Translating the DPP Results to Address the NNHeS Challenge
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Translating the DPP Results to Address the NNHeS Challenge

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Plenary lecture at the PSEM Prediabetes Congress, 21 March 2012.

Plenary lecture at the PSEM Prediabetes Congress, 21 March 2012.

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Translating the DPP Results to Address the NNHeS Challenge Translating the DPP Results to Address the NNHeS Challenge Presentation Transcript

  • 21 March 2012 Diabetes Prevention: Translating the DPP Results to Address the NNHeS Challenge Iris Thiele Isip Tan MD, MSc, FPCP, FPSEM Clinical Associate Professor, UP College of Medicine Department of Medicine, Philippine General Hospital http://www.sxc.hu/photo/1253865Wednesday, March 21, 12
  • Wednesday, March 21, 12
  • Diabetes Prevention Program (DPP) Diabetes Prevention Program Outcomes Study DPP Lifestyle Balance The DPP Lifestyle Change Program National Diabetes Prevention Program US ModelWednesday, March 21, 12
  • I: Lifestyle modification vs Metformin vs placebo M: P: 3234 O: Incidence Randomized with IFG of diabetes controlled or IGT over follow-up trial Diabetes Prevention Program Trial Design Diabetes Prevention Program Research Group NEJM 2002;346:393-403Wednesday, March 21, 12
  • DPP Protocol: Intensive Lifestyle Modification 16-lesson curriculum covering diet, exercise and behavior modification taught one-on-one for 1st 24 weeks Diabetes Prevention Program Research Group. NEJM 2002;346:393-403Wednesday, March 21, 12
  • >7% weight loss: healthy, low-calorie, low-fat diet Diabetes Prevention Program Research Group. NEJM 2002;346:393-403Wednesday, March 21, 12
  • Moderate intensity physical activity i.e. brisk walking >150 min/week Diabetes Prevention Program Research Group. NEJM 2002;346:393-403Wednesday, March 21, 12
  • Diabetes Prevention Program Research Group. NEJM 2002;346:393-403Wednesday, March 21, 12
  • DPP Results Reduction in Incidence of Diabetes (vs placebo) Lifestyle Modification ⬇ 58% (95% CI 48-66%) Metformin ⬇ 31% (95% CI 17-43%) Diabetes Prevention Program Research Group NEJM 2002;346:393-403 p.Wednesday, March 21, 12
  • DPP Results To prevent one case of diabetes during a period of 3 years NNT (lifestyle): 6.9 [95% CI 5.4-9.5] NNT (Metformin): 13.9 [95% CI 8.7-33.9] Diabetes Prevention Program Research Group NEJM 2002;346:393-403 p.Wednesday, March 21, 12
  • Bridge Phase 1-2 week drug wash-out Unmasked to treatment assignments Group-administered version of Lifestyle Balance for allWednesday, March 21, 12
  • I: Lifestyle modification vs Metformin vs placebo P: 2766 O: Incidence Intention- of DPP of diabetes to-treat subjects over follow-up DPP Outcomes Study Trial Design Diabetes Prevention Program Research Group Lancet 2009;374(9702):1677-86Wednesday, March 21, 12
  • DPPOS protocol Intensive lifestyle group offered 2 group classes (each comprising 4 sessions every year) Metformin group continued Metformin 850 mg bid unless already with diabetes (HbA1c >7%)Wednesday, March 21, 12
  • Cumulative incidence of diabetes during three study phases Diabetes Prevention Program Research Group Lancet 2009;374(9702):1677-86Wednesday, March 21, 12
  • Cumulative incidence of diabetes remained lowest in lifestyle group 1 2 3 4 5 6 7 8 9 10 Years since DPP randomization Diabetes Prevention Program Research Group Lancet 2009;374(9702):1677-86Wednesday, March 21, 12
  • Diabetes Prevention ✔ Program (DPP) Diabetes Prevention Program Outcomes Study DPP Lifestyle Balance The DPP Lifestyle Change Program National Diabetes Prevention Program US ModelWednesday, March 21, 12
  • Lifestyle Balance http://www.bsc.gwu.edu/dpp/manuals.htmlvdocWednesday, March 21, 12
  • Lifestyle Balance http://www.bsc.gwu.edu/dpp/manuals.htmlvdoc Overview of strategies to achieve goals Professional resources Optional materials for participants 464 pages!Wednesday, March 21, 12
  • Copyright 1996; 2011 University of Pittsburgh The DPP manual and materials are made available to the public subject to the following Creative commons License: Creative Commons - Attribution-NonCommercial-ShareAlike 3.0. Accordingly, the manuals may be downloaded, duplicated, transmitted and otherwise distributed for educational or research purposes only, provided proper credits are given to the DPP Research Group. (Note that some of the materials may have incorrect formatting while undergoing revisions.) Use of any of the DPP Lifestyle materials herein for commercial purposes is strictly forbidden without the permission or license of the University of Pittsburgh.Wednesday, March 21, 12
  • Key Aspects of DPP Lifestyle Protocol Clearly defined weight loss and physical activity goals Diabetes Prevention Program Research Group. Diabetes Care 2002;25:2165-71Wednesday, March 21, 12
  • Physical Activity Goal Aerobic dance, bicycle riding, skating and swimming Min of 3x/week (at least 10 min per session) Maximum of 75 min of strength training can be applied toward goal Importance of lifestyle activities discussed; cannot be applied toward goal Diabetes Prevention Program Research Group. Diabetes Care 2002;25:2165-71Wednesday, March 21, 12
  • High CV risk: exercise tolerance test Sedentary: increase activity in 30-min increments over 5 weeks Active at baseline: not required to add further exercise (same 150- min weekly goal) Participants can be more active than minimum goal in absence of medical contraindicationsWednesday, March 21, 12
  • Key Aspects of DPP Lifestyle Protocol Individual case managers or “lifestyle coaches” Diabetes Prevention Program Research Group. Diabetes Care 2002;25:2165-71Wednesday, March 21, 12
  • Key Aspects of DPP Lifestyle Protocol Intensive ongoing intervention Initial core curriculum to achieve standardization of intervention Diabetes Prevention Program Research Group. Diabetes Care 2002;25:2165-71Wednesday, March 21, 12
  • DPP 16-session core curriculum 1 - Welcome to the Lifestyle 5 - Move Those Muscles Balance Program 6 - Being Active: A Way of 2 - Be a Fat Detective Life 3 - Three Ways to Eat Less 7 - Tip the Calorie Balance Fat 8 - Take Charge of What’s 4 - Healthy Eating Around You Diabetes Prevention Program Research Group. Diabetes Care 2002;25:2165-71Wednesday, March 21, 12
  • Self-monitoring fat and/or calorie intake Daily for first 24 wks of the study Given food scale & measuring cups/spoons Diabetes Prevention Program Research Group. Diabetes Care 2002;25:2165-71Wednesday, March 21, 12
  • Self-monitoring physical activity Daily for first 24 wks of the study Diabetes Prevention Program Research Group. Diabetes Care 2002;25:2165-71Wednesday, March 21, 12
  • DPP 16-session core curriculum 9 - Problem Solving 13 - Jump Start Your 10 - The Four Keys to Activity Plan Healthy Eating Out 14 - Make Social Cues 11 - Talk back to Negative Work for You Thoughts 15 - You Can Manage 12 - The Slippery Slope of Stress Lifestyle Change 16 - Ways to Stay Motivated Diabetes Prevention Program Research Group. Diabetes Care 2002;25:2165-71Wednesday, March 21, 12
  • Key Aspects of DPP Lifestyle Protocol Intensive ongoing intervention Supervised exercise sessions offered at least 2 times/week throughout the trial Diabetes Prevention Program Research Group. Diabetes Care 2002;25:2165-71Wednesday, March 21, 12
  • Key Aspects of DPP Lifestyle Protocol Intensive ongoing intervention Flexible maintenance program supplemental group classes, motivational campaigns and restart opportunities Diabetes Prevention Program Research Group. Diabetes Care 2002;25:2165-71Wednesday, March 21, 12
  • DPP After Core Curriculum Motivation 1 - Give Yourself Credit for 5 - If You Believe You Can’t Your Success Lose Weight 2 - How Do Successful 6 - The Fight Against Flab Weight Losers Do It? 7 - DPP Lifestyle Progress 3 - A Tough Day, A Better Summary Day 8 - Decision Balance 4 - What If the Scale Doesn’t Budge http://www.bsc.gwu.edu/dpp/manuals.htmlvdocWednesday, March 21, 12
  • Key Aspects of DPP Lifestyle Protocol Individualization through a “tool box” of adherence strategies Diabetes Prevention Program Research Group. Diabetes Care 2002;25:2165-71Wednesday, March 21, 12
  • http://www.flickr.com/photos/pasukaru76/4005076313/Wednesday, March 21, 12
  • http://www.sxc.hu/photo/337742Wednesday, March 21, 12
  • Key Aspects of DPP Lifestyle Protocol Materials and strategies that addressed the needs of an ethnically diverse population Diabetes Prevention Program Research Group. Diabetes Care 2002;25:2165-71Wednesday, March 21, 12
  • Key Aspects of DPP Lifestyle Protocol Materials and strategies that addressed the needs of an ethnically diverse population Diabetes Prevention Program Research Group. Diabetes Care 2002;25:2165-71Wednesday, March 21, 12
  • Key Aspects of DPP Lifestyle Protocol Materials and strategies that addressed the needs of an ethnically diverse population Diabetes Prevention Program Research Group. Diabetes Care 2002;25:2165-71Wednesday, March 21, 12
  • Key aspects DPP Lifestyle Protocol An extensive local and national network of training, feedback and clinical support Diabetes Prevention Program Research Group. Diabetes Care 2002;25:2165-71Wednesday, March 21, 12
  • Case Manager aka “Lifestyle Coach” 4-step Training Required reading Manual of operations, participant notebook, manual for contacts after Core, book chapters and journal articles Videotapes from previous lifestyle training programs Observation of centrally trained personnel Audio taped practice session and lifestyle resource core review http://www.bsc.gwu.edu/dpp/manuals.htmlvdocWednesday, March 21, 12
  • Group Lifestyle BalanceTM Materials http://www.diabetesprevention.pitt.edu/glbmaterials.aspx Diabetes Prevention Program Research Group. Diabetes Care 2002;25:2165-71Wednesday, March 21, 12
  • Diabetes Prevention ✔ Program (DPP) Diabetes Prevention Program Outcomes Study DPP Lifestyle Balance The DPP Lifestyle Change Program ✔ National Diabetes Prevention Program US ModelWednesday, March 21, 12
  • Challenges to the Translation of Prevention Programs in the Community David Marrero, PhD Screening is NOT routinely done to identify the patients most at risk for diabetes. Diabetes Prevention Summit July 12, 2011 Washington DC, USA www.joslin.org/docs/Summit_executive_summary_8.11.11.pdfWednesday, March 21, 12
  • Challenges to the Translation of Prevention Programs in the Community David Marrero, PhD There do NOT currently exist enough facilities in the US to adequately serve people where they Diabetes Prevention Summit to be identified as at-risk. July 12, 2011 Washington DC, USA www.joslin.org/docs/Summit_executive_summary_8.11.11.pdfWednesday, March 21, 12
  • Challenges to the Translation of Prevention Programs in the Community David Marrero, PhD The source of funding is an ever-present challenge. Diabetes Prevention Summit July 12, 2011 Washington DC, USA www.joslin.org/docs/Summit_executive_summary_8.11.11.pdfWednesday, March 21, 12
  • Challenges to the Translation of Prevention Programs in the Community David Marrero, PhD Our overall culture and environment does not support healthy lifestyle choices. Diabetes Prevention Summit July 12, 2011 Washington DC, USA www.joslin.org/docs/Summit_executive_summary_8.11.11.pdfWednesday, March 21, 12
  • Population-based Diabetes Prevention From the presentation of Dr. Ronald T. Ackermann www.allhealth.org/.../Ackermannpresentation--doc-1824.pptWednesday, March 21, 12
  • Partnered Approach for Prevention From the presentation of Dr. Ronald T. Ackermann www.allhealth.org/.../Ackermannpresentation--doc-1824.pptWednesday, March 21, 12
  • Group Delivery of DPP From the presentation of Dr. Ronald T. Ackermann www.allhealth.org/.../Ackermannpresentation--doc-1824.pptWednesday, March 21, 12
  • Group Delivery of DPP From the presentation of Dr. Ronald T. Ackermann www.allhealth.org/.../Ackermannpresentation--doc-1824.pptWednesday, March 21, 12
  • I: Brief counseling vs DPP-group intervention P: 92 with O: Group M: DM RF & differences in Clustered random CBG wt, chol, BP, randomized 110-199 mg/dL HbA1c trial Translating the DPP into the Community The DEPLOY Pilot Study (YMCA) Ackermann R et al. Am J Prev Med 2008;35(4):357-363Wednesday, March 21, 12
  • DEPLOY Pilot Study Body weight Intervention: ⬇6% (95% CI 4.7, 7.3) Control: ⬇2% (95% CI 0.6, 3.3) p<0.001 The YMCA: promising channel for wide-scale dissemination for low-cost approach Ackermann R et al. Am J Prev Med 2008;35(4):357-363Wednesday, March 21, 12
  • I: Enhanced usual care vs DPP-group intervention P: 301 O: Mean M: overweight/ FPG over 12 Randomized obese with FBS mos ff-up controlled 95-125 mg/dL adjusted for baseline glucose trial Healthy-Living Partnerships To Prevent Diabetes (HELP PD) Project Community health workers (volunteers with well-controlled T2DM) Katula JA et al. Diabetes Care 2011;34(7):1451-7Wednesday, March 21, 12
  • HELP-PD Project Intervention vs control Blood glucose -4.3 vs -0.4 mg/dL, p<0.001 Weight -7.1 vs -1.4 kg, p<0.001 Insulin -6.5 vs 2.7 uU/mL, p<0.001 HOMA -1.9 vs -0.8, p<0.001 Katula JA et al. Diabetes Care 2011;34(7):1451-7Wednesday, March 21, 12
  • Centers for Disease Control & Prevention (CDC) National Diabetes Prevention Program Public-private partnership of community organizations, private insurers, employers, health care organizations and government agencies http://www.cdc.gov/diabetes/prevention/Wednesday, March 21, 12
  • National Diabetes Prevention Program COMPONENTS Training: Recognition Program: Intervention Sites: Health Marketing: Increase Workforce sure Quality Deliver Program Support Program Train the workforce Implement a recognition Uptake that can implement program that will: Increase referrals to the program cost effectively. prevention program. a program registry. * Inagural partners: YMCA, USA and UnitedHealth Group http://www.cdc.gov/diabetes/prevention/Wednesday, March 21, 12
  • Diabetes Training & Technical Assistance Center (DTTAC) http://www.cdc.gov/diabetes/prevention/dttac.htm Master trainers will provide a fee-based, 2- day, face-to-face training for lifestyle coaches Curriculum adapted from the original DPP research materials for group delivery Training: Increase Workforce Online learning community at DTTAC Train the workforce website that can implement the program cost effectively. http://www.cdc.gov/diabetes/prevention/Wednesday, March 21, 12
  • Diabetes Prevention Recognition Program (DPRP) http://www.cdc.gov/diabetes/prevention/recognition/index.htm Organizations interested in offering the curriculum apply for recognition Why apply for recognition? Assure potential participants of quality Recognition Program: More likely to get health care provider referrals sure Quality CDC offers technical assistance Implement a recognition program that will: Insurance companies more likely to reimburse recognized programs a program registry.Wednesday, March 21, 12
  • National Diabetes Prevention Program COMPONENTS Training: Recognition Program: Intervention Sites: Health Marketing: Increase Workforce sure Quality Deliver Program Support Program Train the workforce Implement a recognition Uptake that can implement program that will: Increase referrals to the program cost effectively. prevention program. a program registry. * Inagural partners: YMCA, USA and UnitedHealth Group http://www.cdc.gov/diabetes/prevention/Wednesday, March 21, 12
  • Copier-ready Game Plan Tools for Patients 1. Small Steps. Big Rewards. Your GAME PLAN for Preventing Type 2 Diabetes 2. Who Is at Risk for Type 2 Diabetes and Pre-diabetes? 3. Walking ... A Step in the Right Direction 4. Food and Activity Tracker Download the free toolkit at http://ndep.nih.gov/publicationsWednesday, March 21, 12
  • Diabetes Prevention ✔ Program (DPP) Diabetes Prevention Program Outcomes Study DPP Lifestyle Balance The DPP Lifestyle Change Program ✔ National Diabetes Prevention Program ✔ US ModelWednesday, March 21, 12
  • !ank Y" http://www.endocrine-witch.netWednesday, March 21, 12