The government plans to create a diabetes prevention program for Medicare and Medicaid beneficiaries with prediabetes. Sounds good, but the program may well hurt more people than it helps.
The new program will be called MDPP, or Medicare Diabetes Prevention Program. The program is not new, but this is the first time Medicare will be paying for it and supervising it.
MDPP will consist of 16 sessions, mostly training on diet and exercise. It sounds like people will be getting useful support, but for what?
The Center for Medicare & Medicaid Services (CMS) proposal rarely mentions the words “glucose” or “blood pressure.” It’s nearly all about weight loss. People will have to weigh in at every session. There is no provision for testing of HbA1c levels or even blood pressure checks.
Except for a few mentions, you will search in vain through the dozens of pages of regulations for the terms HbA1c or fasting blood sugar. People will have to have numbers in the prediabetes range to qualify for services. From then on, it’s mainly about weight. If you want to read the report, you can see it here.
Why is a weight-loss program pretending to be a diabetes program, and what’s wrong with that? CMS wants hard data, and the easiest data to get is weight. No lab tests, no professional examination. Just step on a scale.
But weight is not diabetes. Roughly 10% to 20% of people with Type 2 are not heavy, and most heavy people do not get diabetes.
Yes, weight loss is often accompanied by lower glucose numbers. Dr. Roy Taylor showed that a very-low-calorie diet could reverse Type 2. Eating a low-carb diet while exercising more will likely lower your weight in the short-term and improve your sugar levels.
But is it the weight loss that lowers sugars, or is it the behaviors that produce weight loss — eating better, moving more, reducing stress? More likely the latter, since we know from bariatric surgery data that diabetes often disappears before weight is lost.
Well, maybe they’re using weight loss as a tool to measure people’s behavior. What’s wrong with that? Plenty.
• Having to weigh in every session will keep some people from participating at all.
• The focus on weight distracts from more meaningful markers like blood sugar and blood pressure and more important behaviors like relaxation, sleep, and exercise.
• Weight is nearly always (90% to 95% of the time in most studies) regained after the intervention stops.
• People do very unhealthy things to lose weight — remember the grapefruit diet? People who already have diabetes sometimes stop taking their insulin to lose weight. Weight loss is a poor marker for healthy behavior.
• People who do not lose sufficient weight, or who regain it, will quit or be pushed out. The guidelines clearly state,” “Suppliers shall furnish ongoing maintenance sessions to [patients] who have achieved and maintained the required minimum weight loss percentage.” So if you don’t keep your weight down, you’re out of the program.
Not only that, but if a program’s participants don’t maintain an average 5% weight loss, the program will lose its funding. Imagine the pressure to lose that patients will be under!
The injustice hits thin people too. If your BMI is 25 or less, you don’t qualify for the program at all, even if you do have prediabetes. Some people who could really benefit would be excluded.
It’s not like this approach hasn’t been tried before. It’s a close copy of the Look AHEAD (Action for Health in Diabetes) trial, which gave intensive support to people with Type 2 diabetes in order to prevent heart disease and strokes. As with MDPP, the focus of Look AHEAD was on weight loss. Weight-loss guru Dr. Rena Wing was one of the people in charge, and people got a lot of coaching time as individuals and groups.
Look AHEAD was halted early, because cardiovascular disease and death rates were the same in the intervention group as in the control group (although certain complication rates were lower). This happened despite the fact that most participants maintained a weight loss of about 5%. So a 200-pound participant would be expected to lose 10 pounds, with frequent clinic visits and telephone support. What kind of cost/benefit ratio is that?
My take on Look AHEAD, which seems verified by the statistics, is that the focus on weight loss led to people receiving advice (especially a low-fat diet) that wasn’t best for their diabetes. I’m afraid the MDPP will take people down the same road.
How is it that after decades of research showing that long-term weight loss is unsustainable for the vast majority of patients, we will now have a nationally funded “Diabetes Prevention Program” that aims primarily for weight loss? Can we try something else?
MDPP could become a useful program if they dropped the weight-loss approach and instead, perhaps, did fingerstick glucose checks or pedometer data for exercise. Maybe they should check the occasional blood pressure, too. That might cost $5 per session more, but you wouldn’t be intimidating patients and sending them on the wrong track. You wouldn’t be turning people into diet junkies when they need to be learning self-care.
I encourage you to contact the Centers for Medicare & Medicaid Services at 7500 Security Boulevard, Baltimore, Maryland 21244-1850, to let them know what you think of this program. You can comment online on the proposal at this page. The contact link is near the top. Contact us too with a comment.