While recent studies suggest that the rates of diabetes and obesity in the U.S. have finally plateaued, experts say reversing the twin epidemics will require widespread adoption of lifestyle intervention techniques that have been proven to reverse obesity, the cause of most Type 2 diabetes.
Yet bipartisan legislation that would invest heavily in the diabetes prevention program languishes in Congress with zero chance of passage, according to the website www.govtrack.us. An analysis of the bill said its $7.7 billion in spending would be more than offset by the estimated $9.1 billion in savings from having fewer diabetic Medicare beneficiaries over the next 10 years, according to an analysis by Avalere Health (PDF).
The study, commissioned by the American Medical Association, the American Diabetes Association and the YMCA of the USA, said the savings would likely continue beyond the next decade, “suggesting even greater impact on longer-term federal spending.”
“We can't treat our way out of the diabetes epidemic, and we can't treat our way out of the obesity epidemic,” said Loel Solomon, vice president of community health for Kaiser Permanente in Oakland, Calif., and a co-author of a new Health Affairs report on diabetes incidence. “Everything we know about public health and everything our doctors know about the conditions their patients live in compels us to solve the problem upstream.”
About 1 in 8 Americans has diabetes while 1 in 3 is “prediabetic,” with a blood-sugar level of 5.7 to 6.4 (with 6.5 considered diabetic). Only about 11% of prediabetics are aware of their status, according to a Centers for Disease Control and Prevention report.
A proven method for preventing obesity-related prediabetes from turning into diabetes has been known for more than a decade. Positive outcomes from the diabetes prevention program was first documented in a February 2002 New England Journal of Medicine report.
Pilot projects involving group counseling sessions at YMCAs around the country have reduced program costs to less than $400 a person, according to the AMA, which issued a joint statement along with the ADA and YMCA endorsing the Medicare Diabetes Prevention Act of 2015. The bill's sponsors include Sens. Al Franken (D-Minn.) and Susan Collins (R-Maine) and Reps. Susan Davis (D-Calif.) and Peter King (R-N.Y.).
Given the lack of action by Congress, the authors of the Health Affairs analysis hope the Affordable Care Act's provision requiring not-for-profit hospitals to conduct a community-needs assessment every three years will provide the mechanism for financing nationwide implementation of the intervention program.
Dr. William Dietz, with George Washington University's Milken Institute School of Public Health in Washington and lead author of the Health Affairs report, noted that while prevalence of obesity and diabetes may be leveling off, it doesn't mean severity of diabetes or obesity has decreased. It also doesn't mean that obesity has declined among the population as a whole, he said.
Tapping into the $37 billion not-for-profits spend annually on community benefit activities would address the “wrong pocket” problem, which has slowed adoption of proven interventions. Savings often “do not flow back to the sponsoring agency or organization” of that intervention, Dietz and his co-authors wrote.
Yet that is beginning to change. “There is an interest in making (community benefit) investments that drive outcomes,” said Kaiser's Solomon. “The healthcare system is going to move to embrace this work quickly.”
The often-cited 2002 NEJM study showed how an “intensive lifestyle intervention” aimed at lowering a prediabetic's weight by 7% resulted in a 58% lower incidence of diabetes than patients receiving a placebo and 39% lower than a group receiving the drug Metformin.
“Our results support the hypothesis that Type 2 diabetes can be prevented or delayed in persons at high risk for the disease,” wrote the authors, members of the Diabetes Prevention Research Group, in 2002. “Thus, it should also be possible to delay or prevent the development of complications, substantially reducing the individual and public health burden of diabetes.”
Despite this unambiguous statement and the strong findings of the National Institutes of Health-supported study, movement toward lifestyle intervention has been sporadic—even when financial analysis provided evidence that it was the right thing to do.
The Avalere study does note that six groups have received CDC grants to operate diabetes-prevention programs: the American Association for Diabetes Educators; the America's Health Insurance Plans (working with its member companies Aetna, EmblemHealth, Florida Blue and Molina Healthcare); Black Women's Health Imperative; the National Association of Chronic Disease Directors; OptumHealth Care Solutions; and the YMCA.
Yet, even though Avalere described the YMCA's program as “the most established,” its only served about 30,000 people at 1,150 sites in 43 states as of February 2015. A CDC study published in 2014 estimated 29 million Americans have diabetes and another 86 million were classified as pre-diabetic.
Minorities are disproportionately affected by the disease and the conditions that trigger it. About 23% of Hispanics, 22% of African Americans and 20% of Asian Americans are diabetic, about twice the rate of whites.
The AMA last year launched a pilot program at 11 physician practice sites in Delaware, Florida, Indianapolis and Minnesota where patients found to be prediabetic are referred to the YMCA by their physicians. According the AMA, participants in the YMCA program averaged a 5.5% weight loss last year.
“The biggest driver in the rise of diabetes has been the rise in obesity,” Dietz said. “It's not a problem that will be solved by a clinical approach alone.”
Solomon agreed. He said what is required is a new mindset from the old way of thinking of population health as a function of disease management.
The Health Affairs report cites the YMCA Diabetes Prevention Program, the PowerUp program operated by the Minneapolis-based integrated healthcare system HealthPartners, and Kaiser's Healthy Eating and Active Living community health initiative as examples of upstream solutions to population health issues such as obesity and diabetes.
Solomon noted that, since 2005, Kaiser has spent $50 million on initiatives benefitting more than 50 communities the giant integrated healthcare system serves. He added that Kaiser Permanente Downey Medical Center's partnership with PIH Health to combat obesity in Whittier, Calif., was recognized last month by the American Hospital Association. The effort, known as Activate Whittier, provided healthy food options in school cafeterias, found substitutions for candy-sale fundraisers, and built a trail on five miles of unused railroad tracks. It was one of five initiatives to receive an AHA NOVA award.
The resources Kaiser has put into these efforts attracts other resources, Solomon said, such as CDC grants, state funding and other revenue which he described as “really well leveraged.”
“We can't do it alone,” Solomon said. “There needs to be a national strategy.”
This strategy would include adding community-based interventions to counseling programs. Examples include efforts by Promedica in Toledo, Ohio, and Truman Medical Centers in Kansas City, Mo., to operate grocery stores in urban food deserts; support for Surgeon General Dr. Vivek Murthy's call to action on walkable communities; and changes in food policies that help make healthy eating choices easier.
“That's the full-tilt boogie,” Solomon said. “In the post-Affordable Care Act world, that is where we need to be operating.”