ADA 81st Symposium: A Targeted Approach of Delivering Diabetes Education Improved Health Outcomes in Vulnerable Populations

Diet and exercise coaches & a targeted approach to diabetes education are the future of preventing T2D in patients with overweight or obesity.  

Dr. Kenrik Duru and his team investigated the Diabetes Prevention Program (DPP) among Medicaid patients living in California. A previous analysis simulated 25-year outcomes of Medi-Cal recipients enrolled in a DPP. The study found that the program reduced the incidence of diabetes between 2.5-3.8% but had no financial savings until 25 years. The program received funding because an estimated twenty-five thousand patients with prediabetes would benefit. As of 2019, Medi-Cal was required to provide qualified adult participants this benefit if they had overweight or obesity. Reimbursement rates were based on patient participation and weight loss. There were several weaknesses found with this program. Many patients had no interest in receiving this assistance, and all three of the approved suppliers offered online classes only.

The researchers of this interrupted time-series study aimed to gather more information on the program. They will conduct partially structured interviews of 10 DPP suppliers and 10 Medi-Cal health plans in California during the summers of 2021-2023. They will also hold focus groups with 60 Medi-Cal participants and 15 DPP lifestyle coaches to inquire about participant attendance, group consistency and to discuss the social determinants of health. The primary outcomes include strategies on recruitment, promotion, retention, and reimbursement.  Secondary outcomes include weight change, systolic blood pressure, the incidence of T2D at 12 and 24 months, and projected future cost savings at 5 and 10 years. The researchers had no conflicts of interest to report.

The second speaker, Gia E. Rutledge, discussed the United States’ efforts to support the National Diabetes Prevention Program. She reviewed the three currently funded programs. DP18-1815 focused on preventing/treating diabetes, heart disease, and stroke on a national level. It assisted health care organizations in identifying individuals with prediabetes so that they might be referred to lifestyle change programs. It also expanded DPP coverage, increased enrollment, and developed statewide infrastructure for reimbursement. DP18-1817 focused on innovative disease prevention and management at a local level. The program funded lifestyle coach education and increased Telehealth. It also lowered barriers for enrollment and increased the use of clinical systems and care practices. Health departments that received this support could refer more patients to a national DPP lifestyle change program. Finally, DP17-1705 focused on implementing the National Diabetes Prevention Program in underserved areas. It increased screening, detection, and referral of patients with prediabetes who would have otherwise been overlooked. Due to increased participation in the Diabetes Prevention Program, more patients had a 5% weight loss, leading to a lowered risk of developing T2D.

The third speaker, Dr. Roubideaux, discussed the prevalence of diabetes among American Indians and Alaskan Natives. In the United States, the death rates from T2D among natives were significantly higher than all other races. The federal government allocated $150 million annually for the Special Diabetes Program for Indians (SDPI) to address this health crisis. These grants allowed native communities to tailor health programs according to local cultural needs. It also increased the use of evidence-based practices. The Special Diabetes Program for Indians 2020 Report to Congress examined the effectiveness of the grants. It found that those sites included more diabetes interventions over time. In 2019, between 95%-96% of sites had diabetes clinical teams and patient registries. In addition, 76%-96% of sites had nutrition services for adults, registered dieticians, physical activity specialists, culturally tailored diabetes education materials, and weight management services. In pediatrics: 90% of sites had nutritional benefits, 85% had community-based physical activity services, and 83% had physical activity for school-age youth. Data shows a significant increase in diabetes-related services since the program was implemented in 1997.

Those enrolled in the SDPI had an average 10% reduction in A1C and 24% reduction in LDL. Hospitalization for adults with uncontrolled diabetes decreased by 24%, and the incidence of diabetes-related mortality was reduced by 37%. New instances of kidney failure were reduced by 54%. The prevalence of diabetes decreased from 15.4% to 14.6% between the years 2013-2017.  The average blood pressure remained normal for most individuals enrolled in the program. A study conducted by the Department of Health and Human Services found that SDPI contributed to reducing end-stage renal disease with a Medicare cost savings of 425-529 million dollars.

Practice Pearls:

• Duru and his associates will investigate why participation in the Diabetes Prevention Program is low.
• The National Diabetes Prevention Program leads to patient weight loss and a decreased risk of developing T2D.
• Those enrolled in the Special Diabetes Program for Indians saw a reduction in A1C, LDL, hospitalization, and kidney failure.

O’Brien, M.J et al. (2021, June). Diabetes Prevention in Vulnerable Populations. American Diabetes Association. Copenhagen; Denmark. (Requires ADA Symposium login.)

Kornelia Ilias, Pharm.D. Candidate, Creighton University School of Pharmacy and Health Professions

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