Tackling Type 2 Diabetes in the US: Translating Science into Public - - PowerPoint PPT Presentation

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.

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics Forecasted Millions of People with Diagnosed Diabetes

Premise of Public Health Action for Diabetes and Pre-Diabetes

10 20 30 40 50 Numbers with diagnosed diabetes (Millions) Year

3 6 9 12 15 18

Incidence (per 1000 PY

Year <high school high school >high school

Incidence of Diagnosed Diabetes Among Adults with Diabetes by Level of Education, 1980-2008

Dysglycemia “Pre-diabetes” Undiagnosed Diabetes

Diabetes: 1 in 3 lifetime Risk

EXTRAS

Diabetes Pyramid of Prevention?

Diabetes

Undiagnosed DM

Adult Prevalence Goal / Intervention Tier 7.6% 2.6% Prevent Morbidity Detect Early

Classic Levers in the Public Health Response to Diabetes

Clinical Services Promotion of Behaviors Population-Targeted Policies

Glycemic control BP control Lipid testing and management Annual eye examinations Foot care for high risk persons Kidney disease testing Flu immunization Preconception care Diabetes education Case Management Targeted Screening Education and awareness for:

• Physical activity
• Reduced Tobacco
• Healthy diet
• Regular doctor visits
• Self monitoring
• Self mgt education
• 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 High A1c Level Smoking

15 30 45 60

1971 - 1974 1976 - 1980 1988 - 1994 1999-2006

Prevalence (%) Year

15 30 45 60 1971 - 1974 1976 - 1980 1988 - 1994 1999-2006 Prevalence (%) Year 20 40 60 80

1999-2000 2001-2002 2003-2004

10 20 30 40 1971 - 1974 1976 - 1980 1988 - 1994 1999-2006 Prevalence (%) Year

80 70 60 50 40 30 20 4.0 3.0 2.0 Events Per 10,000

Amputation End Stage Renal Disease Hyperglycemic Death

Incidence of lower extremity amputation, end stage renal disease, and hyperglycemic death in the U.S. diabetic population, 1990-2006.

Gregg and Albright, JAMA, 2009

10 20 30 40

1971 - 1986 1976 - 1992 1988 - 2000 1971 - 1986 1976 - 1992 1988 - 2000 Mortality rate (deaths/1000 per year)

Cohort follow-up period

Trends in CVD Mortality Between Men and Women with Diabetes

Women Men

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)

2 4 6 8 10 12 14 16 Mortality rate (per1000 per year)

Cohort

Men Women Men Women

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

First author N Age Sessions

• ffered

(wks) Sessions attended Wt loss (%) 7% loss (%) 5% loss (%) 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

Diabetes Prevention Interventions Carried Out in Community Settings

(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

Diabetes Very High Risk (A1c > 5.7%; IGT; GDM)

Undiagnosed DM

Moderate Risk Low Risk

Adult Prevalence

Goal / Intervention Tier

7.6% 2.6%

~12-15% ~15-20% ~57%

Prevent Morbidity Detect Early

High Risk (FPG > 100); Central Obesity; HTN, age

What type of intervention for what level of risk?

Risk Factor Screening

Test for Diagnosis

Preventive Intervention

Find new diabetes

Screening, Diagnosis, and Prevention of Diabetes

Structured Prevention

• Intensive 6 –12 mo
• Extended: > 2 years
• Multi-component

Reduced total intake, Reduced fat intake Exercise Fiber / whole grain Behavioral support Moderate weight loss

• FPG
• OGTT
• HbA1c

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.

• Risk scores most appropriate first stage screening.
• More efficient in “integrated” manner, connected to lipid, BP.
• Ideal thresholds for referral ultimately depend upon resources.
• Discourage :
• Population-wide blood screening in the absence of risk factor

assessment or in low-risk populations.

• Screening in community settings (health fairs, retail stores, etc.)

that lack a direct connections to health care provider.

• 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

Recent Progress in Clinical Community Partnerships to Prevent Diabetes:

Patient Protection and Affordable Care Act, Section 399V-3, page

310: National Diabetes Prevention Program:

• Establishes national Diabetes Prevention Program with grants for model sites
• Recognition program and national registry for quality assurance at CDC.

Cooperative agreements to fund 11 model sites around the country

for training and recognition of YMCA sites for primary prevention.

Partnership between United Health Group and YMCAs for training

and reimbursement for primary prevention in 7 regions of the U.S.

Summary:

Diverse public health efforts have led to a reduction in

several diabetes-related complications for the average person with diabetes but these successes have not kept pace with the increased risk of diabetes incidence.

Diabetes prevention requires a multi-tiered public health

response, that includes

• Efficient identification and referral of high risk people

to structured lifestyle programs using clinical- community partnerships.

Summary:

Diverse public health efforts have led to a reduction in

several diabetes-related complications for the average person with diabetes but these successes have not kept pace with the increased risk of diabetes incidence.

Diabetes prevention requires a multi-tiered public health

response, that includes

• Efficient identification and referral of high risk people

to structured lifestyle programs using clinical- community partnerships.

• Broad population –targeted approaches aimed at food,

social, and economic environment to ultimately change trends in the epidemic.

Thank you

http://www.cdc.gov http://www.cdc.gov/diabetes/statistics/index.htm http://www.cdc.gov/diabetes/statistics/didit/index.htm

Edward Gregg, PhD: edg7@cdc.gov

1000 people 100 true positive tests 900 negative tests 873 non-cases 27 eventual cases 76 non Cases

Population Pre-DM Screen and DX

5-yr result

Definition = > 5.7% Incidence=24% Incidence=3% 24 Eventual cases

Implications For Intervention using Intensive Intervention

• Resources spent on 100 people
• 12 Cases Prevented (if RR= 0.50)
• 76 people intervened upon “unnecessarily”
• 27 people missed
• NNT= 8

1000 people 250 true positive tests 750 neg tests 732 non - cases 18 eventual cases 217 non Cases

Population Pre-DM Screen And DX

5-yr result

Definition = > 5.5% Incidence=13% Incidence=3% 33 Eventual cases

Implications For Intervention using Intensive Intervention

• Resources spent on 250 people (vs 100)
• 16 Cases Prevented (if RR= 0.50) (vs 12)
• 217 people intervened upon “unnecessarily” (vs 76)
• 18 people missed (vs 27)
• NNT= 15 (vs 8)

More equitable, less efficient

Four Key Steps (1) Train work force to implement the program cost-effectively

(2) Implement recognition program to assuring quality, lead to reimbursement, and registry of programs for public reporting (3) Implement sites to build infrastructure and provide a “laboratory” for refinement of this prevention system (4) Increase referrals and utilization of the prevention system through health marketing and other strategies

Recommended Strategies to Prevent Obesity Via Food Environment Policies: Communities Should:

Increase availability and affordability of healthy foods in public areas. Improve geographic availability and give incentives for supermarkets

and healthy foods in under-served and poor areas.

Promote mechanisms for purchasing directly from farms. Restrict availability of unhealthy foods/beverages from public areas. Institute smaller portion sizes in public settings. Limit advertisements of unhealthy foods/beverages. Discourage consumption of sugared beverages.

Recommended Strategies to Prevent Obesity Via Physical Activity Environment Policies: Communities Should:

Require school physical education and increase amount of

physical activity in school physical education.

Increase opportunities for extracurricular physical activity and

access to recreational facilities.

Reduce screen time in public settings. Enhance infrastructure supporting walking and bicycling. Improve access to public transportation. Promote access to mixed use development. Enhance personal and traffic safety in public areas.

Major Factors Influencing the Ideal Screening Cut point

The Intended Intervention The Context

• Health system capacity for screening, follow-up,

and action.

• Incidence in the population at a given level of risk.
• Resources Available