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Looming diabetes crisis spurs call to preventive arms

As health plans start serving newly-insured populations and try to improve outcomes for long-time patients, all while taking on more financial risk, the case for aggressively targeting diabetes and obesity has never been greater.

About 20 percent of Americans over the age of 20 have metabolic syndrome -- a mix of excess weight or obesity, high blood pressure, cholesterol imbalance, and prediabetic high blood sugar -- and if current trends of obesity and physical inactivity continue, one-third of US adults will have diabetes by 2050, warn Charles Hennekens, MD, and colleagues in a call-to-action published in the American Journal of Managed Care.

Unabated, these trends will almost certainly bring a spike in treatment of cardiovascular disease, extremity disease, kidney failure, blindness and more, straining public and private healthcare budgets and also challenging the new business models of population health.

Hennekens, a professor of medicine at Florida Atlantic University, argues that healthcare organizations need to "aggressively utilize a multifactorial approach to risk reduction" using everything from lifestyle interventions to evidence-based drug therapies.

Health plans -- with views of individual health histories, influence of workplace wellness programs and control of benefit designs -- have an important role to play in both connecting at-risk members with clinical treatment and facilitating and initiating lifestyle changes.

Investing in diabetes prevention through diet and exercise interventions -- like L.A. Care Health Plan's new virtual lifestyle management program for obese members -- could lead to significant savings for public and private payers in the long-run, by helping individuals avoid acute care for cardiovascular disease.

And now is the time to do it, argue Hennekens and colleagues.

Most of the 20th century's landmark decline in cardiovascular disease came from treatment, not prevention, and "the rate of decline is leveling off," they write. In some parts of the country, a new generation of Americans could well face cardiovascular disease and diabetes problems earlier in life and in greater numbers than their parents and grandparents.

"U.S. adolescents are already heavier, less physically active, smoke more, and develop (Type 2 diabetes) at a higher rate than their parents' generation did in their adolescence. Thus, they may become the first US generation since 1950 to have higher rates of (cardiovascular disease) than did their parents," Hennekens and colleagues write.

By various estimates, individuals with Type 2 diabetes have twice the risk for premature death due to vascular complications, in addition to higher risk of chronic and end-stage kidney failure, heart attack and stroke.

Successfully stemming those risks for youth and adults who already diabetic or are overweight and prone to developing the condition will require a multi-channel approach, they write.

Blood sugar control is necessary, "but is not sufficient to achieve the maximum benefits in the reduction of microvascular or macrovascular complications," they argue. Therapeutic lifestyle changes have been shown to "produce sustained weight loss and improvements in fitness, glycemic control, and risk factors."

From the perspective of an at-risk individual, it may or may not be ideal to hear from your health insurer that you need to get more exercise and eat differently.

But between helping clinicians identify those at risk, designing employer wellness programs and sponsoring weight loss initiatives, insurers have some of the best opportunities to impact individuals of any players in the healthcare system -- and they also have the right financial incentives.

A range of insurers, including Florida Blue, Aetna, Molina Health and EmblemHealth and most recently L.A. Care Plan, are already offering at-risk members variations of online weight loss and health coaching programs that follow the model of the national diabetes prevention program.

Evidence-based intervention and new frontiers

That national program was developed through a multi-site randomized trial testing the impact of personal diet and exercise tracking combined with coaching and support.

Obese prediabetic individuals who participated in a lifestyle program, which encouraged modest increases in exercise and dietary changes, lost five to seven percent of their body weight (10 to 14 pounds for a 200-pound person) and reduced their risk of developing diabetes by 58 percent. Participants who only took metformin, for comparison, reduced their risk of developing diabetes by 31 percent.

Over the course of each year, just five percent of the intervention group went on to develop diabetes, compared to 7.8 percent of those taking metformin and 11 percent of those in a placebo group.

The national diabetes prevention program and its variations draw on a combination of motivation and positive reinforcement to help individuals start and continue modest changes -- walking for an hour a day and avoiding highly-processed foods, for instance.

Some payers are even starting to go beyond that and experimenting with new frontiers in behavioral health science in a bid to reach those at the most serious risk.

Last fall, Aetna started a pilot for 500 high risk members -- among its own employees who through predictive modelling were found to have metabolic syndrome. Partnering with a wellness startup called Newtopia, the insurer is trying to figure out if genetic screening and personality stratification can help tailor intervention approaches that lead to better outcomes.

Genetic testing can "help people understand it's not their fault necessarily" and help them find the best ways to change their habits, said Jeffrey Ruby, founder and CEO of Toronto-based Newtopia.

The company's genetic testing program screens people for three gene variations associated with obesity, appetite and behavior, including DRD2, a gene linked to dopamine regulation that some research suggests is also tied to addictive behavior like overeating.

Those genetic findings along with an individual's preferences can help craft a personalized behavior change program, Ruby said, to identify the best sources of motivations and messages for education.

"I want to change people's perspective away from thinking about either losing weight by eating right or exercising, toward a more holistic goal in bringing together nutrition, exercise and behavioral well-being," Ruby said in an interview last fall.

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