Diabetes is one of the most pervasive and expensive chronic diseases: It affects an estimated 30.3 million people in the United States and costs a staggering $245 billion per year to treat. In addition there are 84.1 million adults in the United States with high blood sugar levels in danger of developing type 2 diabetes. It is widely acknowledged that the most effective method of treating these prediabetics so they don’t become full-fledged diabetics is diabetes prevention programs (DPPs) that follow a protocol validated by the Centers for Disease Control and Prevention (CDC). But the challenge has been to get people to enroll in them in the first place and stick with them if they do.
Omada Health, a digital therapeutics firm focused on preventing obesity-related chronic conditions such as type 2 diabetes, has made significant strides in achieving both with the 120,000 prediabetics who have participated in its program. Its success demonstrates the potential of digital health services, and its approach can serve as a model for applying such services to other chronic diseases. We studied Omada’s program as part of our Harvard Medical School initiative to identify and share knowledge about innovative approaches to major health challenges that primary care providers play the lead in treating.
DPPs typically include in-person meetings of a small group of prediabetic adults who, with the guidance of a health coach, progress through a diet and lifestyle curriculum. The course usually consists of weekly sessions during the initial four months. Participants then receive monthly support via check-ins with health coaches for an additional eight months. A number of organizations — including the YMCA, the American Association of Diabetes Educators, and the Diabetes Prevention and Control Alliance — provide in-person DPPs at various locations.
One of the barriers to getting prediabetics to participate in these in-person programs is the time and expense required to travel to and attend them. Omada addressed these obstacles by creating a 16-week online behavioral-counseling curriculum with modules on nutrition, physical activity, and strategies to minimize stress. The company worked collaboratively with the CDC and was one the first three digital DPP providers that the agency recognized for meeting its evidence-based standards.
Three critical lessons can be distilled from the Omada experience:
Adopt a validated approach. Rather than create a new prevention method, Omada cofounders Sean Duffy and Adrian James decided to build the company’s program on the foundation of a proven clinical intervention: A landmark 2002 randomized controlled study had demonstrated the efficacy of DPPs, showing the behavior-change programs were more effective than a pharmaceutical intervention for prediabetics. While the in-person DPPs were largely successful in reducing disease risk and incidence, Duffy and James recognized that there was substantial opportunity to better scale the DPP and make it more accessible and personalized by using technology. They essentially took every component of a standard DPP, delivered it digitally, and have continued to add additional elements.
Design the service for the patient. Omada carefully designed its service to guide participants through an interactive journey that is integrated into their everyday lives. There were three design goals: engaging participants, making a good initial impression on them, and making it simple for them to participate in the program.
To ensure that the motivating relationships and connections in traditional DPP programs did not disappear when a digital platform replaced the in-person meeting element, Omada grouped participants and health coaches into cohorts based on where they live. Some of the San Francisco-based groups, for example, bonded via discussions about the Golden State Warriors basketball team and opportunities to be more active in the city. This group dynamic cultivates a social network that offers real-time feedback, support, and accountability.
It is easy for participants to get started in the program. When they qualify for and join the program, they are given access to Omada’s platform, which is available online and via a smartphone app. They use it to take the 16-week initial curriculum (the foundations phase) and then to continue to participate for an additional eight months (the focus phase).
In the foundations phase, participants access weekly lessons, communicate with their virtual cohort, which is led by a professional, full-time health coach, and privately work with the coach to address individual challenges.
During the focus phase, they continue to have access to their health coach and weekly lessons designed to reinforce habits introduced in the initial curriculum. In addition, they retain contact with their initial cohort and can interact with people in others as well (to make a wider range of support and experiences available).
One of the key metrics that the Omada program tracks is participants’ weight. (Weight loss is a clinically-accepted proxy measure for reducing the risk of developing diabetes.) Upon enrollment, each group member receives a welcome kit, which includes a digital scale that connects to cellular networks and automatically transmits daily weigh-in numbers to Omada’s health coaches and data scientists, tracking a participant’s progress towards a goal of losing 5% to 7% of his or her weight. The scale connects without the need for a home wireless network and requires no set-up beyond the insertion of a battery, making the program more accessible for elderly or low-income participants who may not be tech-savvy.
Emphasis on outcomes. Omada is dedicated to delivering results. The digital scale allows health coaches and data scientists to know instantly whether or not participants are weighing in on a daily basis. Omada encourages members to establish a routine for weighing in every day (e.g., weighing themselves first thing in the morning). This increases compliance, allows participants to see their progress, and enables Omada staff to closely monitor any unexpected changes in a participant’s weight so that health coaches can intervene if a participant needs more guidance and support. For example, if a coach observes that a participant is not losing weight, she can talk to him or her about why that is and can suggest healthy recipes. By collecting several daily measures — including weigh-ins, interactions with the health coach, log-ins, and interactions with the group — Omada can study members’ engagement and personalize the approach to better meet their individual needs.
Omada is paid on the basis of outcomes: a participant weighing in a minimum of three times a month and losing weight. This provides the company with an incentive to improve participants’ lifestyle habits and prevent diabetes. Omada’s leaders believe that this pricing model demonstrates their commitment to delivering results and a return on the investment of its partners (employers and insurers). It shares real-time, de-identified, aggregate reports with its partners so they can see the progress and publishes its outcomes data. One study indicated that after 16-weeks, Omada participants lost 4% to 5% of their body weight and kept most of the weight off two years after completing the program, thereby decreasing their risk of developing diabetes.
Going forward, federal payment and reform initiatives to encourage screening to identify prediabetics will make it easier for health care providers to refer prediabetic patients to programs such as Omada’s. Its DPP provides a model of how digital health interventions can be used to address other conditions in ways that reduce costs, improve patient involvement in their own care, and mitigate the overwhelming burden of chronic diseases in the United States.