COMMENTARY

National Clinical Care Commission offers T2D Recommendations

William H. Herman, MD, MPH; Mark Harmel, MPH, CDCES

Disclosures

June 29, 2022

This transcript has been edited for clarity.

In 2017, the Congress established the National Clinical Care Commission, and in 2018, it was convened by the Secretary of Health and Human Services. I had the privilege of chairing the National Clinical Care Commission.

The purpose of the Commission was to leverage federal policies and programs to better prevent, treat, and reduce the complications of diabetes in the United States. In its deliberations, the Commission used elements of both the socioecological model and the chronic care model. It viewed diabetes not strictly as a medical problem requiring medical treatment, but as a societal problem requiring societal solutions.

The commission undertook its work with three subcommittees. The first addressed interventions at a population level to prevent and control diabetes, the second looked at targeted interventions to better control and prevent diabetes in high-risk individuals, and the third addressed the treatment and complications of diabetes.

Initially, the Commission made three foundational recommendations. These were to first address diabetes as a societal problem and not simply as a medical problem. Second, to ensure that all people at risk for and with diabetes have access to comprehensive and affordable healthcare. The third was to keep an eye on health equity as an issue in all federal policies and programs impacting diabetes in the United States.

At the general population level, the Commission recommended that non–health related federal agencies, including the Departments of Agriculture, Transportation, and Housing and Urban Development; the Environmental Protection Agency; the Food and Drug Administration; and the Federal Trade Commission all become engaged in creating a community in which the risk for diabetes would be reduced. Agricultural policies are critically important to population risk for obesity and type 2 diabetes.

The Commission recommended strengthening the Supplemental Nutrition Assistance Program (SNAP), the Women, Infants, and Children (WIC) program, and the school lunch programs to better prevent obesity and type 2 diabetes. It also recommended environmental interventions addressing both the built environment through housing, parks, and neighborhoods, as well as the ambient environment, addressing air pollution, water pollution, and exposure to endocrine-disrupting chemicals.

The Commission also recommended that the Department of Labor establish policies to ensure that all women have up to 3 months of paid maternity leave. The idea behind this is that 3 months of paid leave will encourage women to breastfeed, result in sustained breastfeeding, and reduce both mothers' risk for subsequent diabetes and children's later risk for type 2 diabetes.

The Commission also addressed interventions for high-risk populations for type 2 diabetes. These recommendations focused on better access to proven, effective programs for diabetes prevention, including the National Diabetes Prevention Program and the Medicare Diabetes Prevention Program. It recommended better screening for prediabetes, greater access to these programs, and fewer barriers to participation.

The Commission also recognized that metformin is a safe and effective treatment to prevent progression from prediabetes to diabetes and recommended that the Food and Drug Administration review metformin for diabetes prevention and find in favor of its approval for that indication. The Commission felt that a formal FDA approval of this safe and effective medication would facilitate its uptake and population-level prevention of type 2 diabetes in high-risk individuals.

With respect to treatment and complications, the Commission recognized a gap between needed resources and the resources available to people with diabetes. It recommended that treatments become more readily available, that barriers to the treatments be removed, and that policies and programs be developed to facilitate access to needed resources by people with diabetes. These include clinical care but also access to technologies, including self-monitoring of blood glucose, continuous glucose monitoring systems, and pumps.

In addition, the Commission recognized barriers to the availability of proven effective treatments for the secondary prevention of complications and the tertiary prevention of disability and death due to complications. Whereas there are procedures within the Affordable Care Act for the review and approval of primary prevention interventions for healthcare through the United States Preventive Services Task Force, there is no similar mechanism to review interventions for secondary and tertiary prevention.

The National Clinical Care Commission recommends that an organization be established similar to the US Preventive Services Task Force, to objectively review interventions for the secondary and tertiary prevention of diabetes complications, and based on those findings, that they be covered at no out-of-pocket cost for patients with diabetes.

These might include diabetes self-management education, continuous glucose monitoring systems and pumps, or even dilated retinal exams for the prevention of diabetic blindness. The Commission recommends that such a commission be established to review these secondary and tertiary prevention strategies, and if they were found to be effective, that they be approved for coverage at no out-of-pocket cost to patients with diabetes.

The Affordable Care Act ensured that primary prevention interventions in health would be covered at no out-of-pocket cost to all people who might benefit from them. The mechanism was through the US Preventive Services Task Force review and approval of these interventions. Unfortunately, there is no similar mechanism to review and approve interventions for diabetes.

These interventions include things like technologies for diabetes management to prevent complications as well as treatments for early complications to prevent more serious sequelae. The latter might include dilated retinal examinations to prevent blindness or angiotensin-converting enzyme (ACE) inhibitors to prevent end-stage renal disease.

Finally, to oversee implementation of the 39 recommendations of the National Clinical Care Commission and to ensure that progress is made going forward, the Commission has recommended the establishment of an Office of National Diabetes Policy.

This Office, established at the level of the Executive Branch, would involve agencies from the Department of Health and Human Services as well as agencies from non–health related federal government. These would work together to monitor progress toward the recommendations made by the National Clinical Care Commission, report to the Congress and to the American public on the progress, and measure improvements in the health of people at risk for and with diabetes in the United States.

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