The high cost of diabetes

The weight of suffering for an estimated 21 million Americans, the measurable lapse in federal funding and the astronomical cost of diabetes inflicting the nation: Dr. John Buse, President, Medicine and Science, American Diabetes Association, weighs in on the enormous challenge of the $174 billion diabetes epidemic.

It’s referred to by some as the ‘greatest public health epidemic of the 21st century’ – and with the escalating number of diabetes cases, largely driven by widespread obesity across the nation, set against the dismal backdrop of shrinking federal funding, it just may be.

With approximately 21 million in the US already living with the disease and another 54 million with pre-diabetes on the cusp of developing full diabetes, the whopping $174 billion estimated annual cost burden of diabetes on the nation may actually be an underestimate.

The double-edged sword is that the spike in diabetes comes at the same time as curbed federal funding is drying up resources and stalling research efforts – therefore, the increase in diabetes is surpassing any advances being made in the field.

To the chagrin of diabetes advocates everywhere, the Bush Administration’s Fiscal Year ’09 budget proposal fell dramatically short in relation to the amount needed to offset the cost on the economy and the toll on American lives caused by the mounting epidemic. In the last six years alone, diabetes-related costs are estimated to have jumped 30 percent, and today one-tenth of the nation’s $2 trillion health budget is devoted to diabetes management and prevention.

So there’s no surprise that proposed budget for Fiscal Year ’09 has come under fire by diabetes advocates around the country – as the major diabetes R&D hubs like the National Institutes of Health (NIH) and Centers for Disease Control and Prevention (CDC) will be taking a hit to their allocated diabetes research and prevention funds in relation to the higher cost of living. The National Institute of Diabetes & Digestive & Kidney Diseases (NIDDK) was funded only a .15 percent increase.

“There is a major lack of funds in the NIH research budget for diabetes,” Buse acknowledges. “When you take into account the cost and the inflation rate in biomedical research, it has been more akin to a five to ten percent decrease in funding overall on an annual basis for the last five or so years.”
The CDC budget for diabetes is heralded an even greater disaster, having undergone actual budget cuts in the recent budgetary cycle, with the total amount of funding to be in the neighborhood of $60 million to help drive the prevention of diabetes in America.

“With an estimated 54 million people in the US with pre-diabetes, at risk for developing diabetes in the near term, the sum devoted to the task is pitiful,” Buse admits. “The economic sense of the decision-making is extraordinarily poor and the opportunity lost not only affects the health and wellbeing of Americans, but also will inevitably cost society more as we pay for multiple drugs and expensive treatments as opposed to lifestyle interventions or inexpensive generic products like metformin.”

Thus the ADA is working to raise awareness of the magnitude of the diabetes epidemic and to increase funding from Congress. As part of a fairly broad coalition devoted to increasing research funds for diabetes, the ADA is just one of many groups and lobbyists working to promote greater opportunities for diabetes research. In fact, the ADA’s “Call to Congress,” which will be held April 30 – May 2, involves hundreds of diabetes advocates coming together to call for an increase in funding from Congress for diabetes research and prevention.

But for now the budgetary restrictions are viewed by many as nothing less than a disaster.

The dip in funding has also led to a more significant trouble spot – not only are there less monetary resources to put towards research projects but there’s also less expertise to apply since diabetes professionals have begun to flee the low-funded, grant-dependent field.

“Lots of young investigators have been trained in response to the growing epidemic of diabetes and lots of them are leaving the field because they can’t get funding,” Buse points out. “The pay line on new grants in diabetes is under ten percent now so these talented investigators are deciding to fold up their tents and seek employment in other areas.”

Matters of prevention
While improving diabetes treatment options is a big priority, the number of most concern today is the 54 million with pre-diabetes, since prevention is viewed as one of the greatest opportunities for making a dent in the diabetes epidemic.

One of the best tools for diagnosing and preventing diabetes lies in the form of screening. Screening tests are relatively cheap but often missed opportunities to identify those pre-disposed to developing diabetes and to address preventative measures before the disease develops.

Longstanding recommendations issued by the ADA help to outline who should undergo screening. “Everybody over the age of 45 should be screened for diabetes, and people who are under the age of 45 who are overweight, which is defined as a BMI of 25 or more, and have any risk factor for diabetes, should be screened,” Buse says.

Even though the recommended screening test is a cheap fasting plasma glucose test and the recommended screening interval is every three years, roughly 50 to 100 million people in the US match those characteristics, so screening everyone who falls into those categories is a tall order.

Today the ADA is actively pursuing better screening techniques and is regrouping an expert panel on the diagnosis of diabetes. “We’re going to look at whether hemoglobin A1C, which is the usual test that’s used to follow how well controlled someone’s diabetes is, could be used for diagnosis,” Buse explains. “It has the advantage of not requiring fasting so patients could be screened at any time of the day. There’s even a kit that we are exploring around that technology to see how effectively it could work in detecting new cases of diabetes.”

Individuals should also recognize the red flags of high blood pressure and cholesterol related to diabetes. "Another missed opportunity is that often these people’s blood pressure and cholesterol are much higher than we would recommend for people with diabetes, and so their healthcare is inadequate and puts them at risk for disabling complications,” Buse explains. “Essentially, no one with pre-diabetes in America is aware of it nor are they appropriately aware of the steps they could take to try and avoid the development of diabetes.”

The good news is, however, what’s most promising along the lines of prevention doesn’t require fancy pills or a complex multi-drug regime – primary prevention is still the technique most widely believed to have the best application.

“We know from a number of clinical trials that were funded by the NIH in the past and by European and Asian governmental sources that lifestyle management, basically an attempt to lose five to ten percent of body weight and to exercise for 30 minutes a day, can reduce the rate of developing diabetes by 60 percent over an intermediate term of three to five years,” Buse says.

Along with lifestyle management, the drug metformin is also showing particular promise for certain individual characteristics. “There’s also evidence that a drug called metformin at least in selected patients who are quite heavy with a BMI over 35 and people that are under the age of 45, can have similar benefits at little cost,” Buse says.

Overall, in addition to lifestyle changes and ramped up screening, the ADA is also looking to improve awareness in the hopes of helping to lower risk of developing diabetes. Thus a number of ongoing educational programs at the ADA are top priorities, in addition to events such as Diabetes Alert Day that hope to raise awareness at the national level and provide insight into screening and prevention opportunities.

Winning diabetes
While diabetes care in the US is improving in every respect, the success is still overshadowed by the spiraling cost and total burden of the disease. Buse pinpoints three specific areas where he sees the greatest opportunity for further diabetes care improvement: prevention and early intervention, new drug development, and better understanding of how to prevent cardiovascular disease.

With prevention at the top of the list, learning how to more effectively spread messages of prevention across different demographics is a vital component. Thus research needs to be underway to find low-tech, less intensive ways of preventing diabetes in the US and exploring new avenues for prevention.

“Figuring out how to do prevention in a less intensive way, in a way that can be exported to communities, schools and work places is really key,” Buse says. “We know as an example if you use special healthcare teams involving multiple highly trained, experienced individuals that work with patients on the order of 20 to 30 hours in the first six months and then on an ongoing basis thereafter, that’s where you can get 60 percent reduction of the risk of developing diabetes.”

The second major opportunity for improving diabetes care revolves around discovering better, simpler treatments through new drug development. Most patients express a degree of difficulty with managing a combination of multiple prescriptions and insulin.

“A lot of the benefits that we’ve seen on control of blood sugar, blood pressure and cholesterol in the diabetes arena now involve patients having to take ten tablets a day of medications or multiple injections or both,” Buse points out. “We need better drugs or more durable drugs, or perhaps just poly-pills where these different medications are squashed together in a single tablet to reduce the burden of care on people with diabetes.”

The third major area involves better understanding of how to prevent cardiovascular disease, a major life-threatening complication of diabetes. Currently, a number of studies are underway in relation to how to approach blood pressure or how aggressive to be with cholesterol but Buse points out more studies are always needed. “There are a series of three studies that will be presented to the ADA meeting in June that should really give us a lot better understanding of what the role of glucose management is in preventing cardiovascular disease and diabetes, which is important since three-quarters of those with diabetes eventually die of cardiovascular disease.”

Ultimately, Buse only sees further opportunities and sources of hope in the fight against diabetes at every step of the way. “We think of management and prevention as a spectrum – primary prevention is preventing the disease from happening; secondary intervention is preventing complications from developing once the disease has started, and tertiary intervention is preventing people who already have the disease and related complications from developing a disability and/or death as a consequence of those complications.”

John B. Buse, MD, PhD, is President, Medicine & Science, American Diabetes Association.  He is the Director of the Diabetes Care Center in the Endocrinology Division of the Department of Medicine at the University of North Carolina School of Medicine in Chapel Hill.  Since 2002, he has also been the Chief of the Division of General Medicine and Clinical Epidemiology.

Buse is the Vice-Chair of the National Institutes of Health’s largest ever diabetes study, the ACCORD study, which is aimed at determining optimal treatments for diabetes, blood pressure, and cholesterol in type 2 diabetes. He is a co-Investigator in the HEALTHY study, another NIH trial aimed to demonstrate that changing school environments can produce weight loss in Middle School children. Finally, with the clinical research team at UNC, he participates in numerous pharmaceutical industry sponsored studies to develop better treatments as well as preventative and curative strategies for both type 1 and type 2 diabetes and their complications.

The American Diabetes Association
The American Diabetes Association is the nation’s leading voluntary health organization supporting diabetes research, information and advocacy. The Association’s advocacy efforts include helping to combat discrimination against people with diabetes; advocating for the increase of federal diabetes research and programs; and improved access to, and quality of, healthcare for people with diabetes. The Association’s mission is to prevent and cure diabetes and to improve the lives of all people affected by diabetes. Founded in 1940, the Association provides service to hundreds of communities across the country.

The estimated cost of diabetes
Results from the American Diabetes Association show:

The total estimated cost of diabetes in 2007 is $174 billion, including $116 billion in excess medical expenditures and $58 billion in reduced national productivity.

Medical costs attributed to diabetes include $27 billion for care to directly treat diabetes, $58 billion to treat the portion of diabetes-related chronic complications that are attributed to diabetes, and $31 billon in excess general medical costs.

The largest components of medical expenditures attributed to diabetes are hospital inpatient care (50% of total cost), diabetes medication and supplies (12%), retail prescriptions to treat complications of diabetes (11%), and physician office
visits (9%).

People with diagnosed diabetes incur average expenditures of $11,744 per year, of
which $6,649 is attributed to diabetes. People with diagnosed diabetes, on average, have medical expenditures that are 2.3 times higher than what expenditures would be in the absence of diabetes.

For the cost categories analyzed, $1 in $5 health care dollars in the U.S. is spent caring
for someone with diagnosed diabetes, while $1 in $10 health care dollars is attributed to
diabetes.

Indirect costs include increased absenteeism ($2.6 billion) and reduced productivity
while at work ($20.0 billion) for the employed population, reduced productivity for those not in the labor force ($0.8 billion), unemployment from disease-related disability ($7.9 billion), and lost productive capacity due to early mortality ($26.9 billion).

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