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The diaTribe Foundation hosted its inaugural d16: Executive Innovation Lab on Diabetes and Obesity from January 13–15, 2016 in Palo Alto, CA. d16 engaged leaders across diverse sectors to produce innovative, systems-level solutions that could reduce the societal burden of diabetes, heighten the urgency and need for action around the epidemic, and bring a new way of thinking into the diabetes ecosystem. Using elements of “design thinking,” participants were guided through collaborative workshops to offer innovative solutions to the most pressing challenges in type 2 diabetes.
Forty-two participants attended d16, including prominent medical professionals, entrepreneurs, manufacturing leaders, policy-oriented healthcare experts, academics, tech leaders, government decision makers, educators, media experts, food and nutrition scholars, and philanthropists. Participant biographies are available at d16.diatribe.org.
Summarized below are the twelve ideas that came out of d16 that we believe are the most investible, scalable, and impactful. They are not finalized project proposals, and we welcome any and all feedback to further develop and improve upon them.
The majority of people with diabetes experience stigma related to their disease, and this contributes to many negative consequences, including: patients ‘hiding’ their diabetes from their friends, family, peers and employers; the perpetuation of this stigma in the media; an absence of type 2 diabetes advocates...
Summary: The majority of people with diabetes experience stigma related to their disease, and this contributes to many negative consequences, including: patients ‘hiding’ their diabetes from their friends, family, peers and employers; the perpetuation of this stigma in the media; an absence of type 2 diabetes advocates or a strong patient voice to influence policy and funding; and negative psychosocial impacts that affect quality of life and patient outcomes.
The LGBT community, in particular, offers many lessons in how to address stigma from which the diabetes community can learn. d16 participants created the concept of National Show Up Day, inspired by the LGBT rights movement’s “Coming Out” Day. This day is about a sea change in public perception, behavior, and conversation about type 2 diabetes. It is about providing a safe place for people with diabetes to talk about their disease and about demonstrating that they are not alone. It is an annual day set aside each year for individuals to speak publicly or to their family and friends as people living with type 2 diabetes and for their community — loved ones, employers, caregivers, government, nonprofits, and shops and restaurants — to show people with type 2 diabetes that they are supported in all areas of their lives. This day would be coupled with mechanisms to keep the conversation ongoing, from small efforts like design icons for vendors and restaurants to display to show their support, to larger details like an annual awards program to recognize businesses and individuals who have truly “shown up.” It is backed with a sound partner strategy (i.e., Nike creates a custom “Show Up” shoe, Walgreens gives free A1c tests on Show Up Day, etc.) and a go-to-market plan. While the movement may start with a single “Show Up” day, over the long-term it could evolve into a broader movement surrounding health and wellness in our day-to-day lives.
System Impact: d16 identified “stigma” and the lack of a strong, visible type 2 diabetes patient advocacy community as root causes influencing and perpetuating the scope of the epidemic. When patients and their communities don’t talk to each other about type 2 diabetes:
National Show Up Day mobilizes the entire type 2 ecosystem to “show up” together to combat the root cause of stigma, help eliminate the shame associated with diabetes, put the need to address diabetes at the forefront of people’s minds, and encourage those with type 2 diabetes to become advocates. In addition to addressing stigma, National Show Up Day would aim to transform the conversation to focus on the root causes of the epidemic and free people from self-blame and shame.
Various efforts throughout the US and abroad have been shown to significantly improve outcomes related to diabetes, but many of these models have not been scaled or replicated on a systemic level, due in part to a lack of information-sharing. An opportunity identified at d16 was to create an accessible “anthology”
Summary: Various efforts throughout the US and abroad have been shown to significantly improve outcomes related to diabetes, but many of these models have not been scaled or replicated on a systemic level, due in part to a lack of information-sharing. An opportunity identified at d16 was to create an accessible “anthology” of existing work that has been demonstrated to be effective in improving outcomes for people with type 2 diabetes. The size and scope could be expanded over time. Such an anthology could also include insights from other disease areas that could be applied to diabetes. This could be an evolving anthology with regular updates, and it could be available through multiple platforms (an annual report, a website, etc.). The anthology could include resources for each model including primary contacts, accessible publications or data reports, and other information to help people replicate successful efforts in other networks. On a broader scale, the Anthology of Bright Spots could further highlight those efforts that have impacted the field of diabetes through an awards program or through a national convening event to connect those interested in either contributing resources, scaling existing projects, or in learning about those models.
System Impact: The diabetes ecosystem is fragmented, resulting in a lack of knowledge sharing across people in different sectors. These include those involved with academia, local grassroots efforts, policy initiatives, clinical research, and more. There are several consequences to this fragmentation:
An Anthology of Bright Spots would serve to increase transparent information sharing in diabetes, highlight successful efforts in diabetes that can be scalable, and allow for cross-sector collaboration.
Of the more than 29 million people with diabetes in the US, over eight million of them are undiagnosed. Moreover, 90% of the 86 million Americans with prediabetes don’t know they have it. Early diagnosis of diabetes and prediabetes allows for early intervention, treatment, and prevention efforts...
Summary: Of the more than 29 million people with diabetes in the US, over eight million of them are undiagnosed. Moreover, 90% of the 86 million Americans with prediabetes don’t know they have it. Early diagnosis of diabetes and prediabetes allows for early intervention, treatment, and prevention efforts, hopefully lowering the rates of diabetes complications and significantly altering the patient journey that can often result from prolonged hyperglycemia.
d16 participants examined the underlying causes of this problem. Part of the challenge is a lack of education, and another factor is that screening has not been integrated into mainstream society. Once again, the diabetes community can learn from successful efforts in other areas such as annual flu shots, blood pressure cuffs in super markets, regular mammograms, and regular STI testing. Contributing factors to these examples resulted from public and provider education about the impact of these efforts, guidelines from professional societies, and partnerships with industry groups.
System Impact: Inadequate screening for diabetes and prediabetes has several consequences for the healthcare system:
This program would not only enable more diagnoses of diabetes and prediabetes, allowing for earlier intervention, but it would also raise awareness of the critical need to “know your number” and to be regularly screened for diabetes.
How might we create a standard set of nutrition guidelines for all food distributors (manufacturers, restaurants, vending machines, etc.) with a corresponding score or “award” for those who meet the guidelines...
Summary: How might we create a standard set of nutrition guidelines for all food distributors (manufacturers, restaurants, vending machines, etc.) with a corresponding score or “award” for those who meet the guidelines? The idea stems from carbon taxes, in which the government will decide what the threshold for nutritional foods offered must be for any given food distributor, and those who meet that threshold would receive some form of tax reduction or other financial incentive. Moreover, these places would also receive a very visible, easy-to-understand stamp of approval. For instance, restaurants who meet the threshold would have to put a green stamp on all their menus (and perhaps are also then rewarded financially, i.e. tax subsidies), those who are middle-tiered would put a yellow stamp, and those that very poorly address the guidelines receive a red stamp (and perhaps are also then punished financially, i.e. increased taxes).
System Impact: Across the diabetes ecosystem, many incentives currently in place enforce a “diabetogenic” environment. As one d16 participant said, American culture and society have created a “perfect storm” for creating a diabetes epidemic. By providing financial incentives for food distributors to offer more nutritious foods, the quality of food commercially available will be more likely to improve, thus making “the healthy choice the easy choice.”
The goal of this program would be to incentivize food distributors to offer increased selections of healthier food, and to provide a clear and visible marker for consumers as to where they can eat that provides nutritional foods.
Sugar-sweetened beverages, or SSBs, include soda, sweet tea, sports drinks, juices, and other beverages with high levels of added sugar. These drinks are high in calories but low in nutritional value, and have been estimated to be the number one source of added sugar...
Summary: Sugar-sweetened beverages, or SSBs, include soda, sweet tea, sports drinks, juices, and other beverages with high levels of added sugar. These drinks are high in calories but low in nutritional value, and have been estimated to be the number one source of added sugar and excess calories in the American diet, accounting for 7% of all calories consumed on average. The average American drinks 44.7 gallons, or nearly 500 cans, of carbonated soft drinks every year. And one Gallup poll found nearly half of Americans drink at least one soda a day, with 7% drinking over four cans daily. Sugary drink intake has been linked to weight gain, obesity, and type 2 diabetes. This nationwide tax would be designed to discourage the production and sale of SSBs and reduce overall sugar consumption by people in the US.
Such taxes have already been passed on a national level in Mexico in 2013, which reduced purchases of sugary drinks by 12 percent in one year, with the biggest reductions among low-income populations. In addition, purchases of untaxed beverages increased 4% (36 ml/capita/day), which was mainly driven by growth in the purchases of bottled water.
In 2016, Britain announced plans to enact its own soda tax, with the hopes of instating the tax by 2018. In November 2014, Berkeley, CA became the first city in the US to approve a soda tax, and San Francisco and Philadelphia are actively working to have a soda tax passed as well. In Berkeley, early positive reports show a 16% reduction in sugar-sweetened beverage consumption post-tax. Scaling the SSB tax effort up on a national scale is one example of a “quick win” using policies that can affect a lot of people in a short period of time and at a relatively low cost.
System Impact: Passing a nationwide tax on sugar-sweetened beverages would help to address our current “diabetogenic” society on a systems level by focusing on the environmental factors that perpetuate the development and progression of diabetes and its complications, increasing awareness and shifting public perceptions of the harmful health effects of sugar-sweetened beverages, and could open the door to move aggressive policies down the road once public support has increased. In the past, taxes on cigarettes have been successful at reducing smoking among Americans, and the hope is that a nationwide tax on SSB can also reduce soda consumption and move the needle on public health.
Such policies could have a large-scale impact on prevention of not only type 2 diabetes, but also obesity, high blood pressure, heart disease and strokes. Scientists at UCSF estimated that a nationwide penny-per-ounce tax on sugar-sweetened beverages would prevent nearly 10,000 cases of heart disease, 8,000 strokes, and 26,000 deaths over the next decade, as well as 240,000 cases of diabetes per year. It would save $17 billion over the next decade on healthcare spending related to diabetes and obesity and its complications, and would generate $13 billion per year in direct tax revenue that could be further invested in other areas such as prevention or education.
Some opponents of SSB tax efforts claim that it would disproportionately affect low-income consumers economically. As Dr. Tom Farley, author ofSaving Gotham: A Billionaire Mayor, Activist Doctors, and the Fight for Eight Million Lives stated in the New York Times, however, “…the poor are disproportionately suffering from obesity and type 2 diabetes as a consequence of sugary drinks. They drink more sugary drinks now than people who have more money. Because people with lower incomes are more price-sensitive, they will disproportionately benefit from efforts to reduce sugary drink consumption.”
*Note: Three members of The diaTribe Foundation (Kelly Close, Christie Auyeung, and Nicole Kofman) are currently enrolled in an online class through the Harvard Kennedy School of Public Policy called “Leadership, Organizing and Action: Leading Change.” With a focus on community organizing and leading social change, the class is helping The diaTribe Foundation strengthen its understanding of successful movements and putting its leadership skills to practice. The Foundation has chosen to pursue “A Nationwide Tax on Sugar-Sweetened Beverages” for the required “organizing project,” and anticipates that the class will provide structure and support to help us contribute to the ongoing efforts to pass a soda tax in San Francisco.
Diabetes is a disease that is largely ignored, misunderstood and stigmatized by the general public. While this is due to a complex set of factors, one contributing factor is that there is very little representation of the diabetes patient experience in film and television...
Summary: Diabetes is a disease that is largely ignored, misunderstood and stigmatized by the general public. While this is due to a complex set of factors, one contributing factor is that there is very little representation of the diabetes patient experience in film and television. Just as the gay rights movement benefitted tremendously from shows such as Ellen, Glee, andModern Family, or as the environmental movement benefitted from An Inconvenient Truth, we believe that providing more visibility for diabetes in entertainment and media would help to both build a sense of urgency around addressing this public health epidemic as well as help to educate the public and reduce the stigma associated with the disease. One example from outside of diabetes that can serve as a model is Google’s work with film/television producers to create female characters with computer engineering backgrounds. With funding support, a backbone organization could encourage film and television writers to include characters or families with diabetes. This effort could expand into a broader patient movement, in which people with diabetes get involved through signed petitions, a shared hashtag, or other initiatives to publicly call upon film/media executives to include characters with diabetes and remove inaccurate portrayals of diabetes (i.e., diabetes as a punch line).
System Impact: Stigma and the lack of public understanding about type 2 diabetes deter companies, governmental bodies, or the general public from giving the disease proper attention. Increased visibility of type 2 diabetes through outlets that reach millions of viewers would enhance public health literacy, generate public empathy for patients, and help transform public opinion of diabetes from a shameful or non-serious condition to a major health crisis that impacts society.
The healthcare system in America was developed as an acute care management model — with a primary focus on diagnosing and treating symptoms and illnesses. However, diabetes, obesity, as well as many other chronic conditions...
Summary: The healthcare system in America was developed as an acute care management model — with a primary focus on diagnosing and treating symptoms and illnesses. However, diabetes, obesity, as well as many other chronic conditions, require a shift in the way individuals and their conditions are addressed — with greater participation of the person with the condition and a greater emphasis on daily management or self-management. The Affordable Care Act (ACA) has created unique opportunities to shift our healthcare delivery system to better match the daily needs of the growing segment of our population living with chronic conditions.
According to research by the Commonwealth Fund, the ACA encourages three core approaches for improving healthcare delivery: testing new models of healthcare delivery, shifting from a reimbursement system based on the volume of services to one based on the value of care, and investing in resources for system-wide improvement. Accountable Care Organizations (ACOs) and patient-centered medical homes (PCMHs) are two such examples of evolving care models influenced and/or supported by the ACA. The Centers for Medicare and Medicaid Services also offers a “menu of options” for healthcare systems to improve care, increase care access, and lower costs through better care coordination.
A critical component of this shift is a transformation of the patient’s healthcare team. The typical primary care model in which patients spend less than 20 minutes with their doctor a few times a year does not provide: adequate continuity of care for people with diabetes; the time physicians need to adequately address the complex nature of diabetes and related conditions; and the clinical staff needed to ensure all of the medical, behavioral and psychosocial needs of a person with diabetes are being met. Several models in the U.S. have successfully leveraged care providers in addition to physicians — pharmacists, nurse practitioners, health educators, case managers, social workers, and more — to cost-effectively provide ongoing team-based support for people with diabetes. It is now necessary to identify care models that have proven to improve outcomes, care access, and quality and scale those programs.
System Impact: To provide greater access to a more comprehensive, continuous, and individualized care team for people with diabetes, ultimately driving down costs and improving health outcomes.
Many powerful social movements have originated in schools — D.A.R.E. and recycling are two examples. How might we create a similar movement among school-age children to become change agents for better nutrition and physical activity...
Summary: Many powerful social movements have originated in schools — D.A.R.E. and recycling are two examples. How might we create a similar movement among school-age children to become change agents for better nutrition and increased physical activity? It would originate first on a local level within a specific school or school district, and successful programs or pilots would be scaled on a broader level. These efforts should be in addition to larger, national efforts to improve school lunch offerings and mandated physical fitness curricula. For instance, pilots could include:
System Impact: The goal is to make kids passionate about nutrition and exercise in a way that will not only affect the way they behave, but also that will impact their parents. Just as kids compel their parents to recycle, wear seat belts, quit smoking, etc., they would be aware of what constitutes healthy eating and physical activity and encourage it at home.
Access to peer support upon diagnosis of a disease and/or chronic condition can dramatically impact patient outcomes and quality of life. With advances in technology, access to such support no longer needs to be in-person...
Summary: Access to peer support upon diagnosis of a disease and/or chronic condition can dramatically impact patient outcomes and quality of life. With advances in technology, access to such support no longer needs to be in-person. This is evidenced by the tremendous growth in online patient communities that provide information and support to individuals and/or caregivers sharing a similar diagnosis. Such communities exist within the diabetes community, but many of these communities are large, overwhelming and intimidating for people recently diagnosed when there is so much to learn and adopt. This initiative would create a community, or sub-communities within existing communities, for people based on their date of diagnosis. The goal is to group people together that are processing information, learning, and beginning their patient journey at the same time in a single, safe place. As diabetes often comes with significant levels of stigma, having a social support network can be critical — particularly as many patients find it challenging to talk about their diabetes with friends or loved ones.
System Impact: This program would ensure that nobody feels alone living with diabetes, helping to decrease feelings of stigma felt by patients. It would also help build up a diabetes patient community connected by shared experiences that feels empowered to take action.
The “Diabetes Shark Tank” would entail a conference in which people are invited to submit and defend proposals for diabetes “moonshots,” or programs/interventions that could make wide-scale impact on the lives of people with diabetes...
Summary: The “Diabetes Shark Tank” would entail a conference in which people are invited to submit and defend proposals for diabetes “moonshots,” or programs/interventions that could make wide-scale impact on the lives of people with diabetes. The Epilepsy Foundation and the American Heart Association have launched ‘Shark Tank’ initiatives to spur investment in ideas to help their patient populations. While both of these programs are relatively new, they may yield important insights that would be helpful as we think about a similar program in diabetes. Such an initiative would create an innovative and exciting marketplace bringing together bright minds to create and invest in the future of diabetes prevention and treatment.
System Impact: Funding for diabetes, both at the federal and private philanthropic level, is very low relative to the population impacted. Only 3% of NIH funding goes to diabetes, a disease that affects the entire US population to some extent. Moreover, funding for innovation in health services in delivery, which examines access, care quality, and population health amounts to just 0.3% of total healthcare expenditures and roughly one-twentieth the sum that goes into science research. Under current funding:
This program would encourage more focus and innovation on projects that could make scalable impact and address the societal causes of diabetes, rather than focusing on treatment of symptoms. Moreover, it would create a new funding stream and could attract new investors focused on impact into diabetes.
The past decade has seen a “healthy lifestyle” movement in America; however, this focus on healthy living has largely been concentrated in higher-income, mostly white communities. Examples include organic food markets...
Summary: The past decade has seen a “healthy lifestyle” movement in America; however, this focus on healthy living has largely been concentrated in higher-income, mostly white communities. Examples include organic food markets, boutique exercise studios, or even farm-to-kitchen or chef-to-kitchen food delivery services such as Blue Apron. The idea for this program is to adapt these models for low-income communities, or to scale up programs that have shown effectiveness already around the country. One example is local non-profit grocery stores that bring nutritious food to people at affordable prices. Other ideas would include a mobile “produce truck” in low-income neighborhoods, a low-cost “Blue Apron” product, providing nutrition education inserts at all grocery stores in low-income neighborhoods, and more. These ideas could be piloted in local communities and then, for those that demonstrate effectiveness and feasibility, could be scaled to reach additional communities.
System Impact: Studies consistently show that low socioeconomic status is one of the most significant risk factors for type 2 diabetes. These populations already are the most disadvantaged when it comes to treatment options, as drug prices continue to rise and the most advanced diabetes medications are not yet generic. Thus, altering the built environment and increasing the offerings and affordability of nutritious foods may have a significant impact on reducing diabetes risk in these groups.
How might we create a model built upon currently existing employee wellness programs and other initiatives that provide financial incentives for people to improve their health..
Summary: How might we create a model built upon currently existing employee wellness programs and other initiatives that provide financial incentives for people to improve their health? How might we create healthier communities, companies, and cities by investing in health?
In the case of diabetes prevention and treatment, improving one’s health could mean losing weight, lowering A1c, or even improving mental health through yoga, meditation, or other efforts. Several programs that could be initiated include:
As examples, Aetna’s wellness program currently pays employees $25 for every 20 nights they get at least seven hours of sleep, and IBM offers up to $500 in gift cards for employees and their children to exercise regularly. Piloting these programs in more businesses and scaling them up across the country could be impactful towards building a culture of health and decreasing overall health expenditures. Indeed, tracking outcomes of existing wellness programs has demonstrated a substantial return of interest; Johnson and Johnson leaders estimate that their wellness program saved the company $250 million on health care costs over the past decade.
Another example of how employers could directly influence the health behavior of their employees is UCSF’s campus-wide “ban” on soda, eliminating the sale of sugary beverages on campus to reduce sugar consumption by students and employees. Such efforts to create healthier work and learning environments, encouraging students and employees to reduce sugar consumption, could be replicated and scaled at other universities or companies.
2. Investing in Health: The Way to Wellville and A Culture of Health
How might we shift capital and outcomes to produce health upfront rather than try to recover it after illness occurs? How can we bring Silicon Valley thinking to health to help communities reduce obesity and diabetes, foster a healthy food supply and provide better access to care? Several initiatives are making headway on this front, and scaling up these investible ideas could move the needle on public health.
For example, a nonprofit called the Health Initiative Coordinating Council (HICCup), is leading a collaborative effort titled “The Way to Wellville” a five-year effort giving five small (<100,000 population) communities expert advice on capacity building, development of local leaders and sustainable business and financial models, access to capital and partners, and help with data collection and analysis so that they can meet and measure their goals for health. The “Wellville Accelerator” borrows from startup accelerator models in Silicon Valley, where emerging companies are incubated and mentored by experts. In Wellville, communities are the startups, HICCup is the accelerator, and better health is the return on the investment. Way to Wellville goes beyond pilots and helps communities apply well-known techniques in sustained initiatives and through institutions that are accountable, measurable, and ultimately fundable.
The Robert Wood Johnson Foundation has also partnered with The Reinvestment Fund as part of their Culture of Health program to work closely with cities to use data to better understand the needs of their most at-risk neighborhoods — and then invest in new initiatives that can revitalize housing, health, transportation, education, and other assets that help communities to become stronger and healthier. They’ve launched Invest Health, which will give up to 50 mid-sized cities $60,000 each to work across sectors and start to map out the kinds of changes they want to make.
System Impact: This idea positions health as a return on investment at the level of the workplace or city. For employers, diabetes poses a major economic burden, largely due to medical costs and loss of productivity costs. The incremental cost of diabetes among employees has been estimated at over $4,000 annually per person, with 30% of costs to employers attributed to medically-related work absences and disabilities. While prevention efforts and employee wellness programs may present initial upfront costs to employers, the long-term costs saved could offset them, particularly if there were a financial benefit incentivizing employers to implement these programs. Furthermore, organizations are finding promise in bringing Silicon Valley thinking to health, using data to map out goals based on successful models, working collaboratively across sectors to implement them, and making financial investments in communities and cities. If we can scale up examples of these programs that we know work, this idea presents an impactful, investible, and scalable approach to preventing diabetes.
