Caroline Richardson, M.D., is the Dr. Max and Buena Lichter Research Professor of Family Medicine at the University of Michigan. Her work focuses on preventing diabetes and promoting physical activity through low-cost programs and tools, including a line of research on wearable technology that well predates the advent of FitBits, iPhones, and Apple Watches. Here, Dr. Richardson discusses how her research is informing some key policy and practice issues related to diabetes prevention on a national scale, with an eye toward the ambitious goal of one day eliminating adult onset diabetes altogether.
Why is diabetes such a huge public health issue, and what can be done about it?
Right now, Type 2 diabetes, also called adult onset diabetes, is the single most expensive diagnosis in our health system. With more than 3 million new cases diagnosed each year in the U.S., it’s massive in scale, and seems to be getting worse no matter what we do, even though the majority of cases are preventable with appropriate diet and exercise interventions. If we could significantly reduce the incidence of Type 2 diabetes, it would have a dramatic impact on mortality and morbidity, and healthcare costs.
Unfortunately, very few people at risk for diabetes are engaged in diabetes prevention programs, which focus on healthy weight loss through diet and exercise modifications. Behavior change is hard, and we have a huge hill to climb in tackling diabetes. But I’m optimistic we’re making headway by building on the research on prevention from the past couple decades, as well as through expanded access to interventions that work through online dissemination and the extension of new technologies.
What are some recent advancements in diabetes prevention?
One big policy development is that as of April 1, Medicare began paying for eligible people to participate in Diabetes Prevention Programs recognized by the Centers for Disease Control and Prevention (CDC), which have been proven to prevent or delay Type 2 diabetes. Our group has been studying the effectiveness of the DPP curriculum in various formats for some time, and the Veterans Administration (VA)’s decision to adopt the DPP program nationally was done in part because of results we presented that showed DPP works better than the VA’s previous program [Richardson previously led the VA Diabetes Quality Enhancement Research Initiative, charged with coordinating implementation research related to diabetes and diabetes prevention for the VA nationally.]. And the VA has made the program available to everyone under VA care, not just those with diabetes or prediabetes (when someone’s high blood sugar puts them at risk for developing diabetes), which should go a long way for prevention.
What benefits do online coaching programs have, particularly for weight loss and diabetes prevention?
The main advantage of online programs is that they’re scalable, they’re cheap, and they allow far more people to participate in effective programs who otherwise couldn’t access them. Our analysis across 18 studies that evaluated online diabetes prevention programs found that they consistently resulted in clinically significant amounts of weight loss, as well as improvements in blood sugar levels in patients with prediabetes, and that the programs based on the DPP curriculum worked best of all.
Our group has been studying one of the first online CDC-certified DPPs among a group of veterans who live far away from their closest VA Medical Center, and we’re finding it works as well as if not better than the in-person DPP program, even among individuals who are older, live in more rural settings, and have other chronic conditions, including mental illness.
If there’s engagement with a community of peers or coaches, even if it’s a virtual one, that also makes a big difference in how well these programs work. Research we’ve done looking at online exercise intervention programs has found that those that allowed participants to communicate with each other online had people sticking with the program longer, and had greater engagement among participants – a big problem with online interventions, obviously. So even having a small effect on staying in the program longer and being more engaged makes a big difference.
There are so many people who need these kinds of programs, and access can be a huge barrier – these online programs have huge potential for large-scale implementation and dissemination of diabetes prevention interventions. At this time, Medicare and the VA are covering only in-person DPP, but the evidence is growing that the online programs are just as effective, and we’re continuing to study what works best and how to get it out to more people.
What are you working on with wearable devices and other technologies?
I started using wearable technology in physical activity research about 20 years ago, when those kinds of devices were comparatively primitive, expensive, and difficult to use. Over the years I’ve been involved in various trials that looked at how wearables might benefit people living with heart disease, diabetes, lung disease, and more (and sometimes more than one condition at the same time), as well as how these devices could help healthy people stay healthy, including an ongoing study of boosting physical activity in returned veterans. With this technology becoming so much more useful and less expensive, programs that work can be disseminated far more quickly and broadly than in the recent past, and of course people can find community and motivation toward common goals around these technologies much more easily too.
Glucose monitoring is another exciting area where technology has the potential to make a big impact in prevention and improving quality of life. Continuous glucose monitoring to date has been used primarily for Type 1 diabetes (most often diagnosed in young people), and it’s very expensive and complicated. Now we have a new generation of continuous glucose monitors that are easy to use, inexpensive, don’t need to be calibrated, and don’t require a needle stick. We’re doing some pilot studies with people with prediabetes to see if these devices can offer useful feedback on dietary choices and their effect on blood sugar – this may offer the ability to deliver remote-sensored interventions that would be cheap and scalable around weight loss, diabetes prevention, and management of Type 2 diabetes.
What are you hoping to achieve through these programs?
Health services research is all about finding ways to get what we know that works disseminated with fidelity in a way that actually changes population-level outcomes at a reasonable cost. The big vision is: we really don't need to have Type 2 diabetes at all. It’s preventable. But changing population-level incidence of diabetes is difficult when so few people have access to the support and tools they need to prevent it, and when the environment we live in so readily promotes obesity. We have a lot more work to do to make it easy and effective for individuals to engage in a diabetes prevention-focused lifestyle intervention, but the payoff has the potential to be enormous for the health system and for public health.