Won’t you be my neighbor: How lifestyle change programs for diabetes prevention evolved during COVID-19

November 13, 2020
Daphne Li
Daphne Li

For people addressing prediabetes, a move to virtual coaching hasn’t eclipsed the powerful pull of community-based programs.

The COVID-19 virus has limited face-to-face interactions while also highlighting the value of hyper-local relationships. When sheltering in place or unable to travel, the people living near you play a more prominent role in daily life

Neighborhood relationships are especially meaningful in lifestyle modification programs such as the CDC-endorsed National Diabetes Prevention Program (DPP), a partnership between public and private organizations to prevent or delay people with prediabetes from developing type 2.

There are an estimated 88 million American adults living with prediabetes. Yet more than ever, people need to halt the disease’s progress. A CDC study found coronavirus patients with underlying chronic conditions such as diabetes and cardiovascular disease are six times more likely to be hospitalized and 12 times more likely to die.

Our experience shows that taking DPP to the neighborhood level, where programs are available within 10 minutes of a participant’s home, is the most effective method to promote long-term success. Many aspects of life have moved online, but the power of the neighborhood persists.

Think “community” for lifestyle change programs

The DPP lifestyle change program is proven through AMA and CDC research and testing to restore metabolic control. Since 2010, DPP has helped about 500,00 people delay or avoid developing type 2 diabetes, effective enough that Medicare and many health plans cover the program.

By combining nutritional and health counseling, exercise programs, individual coaching, motivational support, and resources, DPP can reduce participant risk of developing type 2 diabetes by at least 58% and as much as 71% for those over age 60. A critical success factor in making lifestyle changes that endure, however, lies in meaningful human connections. Effective face-to-face community care and support is a foundational element of the program.

Studies show that having social support leads to better adherence to diet and exercise routines. Smartphone apps can monitor diets, and online social networks centered around health motivate many people to eliminate unhealthy habits. But to sustain new habits over time, people really do need people, as the song goes.

Supportive day-to-day human interactions and a sense of a community are key drivers of effective treatment and sustained behavior modification. Participants are more likely to stick to new lifestyle choices when they have a coach and a familiar, trusting group to whom they feel accountable. The group environment serves as a support base when the going gets tough, which often derails people from their goals. Having a group to celebrate accomplishments motivates participants to stay the course.

Location, location — for sustainable lifestyle change

The physician-patient relationship is central to the success of DPP. Doctors diagnose the prediabetes condition and recommend programs where they can monitor the patient’s progress. But even in pre-pandemic days, a physician rarely had adequate time for the necessary follow-up — a gap that DPP coaches can fill.

DPP is most effective when the program extends the physician’s reach into the local community where the patient lives — ideally, within 10 minutes from home. People are more likely to make better health-related choices when options are affordable, convenient, and compatible with their lifestyle.

For example, healthy, home-cooked meals require time, skill, and planning. Gathering relevant local information is easy when sharing with a group — new recipes using seasonal foods, farmer’s market availability, “senior hours,” and special supermarket sales. The most reliable resources and tips come from within the group because participants are neighbors, and coaches are part of the community, too.

But what happens when in-person support groups can no longer meet? Does turning to a virtual community online become an adequate substitute for face-to-face gatherings?

The COVID-19 effect

Most diabetes prevention programs are organized through hospitals or YMCA/YWCAs. But when COVID-19 hit the U.S. in March, those options evaporated. Many Y and other public sites hosting DPP meetings had to close or reduce activities. Hospitals redeployed staff to COVID-19 care or even furloughed staff due to limited elective or non-essential procedures.

Moreover, many DPP participants wished to avoid hospitals and clinics with congregating groups and indoor locations. Fear is now exacerbating the existing tendency to delay routine health appointments.

When COVID-19 shutdowns began, First Mile Care immediately canceled in-person DPP classes, but we wanted to keep the program rolling for current registrants. We offered to change classes to telephone-only as the easiest point of entry, assuming everyone had access to a phone.

We expected to lose a number of participants when we switched to video-based virtual classes. More than 52% of enrollees are over the age of 65, so we assumed they’d have a harder time adjusting to the online-only world. To our gratification, more than 98% of participants agreed to continue in the program — in part because they recognized that an underlying condition like prediabetes put them at greater risk. The remaining handful, assuming the interruption would be short, planned to re-join when in-person meetings resumed.

Because moving in-person coaching sessions to virtual meetings was easier than anticipated, it might be a natural leap to assume that neighborhood groups are now passé. If everyone can meet online, then coaching groups can be cobbled together from multiple regions, right? The answer is Yes — and No.

Meeting people where they are

Our findings are that COVID-19 hasn’t killed in-person lifestyle change meetings; it’s actually created new interest so that we have tripled enrollment and class offerings since the onset of the virus.

We initially paused the creation of new DPP classes as we assumed people were too distracted to be challenged with health-based lifestyle changes when they were already forced to alter routines. But we learned that physicians were eager to find a way for their patients with pre-diabetes to work on prevention. Doctors worried about patients both backsliding in their progress and, for many, becoming isolated. People making poor health decisions in social isolation is already a growing problem.

We also learned that participants were willing to consider DPP not in spite of COVID-19 restrictions, but because of them. If the virus is already turning life topsy-turvy, then why not try something new with actual health benefits? With restaurants closed or restricted, and fitness centers out of bounds, people are willing to experiment with cooking skills and new types of exercise.

But we’ve found it’s important to keep the power of the neighborhood cohort while meeting people where they are now — whether it’s in their living room over group video, or on an optional socially-distanced walk in a nearby park. People like meeting serendipitously in person as well as online — even if it’s at a future post-vaccine date.

Life during a pandemic has helped our DPP participants embrace neighborhood-based connections in support of their shared goals for eating healthier, getting more exercise, and reducing stress. They covet the willing audience with whom they can share the challenges of dealing with dietary and fitness goals while also faced with unexpected changes in their own communities. And because COVID-19 restrictions vary widely by region, keeping groups in neighborhood cohorts, even when online, ensures they’re sharing the same experiences — which also includes hurricanes, wildfires, extreme heat, and street protests.

We have also started online educational sessions for which we’re able to leverage the expertise of coaches in multiple locations and combine participants from across groups in a way we would not have done before COVID-19. It’s been challenging to find ways to work with people on coping during the pandemic, whether it's learning to do resistance strengthening exercises at home when gyms are closed, to prepare healthy meals with pantry staples to reduce supermarket trips, or to use meditation to relieve stress.

Don’t look back

The future of DPP success now seems to embrace a hybrid model. This forced experiment with virtual sessions demonstrates their value for certain activities, but to supplement — not replace — neighborhood cohorts. COVID-19 has highlighted how much we long for personal connections that can’t be provided through a screen. Closer bonds and local knowledge are irreplaceable benefits provided by neighborhood groups that contribute to sustainable lifestyle changes.

Daphne Li is chief operating officer of First Mile Care, a Silicon Valley-based preventative chronic care company. She is also managing director of business acceleration at Health2047 Inc. Previously, Daphne was senior vice president and general manager of enterprise at SaaS platform provider Upwork, and also led marketing and product management at ADP. Earlier in her career, she was director of strategy for Apple’s education group. Her passion for scaling companies started when she was on the business acceleration team at Bain & Company. She holds both an MBA and a BA in economics from Stanford.