In this article, Charles Alessi, MD, chief clinical officer for HIMSS International, details the importance of a global perspective in preventing diabetes.
As clinicians we find ourselves in an ever more challenging environment of managing non-communicable diseases. Faced with several challenges—including the complex management of non-communicable diseases, the difficulty of optimal care given the levels of multimorbidity, and the burdens associated with increased documentation requirements—clinicians are hindered from welcoming diabetes initiatives.
Examining diabetes prevention and care management from a global perspective, however, can create new opportunities for patient care.
Globally, an estimated 108 million adults were living with diabetes in 1980. By 2014, this figure had almost quadrupled to 422 million, an increase in global prevalence from 4.7% to 8.5% in 34 years.
Type 2 diabetes, estimated to make up around 90% of the total, is potentially preventable if we can reduce modifiable risks such as increasing obesity, obesogenic environment and unhealthy lifestyles.
Diabetes prevention programs should reach out at scale to individuals at risk using consistent, evidence-based parameters of eligibility. Interventions should ideally use personalized behavioral digital approaches, either as the only option or as part of a package. A package option could also include more traditional face-to-face offerings, both one-to-one and/or on a group basis.
To help individuals achieve a healthy weight, prevention programs should deliver lifestyle interventions and dietary and physical activity recommendations while, in conjunction, behavioral insights need to influence uptake and retention, driving sustained lifestyle changes.
There are also lessons we can learn from what works in other countries, encapsulated in the following.
Using electronic medical records and electronic health records to identify appropriate cohorts is the route most often taken, although this can be supplemented by opportunistic case findings. What adds value here is engaging physicians in this exercise, as positive reinforcement from clinicians known to the participant can increase the chance of program uptake.
Some jurisdictions have managed more than 50% completion of diabetic prevention programs by participants. There is no doubt that sensitive and targeted financial incentives have a part to play here. For example, differentially incentivizing each intervention within a program with later interventions attracting more resources better encourages providers to design programs people continue to engage in. A focus on these approaches, rather than mandating a strictly defined playbook, will also encourage provider flair and innovation around delivery.
The behavioral approach utilized needs to be designed to be attractive to the individuals selected to form part of the program. This may seem self-evident but is all too often forgotten. Ethnographic research shows that taking strictly biomedical approaches do not work as well as talking to people in language that addresses their aspirations. Furthermore, sensitivity to place and ethnicity is also important, as is having health workers coming from similar backgrounds as participants. Ideally national or regional policies to manage obesogenic environments and other risk factors, such as approaches to manage smoking, can supplement these approaches.
Personalized digital behavioral approaches work better than broad-brush health campaigns. One size fits one rather than one size fits all could be a convenient way of expressing this. Digital approaches could include a series of apps, wearables and online support with built-in monitoring. What also seems to work is adopting a single health and wellness portal where the program is a distinct element and discreet apps around exercise, weight and nutrition are deployed. The use of patient groups to curate and manage patient data has also been successful in increasing people’s comfort around the use of data.
The use of “affinity points” to drive healthy behaviors has been a useful adjunct and deployed successfully. Affinity points are rewards points similar to the ones you get from airlines but designed around the programs. For example, “diabetes prevention points” could be exchanged for other ones from retailers most favored by participants. Affinity points have the advantage of being loved by most people and seem to be disproportionately taken up by the lower socio-economic groups that tend to figure more prominently in the cohorts of high-risk populations.
The American Medical Association is leading the way in developing a diabetes prevention program and we at HIMSS will be with them on this journey. Both organizations have the interests of the physicians and the patients as one of their primary drivers. Successful diabetes prevention will help all of us, not only doctors who will have fewer patients with diabetes, but also participants who will lead healthier and more fulfilled lives.
James L. Madara, MD, AMA CEO
Laurie McGraw, AMA senior vice president, Health Solutions
Michael Hodgkins, MD, AMA chief medical information officer
David Nash, MD, founding dean, Jefferson College of Population Health
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