Diabetes Prevention Nothing to Disclose UCSF Internal Medicine - - PowerPoint PPT Presentation

6/18/2018 1

Diabetes Prevention

UCSF Internal Medicine Updates San Francisco May, 2018

Elizabeth J. Murphy, MD, DPhil Professor of Clinical Medicine Deborah Cowan Endowed Professorship in Endocrinology University of California, San Francisco Chief, Division of Endocrinology San Francisco General Hospital

Nothing to Disclose 1 in every 3 adults in the U.S. will have diabetes by 2050.

• 30.3 million Americans (9.4%) have diabetes
• 25.2% of Americans > 65 have diabetes
• 84.1 million adult Americans (34%) have

prediabetes

Diabetes in America - 2015

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What is the only safe way to cure and treat DM2 long-term?

Don’t develop it in the first place.

Societal Change

Basic Assumptions for today

• Weight loss will prevent/delay diabetes
• Increased activity will prevent/delay

diabetes

• Eating less leads to weight loss
• Weight loss and increased activity are

good no matter what

• Harms associated with behavioral

interventions to promote weight loss are minimal to non-existent

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500 1000 1500 2000 2500 3000

Discrepancy Between Reported and Actual Energy Intake and Expenditure

Kcal/d

Reported

*P<0.05 vs reported.

Lichtman et al. N Engl J Med 1992;327:1893.

Energy Intake

Actual Reported Actual

Activity Energy Expenditure

* *

Slide Source: www.obesityonline.org

My Assumptions

• Intensive lifestyle methods are beneficial

for everyone and we should not just focus

• n those at highest immediate risk
• We should focus lifestyle interventions on

patients who are motivated

• Widespread lifestyle change will have spill
• ver effects

Key Questions

• Who is at highest risk of diabetes and how do

we easily identify them?

• What does the evidence show about success
• f interventions?
• What options are available for Diabetes

Prevention?

• What about cost and what will get paid for?

Key Questions

• Who is at highest risk of diabetes and how do

we easily identify them?

• What does the evidence show about success
• f interventions?
• What options are available for Diabetes

Prevention?

• What about cost and what will get paid for?

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ADA/AMA/CDC National Ad Campaign Ad Council

• Push for self testing of diabetes risk
• In English, Spanish
• With hedgehogs, disco goats or puppies

What was your score?

BMI cut points were roughly

25-30 = 1 point 30-40 = 2 points >= 5 High Diabetes Risk >40 = 3 points

• A. A = 0-4 points
• B. B = 5-6 points
• C. C = 7 or more points
• D. D = I have diabetes

A = 0-4 points B = 5-6 points C = 7 or more points D = I have diabetes

66% 6% 6% 22%

Who is at Highest Risk for DM?

• History of gestational diabetes
• Family history of diabetes
• Age
• Overweight and obese
• Sedentary
• High risk ethnic group
• Impaired glucose metabolism
• High waist to hip ratio

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Karter et al, Diabetes Care 2015

Diabetes Prevalence by Ethnicity – Northern California

35 year old sedentary Asian woman, BMI 29.5 history of GDM with a brother, mother and father with diabetes.

5 or more at increased risk

BMI 25-30 30-40 >40 1 1 1 1

4 Do I have diabetes.org (ADA/AMA/CDC/Ad Council)

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9 or more, high risk

BMI >27

= 13

35 year old sedentary Asian woman, BMI 29.5 history of GDM with a brother, mother and father with diabetes.

• TV screen – 3 points (5) low risk
• ADA paper screen – 4 points (5) low risk
• Doihaveprediabetes.org – 4 points (5) low risk
• National Diabetes Prevention Program Screen –

13 points (9) High risk

Includes questions on smoking, eating fruits and vegetables, waist circumference

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Conclusions – Who and How to Screen?

• Use a screening tool that will capture the

largest number of people

• Use tools that include Asian specific BMI

cut-offs

• As with screening for gestational diabetes,

perhaps easiest to screen widely

Prediabetes

• Fasting glucose 100 or 110-125 mg/dl
• A1C 5.7-6.4%
• 2h glucose post 75 OGTT 140-199 mg/dl

Laboratory Screening Recommendations

• CDC DPP

– Positive on high risk on screening tools AND

• BMI ≥ 24 kg/m2 or ≥ 22 kg/m2 in Asian-Americans OR
• History of GDM
• ADA

– Everyone over age 45 – Adults who are overweight or obese and an additional risk factor (BMI ≥ 25 kg/m2 or ≥ 23 kg/m2 in Asian-Americans)

• USPSTF

– Age 40-75 with BMI ≥ 25 kg/m2

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USPSTF Recommendations

• No ethnicity appropriate BMI cut-offs
• Doesn’t allow for screening of < 40
• Poor sensitivity (45%) and may detect only

25% of dysglycemic patients in 3 year f/u1

1O’Brien MJ, Lee JY, Carnethon MR, Ackermann RT, Vargas MC, et al. (2016) Detecting Dysglycemia

Using the 2015 United States Preventive Services Task Force Screening Criteria: A Cohort Analysis of Community Health Center Patients. PLoS Med 13(7): e1002074.

% Dysglycemic Patients Captured by USPSTF Screening Guideline

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% White African American Latino

O’Brien MJ, Lee JY, Carnethon MR, Ackermann RT, Vargas MC, et al. (2016) Detecting Dysglycemia Using the 2015 United States Preventive Services Task Force Screening Criteria: A Cohort Analysis of Community Health Center Patients. PLoS Med 13(7): e1002074. doi:10.1371/journal.pmed.1002074

USPSTF

• Weight Loss to Prevent Obesity-Related

Morbidity and Mortality in Adults: Behavioral Interventions

– Behavioral interventions led to weight loss, reduced DM2, less weight regain (moderate benefit) – Harms are small to none

Key Questions

• Who is at highest risk of diabetes and how do

we easily identify them?

• What does the evidence show about success
• f interventions?
• What options are available for Diabetes

Prevention?

• What about cost and what will get paid for?

6/18/2018 9

Diabetes Prevention Program

• High Risk:

– 25 years or older – BMI ≥ 24 kg/m2 or ≥ 22 kg/m2 in Asian-Americans – Fasting glucose 95 - 125 mg/dL and OGTT glucose 140 to 199 mg/dL

• 3234 Participants
• Good diversity

– 19% African American – 16% Hispanic – 5% American Indian – 4% Asian and Pacific Islanders

NEJM 346:393, 2002; Lancet 374:1677, 2009.

• Randomized
• metformin (850 mg BID) OR
• extensive, individual lifestyle intervention

Lifestyle Intervention

• 16 week curriculum with individual sessions
• ver 24 weeks
• After 24 weeks follow up individual and group

sessions for reinforcement

• Healthy low fat, low calorie diet
• 150 minutes of moderate-intensity physical

activity per week

Diabetes Prevention Program Research Group. N Engl J Med 2002;346:393-403.

7% weight loss at one year 4% weight loss at 4 years

Lifestyle Group

150 minutes of moderate-intensity physical activity per week

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Reduction in Diabetes by Weight Loss

NEJM 346:393, 2002.

Sub Group Findings

• Metformin

– most effective in < 60 years old and BMI > 35 or if a history of gestational diabetes – As effective as lifestyle in that group – Least effective in lower fasting glucose and lower BMI

• Lifestyle

– more effective with lower base-line OGTT glucose.

• No significant differences based on sex, race or

ethnic group

DPP- Outcomes Study

• All subjects offered lifestyle intervention in a

group format for one year

• Everyone offered maintenance group sessions

quarterly

• Lifestyle group offered further supplementary

group programs and an individual lifestyle check in twice a year

• 88% of DPP enrolled

DPP 15 years

Risk Reduction 18% with metformin 34% with Lifestyle

• Lancet. 2009; 374: 1677–1686

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Microvascular Outcomes

• Followed for Microvascular Outcomes

– Nephropathy – Retinopathy – Neuropathy

• Lower prevalence in those who did not

develop diabetes

• No significant treatment effect (yet)

Finnish Diabetes Prevention Study

• 500+ Finnish participants,
• Abnl OGTT; Ave BMI 31
• Diabetes diagnosed as FBG>140 or OGTT>200
• Lifestyle intervention

– Exercise = Gardening, snow shoveling, berry picking, gathering mushrooms, rowing, forest work

• Weight loss 5%
• ~3 years follow up

NEJM 2001;344:1343-1350

Finnish DPP Results

• 58% reduction in incidence of diabetes
• Diabetes developed in 6% vs. 14%
• As with US DPP, success was dependent on

achieving the goals

NEJM 2001;344:1343-1350

Finnish DPP 7 years

Lancet 2006; 368: 1673–79

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Da Qing Study

• 577 participants with IGT in China

– Control vs. Diet, Exercise, or Diet AND Exercise – 6 year follow up – 30-45% reduction in incidence of diabetes in intervention groups – Different interventions were comparable

Diabetes Care. 1997. 20(4): 537-44.

• 43% reduction in incidence of DM over 20 years
• No difference in rate of CV events or CVD death at 20yr
• At 23 years, CV and all-cause mortality were reduced

– HR 0.59 and 0.71

Da Qing Study- 20 and 23 years

Lancet 2008; 371: 1783–89 Lancet Diabetes & Endocrinology, 2014, 2(6): 474-480

CV mortality All-cause mortality

DPP Translational Studies

• Focus on more cost efficient delivery
• Focused on weight loss

– All achieve early weight loss – Long term durability of weight loss not as clear

• Don’t yet have diabetes prevention data for

translational programs

• Other potential benefits

– Lipids – HTN – Depression

The Future of Type 2 Diabetes Care

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Key Questions

• Who is at highest risk of diabetes and how do

we easily identify them?

• What does the evidence show about success
• f interventions?
• What options are available for Diabetes

Prevention?

• What about cost and what will get paid for?

Your Experience

• A. I have never had a patient

participate in a DPP

• B. I have had patient’s participate in a

DPP but I had nothing to do with it

• C. I have referred patients to an in

internal DPP my organization has

• D. I have looked up and actively found

DPP programs for my patients at

• utside sites or knew about

programs from the health plans

I h a v e n e v e r h a d a p a t i e . . I h a v e h a d p a t i e n t ’ s p a r t i . . . I h a v e r e f e r r e d p a t i e n t s . . I h a v e l

• k

e d u p a n d a c t . . .

39% 7% 27% 27%

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To Qualify For CDC Recognized Program

• Be at least 18 years old and
• Be overweight (body mass index ≥25; ≥23 if Asian) and
• Have no previous diagnosis of type 1 or type 2 diabetes and
• Have a blood test result in the prediabetes range within the

past year:

– Hemoglobin A1C: 5.7%–6.4% or – Fasting plasma glucose: 100–125 mg/dL or – Two-hour plasma glucose (after a 75 gm glucose load): 140–199 mg/dL OR

• Be previously diagnosed with gestational diabetes

CDC DPP Certification Requirements

• CDC-approved curriculum promoting 5-7%

weight loss and increased physical activity

• A lifestyle coach
• A peer support group of program participants
• Submit annual data on weight loss, activity,

class participation

• Enroll > 50% of patients based on lab tests

In person

• In-person sessions:

– Review and check-in on weekly progress – Group discussion about the week’s topic with hand’s

• n demonstrations

– Wrap-up with a to-do list/practice activities and handouts to reinforce what was learned

• Advantages

– Easier group bonding and peer support – More personal

• Disadvantages

– Need to be available at a given place and time

In Person Programs

• YMCA
• Weight watchers
• Kaiser DPP
• Small individual DPP

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Online Programs

• 100% online delivery of sessions
• Live lifestyle coach interaction individually and with a group
• Online tracking programs to help log food and physical activity.
• Typically get things like a digital scale, pedometer and a stretch

band

• Advantages

– Can do anywhere, anytime – Good for folks who don’t like in person groups

• Disadvantages

– Need smartphone (or computer) – Need to be tech savvy and high literacy

Distance Learning

• Delivered 100% by via remote classroom or

telehealth (i.e., conference call or Skype).

• Good for participants who want group

interaction, but live in remote areas and cannot attend an in-person program.

CDC Program Registration

• 1744 registered programs across the US
• 164 have full CDC program recognition
• 293 programs with preliminary status
• 1287 programs pending recognition

CDC Registered Online

• 57 Online programs registered
• 3 full recognition -

– 6 preliminary – 48 pending recognition

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Omada

https://www.omadahealth.com/

Medicare Pilot Program

• Pilot program with YMCA in patients with

Medicare

– Savings of $2650 per person enrolled – CMS plan for diabetes prevention coverage

• Lead to Medicare covering DPP with patients

able to enroll starting April 1, 2018

Medicare Diabetes Prevention Program (MDPP)

• Medicare Part B enrollees
• BMI of at least 25 kg/m2 (or 23 kg/m2 Asian)

AND one of

– FPG 110-125 mg/dL – OGTT of 140-199 mg/dL – HbA1c between 5.7% and 6.4%.

• No previous dx of DM1 or DM2 and no ESRD

Medicare Diabetes Prevention Program (MDPP)

• Medicare Part B enrollees
• BMI of at least 25 kg/m2 (or 23 kg/m2 Asian)

AND one of

– FPG 110-125 mg/dL – OGTT of 140-199 mg/dL – HbA1c between 5.7% and 6.4%.

• No previous dx of DM1 or DM2 and no ESRD

6/18/2018 17

Solera 4 Me

• For Medicare Patients
• Four questions

– Age – Gender – Ethnicity – BMI

• Excludes folks with diabetes or ESRD
• Links you with programs approved by your health

plan

– Asks about online versus in person preferences

Medicaid Coverage

• Montana Medicaid covers everyone
• CDC/Medicaid Pilot Projects end June 2018

– Maryland – Oregon

• July 2017, Medi-Cal announces coverage plan

– DHCS 1/2/2018 posted initial implementation information

• Will include 22 peer-coaching sessions over 12 months, provided regardless of

weight loss

• Participants who achieve and maintain a minimum weight loss of 5 percent by

12 months period will can receive ongoing maintenance sessions

– Programs must comply with CDC guidelines and obtain recognition – To start 1/1/2019

Payments

• Many programs with a fixed fee of around

$450

• Increasingly programs are paid on a pay for

performance basis

• Medicare 2018 payment notice

– $125 for < 5% weight loss – $810 maximum pay for performance

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Unanswered Questions

• Roll of maintenance programs
• Effectiveness in specific vulnerable

populations

• Programs for kids and adolescents?

Other Methods of Diabetes Prevention

• Metformin

– As effective as lifestyle in folks with BMI ≥ 35 – Less effective than lifestyle overall – Not effective if > 60 years old – Cost saving over 10 years

• Bariatric surgery
• Other medications

Medication for DM Prevention

• Diabet. Med. 28, 948–964 (2011)

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DM Trends in US

Age 20-79; 1980-2012

Geiss et al, JAMA. 2014;312(12):1218-1226.