“Let’s prevent diabetes” – the case for a national diabetes prevention program for the high risk We We We We

can can can can

prevent prevent prevent prevent

traffic deaths – and we do head injuries – and we do drownings – and we do type 2 diabetes – why don’t we?

For decades Australia has led the way in large-scale approaches to the prevention of preventable illnesses. It is almost 10 years since the first international randomised controlled trials reported that we can prevent the development of type 2 diabetes in the high-risk population. Despite the COAG National Reform Agenda funding decision in 2007, Australia has not yet established an effective system to prevent type 2 diabetes in the high-risk population.

Background Diabetes is Australia’s fastest growing chronic disease. Around 1.7 million Australians currently live with diabetes (known and diagnosed) and a further 275 Australians develop diabetes every day. Type 2 diabetes represents the vast majority of diabetes in Australia (85-90per cent) and has been called the epidemic of the 21st century. Of all the people who develop type 2 diabetes, about 50per cent come from the high-risk population and the remaining 50 per cent come from the general (low-to-intermediate-risk population) – so if we want to prevent type 2 diabetes, we need to have a high-risk prevention program operating in conjunction with community wide, all of population initiatives An estimated two million Australians have pre-diabetes where they have abnormal glucose metabolism and are at high risk of developing type 2 diabetes. Diabetes is a serious condition and the potential complications include heart disease, stroke, blindness, limb amputation, kidney failure and erectile dysfunction. Yet most Australians are less concerned about diabetes than most other conditions and underestimate their risk of developing it.

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Individual risk factors for type 2 diabetes include:



Overweight and obesity Low physical activity levels A family history of type 2 diabetes A history of gestational diabetes Age (being older than 40 or older than 25 for some black and minority ethnic groups).

In addition, people from the following communities are particularly at risk: those of South Asian, African-Caribbean, black African and Chinese descent and those from lower socioeconomic groups (NICE, 2011). The more risk factors someone has, the more likely they are to develop diabetes (Harding et al. 2006). The AusDiab study (Dunstan et al. 2002; Barr et al. 2005) estimated that 16.3per cent of adult Australians are at high risk of developing type 2 diabetes because they already have abnormal glucose metabolism. Following the COAG National Reform Agenda process in 2007, the Australian Government funded the development of the Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK) to identify an individual’s risk of developing type 2 diabetes. Those with a risk score of ≥12 on the AUSDRISK are considered to be high-risk. This means we don’t need a blood test or invasive procedure to conduct simple community based and opportunistic screening to identify those very likely to be at high risk. Recent results from the Victorian WorkHealth program using the AUSDRISK tool indicate that 23per cent of the workforce is at high risk of developing type 2 diabetes.

“Proven” We know that type 2 diabetes can be prevented or delayed through lifestyle intervention. Numerous international randomised controlled trials have demonstrated that we can prevent the progression from pre-diabetes to type 2 diabetes by using structured lifestyle behaviour change programs (Knowler et al. 2002; Pan et al 1997; Tuomilehto et al. 2001; Saaristo et al. 2007; Uusitupa et al. 2003; Absetz et al. 2009; Ackermann et al. 2008). This lifestyle intervention approach to type 2 diabetes prevention has been shown to be even more effective than drug treatment in clinical trials (Knowler et al. 2002; Gillies et al. 2007) and seems to have a lasting impact at least several years following the active intervention (Lindstrom et al. 2006). The Greater Green Triangle Diabetes Prevention Project (Laatikainen et al. 2007; McNamara et al. 2007) was the first evidence-based implementation project in Australia and demonstrated success in a controlled setting in a regional population. Cost effectiveness studies and community-based evaluations of these programs have concluded that diabetes prevention programs for high-risk groups are cost effective (Pan et al. 1997; Colagiuri et al. 2003; Eddy et al. 2005; Herman et al. 2005; Palmer et al. 2004; Gillies et al. 2008; Vos et al. 2010). PAGE 2

Despite there being strong evidence to implement proven type 2 diabetes prevention programs, diabetes prevention for high-risk groups has not been prioritised in the current national health policy agenda in Australia; there are several consequences of not including this as a priority, including substantial personal, healthcare and societal costs, particularly given the long-term consequences of diabetes and its escalating incidence. According to the DiabCost study (Colagiuri et al. 2003) in 2003 the average total health costs for an individual with type 2 diabetes was $5360 per year. If an individual had macro and micro-vascular complications, the costs were on average 2.4 times higher than for those without complications ($9625 vs. $4020).

“Possible” Diabetes prevention in Victoria Following the COAG National Reform Agenda process in 2007, the Life! program was funded by the Victorian Government with Diabetes Australia – Victoria as the lead agency and fund holder. The Life! program has seen the statewide implementation of evidence-based, lifestyle behaviour change interventions to reduce the risk of progression to type 2 diabetes for people who are at high risk. This program has been successfully implemented and after just four years this program has:





Established a statewide prevention system for those at high risk of type 2 diabetes in Victoria Trained and certified 375 health professionals in type 2 diabetes prevention through a twoday training program with regular follow-up Accredited prevention course provider organisations and contracted 137 health services and providers (private and public) to be in the business of prevention and provide prevention courses Established an effective Riskline (like the Quitline) which has received thousands of calls from people wanting to understand their risk and participate in prevention courses Conducted successful social marketing and communications activities to help people understand the seriousness and risks of type 2 diabetes and create urgency and a strong call to action for people to participate in a prevention course Generated over 26,000 referrals to the program Assigned more than 19,500 people at high risk to prevention courses Achieved a significant reduction in the modifiable risk factors that translates to a 40per cent reduction of risk

This demonstrates that successful implementation can be achieved. If the lessons learned in Victoria are now implemented nationally, then all Australians at high risk of type 2 diabetes can have access to evidence-based prevention. The Life! program comprises three interventions: a group-based intervention (Life! course), telephone health coaching and an Aboriginal and Torres Strait Islander program. The main intervention, the Life! course, is an intensive community based lifestyle behavior change program developed from the evidence-based Finnish Prevention Program (Uusitupa et al. 2003) and the Greater Green Triangle PAGE 3

Diabetes Prevention Program (GGT DPP) (Laatikainen et al. 2007). Centring on health psychology theories which focus on behaviour change, including the self-regulation theory and Health Action Process Approach (HAPA) model (Schwarzer & Fuch 1995) and the use of SMART goals (Absetz et al. 2009), participants are encouraged to work towards adopting a healthy diet and active lifestyle to reduce their risk of developing type 2 diabetes. The intervention consists of six structured group sessions of 1.5–2 hours in duration in groups of 6–15 participants. The first five sessions are conducted fortnightly, with the sixth and final session held six months after session five. As a means to reduce their risk of developing type 2 diabetes, participants are supported to achieve five program goals:



No more than 30 per cent of energy from fat No more than 10 per cent of energy from saturated fat At least 15g/1000kcal fibre At least 30 minutes of moderate physical activity each day At least 5 per cent weight reduction

Translation of a diabetes prevention program to a national scale Components of a NATIONAL DIABETES PREVENTION PROGRAM

Prevention Workforce

Quality Assurance and Development

Capacity building through Facilitator Training

Implement an evaluation program that will assure quality and optimise outcomes for further program development

Intervention Delivery with Service Provider Organisations Develop provider network and build infrastructure to implement program

Applied Social Marketing and Communication Raises awareness of diabetes prevention and increase referrals to program

In Victoria, the WorkHealth program has provided over 500,000 workers with a workplace-based health check in the past four years. These health checks involved screening workers for type 2 diabetes using the AUSDRISK diabetes risk assessment. As mentioned earlier, WorkHealth found that 23 per cent of workers were at high risk (AUSDRISK score ≥12) of developing type 2 diabetes (Victorian WorkHealth report 2011). If the Victorian workforce experience translates to others states and territories it would mean more than 2.5 million workers across Australia are at high risk of developing type 2 diabetes (see Table 1).

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Table 1: Predicted number of workers at high risk of developing diabetes in each state/territory State NSW Vic QLD SA WA Tas NT ACT TOTAL

Total employed persons aged ≥20 years* Number of workers found at high risk** 3,399,800 792,153 2,725,600 635,065 2,175,900 506,985 771,400 179,736 1,194,400 278,295 215,600 50,235 113,100 26,352 196,000 45,668 10,791,800 2,514,489

*Data: Total employed persons in each state/territory Australia aged ≥20 years old as of April 2012, Australian Bureau of Statistics. **Based on Victorian WorkHealth data that 23.3 per cent of workers are at high-risk (AUSDRISK score ≥12) of developing type 2 diabetes. Data reported for 400,000 workers in Victoria who received a WorkHealth check (from July 2009- October 2011).

National program costs Based on the Life! program, the average cost of delivering a high-risk prevention course would be $400 per person. Assuming that 1,257,245 individuals across Australia participated in a course over four years (based on the assumption that 50 per cent of individuals at high risk would participate in a course), this equates to $502,897,880 for the delivery of a lifestyle modification course (Table 2). Taking into account funding for coordination, leadership, training, accreditation, program materials and social marketing and communications, the cost of a national program over four years would be approximately $580 million (Table 3).

Table 2: Predicted course delivery costs by state/territory per year State NSW Vic QLD SA WA Tas NT ACT TOTAL

Number of workers at high-risk 792,153 635,065 506,985 179,736 278,295 50,235 26,352 45,668 2,514,489

Number of persons participating in program per year* 99,019 79,383 63,373 22,467 34,787 6279 3294 5709 314,311

Cost of course delivery per year ($)** $39,607,670 $31,753,240 $25,349,235 $8,986,810 $13,914,760 $2,511,740 $1,317,615 $2,283,400 $125,724,470

*Assuming 50 per cent of individuals at high risk will participate in a lifestyle modification program delivered across 4 years. **Delivery cost of diabetes prevention course $400 per participant PAGE 5

Table 3: Estimated cost of a National high-risk diabetes prevention program over 4 years Item Delivering the course Coordination, leadership, training, accreditation, program materials Social marketing and communications TOTAL

Cost $502,897,880 $32,000,000 ($1 million allocated per state org per year) $48,000,000 ($1.5 million allocated per state org per year) $582,897,880

“Powerful” The number of “cases” prevented: The US Diabetes Prevention Program demonstrated that 58 per cent of cases of type 2 diabetes can be prevented. Therefore, if 1,257,245 individuals participate in a national diabetes prevention program over four years and assuming 58 per cent of cases will be prevented, 729,202 cases of type 2 diabetes will be prevented or delayed. Based on real-world Life! program results, if 1,257,245 individuals participate in a national diabetes prevention program over three years and assuming 37 per cent of cases will be prevented, 465,181 cases of type 2 diabetes will be prevented or delayed. It has been estimated that lifestyle modification in individuals with pre-diabetes would result in a reduction in lifetime healthcare cost by approximately $1087 per person (Palmer et al. 2004). Assuming 1,257,245 people participated in a lifestyle modification program, this equates to a saving of $1,366,624,989 in the Australian healthcare setting.

References National Institute for Health and Clinical Excellence (NICE). (2011). Preventing type 2 diabetes: population and community-level interventions in high-risk groups and the general population: NICE Public health guidance. NICE: London. Harding AH, Griffin SJ, Wareham NJ. (2006). Population impact of strategies for identifying groups at high risk of type 2 diabetes. Prev Med. 42(5):364-8. Dunstan DW, Zimmet PZ, Welborn TA, De Courten MP, Cameron AJ, Sicree RA, et al. (2002). The rising prevalence of diabetes and impaired glucose tolerance: the Australian Diabetes, Obesity and Lifestyle Study. Diabetes Care. 25(5):829-34. Barr ELM, Magliano DJ, Zimmet PZ, Polkinghorne KR, Atkins RC, Dunstan DW, Murray SG, Shaw JE. (2006). AusDiab 2005: The Australian diabetes, obesity and lifestyle study. Tracking the accelerating epidemic: its causes and outcomes. Melbourne: International Diabetes Institute. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, et al. (2002). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 346(6):393-403.

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Pan XR, Li GW, Hu YH, Wang JX, Yang WY, An ZX, et al. (1997). Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study. Diabetes Care. 20(4):537-44. Tuomilehto J, Lindstrom J, Eriksson JG, Valle TT, Hamalainen H, Ilanne-Parikka P et al. (2001). Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med. 344(18):134350. Saaristo T, Peltonen M, Keinänen-Kiukaanniemi S, Vanhala M, Saltevo J, Niskanen L, Oksa H, Korpi-Hyövälti E & Tuomilehto J. (2007). National type 2 diabetes prevention programme in Finland: FIN-D2D. International Journal of Circumpolar Health. 66(2): 101-112. Uusitupa M, Lindi V, Louheranta A, Salopuro T, Lindstrom J, Tuomilehto J (2003). Long-term improvement in insulin sensitivity by changing lifestyles of people with impaired glucose tolerance: 4-year results from the Finnish Diabetes Prevention Study. Diabetes. 52(10): 2532-8. Absetz P, Oldenburg B, Hankonen N, Valve R, Heinonen H, Nissinen A, Fogelholm M, Talja M, Uutela, A. (2009). Type 2 diabetes prevention in the real world: three-year results of the GOAL Lifestyle Implementation Trial. Diabetes Care. 32(8):1418-20. Ackermann RT, Finch EA, Brizendine E, Zhou H, Marrero DG. (2008). Translating the Diabetes Prevention Program into the community. The DEPLOY Pilot Study. Am J Prev Med. 35(4):357-63. Gillies CL, Abrams KR, Lambert PC, Cooper NJ, Sutton AJ, Hsu RT et al. (2007). Pharmacological and lifestyle interventions to prevent or delay type 2 diabetes in people with impaired glucose tolerance: systematic review and metaanalysis. BMJ. 334(7588):299-302. Lindstrom J, Ilanne-Parikka P, Peltonen M, Aunola S, Eriksson JG, Hemio K, et al. (2006). Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. Lancet. 368(9548):1673-9. Laatikainen T, Dunbar J, Chapman A, Kilkkinen A, Vartiainen E, et al. (2007). Prevention of Type 2 Diabetes by lifestyle intervention in an Australian primary health care setting: Greater Green Triangle (GGT) Diabetes Prevention Project. BMC Public Health. 7(1):249-50. McNamara, K, Philpot, B, Janus, ED & Dunbar, JA (2010). Greater Green Triangle Diabetes Prevention Program: remaining treatment gaps in hypertension and dyslipidaemia. The Australian Journal of Rural Health. 18(1):43-4. Colagiuri, S., et al. (2003). DiabCo$t Australia: assessing the burden of Type 2 diabetes in Australia. Diabetes Australia: Canberra. Eddy DM, Schlessinger L, Kahn R. (2005). Clinical outcomes and cost-effectiveness of strategies for managing people at high risk for diabetes. Annals of Internal medicine. 143(4):251. Herman, W.H., et al (2005). The cost-effectiveness of lifestyle modification or metformin in preventing type 2 diabetes in adults with impaired glucose tolerance. Annals of Internal medicine. 142(5):323. Palmer AJ, Roze S, Valentine WJ, Spinas GA, Shaw JE, Zimmet PZ. (2004). Intensive lifestyle changes or metformin in patients with impaired glucose tolerance: Modeling the long-term health economic implications of the diabetes prevention program in Australia, France, Germany, Switzerland, and the United Kingdom. Clinical Therapeutics. 26(2): 304-21. Gillies, C.L., et al. (2008). Different strategies for screening and prevention of type 2 diabetes in adults: cost effectiveness analysis. BMJ. 336(7654):1180-5. Vos, T., et al. (2010). Assessing cost-effectiveness in prevention (ACE-prevention). Final report. University of Queensland, Brisbane and Deakin University, Melbourne. Uusitupa, M, Lindi, V, Louheranta, A, Salopuro, T, Lindstrom, J & Tuomilehto, J 2003, ‘Long-term improvement in insulin sensitivity by changing lifestyles of people with impaired glucose tolerance: 4-year results from the Finnish Diabetes Prevention Study’, Diabetes, vol. 52, no. 10, pp. 2532-2538. Schwarzer R, Fuch R. (1995). Changing risk behaviours and adopting health behaviours: The role of self-efficacy beliefs in: Bandura A (ed.). Self-efficacy in changing societies. Cambridge University Press: New York, pp 259-88.

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