program run by the US Centers for Disease Control and Prevention (CDC), and she was an ideal target for that effort. She mentioned it to her doctor, who was not "super encouraging," she said, but she plowed ahead, having been told by a friend that the program had been effective for her.

A few months into the Diabetes Prevention Program (DPP) — which focuses on nutrition education, stress management, and how to be more active — Johnson is upbeat. "I think it's made a tremendous difference. I've lost a decent amount of weight," she said, adding that she no longer talks herself out of taking walks after dinner.

Johnson is one of 330,000 who have participated in the DPP since the first year it was offered, in 2013, according to data sent to Medscape by the CDC. The number of participants has risen from 9000 the first year to 108,096 in 2018. While that may seem like impressive growth, the number of people eligible for the program is astronomically higher.

The CDC says that 1 in 3 American adults — 84 million — have prediabetes,[1] defined by the American Diabetes Association (ADA) as a hemoglobin A1c of 5.7-6.4; a fasting plasma glucose of 100-125 mg/dL; or an oral glucose tolerance test result of 140-199 mg/dL.[2]

The CDC has certified some 1500 providers to deliver the DPP — through in-person, online, and distance learning — to adults over 18 years of age who meet the eligibility criteria. The agency has a registry of certified programs.

And yet, millions of Americans with prediabetes aren't participating, in part because they aren't being referred by their physicians.

Only 5% of those with prediabetes and 0.4% of those with an elevated risk were told to participate in a lifestyle program like DPP.

The reasons are numerous, said Danielle Pere, vice president of programs and education at the American College of Preventive Medicine (ACPM). "To just get physicians to be aware that prediabetes is a diagnosable condition with a referral process is the main barrier," Pere said.

Another challenge: Doctors often don't have the time in a clinic visit to get to prediabetes, especially if there isn't a trigger for testing in the electronic medical record, she said. Lack of reimbursement for the program and few updates on how DPP patients are doing — as is sometimes the case — are also obstacles for doctors, said Pere.

"Participation in the DPP has not been as widespread as many supporters have hoped," said Robert Lash, MD, chief professional and clinical affairs officer for the Endocrine Society. He echoed Pere's assertion that reimbursement is an issue. Lash also said that many patients don't know that they're eligible, and that despite the growing number of DPP providers, some communities still don't have easy access to a program.

Dissemination at Glacier-Like Speed

The DPP is not new, but it still seems unfamiliar to many. It evolved out of the 1996-2001 Diabetes Prevention Program trial,[3] which randomly assigned patients to lifestyle modification, metformin, or placebo. The study, published in 2002, showed that after 3 years, enrollees who participated in the program — and achieved a mean weight loss of 5%-7% — reduced their chance of developing diabetes by 58% compared with those in the placebo group (5% a year compared with 11%).[4] Individuals over age 60 saw a 71% reduction.[4]

Fifteen years later, 55% of DPP study participants assigned to and continuing lifestyle modification had diabetes, slightly edging metformin (56%), and placebo (62%).[4]

On the basis of the initial results, the CDC started building the DPP in 2011 after receiving congressional authorization in 2010.[5] The CDC created a turnkey lifestyle change program that can be delivered by federal agencies, wellness centers, insurers, state and local health departments, employers, and healthcare providers. All have to follow the CDC's guidance and, to be recognized as a DPP provider, meet certain standards and supply the agency with data.

Among the topics in the curriculum: "Be a Fat and Calorie Detective," "Being Active – A Way of Life," "Make Social Cues Work for You," "Healthy Eating – Taking It One Meal at a Time," "Handling Holidays, Vacations, and Special Events," and "Preventing Relapse."

The CDC has come to rely on private partners to get the program out to the public, as it receives paltry federal funding. The DPP got its first federal money in fiscal year 2014 and has received an average of $18.8 million a year in congressional appropriations since, said Ann Albright, director of the CDC's Division of Diabetes Translation. This year (FY19), the CDC received $25.3 million, she said.

Some $14 million went this year to 10 organizations: The American Pharmacists Association Foundation; National Association of Chronic Disease Directors; American Diabetes Association; National Alliance for Hispanic Health; Trinity Health; Black Women's Health Imperative; American Association of Diabetes Educators; The Balm in Gilead, Inc.; HealthInsight; and the Association of Asian Pacific Community Health Organizations.

The ACPM is also a recipient of CDC funding. The majority of the $500,000 it got in FY19 will go to individual doctors, practices, health centers, and others to help them incorporate screening and testing for prediabetes into their workflow, and to learn how to refer patients to the DPP, said Pere.

The YMCA was one of CDC's first community partners, said Heather Hodge, senior director of evidence-based health interventions for the Y. The DPP is offered by 244 YMCAs at more than 1100 locations (some are not at Y locations). The national organization trains local Ys on how to set up the program, get recognized by the CDC, and work with insurers to secure coverage for participants.

Low Physician Awareness, Confidence

Even though individuals can test themselves for prediabetes risk — for instance, online at the CDC/American Medical Association (AMA) site — and they can enroll in the DPP without a doctor's prescription, clinicians are considered crucial to the DPP's success.

A May 2019 study[6] by CDC researchers (including Albright) reported that "advice and/or referral by a healthcare professional was associated with higher likelihood of participation."

Hodge said that the Y has learned that even if patients know that they have prediabetes, "they wouldn't necessarily activate without their physician really talking to them and encouraging participation."

But studies have shown that physicians aren't good at referring to the DPP.

According to the CDC, physician referrals account for just 4% of total DPP enrollment, although two thirds of participants did not say how they were referred. Twenty-two percent found DPP through an employer or employer wellness program. Much smaller percentages mentioned insurance companies, family, community organizations, and media.

Seventeen percent of referrals to the Y programs come from healthcare providers, said Hodge. That's the largest segment but it's still "not high enough," she said.

A 2018 study[7] by Johns Hopkins University School of Medicine researchers found that only 4% of a sample of adults who were probably eligible for participation had been referred to a DPP by a doctor, and only 2% had participated. Meanwhile, more than a quarter of those eligible expressed interest in participating.

"This suggests a need to improve both program access and referral efforts, the latter being suboptimal in the clinical setting," the authors wrote in the American Journal of Preventive Medicine.

In another 2018 AJPM study,[8] CDC and AMA researchers reported that although the majority of primary care physicians tested for prediabetes, only 23% referred those with the condition to the DPP.

The 2019 CDC study[6] reported that half to three quarters of individuals with either diagnosed prediabetes or an elevated ADA risk score said they'd been told by a doctor to do something to reduce their diabetes risk. Most of the time, though, that advice was to lose weight or increase physical activity.

Only 5% of those with prediabetes and 0.4% of those with an elevated risk were told to participate in a lifestyle program like DPP. About 40% of those who said they followed their doctor's advice ended up participating in DPP.[6]

"Health care professionals may not believe in the effectiveness and cost-benefit of diabetes prevention programs, may be less aware of these programs, or may believe their patients would have less accessibility to programs," concluded the authors.

Hurdles for Patients

The DPP's year-long commitment — usually spread over two dozen or more sessions — can be daunting.

It gave Johnson pause. But "to make any real changes, it takes longer than a few weeks," she said. She was able to negotiate a plan to make up classes she knew she would have to miss. Expense was another issue, but the Y convinced Johnson's Medicare supplemental plan to cover the program.

"It is a big commitment," said Hodge. The YMCA tells prospective participants what to expect during the enrollment and orientation process so that they "aren't surprised when they get to class and find out it's for a year," said Hodge.

The CDC reported in 2017 that most of the DPP dropouts happen in the second half of the program.[9] At the time, only 1 in 10 participants completed all 22 sessions, according to the agency's researchers. The study also found that longer attendance correlated with greater weight loss and increased physical activity.

Insurance coverage continues to be an issue. The CDC reports that more than 100 private employers include the DPP as a covered benefit for those at high risk for diabetes, and that 3.8 million employees and dependents in 20 states also have coverage.[10]

In a widely celebrated change, Medicare began covering the program in 2018, but only for programs that are CDC and Medicare certified. It only pays for up to 2 years, and only if 16 sessions are completed within the first 6 months. Medicare still won't pay for online participation, however.

The YMCA, which has just a few locations that have been able to become Medicare-eligible, subsidizes patients who can't get insurance coverage.

Mississippi Clinic Embraces DPP

Despite the perceived hurdles, the DPP is just what the Hattiesburg Clinic has needed, said Linda Gwaltney, MS, RD, LD, CDE, the clinic's diabetes education program director.

Based in Hattiesburg, Mississippi, and with locations throughout the southern part of the state, the clinic sees more than 27,000 patients with diabetes, out of a patient population of 500,000. Mississippi has the highest rate of diabetes in the nation,[11] and the ADA estimates that 810,000 adult residents — 38% of the state's population — have prediabetes.[12]

"Hattiesburg Clinic has a great opportunity to impact [this] region of the state of Mississippi and the patients who are part of our organization," said Gwaltney. She said it's important to let patients know that a prediabetes diagnosis is a crucial time to act because an intervention can help stop diabetes onset.

A few years ago, the clinic made a commitment to diabetes and prediabetes education, Gwaltney said. Soon after, the clinic landed a grant from the American Association of Diabetes Educators (AADE) to help get its DPP off the ground and become CDC-certified, which will make it eligible for reimbursement from Medicare and other insurers, she said.

The AADE grant covered costs for 39 patients for the first year. That's crucial, because when Gwaltney met with 60 doctors before the program's launch to convince them to get on board, "the predominant question was will this be paid for and will it be convenient for my patient," she said.

Patients have a 25-mile drive to a class on average, but some have made the trip from 90 miles away. Gwaltney and colleagues also made it easy for doctors to refer, setting up a prompt in the Clinic's electronic medical record.

Seventy-five percent of referrals have come from doctors, reflecting their enthusiasm, said Gwaltney. The remainder refer themselves after taking the prediabetes screening test on the "Do I Have Prediabetes ?" website.

But "sometimes patients don't take this diagnosis of prediabetes seriously," she said, so patients are urged to attend a "session zero" to receive information on prediabetes and diabetes. They also complete a readiness-to-change questionnaire that helps gauge motivation. Prospects must sign an agreement to attend all classes and call or use a portal to reschedule missed sessions. "They do that very readily because they don't want to be kicked out of the program," said Gwaltney.

The first group has attended 20 sessions, and a new group is starting. The majority of attendees are aged 65 or older, but a few are in their 30s.

Once the clinic starts being paid for the DPP (probably by fall), Gwaltney will add tools to the EMR, such as a registry of people who have lab values indicating prediabetes, screening and diagnostic tests, and periodic progress reports on DPP patients. "The feedback is important for the physician. It's important for the patient and their interaction," she said.

The clinic is tracking attendance, weight loss, and self-reported minutes of physical activity and calorie intake.

Word is out that the program is making a difference: Non-clinic physicians and a group of hospitalists from a local hospital have asked to make referrals to the Hattiesburg DPP, Gwaltney said.

Changing Behavior Is Difficult

The DPP's main problem may be that it's not a pharmacologic or surgical intervention, which makes it difficult for physicians to prescribe and for patients to accept.

"There is nothing sexy about lifestyle change," said Pere of the ACPM. "It is much easier for a physician to prescribe metformin and say, 'Take this, do this, check your insulin,'" she said. "The DPP is an evidence-based lifestyle-change program that confronts participants with very difficult life changes in terms of eating, physical activity, and sleep. In our culture, that's just not easy to do."

Physicians also aren't trained to consider lifestyle factors that might influence health, she said.

The ACPM's goal "is to change the culture of American medicine so physicians do have competency in prescribing lifestyle and behavior modification as frontline therapy," she said.

CDC's Albright notes that the DPP is, in essence, a pioneer. It "is the first effort to build a nationwide delivery system for lifestyle change in the country," she said. "As such, it takes time to get infrastructure, systems, and stakeholders in place," she said.

Pere predicts wider success in the next 5 to 10 years, especially as value-based contracts give physicians more incentive to prevent diabetes, and as more insurers cover the program.

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