Type 2 diabetes (hereafter referred to simply as “diabetes”) is a common and costly condition. In 2021, more than 38 million adults (11.6%) in the United States had diabetes (1). Significant health consequences of diabetes include cardiovascular disease, lower-extremity amputation, kidney disease, vision disability, and premature mortality (2). Prediabetes is precursory to diabetes and is defined as having a measure of A1C between 5.7 and 6.4%. In 2021, an estimated 97.6 million U.S. adults (38.0%) had prediabetes (1). Preventing diabetes through lifestyle change programs (LCPs) such as the National Diabetes Prevention Program (NDPP) and the Medicare Diabetes Prevention Program (MDPP) can improve cardiovascular health and reduce health care costs (3).
Mississippi consistently has among the highest rates of diabetes (14.4%) and prediabetes (36.5%) and is the only state in which every county is represented in the Diabetes Belt, a geographical region of the United States with the highest prevalence of diabetes (4). Mississippi has the fourth largest rural population (51.2%) and the highest percentage of Black residents (37.8%) of any state in the country (5); it also has persistently high rates of poverty (19.4%) (6). Implementing the NDPP through health care systems such as the University of Mississippi Medical Center (UMMC) may expand the program’s accessibility for high-risk populations and foster cost-effective lifestyle modifications (7–9).
In 2010, Congress mandated the Centers for Disease Control and Prevention (CDC) to disseminate the NDPP to communities throughout the United States. This 12-month LCP consists of 16 core sessions and 6 monthly maintenance sessions at a minimum. In 2016, the Centers for Medicaid & Medicare Services adopted the diabetes prevention program but required an extended model that included an 18-month maintenance phase, making the MDPP LCP a 2-year program. The UMMC received full CDC recognition as a provider of the NDPP in 2019 and became an MDPP supplier in 2020.
A retrospective chart review of the first cohort of MDPP participants at UMMC (n = 9) was conducted in December 2022. Data were extracted to describe changes in cardiometabolic risk factors after participation in the 2-year MDPP. Data extraction included a 1-year look-back period from the start of the MDPP (October 2019 to September 2020). Primary outcomes included a diagnosis of diabetes and changes in A1C. Secondary outcomes included changes in weight, BMI, blood pressure, and lipid profiles.
Patients were identified for the MDPP through the Prediabetes Registry in the UMMC’s Epic electronic health record system. A physical letter with information and a contact number was mailed to each patient’s home address. A staff person then made follow-up phone calls to each patient. Patients were eligible to participate in the program if they had a BMI >25 kg/m2 and an A1C of 5.7–6.4% within 12 months before enrollment and were Medicare beneficiaries. The first cohort began receiving the MDPP via telehealth in October 2020. Since enrollment, all patients have completed the 24-month LCP, which concluded in September 2022. Medicare was successfully billed for participation.
Case Presentations
Case 1
Participant 1 was a 77-year-old, married, Black female with a baseline BMI of 31.21 kg/m2 (weight 211 lb) and an A1C of 6.2%. Medical history included hypertension and dyslipidemia. She attended 31 MDPP classes and lost 31 lb (−14.7% of total body weight). The A1C measurements decreased to 4.8% at 12 months (−1.4%) and increased to 5.7% at 18 months (−0.5%). Total cholesterol decreased from 161 to 159 mg/dL, LDL cholesterol increased from 86 to 89 mg/dL, HDL cholesterol decreased from 58 to 54 mg/dL, and triglycerides decreased from 87 to 79 mg/dL.
Case 2
Participant 2 was a 70-year-old, widowed, Black female with a baseline BMI of 27.4 kg/m2 (weight 180 lb) and an A1C of 5.8%. Medical history included hypertension, neuroendocrine tumor with rectal carcinoid tumor, and premature ventricular contractions. She attended 51 MDPP classes and lost 6 lb (−3.3% of total body weight). No additional A1C values were recorded. One lipid profile was recorded; total cholesterol was 177 mg/dL, LDL cholesterol was 107 mg/dL, HDL cholesterol was 55 mg/dL, and triglycerides were 74 mg/dL.
Case 3
Participant 3 was a 76-year-old, married, Black female with a baseline BMI of 28.8 kg/m2 (weight 164 lb) and an A1C of 5.7%. Medical history included hypertension, hyperlipidemia, and hypothyroidism. She attended 48 MDPP classes and lost 37 lb (−22.6% of total body weight). A second A1C measurement was taken at 6 months and was 5.2% (−0.50%). One lipid profile was recorded; total cholesterol was 160 mg/dL, LDL cholesterol was 97 mg/dL, HDL cholesterol was 55 mg/dL, and triglycerides were 41 mg/dL.
Case 4
Participant 4 was a 77-year-old, married, Black female with a baseline BMI of 37.15 kg/m2 (weight 206 lb) and an A1C of 6.2%. Medical history included hypertension, hyperlipidemia, and hypothyroidism. She attended 32 MDPP classes and lost 23 lb (−11.2% of total body weight). The final A1C measurement was 5.9% (−0.30%). Total cholesterol increased from 188 to 193 mg/dL, LDL cholesterol increased from 94 to 101 mg/dL, HDL cholesterol remained steady at 81 mg/dL, and triglycerides decreased from 65 to 56 mg/dL.
Case 5
Participant 5 was a 71-year-old, single, Black female with a baseline BMI of 31.69 kg/m2 (weight 168 lb) and an A1C of 6.1% (prescribed metformin). Medical history included hypertension, hyperlipidemia, and interstitial lung disease. She attended 34 MDPP sessions and lost 9 lb (−5.4% of total body weight). The A1C measurement at 12 months was 5.8% (−0.30%). One lipid profile was obtained; total cholesterol was 206 mg/dL, LDL cholesterol was 119 mg/dL, HDL cholesterol was 62 mg/dL, and triglycerides were 125 mg/dL.
Case 6
Participant 6 was a 68-year-old, married, Black female with a baseline BMI of 35.15 kg/m2 (weight 192 lb) and an A1C of 5.9%. Medical history included hypertension and hypercholesterolemia. She attended 24 MDPP sessions and gained 2 lb (+1.0% of body weight). The A1C measurement remained unchanged at 5.9% 5 months post-enrollment. No lipid profiles were obtained for this participant.
Case 7
Participant 7 was a 69-year-old, married, Black male with a baseline BMI of 48.35 kg/m2 (weight 327 lb) and an A1C of 6.1%. Medical history included hypertension and hyperlipidemia. He attended 28 MDPP sessions and lost 42 lb (−12.8% of total body weight). The A1C measurement at 4 months post-enrollment was 5.7% (−0.40%). One lipid profile was recorded; total cholesterol was 149 mg/dL, LDL cholesterol was 74 mg/dL, HDL cholesterol was 43 mg/dL, and triglycerides were 158 mg/dL.
Case 8
Participant 8 was a 69-year-old, married, Black female with a baseline BMI of 22.3 kg/m2 (weight 134 lb) and an A1C of 6.0%. Medical history included hypertension and hypercholesterolemia. She attended 54 MDPP sessions and lost 1 lb (−0.7% of total body weight). The A1C measurement at 20 months was 5.7% (−0.30%). Total cholesterol decreased from 368 to 221 mg/dL, LDL cholesterol decreased from 281 to 107 mg/dL, HDL cholesterol increased from 68 to 106 mg/dL, and triglycerides decreased from 95 to 40 mg/dL.
Case 9
Participant 9 was a 75-year-old, married, White male with a baseline BMI of 30.71 kg/m2 (weight 226 lb) and an A1C of 6.1% (prescribed metformin). Medical history included hypertension, hyperlipidemia, and atrial flutter. He attended 32 MDPP sessions and lost 2 lb (−0.9% of total body weight). The A1C measurement at 11 months was 5.8% (−0.30%). At 11 months, total cholesterol had increased from 110 to 126 mg/dL, LDL cholesterol decreased from 51 to 44 mg/dL, HDL cholesterol increased from 43 to 54 mg/dL, and triglycerides increased from 81 to 141 mg/dL.
Questions
- 1.
Is the MDPP effective in decreasing the risk of diabetes?
- 2.
What are the potential factors related to MDPP participation and success?
- 3.
How does MDPP participation affect other cardiometabolic disease risk factors and conditions?
Commentary
Consistent with other studies, the majority of participants were female (n = 7, 77.8%) (10,11). Most of the cohort was non-Hispanic Black (n = 8, 88.9%). The median age was 73.4 years (range 68–77 years).
Participation in the 2-year MDPP was effective in decreasing the risk of diabetes among the first cohort of MDPP participants at UMMC. No participants developed diabetes during the observation period. At enrollment, the mean A1C was 6.0 ± 0.16%. Overall, a 0.3% reduction in A1C was observed among 8 participants (mean 5.7 ± 0.22%). One participant did not have a follow-up A1C measurement.
Collectively, the cohort lost an average of 22 ± 17 lb and reduced BMI by an average of 9.5%. The greatest weight reduction by a single participant was 42 lb, equivalent to a 12.8% reduction in body weight. The highest percentage of weight loss was 22.6%. The reasons for high rates of weight loss are unknown; however, based on observation, this cohort displayed high levels of group cohesion and social support, which has been shown to bolster outcomes in other weight loss studies (12,13).
The average number of sessions attended was 37 out of 54 sessions (68.5%, range 24–54 sessions). Seven of the nine participants (77.8%) were married, one was widowed, and one was single. Marital status appeared to have had a positive impact on LCP participation and outcomes. The participants who reported being unmarried lost 3.3% (participant 2) and 5.4% (participant 5) of their initial body weight, respectively. Married participants had losses ranging from 0.7 to 22.6%, and a single participant gained 1.0% of initial body weight. Findings reported by Baucom and Ritchie (14) encourage the participation of a companion in the NDPP to support participant retention and outcomes. Spousal support may have been a contributing factor to participant success in this MDPP cohort.
Participants also had other cardiometabolic health issues and medical problems. All nine of the participants had been diagnosed with hypertension and hyperlipidemia or hypercholesterolemia. There were no consistent trends among participants regarding their lipid profiles.
Clinical Pearls
This study reinforced the benefits of weight loss and BMI reduction for the prevention of diabetes in Medicare beneficiaries.
By the end of the 24-month LCP, none of the nine patients developed diabetes and none were taking metformin. For the two patients who started the study on metformin, the medication was subsequently deprescribed.
Primary care clinics should routinely seek resources from payers and other funding sources to support the delivery of the MDPP in resource-limited health care settings.
Duality of Interest
No potential conflicts of interest relevant to this article were reported.
Funding
This project was funded in part by the American Medical Association, the Mississippi State Health Department, the Centers for Disease Control and Prevention (award number NU58DP007397), and the Medical Student Research Program at the University of Mississippi Medical Center.
Author Contributions
L.E.P. and I.P.K. conducted the medical chart review and data extraction. L.E.P. and A.G. conceptualized the study and drafted the manuscript. I.P.K., B.D.C., J.H.B., T.K., and A.G. reviewed and edited the manuscript. B.D.C. analyzed the data. A.G. is the guarantor of this work and, as such, had full access to all the data reported and takes responsibility for the integrity of the data and the accuracy of the case report.
