September 12, 2017
Mr. Leroy A. Richardson
Information Collection Review Office
Centers for Disease Control and Prevention
1600 Clifton Road NE
Atlanta, Georgia 30329
Re: Docket Number- CDC-2017-0053; Revision to CDC Diabetes Prevention Recognition Program (DPRP) Standards and Operating Procedures 2018
Dear Mr. Richardson:
The Academy of Nutrition and Dietetics (the "Academy") is pleased to provide comments on CDC-2017-0053, Revision to CDC Diabetes Prevention Recognition Program (DPRP), Standards and Operating Procedures 2018, published in the Federal Register on July 14, 2017. Representing more than 100,000 registered dietitian nutritionists (RDNs)1, nutrition and dietetic technicians, registered (NDTRs), and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States and is committed to improving the nation’s health through food and nutrition across the lifecycle. Academy members provide professional services such as medical nutrition therapy (MNT) and have been involved in the National Diabetes Prevention Program (NDPP) from the start, participating in the development, implementation and provision of services. We look forward to continuing to work with CDC to ensure that the NDPP is scalable, sustainable and effective at providing evidence-based services to prevent diabetes throughout the country.
The Academy supports the proposed revisions to the DPRP and we offer the following substantive comments to ensure the integrity of the NDPP is maintained. We continue to strongly support the NDPP as an evidence-based lifestyle change program aimed at preventing type 2 diabetes2, and urge that the revised DPRP adhere to the strong standards set in programs across the country.
A. Alignment with Medicare Diabetes Prevention Program
The Academy is pleased that in the proposed data collection, CDC has repeatedly underlined its intent to align the revised Diabetes Prevention Recognition Program (DPRP) guidelines with the Medicare Diabetes Prevention Program (MDPP) expansion model standards. We have urged CMS to maintain close alignment with the DPRP so MDPP suppliers are not hampered by conforming to two different regimes, and encourage CDC to continue to provide evidence-based standards that serve as the basis for the MDPP expansion model.
Specifically, we recommend that CDC finalize the interim preliminary recognition standard, which will align with reimbursement for the MDPP standards. We urge CDC to finalize these guidelines in a timely manner so as to expand the pool of potential MDPP suppliers available to service this population, and to not create unnecessary confusion in the supplier community and impose undue administrative burden on the Medicare program.
The Academy also continues to encourage the CDC to evaluate models of virtual delivery programs for the DPP, including platforms that allow remote access and can meet the patient or client at a location that is accessible, particularly for rural communities.
B. Information on Type, Training and Location of Providers
The Academy recommends collecting information on the qualifications of the NDPP lifestyle coaches as part of the new "lifestyle coach" item on the questionnaire. Collecting and evaluating this data would meet two of the future research needs identified by the Institute for Clinical and Economic Review (ICER) in its 2016 Final Evidence Report – Diabetes Prevention Programs: (1) identify specific elements of DPPs that are associated with participant success, and (2) examine the long-term impact of DPPs on population health, and diabetes prevention, and on health care utilization and costs.3
The Academy continues to urge CDC to include a requirement in the DPRP curriculum that the program be delivered by or under the supervision of qualified health care providers, such as an RDN, NDTR, or CDE. We feel such a requirement provides better program integrity by ensuring quality oversight of coaches. The current CDC program recognition standards do not include any specific requirements to ensure these individuals are identified and appropriately referred to necessary health care services and providers. In addition, experience of RDNs/NDTRs who are Academy members delivering DPP's or providing MNT services to participants of such programs reveals the unfortunate frequent occurrence of participants being provided with incorrect nutrition information and advice that is detrimental to their health. Data to date on CDC recognized programs indicates some of the most successful programs use both lay coaches and health professional coaches, such as RDNs. Finally, one of the barriers to expansion of the DPP noted in the ICER report is "the extensive efforts required to screen, identify, train, and retain skilled lifestyle program coaches who can connect to the community targeted by the DPP."4 RDNs and NDTRs already possess these skills and so provide a readily available workforce for the MDPP program.
C. Value of RDNs as NDPP Providers
RDNs remain the most qualified healthcare professional group to provide nutrition-based lifestyle interventions, including MNT and evidence-based nutrition counseling and weight loss management services. RDNs have demonstrated competencies and outcomes that other, less qualified providers of non-medical nutrition services have not been able to demonstrate. The Institute of Medicine found that "the registered dietitian is currently the single identifiable group of healthcare professional with standardized education, clinical training, continuing education and national credentialing requirements necessary to be directly reimbursed as a provider of nutrition therapy."5
A recent study provides more evidence that registered dietitian nutritionists are an effective solution to the expensive health care cost of preventing diabetes. A review of dozens of research studies shows diabetes prevention programs that include nutrition education provided by registered dietitian nutritionists help people reduce their risk of diabetes and are more effective than programs delivered by non-dietitians.6
The review analyzed 69 studies that focused on diabetes prevention for high-risk adults through lifestyle interventions. "This systematic review and meta-analysis indicated that diabetes prevention programs including nutrition education were associated with a reduced risk of diabetes," assessed by standard measures such as weight, body mass index and glucose measurements including FBG, 2-h BG and HbA1c. It found that dietitian-delivered intervention programs demonstrated greater effectiveness than those delivered by non-dietitian delivery agents, which supports the role of dietitians in diabetes prevention programs. Furthermore, RDNs' training could allow them "to more effectively communicate nutrition information, facilitate skill development, and develop strategies for implementation with their patients."
As CDC revises the DPRP standards, it is critical to ensure that the practitioners who delivered results in the NIH's foundational studies demonstrating effective clinical practice are the same practitioners providing or supervising the interventions.
D. Value of Individualized MNT for NDPP Participants Upon Referral
The Academy continues to recommend that CDC include information about referral services for patients who develop diabetes in conjunction with the NDPP, particularly as the MDPP proposes to allow beneficiaries to continue to receive coverage of the program after developing diabetes, if applicable. In a study of a NDPP in Ohio, it was found that a client who had not reached the target weight loss after five weeks would be less likely to benefit from completing the NDPP course.7 These clients would have a greater benefit from receiving a more individualized, targeted intervention at that point, including MNT. In order to ensure the best outcomes for all NDPP participants, is is important to include a referral mechanism for those who would benefit from a more targeted and personalized intervention.
In order to prevent the onset of diabetes and reduce the costs associated with diabetes, the Academy urges CDC to ensure access to MNT for individuals diagnosed in the NDPP who are not responding to standardized care. This would allow the best care for all program participants, and provides flexibility for participants to choose the best program for their individual needs and lifestyle.
Diabetes is a costly and complex disease, and we applaud the progress that CDC has made to scale up the NDPP, in particular by demonstrating cost-savings for the Medicare population. The DPRP is vital to reducing the burden of diabetes in the United States. The Academy understands the challenges in revising the DPRP to ensure the integrity of the MDPP, and we offer our assistance and evidence-analysis resources regarding these important services. Please contact Jeanne Blankenship or Stefanie Winston Rinehart with any questions or requests for additional information.
Jeanne Blankenship, MS, RDN
Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics
Stefanie Winston Rinehart, JD, MPH
Director, HHS Legislation and Policy
Academy of Nutrition and Dietetics
1 The Academy has approved the optional use of the credential "registered dietitian nutritionist (RDN)" by "registered dietitians (RDs)" to more accurately convey who they are and what they do as the nation's food and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.
2 Centers for Disease Control and Prevention; National Diabetes Prevention Prevention Program; About the Program. Accessed September 7, 2017.
3 Diabetes Prevention Programs: Effectiveness and Value. California Technology Assessment Forum. Accessed September 7, 2017.
4 Diabetes Prevention Programs: Effectiveness and Value. California Technology Assessment Forum. Accessed September 7, 2017.
5 Committee on Nutrition Services for Medicare Beneficiaries. "The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population." Washington, DC: Food and Nutrition Board, Institute of Medicine; January 1, 2000 (published).
6 Sen, Y., Almeida, F., Estabrooks, P. Davy, B. Effectiveness and Cost of Lifestyle Interventions Including Nutrition Education for Diabetes Prevention: A Systematic Review and Meta-Analysis. J Acad Nutr Diet. 2017: Vol. 117, Issue 3, p404–421.e36.
7 Miller CK, Nagaraja HN, Weinhold KR. Early Weight-Loss Success Identifies Nonresponders after a Lifestyle Intervention in a Worksite Diabetes Prevention Trial. J Acad Nutr Diet. 2015;115(9):1464-71.