The rising diabetes epidemic: A new approach

Remember back in history class, when they talked about the Great Diabetes Epidemic of 1665? Of course you don’t; there was never any such thing.

Certainly, there have been many epidemics throughout history. These could be enormously destructive; killing millions, toppling empires, depopulating entire landscapes.1 But diabetes as a mass killer? That’s something new.

But that is exactly where we are today. Epidemiologists are warning that the Great Diabetes Epidemic is upon us – right now. The result of the combination of obesity and type 2 diabetes (“diabesity”) is likely to be the biggest pandemic in human history.2

Perhaps the word “epidemic” sounds overly dramatic to some ears. But the Centers for Disease Control (CDC) explains that “epidemic” simply refers to an increase in the number of cases of a disease above what is normally expected in a population in a given area. Relatedly, “pandemic” refers to an epidemic that has spread over several countries or continents, usually affecting a large number of people.3

And so CDC refers quite specifically to the diabetes “epidemic” that currently affects almost 30 million Americans, which is forecast to rise to nearly 55 million people over the next decade.4, 5

This chart illustrates the growth in diabetes in the U.S. through the year 2030:

Regarding the spread to other countries, the World Health Organization estimates that the number of people with diabetes grew by nearly 300% from 1980 to 2014, to 422 million worldwide.6 That number is also predicted to rise, to 642 million people living with diabetes worldwide by 2040.7

Altogether, taking into account both the number of people it will affect, and what it will cost to treat, one researcher has gone so far as to predict that type 2 diabetes is on track to be much bigger and more deadly than the Black Death. 2

The question is, why? Diabetes has never been one of the epic killers in history. It is only in recent times that we have seen the disease on this scale. How did we get here? More importantly, what are we going to do about it?

Diabetes basics

First, let’s quickly review. It is essential for our bodies to always have the correct balance of glucose (sugar) in our blood. To help regulate the sugar in our blood we use a hormone called insulin. Insulin allows glucose to enter the cells where it can be used for fuel.8

In type 1 diabetes, the body doesn't make enough insulin. In type 2 diabetes the body cannot use its own insulin as well as it should. Insulin acts as a “key” that allows blood sugar (glucose) to enter our cells, where it can be used. When the body doesn’t have enough insulin or can’t use it effectively, sugar builds up in the blood.4

Type 2 diabetes accounts for about 90% to 95% of all diagnosed cases of diabetes.4

The sour side of sweet

Driven by rising obesity, diabetes is among the most common of all chronic diseases. Just over 29 million people in the US are diabetic – that’s more than one in ten.9 And the affected population is growing fast, with nearly 2 million new diagnoses each year.10

The consequences of uncontrolled blood sugar can be severe. High blood sugar levels can lead to heart disease, stroke, blindness, kidney failure, and amputation of toes, feet, or legs. Specifically:

  • Diabetes is the leading cause of kidney failure, lower-limb amputations, and adult-onset blindness.8
  • More than 20% of all health care spending is for people with diagnosed diabetes.8
  • It is commonly ranked as the seventh leading cause of death in the United States, but may be much higher.8

One forecasting model shows that diabetes will remain a major health crisis in America, despite medical advances and prevention efforts. Unfortunately, with more diabetes, we are also facing increasing number of deaths from diabetes and its complications. This chart traces the increase, with just under 400,000 deaths per year by the year 2030:

Lifespan revolution

Looking back now at those historical epidemics we mentioned at the outset, the key thing to notice is that they mainly consisted of infectious diseases like plague, yellow fever, diphtheria, flu, or cholera. They were communicable diseases – people could catch them from each other (and other vectors, like fleas).11, 12

But over the last century or so, something interesting has happened. Something wonderful and interesting, that is: People stopped dying so much from the big communicable diseases.11

The turnaround came mainly from widespread improvements in basic public health, including clean water, better sanitation, and immunizations.13 Worldwide, most babies born in 1900 did not live past age 50. Today, the average life span now exceeds 81 years in several countries.11

By the second half of the 20th century, chronic diseases such as cancer, cardiovascular diseases, stroke, and yes, diabetes, had replaced infectious diseases as the leading causes of death in the U.S.13

The dramatic increase in average life expectancy during the 20th century must surely rank as one of humanity’s greatest achievements. However, in an ironic twist, while a far larger proportion of us are now surviving into adulthood and old age, this seems only to have exposed us to a brand new list of chronic disease health threats.

Next we will examine some of the legacy forces that help make diabetes (and obesity) such a threat today.

Our genetic legacy

Diabetes and obesity are firmly embedded in human behavior. The drive to eat is powerful; it would have to be to motivate us to venture out from our warm, safe, cave in order to hunt and forage.14

In order to manage these competing drives, our bodies evolved multiple, overlapping gut and brain signals that trigger hunger and satiety, which are also intricately linked to motivators such as stress, fear, and reward seeking. These hormonal, neural, and physical signals collaborate to control multiple, often redundant, links between short-term eating behaviors and long-term body weight.14

It appears that, in addition to these hunger and satiety signals, natural selection also operated to favor human body types that were better able to store body fat in order to survive.15, 16 From a strategic standpoint, storing energy inside the body provides a buffer that offers survival options. Over thousands of generations, this strategy has proven to be an evolutionary winner.15

The diabetes-obesity link

We know that there is a very close link between obesity and type 2 diabetes. Obesity is frequently described as the most important cause of diabetes.4

This graph demonstrates the near-lockstep relationship between increasing Body Mass Index (BMI) and the risk of type 2 diabetes:

With obesity rates rocketing skyward in the U.S., it’s clear that when we talk about diabetes, to a large extent we are also talking about obesity, and vice-versa. And things are poised to get even worse, as this graph showing projected rates of those who are overweight:

Nice niche?

Today, obesity and diabetes are embedded in a complex physical and social environment that shapes and directs our actions.15 Unfortunately, the human environment where we currently live has been described as the ‘obesogenic niche.’15 This is simply the urbanized, industrialized environment we see when we look around us; a place with little call for strenuous physical work and easy access to rich foods.

In our new environment, energy-dense foods are nearly always readily available, and our appetites are artfully manipulated by the food industry. One critical question now being studied is how the human fat storage function has been affected by modern environmental pressures to produce weight gain and obesity.15

Unfortunately, the evidence seems to show that by living in an obesogenic environment, the simple act of eating can lead to such an accumulation of body fat that it can compromise our physical health.15

What can be done?

In general, when addressing chronic illnesses such as diabetes, perhaps the biggest opportunity in the PBM space is integration, which means breaking-through the traditional boundaries that have been established to define what a pharmacy benefit manager (PBM) is and does.

Originally, PBMs were designed mainly around the task of distributing medications. They negotiated with pharmaceutical companies to get lower drug prices, negotiated rebates, operated mail order programs, processed claims and managed formularies.

Facing a world where over 150 million Americans will be afflicted with a chronic disease by the year 2030 – including 55 million diabetics – such a limited writ is no longer sufficient.17

Chronic conditions such as diabetes are characterized by high levels of co-morbidity – i.e., multiple conditions.18 These patients can be overwhelmed, not only by their conditions, but by the sheer complexity of their treatments. They require an extraordinary degree of support in order to close gaps in care, monitor their vital signs, and keep them adherent to their medications.17

A PBM that is simply handing out pills is failing these patients at a very fundamental level.17

The new pharmacy care services model for OptumRx goes far beyond drug distribution to include new, fully integrated management strategies that bring together data, insight and clinical skills from a broad range of sources, including pharmacy, medical, ancillary care, and lab results. We target members and tailor interventions based on risk, engaging members and providers through multiple touchpoints. This results in better engagement, improved health outcomes and lower health care costs.

The difference between the new OptumRx model and the existing PBM model couldn’t be more stark. For example, in reviewing factors that contribute to poor glycemic control among diabetics, one research review specifically calls-out the lack of integrated care in many health care systems.19 In contrast, the McKinsey consultant group has found that, after assessing all the available evidence, integrated-care programs were associated with a 19% reduction in hospital-admission rates, compared with usual care.20

Another large consulting house (PwC) also advocates for integrated care for managing chronic disease. They cite research which demonstrates how multidisciplinary teams that utilize a variety of clinical professionals, including pharmacists acting outside their traditional roles, can improve care, and, at times lower costs, for patients with chronic diseases.17

The OptumRx Connected Condition Management program is an integrated solution that provides a holistic approach for members who suffer from five key complex chronic conditions, including diabetes (others include coronary artery disease (CAD), heart failure, chronic obstructive pulmonary disease (COPD) and asthma).

Four elements that are particularly important include patient education and empowerment, care coordination, multidisciplinary teams, and individual care plans. Each of these components has been proven to reduce hospitalization rates by a minimum of 23% and as much as 37%.20

Connected Condition Management includes patient support elements that are consistent with those found in highly successful integrated care programs aimed at diabetes that have been studied. Look for much more on this program, as well as our other integrated diabetes management tools in our upcoming “management strategies” article.

Pending a revolutionary advance in preventive health techniques, for the time being we appear to be in for a prolonged period of dealing with obesity, diabetes, and their consequences. The remainder of the papers in this series will address the various dimensions of the problem: spending, cost drivers, new treatments, and the management strategies available through OptumRx and the broader Optum family of companies.

 

STATEMENT REGARDING FINANCIAL INFLUENCE:
This article is directed solely to its intended audience about important developments affecting the pharmacy benefits business. It is not intended to promote the use of any drug mentioned in the article and neither the author nor OptumRx has accepted any form of compensation for the preparation or distribution of this article.

References

  1. World Atlas. The 10 Worst Epidemics in History. March 13, 2017. Accessed at: http://www.worldatlas.com/articles/the-10-worst-epidemics-in-history.html on 07.07.2017.

  2. Clinical Diabetes and Endocrinology. Diabetes and its drivers: the largest epidemic in human history? January 18, 2017. 20173:1 DOI: 10.1186/s40842-016-0039-3. Accessed at: https://clindiabetesendo.biomedcentral.com/articles/10.1186/s40842-016-0039-3 on 07.07.2017.

  3. Centers for Disease Control. Principles of Epidemiology in Public Health Practice, Third Edition. An Introduction to Applied Epidemiology and Biostatistics. Lesson 1: Introduction to Epidemiology. May 18, 2012. Accessed at: https://www.cdc.gov/ophss/csels/dsepd/ss1978/lesson1/section11.html on 08.29.2017

  4. Centers for Disease Control and Prevention National Center for Chronic Disease Prevention and Health Promotion. Diabetes At A Glance 2016. [pdf]

  5. Population Health Management. 2017 Feb 1; 20(1): 6–12. Diabetes 2030: Insights from Yesterday, Today, and Future Trends. Accessed at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5278808/

  6. World Health Organization. Global Report on Diabetes. 2016. Accessed at: http://www.who.int/diabetes/global-report/en/ on 08.29.2017.

  7. International Diabetes Federation. IDF Diabetes Atlas 7th Edition- Across the globe. Accessed at: http://www.diabetesatlas.org/across-the-globe.html on 08.29.2017.

  8. Centers for Disease Control and Prevention. Basics About Diabetes. March 31, 2015. Accessed at: http://www.cdc.gov/diabetes/basics/diabetes.html on 09.30.2015.

  9. American Diabetes Association. Statistics About Diabetes. National Diabetes Statistics Report, 2014. May 18, 2015. Accessed at: http://www.diabetes.org/diabetes-basics/statistics/?loc=db-slabnav on 10.19.2015.

  10. National Center for Disease Prevention and Health Promotion. Infographic: A Snapshot of Diabetes in America. June 11, 2014. Accessed at: http://www.diabetes.org/diabetes-basics/statistics/cdc-infographic.html on 07.18.2017.

  11. National Institute on Aging/National Institutes of Health/ World Health Organization. Global Health and Aging. Oct. 2011. Accessed at: https://www.nia.nih.gov/research/publication/global-health-and-aging/living-longer on 07.06.2017.

  12. BBC History Extra. Your 60-second guide to the Black Death. Nov. 19, 2014. Accessed at: http://www.historyextra.com/feature/your-60-second-guide-facts-black-death-how-when-why on 07.13.2017.

  13. Institute for Alternative Futures. Public Health 2030: Chronic Disease Driver Forecasts. Accessed at: http://www.altfutures.org/health/iaf-releases-national-public-health-2030-scenarios/ on 07.06.2017.

  14. Chemical & Engineering News. Hungering for obesity treatments. Volume 95 Issue 13 | pp. 19-21. March 27, 2017. Accessed at: http://cen.acs.org/articles/95/i13/Hungering-obesity-treatments.html on 08.08.2017.

  15. Disease Models & Mechanisms. The evolution of human adiposity and obesity: where did it all go wrong? Sept 5, 2012.doi: 10.1242/dmm.009613. Accessed at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3424456/ on 07.13.2017.

  16. Science. Why humans are the fat primate. June 1, 2015. Accessed at: http://www.sciencemag.org/news/2015/06/why-humans-are-fat-primate on 07.18.2017.

  17. Benefits Quarterly. The Changing Role of Pharmacy Benefit Administration in Managing Chronic Conditions. First Quarter, 2014. [PDF]

  18. Centers for Disease Control. Multiple Chronic Conditions. Jan. 20, 2016. Accessed at: https://www.cdc.gov/chronicdisease/about/multiple-chronic.htm on 06.23.2017.

  19. American Journal of Managed Care. Medication Adherence and Improved Outcomes Among Patients With Type 2 Diabetes. Published Online: July 31, 2017. Accessed at: http://www.ajmc.com/journals/issue/2017/2017-vol23-n7/medication-adherence-and-improved-outcomes-among-patients-with-type-2-diabetes/P-1 on 08.02.2017.

  20. McKinsey & Company, Healthcare Practice. The evidence for integrated care March 2015. [PDF]