Maya Venkataramani, MD, MPH, on the Key Takeaways for PCPs on Diabetes Prevention Programs

Prediabetes affects approximately 84 million US adults, or one-third of the adult population, according to the Centers for Disease Control and Prevention (CDC).¹ Many of these individuals would likely be eligible for a diabetes prevention program involving dietary and lifestyle interventions.

However, a new study published in the American Journal of Preventive Medicine suggests that, although more than 25% of adults who may be eligible for this type of program say they would be interested in participating, very few are actually referred, and even fewer have participated in this type of program.²

Consultant360 spoke with Maya Venkataramani, MD, MPH, assistant professor of medicine at the Johns Hopkins University School of Medicine and lead author of the study, about increasing utilization and access to these programs, and key takeaways for primary care providers.

Consultant360: What does a diabetes prevention program typically involve?

Dr Venkataramani: In general, a diabetes prevention program would enable participants to meet certain lifestyle goals, usually related to weight loss and physical activity, which have been proven to delay or prevent diabetes. The program is intended for individuals who are at high-risk for type 2 diabetes (either because they have prediabetes, have a history of gestational diabetes, or have a high score on a diabetes risk test) AND meet body-mass-index criteria (being overweight or obese). It would be a very important part of a “prediabetes treatment plan.”

More specifically, the CDC’s National Diabetes Prevention Program (National DPP) intervention is an evidence-based, year-long, group based program. Participants meet in groups that are led by a trained lifestyle coach. Initially, they meet about once weekly, then less frequently near the program’s end, for a minimum of 22 sessions. The sessions teach participants skills and strategies regarding monitoring and changing their dietary intake, enhancing their physical activity, addressing challenges to lifestyle change, and sustaining lifestyle changes over time. The program’s goals are for participants to lose 5% of their weight and perform 150 minutes per week of moderate physical activity. These goals were chosen based upon results of the research study that established the evidence behind the program’s effectiveness.³ Of note, in addition to in-person programs, there are also virtual programs and hybrid in-person/virtual programs that are available. The program is covered by Medicare, and coverage under Medicaid has also increased, with more states opting to cover the program . Some private insurance programs have been reimbursing for the program as well.

C360: The findings from your study indicated that race was associated with referral, age was associated with participation, and that more than 25% of patients who would be interested in this type of program either were never referred or had never participated. Why do you think this was the case?

Dr Venkataramani: It is important to note that our analysis was based on 1 data source and self-reported measures, and so we would hesitate to make broad conclusions about the associations we found without confirming them with additional analyses. That being said, among those eligible, finding that increasing age was associated with participation was not surprising. This has been demonstrated in other studies related to the DPP, as well as in prevention-related activities in general. Regarding the findings related to race, we take caution again in interpreting this. Racial minorities have historically had disparate access to preventive services, and so we would want to first confirm that these trends are true. If so, it will then be important to understand why this is the case, as it can have important implications for health equity.

In terms of the finding related to individuals who were never referred or never participated, yet had expressed interest in this type of programming, I think this finding could speak to lack of access to the program in certain communities. There may not have been programs in the area to which patients could be referred. In addition, I think this finding may highlight the potential lack of awareness regarding the program’s existence on the part of providers, as well as patients (there could be programs recruiting from the community that do not require provider referral).

C360: What efforts, especially among primary care providers, might help improve referrals and access to a diabetes prevention program?

Dr Venkataramani: In terms of improving referrals, I think first and foremost, it is important for primary care providers to be aware that such a program exists. It is also key for providers to learn how to refer their patients to these programs, particularly if the programs are being delivered by organizations outside their health systems, like community-based groups. The CDC’s National DPP team is leading the way in enhancing access to the program by increasing the number of programs offered and improving our understanding of how to promote referral from healthcare settings. Primary care providers are busy, so streamlining the process of being able to identify and refer patients to the program would truly be beneficial and could improve the referral process.

C360: What key clinical takeaways would you like to leave with providers?

Dr Venkataramani: One important point to note is that 9 in 10 adults who have prediabetes are unaware of their status¹, possibly because they have not been screened recently, or perhaps because they were not counseled about prediabetes by their healthcare providers. Given the potential to delay or prevent type 2 diabetes in these individuals, it is important for physicians to become aware of the guidelines regarding management of prediabetes (including behavioral counseling), and to familiarize themselves with the availability of lifestyle intervention programs, such as the National DPP intervention, in their localities. It is also important that physicians are screening high-risk individuals for diabetes (and thereby prediabetes), by recognizing risk factors for type 2 diabetes development, even among younger adults who may not meet age-based screening guidelines, but are considered high-risk.

Maya Venkataramani, MD, MPH, is a board-certified general internist, general pediatrician, assistant professor of medicine at the Johns Hopkins University School of Medicine, and core faculty of the Johns Hopkins Brancati Center for the Advancement of Community Care.

—Christina Vogt

References:

1. About prediabetes & type 2 diabetes. CDC-Recognized Lifestyle Change Program. Centers for Disease Control and prevention. https://www.cdc.gov/diabetes/prevention/lifestyle-program/about-prediabetes.html. Page last reviewed April 4, 2019. Accessed June 3, 2019.

2. Venkataramani M, Pollack CE, MD, Yeh HC, Maruthur NM. Prevalence and correlates of diabetes prevention program referral and participation. Am J Prev Med. 2019;56(3):452-457. https://doi.org/10.1016/j.amepre.2018.10.005.

3. Diabetes Prevention Program Research Group. Long-term effects of lifestyle intervention or metformin on diabetes development and microvascular complications over 15-year follow-up: the Diabetes Prevention Program Outcomes Study. Lancet Diabetes Endocrinol. 2015;3(11):866-875. https://doi.org/10.1016/S2213-8587(15)00291-0.