Michigan s Diabetes Crisis: Today and Future Trends Dr. William Rowley Institute for Alternative Futures 1
What s Happening to Our Children? 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 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.
Increasing Prevalence of Obesity Michigan Statistics 1990 2005 28% 2015 45% 2030 56% Adults over 20 y/o Obesity Health costs for MI = 30B/yr No Data <10% 10-14% 15-19% 20-24% 25-29% 30-34% 35-39% 40-44% 45-49% 50-54% 55-60% >60% 3 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.
Prevalence in Millions Diagnosed Diabetes Projections 70 60 50 40 30 20 10 0 2000 2010 2020 2030 2040 2050 CDC 2001 CDC 2003 CDC 2006 CDC 2010 4 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
Progression of Diabetes Increasing Prevalence 17.5 M 32.3 M 2000 6.3% 2010 11.2% 39.7 M 53.1 M 2015 2025 12.8% 15.3% 5 Percent of Total Population with Diabetes <6% 6-7% 8-9% 10-11% 12-13% 14-15% 16-17% 18-19% Improvements in therapies and medical management over time are factored in 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
Progression of Diabetes Increasing Annual Diabetes Cost in $ Billions* 2010 Entire US: $299B $11B $36B $30B 2015 $13B 2025 Entire US: $374B Entire US: $514B $16B $28B $46B $64B $37B $27B $52B $40B 6 Total Annual Direct Medical and Indirect Societal Costs of Diabetes in Billions of Dollars* *Constant 2010 Dollars <1 1-2.9 3-4.9 5-9.9 10-14.9 15-24.9 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. 25+
Increasing Prevalence of Diabetes DIABETES IN MICHIGAN 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 * Cost of diagnosed diabetes only 7 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.
Increasing Prevalence of Diabetes DIABETES COMPLICATIONS IN MICHIGAN 131,800 Total Visual Impairment 1,770 New Kidney Failure 2,300 New Amputations 8 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.
Michigan: Race and Hispanic Origin AFRICAN AMERICANS HISPANIC AMERICANS NATIVE AMERICANS 216,300 cases of diabetes Twice as likely to be diagnosed with diabetes* Almost twice as likely to die from diabetes* *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 9 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.
Increasing Prevalence of Diabetes DIABETES IN METRO DETROIT 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 *Cost of diagnosed diabetes only 10 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.
What Can Be Done? Screening for Risks and Disease 11
Diabetes and America's Seniors SENIOR POPULATION IN MICHIGAN 65 and older 1,334,500 Known diabetes 262,100 Undiagnosed diabetes 96,900 Pre-diabetes 667,200 Must find these: 764,100 Medicare pays for screening, but early on only 10% utilized it 12 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.
Screening 79,000,000 Americans Have Pre-diabetes 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 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 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.
What can be done? Effective Management of Diabetes and its Comorbidities 14
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 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.
Asheville Project PATIENT SELF-MANAGEMENT PROGRAM 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 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 Results at 5 Years 8 6 4 2 0 Avg. Glycosylated Hemoglobin 7.6 6.7 150 100 50 0 121 LDL Cholesterol 95 15 10 5 0 Avg. Ann. Diabetic Sick-Leave 12.61 6.01 Total Individual Diabetes Medical Costs $7,248 $7,000 $6,127 58% $6,000 $5,000 $4,651 Savings $4,000 $3,000 $2,000 $1,000 $0 17 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 Accountable team leader Continuity of care using evidencebased medicine Collaborative team of providers Ongoing Monitoring & support Electronic records Navigation, Education & coaching Shared decisionmaking Life-long continuity of care Easy access to care Global payment with incentives for outcomes Entire health system of specialty care services 18
What can be done? 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 19 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.
Preventing Diabetes Healthy Lifestyles 80% 60% 40% 3% 20% 0% Don't Smoke Maintain Healthy Wt. Eat 5 F&V/d Exercise 5X30 Do all 4 20 Reeves, Healthy Lifestyle Characteristics Among Adults in the United States, 2000, Arch Intern Med, 2005
Preventing Diabetes 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% Seniors who exercise 30 minutes 5 days a week and lose 7-15 pounds can prevent pre-diabetes from becoming diabetes by 71% 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
Why the epidemic of diabetes? Our Lifestyles 22
Dramatic Change in Our Food Calories Fat (g) Sat Fat (g) Carb (g) Protein (g) Sodium (mg) Commercial Burrito Tarahumara Burrito 1,174 60 23 142 52 2,295 215 5 0.6 14 29 170 23 Daphne Miller, MD, The Jungle Effect, Harper Collins, NY, 2008.
Community Action Set up an environment in ways that make healthy choices easy EAT WELL Eat Better Mindlessly Smaller plates Plant Slant Healthy school lunches Home gardens Daily weight 24 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 Community Connections Finding a Purpose 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
Creating Healthy Employees Bringing healthy behavior into the workplace
Creating Healthy Employees Have a well designed wellness program Health Risk Appraisal Advice Nurse Nutritional Counseling Health Education Financial Incentives $150 for health risk appraisal $20/mo for fitness center $14 per 1% weight lost $150 if quit smoking Redeemable points Online Support Customized to employee needs Measure return on investment 28 Jones AP et al. Understanding Diabetes Population Dynamics Through Simulation Modeling and Experimentation, Am J Public Health 2006; 96:488-494.
Diabetes in Counties Percent with Diagnosed Diabetes by County in 2007 29 CDC. County Level Estimates of Diagnosed Diabetes. Accessed 3/25/11. http://apps.nccd.cdc.gov/ddt_strs2/nationaldiabetesprevalenceestimates.aspx?mode=dbt.
Systems Dynamic Modeling of diabetes Lifestyle Changes Risks of diabetes Detection Normal Blood Sugar Diagnosed Pre-diabetes Diagnosed Uncomplicated Diabetes Diagnosed Complicated Diabetes Death Pre-diabetes Management Control of Diabetes Healthy lifestyles Clinical management, medications, self-monitoring & compliance, healthy lifestyles 30 Jones AP et al. Understanding Diabetes Population Dynamics Through Simulation Modeling and Experimentation, Am J Public Health 2006; 96:488-494.
Diabetes Prevalence What can be done to reduce the prevalence of diabetes? 31 Jones AP et al. Understanding Diabetes Population Dynamics Through Simulation Modeling and Experimentation, Am J Public Health 2006; 96:488-494.
Diabetes Prevalence What can be done to reduce the prevalence of diabetes? Clinical management ramped up from 48% in 2006 to 67% in 2012 with no further improvement after that. 32 Jones AP et al. Understanding Diabetes Population Dynamics Through Simulation Modeling and Experimentation, Am J Public Health 2006; 96:488-494.
Diabetes Prevalence What can be done to reduce the prevalence of diabetes? Ramp up management of prediabetes from 20% in 2006 to 50% in 2012 with no further improvement after that. 33 Jones AP et al. Understanding Diabetes Population Dynamics Through Simulation Modeling and Experimentation, Am J Public Health 2006; 96:488-494.
Diabetes Prevalence What can be done to reduce the prevalence of diabetes? 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 What can be done for reducing deaths associated with diabetes? 35 Jones AP et al. Understanding Diabetes Population Dynamics Through Simulation Modeling and Experimentation, Am J Public Health 2006; 96:488-494.
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