Distinguished Colloquium Speaker Series

Description of the video:

All right, Good morning. Good afternoon everybody. Welcome to the first distinguished Colloquium Series lecture in 2022. The first live in-person TCS speaker in three years. It's a pleasure to be here and to the mentor. Dr. David marrow. Present, Dean David Allison, momentarily, we'll do a brief introduction of Dr. Moreau as well as our introducing Dr. Carlin. We will formally introduce Dr. Murray. So without further ado. Thank you. I'm quickly that we will do a Q&A at the end, the last 15 min or so like Dr. Maurice, first-time. Thanks so much for coming. Thank you. So this is a very special event. We began this distinguished Colloquium Series shortly after I joined here his knee. And it is truly distinguish. We have been way laid by or we're waiting to find the pandemic. And so like everything else starting in early 2020 with my virtual. But now we're back. This is the first one that's not virtual. And I think people are still coming back, but we want them to bring in a good or a bad guy for some very exciting about who truly merits and the title Distinguished Speaker. He is truly distinct. Years ago when I was actually be one of my colleagues back into larvae and said, You need to get something that somebody was on. Community outreach and implementation science around diabetes. Can't sell anything less than one guy, get him no guy around railroad. Then we got the grant and I said, Yeah, it really is. So real excited to happen here. There's also lose your connection. So this is like coming home for him. And in addition, I wanted to say we have another one, the person, I'm wondering if some of you, many know, but she's new. Professor Karla Miller, who actually knows Dr. and she is one of our in-house distinguished competence. And I'm going to turn it over for that. It is indeed a pleasure for me to get emotional. I couldn't believe it is indeed a pleasure for me to introduce Dr. David Hero. Well, I hope I can get through this. I have known Dave for many years. We've worked together on a few projects. And Dr. Carrera is the real deal. Let me tell you a little bit about him and I had to write it all down because his CV is hundreds of pages long. Currently, Dr. Morell is the Director of the Center for Health Disparities Research at the University of Arizona in Tucson. He joined the Department of Medicine at the IU School of Medicine in 1985. While at IU, he lived the Diabetes Translational Research Center and he was the JO Richie endowed professor of medicine. In medicine. Dr. has almost 400 applications. If that doesn't impress you. And now he is a sought after speaker, is presented at numerous national and international research conferences. He's received numerous awards. I'm only going to highlight a few of them. He has received the eileen von Sun Award for diabetes patient education tools from the American Association of Diabetes Educators twice, he's receiving the award. He's received the Outstanding Educator in Diabetes Award from the American Diabetes Association, has also received a Josiah hey Lily Distinguished Service Award from ADA. He's received the Libin Medal Award from ADA and he's received Richard are flipping Award, which recognizes a behavioral researcher who has made outstanding and innovative contributions and steady and understand behavioral aspects of diabetes. Dr. where I was at past president of health care and education for ADA. He currently is the associate editor for the journal Diabetes forecast. And in 2006, he was voted the alumni of the year for his Alma mater, university of California, Irvine. And deservedly so. Here's another important tidbit. Dr. Ferrero has received continuous funding for his research since 1981, for numerous federal non-profit sources. As part of his research endeavors, he was the sole behavioral scientists involved in developing the lifestyle intervention for the diabetes prevention program, which demonstrated that weight reduction through lifestyle change dramatically reduce the occurrence of type two diabetes in adults at hybrids with pre-diabetes. He then went on to become the PI for the follow-up study to the DPP called the Diabetes Prevention Program Outcomes study. Were those participants have been followed for 12 to 15 years. Dr. railroads research in which the DPP intervention was translated for group-based delivery through the YMCA was groundbreaking. As a result of his efforts. Striated at the YMCA as a viable avenue for disseminating this highly efficacious intervention. As a result, the intervention has been delivered through YMCAs across the country, reaching thousands of people and reducing the burden of type two diabetes. Dean Allison regularly admonishes us to do good work and to leave the world a better place. Dave is one of those individuals who's actually done that. Please join me in welcoming Dr. I wish my mom could have heard that. I just always wonder where they find all this stuff because I'm one of those people that I don t think about the path I've taken. I just keep pushing forward. I've got the head right. I always blows me away when I hear these things. So I almost got it. I guess I didn't do that. Blows my mind. Alright, let me get going here because I have a lot to cover. I wanted to talk about my work and translate into diabetes prevention program into the Public Health. I'm a social psychologist by training. Social ecology, which nobody knows what it is, is a multi-disciplinary degree out of the University of California at Irvine. And they teach us to do interventions in community settings. And I took that to heart. So this is what we're going to talk about today. To organize this, I want to first start with the problem of diabetes. What is diabetes, if I may? Is it a public health problem? Is it really reached the stature where we need to be concerned about it as a nation, a society, a group of people. 38 million Americans right now have diabetes that we know of, okay, they were sure habit, and that's 10% of the US population. So that's pretty good sized numbers. And if we look at pre-diabetes, which is the term that we use to talk about a metabolic change in the body that is not frank diabetes, but yet shows disruption and the ability to metabolize essentially a usable form of energy, which is what your body does with everything you eat. We see 96 million Americans, that's one in three people. And I suspect if I do the statistics and Dr. Alison Bechdel is way better at this than I am. That somebody in here has pre-diabetes. I mean, it's almost you can almost throw the rock and be assured of that, right? So it's 50% of adults over the age of 65. So these are big numbers and then progressions one to 15% a year. Now, the cost, I always got the slides up for the cost, but I got to cut somewhere. It's boatload of money, just a boatload of money, billions of dollars annually spent on diabetes. And there's some reasons for that. This is one of them. Diabetes is a leading cause of several end-stage complications that are really nasty and quite expensive. You can see here it affects brains, the brain stroke, and now dementia is pretty much on the board, is the leading cause of cardiovascular disease. That's a leading cause of diabetic kidney disease requiring dialysis. Dialysis is so expensive now, it's gone up to about $150,000 a year in most places. So it's, it's, it's big money, right? We're talking about diabetic neuropathy, which causes all kinds of complications. Not the least of which is erectile dysfunction, which always gets my attention. So we have diabetic retinopathy, which is eye disease is the leading cause of blindness in this country. Alright? We have periodontal disease, which I love this slide because you never see the periodontal disease. People with diabetes have crappy teeth. Surprise. And it's sort of an interesting mechanism, but that's for another talk. It also has peripheral vascular disease and foot damage. It's the leading cause of lower extremity amputation. If you add all these things up, strokes, heart attacks, blindness, amputations, you're talking major impact at a social level, a psychological level, at a physical level, big cost. So I submit, it's a public health problem. Here's the fun part. This is an old slide. I keep looking for a neuron because it goes up to 2015. But you can see that the rate of diabetes and the percentages have gone up almost like a meteor, right? It's gone up so rapidly, so quickly that it kind of blows people away. So starting way back in 1958, which some of you weren't even born. I mean, it's just growing and growing. And if we had 2023 David, it'd be like here. I couldn't find a good graphic often make when, when David, this is a remarkably rapidly expanding disease, such that in 1998, the CDC, so this is almost becoming an epidemic. In 2006, it was declared it epidemic. Okay. So why is this happening now? Just real quickly, anybody want to venture a guess? I was like, I hate talking to myself all the time. So, you know, maybe why do you think that line was going up like that? Why do you think of the Surette? Yeah. More sedentary lifestyle. Sedentary lifestyle and we'll settle the guest process. Yeah. Yeah. Adding sugar to foods and they took up well, there you go. I think that Lewis Carroll, was it just a kid author that I enjoy what I was showing? He was a public health profit because this is a quote, The Walrus, so the carpenter. But wait a bit, the Jewish just cried before we have our Chat for some of us are out of breath and all of us are fat. Turns out that what's happening with diabetes as shown in this slide. And again, I'm trying to find a slide that will give it to 2022. But this shows the change in obesity starting 1994-2015. And this is diabetes corresponding going up to 2015. And what you can see in this slide is pretty evident that as we move through time, more and more obesity is happening, right? Greater amounts of it are occurring. And that is the cause of type two or non-insulin dependent diabetes and causes insulin resistance. Moral, be sure, the harder it is for you to use your insulin effectively to metabolize things into a usable form of energy. Okay. And in 20, I just saw the data last night but couldn't get the slide made time. I saw the data for 2021. Okay, they have a new color because this now says this is, this color here is greater than 26%. The state is obese, okay? And now they have a new one because they reached 35%. There are states that fully have 35% more than a third of the state are technically obese. Alright, Stunning, Absolutely. Study. So how can this guy, you know, we know that there's a lot of obesity. How words can we get? Well, let me show you, because I have a hypothesis. I think it's more than simply changes and our eating habits all brought up things which were 100% correct. Okay. I think that in the US and I conclude Mexico because I work at a place where Mexico is a dominant element in my world. We have changed our culture regarding eating habits and physical activity. We have changed the way we see it and think about it. It's very, very common and very evident. Here's an example. You could make up your own. You know, I mean, there are everywhere I loved this one smaller is better works only for gadgets. The bacon later. Come on man, you could get a serious burger down. This is serious eating. Come on. If you're a man, you're going to eat a bacon in Super Size Me is now a term and the urban dictionary. Okay, we've created that. That's something that our culture manifested and said this is a value. This is good. Okay. This does anybody know where this picture came from? Biowaste face there? The Indiana State Fair. This is the Indiana State freakin fair. And I used to have a joke. I used to make this joke all the time. It's only a matter of time before the deep fried butter. I used to think it was funny when you catch it by little catchy phrase, they did it. They deep fried butter, forgotten sakes. That's on the walkway, the Indiana State Fair about seven years ago. Okay. Now you're probably wondering what's deep fried butter. How did they do that? Well, I took one for the team and I ordered, this is deep fried butter. What deep fried butter is a cube of frozen butter or a cube that is then dipped in batter and deep fried could see, it's hard to see if that's a liquid pool of butter. Okay? And of course, just because the calories weren't quite sufficient, we pull up our sugar. Now I got to try something. It was fabulous. It's like buttery and biscuit from the inside. Yeah. It was really, really good. I see why people gravitate towards it because we are wired genetically for high caloric fat sources since top, there's an evolutionary story that we can tell us some time, but that's part of who we are as organisms. But this is what we do. And people were eating this stuff wasn't enough that we deep fried Oreos, It's stickers at Twinkies. We went right to the source. This is a television program. Anybody's seen it. Member's food celebrating. This is a person that goes out and challenges eating enormous amounts of food. Enormous amounts. I mean, things that are just like, oh my God, are you kidding me? But it's a program now. And as you know, highly watched. This is another thing that's happened in the last 30 years or so. You no longer have to get out of your car to do a whole bunch of stuff or even get up to change the channel on your TV. Okay, that's gone. Now when I was a kid, I'm 70 years old. When I was a kid, we had a knob and yet to turn it and there was an argument in the family there you get up, you do it. That's what we had to do. And when the NADH broke, you put on a pair of ratchet pliers on it. And that strategic use to turn the television. That was sort of the thing. But we've changed physical activity rates at a rate that's phenomenal. And in Indiana, he talked to farmers, they get up inside the John Deere air conditioning cultivator and they drive the South 40. They used to walk it. We don't do any of that anymore. Any of them. This is a common picture. This is a real picture show. We're not talking a huge flight of stairs here, but look at that really is the lined up because this is just our culture. We've embraced reduction in physical activity and we've embraced consumption of large volumes of food. So what can we do that? By the way, I had to tell you because I'm sniffling. My allergies have kicked in. I bid out of Indiana for awhile. I forgot what it's like to drive that here. So I apologize for that, but that's how it goes. Well, a group of folks back in the early nineties decided to take on the issue of diabetes. And could it be prevented in people that were enriched for it? It had some risk factors going into the game. And they called this study the Diabetes Prevention Program, and it became the diabetes outcome study after the, after we tracked it. But this was a sort of a famous study that was done by the NIH to figure out, could we actually pull this off? And what they did was a three arm nationwide randomized controlled trial. There were over 3,000 participants with prediabetes. And that was determined by the presence of impaired glucose tolerance, which is determined by an oral glucose tolerance test. If any of you have had pregnancies and you've had children, you probably had an oral glucose tolerance test at 38 weeks where you suck down 75 g of an incredibly sweet beverage and then you find out what your glucose levels does over time. Okay, and there's a prediction on that. There's a prediction on the curve and the time it takes to resolve itself. Alright? And we compare three groups. We did an intensive lifestyle intervention, which I'll talk about more in a minute. We use metformin, which is a diabetes medication that's used for diabetes. But we thought there were say, a physiological reason why it might help with prediabetes and prevent the conversion. And then we had a placebo, which is basically a fake pill. And good advice, you should eat better, you should exercise more that kind of thing. Now the lifestyle was a 16 session and I'm surprised at you. You said this because people usually don't. When the DPP started, there were only two behavioral scientists at the principal investigators table, myself and right away. And nobody, you know, nobody thought that lifestyle was gonna make it. Everybody thought the lifestyle was going to be a control condition. That's what they wanted to well, Rena, I said no, that's that's bunk. You know, this is worth challenging. Let's test this out. So one of the best things I ever did in my career was convinced people that that should be a condition. Seriously, I'm very, very proud of that because they were going to blow it off because everybody else was an MD at endocrinologists and their experience was that this doesn't work lifestyle, not Noonan syndrome. So this is a 60th session program, is originally was taught one-on-one, but transformed into a group program at the second phase of the study. But everybody had their own coach, their own personal trainer, and we had an amazing amount of resources to throw at it. It might place I had the second largest cohort of subjects in the study here at Indian app, indianapolis, 197 people. I gave them all of the lifestyle group, Nike tennis shoes for free, gave them membership into health clubs. I mean, you could test the hypothesis, Let's cut it back. The goal of this thing was to cut back your weight by five to 7%. Okay, that was the chart. Actually, it was, originally, was 5%, but we chose 7% because we thought nobody will get to 5% unless we make a 7% and creep up on it, right? So we focused on behaviors and not a diet. Wasn't a diet. Was it eat this, do that. Don't eat this. Don't eat that. It was about things that you do that caused you to eat in productive ways. We had an emphasis on fat grams and physical activity. So the way we approached fat loss was trying to reduce the number of daily calories that you consume by reducing your fat grams. Now, does anybody have any idea how many what percentage of the daily diet his consumed by fat? They wanted to guess. Currently. In Indiana. I noticed in Mexico, I noticed is in Arizona percent of 47%, 47%. Okay. Almost half daily calories on the average person, particularly in Indiana, is from fat. She thinks it needs to be more. In some, in some, in some groups. It is. If you go down to Tucson and you go to the southern part of Tucson, were Mexican origin people live, their diet is insanely high in fats, 60, 70% its protein and fat. That's kinda vet and with some carbohydrate and mixed into it. But it's very high levels of fat because of the way they prepare foods, large soul functioning and stuff like that. Anyway, we deep fried butter people, I mean, come on. How else can we get away from this? We eat an enormous amount, so we tried to cut people down to about 20%, okay? And we wanted them to do physical activity and walking with the standard. 20 min today was the standard, give me 20 min of walking that everybody in this study was really large, sedentary was overweight or obese. Alright? We also talked about psychological and social factors that influenced eating behavior. That was a lot of the focus. It wasn't a diet. Okay? It was it approach, it was a cultural, ideological structure. And here's the results. Famous study. Lifestyle smoked the drug, almost doubled it. The drug reduce risk by 31%. Okay, but lifestyle did it by 58%. And if you're over the age of 65, it was almost 70%, was an awesome clinical finding. And not only did it do it, but if you look at the step stair observation periods of the study, It's the effect happened within six months and sustained itself for five years. They terminated the study early. They said, okay, look, we don't need to prove this anymore. Let's just, let's come up with Phase II because we did it. This is a whopping clinical trial, alright? The number needed to treat because see it down there. So lifestyle proved to be a highly effective method to prevent people from converting from pre-diabetes to diabetes. Now here's the fun part to me. We got 50% of this sample with people of color, 50%. Okay, We have people from every racial ethnic group you can think of, Native Americans, Latinx people, Asian, Asians, African-Americans, the whole 9 yd. And it didn't matter what group you're in. And usually there's not a, in most clinical trials you see a race effect is very common. You know what I mean in clinical trials. But it didn't happen here, didn't matter or raise. Sure. It didn't matter whether you are male or female. And that's oftentimes it demarcating factor in clinical trials. Women respond differently than men. You know, not, not a surprise, many different than women. I mean, it's just what happens. It didn't matter how fat you were coming in. So you can be really fat because you can be really morbidly obese in this study or you could be overweight. Bmi over 27, 30 is the definition would be okay. And it worked for everybody. Didn't matter. How many clinical trials have you ever heard of work? Everybody got better. Everybody, you know, remarkably better. Huge, big number better. So I was thrilled. We were all thrilled. I thought this is a good day at the office. Okay. We're rocking this this boat. So here's the question. Why don't we have a diabetes prevention program in every corner? How many of you know where there is one? Just raise your hand if you do diabetes prevention pub. I got to two hands. How come? We don't have on every corner, we've got this enormous disease, huge numbers of catastrophic social, psychological, physical impacts, fiscal impacts, and we don't have every one of these on every corner. What the hell's going on? It's like crazy to me. So there are some things to think about. This is where we start talking about the translation and public health. First, it was a well-funded study and it was an efficacy trial. All we cared about was proven that hypothesis. And boy, we have a lot of money. There was $190 million spent on getting data and providing intervention for about 3,400 people. Okay. That's big bucks. Big bucks. How would you like to have those monies today for your own research? I mean, come on, you can do some damage. We didn't design this study for broad-scale application. As a consequence, everybody had their own personal coach for God's sakes, if I could give everybody in into your own personal coach and cooking classes in Nike tennis shoes, and membership into gyms and blah, blah, blah, blah, blah. You could probably do pretty well. But that's not a good public health bone. It's not going to cut it, right? So that was a problem that one-on-one coaching the incentives. Every time you showed up, every time you did something, every time you gave me data, I paid you page, you know, The retention on this study was over 98%. For years. I mean, for years, we're still following these people. They're still in the study that we're doing 23 years now. So I'm like that Good Lord. And they still show up, you know, many of them have died. Their age. Brackets have pushed them into, into death, but we did everything we could to prove a point. But that doesn't mean it becomes public health. It's not how it works. Also, at that time when the results came out, there was a lack of awareness of and testing for prediabetes. Pre-diabetes wasn't even a term. And I was actually in the room and we coined that term. But it shows her sitting around saying, what are we going to call this? I mean, how do we explain this to the public? We should call it this, we should call it that. We've thought about it like a bunch of academics will do. And we came up with prediabetes. So if you didn't like the term, you can partially blame me. But the very first thing that happened was they said, Hey Dave, your behavioral scientists, why don't you come up with a way to translate this? You can do that. Dave, translate this. I said, Well, what am I supposed to do? Good Lord. I mean, it's like you give me this really complex study with a ton of money, asked us to come up with a model to put it into the real-world. They said, well, let's try educating people first. Let's make them aware of it because nobody knew what pre-diabetes wads. It wasn't a term didn't exist. So we develop the National Diabetes Education Program, my center up here in Indianapolis. We did this. It was a federally sponsored initiative for the National Institutes of Health, the Centers for Disease Control and Prevention. And it had a bunch of partners and the private sector as well. And it was to reduce morbidity, mortality of diverse since complications. So we put out a bunch of materials to educate people. These are the things that can usually be aware of these two, what we know about it now, these are the things you should think about doing. Now, if education by itself was effective, what do we have any fat people? No, we would not. But we do it because it's never enough educations and necessary but not sufficient step. And we knew that, but it's where you started. We got a little more aggressive. We developed something called the small steps of big rewards program prevent Type-2 diabetes. And you can see the quote by Tommy Thompson when you put this thing out. What this was, was a little booklet that talked about how you can approach the eating the way we learned to do it, gave you some guidelines and gave you some tools to use and record your diet. Because we found the number one predictor of losing weight was recording what you eat on a daily basis. And if you don't believe that's true, try it. Go home and for the next two weeks, write down everything you eat. And what you'll learn like most people do, is, oh my God, I'm eating 45% of my calories from fat. And oh my God, I'm eating a whole bunch of sweet stuff and all my ear. We call it the oh my God, effective. Even Wilson, you're seeing it. You don't realize you're doing it, you just don't see it. So we gave them tools to do this with. Okay. But they were self-help stuff. It was like, Here you go. Here's some simple guides. It wasn't a complete program obviously, but it was there. And we distributed that all over the place. Did that make a big difference? No. But it was a step in the right direction. So we've got to go beyond education. And I want to talk now about how we move the DPP into the community. As Carlos said, we came up with an idea. And let me tell you how I got to the idea. I'm I'm the guy who brought to the YMCA. Okay. I'll take credit for that in what we call the deploy study, which was a funky acronym, but it was the best one we'd come up with the times funny quick story. We were doing screenings for the deploy study. We went to a YMCA by forbidden Harrison and we had a site deploy data collection. All these soldiers who work out the why we're showing up thinking, Oh my God, I've been deployed. We hadn't thought about it, but that's what happens. Anyway. I'm at a meeting one day talking to a bunch of people from the public health department. We're at a break, Haven't you? Getting coffee? And I talked about the DPP study which had just broken. It was big news. It was making all the new sources and stuff like that. The head of the YMCA system for the Indianapolis region. So that's a really interesting study, says we could do that. I looked, I said Why? Because I go to the white bug basketball there, says yes is we're trying to be more of a community partner. We can do programs like that. Why don't we do it in the y was like the light bulb went out. Oh my god. Why not? Why not? Could we do this? Can we actually pull this off? Why do we choose the y there, lower-cost, right? From a public health perspective, a good idea. They use lay people for liters. All of our people delivering the program were highly trained, highly specialized people that were very expensive. They operate to achieve cost recovery only they don't want to make a profit. They're just trying to break even all the time. But the why and how many of you knew this, that they have a national policy to turn nobody away for the inability to pay for a program. If you go to a y and you can't afford what they're charging to work with you. They'll come up with a few you could do, but they don't. This last part, I'll tell you what, they don't advertise it a lot. They'll let you go for free if you can't afford it. That's the why is the Young Men's Christian Association, and that's the ideological frame that they use. Christian, this is a Christian idea, we should do it. Okay? And they also have past experience with national program scaling. They've done some stuff with CPR and asthma. It's not a thing. So I jumped all over this and said, Oh my God, this is a really good place to do it. And this was the other thing. They're everywhere. They're everywhere. How many of you know that there's a YMCA? Just raise your hand. I mean, come on. There you go. I mean, it's like how do you put something into the community? You put it where people go. They feel safe, they don't feel encumbered, and they know where it is. So this is what we did. We did a comparative effectiveness trial where we did the group, a group based version at this point, the why wasn't the DPP wasn't group-based. I turned it into a group mob. Okay? I also wanted to use the social support networks of groups to help facilitate it. And we did that against the brief education. We use the small steps, big rewards. We counsel people and sent them home. Okay, But see it. Alright. We had 92 people that we screened for risk. We got 92 enrolled in this study and we asked three basic questions. Can they deliver a group-based TPP hadn't been tried yet. We figured, let's give it a shot, right? Could achieve a similar weight-loss to what we saw in the DPP, which is about 5-7%, which caused that big risk reduction. Would it be less costly? That's what we wanted to know. Simple questions. And here's the data. And what you see is that there was a remarkable uptake. At that level. People hit 7% mark and they were losing the weight commensurate with what we saw in the DPP using a group model. And we pushed it out for 28 months. So not only did they lose their way, they kept it off. How many of you do weight loss research of any kind? Where you see frequently? Start here, lose a bunch of weight, gained it all back a V, You see it all the time. Boom, boom, boom. We didn't get that. However, notice that the control group, which all they got, they didn't get to, why they weren't allowed to go into why they weren't, why members they had to take the self-help materials. I would sit down or Dr. Ron Ackerman and my colleague in this, we will sit down and counsel these people and talk to him a little bit. And then this is what you could do and how you can approach it and sort of give them the, you know, go for a, here's some monitoring things to write your food. And that was it we see in six months for the digit collection, right? Why do you think they lost weight? I always asked us to crowds like this because I'm curious what you guys think. Why did everybody wait? And a weight-loss studies, you never see that it's almost unheard of, especially for 28 months. What was going on? In the same social networks? Not really. Not really. They were all up in Fishers, Indiana. That's all I can tell you. How did they know each other? I don't think so. Regression to the mean. I don t think that's correct, although they're trusting the power of having someone encourage you. I often wonder about that because I think that makes a big difference in time. So some of the supports you. There's an impact. Anybody else have a recession? I'm sorry. Recession. What do you mean? Well, 22,008. I don't know when this was. There was a housing crisis and they're somewhat of a recession. I don't know what if there's cyclical. Yeah. We never looked at that. See, this is why I asked this. Do you never know if there's a good idea we should probably check out. I don't think that I have another idea, but outside a second, I'll give what data we're much prior to 2018. Yes. The patient is 2008. Yeah. I think that recession started to write your advertising. Okay. You're you're going down the path that I know I know a factoid that you don't. We screened 138,000 people to get into the DPP study. And we screened 30,000 in Indiana, Indianapolis, 30,000 to get by 192. Huge screening curve. Okay, here's one thing I learned pretty quickly is that almost everybody that came for screening had a first-degree relatives. Mom, dad, sister, brother that had suffered from diabetes. Remember, diabetes is not a gentle disease. You don't flame now, you rust away. So you'll watch mom's foot come off. He watched dad go blind. You watched it. You know, your sister have a stroke on and on and on. It's an unkind, unpleasant experience at every one. I'm almost forgot into this study are showed up to be screened, had that experience. And my personal thing and thinking about this is in the darker night. They lay around in bed, say, God, I hope that doesn't happen to me. That that's what they're thinking. So when I give them anything and some suggestion about this can work. If you lose this weight, they do it. And when I don't have a purist, a slide that shows you that the people that lost this way did it totally differently. They did it by portion control and absolute calories. They didn't do it by backgrounds. And I can show you that. I can show you differences in fat consumption, all that kind of stuff. So there's a huge group of people out there that have a real serious issue in their hearts and their minds. And they'll talk about it too much. Maybe they only recognize it, but when you activate them, suddenly they're activated. They get it enough to do something. And in fact, this 20-month split to 28 months on the 27th split was the time when we started having people creeping up with numbers. Well, yeah, A1C was getting a little higher or a year. Their weight was certainly come back up, stuff like that. And we would counsel them at the data collection. Not a big counseling deal, but hey, you got married, looking pretty good here, but what's going on? You know, you're doing this or that and they re-energized. There's a public health message in that guy is the public health message. And sometimes we just need to focus people on what they already want to do and give them the way to get there. Good news here was we did it for a lot less money. A lot less money. That's tune and $3 free year. Okay. We can get it done. We can replicate the findings of the DPP and we could do it with lay people that we trained and we train them carefully and get it done. Now, a lot of people cartilage at a brilliant study with the workforce at Ohio, alright, and we use this model and we kinda train people to do it and away we go and it was equally effective. You can train a lot of people to do this. And if you haven't informed group that's activated because you've woken up their darkness of the night. You know, you can get this done. It's doable. It's doable. Okay. Where am I going here? So that was the YMCA experience. It was an interesting experience for me as a social psychologist. Interesting for our society because it, it, it awakened the idea that communities can be a place to put interventions. You don't have to do multiple medical school and spent tons of money. You can make it happen if you use your head a little bit. And what happened from this? Well, the National YMCA DPP took off from this to the YMCA, woke up and said, Jesus is pretty good idea. We can make this a national program. And they did. So, they decided to ramp it up to YMCAs across the country. Country. They got me to standardize the training and created a manual and figured out how to just train everybody regardless of where they were from. And we got program elements that adapted themselves to the White culture. Because y is have a culture you can't ignore that. You can't say I'm going to do it this way without accommodating what they do. One of the things about wise, and you'll appreciate this, David, just like you can't randomize within a y. You cannot do it. And the reason is the Y doesn't allow anybody to have anything that other members can't have. You could randomize wise, which is what we did. But you can't randomize within Hawaii. Well, okay. Fine. So we no longer were interested in doing a study anymore. We wanted to ramp it out. I spent a year flying around the country, training YMCA coaches in 15 states. Just go in here, go in there and setting up the programs. No research. I didn't click dated because it wasn't interested in doing that anymore. It's interesting in the program. And once I did that, we started training people to train, you know, I mean, it's like okay, I can't do this for the rest of my life, although I love Delaware and I got some cool gifts, but that's not good. So we started doing that, but they became a national program. So that was a good start. Is it enough now there's 2,700 wise, that's not nearly enough when you're talking 90 million people. It's a problem. That brought us to the UnitedHealth Group Project. There was a meeting that was held in Indianapolis after request to the NIH. My center hosted the meeting and the intention of the meeting was to bring stakeholders together to talk about what could we do to expand access to the DPP. And there were people that the VA was there and the Indian Health Service was there. Cms was there on a bunch of payers, third-party payers. Well, United Health Group is there, which is the largest provider of benefits the country. And they had a moment and they said, You know, we could do that because we collect all this data. We can identify people at risk. We have this huge database. Let's do that. We cooked up a study to study it. It 11 states with 10,000 people, but we weren't allowed to publish it. This is sort of an irony of this because it's somewhat proprietary to them. And so I didn't care. Again, there's a point in academia we have to decide, is it my career is that the public health where we could go with this? So we got the data to show them that there was a business case for it, that it made sense economically to them to prevent diabetes and not have to pick up the cost of end-stage disease, which almost everybody was faded for if they left a challenge to uncheck. Okay. And it turns out that they cover the benefit for persons identified by a high-risk by providers and referred them to why DPP sites. And they incentivize the providers to find them. They actually came up with a very elaborate structure for you get this much if you do that and you get this much if the patient does this. And they came up with an interesting model and scale, their payment was based on the performance to the Dr. right. Our whatever health care provider because it's not always doctors. And so lo and behold, we figured out how that could work. And that became a model for other companies who are provider systems to start adapting and moving it on. That was a fun day at the office. Then I got asked to help contribute to the National Diabetes Prevention Program, which is run by the CDC. This was 2011 when congressional legislation asked the CDC to come up with a national program. They established local evidence-based lifestyle change for grants for people. And you sort of see what was going on here. But they did it, which is interesting is they developed a recognition programs. If you had a DPP Program that they trained you to put up and they didn't care whether it was a YMCA or not, can be any community site. If you are performing well and getting a certain percentage of your people agate goal, you've got recognition and you've got additional support. So that was a clever thing. My contribution to that was I, I figured out the training model to figure out how to train people to implement these programs at different sorts of centers, insights. And the YMCA was an UnitedHealth Group or their inaugural partners, but they've gone way beyond that now. I was trying to look it up. But they have a little over 2000 organizations that deliver this program in 50 states. And since February, February of 2012, more than 600,000 people have gone through this program. Okay. Okay. Is that enough? No. Then cause it's not enough. It's never enough. It's a good start. It's like all the Y's work at the National GPP program is working. We have about 3 million people at 11 states to the last time they checked in 2,016.65 different private insurance companies provide some form of coverage for this program. Now we're beginning to get into public health. We're getting a public health impact. So the closest thing out, my best day at the office was in 2016 when I got a phone call from the director or CMS. Why did recognize the person says Dr. Morrow. Yes. He said, I just wanted to thank you for all your work in the GPP. So hey, thanks. Who is this like, who is this person talking to me? And they were telling me that they had made the decision to cover the benefit of going to a diabetes prevention program, either a wide base one or a CDC baseline for anybody who's covered by CMS. He said the people that bring you a Medicaid and Medicare had in my mind, that's where I started seeing there were hit policy because once CMS does it, It's a lot. I mean, it's not a lot, but it's really going to take off from there. So that's where this study led to. Okay, so I started off with an idea with a bunch of people. We fought our way into lifestyle intervention because nobody wanted to do it initially. We've showed that to work. We showed that we can expand it into community settings using lay people and less costly structures. We expanded to different places. And finally, because of the data we were generating, CMF society was worth their while and they made it part of the program. Now you're wondering, what does this, where I live, we have a wild pig varietals called heavily lean and those are all my backyard. Pick it up, bird seed. Yeah, it's an interesting phenomenon. But anyway, that's all I really had to share with you today. I can tell you about other stuff I should have talked to you more about what Karla we did with this, which is brilliant. I could talk to you about it. We used Weight Watchers is a program improve. We could use Weight Watchers effectively as a model. There's other things but, but we took a rigorous scientific study and we brought it all the way to a policy level application. Good day at the office. So thank you. Dr. Brown was wonderful. We got a good amount of time for some Q&A. Gotten any questions. I think you want to stay away from Halloween, those don't you? They can be pretty territorial and protective, right? You know what's funny about that? Because if you ever come to see me, you'll find this out heavily into our smart, intelligent group animals. And if they have a baby, There's a little one there. Excuse me. You have a baby and you get between the mom and the baby, you're in trouble. Yeah. Okay. But but I have learned to adapt to them. So if there's a table right over here, we can be sitting there having some beers. They will show up. Come right up to us. Do you have any food because they want if he jumped in the league, they said they're opportunistic because as all get out, I find that they're actually kind of interesting and they don't bother me. That wasn't my actual question, but I appreciate the local contexts. I'm impressed with the adaptations that from a group-based format. I'm curious if you've gone further or if you have thoughts on the implementation in a digital format. I mean, we've got COVID forced us to stop the meeting and groups for awhile if people do utilize digital technologies. So can you say any words about this particular intervention and digital the digital space? Has it worked? Have you tried it? Yeah, I haven't an abstract way. I started working with the group called num. Oh yeah, sure. And I'm their scientific advisor actually. And I helped them develop their program which uses a psychological, social approach to regulating eating behaviors. I'm a huge believer in the prescribing diets is worthless. Nobody can say on them and nobody wants to stay on. And everybody asked what's the best diet? It's the one you'll stay on. Changing the way you approach food is the answer. And num decided to do that with a slightly different model. But they have live coaches that you can get online with and then interact. And they have groups. That's sort of been one example. And they've actually done pretty well. They've got pretty good data is it's impressive to me. Other people come at me all the time with can we do this online and virtual? The one thing that I also learned though, is when I do groups with the DPP, like I did the y's style groups. The group process and the dynamic is very rich and vital. And it propels people to do things that normally you probably wouldn't do it yourself. I mean, the accountability to other people in sort of problem-solving. You sort of talk to somebody, how can you get around this or that? If I asked everybody in your how to get around the problem, one or two, you're going to come up with an idea that I would've never thought of. And it's a good idea. It's like, wow, that's a great idea. I should do that. So I like that dynamics. So I'm not a huge fan of created a single app and you sort of toggle on and off and stay on it. Also the data on apps that are gotten interactive apps. There's a half-life, they fall off. And that's a prog, one thing but the DPP, which people don't know, you can see all the weight back, the risk comes back, disappears. However you want to say that you start getting risk again. So it's sort of sustainability issue. So it's going to happen, someone's going to crack that nut. I think Newman did a good job, not a great job, but a good jobs. Other people are playing with it. But somehow it's about a community to me. Yeah, I'd love to see those data because you see those nomads and I wonder like, is this just another tap or another attempt? Thank you. I appreciate it. Yeah. Well, the one thing they did this very, very clever is they learn to put you in contact with a virtual coach, which is a live person, actually a live interaction. And the degree to which people interact virtually now it's pretty amazing to me. My son barely talks to me anymore. It's all done by text message and stuff like that. So I see it. I see it's coming in. I haven't thought that through yet to my satisfaction. I have a couple of questions. Sure. Definitely in persons with disability. So couple of things that we're thinking about is, how are you How was fidelity measure once you, Stephanie, you're providing training to the coaches at the different wires or fatality. And I'm going to tell you guys the truth to this and it's an ethical response. So when I started doing YMCA, National YMCA trainings, okay, When I started building this model to not only train other coaches, but to train trainers. I put Confederates into their groups. And one of the confederates without time. I mean, I mean, clearly it's just you and you go up and I picked people that would benefit. Yeah. So I had one woman that worked for me that lost 60 pounds and one of the group she was she was the big winner of that group and stuff. And she report oximeter every day. I look back on that and realize that sort of an unethical thing to do. You already mentioned I tell somebody that you could do that or something to know. I had to know. And the fidelity was quite high and I did it five or six times in different players, you know, the fidelity is pretty high. But in my training, I hammer, I mean, I hammer that there's a right way or wrong way in my way. And you do it my way as it's written here. And you're gonna get reliable results. I had done iterations and try to figure that out. And that's kind of part of the training to make sure that you understand you don't get to freewill. Because the one thing that can destroy a group, but it happens a lot. As all of a sudden you get a person who's so kinda nutritional expert and they sink the flax seed oil is the answer to everything and they just divert the program and it's happens, it happens. So that's always a problem. So I'm a real big heavy-duty, heavy handed guy about follow the script. You don't, I mean, not to say everything exactly the way I say it, but you have to follow the curriculum, you've got to follow the lesson plan. If you do that, chances are you going to get a good outcome. If you don't do that, you're on your own. Other question, I upstream or ecological models. I love that you're hitting policy or getting access to that community. But I'm thinking a lot about how I were on my work, caregiver and family based approaches. So how's this program and leverage to really hit on family support network? Everyone doing this type of program or talking about caregiver support? Yeah, we caregiver support, not so much. But I was in the middle of a study when COVID hit co-opting Mexican origin, men and women, families as a unit, teaching families instead of trying to do it as individuals. And we did a program in Indiana where we had entire families that we talk to kids on one arm and the mothers and fathers on the others. We've done some models like that. And they all work pretty well. The provenance, recruiting them, the problems getting families to participate. It's brutal. And so while I like the model that make sense to me, It's not easy, easy implementation stuff at one of the things that is a death shot to a good intervention is if this happens mostly with men to women. If I teach you how to do all this and you're the person who risks and you're making all these changes, then your husband comes home and says, I'm not going to eat that crap. We're done. You know what I mean? It's just like this isn't going to go anywhere. It's terrible. I would frequently call husbands or invite them to a session ID, a co-op them sometimes all it took was to make them aware of what the risk really was. Because a lot of people don't appreciate Di uses a 20-year later or disease. You don't remind you, you have to have a long time for you see bad outcomes. And I've had husbands break into tears because they also had a mom who lost her foot or something like that. They just didn't want to see it in their wife, that kind of thing. But how you build that in systematically, I've never quite figured out how to do that, except for putting these family programs here. When I did that, it worked and we post the data, it's pretty reasonable, but it took me forever to get enough families to make science out of it. Yeah. Dr. Ackerman is paper from 2020, that's less than 1% of the hybrid population. It was a paper on translation, DPP, and all kinds of communities and clinics. And they showed that less than 1% of the high-risk population actually received the DPP. And so I think they highlighted low-income populations in rural communities. And so how do you extend this to those communities that may not have a YMCA? The wife says, I'm sorry, great facility to have in the community, but for those that may not have that. What do you think? Some alternative solutions? Well, I liked the CDC model. Let me find any community spot there works and use it as you and I were talking about earlier in Tucson. I don't have a YMCA, So I have to use community centers and churches and whoever there's a place where people congregate and you have to factor in safety. Because in some communities, some places are gang overlapping territory sorts of issues and stuff like that, which can pull you out of the water. So I always had to find places. It was sort of let me have a neutral ground. So Historically I've used churches in both the Latino and African-American communities, worked pretty well. I've used community centers of which there's usually some around. I've used VA halls for this VH segments, something like that. And those are highly protected. Surprisingly, the V8 guys sort of washed out after the road. I love them. So it's sort of like that's what she would have to work with. You don't I mean, just got to find a place. That's if you're doing group program, if you're doing it in smaller aggregates are families and other models to do with family by family, It's just that's a very slow taking forever to get through a community, but you can do it that way. Yeah. For approval lifestyle. But there's a lot of up and coming that are getting alive, but I'm just curious what your thoughts are. Yeah. I I forget the name of the drug now. The one that just came out with that 30% weight loss reserve a time. Yeah. There you go. That can be the game changer. The downside to that. I mean, if I had a reliable drug that didn't require you to do extraordinary behavioral change and you could drop off ten to 30% of your weight. I'm going to eliminate a ton of type two diabetes at time. The problem is a side-effects and be cost. And so it's great if you could afford it or you can convince a third party payer to pay it, which would be within your interests. I could argue, I can, I can model for them. You would have an ROI that makes sense, but that's the problem. So until that happens, I've got a, I'm not a huge fan of that because lifestyle is accessible, syllabus Everybody, They don't have to put out a lot of money to participate per cent. So that's sort of how I feel about that. But the day is coming where it's going to be medically mediated. Yeah. They did studies where they did metformin and lifestyle together. We did that study. They actually three of them were done. One was done in Saudi Arabia, one was done in India, and one was Sunday United States. And it didn't make any difference. Could combine them. Surprising, Surprising. So lifestyle in it of itself is still very effective. And adding the drug didn't add anything to it. So that's with metformin, which is a mild weight-loss effect. Yeah. Switching gears a little bit. Your story before we awesome scene on your porch there was 2016. So for the CPC is programmed and prevent T2 where they've gotten the message because clearly they moved away from that Grand County and more towards weight loss. And now physical activity is finally coming a little bit more main stage. Thoughts on that. Yeah. I think you'd like to see more movement. Well, the data from the DPP showed that physical activity in and of itself had no impact. And everybody did physical activity, but she's here. So the average number of minutes people did was 225 to 27. Somebody in that neighborhood. It was quick to adopt, right. But if all you do is the exercise without the weight-loss, it doesn't work. And weight-loss with exercise requires training. It's not an easy thing to do. And many people are lulled into a false confidence that if I'm walking every day now 30 min, I can eat more. That's very common that I've observed. So it's sort of a catch-22. So I'm a huge fan of exercise. I think it's important that we clearly is a benefit. It helps maintain weight loss. But I used to say in the trainees, weight-loss as king. And weight-loss is 90% to me is mediated by calorie control of some kind. Whether you do with fat grams or non-fat grams, you would like I showed you with the control group. The control group in the deploy study, lost weight. And for every kilogram of weight you lose your risks. Risks reduced by about 11%. It's very sensitive system. So what the heck? I'm thrilled. One of the things I'm really gung ho about is when I'm running programs is if you lose anything, if you make any improvement in your physical activity rates. I'm a static. I am cheering and we're dancing, were having a party. It's like come on, because that's the thing that's hardest to get people to get out of the blocks you don't have mean and get them gone. So I have seen some data that came out of China that showed that just exercise can do it, you know, but they were exercising pretty aggressive way from my read of the data. And it wasn't always voluntary. That's the case. I mean, it was sort of like this is a program you will show up, you'll do it. And so, yeah, but if you exercise sufficiently and it wasn't like extraordinary exercise always like they're training for the Olympics or something. But it had an impact in the physiology of it made sense. So yeah, I think people should move more. So based on what you're telling me, I'm curious to know why versions that you will away from the fact that I am not suggesting that the PA is above the weight loss, but if it's king and queen, right? I, I cannot answer precisely why they chose the fat gram difference because part of the reason of surfactants, the DPP was the lipid impact as well, which is a co-morbid condition with diabetes. But it got to the point where we realized that people had a hard time tracking fact grams. It's not easy to track backwards. You have to look it up. You've got to know stuff in combination foods or a bitch, mean casseroles and stuff like that. So I think they decided just calorie control however you achieve it, because lots of data showed that that work. Was it. The increase in physical activity makes perfect sense. And I did talk to people about that because people are much more quick to adopt that and it's reinforcing. So if all of a sudden you'd never walked outside your house or to the mailbox or something. Now you're walking around the block. That's the first step in a cognitive shift to a more healthy lifestyle. And so I think they said, Well, okay, with the security market size. Because it's going to activate the individual. And then on top of Australia gets a portion control and reduce the shirt galleries. Excuse me, sir. So one of the things that strikes me often when we talk about behavioral sort of approaches to many health problems, is that we have the behavioral community sort of bring our hands a little bit to look at this great thing we have to offer. Why is it the world beating a path to mark your work? Don't they get? And the reality is apparently not since we have this conversation regularly. And so are we, in some sense addressed the world as we wish it would mean? That is a people say, That's good, I liked that behavioral thing and I'll need a path to your door. As opposed to the way history shows us. When we look at here, have we had a big impact and think about fatter tires on her. She put airbags with guardrails on the roads. You built them with better engineering proceeding. Miners. The Davy lamp for them liners, right? So often, smallpox, you make a vaccine and then people not to do anything and they get the vaccine. And we know that's an issue with polio. You have to do something and there's a choice. Some things don't always go quite right, but too much trying to address the world as we wish it would be people who should be, what we think is rational to come to us for our behavioral. Don't have that. Where even though as you said, if you can get them in it works. Whereas fluoride in the water, chlorinating water, airbags and vehicles be able to do anything. And they say, What are your thoughts about? It's an interesting question. I'm going to free associate here. Might look at the data over all the studies to try to do this type of thing is about 15% to 20% of people here at religion and they take to it. They show up the rate of play. I'd say probably about 20% of people have nothing to do with it. They, their lives just so much more complicated. Lifestyle change to dietary regulation is a non-issue. They're trying to put meals together avoid being beaten up by their spouse. Their lives are complicated, so it's that this is not what they're gonna do, regardless of what I could convince them up. Subgroup in the center of that 60%. And in my mind, the goal is always to elevate as many people up to the, I'll do it and keep as many people from going down into the, My Life is too complicated. So that sort of gets us into a social determinants issue, which is the world I live in now, which is a big deal. You know, it's like I could convince a lot of people that I have a great idea. But if their lives are so impacted by racism and food deserts in health access and on and on and on. The plethora of social factors that can interfere with any behavioral change and their interests survival mode. Unless I addressed that, the rest of this is meaningless. I'm wasting my time and I'm wasting them. It's like teaching the pig to dance analogy, you know, irritates the pig, frustrates the teacher. You know, it's sort of like, I don't bother anymore. So I've been spending most of my time attacking the high health disparity population is of Southern Arizona, right? Which trust me, there's some real nightmare crap going on in there. And I'm happy if I can improve their life, let alone change it to promote their health. Does that make sense? So, so, so much, I sort of agree with you the sense of like, I'm not going to waste my time. If I go into a family or a community, I sell my God. These people are just yeah, they don't have food, they have water there on this, they don't have that. Then I shift gears right through there and say, Okay, I'm going to start linking you with these services. This is what you need to be into. I'll come back around when we've fixed some of this stuff, we can talk about it. And by the way, if you lose a little weight, we could. Because I always tell them, you know, just, just one kilo is a big improvement. So think about it, but that's the conundrum I find myself in all the time, all the time. So don't waste your time trying to promote a perfect program to a population where at least 40 to 60% of them aren't ready for it. Our couldn't utilize it in a meaningful way. That's wasting time or resource. So for that 15, 20% step on it and let me get you fixed. I don't have to worry about them. They just take off. It's like a falcon, take up the hood and go get the bird. And so off they go that 20% at the bottom. They need so much more than I can give them, you know, but you try, if you tried to save what you can have also achieved the reality that I let some people think, you know, I can't say. I want to buy Kent. And so there was a time when David where I was just it was so upsetting to me. I just I couldn't believe I lost this person did they went under and then finally one day I realized, you know, come on man, You know, you gotta, you gotta do what you can for those can receive it. If they can't receive it, then you can try to help with other stuff, but you can't you can't hurt your program and your effort because they sunk, if that makes sense. Yeah. So that's how I think. That makes me a little weird. Well, one more question. All right then. Well, thank you so much. It's been a pleasure being here today with Dr. Miller. Dr. Brown. Oh, wow. We can't dance now. Yeah. This woman did remarkable work in a tough environment in Ohio. You should get her to talk about it sometimes. I mean, unbelievable. So on behalf of the school to college, get handed to you. Thank you. Thank you very much. Oh, wow. Very cool. Yeah. Hello. Am I kind of just so you have a little something heavy to carry back. Oh, wow, we have this nice token of our esteem here because you truly are distinguished professor and you truly have made a difference in the world. And you are truly embracing the spirit of Public Health Scholarship in both being a great scholar with the evidence generates a great portrayed her beneficence will help someone who does not only well, but does good. Thank you. Thank you so much. Wow, this is amazing. Show that to everybody else like Vanna White. Good. Thank you. Alright, yes, remarkable. Thank you. And I'd love to story about the Halloween it breaks. Those are the only needed pigs in North America. Now, when you get that while or at the restaurant, Excuse me, why? Were you know that? Technically those are peccaries. They're not actually pigs. It's a derivative of the family. They're terrible, terrible. A lot of them are autumn Indians which are indigenous to this area. They perfected how to cook because I've actually had handled in it because they can be hunted as a season forms. But they're miserable and nobody likes to eat them. So nobody Hudson, yeah, I mean, it's, it's only the Indians. That's it. So, you know, and I have heard from people who have shot them thinking it's like pork. It's not that it's gamey is terrible. And one that's a little trivia thing where people hunt them. They have to take a kiddie pool, like a little foot inflatable kiddie pool and fill up with a flea dip. Because these things have fleas on them that are supposedly epic. Last thing where they get, when they get afraid, this hair which is very core, stands up and it's about 6 " long and they go like a like a big puff ball. You don't even eat. And they were quite intimidating when they do that. Anyway, but yeah, so that's you can put all those together. I have no interests to need you to handle. We'll stick with the federal law. Yeah. Yeah. Barrel horse. Very good. Yes. Thank you. Dr. Marilyn