Diabetes is one of the fastest growing killers, as I discussed in Part 1 of this series. Thirty million adults in the U.S. suffer from it today. Another 84 million have a milder condition, prediabetes, that puts them at high risk for developing type 2 diabetes. Over time, if current trends continue, the disease will strike 25 to 58 million new victims in the U.S. All will contend with a disease that is the leading cause of blindness and kidney failure, often leads to the loss of a leg or foot, significantly increases the risk of heart disease and is one of the leading causes of death.
We can save many from this fate. We have the knowledge and resources to dramatically lower new incidences of diabetes. To do so, we must first discard three misconceptions: prevention doesn’t work, it is too expensive, or it takes too long.
The first misconception is that diabetes prevention doesn’t work. Few doubt that most cases of diabetes can be prevented at early, prediabetic stages through lifestyle changes, especially by weight control, healthier diet and more exercise. In fact, recent studies and field experience point to the potential of even reversing full-blown type 2 diabetes through carbohydrate restriction when used in conjunction with a structured weight loss and medication management program. Consider, for example, the work at Virta Health. The misconception about prevention stems from skepticism about whether widespread lifestyle change can be achieved and sustained. In fact, there is ample evidence on how to do it.
For example, one multicenter randomized controlled clinical study, funded by the National Institutes of Health (NIH), tracked 3,234 overweight adults with prediabetes over ten years.
After approximately three years, the group of patients who participated in a structured lifestyle program had 58% fewer new cases of diabetes compared to patients who received standard treatment. Those over age 60 had 71% fewer new cases of diabetes. That’s because the participants were supported all the way through, with a systematic program of education, coaching, mindful self-monitoring of activity and results, and a support network in which they encouraged one another. Unlike many efforts that were similar but lacking in support, the results lasted: Ten years later, new diabetes cases had been reduced by 34% in the intervention group.
The study also found that a second group of participants who took metformin lowered their chances of developing type 2 diabetes by 31% compared with participants who took a placebo. The participants in the metformin and placebo groups were also provided standard advice about diet and physical activity. After 10 years, participants who continued to take metformin had a delay in the development of diabetes by 18 percent—and developed diabetes about 2 years later—compared with participants who took a placebo.
This work was so successful that Congress directed the US Centers for Disease Control (CDC) to establish the National Diabetes Prevention Program (National DPP). A key component of the National DPP is a set of standards and quality controls to recognize successful community-based diabetes prevention programs (DPPs). To date, the CDC has recognized more than 1,600 such programs. (These programs, however, have collectively served less than one percent of those with prediabetes. Part three of this series will address why the impact has been so slight and how to better leverage them.)
The second misconception is that prevention is too expensive. Clinical results cannot be translated cost-effectively into practice, this thought goes, and therefore it is not practical for employers and insurers to bear the cost of such programs.
On the contrary, innovative care providers such as the YMCA have reproduced the results of the NIH-funded studies in community settings. Forty-two-thousand prediabetic participants in YMCA locations in 42 states lost an average of 5.5% of their body weight after one year. This met the 5 to 7% weight-loss target at which the NIH-funded research showed a marked reduction of risk for developing diabetes.
What’s more, according to the U.S. Department of Health and Human Services (HHS), which evaluated the YMCA program results, the programs improve healthcare quality while reducing healthcare costs. The HHS concluded that Medicare could save $2,650 for each person enrolled. That is more than enough to cover the program costs.
Numerous startups are working to leverage advanced information technologies for less costly and more scalable delivery of prevention programs. Omada Health, for instance, has successfully adapted the techniques for use online. The Omada DPP (diabetes prevention program) uses connected digital scales, activity trackers, interactive multimedia, and gamification to augment patients’ email and online forum interaction with human coaches. Fruit Street Health’s DPP connects coaches and patients via a secure, HIPAA-compliant video platform. Lark Health takes automation even further. It offers a DPP program via smartphone apps with always-available AI-powered virtual coaches. First Mile Care is harnessing technology not for digital delivery, but to create an Uber-like platform that connects prediabetes sufferers with certified human coaches. It aims to establish a network of certified coaches in the majority of the country’s 42,000 ZIP codes.
Of all digital programs, Omada is the furthest developed. It has enrolled more than 200,000 patients in its DPP programs. Omada claims 4-5% body weight loss on average and about 40% of participants lose 5% or more. These weight-loss outcomes translate into a 30% decrease in type 2 diabetes, 16% reduction in stroke and a 13% reduction in heart disease. Fruit Street Health and Lark Health have less extensive experience but have also shown promising results.
I can personally vouch for the effectiveness of the Omada program. A family history of diabetes, excess inches around the waist and the experiences of friends like Tony motivated me to enroll. In one year, I lost 18 pounds, exceeding the NIH targets for risk reduction. My investment — $520 for the Omada diabetes prevention program, plus $12 a month for its ongoing program to help sustain that weight loss — is tiny compared to the potential personal and monetary costs of diabetes.
The third misconception is that prevention’s benefits accrue too slowly, long after patients have left the employers and insurers who bear the cost. Because people change jobs and health insurance plans every few years, this misconception goes, it doesn’t make economic sense for commercial insurance to pay for prevention programs that won’t deliver benefits until long after the covered person has moved on.
Research shows that this is not the case, however. A study led by researchers at the American Medical Association (AMA) followed the medical costs of a large group of adults diagnosed with prediabetes and covered by commercial insurance. Researchers found that diabetes prevention programs could deliver meaningful cost savings within a three-year horizon, which generally falls within employee and health insurance plan turnover. The three-year ROI is estimated to be as high as 42%. (Disclosure: I am an innovation advisor to the AMA. I was not involved in this study and the views expressed in this series are my own.)
Robust clinical studies translated into real-world results are shredding the misconceptions that diabetes prevention doesn’t work, is too expensive or takes too long.
This comes not a moment too soon, because most people at high risk for diabetes lack awareness, treatment options, and social support. 90% of those with prediabetes don’t know it, most physicians don’t screen for it, and few enter into effective treatment, such diabetes prevention programs, medication or qualified diet programs.
Many of the ingredients necessary to launch an innovation moonshot to change that are in place, however. It is high time to do so, as I will discuss in part three.
— Read the series: We Need a Moonshot For Diabetes Prevention
- The Case For Action
- Three Misconceptions
- The Urgent Goal
- A Future History Of Success In 2025
- A Ten Point Plan