The Impact of
Diabetes Mellitus in the
United States
Epidemiology, Costs, and
Future Projections
Table of Contents
Section
Epidemiology
Slide No.
3-34
Costs
35-43
Future Projections
43-49
Section 1
EPIDEMIOLOGY
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/
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/
Racial/Ethnic Differences
in Diagnosed Diabetes
• 2007–2009 national survey data for
people ages 20 years or older
Race/Ethnicity
Non-Hispanic whites
%
7.1
Asian Americans
Hispanics/Latinos
Cuban Americans
Central and South Americans
Mexican Americans
Puerto Ricans
8.4
11.8
7.6
7.6
13.3
13.8
Non-Hispanic blacks
12.6
National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at:
http://diabetes.niddk.nih.gov/dm/pubs/statistics/
Diagnosed and Undiagnosed Diabetes
Source: 2005-2008 National Health and Nutrition Examination Survey
National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at:
http://diabetes.niddk.nih.gov/dm/pubs/statistics/
New Cases of Diagnosed Diabetes
Source: 2005-2008 National Health and Nutrition Examination Survey estimates projected to the year 2010
National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at:
http://diabetes.niddk.nih.gov/dm/pubs/statistics/
County-Level Estimates of Diagnosed
Diabetes (%), Adults ≥20 years, 2008
Percent
00 -–6.5
6.5
6.6
8.08.0
6.6- –
8.1
9.49.4
8.1- –
9.5
11.1
9.5- –
11.1
>≥11.2
11.2
www.cdc.gov
Number of Americans with
Diagnosed Diabetes, 1980-2009
www.cdc.gov
Annual, Age-Adjusted Incidence Rate
of Diagnosed Diabetes*, 2005-2007
MMWR. 2008;57(43):1169-1173.
Prevalence of Overweight and Obesity
Among Adults with Diabetes
• 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%
MMWR. 2004;53(45):1066-1068.
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)
CDC=Centers for Disease Control and Prevention; NIH=National Institutes of Health
SEARCH for Diabetes in Youth Study Group. Pediatrics. 2006;118:1510-1518.
SEARCH for Diabetes in Youth
Results
• 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
Demographics, Prevalence
Characteristic
Total population
No. of cases
(%)
Population
denominator,
n (%)
Prevalence, cases
per 1000 youth
(95% CI)
6379
3,499,846
1.82 (1.78-1.87)
Age group
0-4 y
5-9 y
10-14 y
15-19 y
255
1094
2120
2910
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
1.93
1.29
0.83
1.29
(4.0)
(17.2)
(33.2)
(45.6)
829,589
876,263
925,426
868,568
(23.7)
(25.0)
(26.5)
(24.8)
0.31
1.25
2.29
3.35
(0.27-0.35)
(1.18-1.32)
(2.20-2.39)
(3.23-3.47)
(2.10-2.23)
(1.79-2.08)
(1.21-1.38)
(0.74-0.94)
(1.12-1.50)
NHW=non-Hispanic white; AA=African-American; H=Hispanic; API=Asian/Pacific Islander; AI=American Indian
SEARCH for Diabetes in Youth Study Group. Pediatrics. 2006;118:1510-1518. Table 1.
SEARCH for Diabetes in Youth
0-9 Years by Race/Ethnicity
Prevalence
NHW=non-Hispanic white; AA=African-American; H=Hispanic; API=Asian/Pacific Islander; AI=American Indian
SEARCH for Diabetes in Youth Study Group. Pediatrics. 2006;118:1510-1518.
SEARCH for Diabetes in Youth
10-19 Years by Race/Ethnicity
Prevalence
NHW=non-Hispanic white; AA=African-American; H=Hispanic; API=Asian/Pacific Islander; AI=American Indian
SEARCH for Diabetes in Youth Study Group. Pediatrics. 2006;118:1510-1518.
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.
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/
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/
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/
Complications of Diabetes
Heart Disease, Stroke, Hypertension
• 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
National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at:
http://diabetes.niddk.nih.gov/dm/pubs/statistics/
Complications of Diabetes
Blindness, Eye Problems
• 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
National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at:
http://diabetes.niddk.nih.gov/dm/pubs/statistics/
Complications of Diabetes
Renal Disease
• 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
National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at:
http://diabetes.niddk.nih.gov/dm/pubs/statistics/
Complications of Diabetes
Nervous System Disease
•
~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
National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at:
http://diabetes.niddk.nih.gov/dm/pubs/statistics/
Treatment of Diabetes
No
medication
16%
Insulin only
12%
Insulin
and oral
medication
14%
Oral
medication
only
58%
National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at:
http://diabetes.niddk.nih.gov/dm/pubs/statistics/
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/
Age Distribution of Deaths
Associated with Diabetes
Age 18-34
1,918
1%
Age <18
488
0%
Age 35-44
5564
2%
Age 45-54
16,663
Age 55-59
6%
13,907
5%
Age 60-64
17,634
6%
Age 65-69
20,656
7%
Age 70+
206,791
73%
American Diabetes Association. Diabetes Care. 2008;31:596-615. Figure 4.
All-cause mortality rate among people
with and without diabetes
With diabetes
*
Without diabetes
*Rate difference between 1997/1998 and 2003/2004, –5.2; P < 0.02 for trend
Gregg et al., Diabetes Care 35: 1252—1257, 2012
CVD mortality rate among people
with and without diabetes
Deaths/1000 person-years
10
With diabetes
8
Without diabetes
6
*
4
2
0
1997-1998 1999-2000 2001-2002 2003-2004
NHIS Sample Periods
*Rate difference between 1997/1998 and 2003/2004, –4.0; P < 0.001 for trend
Gregg et al., Diabetes Care 35: 1252—1257, 2012
CVD mortality rate among women
with and without diabetes
Deaths/1000 person-years
10
Women with
diabetes
8
Women without
diabetes
6
*
4
†
2
0
1997-1998 1999-2000 2001-2002 2003-2004
NHIS Sample Periods
*Rate difference – 3.5; P < 0.01 for trend; †Rate difference – 0.5, P < 0.03 for trend
Gregg et al., Diabetes Care 35: 1252—1257, 2012
Deaths/1000 person-years
All-cause mortality rate among women
with and without diabetes
16
Women with
diabetes
*
12
Women without
diabetes
8
4
0
1997-1998 1999-2000 2001-2002 2003-2004
NHIS Sample Periods
*Rate difference – 5.6; P < 0.01 for trend
Gregg et al., Diabetes Care 35: 1252—1257, 2012
CVD mortality rate among men
with and without diabetes
Deaths/1000 person-years
12
Men with
diabetes
10
8
*
Men without
diabetes
6
4
2
0
1997-1998 1999-2000 2001-2002 2003-2004
NHIS Sample Periods
*Rate difference between 1997/1998 and 2003/2004, –5.2; P < 0.002 for trend
Gregg et al., Diabetes Care 35: 1252—1257, 2012
Deaths/1000 person-years
All-cause mortality rate among men
with and without diabetes
24
Men with
diabetes
20
Men without
diabetes
16
12
8
4
0
1997-1998 1999-2000 2001-2002 2003-2004
NHIS Sample Periods
Rates between 1997/1998 and 2003/2004 not significantly different
Gregg et al., Diabetes Care 35: 1252—1257, 2012
Section 2
COSTS
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.
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.
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 $10 health care dollars is attributed
to diabetes
American Diabetes Association. Diabetes Care. 2008;31:596-615.
Health Resource Use
Attributed to Diabetes, 2007
Age (years)
Health resource
<45
45-64
Institutional care
Hospital inpatient days
Nursing/residential facility
days
2,115
1,269
7,586
11,103
14,562
43,687
24,262
56,059
7,353
1,499
1,307
26,552
1,984
2,535
30,808
2,084
1,888
64,713
5,567
5,730
0
4
15,181
8,939
22
71,295
18,449
27,388
165
192
88,841 175,317
Outpatient care
Office-based physician visits
Emergency visits
Hospital outpatient and
freestanding ambulatory
surgical center visits
Home health visits
Hospice care days
Retail prescriptions
≥65
Total*
*Numbers do not necessarily sum to totals because of rounding
American Diabetes Association. Diabetes Care. 2008;31:596-615. Table 5.
Indirect Costs
Attributed to Diabetes, 2007
Cost component
Productivity loss
Total cost
attributable
to diabetes
($ billions)
Work days absent
15 million days
2.6
4
Reduced performance
at work
120 million days
20.0
34
Reduced productivity
days for those not in
labor force
6 million days
0.8
1
Permanent disability
445,000 people,
107 million days
7.9
14
Mortality
284,000 deaths
26.9
46
58.2
100
Total
Proportion
of indirect
costs (%)
American Diabetes Association. Diabetes Care. 2008;31:596-615. Table 14.
Mortality Costs
Attributed to Diabetes, 2007
Deaths attributed to diabetes
Value of
lost
productivity
(millions of
dollars)
Total US
deaths
Deaths
% of
total
of US
deaths
Diabetes
77,000
77,000
100.0
9,520
Renal disease
43,000
25,000
57.4
2,116
Cerebrovascular
disease
155,000
59,000
37.6
3,849
Cardiovascular
disease
739,000
123,000
16.5
11,417
NA*
284,000
NA*
26,902
Primary cause
of death
Total
*Total comprises mortality for reasons other than those listed here
American Diabetes Association. Diabetes Care. 2008;31:596-615. Table 16.
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.
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.
Section 3
FUTURE PROJECTIONS
IDF Global Projections for Number of
People with Diabetes, 2010-2030
IDF Diabetes Atlas, 4th ed. ©International Diabetes Federation, 2009.
Estimated Number of People with
Diabetes Worldwide, 2010 and 2030
Country/Territory
2010
Millions
Country/Territory
2030
Millions
1 India
50.8
1 India
87.0
2 China
43.2
2 China
62.6
3 USA
26.8
3 USA
36.0
4 Russian Federation
9.6
4 Pakistan
13.8
5 Brazil
7.6
5 Brazil
12.7
6 Germany
7.5
6 Indonesia
12.0
7 Pakistan
7.1
7 Mexico
11.9
8 Japan
7.1
8 Bangladesh
10.4
9 Indonesia
7.0
9 Russian Federation
10.3
10 Mexico
6.8
10 Egypt
8.6
IDF Diabetes Atlas, 4th ed. ©International Diabetes Federation, 2009.
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 prediabetes
• Equations used to model future burden of
diabetes on U.S. adults through 2050
Boyle JP, et al. Popul Health Metr. 2010;8:29.
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.
Total U.S. Adult Population
Diabetes Prevalence Projections
Boyle JP, et al. Popul Health Metr. 2010;8:29.