Bringing the Results of DAWN to Life— A Patient-Centered Focus to Diabetes Education Susan Harrow Rago, MS, RD Associate Director Patient Services & Professional Relations Novo Nordisk Inc.

Agenda The worldwide diabetes epidemic The DAWN Study Objectives Methodology Key findings Bringing DAWN to Life in the United States— Changing Life With Diabetes DAWN Youth DAWN worldwide initiatives DAWN Call to Action

The Diabetes Epidemic International Diabetes Federation. Facts and Figures. Available at: Accessed November 16, Centers for Disease Control and Prevention. National Diabetes Fact Sheet, Available at Accessed November 16, About 246 million adults have diabetes worldwide 23.6 million people in the US 90%-95% have type 2 diabetes 7 million people worldwide develop diabetes each year 1.6 million new US cases in in 3 Americans born today will develop diabetes

The Human Cost of Diabetes Diabetes can cost a patient their health Heart disease and stroke are 2- to 4-fold more likely than for an individual without diabetes Diabetes is the leading cause of Adult blindness Kidney failure Nontraumatic lower-limb amputations 2 out of 3 people with diabetes have nerve damage Diabetes has a significant mortality burden Over 3 million deaths each year The 4 th leading cause of death People with type 2 diabetes lose 5-10 years of life International Diabetes Federation. Facts and Figures. Available at: Accessed November 16, Centers for Disease Control and Prevention. National Diabetes Fact Sheet, Available at Accessed November 16, 2008.

The Societal Cost of Diabetes US cost of diabetes in 2007 was $174 billion Direct Medical Cost Extra costs for people with diabetes Indirect Costs Lost productivity, absenteeism, disability, and early death $116 billion $58 billion American Diabetes Association. Diabetes Care. 2008;31: $1 in $5 for health care in the US is spent for diabetes care Complications of diabetes account for over 40% of costs

Better Control of Glucose Reduces Complications Better glycemic control DCCT in type 1 diabetes UKPDS in type 2 diabetes Medical experts recommend good glycemic control ADA targets A1C <7% AACE targets A1C  6.5% but ≈2 of 5 people with diabetes in the US have A1C >7%  Risk of complications American Diabetes Association. Diabetes Care. 2008;31(suppl 1):S12-S54. AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. Endocr Pract: 2007:13(suppl 1)3-68. Hoerger TJ et al. Diabetes Care. 2008;31: ≥7% <7%

Who Is Treating Patients With Diabetes? The majority of patients with diabetes are treated by primary care physicians Data on file. Novo Nordisk Inc., Princeton, NJ.

Diabetes Self-Management Is Key to Better Outcomes Data on file. Novo Nordisk Inc., Princeton, NJ.

Study Background In 2001, Novo Nordisk, with the International Diabetes Federation and an international expert advisory board, commissioned the DAWN study to identify: Attitudes, wishes, and needs of People with diabetes HCPs treating those living with diabetes New ways to improve the management of diabetes care Data on file. Novo Nordisk Inc., Princeton, NJ.

Study Methodology Identify psychosocial issues Literature review Focus groups in 8 countries 1-hour interview survey in 13 countries 5418 adults with diabetes Type 1=2569 (US, n=99) Type 2=2849 (US, n=386) 3827 diabetes HCPs 2705 physicians (US, n=216) 1122 diabetes nurses (US, n=101) US India Australia Japan UK France Germany Spain The Netherlands Scandinavia Poland Data on file. Novo Nordisk Inc., Princeton, NJ.

Key DAWN Topics Access to team care Patient-provider communication Access to diabetes therapy Emotional health Diabetes Self-Management Data on file. Novo Nordisk Inc., Princeton, NJ.

Current Trends in Self-Management Are Less Than Optimal Patients completely following most HCP recommendations (%) According to patients… According to HCPs… Base: All respondents.

Patients with ‘great extent’ of control (%) Self-Management Is Less Than Optimal (cont’d) Fewer than half of patients feel their diabetes is under control Base: All respondents.

Emotional Issues Affect Self-Management US patients report poor emotional well-being Feel stressed because of diabetes Patients agreeing (%) Afraid diabetes is getting worse “Diabetes is preventing me from doing what I want to do Poor emotional well-being (WHO-5)

US Patients Feel Emotional Distress at Diabetes Diagnosis Patients (%)

Reaction to Diagnosis US patient outcomes Good adherence US patients (%) Perceived good diabetes control High diabetes-related distress Poor quality of life Reaction to Diagnosis Predicted Later Outcomes

Emotional Issues Affect Compliance HCPs disagreeing (%) Health care professionals’ response to “Emotional issues play only a small part in noncompliance” Base: All respondents.

Patients (%) HCPs Recognize Psychological Problems Related to Diabetes

Despite Recognition of Emotional Issues, Lack of Treatment Exists HCPs recognize emotional problems as important reasons for self-management problems, yet: Base: US respondents. HCPs feel able to provide necessary psychological support HCPs feel able to identify and evaluate psychological problems >75% < 65% < 33% Patients report receiving psychological treatment ≈ 10%

Relationship With HCP Predicts Outcomes Patients (%) Relationship

Good Access to Team Care Improves Outcomes Patients (%) Access to Team

Time spent communicating (minutes) HCPs wanting more/better communication (%) Specialist MD Nurse 51% GP 40% 55% Base: US respondents. HCPs Want More/Better Communication But Lack Time

All HCPs under 1 roof HCPs talk to each other US Patients (%) Type 2 Type 1 55%58% 61%66% 61%52% Nurses available at GP Overall Type 2Type 1 34%44% 61%60% 59%48% Patients (%) Base: All respondents. Good Access to Team Care Improves Outcomes

‘There should be better access to psychologists or psychiatrists for referral’ ‘There should be better communication within the diabetes management team’ ‘More qualified nurse- educators/specialist diabetes nurses should be available’ Agreeing (%) Base: US respondents. Areas for Potential Improvement in Diabetes Care

‘I prefer to delay initiation of oral therapy until absolutely essential’ ‘I prefer to delay initiation of insulin until absolutely essential’ US HCPs agreeing (%) 23%68% GP Specialist MD 10%34% Nurse 32%46% HCP Resistance to Initiating Effective Diabetes Therapy

56% Worried about starting insulin 58% Believe taking insulin means they failed to manage diabetes Don’t believe taking insulin will help manage diabetes 79% US patients with type 2 diabetes Patient Resistance to Initiating Insulin Therapy

Summary Diabetes self-management is less than optimal Problems with self-management are often due to emotional issues Good communications between people with diabetes and health care providers improves outcomes Access to team-based diabetes care improves outcomes Resistance to initiating effective therapy is common

More Information Publications in Diabetes Care Diabetic Medicine Diabetologia Diabetes Spectrum Diabetes Educator Diabetes Voice Practical Diabetes International

Key DAWN Goals for Worldwide Action Improve communication between people with diabetes and health care professionals Promote a team-based care approach Promote active self-management Help people with diabetes overcome psychosocial barriers to effective therapy Improve psychological care and support

Video

Bringing DAWN “to Life” in the United States Changing Life With Diabetes

DAWN PCP Advisory Board Launched at 3 rd Annual DAWN Summit in 2006 Practice includes patient-centered strategies Committed to helping advance DAWN objectives

ChangingDiabetes-us.com Tools to address psychosocial issues Solutions to self-management barriers Content includes Learning about diabetes Managing diabetes Menu planner and recipes Food exchange lists Diabetes care planning Monthly s

Measuring the Impact of Changing Life With Diabetes Web Site* New registrations = + 37,672 Total registrations = > 200,000 Unique visits = 187,997 Site visits = 219,351 * January 1-Octoberr 30, 2008.

Web Content Structured According to AADE 7 TM Self-Care Behaviors Facts about diabetes Patient self-management for physical and emotional health Healthy eating Being active Monitoring Problem solving Reducing risks Coping Working with my care team Menu planning tools

Promote Active Self-Management Care Plan–Based Diabetes Self-Management Interactive Diabetes Care Plan Helps track and manage diabetes care Daily – SMBG, BP, activity Long-term – A1C, physical exam, eye and foot exam, weight Goal-setting keeps users motivated Date for achieving goal is next scheduled appointment

Promote Active Self-Management Menu Planning Tools Meal Planning Tools Menu planner and recipes Food look-up Food exchange lists

Promote Active Self-Management “Voices of Diabetes” Topics Coping with diabetes Managing your diabetes at work Overcoming barriers to exercise Tips for following a meal plan Overcoming fears of insulin Getting the most from your diabetes care team How to avoid diabetes burnout Gaining support from loved ones More than 200 contributions from People with diabetes Caregivers Diabetes educators

Improve Psychological Care and Support Helping Users Set Priorities Prioritization based on users’ own goals and psychosocial profile Diabetes care priorities Medication Monitoring Healthy eating Staying active Psychosocial profile Readiness to change Self-confidence in ability to change

Improve Psychological Care and Support Coping Content The diagnosis of diabetes A change in diabetes treatment Insulin therapy Complications Day-to-day management The support of loved ones Burnout Life changes

Patient Education Booklets Concise, easy-to-read information Updated content Variety of topics: Diabetes and You Diabetes Medicines Caring for Your Diabetes Your Guide to Better Office Visits Carb Counting and Meal Planning

Patient Education Fact Sheets What Is Diabetes? Hypoglycemia Checking Your Blood Glucose Foot Care Leg Exercises Gestational Diabetes Meal Plans

DAWN Youth

A Global Partnership Initiative

Objectives of DAWN Youth To facilitate national and international awareness to improve health and quality of life for children and youths with diabetes and their families

DAWN Youth Survey Results Current health care systems have failed to provide adequate social and psychological support, which may result in outcomes such as poor control and long-term complications Four key areas of support require urgent action School-based support for children with diabetes Age-appropriate education and psychosocial support from HCPs Parent and family-centered support Peer support and networking Data on file. Novo Nordisk Inc., Princeton, NJ.

DAWN Worldwide Initiatives

Call to Action

DAWN MIND: Monitoring Individual Needs in Siabetes DAWN MIND is an international initiative creating an opportunity to network with leading diabetes clinics to encourage psychological needs assessment as a part of routine care The goal is to discover innovative and effective ways to provide psychosocial support for patients with diabetes Data on file. Novo Nordisk Inc., Princeton, NJ.

Call to Action Raise awareness and advocacy Engage and educate people with diabetes Train health care providers Provide practical tools and systems Drive policy and health care systems change Develop psychosocial research in diabetes

The DAWN Worldwide Mission To improve outcomes in diabetes, we must address the person behind the disease

Additional Information and Resources NovoMedLink.com ChangingDiabetes-us.com

Discussion

Supplemental Slides

Call to Action Raise awareness and advocacy Engage and educate people with diabetes Train health care providers Provide practical tools and systems Drive policy and health care systems change Develop psychosocial research in diabetes DAWN Dialogues DAWN Minorities

Call to Action Raise awareness and advocacy Engage and educate people with diabetes Train health care providers Provide practical tools and systems Drive policy and health care systems change Develop psychosocial research in diabetes National Patient Driven Education Programs

Call to Action Raise awareness and advocacy Engage and educate people with diabetes Train health care providers Provide practical tools and systems Drive policy and health care systems change Develop psychosocial research in diabetes DAWN Experiment ‘5 A’s’

Call to Action Raise awareness and advocacy Engage and educate people with diabetes Train health care providers Provide practical tools and systems Drive policy and health care systems change Develop psychosocial research in diabetes

Call to Action Raise awareness and advocacy Engage and educate people with diabetes Train health care providers Provide practical tools and systems Drive policy and health care systems change Develop psychosocial educational research in diabetes Survey tools