This slide set provides an overview of the impact of type 1 and type 2 diabetes mellitus in the United States, focusing on epidemiology, costs both

This slide set provides an overview of the impact of type 1 and type 2 diabetes mellitus in the United States, focusing on epidemiology, costs both direct and indirect and the projected burden of diabetes, including globally 1

National Diabetes Statistics, 2014 provides an overview of the epidemiology of diabetes in the United States Diabetes affects 29.1 million people of all ages, or 9.3% of the population Of that number, about one-third, or 8.1 million, have diabetes that is undiagnosed 21 million have diagnosed diabetes Diabetes is the leading cause of kidney failure, nontraumatic lower-limb amputation, and new cases of blindness among adults Diabetes is also a major cause of heart disease and stroke and is the seventh leading cause of death 1.25 million with type 1 diabetes is estimated from Statistics Report statement that 5% of people with diagnosed diabetes have type 1 and from diagnosed adult and youth prevalence data National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/ 2

After adjusting for population age differences, 2010 2012 National Health Interview Survey and 2012 Indian Health Service s National Patient Information Reporting System data for people ages 20 years or older indicated the percentage of racial/ethnic populations with a diagnosis of diabetes As indicated on this slide, Puerto Ricans, at 14.9% and Mexican Americans, at 13.9%, represented the populations with the highest percentage of diagnosed diabetes Non-Hispanic white had the lowest percentage, 7.6% National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/ 3

The estimated percentage of people in the United States from 2012 age 20 years or older living with diabetes (diagnosed and undiagnosed) is summarized on this slide As the population ages, an increasing percentage is living with diabetes 20-44 years: 4.1% 45-64 years: 16.2% 65 years: 25.9% Source: 2009 2012 National Health and Nutrition Examination Survey estimates applied to 2012 U.S. Census data. National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/ 4

This slide highlights the number of civilian, noninstitutionalized persons with diagnosed diabetes in the United States from 1980-2011 From 1980 through 2011, the number of Americans with diabetes has more than tripled, from 5.6 million to 20.9 million Source: Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Health Interview Statistics, data from the National Health Interview Survey http://www.cdc.gov/diabetes/statistics/prev/national/figpersons.htm Centers for Disease Control and Prevention. Number (in millions) of civilian, non-institutionalized persons with diagnosed diabetes, United States, 1980 2009. Available at: http://www.cdc.gov/diabetes/statistics/prev/national/figpersons.htm 5

Methodology The percent of U.S. adults who are obese or who have diagnosed diabetes was determined by using data from the Behavioral Risk Factor Surveillance System (BRFSS, available at http://www.cdc.gov/brfss). An ongoing, yearly, state-based telephone survey of the noninstitutionalized adult population in each state, the BRFSS provides state-specific information on behavioral risk factors for disease and on preventive health practices. Respondents who reported that a physician told them they had diabetes (other than during pregnancy) were considered to have diagnosed diabetes. Self reported weight and height were used to calculate body mass index (BMI): weight in kilograms divided by the square of height in meters. A BMI greater than or equal to 30 was considered to be obese. Rates were age-adjusted using the 2000 U.S. Standard Population. 6

Methodology The percent of U.S. adults who are obese or who have diagnosed diabetes was determined by using data from the Behavioral Risk Factor Surveillance System (BRFSS, available at http://www.cdc.gov/brfss). An ongoing, yearly, state-based telephone survey of the noninstitutionalized adult population in each state, the BRFSS provides state-specific information on behavioral risk factors for disease and on preventive health practices. Respondents who reported that a physician told them they had diabetes (other than during pregnancy) were considered to have diagnosed diabetes. Self reported weight and height were used to calculate body mass index (BMI): weight in kilograms divided by the square of height in meters. A BMI greater than or equal to 30 was considered to be obese. Rates were age-adjusted using the 2000 U.S. Standard Population. 7

The Centers for Disease Control and Prevention (CDC) analyzed the prevalence of overweight and obesity among US adults aged 20 years with previously diagnosed diabetes by using data from two surveys: the Third National Health and Nutrition Examination Survey (NHANES III), 1988-1994, and NHANES 1999-2002. This analysis found that most adults with diagnosed diabetes were overweight or obese; during 1999-2002, the prevalence of overweight or obesity was 85.2%, and the prevalence of obesity was 54.8% In NHANES III, 1998-1994, participants were asked, Have you ever been told by a doctor that you have diabetes or sugar diabetes? For women, the question was preceded by other than during pregnancy In NHANES 1999-2002, the same questions were asked, but doctor was replaced with doctor or health-care professional Participants who responded yes were categorized as having diagnosed diabetes The body mass index (BMI) of each participant was calculated as weight in kilograms divided by height in meters squared; overweight was defined as a BMI of 25.0-29.9 and obesity as a BMI of 30.0 For the periods 1988-1994 (45.7%) and 1999-2002 (54.8%), prevalence of obesity was similar among all survey participants with diagnosed diabetes Among women in the 1999-2002 survey, the prevalence of overweight or obesity was 84.2% and the prevalence of obesity was 58.0% Compared with women aged 65 years, women aged 20-64 years had a significantly higher prevalence of obesity (64.7% vs 47.4%)(P<0.05) Centers for Disease Control and Prevention. Prevalence of overweight and obesity among adults with diagnosed diabetes United States, 1988-1994 and 1999-2002. MMWR. 2004;53(45):1066-1068. 8

SEARCH results were used to estimate the number of cases of diabetes mellitus in the US in 2001 154,369 (95% CI: 150,489-158,248) youth had physician-diagnosed diabetes The majority of these youth (78.7%, or 121,509) were ages 10-19 years Non-Hispanic white youth represented 62% of the US population <20 years of age but 71% of all children with diabetes Of those 0-9 years, 32,860 youth had diabetes Similarly, non-hispanic white youth had a disproportionate percentage of diabetes compared with the other racial/ethnic groups: they represented 60% of the population but 77% of all children with diabetes SEARCH for Diabetes in Youth Study Group. The burden of diabetes mellitus among US youth: prevalence estimates from the SEARCH for Diabetes in Youth Study. Pediatrics. 2006;118:1510-1518. 9

86 million adults ages 20 years and older are estimated to have prediabetes 37% were ages 20 years or older 51% were ages 65 years or older Prediabetes can lead to increased risk of developing type 2 diabetes, heart disease, and stroke Losing weight and increased physical activity can prevent or delay type 2 diabetes in those with prediabetes; in some cases, blood glucose levels return to normal National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/ 10

Complications of diabetes are included on this slide; the following slides summarize those of heart disease and stroke, hypertension, blindness, eye problems, nervous system disease and amputations In addition, periodontal disease is more common in those with diabetes Other complications include nerve disease, nonalcoholic fatty liver disease, periodontal (gum) disease, hearing loss, erectile dysfunction, depression, and complications of pregnancy, among others. National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/ 11

In 2004, heart disease was noted on 68% of diabetes-related death certificates among people ages 65 years and stroke was noted on 16% Adults with diabetes have death rates approximately 2-4 times higher from heart disease compared to those without diabetes Risk for stroke is 2-4 times higher among people with diabetes In 2005-2008, 67% of adults ages 20 years or older with diabetes had hypertension ( 140/90 mmhg) or used prescription medications for hypertension National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/ 12

Among adults ages 20-74 years, diabetes is the leading cause of new cases of blindness In 2005-2008, 4.2 million people with diabetes ages 40 years and older (28.5%) had diabetic retinopathy and of these, 655,000 (4.4% of those with diabetes) had advanced diabetic retinopathy that could lead to severe vision loss National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/ 13

44% of all new cases of kidney failure in 2008 were caused by diabetes Also in 2011 49,677 began treatment for end-stage renal disease 228,942 people with ESRD due to diabetes were living on chronic dialysis or with a kidney transplant National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/ 14

Rates of all five complications declined between 1990 and 2010, with the largest relative declines in acute myocardial infarction (-67.8%; 95% confidence interval [CI], -76.2 to -59.3) and death from hyperglycemic crisis (-64.4%; 95% CI, -68.0 to -60.9), followed by stroke and amputations, which each declined by approximately half (-52.7% and -51.4%, respectively); the smallest decline was in end-stage renal disease (-28.3%; 95% CI, -34.6 to - 21.6). The greatest absolute decline was in the number of cases of acute myocardial infarction (95.6 fewer cases per 10,000 persons; 95% CI, 76.6 to 114.6), and the smallest absolute decline was in the number of deaths from hyperglycemic crisis (-2.7; 95% CI, -2.4 to -3.0). P < 0.01% for all changes. National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/ 15

60%-70% of people with diabetes have mild to severe forms of nervous system damage, including neuropathy, erectile dysfunction, or carpal tunnel syndrome About 60% of nontraumatic lower-limb amputations occur in those with diabetes National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/ 16

Based on US death certificates in 2010, diabetes was the seventh leading cause of death in which diabetes appeared as any-listed cause of death This ranking is based on 69,071 death certificates that listed diabetes as the underlying cause of death and 234,051 in which diabetes was listed as a contributing cause of death Diabetes is likely to be underreported as a cause of death; studies have found that 35%- 40% of those who died had diabetes listed anywhere on the death certificate; in about 10%-15%, it was listed as the underlying cause of death Risk for death among people with diabetes is 1.5 times higher than that of people of a similar age who do not have diabetes National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/ 17

Section 2, Costs, examines the economic costs of diabetes, including medical expenditures, health resource use, health care expenditures, indirect costs, and mortality costs attributed to diabetes 18

Diabetes is a disease that touches almost everyone in society and nowhere is this more true than with respect to costs of diabetes In 2007, diabetes cost the US an estimated $254 billion; $176 billion in excess medical expenditures and $69 billion in reduction in national productivity American Diabetes Association. Economic costs of diabetes in the U.S. in 2007. Diabetes Care. 2008;31:596-615. 19

The largest components of medical expenditures attributed to diabetes were Hospital inpatient care (43% of total costs) Retail prescriptions to treat complications of diabetes (18%) Diabetes medication and supplies (12%) Physician office visits (9%) Nursing/residential facility stays (8%) American Diabetes Association. Economic costs of diabetes in the U.S. in 2007. Diabetes Care. 2008;31:596-615. 20

People with a diagnosis of diabetes incur average expenditures of $11,744 annually, of which $6,649 is attributed to diabetes Medical expenditures for those with a diagnosis of diabetes are, on average, approximately 2.3 times higher than what expenditures would be in the absence of diabetes For the cost categories analyzed, approximately $1 in $5 health care dollars is spent caring for someone with a diagnosis of diabetes, while approximately $1 in $10 health care dollars is attributed to the disease itself American Diabetes Association. Economic costs of diabetes in the U.S. in 2007. Diabetes Care. 2008;31:596-615. 21

These data illustrate the estimated health resource use attributed to diabetes by type of service, aggregated into the age categories younger than 45 years; 45-64 years, and older than 65 years of age The population group aged 65 years and older was found to use a large proportion of services, reflecting the burden diabetes places on the Medicare program American Diabetes Association. Economic costs of diabetes in the U.S. in 2007. Diabetes Care. 2008;31:596-615. 22

The number of workdays absent because of diabetes in 2007 was estimated at 15 million, at a national cost of $2.6 billion Reduced performance at work, or presenteeism, was estimated at 120 million lost workdays, with an estimated national cost of $20 billion The estimated productivity loss for those not in the labor force was equivalent to 6 million days, with a national cost of $800 million At any given time during 2007, approximately 16 million people were unemployed and receiving Supplemental Security Income (SSI) payments due to disability More than 1 million of these people had diabetes More than 445,000 cases of unemployment were attributed to diabetes, equating to 107 million lost workdays at a national cost of $7.9 billion An estimated 284,000 deaths in 2007 were attributed to diabetes (see Slide 26) Total cost attributable to diabetes was $58.2 billion American Diabetes Association. Economic costs of diabetes in the U.S. in 2007. Diabetes Care. 2008;31:596-615. 23

An estimated 284,000 deaths in 2007 were attributed to diabetes, including: 77,000 deaths where diabetes was listed as the primary cause of death 123,000 deaths where cardiovascular disease was listed as the primary cause of death (with 16.5% of national deaths from cardiovascular disease attributed to diabetes) 59,000 deaths where cerebrovascular disease was listed as the primary cause of death; and 5,000 deaths where renal disease was listed as the primary cause of death Taking into account the age and sex distribution of these deaths, the value of lost productivity from premature mortality is $26.9 billion American Diabetes Association. Economic costs of diabetes in the U.S. in 2007. Diabetes Care. 2008;31:596-615. 24

A cost of Diabetes Model was used to estimate the U.S. economic burden associated with diabetes These revised estimates suggesting the US national economic burden is even higher: $322 billion, which includes $244 billion in higher medical costs and $78 billion in productivity loss Specifically, the $322 billion comprises $245billion for diagnosed diabetes, $32.8 billion for undiagnosed diabetes, $43.9 billion for prediabetes, and $1.3 billion for gestational diabetes Dall TM, Zhang Y, Chen YJ, Quick WW, Yang WG, Fogli J. The economic burden of diabetes. Health Affairs. 2010;29(2):297-303. 25

Section 3, Future Projections, examines International Diabetes Federation global projections for the number of people with diabetes, 2010-2030 as well as the number of people with diabetes ages 20-79 years, 2010 and 2030, by the top 10 countries In addition, a model provides an estimate of the future burden of diabetes through 2050 26

In 2009, the International Diabetes Federation estimated the number of people with diabetes ages 20-79 years in 2010 and 2030 by top 10 country (or territory) India, China, and the United States had the greatest number of people with diabetes in 2010, and these countries are expected not only to maintain this ranking but see their population of those with diabetes increase by more than 65 million International Diabetes Foundation. IDF Diabetes Atlas, 4 th ed. 2009. Available at: http://www.idf.org/diabetesatlas/downloads. 27

Results indicate that by the year 2050, the prevalence of total diabetes, both diagnosed and undiagnosed, is projected to increase from 1 in 10 U.S. adults to between 1 in 5 and 1 in 3 adults The annual incidence of new cases of diagnosed diabetes is projected to increase from 8 cases per 1000 in 2008 to approximately 15 cases per 1000 by the year 2050 The projected increases are largely attributed to three key demographic factors The aging of the US population Increasing size of higher-risk minority populations in the population; and Declining mortality among people with diabetes Boyle JP, Thompson TJ, Gregg EW, Barker LE, Williamson DF. Projection of the year 2050 burden of diabetes in the US adult population: dynamic modeling of incidence, mortality, and prediabetes prevalence. Popul Health Metr. 2010;8:29. 28

This figure illustrates projections of total diabetes prevalence as a percentage of the total U.S. adult population for four scenarios Low incidence projections and r 1 =1.77, r 2 =2.11; low incidence projections and r 1 =1.00 and r 2 =4.08; middle incidence projections and r 1 =1.77, r 2 =2.11; middle incidence projections and r 1 =1.00, r 2 =4.08 [Data not shown] Total diabetes prevalence is projected to increase from 14% of the U.S. adult population in 2010 to as high as 33% in 2050, based on the following scenarios: Low incidence, high mortality: to 21% Middle incidence: to 25% to 28% High incidence, low mortality: to 33% Boyle JP, Thompson TJ, Gregg EW, Barker LE, Williamson DF. Projection of the year 2050 burden of diabetes in the US adult population: dynamic modeling of incidence, mortality, and prediabetes prevalence. Popul Health Metr. 2010;8:29. 29