Arizona's Diabetes Crisis: Today and Future Trends - Greater Detroit

Michigan’s Diabetes Crisis: Today

and Future Trends

Dr. William Rowley

Institute for Alternative Futures

1

During their lifetimes:

1/2 will become obese

1 in 3 males & 2 in 5

females will get diabetes

Earlier disability

Life expectancy 2-5 years

What’s Happening to Our Children?

2

Wang. Will All Americans Become Overweight or Obese? Estimating the Progression and Cost of the US Obesity Epidemic, Obesity, 2008;16:2323-2330; Hannon, Tamara, et.al., Childhood Obesity and Type 2 Diabetes Mellitus, Pediatrics Vol. 116 No. 2 August 1, 2005 pp. 473 -480 Narayan, Lifetime Risk for Diabetes Mellitus in the United States, JAMA 2003;290:1884-1890; Population Reference Bureau. Will Rising Childhood Obesity Decrease U.S. Life Expectancy? Accessed 3/25/11. http://www.prb.org/Articles/2005/WillRisingChildhoodObesityDecreaseUSLifeExpectancy.aspx.

http://www.prb.org/Articles/2005/WillRisingChildhoodObesityDecreaseUSLifeExpectancy.aspx

Increasing Prevalence of Obesity

20-24% 25-29% 35-39% 30-34% 40-44% 50-54% 45-49% 15-19% 10-14% <10% 55-60% >60%

1990 2005

Adults over 20 y/o

2015

Obesity Health costs for MI = 30B/yr

2030

No Data

Michigan Statistics

3

56% 45%

Sources: CDC Behavioral Risk Factor Surveillance System; Wang & Beydoun, The Obesity Epidemic in the United States – Gender, Age, Socioeconomic, Racial/Ethnic, and Geographic Characteristics: A Systemic Review and Meta-Regression Analysis. Epidemiol Rev 2007;29:6-28; Wang Will All Americans Become Overweight or Obese? Estimating the Progression and Cost of the US Obesity Epidemic. Obesity 2008;16:2323-2330; Translation of national data to state data by the Institute for Alternative Futures.

28%

Diagnosed Diabetes Projections

4

0

10

20

30

40

50

60

70

2000 2010 2020 2030 2040 2050

Pre

vale

nce i

n M

illi

on

s

CDC 2001 CDC 2003 CDC 2006 CDC 2010

CDC 2001 = Boyle, et al. Projection of Diabetes Burden Through 2050, Diabetes Care 2001;24:1936-1940 CDC 2003 = Honeycutt, A Dynamic Markov Model for Forecasting Diabetes Prevalence in the United States Through 2050, Health Care Manag Sci 2003;6:155-164 CDC 2006 = Narayan, Impact of Recent Increase in Incidence on Future Diabetes Burden, Diabetes Care 2006;29:2114-2116 CDC 2010 = Boyle, Projection of the year 2050 burden of diabetes in the US adult population, Population Health Metrics ,2010, http://www.pophealthmetrics.com/content/8/1/29

http://www.pophealthmetrics.com/content/8/1/29

Progression of Diabetes

5

Percent of Total Population with Diabetes

6-7% 10-11% 18-19% 12-13% <6% 16-17% 8-9% 14-15%

2000 diabetes prevalence by state map - CDC Behavioral Risk Factor Surveillance System prevalence of diabetes maps, http://www.cdc.gov/diabetes/statistics/maps/; 2010, 2015 & 2025 – IAF Diabetes 2025 Model http://www.altfutures.org/diabetes2025 utilizing latest national projections from Boyle, Projection of the year 2050 burden of diabetes in the US adult population, Population Health Metrics ,2010, http://www.pophealthmetrics.com/content/8/1/29

2000 2010

2015 2025

Increasing Prevalence

6.3%

12.8% 15.3%

11.2%

39.7 M 53.1 M

17.5 M 32.3 M

Improvements in therapies and medical management over time are factored in

http://www.cdc.gov/diabetes/statistics/maps/

http://www.altfutures.org/diabetes2025


Progression of Diabetes

*Constant 2010 Dollars

Total Annual Direct Medical and Indirect Societal Costs of Diabetes in Billions of Dollars*

25+ <1 3-4.9 5-9.9 15-24.9 1-2.9 10-14.9

$64B

$52B $40B

$28B

$37B

$30B

$36B

2010

2015 2025

Increasing Annual Diabetes Cost in $ Billions*

Entire US:

$374B

Entire US:

$299B

Entire US:

$514B

$46B

$27B

6

IAF Diabetes 2025 Model http://www.altfutures.org/diabetes2025 utilizing cost estimates by: Zhang Y. Medical Costs Associated with Prediabetes. Population Health Management. 2009; 12(2):157-163; Zhang Y, et al. Economic Costs of Undiagnosed Diabetes. Population Health Management. 2009; 12(2):95-101; Dall TM, et al. Distinguishing the Economic Costs Associated with Type 1 and Type 2 Diabetes. Population Health Management. 2009; 12(2):103-110.

$13B

$11B

$16B


2000 2010 2025

Total Diabetes 625,800 1,156,300 1,639,900

Pre-diabetes 1,452,700 2,629,600 2,728,800

Annual Cost $4.8B* $10.6B $15.8B

Increasing Prevalence of Diabetes

7

DIABETES IN MICHIGAN

* Cost of diagnosed diabetes only

Rowley W, Bezold C. Creating Public Awareness: State Diabetes Forecasts. Publication Health Management, accepted for publication. This study utilizes a national diabetes model by Boyle, Projection of the year 2050 burden of diabetes in the US adult population, Population Health Metrics ,2010, http://www.pophealthmetrics.com/content/8/1/29; US Census Bureau population estimates; latest CDC national diabetes statistics and state prevalence rates.



8

1,770

New Kidney Failure

2,300

New Amputations

DIABETES COMPLICATIONS IN MICHIGAN

131,800

Total Visual Impairment



Michigan: Race and Hispanic Origin

9

HISPANIC AMERICANS AFRICAN AMERICANS NATIVE AMERICANS

*Compared to non-Hispanic Whites

• 50,600 cases of diabetes

• 90% greater risk of

developing diabetes*

• 70% greater risk of renal

failure*

• 50% greater risk of dying

from diabetes*

• 7,600 cases of diabetes

• Twice as likely to be

diagnosed with diabetes*

• Over twice the risk of

renal failure &

amputations*

• Life span shortened

13-17 years

• 216,300 cases of

diabetes

• Twice as likely to be

diagnosed with diabetes*

• Almost twice as likely to

die from diabetes*




10

*Cost of diagnosed diabetes only

Diabetes Data & Forecasts. 2025 Diabetes Forecasts for State and Metropolitan Areas Study by the Institute for Alternative Futures. This study utilizes: a

national model from Narayan. Impact of Recent Increase in Incidence on Future Diabetes Burden. Diabetes Care 2006, 29:2114-2116; the latest CDC

projections by Boyle; US Census Bureau population estimates; and latest CDC national diabetes statistics and state prevalence rates.

2000 2010 2025

Total Diabetes 288,900 512,000 703,000

Pre-diabetes 649,400 1,131,700 1,130,100

Annual Cost $2.2 B* $4.7 B $6.8 B

DIABETES IN METRO DETROIT

What Can Be Done?

11

Screening for Risks

and Disease

Diabetes and America's Seniors

12

Medicare pays for screening, but early

on only 10% utilized it

65 and older 1,334,500

Known diabetes 262,100

Undiagnosed diabetes 96,900

Pre-diabetes 667,200

Must find these: 764,100

SENIOR POPULATION IN MICHIGAN

Centers for Disease Control and Prevention, National Diabetes Fact Sheet, 2011. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf; Institute for Alternative Futures Diabetes 2025 Methodology, http://www.altfutures.org/diabetes2025; Ask.Screen.Know. Brochure.

http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf


Screening

• If 50% with prediabetes

made these lifestyle

changes, 330,000 fewer

people would develop

diabetes a year

(~4,700,000 by 2025)

• 12,000,000 have

undiagnosed diabetes

• May already be causing

organ damage

13

Diabetes Prevention Program:

Lifestyle modification reduced

incidence of diabetes 58%

(71% seniors aged 60+) - 3 year

follow-up • 30 minutes of physical activity

5 days a week

• At least a 7% weight loss

Rowley W, Bezold C. Creating Public Awareness: State Diabetes Forecasts. Publication Health Management, accepted for publication. This study utilizes a national diabetes model by Boyle, Projection of the year 2050 burden of diabetes in the US adult population, Population Health Metrics ,2010, http://www.pophealthmetrics.com/content/8/1/29; US Census Bureau population estimates; latest CDC national diabetes statistics and state prevalence rates; ; Diabetes Prevention Program Research Group, Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393-403.

79,000,000 Americans Have Pre-diabetes


What can be done?

14

Effective Management

of Diabetes and

its Comorbidities

Impact of Effective Management

• Effective management can lower decline of renal function

by 30-70%

› If 50% with diabetes complied with effective

management it could prevent 15,000 cases of renal

failure a year

15



Asheville Project

• Sponsored by employer – an investment

• Employees with diabetes volunteer

• Receive additional diabetes education

• Lab, glucometer, meds – no co-pays

• Meet with trained pharmacist

• Collaboration with doctor

16

PATIENT SELF-MANAGEMENT PROGRAM

Cranor, Bunting & Christensen, The Asheville Project: Long-Term Clinical and Economic Outcomes of a Community Pharmacy Diabetes Care Program, Am Pharm Assoc 2003;43:174-184.

Asheville Project

17

0

2

4

6

8

0

50

100

150

Avg. Glycosylated Hemoglobin LDL Cholesterol

6.7 95

7.6 121

0

5

10

15

6.01

12.61

Total Individual Diabetes Medical Costs

$0$1,000$2,000$3,000$4,000$5,000$6,000$7,000 58%

Savings $4,651

$7,248

$6,127

Results at 5 Years

Avg. Ann. Diabetic Sick-Leave

Cranor, Bunting & Christensen, The Asheville Project: Long-Term Clinical and Economic Outcomes of a Community Pharmacy Diabetes Care Program, Am Pharm Assoc 2003;43:174-184.

A Patient-Centered Medical Home

18

Accountable

team leader Continuity of care

using evidence-

based medicine

Collaborative

team of

providers

Ongoing

Monitoring

& support

Electronic

records

Global payment with

incentives for outcomes

Life-long continuity

of care

Easy access to care

Navigation,

Education

& coaching

Shared

decision-

making Entire health system of

specialty care services

What can be done?

19

Prevention Even if 50% of those with pre-diabetes

dramatically changed their lifestyles starting now

there would still be 48,400,000 people with

diabetes in America in 2025

The only realistic solution is preventing

pre-diabetes in the first place



0%

20%

40%

60%

80%

Don't Smoke

Maintain

Healthy

Wt.

Eat 5

F&V/d

Exercise

5X30

Do all 4

3%

Preventing Diabetes

20 Reeves, Healthy Lifestyle Characteristics Among Adults in the United States, 2000, Arch Intern Med, 2005

Healthy Lifestyles

Preventing Diabetes

21

Crowley & Lodge, Younger Next Year, Workman Publishing Company, 2004; Diabetes Prevention Program Research Group, Reduction in the incidence

of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393-403; NDIC. Diabetes Prevention Program. Accessed 3/25/11.

http://diabetes.niddk.nih.gov/dm/pubs/preventionprogram/; Ford, Healthy Living is the Best Revenge: Findings from the European Prospective

Investigation into Cancer and Nutrition, Arch Intern Med 2009;169:1355-1362

Seniors who exercise 30 minutes 5 days a week

and lose 7-15 pounds can prevent pre-diabetes

from becoming diabetes by 71%

70% of premature death is lifestyle-related

50% of all illness & injuries in the last third of life

can be eliminated by changing lifestyle

Healthy lifestyle can reduce cancer risk 36%,

diabetes risk 93%, heart attack by 81%

http://diabetes.niddk.nih.gov/dm/pubs/preventionprogram/

Why the “epidemic” of diabetes?

22

Our Lifestyles

Dramatic Change in Our Food

Calories

Fat

(g)

Sat Fat

(g)

Carb

(g)

Protein

(g)

Sodium

(mg)

Commercial

Burrito 1,174 60 23 142 52 2,295

Tarahumara

Burrito 215 5 0.6 14 29 170

23 Daphne Miller, MD, The Jungle Effect, Harper Collins, NY, 2008.

Community Action

24

EAT WELL – Eat Better Mindlessly

Plant Slant

Home gardens Healthy

school

lunches

Smaller plates

Daily

weight

Set up an environment in ways that make healthy

choices easy

AARP. The Minnesota Miracle. Accessed 3/25/11. http://www.aarp.org/health/longevity/info-01-2010/minnesota_miracle.html.

Community Action

GET MOVING – Throughout the Day

Finding a Purpose Community Connections

AARP. The Minnesota Miracle. Accessed 3/25/11. http://www.aarp.org/health/longevity/info-01-2010/minnesota_miracle.html.

Diabetes Burden on Workers

• If onset of diabetes at

age 40:

› Quality of life shortened

18-22 years

› Lifespan shortened

11-15 years

› 2-4 X risk dying of heart

disease

› Avg. cost of complications

$11,600/year*

*In 2010 dollars

26

Narayan, et al. Lifetime Risk for Diabetes Mellitus in the United States. JAMA 2003;290:1884-1890; CDC. Diabetes Fact Sheet, 2011. CDC

Web site. Accessed 1/27/11. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf; WebMD. Diabetes Complications Cost Billions.

Accessed 3/25/11. http://diabetes.webmd.com/news/20070410/diabetes-complications-cost-billions

http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf

http://diabetes.webmd.com/news/20070410/diabetes-complications-cost-billions







Creating Healthy Employees

Bringing healthy behavior into the workplace

Creating Healthy Employees

28

Financial Incentives

• $150 for health risk appraisal

• $20/mo for fitness center

• $14 per 1% weight lost

• $150 if quit smoking

• Redeemable points

Health Risk

Appraisal

• Customized to employee needs

• Measure return on investment

Advice

Nurse

Nutritional

Counseling

Online Support

Health

Education

Have a well designed wellness program

Jones AP et al. Understanding Diabetes Population Dynamics Through Simulation Modeling and Experimentation, Am J Public Health 2006; 96:488-494.

Diabetes in Counties

29

Percent with Diagnosed Diabetes

by County in 2007

CDC. County Level Estimates of Diagnosed Diabetes. Accessed 3/25/11. http://apps.nccd.cdc.gov/DDT_STRS2/nationaldiabetesprevalenceestimates.aspx?mode=DBT.

http://apps.nccd.cdc.gov/DDT_STRS2/nationaldiabetesprevalenceestimates.aspx?mode=DBT

Normal Blood

Sugar

Diagnosed

Pre-diabetes

Diagnosed

Uncomplicated

Diabetes

Death Diagnosed

Complicated

Diabetes

Systems Dynamic Modeling of diabetes

30

Lifestyle

Changes

Risks of

diabetes

Control of Diabetes Clinical management, medications,

self-monitoring & compliance, healthy

lifestyles

Pre-diabetes Management Healthy lifestyles

Detection

Jones AP et al. Understanding Diabetes Population Dynamics Through Simulation Modeling and Experimentation, Am J Public Health 2006; 96:488-494.

Diabetes Prevalence

31

Jones AP et al. Understanding Diabetes Population Dynamics Through Simulation Modeling and Experimentation, Am J Public Health 2006; 96:488-

494.

What can be done to reduce the prevalence of diabetes?

Diabetes Prevalence

32

Clinical

management

ramped up from

48% in 2006 to 67%

in 2012 with no

further improvement

after that.


494.


Diabetes Prevalence

33

Ramp up

management of pre-

diabetes from 20%

in 2006 to 50% in

2012 with no further

improvement after

that.


494.


Diabetes Prevalence

34

Jones AP et al. Understanding Diabetes Population Dynamics Through Simulation Modeling and Experimentation, Am J Public Health 2006;

96:488-494.


Reducing Diabetes Related Deaths

35

Jones AP et al. Understanding Diabetes Population Dynamics Through Simulation Modeling and Experimentation, Am J Public Health 2006;

96:488-494.

What can be done for reducing deaths associated

with diabetes?

Challenges and Opportunities

• Diabetes is a rapidly growing societal burden for Michigan

• We know how to prevent and manage diabetes –

must reach everyone

• My advice:

› Health providers – screen & aggressively manage diabetes

› Public – be proactive and get tested

› Exercise 30 min × 5; eat 5 fruits & vegetables daily

36

Research funded by Novo Nordisk, Inc.

For more information:

www.altfutures.org/diabetes2025

©2011 Novo Nordisk 144079 April 2011

37


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