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Diabetes : The Pandemic & Potential Solutions

Diabetes : The Pandemic & Potential Solutions. Disease Control Priorities in Developing Countries a book chapter in DCP2 (2nd version) http://www.dcp2.org/pubs/DCP Chapter 30 – April 2006. Topics. Nature & distribution Interventions & delivery modes

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Diabetes : The Pandemic & Potential Solutions

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  1. Diabetes: The Pandemic & Potential Solutions Disease Control Priorities in Developing Countries a book chapter in DCP2 (2nd version) http://www.dcp2.org/pubs/DCP Chapter 30 – April 2006

  2. Topics • Nature & distribution • Interventions & delivery modes • Cost-effectiveness of interventions & priorities • Lessons & experience • R & D agenda • Conclusion Table 30.2 Table 30.3 Table 30.4 Conclusion Table:Prioritized Key Interventions

  3. 1.Nature & Distribution

  4. Secular trend and projections • Y 2003-2025 : 12 yrs • Pop. 20-79 yrs • 6 Developing regions : • East Asia & the Pacific, • Europe & Central Asia, • Latin America & the Caribbean, • Middle East and North Africa, • South Asia, • Sub-Saharan Africa Prev. 5.1  6.3% (24% increase) DM Pop.194m  333 m. (72% increase) • VARIATIONS • Age structure • Level of urbanization

  5. World : Direct medical costs, 2003 128,669-240,887 US$ million IDF2003b, other info, WHO2004

  6. Dibetes-related mortality & disability • Death rate: F>M cDM 2.6(F) & 1.9(M) times sDM • Premature: ~12-14 of life lost • Cause of all deaths (developed C): 65% CVD • US physical limitation: 66%cDM vs 29%sDM • DALYs DM (1990-2001): ↑250%ww, 266%lmic

  7. WHO Estimates • Deaths ww DM 1.6% of all deaths, 2001 • 3% of all deaths ww caused by NCDs • 2/3 deaths occur in developing C • Actual no. 3 times this estimates • Most deaths by DM in developing C occur in East Asia & the Pacific, largest burden • 80%DALYs DM  developing C • DM Complication: micro / macrovascular dis Retinopathy, blindness, nephropathy, kidney failure / coronary heart disease, stroke, peripheral vascular disease, lower extremity amputation

  8. Economic Burden of DM • DM Affects both national, individual & family economies • Direct health care costs of DM: 2.5-15% of annual health care budgets, depending on local prevalence & Rx available • Indirect & intangible costs > direct: rise in DM be among 20-64 y.in next 3 decades DM QoL value = 0.77 (UK pop, prospect study)

  9. Risk factors for DM (1) • T1DM: a polygenic dis., INCONCLUSIVE • T2DM: genetic determinants play a role • Environmental factors : prenatal factors, obesity, PA, dietary, socioeconomic factors, exposure to DM in utero, disproportionate growth and low birthweight

  10. Risk factors for DM (2) • Among different populations • The strongest & most consistent: Obesity & weight gain (↑1 Unit BMI = ↑12% Risk of DM) • Central obesity • Sedentary lifestyle • Physical inactivity • Dietary fat, specific types of fat and carbohydrates (sat.fat & trans FA)may be more important than total intake • Sugar sweetened beverages

  11. Risk factors for DM (3) • Developing economies VS Developed C • ↑ Affluence & Westernization  assoc. c ↑ in prevalence DM in many indigenous pop. & in developing economies • Developed C, those in LOWER economic gr. have a higher risk of obesity  T2DM • (Surrogates) Level of education & income in the high income countries: are inversely assoc. c DM

  12. Factors that may reduce risk DM • Breastfeeding protects against the development of obesity, insulin resist & DM • Increase PA. • Polyunsat.fats & long-chain omega-3 fatty acids found in fish oils • High intakes of dietary fiber & of vegetables

  13. 2. Interventions & delivery modes

  14. Preventing T1DM • Not enough scientific evidence

  15. Preventing T2DM (1) • Intensive lifestyle interventions involving combination of diet and PA. among people at high risk • 4 major trials: China, Finland, Sweden, USA • Goals of intensive: weight loss 7% through low caloric diet, mod. PA at least 150 min./week  ↓ incidence of DM 58%

  16. Preventing T2DM (2) • Pharmacologic studies : Some drugs lower DM incidences • Metformin • Acarbose • Orlistat • Troglitazone • ACE inhibitors • Statins • Estrogens • Progestins Expense Side effects Cumulative years of drug intervention  are practical concern

  17. Screening for DM or PreDM • Benefit of early detection of T2DM through screening are not clearly documented, nor is the choice of the appropriate screening test established • Questionnaires used alone tend to work poorly • A better alternative: • Biochemical tests alone • Biochem c assessment of risk factors

  18. Managing DM Table 30.2 • Strategy: Preventing, Screening, Treating • Benefit: ↓ incidence, microvascular dis., macrovascular dis., death rate, quit smoking, nephropathy, serious vision loss, MI, CVD, hospitalizations, hospital charges, hospital days • Quality of evidence: Level I, II-1, II-2, III

  19. 3. Cost-effectiveness of interventions & priorities

  20. Estimating cost-effectiveness of interventions in developing countries • Table 30.2 – in developed countries, mainly USA • Table 30.3 – in 6 developing regions Cost/QALY of each intervention was assessed by ‘estimate the cost-effectiveness ratio from Table 30.2 by cost in 6 developing regions’ Feasibility was assessed by ‘difficulty of reaching the intervention population, technical complexity, capital intensity and cultural acceptability’ Implementing Priority (1  3) was assessed by‘Cost-effectiveness of an intervention’ + ‘Its implementation feasibility’

  21. Ranking • Level 1 • Glycemic control: people HbA1C >9 • BP control: people BP > 160/95 • Foot care: people high risk of ulcer • Level 2 • Preconception care: women, reproductive age • Lifestyle intervention: for preventing T2DM • Influenza vaccine: elderly T2DM • Annual eye exam • Smoking cessation • ACE inh use: people c DM • Level 3 • Metformin: for preventing T2DM • CHO control: people c TC > 200 • Intensive glycemic control:people c HbA1C > 8 • Screening: for undiagnosed DM • Annual screening for microalbuminuria

  22. Cost-effectiveness of a polypill to prevent CVD • Theoretical idea: still no RCT • Meta-analysis: aspirin + statin + folic acid & half dose anti-hypertensive • ↓ risk of CVD by 80% - people > 55 y, or DM any age • Barrier: Feasibility to produce, need RCT, SE

  23. Cost-effectiveness of DM education • Evaluating : Difficulty of separating out its effect from that of other interventions • The cost of education low, the interventions may be cost-effective • Feasible: low tech, low complexity, low capital requirements, & cultural acceptability • DM education should be a high priority intervention for all developing regions

  24. 4.Lessons & experience

  25. Lessons & experience • Prevention: T2DM can be prevented, its onset can be delayed • Treatment: Suboptimal quality ww. • Quality of DM care: need • Systems & organization of practices, • Interventions that empower patient • Newer systems of care • Newer ways of thinking

  26. 5.Research & development agenda

  27. Proposed Agenda for Developing C • Prevention: • Community-based primary prevention, drug, long-term prevention on CVD & outcome, monitoring BS, screening, education, impact on control of risk factor • Epidemiological & Economics Research: • Future BOD, effect of risk factor on DM, standardized dataset, costs, QoL, cost-effectiveness interventions • Health Systems & Operational Research: • Translation research, quality of care, chronic disease care, computer model/ resource allocation • Basic Research: • Genetic basis of T2DM, gene-environmental interactions, role of prenatal influence, role of socioeconomic factors, urban stress and lifestyle factors on causation of DM productive

  28. 6.Conclusion

  29. Magnitude of problem • Pandemic – rapid increase in DM prevalence • Health care cost of diabetes ↑ worldwide • Developing C spend 2.5-15% annual direct health budget on DM care • Families DM spend 15-25% of their income on DM care • Effective interventions (prevention) is available • Potential cost-effectiveness in developing regions – had been assessed • Prioritized interventions into 3 Levels (Using estimations + qualitative assessment of feasibility of implementation)

  30. Interventions available • Level 1: cost saving, high feasible • Level 2: cs, <1,500 US$/QALY, some feas • Level 3: cost 1,640-8550 US$/QALY, sig feas DM education = essential intervention;  precise components  its effect on long-term outcome Potentially promising polypill Interventions at the level of Pt. + Provider + System  improve suboptimal quality of DM care Making drugs available at cheaper costs

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