YMCA Diabetes Prevention Program

Summary

The YMCA’s Diabetes Prevention Program (Y-DPP) is a small-group program specifically for individuals who are at-risk for developing type 2 diabetes. Its model is based on the original Diabetes Prevention Program (DPP) study. The program consists of 25 one-hour sessions distributed over the course of a year. The program aims to reduce participants’ portion sizes and to increase physical activity by setting specific goals to lose 5–7% of body weight and increase physical activity to 150 minutes per week. In self-reported data, 94% of participants said they reduced their portion size, and 88% said they have increased their level of physical activity; 83% say their self-esteem increased; 84% report more energy; and 91% say their overall health has increased.^[1] Although there is a financial cost to enroll in the program, the YMCA website reports that the program provides financial assistance for those in need. The program is now available at 200 YMCA centers across the country.

Keys to Success

Group-based

The YMCA’s Diabetes Prevention Program (Y-DPP) is a small-group program specifically for individuals who are at-risk for developing type 2 diabetes. Its model is based on the original Diabetes Prevention Program (DPP) study. The program consists of 25 one-hour sessions distributed over the course of a year. The program aims to reduce participants’ portion sizes and to increase physical activity by setting specific goals to lose 5–7% of body weight and increase physical activity to 150 minutes per week. In self-reported data, 94% of participants said they reduced their portion size, and 88% said they have increased their level of physical activity; 83% say their self-esteem increased; 84% report more energy; and 91% say their overall health has increased.^[2] Although there is a financial cost to enroll in the program, the YMCA website reports that the program provides financial assistance for those in need. The program is now available at 200 YMCA centers across the country.

Uses existing resources

Y-DPP requires few additional contributions or amenities beyond the existing infrastructure of the YMCAs, contributing to the program’s cost-effectiveness. Recruitment can be done at low cost with moderate (though limited) success through mail advertising^[3] or through referrals from clinicians.^[4] B Group sessions are carried out in YMCA facilities, and participants can be provided with memberships to these facilities to make physical activity convenient. The leaders of the group sessions can be employees of the YMCA rather than independent behavioral experts. An early pilot of the Y-DPP found that behavioral interventionists’ wages were about half of those of the original Diabetes Prevention Program study, compounding the savings that result from group, rather than individual, sessions.^[5] Additionally, training YMCA staff to implement the DPP is relatively simple. In the first pilot study of the Y-DPP, staff members underwent a two-and-one-half-day training curriculum led by facilitators of the original DPP study.^[6]

Sustained participant engagement

The Y-DPP features 16 weekly sessions, followed by monthly maintenance sessions for the remainder of the year.^[7] The continuity of the program is critical in allowing the Y-DPP to produce sustained lifestyle changes. Many pilots have found that the proportion of participants who lose at least 5% to 7% of their weight at 10–12 months is as high as or even higher than at 4–6 months, indicating that improvements are sustained over the course of the year, rather than successes concentrated near the start of the program and then fading over time.^[8] Additionally, the duration of the program does not appear to be overly prohibitive to enrollment. In fact, the majority of participants in Y-DPP pilots indicate that they would prefer an even longer program for sustained results.^[9]

Ability to Inspire

The YMCA was a recipient of the Center for Medicare & Medicaid Services (CMS) Healthcare Innovation Award, receiving a grant of almost $12 million to test its DPP.^[10] The YMCA’s demonstrated DPP successes played a crucial role in the 2016 CMS decision to reimburse DPPs. This distinction is particularly noteworthy, as this is the first preventive service model to be covered by Medicare.^[11] While the YMCA is not the only DPP covered, the success of Y-DPP programs is explicitly noted in the CMS Office of the Actuary’s recommendation to begin reimbursements for diabetes prevention.^[12] The sheer growth of the Y-DPP is also indicative of its success. By 2016, there were 252 YMCA branches, in 47 states, trained to deliver the program.^[13]

Cost Effectiveness

The strongest testimony to the Y-DPP’s cost effectiveness is certainly its role in making DPPs the first preventive service programs to be reimbursed by Medicare. In deciding to cover DPPs, the CMS found that DPP reimbursement could be expected to break even in its fourth year, based on demonstrated successes thus far.^[14]In fact, the CMS actuaries’ estimates suggest that, over longer periods of time, the only major possibility that could drive up costs due to DPPs would be increased lifetime medical costs due to decreased mortality rates from diabetes.^[15] Additionally, a modeling study that estimates the Y-DPP’s impact on coronary heart disease has found a statistically significant improvement in participants’ 10-year outlook.^[16]

Even before CMS decided it would reimburse for Y-DPPs, other modeling had suggested the cost effectiveness of group-format programs like the Y-DPP model. One model estimated that a group-style intervention could see a complete return on investment within three years if interventions with groups of approximately 10 people could achieve comparable efficacy as the one-on-one interventions of the original DPP.^[17] This study noted that the economic benefits of the intervention are greater when younger participants are enrolled (the model compared 50 year-olds to 65 year-olds), meaning that private payers could see returns on investment even before people age into the Medicare system.^[18]

Drawbacks and Limitations

Early pilot studies of the Y-DPP indicated that program non-completion was more likely among black participants than any other group, and less likely among white participants than non-white participants.^[18] These results were recorded in just two locations in the same state, and thus may not extend more broadly. Nonetheless, the results indicate that deliberate recruitment and retention efforts may be needed in order to ensure that the Y-DPP can serve to reduce health disparities in diabetes and prediabetes.

Additionally, participants in pilots have given feedback that the group arrangement—which may increase commitment and accountability for some—can lead others to feel unwelcome or excluded. For example, participants have reported feeling less welcome when they are of lower socioeconomic status than others in their group.^[19]

Lastly, the behavioral interventionists in the Y-DPP are not clinical professionals, unlike those in the original DPP. While reducing the number of clinicians can lead to cost savings, further research is needed in order to determine whether this change has a negative impact on outcomes.