1. The Impact of Diabetes Mellitus in the United States Epidemiology, Costs, and Future Projections

2. Table of Contents Section Slide No. Epidemiology 3-28 Costs 29-37 Future Projections 38-43

3. EPIDEMIOLOGY Section 1

4. Epidemiology of Diabetes Diabetes affects 25.8 million people of 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/

5. Diagnosed and Undiagnosed Diabetes 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%) National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/

6. Racial/Ethnic Differences in Diagnosed Diabetes National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/ Race/Ethnicity % Non-Hispanic whites 7.1 Asian Americans 8.4 Hispanics/Latinos Cuban Americans Central and South Americans Mexican Americans Puerto Ricans 11.8 7.6 13.3 13.8 Non-Hispanic blacks 12.6 2007–2009 national survey data for people ages 20 years or older

7. Diagnosed and Undiagnosed Diabetes National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/ Source: 2005-2008 National Health and Nutrition Examination Survey

8. New Cases of Diagnosed Diabetes National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/ Source: 2005-2008 National Health and Nutrition Examination Survey estimates projected to the year 2010

9. www.cdc.gov County-Level Estimates of Diagnosed Diabetes (%), Adults ≥20 years, 2008 Percent 0 – 6.5 6.6 – 8.0 8.1 – 9.4 9.5 – 11.1 ≥ 11.2

10. Number of Americans with Diagnosed Diabetes, 1980-2009 www.cdc.gov

11. Annual, Age-Adjusted Incidence Rate of Diagnosed Diabetes*, 2005-2007 MMWR. 2008;57(43):1169-1173.

12. Prevalence of Overweight and Obesity Among 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%

13. SEARCH for Diabetes in Youth 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

14. 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 2001 1.82 cases per 1000 youth (95% CI: 1.78-1.87 per 1000 youth) Cancer: 1.24 per 1000 Asthma: 120 per 1000 SEARCH for Diabetes in Youth Study Group. Pediatrics. 2006;118:1510-1518. SEARCH for Diabetes in Youth Results

15. SEARCH for Diabetes in Youth Demographics, Prevalence Characteristic No. of cases (%) Population denominator, n (%) Prevalence, cases per 1000 youth (95% CI) Total population63793,499,8461.82 (1.78-1.87) Age group 0-4 y 5-9 y 10-14 y 15-19 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) Gender Male Female 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/ethnicity NHW Black Hispanic API AI 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

16. SEARCH for Diabetes in Youth 0-9 Years by Race/Ethnicity SEARCH for Diabetes in Youth Study Group. Pediatrics. 2006;118:1510-1518. NHW=non-Hispanic white; AA=African-American; H=Hispanic; API=Asian/Pacific Islander; AI=American Indian Prevalence

17. SEARCH for Diabetes in Youth 10-19 Years by Race/Ethnicity SEARCH for Diabetes in Youth Study Group. Pediatrics. 2006;118:1510-1518. Prevalence NHW=non-Hispanic white; AA=African-American; H=Hispanic; API=Asian/Pacific Islander; AI=American Indian

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

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

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

21. Complications of Diabetes Heart disease and stroke Hypertension Blindness, eye problems Renal disease Nervous system disease Amputations Dental disease Complications of pregnancy Other complications National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/

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

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

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

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

26. Oral medication only 58% No medication 16% Insulin only 12% Insulin and oral medication 14% Treatment of Diabetes National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/

27. Deaths 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 cause of death Overall, risk for death among those with diabetes is about twice that of people with similar age but without diabetes National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/

28. Age Distribution of Deaths Associated with Diabetes Age 70+ 206,791 73% Age <18 488 0% Age 18-34 1,918 1% Age 35-44 5564 2% Age 45-54 16,663 6% Age 55-59 13,907 5% Age 60-64 17,634 6% Age 65-69 20,656 7% American Diabetes Association. Diabetes Care. 2008;31:596-615. Figure 4.

29. COSTS Section 2

30. Economic 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.

31. Medical Expenditures Attributed to Diabetes, 2007 Hospital inpatient care (50%) Diabetes medication and supplies (12%) Retail prescriptions to treat complications of diabetes (11%) Physician office visits (11%) American Diabetes Association. Diabetes Care. 2008;31:596-615.

32. Costs Incurred by People with a Diagnosis 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 American Diabetes Association. Diabetes Care. 2008;31:596-615.

33. Health Resource Use Attributed to Diabetes, 2007 American Diabetes Association. Diabetes Care. 2008;31:596-615. Table 5. Health resource Age (years) Total* <4545-64≥65 Institutional care Hospital inpatient days Nursing/residential facility days 2,115 1,269 7,586 11,103 14,562 43,687 24,262 56,059 Outpatient care Office-based physician visits Emergency visits Hospital outpatient and freestanding ambulatory surgical center visits Home health visits Hospice care days Retail prescriptions 7,353 1,499 1,307 0 4 15,181 26,552 1,984 2,535 8,939 22 71,295 30,808 2,084 1,888 18,449 165 88,841 64,713 5,567 5,730 27,388 192 175,317 *Numbers do not necessarily sum to totals because of rounding

34. Indirect Costs Attributed to Diabetes, 2007 American Diabetes Association. Diabetes Care. 2008;31:596-615. Table 14. Cost component Productivity loss Total cost attributable to diabetes ($ billions) Proportion of indirect costs (%) Work days absent15 million days2.64 Reduced performance at work 120 million days20.034 Reduced productivity days for those not in labor force 6 million days0.81 Permanent disability 445,000 people, 107 million days 7.914 Mortality284,000 deaths26.946 Total58.2100

35. Mortality Costs Attributed to Diabetes, 2007 American Diabetes Association. Diabetes Care. 2008;31:596-615. Table 16. Primary cause of death Total US deaths Deaths attributed to diabetes Deaths % of total of US deaths Value of lost productivity (millions of dollars) Diabetes77,000 100.09,520 Renal disease43,00025,00057.42,116 Cerebrovascular disease 155,00059,00037.63,849 Cardiovascular disease 739,000123,00016.511,417 TotalNA*284,000NA*26,902 *Total comprises mortality for reasons other than those listed here

36. Economic Costs of Prediabetes and 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.

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

38. FUTURE PROJECTIONS Section 3

39. IDF Diabetes Atlas, 4 th ed. ©International Diabetes Federation, 2009. IDF Global Projections for Number of People with Diabetes, 2010-2030

40. Estimated Number of People with Diabetes Worldwide, 2010 and 2030 IDF Diabetes Atlas, 4 th ed. ©International Diabetes Federation, 2009. Country/Territory 2010Millions Country/Territory 2030Millions 1India 50.8 1India 87.0 2China 43.2 2China 62.6 3USA 26.8 3USA 36.0 4Russian Federation 9.6 4Pakistan 13.8 5Brazil 7.6 5Brazil 12.7 6Germany 7.5 6Indonesia 12.0 7Pakistan 7.1 7Mexico 11.9 8Japan 7.1 8Bangladesh 10.4 9Indonesia 7.0 9Russian Federation 10.3 10Mexico 6.8 10Egypt 8.6

41. Modeling the Future U.S. Burden of Diabetes 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 prediabete s Equations used to model future burden of diabetes on U.S. adults through 2050 Boyle JP, et al. Popul Health Metr. 2010;8:29.

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

43. Total U.S. Adult Population Diabetes Prevalence Projections