Creating Policy to Promote and Support Individual Change Ann Albright, PhD, RD Director, Division of Diabetes Translation Centers for Disease Control and Prevention The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the CDC.
Vision World free of the devastation of diabetes
Where are We?
Age-adjusted Percentage of U.S. Adults with Diagnosed Diabetes or Obesity Diabetes 1994 2000 2007 No Data <4.5% 4.5-5.9% 6.0-7.4% 7.5-8.9% >9.0% Obesity (BMI 30 kg/m 2 ) 1994 2000 2007 No Data <14.0% 14.0-17.9% 18.0-21.9% 22.0-25.9% >26.0%
Age-adjusted Percent of Adults 20 Years Old with Diagnosed Diabetes, 2007 MMWR 58:1259-1263, 2009
Age-adjusted Percent of Adults 20 Years Old Who are Obese, 2007 MMWR 58:1259-1263, 2009
Counties in the Top and Bottom 2 Quintiles of Both Diabetes and Obesity, 2007 MMWR 58:1259-1263, 2009
Public Health Implications The prevalence and incidence of diagnosed diabetes has increased rapidly, particularly since the 1990s Number of factors may be driving increase change in diagnostic criteria enhanced case detection decreased mortality or a true increase in incidence
SEARCH for Diabetes in Youth Prevalence (p er 1, 000) 3 2.5 2 1.5 1 0.5 0 0-9 Years 10-19 19 Years NHW AA H API AI T1 T2 T1 T2 SEARCH Study Group, Pediatrics, 2006
1 in 3 Americans born in 2000 are expected to develop diabetes sometime during their lifetime Narayan, Boyle, Geiss, Saaddine, Thompson. Diabetes Care 29(9):2114 2116, 2006
Diabetes is a Growing Problem Projected Burden, U.S. 2005-2050 50 40 30 20 10 Numbers with diagnosed diabetes (M illions) 0 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050 Narayan et al. JAMA 2003 Year
Preventive Care Practices
Opportunities to Control Diabetes Eye exams lead to 50-60% decrease Vision Loss Foot exams lead to 45-85% decrease Foot ulcers and amputations Glucose control lead to 40% decrease Kidney failure, Vision loss Lipid control lead to 20-50% decrease Cardiovascular Disease Flu vaccine Narayan et al., 2006 leads to 32% decrease Hospitalization
Progress in Control: Diabetes Preventive Care Between 1988-1994 and 1999-2004 100 80 60 % 40 20 0 Foot exams Flu vaccine Lipid testing Eye exams Aspirin use Saaddine et al. Annals of Internal Medicine, 2006
Trends in Processes of Diabetes Care from 1988-1994 to 2003-2006, United States 85 75 65 55 Foot Exams 85 75 65 55 Eye Exams 85 75 65 55 Lipid Test 45 45 45 35 35 35 1995 1995 2002 2002 2005 2005 1995 1995 2002 2002 2005 2005 1995 2002 NHW Non-white Low Educ No Health Insurance NHW Non-white Low Educ No Health Insurance NHW Non-white Low Educ No Health Insurance Saaddine et al., Ann Intern Med, 2006; additional analyses, 2008
Foot Exam in the Last Year 1995 and 2005 1995 2005 Age-adjusted rates per 100 adults with diabetes. Centers for Disease Control and Prevention. Diabetes Surveillance System at http://www.cdc.gov/diabetes/statistics/index.htm
> 2 A1c Tests in the Last Year 2000 and 2005 2000 2005 Age-adjusted rates per 100 adults with diabetes. Centers for Disease Control and Prevention. Diabetes Surveillance System at http://www.cdc.gov/diabetes/statistics/index.htm
Eye Exams in the Last Year 1995 and 2005 1995 2005 Age-adjusted rates per 100 adults with diabetes. Centers for Disease Control and Prevention. Diabetes Surveillance System at http://www.cdc.gov/diabetes/statistics/index.htm
Intermediate Outcomes
Secular Changes in Quality Measures of Diabetes Care, 1988-1994 and 1999-2004 100 80 % 60 40 20 0 Foot exams Flu vaccine Lipid testing Eye exams Aspirin use HbA1c >9.0% BP <140/90 LDL <130 mg/dl Processes of care Intermediate measures Saaddine et al. Annals of Internal Medicine, 2006
Prevalence of high cholesterol among U.S. adults with diabetes aged 20-74 from 1971 to 2006, according to poverty income ratio 50 Prevalence (%) 40 30 20 10 Lowest 25% of income Middle 50% of income Highest 25% of income 0 1971-1974 1976-1980 1988-1994 1999-2006 Year Cheng and Gregg, Unpublished Analyses, NHANES, 2008
Prevalence of high blood pressure among U.S. adults with diabetes aged 20-74 from 1971 to 2006, according to poverty income ratio 60 Prevalence (%) 50 40 30 20 10 Lowest 25% of income Middle 50% of income Highest 25% of income 0 1971-1974 1976-1980 1988-1994 1999-2006 Year Cheng and Gregg, Unpublished Analyses, NHANES, 2008
Prevalence of smoking among U.S. adults with diabetes aged 20-74, according to income group, 1971 to 2002 Prevalence (%) 30 20 10 Lowest 25% of income Middle 50% of income Highest 25% of income 0 1971-1976 - 1988-1974 1980 1994 Cheng and Gregg, Unpublished Analyses, NHANES, 2008 Year 1999-2006
Distal Outcomes
Progress in Control: Diabetes Outcomes 1995 to 2005 Vision Loss 25% Amputation 36% End Stage Renal Disease 23% CVD Hospitalization 16% Total Hospitalization 33% www.cdc.gov/diabetes
Persons with Diagnosed Diabetes
Total Population
Successes in the Public Health Response to Diabetes: Impact of Clinical and Public Health Advances Fewer acute complications/hospitalization Lower amputation rates Lower incidence of end stage renal disease Reduced CVD hospitalization Reduced mortality rates..for the average person with diabetes
Closing the Gap
"We can't solve problems by using the same kind of thinking we used when we created them." Albert Einstein
Ecological Model Community and policy System, group, culture Family, friends, small group Individual The health of individuals is inseparable from the health of communities (Healthy People 2010)
Must Address Disparities/Social Determinants of Health Stalling of some risk factor improvements Persistent disparities Renal disease in African Americans, Native American, Latinos Stroke in African Americans Blood pressure and glucose Diabetes incidence and prevalence in non-whites Trends in incidence of diabetes Growing burden in youth and young adults represent a newer area of concern
POLICY DISTRIBUTION POLICY AVAILABILITY POLICY EFFECTIVENESS EFFICIENCY Supply Diffusion of interventions BASIC SCIENCE EFFICACY Biggest effect on most people Real world settings Ideal settings Molecular/ physiological
Transforming Health Care Chronic (Planned) Care Model Creating partnerships between health system and community Community: resources and policies Health System: self-management support, delivery system design, decision support, clinical information systems
Critical Elements collaborating cooperating coordinating networking True synergy to cocreate & achieve mutual benefit Altering & sharing resources for a common goal Identifying & aligning complimentary resources Exchanging information for mutual benefit
System Dynamics Modeling Population Flow Map Burden of diabetes People with normal blood sugar levels Obesity in general population Prediabetes onset Recovery People with prediabetes Diabetes Onset Pre-diabetes detection and management People with undiagnosed diabetes Deaths Total Prevalence (People with diabetes) Diagnosis Diabetes detection Unhealthy days per person with diabetes People with diagnosed diabetes Costs per person with diabetes Deaths Diabetes management Children Adults
Prevention of Type 2 Diabetes The Community Clinic Partnership Model Community Clinic Insurers Employers Informed Population Strong Community Organizations Healthy Public Policy } Screening for High Risk Partnership Zone Reimbursement Lifestyle DPP-like Programs Diagnosis of Pre-diabetes Proactive Practice Team Decision Support Information Systems Supportive Environments Regular Glucose Monitoring Informed, Activated Patients Total Population Pre-diabetes Diabetes Complications
Prevention of Type 2 Diabetes Goal: Systematically scale the translated model of the Diabetes Prevention Program (DPP) with the Y, Indiana University and others to reduce the incidence of type 2 diabetes
Four Key CDC Levers (1) Training the work force that can implement the program cost effectively (2) Implementing a recognition program that will contribute to assuring quality, lead to reimbursement, and allow CDC to develop a registry of programs
Four Key CDC Levers (3) Implementing model sites that will build the infrastructure and provide a laboratory for additional refinement of this prevention system (4) Increasing referrals and utilization of the prevention system
Control and Primary Prevention Sustaining and building on gains in control Building and expanding primary prevention
Leadership matters most in times of uncertainty Michael Useem, The Leadership Moment
24 million with Diabetes 57 million with Prediabetes