the impact of diabetes mellitus in the united states epidemiology, costs, and future projections

The Impact ofThe Impact of Diabetes Mellitus in the Diabetes Mellitus in the

United StatesUnited States

Epidemiology, Costs, andEpidemiology, Costs, andFuture ProjectionsFuture Projections

Table of ContentsTable of Contents

SectionSection Slide No.Slide No.

Epidemiology 3-34

Costs 35-43

Future Projections 43-49

EPIDEMIOLOGYEPIDEMIOLOGYSection 1Section 1

Epidemiology of DiabetesEpidemiology of Diabetes

• Diabetes affects 25.8 million peopleof all ages

• 8.3% of the U.S. population

– Diagnosed: 18.8 million– Undiagnosed: 7.0 million

• Leading cause of kidney failure, nontraumatic lower-limb amputation,new cases of blindness among adults

• Major cause of heart disease and stroke

• Seventh leading cause of death

National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/

Diagnosed and UndiagnosedDiagnosed and UndiagnosedDiabetes in 2010Diabetes in 2010

• ~1.9 million people ≥20 years of age newly diagnosed; 215,000 were <20 years

• Of the 25.6 million (11.3%) ≥20 years

• Men: 13.0 million (11.8%)• Women: 12.6 million (10.8%)• Non-Hispanic whites: 15.7 million (10.2%)• Non-Hispanic blacks: 4.9 million (18.7%)

• >65 years, 10.9 million (26.9%)


Racial/Ethnic DifferencesRacial/Ethnic Differencesin Diagnosed Diabetesin Diagnosed Diabetes


Race/EthnicityRace/Ethnicity %%

Non-Hispanic whites 7.1

Asian Americans 8.4

Hispanics/LatinosCuban AmericansCentral and South AmericansMexican AmericansPuerto Ricans

11.8 7.6 7.613.313.8

Non-Hispanic blacks 12.6

• 2007–2009 national survey data for people ages 20 years or older

Diagnosed and Undiagnosed DiabetesDiagnosed and Undiagnosed Diabetes


Source: 2005-2008 National Health and Nutrition Examination Survey

New Cases of Diagnosed DiabetesNew Cases of Diagnosed Diabetes


Source: 2005-2008 National Health and Nutrition Examination Survey estimates projected to the year 2010

www.cdc.gov

County-Level Estimates of Diagnosed County-Level Estimates of Diagnosed Diabetes (%), Adults ≥20 years, 2008Diabetes (%), Adults ≥20 years, 2008

Percent

0 - 6.5

6.6 - 8.0

8.1 - 9.4

9.5 - 11.1

> 11.2

0 – 6.5

6.6 – 8.0

8.1 – 9.4

9.5 – 11.1

≥ 11.2

Number of Americans withNumber of Americans withDiagnosed Diabetes, 1980-2009Diagnosed Diabetes, 1980-2009

www.cdc.gov

Annual, Age-Adjusted Incidence Rate Annual, Age-Adjusted Incidence Rate of Diagnosed Diabetes*, 2005-2007of Diagnosed Diabetes*, 2005-2007

MMWR. 2008;57(43):1169-1173.

Prevalence of Overweight and Obesity Prevalence of Overweight and Obesity Among Adults with DiabetesAmong Adults with Diabetes

MMWR. 2004;53(45):1066-1068.

• CDC analysis of prevalence of overweight and obesity among U.S. adults ≥20 years with previously diagnosed diabetes– Overweight or obesity: 85.2%– Obesity: 54.8%

• Women aged 20-64 years had a significantly higher prevalence of obesity than women ≥65 years of age (64.7% vs 47.4%; P<0.05) during 1999-2002

• Among men, prevalence of overweight or obesity was 86.3% and obesity, 53.0%

SEARCH for Diabetes in YouthSEARCH for Diabetes in Youth Study Overview Study Overview

• Population-based, observational study of physician-diagnosed diabetes among youth <20 years of age

• Initiated in 2000

• Funded by CDC, NIH

• Collects data from 6 centers

– 4 geographically based (Colorado, Ohio,South Carolina, Washington)

– 2 health plan-based (California, Hawaii)

SEARCH for Diabetes in Youth Study Group. Pediatrics. 2006;118:1510-1518.

CDC=Centers for Disease Control and Prevention; NIH=National Institutes of Health

• 6379 youth with diabetes in a population of ~3.5 million– Average age at diagnosis: 8.4 years– Average duration of diabetes:

56 months (range, 38-60 months) • Estimated prevalence of U.S. youth aged

0-19 years with diabetes in 20011.82 cases per 1000 youth

(95% CI: 1.78-1.87 per 1000 youth)Cancer: 1.24 per 1000Asthma: 120 per 1000


SEARCH for Diabetes in YouthSEARCH for Diabetes in Youth ResultsResults

SEARCH for Diabetes in YouthSEARCH for Diabetes in YouthDemographics, PrevalenceDemographics, Prevalence

CharacteristicCharacteristic No. of cases (%)No. of cases (%)

Population Population denominator,denominator,

n (%)n (%)

Prevalence, cases Prevalence, cases per 1000 youth per 1000 youth

(95% CI)(95% CI)

Total population 6379 3,499,846 1.82 (1.78-1.87)

Age group0-4 y5-9 y10-14 y15-19 y

255 (4.0)1094 (17.2)2120 (33.2)2910 (45.6)

829,589 (23.7)876,263 (25.0)925,426 (26.5)868,568 (24.8)

0.31 (0.27-0.35)1.25 (1.18-1.32)2.29 (2.20-2.39)3.35 (3.23-3.47)

GenderMaleFemale

3156 (49.5)3223 (50.5)

1,787,208 (51.1)1,712,638 (48.9)

1.77 (1.71-1.83)1.88 (1.82-1.95)

Race/ethnicityNHWBlackHispanicAPIAI

4382 (68.7)721 (11.3)829 (13.0)267 (4.2)180 (2.8)

2,025,426 (57.9)373,599 (10.6)641,414 (18.3)320,403 (9.2)139,004 (4.0)

2.16 (2.10-2.23)1.93 (1.79-2.08)1.29 (1.21-1.38)0.83 (0.74-0.94)1.29 (1.12-1.50)

SEARCH for Diabetes in Youth Study Group. Pediatrics. 2006;118:1510-1518. Table 1.

NHW=non-Hispanic white; AA=African-American; H=Hispanic; API=Asian/Pacific Islander; AI=American Indian

SEARCH for Diabetes in YouthSEARCH for Diabetes in Youth0-9 Years by Race/Ethnicity0-9 Years by Race/Ethnicity



Prevalence

SEARCH for Diabetes in YouthSEARCH for Diabetes in Youth10-19 Years by Race/Ethnicity10-19 Years by Race/Ethnicity


Prevalence


SEARCH for Diabetes in YouthSEARCH for Diabetes in Youth Population Estimates, 2001 Population Estimates, 2001

• Estimated number of cases of diabetes mellitus, extrapolated from SEARCH data

154,369 youth(95% CI: 150,489-158,248)

• Majority (78.7%) 10-19 years of age

• Non-Hispanic white: 62% of those <20 years but 71% of all children with diabetes

• 32,860 children <10 years of age

– Non-Hispanic white: 60% of population but 77% of all children with diabetes


PrediabetesPrediabetes

• In 2005-2008, based on fasting glucose or hemoglobin A1C levels, prediabetes was detected in

– 35% of adults ages 20 years and older– 50% of adults ages 65 years and older– An estimated 79 million adults ages

30 years and older

• People with prediabetes have an increased risk of developing type 2 diabetes, heart disease, and stroke


Gestational DiabetesGestational Diabetes

• Range from 2%–10% of pregnancies

• Postpartum, 5%–10% of women with gestational diabetes are found to have diabetes, usually type 2

• Women who have had gestational diabetes have a 35%–60% chance of developing diabetes within 10–20 years

• Using new diagnostic criteria, international multicenter study of gestational diabetes found 18% of pregnancies were affected


Complications of DiabetesComplications of Diabetes

• Heart disease and stroke• Hypertension• Blindness, eye problems• Renal disease• Nervous system disease• Amputations• Dental disease• Complications of pregnancy• Other complications


• In 2004, of diabetes-related death certificates among people ages ≥65 years, 68% noted heart disease and 16%, stoke

• Adults with diabetes have heart disease death rates ~2–4 times higher than those without; stroke risk is 2–4 times higher

• In 2005-2008, of adults ages ≥20 years with self-reported diabetes, 67% had blood pressure ≥140/90 mmHg or used prescription medications for hypertension

Complications of DiabetesComplications of DiabetesHeart Disease, Stroke, HypertensionHeart Disease, Stroke, Hypertension


• Diabetes is leading cause of new cases of blindness among adults ages 20–74 years

• Of people with diabetes aged ≥40 years, 4.2 million (28.5%) had diabetic retinopathy in 2005-2008

• 655,000 (4.4% of those with diabetes) had advanced diabetic retinopathy that could lead to severe vision loss

Complications of DiabetesComplications of DiabetesBlindness, Eye ProblemsBlindness, Eye Problems


• In 2008, diabetes was leading cause of kidney failure, accounting for 44% of all new cases of renal failure

• 48,374 people with diabetes began treatment for end-stage renal disease (ESRD)

• 202,290 people with ESRD due to diabetes were living on chronic dialysis or with a kidney transplant

Complications of DiabetesComplications of DiabetesRenal DiseaseRenal Disease


• ~60%–70% of people have mild to severe forms of nervous system damage– Impaired sensation or pain in feet

or hands– Slowed digestion of food in the stomach– Carpal tunnel syndrome– Erectile dysfunction

• Severe forms are a major contributing cause of lower-extremity amputations: >60% occur in people with diabetes

Complications of DiabetesComplications of DiabetesNervous System DiseaseNervous System Disease


Oralmedication

only58%

No medication

16%

Insulin only 12%

Insulin and oral

medication14%

Treatment of DiabetesTreatment of Diabetes


Deaths Among People with DiabetesDeaths Among People with Diabetes

• In 2007, diabetes seventh leading cause of death based on death certificates

– 71,382 underlying cause– 160,022 contributing cause

• Likely to be underreported as a causeof death

• Overall, risk for death among those with diabetes is about twice that of people with similar age but without diabetes


Age Distribution of DeathsAge Distribution of DeathsAssociated with DiabetesAssociated with Diabetes

Age 70+ 206,791

73%

Age <184880%

Age 18-34 1,9181%

Age 35-44 55642%

Age 45-54 16,663

6% Age 55-59 13,907

5%

Age 60-64 17,634

6%

Age 65-6920,656

7%

American Diabetes Association. Diabetes Care. 2008;31:596-615. Figure 4.

All-cause mortality rate among peopleAll-cause mortality rate among peoplewith and without diabeteswith and without diabetes

Gregg et al., Diabetes Care 35: 1252—1257, 2012

With diabetes

Without diabetes*

*Rate difference between 1997/1998 and 2003/2004, –5.2; P < 0.02 for trend

CVD mortality rate among peopleCVD mortality rate among peoplewith and without diabeteswith and without diabetes


With diabetes

Without diabetes


*

CVD mortality rate among womenCVD mortality rate among womenwith and without diabeteswith and without diabetes


Women with diabetes

Women without diabetes

*Rate difference – 3.5; P < 0.01 for trend; †Rate difference – 0.5, P < 0.03 for trend

*

†

All-cause mortality rate among womenAll-cause mortality rate among womenwith and without diabeteswith and without diabetes


Women with diabetes

Women without diabetes

*Rate difference – 5.6; P < 0.01 for trend

*

CVD mortality rate among menCVD mortality rate among menwith and without diabeteswith and without diabetes


Men with diabetes

Men without diabetes


*

All-cause mortality rate among menAll-cause mortality rate among menwith and without diabeteswith and without diabetes


Men with diabetes

Men without diabetes

Rates between 1997/1998 and 2003/2004 not significantly different

COSTSCOSTSSection 2Section 2

Economic Costs of Diabetes, 2007Economic Costs of Diabetes, 2007

• Cost of Diabetes Model

• Total cost of diabetes: $174 billion

– $116 billion: excess medical expenditures

• $27 billion to treat diabetes directly• $58 billion to treat diabetes-related

chronic complications attributed to diabetes

• $31 billion excess medical costs

– $58 billion: reduced national productivity

American Diabetes Association. Diabetes Care. 2008;31:596-615.

Medical ExpendituresMedical ExpendituresAttributed to Diabetes, 2007Attributed to Diabetes, 2007

• Hospital inpatient care (50%)

• Diabetes medication and supplies (12%)

• Retail prescriptions to treat complications of diabetes (11%)

• Physician office visits (11%)


Costs Incurred by People with a Costs Incurred by People with a Diagnosis of Diabetes in 2007Diagnosis of Diabetes in 2007

• Average annual expenditures: $11,744

– $6,649 attributed to diabetes

• On average, people with diagnosed diabetes have medical expenditures ~2.3 times higher than those without diabetes

– ~$1 in $5 health care dollars is spent caring for someone with diagnosed diabetes

– ~$1 in $10 health care dollars is attributed to diabetes


Health Resource UseHealth Resource UseAttributed to Diabetes, 2007Attributed to Diabetes, 2007

American Diabetes Association. Diabetes Care. 2008;31:596-615. Table 5.

Health resourceHealth resource

Age (years)Age (years)

Total*Total*<45<45 45-6445-64 ≥≥6565

Institutional careHospital inpatient daysNursing/residential facility days

2,1151,269

7,58611,103

14,56243,687

24,26256,059

Outpatient careOffice-based physician visitsEmergency visitsHospital outpatient and

freestanding ambulatory surgical center visits

Home health visitsHospice care daysRetail prescriptions

7,3531,4991,307

04

15,181

26,5521,9842,535

8,93922

71,295

30,8082,0841,888

18,449165

88,841

64,7135,5675,730

27,388192

175,317*Numbers do not necessarily sum to totals because of rounding

Indirect CostsIndirect CostsAttributed to Diabetes, 2007Attributed to Diabetes, 2007


Cost componentCost component Productivity lossProductivity loss

Total cost Total cost attributableattributableto diabetesto diabetes($ billions)($ billions)

Proportion Proportion of indirect of indirect costs (%)costs (%)

Work days absent 15 million days 2.6 4

Reduced performance at work

120 million days 20.0 34

Reduced productivity days for those not in labor force

6 million days 0.8 1

Permanent disability445,000 people, 107 million days

7.9 14

Mortality 284,000 deaths 26.9 46

TotalTotal 58.258.2 100100

Mortality CostsMortality CostsAttributed to Diabetes, 2007Attributed to Diabetes, 2007


Primary cause Primary cause of deathof death

Total US Total US deathsdeaths

Deaths attributed to diabetesDeaths attributed to diabetes

DeathsDeaths

% of % of total total of US of US

deathsdeaths

Value of Value of lost lost

productivity productivity (millions of (millions of

dollars)dollars)

Diabetes 77,000 77,000 100.0 9,520

Renal disease 43,000 25,000 57.4 2,116

Cerebrovascular disease

155,000 59,000 37.6 3,849

Cardiovascular disease

739,000 123,000 16.5 11,417

TotalTotal NA*NA* 284,000284,000 NA*NA* 26,90226,902*Total comprises mortality for reasons other than those listed here

Economic Costs of PrediabetesEconomic Costs of Prediabetesand Diabetes, 2007and Diabetes, 2007

• Higher medical costs: $153 billion

• Productivity loss: $65 billion

• Total cost: $218 billion+

– $174.4 billion for diagnosed diabetes– $18 billion for undiagnosed diabetes– $25 billion for prediabetes– $636 million for gestational diabetes

• Total burden for each American, regardless of diabetes status: $700 annually

Dall TM, et al. Health Affairs. 2010;29(2):297-303.

Reducing the Burden of DiabetesReducing the Burden of Diabetes

• Burden of diabetes, complications on individuals, health care system significant

• Much of the cost is preventable through

– Improved diet and exercise– Prevention initiatives to reduce prevalence

of diabetes, comorbidities– Improved care for people with diabetes to

reduce need for costly complications

• Understanding economic cost, major determinants of costs, can help inform, motivate decisions to reduce burden


FUTURE PROJECTIONSFUTURE PROJECTIONSSection 3Section 3

IDF Diabetes Atlas, 4th ed. ©International Diabetes Federation, 2009.

IDF Global Projections for Number of IDF Global Projections for Number of People with Diabetes, 2010-2030People with Diabetes, 2010-2030

Estimated Number of People with Estimated Number of People with Diabetes Worldwide, 2010 and 2030Diabetes Worldwide, 2010 and 2030

IDF Diabetes Atlas, 4th ed. ©International Diabetes Federation, 2009.

Country/TerritoryCountry/Territory20102010

MillionsMillions Country/TerritoryCountry/Territory20302030

MillionsMillions

1 India 50.8 1 India 87.0

2 China 43.2 2 China 62.6

3 USA 26.8 3 USA 36.0

4 Russian Federation 9.6 4 Pakistan 13.8

5 Brazil 7.6 5 Brazil 12.7

6 Germany 7.5 6 Indonesia 12.0

7 Pakistan 7.1 7 Mexico 11.9

8 Japan 7.1 8 Bangladesh 10.4

9 Indonesia 7.0 9 Russian Federation 10.3

10 Mexico 6.8 10 Egypt 8.6

Modeling the Future U.S. Burden of Modeling the Future U.S. Burden of Diabetes Through 2050Diabetes Through 2050

• Constructed system of dynamic equations

– Initial prevalence (percentage of population with diagnosed/undiagnosed diabetes)

– Incidence (percentage of population with newly diagnosed diabetes)

– Migration– Mortality– Prevalence of prediabetes

• Equations used to model future burden of diabetes on U.S. adults through 2050

Boyle JP, et al. Popul Health Metr. 2010;8:29.

Annual U.S. Diabetes Burden in 2050Annual U.S. Diabetes Burden in 2050

• By 2050, prevalence of total diabetes (diagnosed and undiagnosed) is projected to increase from 1 in 10 adults to between 1 in 5 and 1 in 3 adults

• Incidence: from 8 in 1000 to 15 in 1000

• Largely attributed to three key factors

– Aging of the U.S. population– Increasing size of higher-risk minority

populations– Declining mortality among those with

diabetes



Total U.S. Adult PopulationTotal U.S. Adult PopulationDiabetes Prevalence ProjectionsDiabetes Prevalence Projections

the impact of diabetes mellitus in the united states epidemiology, costs, and future projections

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