This webinar will discuss the prevalence of pre-diabetes and it’s contributing factors and the initial efforts to translate the National Diabetes Prevention Program to public health. We will also look at new approaches to providing interventions. Learning objectives: Scope and scale of pre-diabetes and what factors contribute to it. Review initial efforts to translate the DPP to public health. New approaches to providing interventions. About The Presenter Dr. Marrero received a B.A. (1974), M.A. (1978) and Ph.D. (1982) in Social Ecology from the University of California, Irvine. He joined the IU School of Medicine in 1984 and became the J.O. Ritchey Professor of Medicine in 2004. He was a member of the Diabetes Research & Training Center and served as Director of the Diabetes Prevention and Control Division. He is currently the Director of the Diabetes Translational Research Center. Dr. Marrero is an expert in the field of clinical trails in diabetes and translation research which moves scientific advances obtained in clinical trails into the public health sector. He helped design the Diabetes Prevention Program and the TRIAD study, which evaluated strategies to improve diabetes care delivery in managed care settings. His research interests include strategies for promoting diabetes prevention, care settings, improving diabetes care practices used by primary care providers, and the use of technology to facilitate care and education. Dr. Marrero was twice awarded the Allene Von Son Award for Diabetes Patient Education Tools by the American Association of Diabetes Educators, nominated to Who’s Who in Medicine and Health care in 2000, served as Associate Editor for Diabetes Care (1997-2002) and is currently the Associate Editor for Diabetes Forecast. He was selected as Alumni of the Year for University of California Irvine in 2006 and The Outstanding Educator in Diabetes in 2008 by the American Diabetes Association. He is the current President of the American Diabetes Association.

1. Translational Clinical Research
to the Community in the Case
of Diabetes Prevention
David G Marrero, Ph.D.
J.O. Ritchey Professor of Medicine
Director, Diabetes Translational Research Center
Indiana University School of Medicine

2. THE PROBLEM

3. The Problem of Diabetes is Growing….

5. Pre-diabetes:
• 86 million Americans
• 35% of all adults
• 50% of adults >65
• Progression to diabetes
5 – 15% per year
Diabetes in U.S. – Tip of the Iceberg
Diabetes –
• 29 million Americans
• 8.3% U.S. population

7. Why is this happening?

8. Age-adjusted Prevalence of Obesity and
Diagnosed Diabetes Among US Adults
Obesity (BMI ≥30 kg/m2)
Diabetes
1994
1994
2000
2000
No Data <14.0% 14.0%–17.9% 18.0%–21.9% 22.0%–25.9% > 26.0%
No Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% >9.0%CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at
http://www.cdc.gov/diabetes/statistics
2013
2013

9. Etiology of Obesity: Dietary Intake
Daily caloric intake increased
dramatically in the past 30 years
- Increased portion sizes
Marketplace portions are 2-
8 fold larger than FDA
recommendations
- Increased frequency of
eating out/fast food
consumption
- Fast-food consumption has
strong positive associations
with weight gain and insulin
resistance
Pereira MA et al. The Lancet. 365(9453):36-42

15. Building/Community Designs Discourage
Walking

19. WHAT CAN WE DO ABOUT IT?

20. The Diabetes Prevention
Program

21. Diabetes Prevention – the DPP
3-arm nation-wide RCT with >3,000 participants
with pre-diabetes (IGT)
 Intensive Lifestyle Intervention
 Metformin (Diabetes medication)
 Placebo (Basic advice)

22. Development of Diabetes
Placebo Metformin Life-style
Development of diabetes 11.0% 7.8% 4.8%
(percent per year)
Reduction of diabetes ---- 31% 58%
compared with placebo
Number needed to treat ---- 13.9 6.9
to prevent 1 case in 3 yrs

23.  All ethnic/racial groups
 Men and women, lean, plump or fat
 All adults, especially those over age 60
DPP Lifestyle Intervention Worked for:

24. SO WHY DON’T HE HAVE A
DIABETES PREVENTION
PROGRAM ON EVERY STREET
CORNER?

25. DPP Translation: Efficacy vs. Public Health
Population-
Level Diabetes
Prevention
Evidence-base
Real-World
Implementation
Linked to healthcare
Feasible across settings
Scalable nationally
Worth the investment
Health Payers
Employers
Individuals
Minimize Costs : Optimize Effectiveness

26. Barriers to “DPP for All”
 Evidence only supports Pre-Diabetes
 Requires a blood test
 Not a routine in primary care settings
 Not well understood by public
 Need for Scalable Models
 Purchaser must believe a program has fidelity
 Programs must be widely available (meet demand)
 Must be cost effective
 What do we translate?

27. Goals for DPP Translation
 Maintain fidelity to “core” evidence
 Paying for intensive lifestyle interventions is a value for the
dollar in adults with PRE-DIABETES
 We don’t know if other strategies are cost effective
 Less intensive interventions
 Targeting lower risk groups (e.g. all obesity)
 Adopt “practical” solutions for barriers
 Seek to demonstrate possible cost savings
 Minimize intervention costs
 Preserve effectiveness (weight maintenance)

28. Developing a Scalable Model
 Simplify testing
 Lower intervention costs
 Partner with community to share
resources

29. Partnered Approach for Prevention
Healthcare
Glucose testing
Risk/benefit assessment (safe?)
Prescriptive advice (role for meds?)
Gateway to reimbursement
Formal
Programs
Community
Population Resources
Environment
Education by Schools & Media
Lower intensity programs
Risk assessment opportunities
Reciprocal
Interactions
Personnel
Experience
Facilities
Contact

30. A FEW EXAMPLES FROM OUR
CENTER…

31. PLDiabetes Education & Prevention with a Lifestyle
Intervention Offered at the YMCA
DE OY

32. Why the Y?
 Lower Cost Programs
 Lower cost “lay” group leaders
 Operate to achieve cost recovery only
 Policy to turn no person away for inability to
pay
 Past experience with national program
scaling

33. Availability and Penetration
• 2700 Y
facilities
• 57% of U.S.
households
are located
within 3 miles
of a YMCA

34. DPP Lifestyle Intervention
Delivered in the YMCA
 Group randomized pilot comparative effectiveness trial
 Participants (N = 94)
 Overweight/obese
 High random capillary glucose + T2DM risk factors*
 Allocated based on YMCA site for screening
 Intervention – Offered group-based DPP
 Control – Given basic advice & other Y programs
 Can the YMCA deliver group-based DPP?
 Could it achieve similar weight loss to DPP?
 Would it be less costly?
Ackermann, et al. Am J Prev Med. 2008 Oct;35(4):357-63;

35. Results: Weight Loss & Maintenance
p<0.001 p=0.008
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
6 months 12 months 20 months 28 months
PercentWeightLoss
Brief Advice
YMCA Group DPP
P=0.003
P=0.003
*p-values
comparing Group
DPP to Brief
Advice
Ackermann, et al. Am J Prev Med. 2008 Oct;35(4):357-63;
Same intervention
now offered to both
groups

36. DEPLOY Cholesterol & Maintenance
p<0.001
P<0.002
-25%
-20%
-15%
-10%
-5%
0%
5%
10%
PercentChange
6 month 12 month 24 month 32 month
*p-values comparing
Group DPP to Brief AdviceAckermann, et al. Am J Prev Med. 2008 Oct;35(4):357-63
P=0.52
P=0.003

37. Minimizing Program Costs
Cost Category
Original
DPP No Incentives
Group
Format
Group
Format –
YMCA
Instructor
Personnel $794 $794 $156 $151
Supplies $11 $11 $11 $10
Incentives $123 $10 $10 $10
Overhead $548 $548 $108 $34
Total $1,476 $1,363 $284 $205

38. WHERE DID THIS WORK GO?

39. The National YMCA DPP
 Decision to ramp up DEPLOY to YMCAs
across the country
 Standardize training
 Standardize program elements and adapt
to Y culture.

40. The National Diabetes Prevention
Program
 2011: Congressional legislation established the CDC-led
National Diabetes Prevention Program
 Establish local evidence-based lifestyle change programs for
people at high risk for type 2 diabetes
 Train workforce to implement cost effectively
 Recognition Program: Assure quality and (hopefully) lead
to reimbursement
 Develop intervention sites
 Marketing to support program uptake
 Inaugural partners (YMCA and United Health Group)
 Already provided services to thousands of patients

41. Getting it covered as a Benefit: The United
Health Group Project
 Collaboration between the YMCA and UHG
 First payer to cover the benefit for persons
identified as high risk by providers and
referred to YDPP sites
 Scaled payment based on performance

42. THE YDPP AND THE NDPP ARE GOOD
STARTS, BUT STILL FALL FAR SHORT OF THE
SCALE WE NEED TO COMBAT THIS
EPIDEMIC.
WHERE CAN WE GO NEXT? HOW CAN WE
EXPAND REACH AND ACCESS?

43. CAN A COMMERCIAL PROGRAM
PROVIDE AN ALTERNATIVE APPROACH?

44. Weight Watchers
 Leading global provider of weight
management services
 Teach people to lose weight and keep it off
by adopting a healthier lifestyle
 Clinically proven lifestyle program promotes
healthy habits, a supportive environment,
exercise, and smarter food choices 44

45. Weight Watchers Reach – U.S.
 Annually more than 1.7 million enrollments in Weight
Watchers meetings and 1 million signups for
WeightWatchers.com
 25,000 meetings each week held in convenient times and
locations (~5,000 in workplace)
 75% of members live with a 12 minute drive to a
meeting
 Open attendance – no need to reserve or schedule
ahead of time
 25,000 field staff, all of whom are Lifetime Members
 LTMs attend meetings for free as a reward when
maintaining their weight goal 45

47. The Study
 RCT with 250 subjects with diagnosed IGT
 Wait list control
 Comparison of WW with the same self help
program used in DEPLOY
 Data collected at 6, 12, and 24 months
 At 6 months, 5.7% weight loss vs. 1% in
controls.
 At 12 months, 5.8% vs. 2%

48. The Public Health Promise
 Weight Watchers is the only at-scale provider of education
behavior modification for weight management in the
world, and the only potential DPP partner with
 Brand awareness, channel access and investment to
drive demand for Diabetes Prevention Programs
 Infrastructure to fulfill demand at scale quickly
 Experience with recruitment, training and
management to deliver consistent, high quality results
 A built-in base of role model service providers
 A science-based approach that mirrors that of the DPP
48

49. The Encourage Study: targeting kids
 Introduction of “primordial” prevention
 Targeting mothers with GDM and their
children
 Two group RCT:
 Moms only
 Moms plus kids in parallel programs