Monday, March 26, 2018

The Medicare Diabetes Prevention Program

The National Institute of Diabetes and Digestive and Kidney Diseases (NIKKD) conducted a study to determine if weight loss could prevent type 2 diabetes. The study was called the Diabetes Prevention Program (DPP). The researchers concluded that a relatively small amount of weight loss can prevent type 2 diabetes for those people with prediabetes. Because of positive results from the study and other studies related to the DPP study, Medicare will reimburse suppliers who offer a Medicare version of the type 2 diabetes prevention program. That program is called the Medicare Diabetes Prevention Program (MDPP).

The Diabetes Prevention Program or DPP trial was initiated in 1996 by the NIKKD to determine if weight loss could be used to prevent type 2 diabetes in persons with prediabetes. The study was a randomized trial consisting of three groups. All three groups contained prediabetic subjects that were overweight but not obese. Results from the trials were reported in 2002.

Subjects in one of the groups received placebo treatment for type 2 diabetes treatment. Subjects in another group were given the diabetes drug metformin. And subjects in the third group were provided intensive lifestyle intervention, with the goal of a 7% weight loss using diet, exercise and lifestyle modification.

The specific goal of the study was to determine if individuals with prediabetes could avoid type 2 diabetes by losing 7% of their weight through diet, exercise, and lifestyle modification. Actually, all three groups lost weight. At one point in the study, the subjects in the intensive lifestyle group lost 15.4 pounds, compared to 5.5 pounds for the metformin treatment group, and about 2.2 pounds for the placebo  group.

During the 2.8 years of the study, it was found that the intensive lifestyle subjects experienced a 58% reduction in the incidence of type 2 diabetes, and the metformin group experienced a 31% reduction compared to the placebo group. And after ten years, the type 2 incidence "was reduced by 34% ... in the lifestyle group and 18% .. in the metformin group compared with placebo." Furthermore, another study, looking at results from the original DPP study and  a follow-on study called the DPP Outcomes Study (DPPOS), concluded that DPP treatment was cost-effective when compared to metformin or placebo treatment.

And finally, a study called the Diabetes Education and Prevention with a Lifestyle Intervention Offered at the YMCA  or DEPLOY, was carried out in  two YMCAs in greater Indianapolis. The researchers concluded that "YMCA wellness instructors can be trained to deliver a group-based DPP lifestyle intervention and achieve changes in body mass after 6 and 12 months that are comparable to the DPP study."

Based on the DEPLOY positive results, Medicare carried out its own test to determine if the DPP method could be cost effective for Medicare beneficiaries. The MDPP test program was implemented in 17 YMCAs in the U.S. Based on positive results from its study, Medicare decided to expand the program to all prediabetic Medicare beneficiaries who satisfy criteria established by Medicare. That program is set to start in April of 2018. The program is called the Medicare Diabetes Prevention Program or MDPP.

The program uses CDC trained coaches to engage with the beneficiaries to help them adhere to the guidelines of the program. The settings for the MDPP could be within a typical healthcare organization or within some community organization, such as the YMCA. Healthcare providers can refer Medicare beneficiaries to organizations offering the MDPP.

Since Medicare will reimburse organizations that provide the program, there is an opportunity for primary care physicians, who want to improve the outcomes of their prediabetic patients, to play an important role in their patients' care.

Thursday, March 22, 2018

It Is Possible to Lose and Maintain Weight Loss Long-Term

It is believed by most people that no one can lose weight and maintain weight loss long-term. Further, it is often stated that there is no way to predict who will be successful at losing weight. However, a long-term study, called the Look AHEAD study, showed that it is possible to lose weight and maintain the weight loss long-term. The study results also showed that it is possible to predict who will be the most successful at losing weight.

“The Look AHEAD (Action for Health in Diabetes) study [was] a multi-center, randomized controlled trial, designed to determine whether intentional weight loss reduces cardiovascular morbidity and mortality in overweight individuals with type 2 diabetes.” The study consisted of over 5000 subjects, and ran for about ten years.

It was found that for 42% of the persons, who lost at least 10% of their weight during the first year of the weight loss program, were able to maintain the weight loss for at least four years. Further, it was concluded that those participants who lost at least 5% of their body weight, at the end of the first month of a weight loss program, were more likely to lose at least 10% of their weight after one year compared to those participants who lost less than 2% of their weight at one month.

At any rate, it appears that providers should resist the temptation to tell people that weight loss and long-term weight-loss maintenance are virtually impossible. It is possible to lose and maintain weight loss as the above mentioned study shows. And those individuals most likely to lose appreciable weight can be identified early in the weight loss program.

Finally, weight loss lessens the risk of negative cardiovascular outcomes. A study, which was a follow-on study to the Look AHEAD study, found that 85% of the Look AHEAD subjects experienced a significant reduction in cardiovascular events as a result of the weight loss. Although 15% of the subjects did experience negative outcomes, for those subjects, the negative outcomes may be associated with depression. Also, the subjects' "substantially poorer compliance with the exercise portion of the intervention" may have played a role in the negative outcomes.

At any rate, it is possible to lose weight and maintain the weight loss for a long period of time.

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