Translating the DPP Results to Address the NNHeS Challenge

21 March 2012

Diabetes Prevention:
Translating the
DPP Results
to Address the
NNHeS Challenge
Iris Thiele Isip Tan MD, MSc, FPCP, FPSEM
Clinical Associate Professor, UP College of Medicine
Department of Medicine, Philippine General Hospital
http://www.sxc.hu/photo/1253865

Wednesday, March 21, 12

Diabetes Prevention
Program (DPP)
Diabetes Prevention
Program Outcomes Study

DPP Lifestyle Balance
The DPP Lifestyle Change Program

National Diabetes
Prevention Program
US Model


I: Lifestyle
modiﬁcation
vs Metformin
vs placebo

M:
P: 3234 O: Incidence Randomized
with IFG of diabetes
controlled
or IGT over follow-up
trial

Diabetes Prevention Program
Trial Design

Diabetes Prevention Program Research Group NEJM 2002;346:393-403


DPP Protocol:
Intensive Lifestyle Modiﬁcation

16-lesson curriculum
covering diet, exercise and
behavior modiﬁcation taught
one-on-one for 1st 24 weeks

Diabetes Prevention Program Research Group. NEJM 2002;346:393-403


>7% weight loss:
healthy, low-calorie,
low-fat diet



Moderate intensity physical activity
i.e. brisk walking >150 min/week



DPP Results
Reduction in
Incidence of Diabetes
(vs placebo)

Lifestyle Modiﬁcation
⬇ 58% (95% CI 48-66%)

Metformin
⬇ 31% (95% CI 17-43%)

Diabetes Prevention Program Research Group NEJM 2002;346:393-403 p.


DPP Results

To prevent one case
of diabetes during a
period of 3 years
NNT (lifestyle): 6.9
[95% CI 5.4-9.5]

NNT (Metformin): 13.9
[95% CI 8.7-33.9]

Diabetes Prevention Program Research Group NEJM 2002;346:393-403 p.


Bridge Phase
1-2 week drug
wash-out
Unmasked to
treatment assignments
Group-administered
version of Lifestyle
Balance for all


I: Lifestyle
modiﬁcation
vs Metformin
vs placebo

P: 2766 O: Incidence Intention-
of DPP of diabetes to-treat
subjects over follow-up

DPP Outcomes Study
Trial Design

Diabetes Prevention Program Research Group Lancet 2009;374(9702):1677-86


DPPOS
protocol
Intensive lifestyle
group offered 2 group
classes (each comprising 4
sessions every year)

Metformin group
continued Metformin
850 mg bid unless already
with diabetes (HbA1c >7%)


Cumulative incidence of diabetes
during three study phases



Cumulative incidence of diabetes
remained lowest in lifestyle group

1 2 3 4 5 6 7 8 9 10
Years since DPP randomization


Diabetes Prevention
✔ Program (DPP)
Diabetes Prevention


National Diabetes
Prevention Program
US Model


Lifestyle Balance
http://www.bsc.gwu.edu/dpp/manuals.htmlvdoc


Lifestyle Balance

Overview of strategies to
achieve goals
Professional resources
Optional materials for
participants
464 pages!


Copyright 1996; 2011
University of Pittsburgh

The DPP manual and materials are made available to the public subject
to the following Creative commons License: Creative Commons -
Attribution-NonCommercial-ShareAlike 3.0. Accordingly, the manuals
may be downloaded, duplicated, transmitted and otherwise distributed for
educational or research purposes only, provided proper credits are given to
the DPP Research Group. (Note that some of the materials may have
incorrect formatting while undergoing revisions.) Use of any of the
DPP Lifestyle materials herein for commercial purposes is strictly
forbidden without the permission or license of the University of
Pittsburgh.


Key Aspects of DPP Lifestyle Protocol
Clearly deﬁned weight loss
and physical activity goals

Diabetes Prevention Program Research Group. Diabetes Care 2002;25:2165-71


Physical Activity Goal

Aerobic dance, bicycle riding,
skating and swimming
Min of 3x/week (at least 10 min per
session)
Maximum of 75 min of strength
training can be applied toward
goal
Importance of lifestyle activities
discussed; cannot be applied
toward goal



High CV risk: exercise tolerance
test
Sedentary: increase activity in
30-min increments over 5 weeks
Active at baseline: not required
to add further exercise (same 150-
min weekly goal)
Participants can be more active
than minimum goal in absence of
medical contraindications


Individual case
managers or “lifestyle
coaches”




Intensive
ongoing
intervention
Initial core curriculum to
achieve standardization
of intervention



DPP 16-session core curriculum

1 - Welcome to the Lifestyle 5 - Move Those Muscles
Balance Program 6 - Being Active: A Way of
2 - Be a Fat Detective Life
3 - Three Ways to Eat Less 7 - Tip the Calorie Balance
Fat 8 - Take Charge of What’s
4 - Healthy Eating Around You



Self-monitoring fat and/or calorie intake
Daily for ﬁrst 24 wks of the study
Given food scale & measuring cups/spoons



Self-monitoring physical activity
Daily for ﬁrst 24 wks of the study



DPP 16-session core curriculum

9 - Problem Solving 13 - Jump Start Your
10 - The Four Keys to Activity Plan
Healthy Eating Out 14 - Make Social Cues
11 - Talk back to Negative Work for You
Thoughts 15 - You Can Manage
12 - The Slippery Slope of Stress
Lifestyle Change 16 - Ways to Stay
Motivated




Intensive
ongoing
intervention
Supervised exercise
sessions offered at
least 2 times/week
throughout the trial




Intensive
ongoing
intervention
Flexible maintenance
program
supplemental group
classes, motivational
campaigns and restart
opportunities



DPP After Core Curriculum
Motivation

1 - Give Yourself Credit for 5 - If You Believe You Can’t
Your Success Lose Weight
2 - How Do Successful 6 - The Fight Against Flab
Weight Losers Do It? 7 - DPP Lifestyle Progress
3 - A Tough Day, A Better Summary
Day 8 - Decision Balance
4 - What If the Scale
Doesn’t Budge



Individualization
through a
“tool box” of
adherence strategies



http://www.ﬂickr.com/photos/pasukaru76/4005076313/


http://www.sxc.hu/photo/337742


Materials and strategies that addressed the
needs of an ethnically diverse population



Key aspects

DPP Lifestyle Protocol
An extensive local and national network
of training, feedback and clinical support



Case Manager aka “Lifestyle Coach”

4-step Training
Required reading
Manual of operations, participant notebook,
manual for contacts after Core, book chapters
and journal articles
Videotapes from previous lifestyle training
programs
Observation of centrally trained personnel
Audio taped practice session and lifestyle
resource core review



Group Lifestyle BalanceTM Materials
http://www.diabetesprevention.pitt.edu/glbmaterials.aspx



Diabetes Prevention
✔ Program (DPP)
Diabetes Prevention


✔
National Diabetes
Prevention Program
US Model


Challenges to the
Translation of
Prevention Programs
in the Community
David Marrero, PhD

Screening is NOT
routinely done to identify
the patients most at risk
for diabetes. Diabetes Prevention Summit
July 12, 2011
Washington DC, USA

www.joslin.org/docs/Summit_executive_summary_8.11.11.pdf


Challenges to the
Translation of
Prevention Programs
in the Community
David Marrero, PhD

There do NOT currently
exist enough facilities in
the US to adequately
serve people where they Diabetes Prevention Summit
to be identiﬁed as at-risk. July 12, 2011
Washington DC, USA



Challenges to the
Translation of
Prevention Programs
in the Community
David Marrero, PhD

The source of funding is
an ever-present
challenge.
Diabetes Prevention Summit
July 12, 2011
Washington DC, USA



Challenges to the
Translation of
Prevention Programs
in the Community
David Marrero, PhD

Our overall culture and
environment does not
support healthy lifestyle
choices. Diabetes Prevention Summit
July 12, 2011
Washington DC, USA



Population-based Diabetes Prevention

From the presentation of Dr. Ronald T. Ackermann
www.allhealth.org/.../Ackermannpresentation--doc-1824.ppt


Partnered Approach for Prevention



Group Delivery of DPP



I: Brief
counseling vs
DPP-group
intervention

P: 92 with O: Group M:
DM RF & differences in Clustered
random CBG wt, chol, BP, randomized
110-199 mg/dL HbA1c trial

Translating the DPP into the Community
The DEPLOY Pilot Study (YMCA)

Ackermann R et al. Am J Prev Med 2008;35(4):357-363


DEPLOY Pilot Study

Body weight
Intervention: ⬇6% (95% CI 4.7, 7.3)
Control: ⬇2% (95% CI 0.6, 3.3)
p<0.001

The YMCA: promising channel
for wide-scale dissemination
for low-cost approach

Ackermann R et al. Am J Prev Med 2008;35(4):357-363


I: Enhanced
usual care vs
DPP-group
intervention

P: 301 O: Mean M:
overweight/ FPG over 12 Randomized
obese with FBS mos ff-up controlled
95-125 mg/dL adjusted for
baseline glucose trial

Healthy-Living Partnerships To Prevent Diabetes
(HELP PD) Project
Community health workers (volunteers with well-controlled T2DM)

Katula JA et al. Diabetes Care 2011;34(7):1451-7


HELP-PD Project
Intervention vs control
Blood glucose
-4.3 vs -0.4 mg/dL, p<0.001
Weight
-7.1 vs -1.4 kg, p<0.001
Insulin
-6.5 vs 2.7 uU/mL, p<0.001
HOMA
-1.9 vs -0.8, p<0.001

Katula JA et al. Diabetes Care 2011;34(7):1451-7


Centers for Disease Control &
Prevention (CDC)

National Diabetes
Prevention Program

Public-private
partnership of
community organizations,
private insurers,
employers, health care
organizations and
government agencies

http://www.cdc.gov/diabetes/prevention/


National Diabetes Prevention Program
COMPONENTS

Training: Recognition Program: Intervention Sites: Health Marketing:
Increase Workforce sure Quality Deliver Program Support Program
Train the workforce Implement a recognition
Uptake
that can implement program that will: Increase referrals to
the program cost
effectively. prevention program.

a program registry.

* Inagural partners: YMCA, USA and UnitedHealth Group



Diabetes Training & Technical
Assistance Center (DTTAC)
http://www.cdc.gov/diabetes/prevention/dttac.htm

Master trainers will provide a fee-based, 2-
day, face-to-face training for lifestyle
coaches
Curriculum adapted from the original DPP
research materials for group delivery Training:
Increase Workforce
Online learning community at DTTAC Train the workforce
website that can implement
the program cost
effectively.



Diabetes Prevention
Recognition Program (DPRP)
http://www.cdc.gov/diabetes/prevention/recognition/index.htm

Organizations interested in offering the
curriculum apply for recognition
Why apply for recognition?
Assure potential participants of quality
Recognition Program:
More likely to get health care provider referrals sure Quality
CDC offers technical assistance Implement a recognition
program that will:
Insurance companies more likely to
reimburse recognized programs
a program registry.


Copier-ready Game Plan
Tools for Patients
1. Small Steps. Big Rewards.
Your GAME PLAN for Preventing
Type 2 Diabetes
2. Who Is at Risk for Type 2
Diabetes and Pre-diabetes?
3. Walking ... A Step in the Right
Direction
4. Food and Activity Tracker

Download the free toolkit at
http://ndep.nih.gov/publications


Diabetes Prevention
✔ Program (DPP)
Diabetes Prevention


✔
National Diabetes
Prevention Program

✔ US Model


!ank Y"
http://www.endocrine-witch.net


Translating the DPP Results to Address the NNHeS Challenge

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