Diabetes

Goal

Reduce the disease and economic burden of diabetes mellitus (DM) and improve the quality of life for all persons who have, or are at risk for, DM.

Overview

DM occurs when the body cannot produce or respond appropriately to insulin. Insulin is a hormone that the body needs to absorb and use glucose (sugar) as fuel for the body’s cells. Without a properly functioning insulin signaling system, blood glucose levels become elevated and other metabolic abnormalities occur, leading to the development of serious, disabling complications.

Many forms of diabetes exist. The 3 common types of DM are:

• Type 2 diabetes, which results from a combination of resistance to the action of insulin and insufficient insulin production.
• Type 1 diabetes, which results when the body loses its ability to produce insulin.
• Gestational diabetes, a common complication of pregnancy. Gestational diabetes can lead to perinatal complications in mother and child and substantially increases the likelihood of cesarean section. Gestational diabetes is also a risk factor for subsequent development of type 2 diabetes after pregnancy.

Effective therapy can prevent or delay diabetic complications.1, 2 However, almost 25 percent of Americans with DM are undiagnosed, and another 57 million Americans have blood glucose levels that greatly increase their risk of developing DM in the next several years.3 Few people receive effective preventative care, which makes DM an immense and complex public health challenge.

Why Is Diabetes Important?

DM affects an estimated 23.6 million people in the United States and is the 7th leading cause of death.3 DM

• Lowers life expectancy by up to 15 years.
• Increases the risk of heart disease by 2 to 4 times.
• Is the leading cause of kidney failure, lower limb amputations, and adult-onset blindness.3, 4

In addition to these human costs, the estimated total financial cost of DM in the United States in 2007 was $174 billion, which includes the costs of medical care, disability, and premature death.3

The rate of DM continues to increase both in the United States5, 6 and throughout the world.7 Due to the steady rise in the number of persons with DM, and possibly earlier onset of type 2 DM, there is growing concern about:

• The possibility of substantial increases in diabetes-related complications
• The possibility that the increase in the number of persons with DM and the complexity of their care might overwhelm existing health care systems
• The need to take advantage of recent discoveries on the individual and societal benefits of improved diabetes management and prevention by bringing life-saving discoveries into wider practice
• The clear need to complement improved diabetes management strategies with efforts in primary prevention among those at risk for developing DM

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Understanding Diabetes

Four “transition points” in the natural history of diabetes health care provide opportunities to reduce the health and economic burden of DM:

• Primary prevention: movement from no diabetes to diabetes
• Testing and early diagnosis: movement from unrecognized to recognized diabetes
• Access to care for all persons with diabetes: movement from no diabetes care to access to appropriate diabetes care
• Improved quality of care: movement from inadequate to adequate care

Disparities in diabetes risk:

• People from minority populations are more frequently affected by type 2 diabetes. Minority groups constitute 25 percent of all adult patients with diabetes in the United States and represent the majority of children and adolescents with type 2 diabetes.
• African Americans, Hispanic/Latino Americans, American Indians, and some Asian Americans and Native Hawaiians and other Pacific Islanders are at particularly high risk for the development of type 2 diabetes.
• Diabetes prevalence rates among American Indians are 2 to 5 times those of whites. On average, African American adults are 1.7 times as likely and Mexican Americans and Puerto Ricans are twice as likely to have the disease as non-Hispanic whites of similar age.

Barriers to progress in diabetes care include:

• Systems problems (challenges due to the design of health care systems)
• The troubling increase in the number of people with diabetes, which may result in a decrease in the attention and resources available per person to treat DM

Emerging Issues in Diabetes

Evidence is emerging that diabetes is associated with additional comorbidities including:

• Cognitive impairment
• Incontinence
• Fracture risk
• Cancer risk and prognosis

The importance of both diabetes and these comorbidities will continue to increase as the population ages. Therapies that have proven to reduce microvascular and macrovascular complications will need to be assessed in light of the newly identified comorbidities.

Lifestyle change has been proven effective in preventing or delaying the onset of type 2 diabetes in high-risk individuals. Based on this, new public health approaches are emerging that may deserve monitoring at the national level. For example, the Diabetes Prevention Program demonstrated that lifestyle intervention had its greatest impact in older adults and was effective in all racial and ethnic groups.

Another emerging issue is the effect on public health of new diagnostic criteria, such as introducing the use of HbA1c for diagnosis of diabetes and high risk for diabetes, and lower thresholds for gestational diabetes. These changes may impact the number of individuals with undiagnosed diabetes and facilitate the introduction of diabetes prevention at a public health level.

Several studies have suggested that process indicators such as foot exams, eye exams, and measurement of HbA1c may not be sensitive enough to capture all aspects of quality of care that ultimately result in reduced morbidity. New diabetes quality-of-care indicators are currently under development and may help determine whether appropriate, timely, evidence-based care is linked to risk factor reduction. In addition, the scientific evidence that type 2 diabetes can be prevented or delayed has stimulated new research into the best markers and approaches for identifying high-risk individuals and the most effective ways to implement prevention programs in community settings.

Finally, it may be possible to achieve additional reduction in the risk of diabetes or its complications by influencing various behavioral risk factors, such as specific dietary choices, which have not been tested in large randomized controlled trials.

References

1Knowler WC, Barrett-Connor E, Fowler SE, et al; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002 Feb 7;346(6):393-403.

2Knowler WC, Fowler SE, Hamman RF, et al; Diabetes Prevention Program Research Group. Ten-year followup of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet. 2009 Nov 14;374(9702):1677-86.

3Centers for Disease Control and Prevention (CDC). National diabetes fact sheet: General information and national estimates on diabetes in the United States, 2007. Atlanta: CDC; 2008.

4Portuese E, Orchard T. Mortality in insulin-dependent diabetes. In Diabetes in America, pp. 221-32. Bethesda, MD: National Institutes of Health, National Diabetes Data Group; 1995.

5Geiss LS, Pan L, Cadwell B, et al. Changes in incidence of diabetes in US adults, 1997–2003. Am J Prev Med. 2006;30:371-7.

6Cowie CC, Rust KF, Ford ES, et al. Full accounting of diabetes and pre-diabetes in the US population in 1988–1994 and 2005–2006. Diabetes Care. 2009;32:287-94.

7International Diabetes Federation. The Diabetes Atlas, 3rd edition. Brussels: International Diabetes Federation; 2006.

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