Fixes looks at solutions to social problems and why they work.
Oralia Barrios knew she'd gotten heavy, but she didn't realize how heavy until she went to the doctor last year. At 5-foot-2, she weighed 190 pounds. And her doctor at the Open Door Family Medical Center in Port Chester, N.Y., had bad news: her blood sugar was too high. Her A1c test showed that her hemoglobin level was 5.9, making her pre-diabetic.
We know how to prevent diabetes. But the U.S, medical system, with its twisted priorities, doesn't cover prevention.
"I heard that, and I went to pieces," she said. In 2002, her father had died of diabetes-related kidney failure. "He was diabetic for a long time," she said. "He had high blood pressure and was nearly blind. He suffered a lot — and we suffered with him." He was 52 when he died — 15 years older than Barrios is now.
Unlike her father, however, Barrios could get effective help. The YMCA in nearby Rye is one of 128 YMCAs across the country running the Diabetes Prevention Program. The Y coordinates patient groups at various sites, including at Open Door. Barrios' doctor sent her to Rolando Alvarez, a patient advocate at Open Door, who was starting a new group at the clinic for people who were pre-diabetic. It was a big commitment, Alvarez said — she would have to attend a weekly meeting for four months, and a monthly meeting for the rest of the year.
Barrios joined a Spanish-language group with four other women. They met around a conference table at Open Door. Alvarez used the Program's formal curriculum: What are healthy foods? How can I be active? What can I do besides eat to alleviate stress? How can I eat healthy food when I eat out ? How do I deal with setbacks? Participants were given a calorie and fat counter book, and had to record everything they ate.
A lot of it was conversation, though — the women helping each other. The most useful thing she learned, Barrios said, was how to say "no" in a way that was courteous but firm. Some of the women took Zumba or yoga classes together. Barrios started walking and biking, and learned to build more exercise into her job as a housekeeper. "I used to wait to collect all the towels and bring them upstairs together. Now I bring them upstairs one by one — I go up and down those stairs with energy."
Barrios crash dieted while she waited for the class to start, and lost 22 pounds. By three months into the class, she had lost 23 more, and her blood sugar returned to normal levels. She has now gained back some weight, but it's not because her diet is slipping — she's five months pregnant.
As anyone who has ever dieted knows, Barrios' journey is remarkable. Changing a lifestyle is very, very hard. But the journey of the Diabetes Prevention Program itself is just as remarkable. In 2002, the New England Journal of Medicine published results of a randomized controlled trial comparing two interventions designed to keep people at high risk for Type 2 diabetes from developing the disease. Participants who took the drug metformin had a 31 percent lower incidence of developing diabetes than people who took a placebo. But far more effective was a lifestyle-change program: participants met individually with nutritionists, exercise physiologists or behavioral psychologists weekly for six months, plus monthly classes afterwards.
This group had a 58 percent lower incidence rate — so effective that the study was stopped early, and all participants offered classes.
These were great results. But dozens, maybe hundreds, of papers on successful programs are published every year. "I'm around this type of research a lot: wow! this works! — and then it never goes anywhere," said Ronald Ackermann, director of the Center for Community Health at Northwestern University Feinberg School of Medicine. This one looked particularly unpromising. Hiring professionals for a year's worth of training is expensive. And it's preventive medicine that the U.S. medical system, with its twisted priorities, doesn't cover. And one-on-one programs can't reach a lot of people. There are 86 million prediabetics among Americans over 20. Of Americans over 65, only 23 percent are not prediabetic or diabetic. The problem is big — but this intervention seemed destined to be small.
Yet 11 years after the study was published, the Diabetes Prevention Program helped Oralia Barrios to climb out of the danger zone. More than 20,000 people have done the program, and it has the potential to reach enough people to make a significant difference in America's diabetes epidemic.
So how did the Diabetes Prevention Program grow? Here are the steps.
Discover what people should do. Type 2 diabetes, the kind that's epidemic, can be prevented most of the time by eating right and exercising. This was not a mystery; lack of knowledge wasn't the obstacle.
Get people to do it. The obstacle was getting people to actually make these changes — and the news in the study was that people can be helped to make them. Research published this year of those participants in the original showed that while there was falloff, there was falloff in every group — but the program group was still better off. In other words, the gains persisted.
The next big breakthrough came with the addition of the YMCA. Ackermann, then at Indiana University's School of Medicine, had worked with the Y in Seattle on a previous research project. In 2003, he and Dr. David Marrero began a study with two YMCA sites in Indianapolis. The control group got normal testing and counseling. At the other Y, the staff was trained in the Diabetes Prevention Program curriculum — adapted for use in group classes. After six months, the program participants had lost 6 percent of their body weight, while the control group members lost only 2 percent, and the differences lasted.
This study was proof-of-concept of several steps necessary for scale-up.
Get people to do it cheaply. Hiring health professionals to counsel patients individually was expensive — a patient's first year cost $1400. But the Y does it for $275 to $325. They hired good facilitators — who made a lot less money than nutritionists or psychologists — and then trained them in the Diabetes Prevention Program curriculum. Numerous studies have since shown that outcomes are the same.
Group classes that use the huge national network of YMCA have proven to be effective in fending off the disease.
Get lots of people to do it cheaply. The more significant savings came from switching to group classes — a way to treat many times the people for the same cost. We've long known that groups are effective at helping people lose weight — at every kind of behavior change, really. "The group model combines all these ingredients we know are essential and does it in a way that you get the support and assistance you need," said Michele Heisler, a professor of internal medicine and health behavior and health education, at the University of Michigan's School of Public Health.
Systematically get lots of people to do it cheaply. "The discussion was: how do we create a national program?" said Ackermann. "It wasn't that we thought it's not a good idea to do this in a church basement. GM and Ford wanted to do worksite groups. But we wanted a national approach."
The YMCA had the national structure to spread the program and train facilitators. It focuses on health, knows how to reach low-income people and has thousands of branches. Eighty percent of Americans live within five miles of a Y, and Y's are in or near many neighborhoods that suffer the most from diabetes. "If the Y couldn't do it — well, we couldn't think of another national organization," said Ackermann.
Today, YMCAs in 41 states run program group classes. Half meet at Ys, and the other half meet in places such as libraries, church basements and health centers.
Participants' average weight loss at the end of the year-long program is 6.1 percent of their body weight. But averages can mislead — a few successes like Barrios can distort them. Alvarez's first class was cancelled because not enough people enrolled. And in the second class he ran, only two of the seven participants met the goal of losing 7 percent of their weight and exercising 150 minutes per week.
The day I visited Alvarez's group, which was in its maintenance phase, talking about strategies for dealing with setbacks, only Juana Damián was there. (I spoke to Barrios later by phone.) "They get through the weekly classes fine," Alvarez said. "But with maintenance, they'd like to come but it's more difficult. Since its once a month, they might forget. And work will always come first."
Damián is his most consistent participant. She, like Barrios, lost a lot by crash dieting before the class began. She hasn't lost much more, though — one big reason is the stress of caring for her mother, who is paralyzed from a diabetes-related stroke. But the class has helped her maintain a loss that otherwise might have evaporated.
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Get someone to pay for it. A work in progress. The Y charges $429 for the program (there are scholarships) — but it should be free. Diabetes is an expensive disease. A 2010 report from UnitedHealth Group says that its average cost to cover a person with no chronic disease is $4,400 per year. For a diabetic with no symptoms, $11,700. With complications: $20,700.
Another study calculates the cost savings over 10 years if Medicare covered participation in the diabetes program and three to five percent of senior participated: $1.3 billion. Such coverage would also result in a million fewer diabetes cases over 10 years.
The American health system doesn't much care. Obamacare has brought piecemeal progress (see here and here) towards expanding and getting coverage for the program, but in general neither Medicaid, Medicare nor most private insurers cover prevention — although this is starting to change with Obamacare's Accountable Care Organizations.
In 2009, the Centers for Disease Control convened a meeting with diabetes experts, YMCA officials and representatives of various insurance companies to discuss what it would take to get coverage. The Y offered a deal: pay for performance. It proposed that insurers only pay when participants attend classes and lose weight. United Healthcare became the first to accept; now 28 different insurers cover the program. Sen. Al Franken has introduced a bill that would have Medicare cover the program as well.
"There is a change in the conversation nationally," said Jonathan Lever, vice president for health strategy and innovation at the YMCA of the USA. "For ACOs, this is attractive. Prevention is a topic. But it's not happening in a systematic way. We're knocking at the door. But the jury's still out on whether systems will align to make it possible."
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Tina Rosenberg won a Pulitzer Prize for her book "The Haunted Land: Facing Europe's Ghosts After Communism." She is a former editorial writer for The Times and the author, most recently, of "Join the Club: How Peer Pressure Can Transform the World" and the World War II spy story e-book "D for Deception."
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