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Stopping Diabetes in its Tracks

Effective, affordable interventions key to halting this health epidemic

About 29 million people in the United States have Type 2 diabetes. But perhaps more alarming is that another 86 million have prediabetes: higher than normal blood sugar levels likely to accelerate and become full-fledged diabetes in the next five to 10 years unless someone intervenes. The consequences aren’t just medical; they’re financial, too. Diabetes and prediabetes cost Americans an estimated $322 billion in 2012, according to the American Diabetes Association.

For the last decade, Northwestern Medicine investigator Ronald Ackermann, MD, MPH, has worked on implementing a method to halt diabetes that is both effective for patients and affordable for insurers. He and colleagues have focused on adapting an intervention called the Diabetes Prevention Program (DPP), which involves making small dietary changes, finding practical ways to increase physical exercise and receiving one-on-one encouragement and troubleshooting from a professional lifestyle coach. When first developed, the program was shown to cut diabetes progression in half, but at a cost of about $1,500 per patient. Ackermann’s group designed and evaluated an inexpensive – and therefore more feasible – version of the DPP delivered at community YMCAs for an annual cost of only about $200 to $300 per person.

Diabetes-chart-2_500“Our intervention is based on the best evidence for how you help people lose weight,” says Ackermann, co-director of Northwestern’s new Center for Diabetes and Metabolism. “We changed the program by offering it at the Y in a group format. Participants still have face-to-face coaching to keep them on track to meet their goals and to guide them through stumbles and falls.”

With funding from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the investigators proved that their program worked in a series of studies at Ys in Indianapolis. The positive results led to a partnership between YMCA of the USA, health insurance company UnitedHealth Group and the Centers for Disease Control and Prevention, which rolled out the program nationally. Over the last five years, Ackermann has led a study at Northwestern evaluating this partnership, comparing the healthcare expenditures of people across the United States who participated in the program with those who didn’t.

We shared our own research with the Medicare team, helping to demonstrate that if insurers pay for this Y program, they can recover their investment because people have better health – over time they don’t have to go the doctor as much or take as many medications.

The data from all this work contributed to a huge milestone reached this spring: Medicare, which spends a third of its funding caring for people with diabetes, announced it would cover the Y intervention, as well as other similar programs recognized by the Center for Disease Control’s National Diabetes Prevention Program.

“The Medicare policy follows a study conducted by the Center for Medicare and Medicaid Innovation and Medicare’s lead actuary, which concluded that the program was likely to be cost-neutral or cost-saving,” explains Ackermann, who is also a professor of Medicine in the Divisions of General Internal Medicine and Geriatrics and Endocrinology. “We shared our own research with the Medicare team, helping to demonstrate that if insurers pay for this Y program, they can recover their investment because people have better health – over time they don’t have to go the doctor as much or take as many medications.”

Ronald Ackermann, MD, MPH

Ronald Ackermann, MD, MPH

With half of the Medicare population considered to have prediabetes, the Y program has the potential to assist an enormous number of patients. But Ackermann acknowledges that this intervention won’t reach everyone.

“We need to divide the prediabetes population further to find out who is most likely to benefit from this program and who may need another intervention,” says Ackermann. “We need to become smarter about offering the right interventions to the right people.”

Thanks to a contract Northwestern has with UnitedHealth Group, Ackermann has access to a database of more than 20 million patients, containing information about everything from their hospitalizations to lab tests to medication history, and enabling analysis of subgroups of people.

“At Northwestern, we’re developing special skills and methods that allow us to analyze huge data sets to do natural experiments that inform not only policy decisions about health insurance coverage, but also better health care,” he says.

Matthew O’Brien, MD, assistant professor of Medicine, and Namratha Kandula, MD, MPH, associate professor of Medicine, both in the Division of General Internal Medicine and Geriatrics, are also exploring how versions of the DPP lifestyle intervention could benefit subgroups of patients. O’Brien concentrates on Latinos in the United States and Kandula, on South Asians. (Read more about O’Brien’s recent research showing that current diabetes screening guidelines miss more than half of high-risk patients, especially racial and ethnic minorities.)

Meanwhile, Bonnie Spring, PhD, director of the Center for Behavior and Health and a professor of Preventive Medicine, develops innovative interventions using technology such as cell phones and wearable devices to reduce unhealthy habits. Mercedes Carnethon, PhD, associate professor of Preventive Medicine, conducts epidemiologic studies to understand how factors like race/ethnicity, neighborhood resources and sleep affect cardiovascular risk factors like obesity and diabetes.

Joseph Bass, MD, PhD

Joseph Bass, MD, PhD

Combatting societal norms is a challenge for all of these investigators. Ackermann points to the limited availability and higher costs of healthy foods, perceptions about what is considered “good” food, large portion sizes and using food as a social medium as examples of how the environment perpetuates diabetes in our country.

“The biggest challenges we face in adult primary care today are related to chronic diseases like diabetes,” he explains. “Chronic diseases are tightly linked to behavior – smoking, physical inactivity, unhealthy diet. People know this, but actually changing their behavior is another thing, particularly when the world around them isn’t supporting healthier choices. Our research is about providing a supportive structure, accountability and a behavioral scheme to help them live healthier lives now. Until the world changes, we need programs that can help people succeed.”

Uniting Research Strengths

While the environment is a big factor behind diabetes, genetics is another. As Ackermann and his colleagues focus on behavior, policy and costs in clinical settings to prevent the disease from developing, another set of Northwestern Medicine scientists is at work in labs trying to understand the internal pathways that predispose people to diabetes, knowledge that can apply to prevention. All of this work – and more – is united within the Center for Diabetes and Metabolism, spearheaded by Ackermann and Joseph Bass, MD, PhD, chief of Endocrinology in the Department of Medicine.

“We’re a leading diabetes center in the Midwest, integrating patient care with a broad spectrum of research, extending from the biology of the disease to community-based interventions to clinical trials testing new therapies,” says Bass.

Bass’s own research centers on circadian and metabolic gene networks and their role in the development of diabetes and obesity. In a recent study, his lab pinpointed thousands of genetic pathways an internal body clock in the pancreas takes to dictate how and when the organ must produce insulin and control blood sugar, findings that could inform new therapies for people with diabetes.

Among additional basic scientists involved in the center, Grant Barish, MD, assistant professor of Medicine in the Division of Endocrinology, studies the molecular mechanisms that control metabolism. He’s already made the surprising discovery that a transcription repressor called BCL6 can prevent the fatty buildup that plugs arteries in atherosclerosis, and he has a new grant to explore how this “gene switch” can control body fat distribution to reduce the morbidity of obesity and Type 2 diabetes.

With more than 70 members, the scope of the center extends far beyond prevention, from developing new treatments to managing the care of current patients. But nipping diabetes in the bud remains a crucial goal.

“About one in three adults have prediabetes. Somewhere in the neighborhood of 30 percent of those people will develop diabetes in the next five to seven years,” stresses Ackermann. “If we don’t act, we’re going to have a lot more Type 2 diabetes in the health system in the next decade.”