The challenge holding back the diabetes prevention program

The latest statistics say that 96 million Americans —38% of the adult population —have prediabetes, or seriously elevated blood glucose, and are thus at risk for developing type 2 diabetes and its associated conditions such as heart disease, stroke, kidney damage, blindness, and dementia. That number keeps rising and the isolated lifestyle that many people adopted during the pandemic didn’t help. Nor has COVID-19, which emerging research indicates can include prediabetes as well as type 2 among the many long COVID impacts. What’s worse, more than eight out of ten people with prediabetes don’t even know they have it!

The National Diabetes Prevention Program (DPP) launched by the Centers for Disease Control (CDC) in 2010 is clinically proven to reduce the risk of developing type 2 by 58%, and by 71% for those over age 60. The DPP should be a resounding success. Yet despite the DPP being covered by Medicare, Medicaid, and most major health insurance providers, barely half a million people have gone through the program. That means they may not be making the simple lifestyle adjustments advocated by the DPP to prevent type 2.

So why aren’t more doctors prescribing the DPP to their patients with prediabetes? Perhaps it’s just not available to enough people when and where they need it. In addition to complex regulatory requirements and low reimbursement rates for providers, there’s the changing reimbursement rules for online classes versus in-person ones.

The solution to prediabetes must scale with the problem. It has to reach as many of those 96 million as possible. Part of the challenge is that oftentimes the most at-risk people are older, on limited incomes, in food deserts, without 24/7 broadband internet, and who may not have access to an employee assistance program (EAP) or the kind of health insurance that covers diabetes prevention.

So, if we talk about really trying to address the growth in prediabetes, we need to make sure that the solution is available to the most vulnerable populations. There needs to be a greater push at offering the DPP as covered by Medicare and Medicaid, which require a year of in-person classes. Pandemic restrictions made online classes a temporary necessity, but that was a compromise for learning and changing habits. Digital is an enabler for the back-office automating and lowering of costs, but it can lead to mere class auditing rather than focused participation that results in lifestyle change. In-person is truly the gold standard.

The support of others

Healthcare often presumes that people won’t or can’t change their habits. But the consumer retail product business (my background) is built around the assumption that millions of people can be persuaded to change their habits and shopping preferences to adopt new products. And they do. And people can change their health-related habits, too.

The CDC-designed DPP is a year-long program because it takes time to make healthy lifestyle changes permanent. People have to be able to alter the cues, triggers, and rewards for their behaviors and create new habits that stick. Too many big changes in a short time simply aren’t sustainable from a habit-change perspective. (That’s also why one-off cash incentives or rewards may work to change a single habit like smoking, but not cross-lifestyle habits.)

Diabetes prevention can be aided by technology platforms and smartphone apps. However, lifestyle change is not a tech problem; it's a human problem. I know from managing personal care brands that connections with other people make a difference. People take care of themselves out of care for others. That’s why the DPP offered in-person has proven successful, as it involves coaching with a peer support group and 12 months of personal action planning along all the dimensions required for success. Some people can be as effective online, but the accountability of showing up for others is a next-level commitment.

A successful diabetes prevention program embraces and enriches the person’s daily life. Participants need hyperlocal, culturally sensitive advice that’s relevant to where they actually live, eat, and shop, from people familiar with their communities. The DPP should connect people who live in the same neighborhood and allow them to learn from each other, neighbors listening to neighbors, facilitated by a trained DPP expert who’s also a member of the community. The hyperlocal aspect increases the chance that participants will feel invested and stay committed, ultimately building lasting bonds with others on the same journey to creating a healthier lifestyle. It’s a practical journey rooted in the actual constraints to good health that the person experiences in the daily reality of their ZIP code.

Scaling coaching on-demand

The DPP has the classic trial and retention problem. Not only, how do health professionals get people to enroll, but how do we get them to follow through? It’s unlikely that people will just decide to enroll on their own and stick it out for 22 classes over one year.

A “prescription” is crucial to ongoing enrollment, as people take prediabetes seriously if their trusted physician explains it. However, many people only see their doctor on an annual basis, so prescribing DPP to a patient with prediabetes is time-sensitive or the demand/interest on the part of the patient will fade. As with any prescription, if it’s not filled within a couple of weeks, it’s probably not going to be taken. That’s human nature.

But a physician can’t prescribe what isn’t there. The challenge of the in-person DPP is to couple the building of demand (among participants) with supply (of DPP providers) within a small radius of the physician’s practice. The doctor needs to be certain that a DPP provider can build out capacity to fill the patient’s prescription at a convenient time and location within a few minutes of the person’s home. This finely tuned supply and demand has to be achieved simultaneously, ZIP code by ZIP code, to reach critical mass so the DPP provider is able to make an offering of in-person classes that is also cost-effective.

Type 2 diabetes will continue to grow unless we can persuade people that sustainable lifestyle change is within their reach. And to do that, physicians need DPP partners to help them design their practice to instantly match supply and demand so that they can deliver in-person diabetes prevention when and where their patients need it.

Karl Ronn is the founder and CEO of First Mile Care (www.firstmilecare.com), a preventative chronic care company. Mr. Ronn is a former vice president of R&D and general manager of new business/healthcare for Procter & Gamble. First Mile Care is a spinout company from Health2047, the Silicon Valley innovation subsidiary of the American Medical Association.