The toll that type 2 diabetes takes on our health system is well known: the American Diabetes Association estimates that more than $300 billion is spent each year between direct medical costs and reduced productivity due to the ever-growing number of Americans living with type 2 diabetes. This number is compounded when we include the millions who have other cardiometabolic conditions that are comorbid or share underlying causes with type 2 diabetes. And while we can quantify the monetary costs of these conditions, the effects of reduced quality of life, worsened health and earlier death exact their own cost on individuals and communities.
Digital therapies: the missing piece in diabetes care
By Kevin Appelbaum, Better Therapeutics
While this challenge is well known, well understood and too large to ignore, the treatments available to type 2 diabetes patients often fall short. Despite significant advances in pharmaceuticals that can limit the symptoms of type 2 diabetes, little is done to address the underlying causes of the disease. This leaves us with a disease that will inevitably progress over time, while creating a reliance on costly medications that increase its economic impact.
Since type 2 diabetes and other cardiometabolic diseases are linked directly to specific behavioral choices like diet and exercise, we know that the impact can be significantly reduced by changing those behaviors. The ADA’s most recent “Standards of Medical Care in Diabetes” says succinctly that self-management of these factors is directly associated with “lower A1C, lower self-reported weight, improved quality of life, reduced all-cause mortality risk, positive coping behaviors and reduced healthcare costs.”
So, why has more attention been placed on costly pharmaceutical treatments that reduce symptoms, while ignoring the behavioral changes that can lower mortality and improve quality of life? In short, it’s because changing behaviors is hard, especially for people who are now living with the challenges of a chronic disease. It is not impossible, though, and we know that psychological approaches like cognitive behavioral therapy can be effective in helping individuals make sustainable behavioral changes. But until very recently, we simply did not have a way to deliver at scale that sort of therapeutic support to the millions who live with type 2 diabetes.
Digital connectivity could provide the missing piece to that puzzle – offering a near ubiquitous, affordable and reactive way to deliver behavioral therapies to people living with conditions that can be mitigated by behavioral changes. In fact, the ADA supported this as part of its revised “Standards of Medical Care,” stating that “digital coaching and digital self-management interventions can be effective methods to deliver [diabetes self-management education and support].”
This acknowledgement is a significant milestone for a new field of prescription digital therapeutics that can be used to combat diseases like diabetes. As part of the widely accepted standards of care for the disease, the ADA’s guidelines are trusted by physicians and give them a framework within which they can diagnose and prescribe therapies consistent with evidence. The digital interventions that the ADA feels confident supporting are not simply apps that you might find on any app store, but clinically validated, FDA-regulated digital therapies that require the same level of safety and efficacy evidence required for pharmaceutical solutions. The difference is that these digital therapies can approach the root behavioral causes of cardiometabolic conditions like diabetes.
The difference between a digitally delivered approach to behavioral therapy and previous practices is the mechanism of action. We know that behavioral therapy can and does work – but it has traditionally relied on a one-on-one relationship between a single patient and a single therapist. The approach uses well-understood behavioral science approaches to get at a patient’s underlying thoughts and beliefs and to affect their subconscious mind so they can make sustainable changes to the way they live. While CBT began by applying this concept to anxiety, depression and other mental health conditions, it has been shown to be effective in treating addiction and cardiovascular disease.
Using a digital tool, this relationship can be scaled up, with a program that can support exponentially more individuals while still providing them the personalized treatment and support that is needed to make CBT successful. As a society, we have become very adept at designing user experiences that impact behavior, with both subtle and overt design decisions that reward people for interactions and keep them engaged with a program. This design – along with the ability to capture data and constantly tailor treatment to each user – makes digital apps a uniquely well-suited medium for applying CBT at scale.
As digital therapeutics are increasingly looked to as a new pillar of healthcare, the use of digitally delivered CBT has the potential to make a meaningful difference in the way diseases like type 2 diabetes are treated. The digital application of CBT could help more people make the changes needed to achieve better glycemic control and inhibit the progression of the disease, meaning lower spending on medication or adverse events treatments for payers, and – most significantly – a higher quality of life for patients.