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.
Premise of Public Health Action for Diabetes and Pre-Diabetes Forecasted Millions of People with Incidence of Diagnosed Diabetes Among Adults Diagnosed Diabetes with Diabetes by Level of Education, 1980-2008 18 50 <high school high school >high school Numbers with diagnosed diabetes (Millions) 15 40 12 Incidence (per 1000 PY 30 9 20 6 10 3 0 0 Year Year CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
Diabetes: Undiagnosed Diabetes Dysglycemia “Pre-diabetes” 1 in 3 lifetime Risk
EXTRAS
Diabetes Pyramid of Prevention? Adult Prevalence Goal / Intervention Tier Prevent Morbidity 7.6% Diabetes Detect Early 2.6% Undiagnosed DM
Classic Levers in the Public Health Response to Diabetes Glycemic control BP control Lipid testing and management Clinical Promotion of Services Behaviors Annual eye examinations Education and awareness for: Foot care for high risk persons • Physical activity Kidney disease testing • Reduced Tobacco Flu immunization • Healthy diet Preconception care Diabetes education • Regular doctor visits Case Management • Self monitoring Targeted Screening • Self mgt education Population-Targeted Policies • Health care access legislation • Drug and supply reimbursement policies • Population registry and feedback systems
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) High Blood Pressure High Cholesterol 60 60 45 Prevalence (%) 45 Prevalence (%) 30 30 15 15 0 0 1971 - 1974 1976 - 1980 1988 - 1994 1999-2006 1971 - 1974 1976 - 1980 1988 - 1994 1999-2006 Year Year High A1c Level Smoking 80 40 Prevalence (%) 60 30 40 20 10 20 0 0 1971 - 1974 1976 - 1980 1988 - 1994 1999-2006 1999-2000 2001-2002 2003-2004 Year
Incidence of lower extremity amputation, end stage renal disease, and hyperglycemic death in the U.S. diabetic population, 1990-2006. 80 70 Amputation 60 Events Per 10,000 50 40 End Stage Renal Disease 30 20 4.0 Hyperglycemic Death 3.0 2.0 Gregg and Albright, JAMA, 2009
Trends in CVD Mortality Between Men and Women with Diabetes 40 Mortality rate (deaths/1000 per year) Men 30 Women 20 10 0 1971 - 1976 - 1988 - 1971 - 1976 - 1988 - 1986 1992 2000 1986 1992 2000 Cohort follow-up period Gregg et al., Ann Intern Med, 2007
CVD Mortality Trends During the Past Decade, U.S. Adult Population with Diabetes, National Health Interview Survey (follow-up through 2006) 16 Men Men Women Women 14 Mortality rate (per1000 per year) 12 10 8 6 4 2 0 Cohort Unpublished Analyses, National Health Interview Survey, Gregg and Cheng, 2010
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
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 .
Incidence of lower extremity amputation, end stage renal disease, and hyperglycemic death in the U.S. population, 1990-2006. Gregg and Albright, JAMA, 2009
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
Diabetes Prevention Interventions Carried Out in Community Settings Sessions offered Sessions Wt loss 7% loss 5% loss First author N Age (wks) attended (%) (%) (%) DPP 1079 51 16 (24) 15 7 50 nr Amundson 295 54 16 (16) 14 6.7 45 67 Ackermann 46 57 16 (20) 9 6 36 59 Pagoto 118 49 16 (16) 13 4.6 30 49 Boltri 8 - 16 (24) 10 3.6 - - Aldana 35 - 16 (24) 11 3.3 - - Wolf 73 53 12 (52) 7 4.9 - 20 McBride 40 52 12 (12) - 4.6 - - Kramer 93 55 12 (14) 8 3.5 24 52 - - McTigue 72 53 12 (52) 27 - Seidel 88 54 12 (14) 9 - 26 46 Davis-Smith 10 - 6 (6) 5 3.8 - - Cramer 27 - 7 (28) - 2.7 - - Whittemore 31 48 11 (36) 8 - - 25 (Williamson and Marrero, 2010)
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?
Diabetes Pyramid of Prevention Adult Prevalence Goal / Intervention Tier Prevent Morbidity 7.6% Diabetes Detect Early 2.6% Undiagnosed DM Very High Risk ~ 12-15% (A1c > 5.7%; IGT; GDM) What type of High Risk (FPG > 100); ~ 15-20% intervention Central Obesity; HTN, age for what level of risk? Moderate Risk ~57% Low Risk
Screening, Diagnosis, and Prevention of Diabetes Find new diabetes Risk Test for Preventive Factor Diagnosis Intervention Screening Structured Prevention • Intensive 6 –12 mo • FPG • Extended: > 2 years • OGTT • Multi-component • HbA1c Reduced total intake, Reduced fat intake Exercise Fiber / whole grain Behavioral support Moderate weight loss
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.
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 .
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.
Macro-Level Determinants Obesity and Diabetes: Current Debates Over Policy Strategies � Physical environment � Food environment � Social environment � Economy and poverty
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.
� 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
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