Community-based Diabetes Prevention – The YMCA Model

1. Community-based Diabetes Prevention – The YMCA Model Ronald T. Ackermann, MD, MPH Diabetes Translational Research Center Indiana University School of Medicine

2. Diabetes – the Tip of the Iceberg! • Diabetes • 25 million Americans • Prediabetes = High Risk • 65 million Americans (30% of all adults) • ~25% will have diabetes within 7 years

3. Economic Burden of Diabetes in U.S. *Projections from Hogan et al. Diabetes Care. 2003 Mar;26(3):917-32. AND American Diabetes Association. Diabetes Care. 2008 Mar;31(3):596-615

4. National comparative effectiveness trial (NIDDK/CDC) 3,200 overweight / obese adults with prediabetes Compared 3 preventive interventions Brief Education (usual care) Diabetes Pill Metformin Intensive Diet & Physical Activity Program Lifestyle Program most effective Prevented 58% of new diabetes cases Worked for all age, gender, and race subgroups U.S. Diabetes Prevention Program

5. DPP Lifestyle Program • 16-lession course over 24 weeks; then monthly • One-on-one personal coach format • Goal to lose/maintain ≥7% of body weight • Cut down dietary calories & fat • ≥150 min/week moderate physical activity • Education & training in behavior modification (Self-monitoring; problem solving) • Strong support structure (building self esteem, empowerment, social support; accountability)

6. DPP: Modest Weight Loss is the Goal In DPP… …every 1 kilogram of weight loss = 16% decrease in chances of getting diabetes …just 5 kg (11 pounds) of weight loss = 58% decrease in chances of diabetes *Hamman, et al. Diabetes Care 2006; 29:2102–2107.

7. DPP Lifestyle Program Summary Treating 100 high risk adults (age 50) for 3 years… • Prevents 15 new cases of Type 2 Diabetes1 • Prevents 162 missed work days2 • Avoids the need for BP/Chol pills in 11 people3 • Avoids $91,400 in healthcare costs4 • Adds the equivalent of 20 perfect years of health5 1 DPP Research Group. N Engl J Med. 2002 Feb 7;346(6):393-403 2 DPP Research Group. Diabetes Care. 2003 Sep;26(9):2693-4 3 Ratner, et al. 2005 Diabetes Care 28 (4), pp. 888-894 4 Ackermann, et al. 2008 Am J Prev Med 35 (4), pp. 357-363; estimates scaled to 2008 $US 5 Herman, et al. 2005 Ann Intern Med 142 (5), pp. 323-32

8. Maintain fidelity to DPP Goal-oriented; weight loss through diet & exercise Target adults at highest risk for diabetes now (prediabetes) Adopt “practical” solutions for key barriers Minimize intervention costs Preserve effectiveness (weight maintenance) IUSM’s Approach for DPP Translation

9. IUSM Research Program DPP Evidence-base DEPLOY1 Construct & Pre-test Community DPP D-LINC2 CC-LINC3 Link to Primary Care RAPID4 Minimize Cost Preserve Effect Diabetes Px Act5 UHG Demo Controlled Trial of Linkage Identify Target Group (PreDM) Make Routine in Primary Care Regional Demonstrn Project Can a linkage work in the real world? National Model for Diabetes Prevention Funding Sources 1R34-DK070702 (NIH) 2R34-DK071527 (NIH) 3RWJF #57398 4R18-DK079855(NIH) 5S.2734.IS & H.R.4124.IH Develop Infrastructure Who should pay? Is it scalable?

10. Lower cost program in community setting Lower cost “lay” group leaders Operate to achieve cost recovery only Policy to turn no person away for inability to pay Promise for national scalability 2,700 YMCAs in U.S. 57% of U.S. households within 3 miles of a Y Past experience with national program scaling Why Partner with the YMCA?

11. Study Design Comparative effectiveness trial High risk community volunteers Group-based DPP at YMCA vs. brief education only Study Questions Can the YMCA deliver group-based DPP? Can it achieve at least 5% weight loss? What will it cost? DEPLOY Study* R34-DK070702 (NIH)*

12. DEPLOY Weight Loss & Maintenance 6 monthly visits NO VISITS! 12 visits in 8 mos Same intervention now offered to both groups *p-values comparing Group DPP to Brief Advice Ackermann, et al. Am J Prev Med. 2008 Oct;35(4):357-63; Long term results under review 04/2010

13. Costs and Cost-effectiveness * https://research.tufts-nemc.org/cear/ratio0.aspx † Ackermann, et al. Am J Prev Med. 2008 Oct;35(4):357-63 ‡ Herman, et al. 2005 Diabetes Care

14. Study Design Comparative effectiveness trial High risk adult primary care patients (N=510 from 9 clinics) Group-based DPP at YMCA vs. brief education only Study Questions Can primary care practices identify & refer high risk adults? Will those adults attend the YMCA program? Will the program still achieve at least 5% weight loss? Will the linkage be cost-effective? RAPID Study* R18-DK079855(NIH)*

15. Primary care-based testing (A1c or fasting glucose) Over 3800 new patients tested in past 9 mos Accrual 350 already enrolled (12/week new) Retention ≥ 81% at 12 month visit YMCA Intervention uptake 74% of those randomized to Y have used program 20 active groups; 14 group instructors in 11 community sites RAPID Study Progress

16. The DPP can prevent more than HALF of new cases of type 2 diabetes & improve health in many other ways Individuals; society; health payers; employers ALL stand to benefit Group delivery + YMCA = effective & sustainable & scalable This may be the strongest evidence for a specific chronic disease prevention program to be both effective AND scalable Active attempts to scale nationally are ongoing Bottom Line

17. YMCA as a Research Partner • Relationship development (6-24 months) • Result of community networking • Synergy / Win-win opportunity • Involvement • Study design (randomization; controls) • Grant development • Intervention adaptation (training; delivery) • Fidelity measures (quality assurance) • Measures of “success”

18. I-CTSI and Community Research • I-CTSI • Protocol development • Community networking opportunities • Relationship development • Training in community research methods • CTSA Consortium • KFC sharing “best practices” / building tools • Multi-center demonstration projects?

19. www.indianactsi.org/CHEP email us at: chep@iupui.edu