Richard Smith: National programmes to prevent diabetes

Richard SmithEurope has started 187 programmes to prevent diabetes, but fewer than 10 survived to the end of funding, said Peter Schwarz from Dresden, at the World Congress on Prevention of Diabetes in Madrid earlier this month. Of the 150 million people in Europe at risk of diabetes only a very few are reached by prevention programmes. Australia had a national programme, but it has been stopped. The United States has developed a programme, but at the moment reaches only some 10 000 of the 79 million at high risk. Yet we know a lot about how to prevent diabetes.

A series of randomised trials have shown that if people with prediabetes lose weight, eat a healthier diet, and exercise more then they more than halve their chance of developing diabetes in the next year. Indeed, a Lancet study shows that if people can control their weight, reduce their intake of total and saturated fat, increase their intake of fibre, and exercise more then they have almost no chance of developing diabetes.

These studies are, however, efficacy studies—those conducted in ideal circumstances—and the difficult challenge is to climb what Ann Albright from the US Centers for Disease Control (CDC) called “the stairway to heaven.” The classic stairway is an ascent from basic science through efficacy studies, effectiveness studies, efficiency, availability, and distribution. Effectiveness studies are trials of whether the intervention will work in the real as opposed to ideal world, and the way I always remember is through the saying that “Efficacy is what works at the Sloan Kettering, effectiveness is what works in Kettering.”

Basic science and efficacy studies are the territory of researchers, whereas effectiveness and efficiency studies might be called “translation research.” Finding ways to increase the efficiency of the intervention, make it available, and distribute it to everybody is the job of managers and policy makers.

Albright and others have identified sevens steps that they consider essential for creating a sustainable national programme to prevent diabetes. They are: effective partnerships and coordination; technology; a business model that ensures that the programme can be paid for; participant engagement; quality assurance; policies for growth and sustainability; and continued testing and development of the models to expand the reach of the programme.

The programme, believes Albright, probably needs to be developed outside of the traditional health system, not least because a programme delivered by medical professionals will probably be unaffordable. The best way to prevent diabetes is to create an environment in which healthy eating and physical activity are the norm, which clearly depends on many groups—“the whole of society and whole of government” approach advocated by WHO. But the meeting in Madrid concentrated on individuals at high risk, and many different organisations are needed for this as well. Training, quality assurance, an intervention site, and marketing are all needed, and the US programme brings together many organisations backed up by CDC. “We don’t agree all the time,” said Albright, but there is a joint aim.

Training of lifestyle counsellors is delivered, for example, by Emory University in Atlanta and other groups, but CDC sets standards and approves the curriculum. But the assumption that “if you build it they will come,” is sadly wrong, said Albright. Work is needed to encourage growth in the number of programmes and to get people to join and complete programmes.

The UnitedHealth Group (my employer, see conflict of interest statement below) is one of CDC’s major partners, and Tim Koehler, a general manager from the company, described the programmes that United has developed and is developing. One programme involves identifying people at risk through analysing claims data, encouraging them to come for a definitive test, and then persuading them to enter a group programme of lifestyle changes delivered by the YMCA, which has centres right across the country. This programme costs about $400 per head compared with $1500 per head in the efficacy trial which used individual counselling and yet has been shown in trials to produce equally good results. At $400 per head an organisation—perhaps an insurance company, a government body, or a private company that covers its employees health costs can expect a positive return on investment within a year or so because of avoiding or delaying the costs of managing patients with full diabetes and its complications.

An effective programme depends on having technology at the heart of it that will cover identifying those a risk, reaching out to them, encouraging them to join and stay in programmes, providing call centre support, reporting on outcomes, and managing the finances.

“You’ll fail if you don’t have somebody like Tim,” said Deneen Vojta, a physician who works for the UnitedHealth Group, emphasising that creating a successful national programme is more of a management than a medical problem. Programmes need constant development, said Vojta, if it’s going to be possible to cover all those at risk. One experiment that Vojta has led is to use reality television, a professionally made television programme of people trying to change their lifestyles, supported by social media. A clip of the programme can be seen at, and a televised request for 300 people to enter a trial led to recruitment in just two weeks. Preliminary results suggest that the combination of the programme and social media can achieve results that are nearly as good as in the original efficacy studies.

Some in the audience asked whether encouraging organisations to create individuals to join them was enough and whether the US government shouldn’t legislate. For now, answered Albright, enough organisations are joining in, but legislation might be needed. Presumably legislation would put an onus on health payers and providers to offer a preventive programme to all those at risk.

But is this US view of the world applicable in other parts of the world? Schwarz told of the failures in Europe, but said how the OECD emphasises the economic benefits from prevention. Although no expert on diabetes prevention, I presented at the meeting a survey I had conducted of colleagues in China, India, Mexico, Nigeria, South Africa, Guatemala, Bangladesh, Peru, and Tunisia of their views on diabetes prevention. Rather to my surprise, most of them said that their countries had national programmes to prevent diabetes, although in many cases they are simply plans, have been only partially implemented, and lack financial support.

The respondents thought that most of the steps identified by Albright and colleagues were important, although they placed less importance on technology—perhaps thinking of the difficulty of implementing large scale information technology projects in low and middle income countries (or any country, come to that). Although they thought the steps important, they reported that most were not present in their national systems at the moment, but should be possible.

In open comments they emphasised the importance of political leadership, bringing together and working across fragmented health systems, and including the prevention of other non-communicable diseases alongside programmes to prevent diabetes.

Although this was the seventh world congress on preventing diabetes, there is clearly a very long way to go when most programmes in Europe have failed, the US system has reached less than 0.001% of those at risk, and most programmes in low and middle income countries exist on paper, but not in reality. Perhaps there will be progress to report at the next congress in Norway in 2014.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.

Competing interest: RS is employed by the UnitedHealth Group, which, as described in the blog, is one of the companies working on diabetes prevention in the US. He also has shares and share options in the company. He does, however, run a philanthropic programme for the company in low and middle income countries and is unlikely to benefit directly from any expanded success of the United diabetes programme, and the share price is unlikely to be affected because the diabetes work is such a small part of the $120 billion company.