Ron Ackermann, MD, MPH, Scientific Advisory Council Co-Chair

How did your interest in health equity begin? 

I started to be interested in health equity when I was training as a resident in San Antonio, Texas. I saw patients in a county-run primary clinic, and my patients were probably 60 to 65% Spanish language primary, mostly Mexican first-generation immigrants, and they had a disproportionately high burden of diabetes, high cholesterol, and heart disease. It struck me that I was learning how to prescribe medications really well as a trainee, and I knew what what I was supposed to monitor in terms of their blood glucose and blood pressure and target goals for all of those treatments, but a lot of times my patients couldn’t get access to the medications. They would come back with persistently high blood pressure, I would talk to them about their medications, and prescribe a new medication. Over time, I realized a lot of times they were facing barriers to fill the medications. They didn’t always understand the dietary advice or other advice because of linguistic or cultural barriers. I didn’t always have access to translators even though it was San Antonio. I came to realize we weren’t always offering culturally salient care.

I got interested in chronic disease and adults and how the greatest burden of conditions like diabetes affect people of minority race and ethnicity, people who live in low socioeconomic environments or face social barriers. Our health system was not designed in ways that were equally effective or beneficial for everybody. It seemed like the people with the greatest burden of disease were at the greatest chance of being disconnected from the benefits of the health system. I got interested in how research can help identify the root of those sorts of problems and potentially test solutions that improve both population health for chronic conditions and health equity.

Where did your research begin, and what are you working on now?

Like a lot of physicians who realize they want to pursue research as part of their career, I did a fellowship after my clinical residency and learned epidemiology, biostatistics, how to formulate strong research questions, how to write grants, and how to work in teams. I developed the knowledge and skills I thought I would need to be an effective academic researcher. At my first job at Indiana University, I worked on two active projects. One was TRIAD (Translating Research into Action for Diabetes), a study of how the way we offer care to people with diabetes impacts their outcomes. Part of the study looked at the distribution of those outcomes in a very large and diverse patient population that spanned multiple parts of the country, so we asked questions like, does it matter what sort of neighborhood or environment you live in or what race or ethnicity you identify with. I also worked on a project that was evaluating policies and systems interventions for Medicaid patients so I spent about half of my time collaborating with a team that was specifically evaluating ways to improve health outcomes for chronically ill children and adults on Medicaid. I learned a lot about how public insurance works and how they strive to try to improve health equity for patients that are particularly vulnerable. I was still seeing patients then in a federally qualified health center setting in Indianapolis, and I began doing research studies in diabetes care and prevention.

As a fellow, I had done research on behavioral interventions and communities, particularly physical activity promotion. When I got to Indiana, there was a group that had participated in the Diabetes Prevention Program. The whole study group nationally was asking, “how can this be delivered in the real world, and how can it reach populations that are at highest risk for developing diabetes?” Part of what I took with me from my fellowship was that to change behavior of populations, you need to get to a community level. You can’t really do that from a primary care office. I had learned in my fellowship to work with a variety of stakeholders and community groups, namely public agencies. We worked with senior services and community centers that served seniors and health payers in the Seattle area. I started to do that around diabetes when I was in Indianapolis. Within two months, we developed a partnership with YMCA. It was a kind of neighborhood-level access because YMCAs could reach a diverse population. I wrote grants really early in my career that were about can you implement lifestyle interventions like the Diabetes Prevention Program in the community, and will it be accessible to high need populations or particularly vulnerable populations?

Most of my research over the last 20 years has been focused on community-level interventions or primary care interventions, and the outcomes include not just the effectiveness and implementation of the programs but whether they reach large populations and representative diverse populations. When it comes to diabetes care and prevention a lot of times the goal is to actually lift up relatively worse outcomes for people that identify as Black or Latinx, so a lot of the research attempts to enroll those patient populations and to study the effects of interventions across them.

When it was launched, NIH required every [Clinical and Translational Science Award] to have a community engagement program. Because I did community research at a time when it was becoming recognized as important, the Indiana CTSA asked me to lead their community engagement program relatively early in my career. Because of that, I got involved in a lot of other research projects collaborating with community partners. I’ve been doing that ever since, and in 2011, I was recruited to lead the Community Engagement Center at Northwestern.

I do two types of research: one is nationally facing research where we use insurance claims data from Medicare and UnitedHealthcare to evaluate policies on things like the Diabetes Prevention Program to whether a state tries to subsidize the cost of expensive new medications like Ozempic, and whether that makes it accessible to the people that are on limited income and are disabled on Medicaid. It’s a question of whether policies or large scale interventions work equitably.

I also develop and test primarily behavioral interventions, mostly weight management interventions in primary care, such as providing education and coaching services through community partners that do that or training office staff to be able to do that in a way that’s scalable. We use technology in a way that’s accessible to the population, so we’ll use everything from simple text-messaging platforms on mobile phones to smartphone interventions. Increasingly we are studying the interaction between lifestyle interventions and drugs like Ozempic. We are interested in whether minoritized communities can access beneficial new treatments for diabetes and try to study different ways to do that both by changing the primary care system and also focused on policy.

Have you found anything that works?

When you are struggling to change the food environment or the policy environment or systems of care to support healthy eating and healthy food access in all communities and safe places for physical activity and you’re trying to improve health care delivery, you realize that there’s still a gap in the environment. It often turns out that the food that has the highest caloric content when you’re hungry and is the easiest to buy economically and is most accessible is not the healthy food that prevents diabetes. I’d like to say that we’re making a difference, but it’s a slow moving train. We need to continue to push towards those sorts of solutions, but behavioral interventions like the Diabetes Prevention Program can provide a safety net of behavioral support resources that help people eat differently when they still continue to live in that sort of environment that’s not supportive.

The Diabetes Prevention Program teaches basic nutritional knowledge: some foods that are readily accessible are really not healthy, everything from milkshakes at McDonald’s to coffee drinks at Starbucks or Dunkin Donuts. Any form of physical activity can be beneficial, even lifestyle physical activities like gardening and walking to and from the store. It also teaches people to change their diets in a healthful way where they’re not going to be hungry or displaced from their friends because they’re no longer able to eat together. It’s basically trying to figure out a plan and having a coach give feedback on your progress in weekly meetings. The Diabetes Prevention Program builds people’s self-confidence so that they can eat differently and not feel socially disconnected or emotionally stressed, and then it provides emotional support and problem solving over the long term.

Our research on the Diabetes Prevention Program informed a policy document called the Diabetes Prevention Act of 2009. It was passed into law in the Affordable Care Act, which authorized the formation of the National Diabetes Prevention Program and a commercial partnership that came out of work that I was doing with UnitedHealthcare and the YMCA to demonstrate nationally that if health insurance paid for the Diabetes Prevention Program, it could reach people from coast to coast, and it was at least cost neutral, meaning that they didn’t lose money (it’s hard to save money on diabetes in two years). It had benefits for the health insurance plan because people want programs that are preventive.

On the one hand, there’s 80 million people at high risk for diabetes in the United States, and there’s been about a million people participating in the DPP, so 1/80th of the people that could benefit have gone through it. Some people would position that as a failure, and the DPP will continue to try to improve to get more into rural settings and into disinvested community settings, but on balance it is a success because it is reaching more people than could ever have been imagined.

Today there’s a lot of excitement about Ozempic and similar drugs, which are causing people to ask whether we need investments in supporting people to eat healthfully when we can just write a prescription, and it causes 15% weight loss. But the problem is that those medications cost thousands of dollars a month, the insurance companies don’t pay for them, and vulnerable people at risk aren’t getting access to those medications. They’re not a universal solution. So I think the Diabetes Prevention Program, despite it not being perfect, is a success story and I’m proud to say that I did some work to help translate that research into policy.

What are you most proud of in your career? 

I’m proud that at a time when very few general internists were interested in community-engaged research, I followed that path. Internists have formulas and algorithms for everything, and the tradition was to do other forms of research and focus more clinically. Now a lot more people are doing community-engaged research. I draw the biggest enjoyment in watching this groundswell of new work that builds on research that I and others began 20 or more years ago.

Do you have any fun facts? 

I played soccer in college at the University of Wisconsin, so if you would have told me then that I would become a professor at Northwestern’s Medical School and a Senior Associate Dean, I would have thought that was the funniest thing you could imagine.