Melinda Maryniuk, RD, MEd, CDE
When the results of the Diabetes Prevention Program (DPP) were released in 2002 showing the undisputed benefits of modest weight loss and exercise on diabetes prevention, there was initial excitement that such a simple, inexpensive solution to preventing diabetes had been found. However, efforts to translate the DPP into community settings have had only modest success. It is hard to attend a series of 12 classes. It is hard to lose weight and keep it off. The nearly 80 million Americans at risk for diabetes are not rushing to dietitians, exercise physiologists, health coaches and local YMCAs demanding to receive a program similar to that used in the DPP so that they can also decrease their risk for developing diabetes by 58%. Motivating people who do not have diabetes (even though they may be “at risk” for it) to make lifestyle changes to prevent diabetes remains a challenge. Furthermore, lifestyle programs are certainly not “simple”.
Thus, researchers at Massachusetts General Hospital in Boston had a very good idea. They wanted to see if overall success in effecting changes in lifestyle behaviors could be improved by targeting DPP interventions to those at the greatest risk. They tested the hypothesis that diabetes genetic risk testing along with a personalized 15-minute genetic risk counseling session can motivate the behavior changes necessary to prevent diabetes. Sure enough, those determined to be at highest risk reported that they were “much more/somewhat more” motivated to participate in the 12-week DPP program than the lower-risk participants (78.6% vs 43.8%). High-risk participants also reported that they were more likely to make lifestyle changes to prevent diabetes (85.7% vs 56.3%). However, the results from the randomized, controlled trial did not demonstrate a difference in outcomes. (The control group did not receive any genetic counseling, but did attend a 12-week lifestyle course promoting weight loss and increased exercise.) Attendance at the series of 12 classes was similar between all three groups (high-risk, low-risk and control), with the mean attendance rate being 6.8 ± 4.3 sessions attended. Only about 60% of the participants attended seven or more sessions (similar in all groups). Weight loss was similar between groups (8.5±10.1 lb) and only 30.6% (33 of 108) achieved ≥5% weight loss. Thus, genetic testing and awareness of one’s personal genetic risk do not significantly improve adherence to a proven diabetes prevention program.
So back to the original challenge. How do we reach those 80 million at risk? Attending a series of 12 classes is not high on most people’s list of “things to do,” even if it has been proven effective in warding off a serious disease. One of the most successful DPP translation efforts has been bringing the program to community-based YMCA programs and having the 12 classes taught by trained health coaches, which is less expensive than the health care providers/educators used in the DPP. However, people learn in a variety of ways and not everyone can attend or enjoys attending group sessions. Thus, it is promising to know that a variety of initiatives are being developed and studied that take the DPP lessons and are converting them to more accessible formats including personalized, interactive online “classes,” an approach combining classes accessible on a DVD along with phone calls from a coach as well as a cable television show. It is important to recognize that “one size does not fit all” when it comes to offering options to patients to facilitate lifestyle and behavior change. Lifestyle changes in this high-risk group may not be enhanced by genetic risk counseling, but offering “classes” in a wider array of flexible formats with personalized but remote coaching holds promise.
Melinda Maryniuk, RD, MEd, CDE
Director of Clinical Education Programs
Joslin Diabetes Center
Disclosures: Maryniuk reports no relevant financial disclosures.