Tackling Type 2 Diabetes in the US: Translating Science into Public Policies and Actions

Transcription

1 Tackling Type 2 Diabetes in the US: Translating Science into Public Policies and Actions Edward Gregg, PhD Division of Diabetes Translation Centers for Disease Control and Prevention Atlanta, GA The findings and conclusions of this presentation are those of the presenter and do not necessarily represent views of the Centers for Disease Control and Prevention.

2 Premise of Public Health Action for Diabetes and Pre-Diabetes Forecasted Millions of People with Diagnosed Diabetes Incidence of Diagnosed Diabetes Among Adults with Diabetes by Level of Education, Numbers with diagnosed diabetes (Millions) Incidence (per 1000 PY <high school high school >high school 0 0 Year Year CDC s Division of Diabetes Translation. National Diabetes Surveillance System available at

3

4 1 in 3 lifetime Risk Diabetes: Undiagnosed Diabetes Dysglycemia Pre-diabetes

5 EXTRAS

6 Diabetes Pyramid of Prevention? Adult Prevalence Goal / Intervention Tier 7.6% 2.6% Diabetes Undiagnosed DM Prevent Morbidity Detect Early

7 Glycemic control BP control Lipid testing and management Classic Levers in the Public Health Response to Diabetes Clinical Services Annual eye examinations Foot care for high risk persons Kidney disease testing Flu immunization Preconception care Diabetes education Case Management Targeted Screening Population-Targeted Policies Health care access legislation Drug and supply reimbursement policies Population registry and feedback systems Promotion of Behaviors Education and awareness for: Physical activity Reduced Tobacco Healthy diet Regular doctor visits Self monitoring Self mgt education

8 Prevalence of CVD risk factors among U.S. adults with diabetes aged 20-74, according to income group, 1971 to 2006 (* red=low income; green=middle income; yellow=high income) 60 High Blood Pressure 60 High Cholesterol Prevalence (%) Prevalence (%) Year Year Smoking High A1c Level Prevalence (%) Year

9 Incidence of lower extremity amputation, end stage renal disease, and hyperglycemic death in the U.S. diabetic population, Amputation 60 Events Per 10, End Stage Renal Disease Hyperglycemic Death 2.0 Gregg and Albright, JAMA, 2009

10 Trends in CVD Mortality Between Men and Women with Diabetes Mortality rate (deaths/1000 per year) Men Gregg et al., Ann Intern Med, Cohort follow-up period Women

11 CVD Mortality Trends During the Past Decade, U.S. Adult Population with Diabetes, National Health Interview Survey (follow-up through 2006) 16 Mortality rate (per1000 per year) Men Women Cohort Unpublished Analyses, National Health Interview Survey, Gregg and Cheng, 2010

12 What has worked in secondary prevention? Health Services: Acute care and major medical interventions Diffusion of new science of risk factor management Emphasis on quality of care Health system adaptation and CQI Health Promotion and Health Protection Improved education/awareness of diabetes control. Improved CVD risk factor education and awareness. Reduced Tobacco / tobacco legislation Less directly atherogenic food supply

13 Failures in the Public Health Response to Diabetes Levels of care and preventive health behaviors are still suboptimal. Improvements in blood pressure may have stalled. Disparities remain in renal disease, amputation, acute complications, and costs. Major differences in morbidity remain between people with and without diabetes. Diabetes is economically disabling for people and their families. While the average person with diagnosed diabetes has better control and lower risk of complications, the risk of diabetes or a diabetes complication for the average person in the total population has increased.

14 Incidence of lower extremity amputation, end stage renal disease, and hyperglycemic death in the U.S. population, Gregg and Albright, JAMA, 2009

15

16 Longer-term Impact? Magnitude of Incidence Reduction in Long-term Diabetes Prevention Legacy Studies Primary Outcome Extended Outcome Finnish DPS 58% at 3 yr 43% at 7 years Da Qing Study 41-46% at 6 yr 43% at 20 years DPP- OS 58% at 2 yr 24% at 10 years Lindstrom, et al. 2006; Li et al. 2008; DPPOS; 2009

17 Diabetes Prevention Interventions Carried Out in Community Settings First author N Age (Williamson and Marrero, 2010) Sessions offered (wks) Sessions attended Wt loss (%) 7% loss (%) 5% loss (%) DPP (24) nr Amundson (16) Ackermann (20) Pagoto (16) Boltri 8-16 (24) Aldana (24) Wolf (52) McBride (12) Kramer (14) McTigue (52) Seidel (14) Davis-Smith 10-6 (6) Cramer 27-7 (28) Whittemore (36)

18 Current Dilemmas in Diabetes Prevention Policy High risk vs population approach Whom to Target? Imminent risk based on glycemia vs broad risk factors vs everyone? Is screening for pre-diabetes good policy? And if so, how should we screen? What interventions to apply? Structured and tied to clinical services? Broad health promotion? Population-targeted policies?

19 Diabetes Pyramid of Prevention Adult Prevalence Goal / Intervention Tier ~57% 7.6% 2.6% ~12-15% ~15-20% Diabetes Undiagnosed DM Very High Risk (A1c > 5.7%; IGT; GDM) High Risk (FPG > 100); Central Obesity; HTN, age Moderate Risk Prevent Morbidity Detect Early What type of intervention for what level of risk? Low Risk

20 Screening, Diagnosis, and Prevention of Diabetes Risk Factor Screening Test for Diagnosis FPG OGTT HbA1c Find new diabetes Preventive Intervention Structured Prevention Intensive 6 12 mo Extended: > 2 years Multi-component Reduced total intake, Reduced fat intake Exercise Fiber / whole grain Behavioral support Moderate weight loss

21 Tradeoffs of high vs low pre-diabetes cut points High / Exclusive Cut points (A1c > 5.7%; IGT) Preferred if intervention demands moderately high resources and risk of missing people is not catastrophic. More efficient use of resources. Limited scope of impact. Low / Inclusive Cut points (FPG > 100; risk factors) Preferred if a low-cost intervention is to spread broadly over population and risks of the intervention are low. More equitable (ultimately prevents more cases). Less efficient use of resources.

22 Summary and Recommendations: Related to Screening and Identification Encourage identification of pre-diabetes and undiagnosed diabetes in adults in clinical settings and established clinical/community partnerships. o Risk scores most appropriate first stage screening. o More efficient in integrated manner, connected to lipid, BP. o Ideal thresholds for referral ultimately depend upon resources. Discourage : o Population-wide blood screening in the absence of risk factor assessment or in low-risk populations. o Screening in community settings (health fairs, retail stores, etc.) that lack a direct connections to health care provider. o Screening of youth and adolescents.

23 Potential Barriers to Effective Clinical-System Based Lifestyle Intervention Programs Clinical health systems lack structure and expertise to change lifestyle. Too expensive and not scalable. Previous models of clinical based / lifestyle change have not achieved sustainable reimbursement. Waiting until people have elevated glucose is too late. Diabetes is a common-source epidemic rooted in culture and society.

24 Macro-Level Determinants Obesity and Diabetes: Current Debates Over Policy Strategies Physical environment Food environment Social environment Economy and poverty

25 Policy Options to Influence Diabetes Risk Taxation Food and Menu labeling Engage Private Industry Crop subsidy policies Incentives/promotion for community availability and affordability of foods. Incentives/promotion for community support for physical activity. Regulation of foods in public areas. School food and physical education policies.

26 National Diabetes Education Program Diabetes Prevention and Control Programs Native Diabetes Wellness Program A life of balance A community of support A program of prevention A message of hope

27 Recent Progress in Clinical Community Partnerships to Prevent Diabetes: Patient Protection and Affordable Care Act, Section 399V-3, page 310: National Diabetes Prevention Program: Establishes national Diabetes Prevention Program with grants for model sites Recognition program and national registry for quality assurance at CDC. Cooperative agreements to fund 11 model sites around the country for training and recognition of YMCA sites for primary prevention. Partnership between United Health Group and YMCAs for training and reimbursement for primary prevention in 7 regions of the U.S.

28 Summary: Diverse public health efforts have led to a reduction in several diabetes-related complications for the average person with diabetes but these successes have not kept pace with the increased risk of diabetes incidence. Diabetes prevention requires a multi-tiered public health response, that includes Efficient identification and referral of high risk people to structured lifestyle programs using clinicalcommunity partnerships.

29 Summary: Diverse public health efforts have led to a reduction in several diabetes-related complications for the average person with diabetes but these successes have not kept pace with the increased risk of diabetes incidence. Diabetes prevention requires a multi-tiered public health response, that includes Efficient identification and referral of high risk people to structured lifestyle programs using clinicalcommunity partnerships. Broad population targeted approaches aimed at food, social, and economic environment to ultimately change trends in the epidemic.

30 Thank you Edward Gregg, PhD:

31 Implications For Intervention using Intensive Intervention Resources spent on 100 people 12 Cases Prevented (if RR=0.50) 76 people intervened upon unnecessarily 27 people missed NNT=8 Population 1000 people Pre-DM Screen and DX 5-yr result 900 negative tests 100 true positive tests Definition = > 5.7% 873 non-cases 27 eventual cases 76 non Cases 24 Eventual cases Incidence=3% Incidence=24%

32 Population 1000 people Pre-DM Screen And DX 5-yr result 750 neg tests 250 true positive tests Definition = > 5.5% 732 non - cases Incidence=3% 18 eventual cases 217 non Cases 33 Eventual cases Incidence=13% Implications For Intervention using Intensive Intervention Resources spent on 250 people (vs 100) 16 Cases Prevented (if RR=0.50) (vs 12) 217 people intervened upon unnecessarily (vs 76) 18 people missed (vs 27) NNT=15 (vs 8) More equitable, less efficient

33 Four Key Steps (1) Train work force to implement the program cost-effectively (2) Implement recognition program to assuring quality, lead to reimbursement, and registry of programs for public reporting (3) Implement sites to build infrastructure and provide a laboratory for refinement of this prevention system (4) Increase referrals and utilization of the prevention system through health marketing and other strategies

34

35 Recommended Strategies to Prevent Obesity Via Food Environment Policies: Communities Should: Increase availability and affordability of healthy foods in public areas. Improve geographic availability and give incentives for supermarkets and healthy foods in under-served and poor areas. Promote mechanisms for purchasing directly from farms. Restrict availability of unhealthy foods/beverages from public areas. Institute smaller portion sizes in public settings. Limit advertisements of unhealthy foods/beverages. Discourage consumption of sugared beverages.

36 Recommended Strategies to Prevent Obesity Via Physical Activity Environment Policies: Communities Should: Require school physical education and increase amount of physical activity in school physical education. Increase opportunities for extracurricular physical activity and access to recreational facilities. Reduce screen time in public settings. Enhance infrastructure supporting walking and bicycling. Improve access to public transportation. Promote access to mixed use development. Enhance personal and traffic safety in public areas.

37 Major Factors Influencing the Ideal Screening Cut point The Intended Intervention The Context Health system capacity for screening, follow-up, and action. Incidence in the population at a given level of risk. Resources Available