The burden imposed on our society by type 2 diabetes mellitus has grown dramatically over the last decade.  Greater numbers of people than ever before are being diagnosed with diabetes at younger ages.  These people and their families must face the spectrum of implications brought on by diabetes, including its many associated medical complications.

The excess costs imposed on our health care system by type 2 diabetes are no less significant.  Each year, the average person with type 2 diabetes will incur almost $7,000 in excess health care costs when compared to his or her counterparts who do not have diabetes.

Fortunately, in the face of this alarming growth in the incidence and prevalence of diabetes, an important ray of hope has come from the scientific community: the results of the National Institutes of Health-funded Diabetes Prevention Program (DPP).  A study of impressive scale with over 3000 patients at sites across America, the DPP has demonstrated that medications and lifestyle interventions can dramatically reduce progression to diabetes — and, along with this, reduce the accompanying health care costs.

It is time to build on the results of the DPP, and the important follow-up work that has already been done, to create a diabetes prevention effort of national scale that can reach all who are at risk for this disease.

The Background

The lifestyle intervention in the DPP consisted of 16 visits conducted in a primary care setting that provided counseling about nutrition and exercise, as well as the implications of diabetes.  The medication intervention was use of the drug metformin.

Nearly 10 years have passed since the initial study was published in the New England Journal of Medicine.  In that time, we have found that the results persisted long after the initial intervention was delivered.  Remarkably, as many as one-third fewer patients progressed to type 2 diabetes.  Consider that — 33 of 100 patients who might have developed diabetes did not.

These are fundamentally groundbreaking findings that have inspired others to pursue diabetes prevention initiatives.  The CDC, United HealthCare, and the YMCA have all been involved in efforts to use group visit, community-based interventions based on the DPP model to achieve results comparable to the initial study.

Next Steps

With such promising results from the DPP and the ensuing early efforts underway to replicate them, the question before us today is a simple one: From these beginnings, how do we bring the diabetes prevention effort to a scale that can impact all who are at risk?  We all know it’s needed.  We all know it has the potential to advance the three-part aim and improve health and reduce costs.  The question that we must therefore grapple with is: how?

The Affordable Care Act has chartered the Center for Medicare and Medicaid Innovation to bring effective interventions to national scale through payment policy.  With an Innovation Center demonstration project that builds on the results of the Diabetes Prevention Project — along with robust collaboration with commercial health plans in the private sector — the promise of diabetes prevention could go from the realm of scientific experiment to a broadly available benefit that has the potential to improve the lives of countless Americans and save money for years to come.

The process of successfully bringing diabetes prevention to scale requires that we address some key components of this process.  First, what are the key components that define the increased risk of a target population for these diabetes prevention efforts, and how can we best to screen for them? Second, how do we optimally design the interventions that will effectively and with reasonable cost bring diabetes prevention to scale and impact the millions of people in need?  Third, given the long time horizon in the development of diabetes and its complications, how do we effectively measure the impact of our interventions at milestones along the way, to insure that we are heading for success and to allow us to adapt, intervene, and modify the program as needed as new knowledge or clinical methodology becomes available?

The job of diabetes prevention is one of increasing importance.  With multi-sector collaboration, it can become an important and lasting keystone of a new health care paradigm that prioritizes prevention of chronic diseases over managing them.