1. Diabetes THE APPROACHING TSUNAMI

2. The Ironman Effect

4. 26% of Americans above age 65 have type II DM

6. That means we are creating 2500 diabetics every single day.

7. Medicare is predicted to become insolvent in 2030.

11. America’s Growth Spurt

12. BMI >30 and Diabetes

13. Diabetes has increased nearly 10-fold since 1958

15. Creeping Normalcy

17. Diabetes and Weight Gain  Gain of 11-16 lbs. doubles the risk of type 2 diabetes  Gain of 17-24 lbs. triples the risk of type 2 diabetes

19. Costs of Diabetic Meds  Metformin - $4/month  Januvia - $300/month  Farxiga - $460/month  Victoza - $600/month  Trulicity - $1000/mo., lowers A1c 1-1.5%  Januvia lowers A1c by average of 0.7%  Exercise for 8 weeks lowers A1c by 0.66%

20. The High Cost of Diabetes

23. Shadow Pricing  On May 30, 2014, the price for a vial of the blockbuster diabetes medication Lantus went up by 16.1 percent. On the next day, Lantus’s direct competitor, Levemir, also registered a price increase -- of 16.1 percent.  Six months later Lantus was marked up 11.9 percent, and Levemir matched again exactly.  In 13 instances since 2009, prices of Lantus and Levemir have gone up in tandem in the U.S.

26. “I used to be afraid of failing at something that really mattered to me, but now I'm more afraid of succeeding at things that don't matter.” ― Bob Goff, Love Does: Discover a Secretly Incredible Life in an Ordinary WorldBob GoffLove Does: Discover a Secretly Incredible Life in an Ordinary World

27. You Are Not Just Treating Diabetes DiabetesDepression Obesity Social isolation

29. Exercise ROI  Modest exercise can prevent or delay onset of DM by 58% (71% in patients over 60) – NIH/CDC DPP  Loss of 5-7% body weight – 10 lbs. in 200 lb. male, 8 lbs. in 160 lb. female

30. Gluconomics

33. Population Statistics  Kootenai county 150,000  Region 1 (5 northern counties) – 220,000  Idaho – 1.5 million  8.4% diabetes Statewide, only 7% Region 1

34. Idaho Diabetes Statistics  Idaho – 1.5 million  8.4% diabetes Statewide, only 7% Region 1  126,000 diabetics (8.4%)  555,000 prediabetics (37%)

35. Region 1 Diabetes Statistics  Region 1 – 220,000  15,400 diabetics (7%)  81,400 prediabetics (37%)

36. Region 1  20 lifestyle coaches  100 patients per coach per year  2000 prediabetics per year  Of 2000 participants, 300-600 cases of diabetes expected (15-30%)  200-400 cases prevented (60-70% reduction)  At 81,400 prediabetics, it would take over 40 years to reach all current at-risk individuals  Remaining 80,000 patients, 12,000-24,000 will become diabetic  Classes reduce rate of conversion to DM by 1.6%

37. Idaho Statistics  50 lifestyle coaches  100 patients per coach  5000 prediabetics per year  Of 5000 participants, 750-1500 cases of diabetes expected (15-30%)  500-1000 cases prevented (60-70% reduction)  At 550,000 prediabetics, it would take 110 years to reach all current at-risk individuals  Remaining 545,000 patients, 81,750-163,500 will become diabetic  Classes reduce rate of conversion to DM by 0.9%

38. Population Health

39. Department of Health and Welfare  Clinical services account for a relatively small impact on population health. To improve the health of a broadly defined population, integration of clinical services, public health and community based initiatives is necessary.  John Auerbach ’s (Associate Director for Policy, Centers for Disease Control and Prevention) method for analyzing the measures of health (adopted by Get Healthy Idaho).

40. Auerbach’s Buckets  Bucket #1 – Traditional Clinical Approaches. Patient construct, one- on-one patient interaction.  Bucket #2 – Innovative Clinical Care. Patient construct with a narrow population view, e.g. accountable care organization, patient centered medical home.  Bucket #3 – Community-wide Health. Community construct, focus is on a broad population (Health District or the state of Idaho). Typically has a policy focus.

41. YMCA Diabetes Prevention Program  Three-year, $12 million grant from the federal Center for Medicare and Medicaid Innovation to make its diabetes-prevention program available to about 10,000 Medicare patients in 17 communities.  $1200 per participant

42. YMCA’s Effort By The Numbers  11,714: Participants who attended at least one diabetes-prevention class session.  1,477: Classes started.  1,295: Lifestyle coaches trained to teach the CDC's evidence-based curriculum.  569: Diabetes-prevention class locations.  86: Community YMCAs with teachers trained to deliver the program.  35: States where the program is offered.  4.9%: Average body weight loss achieved by program participants.  Source: “YMCA's Diabetes Prevention Program Overview,” YMCA of the USA, June 17

43. YMCA’s Effort By The Numbers  1,295 certified Lifestyle coaches  1,477 classes  11,714: Participants who attended at least one session  8 participants per class  We would need 9 million DPP classes

45. Diet and Exercise  DM  HTN  High cholesterol  Obesity  CAD  Sleep apnea  Anxiety  Depression  Social isolation

46. Kroc Rx

47. The Doctor Will See You Now

49. Pathways to Health  We must offer pathways to health.  The model will be based on:  visits at the health facility  group support, and  education through shared medical appointments  We will bring resources TO the patient rather than asking the patient to travel to the resources.

52. Evaluation and Management  Everyone should be offered diet and exercise.  Everyone should have a psychosocial evaluation.  It is not enough to recommend these things, they must be provided as part of the health care visit.

53. What Constitutes an Office Visit?  Exercise IS a visit.  Diet instruction IS a visit.  Behavioral health instruction IS a visit.  (goal setting, behavioral activation, CBT, mindfulness solution)

54. Heritage Health University PhD in Health  Exercise module  Nutrition module  Behavioral health module  Life Skills module – financial, spiritual, social  Medication reduction module

55. A Different Strategy  Collaboration  Relationship  Think outside your 4 walls  Find your largest partner(s)  Churches, colleges, community centers  Look for champions with passion  Surround your patients with healthy role models