Diabetes

A CLOSER LOOK AT

The number of Americans

diagnosed with diabetes
jumped 49 percent from
1990 to 2000.

A JOINT PROJECT BETWEEN

T H E A M E R I C A N D I A B E T E S A S S O C I AT I O N A N D
T H E N AT I O N A L P H A R M AC E U T I C A L C O U N C I L
I
t is estimated that 17 million Americans suffer from
diabetes, a group of chronic diseases characterized by
defects in the way the body produces and uses insulin
leading to elevated levels of blood sugar
1,2
(glucose). The number of Americans
diagnosed with diabetes jumped 49 percent
from 1990 to 2000, and approximately one
million new cases are diagnosed each
1,2
year. This may reflect improved methods
of diagnosis, an increase in obesity, an
aging population, and growth among
demographic groups for which diabetes
is increasingly becoming a problem. The
Centers for Disease Control and Prevention
(CDC) conservatively estimate that diabetes
in the U.S. will increase 165 percent by
2050.
There are two major types of diabetes. Type
1 is an autoimmune disease in which the
body attacks and ultimately destroys the
insulin-producing cells of the pancreas.
With the body’s natural supply of insulin
cut off, blood sugar levels rise. The disease
can develop at any age, although onset is
most common at puberty. Type 1 diabetes
accounts for five to ten percent of all
1
diagnosed cases of diabetes. Type 2 diabetes is a metabolic
disorder in which the body is unable to properly use
insulin to control blood sugar levels, and in some cases, to
make enough insulin. Type 2 diabetes is the most common
form of diabetes, representing 90 to 95 percent of all cases
1
of diagnosed diabetes. Other forms of diabetes account for
1
one to five percent of all diagnosed cases.
Undiagnosed and untreated diabetes can lead to many
serious and often fatal health conditions. Diabetes is the
main cause of kidney failure, new cases of blindness, and
lower limb amputations, and is a major risk factor for heart
disease and stroke. In 1999, over 114,000 people with
1
diabetes underwent dialysis or kidney transplantation.
Nearly two-thirds of people with diabetes die of heart
3
disease or stroke. Each year, 82,000 people lose a foot or
leg to diabetes, and it is the most frequent cause of lower
4
limb amputations. The risk of having a leg amputated is 15
to 40 times greater for a person with diabetes than for a
person without diabetes. Since 1980, the number of deaths
5
related to diabetes has increased 40 percent.
Unfortunately, the amount of money available for diabetes
research and education programs has not matched the
2
increase in disease prevalence and death.
According to the American Diabetes Association, the total
annual economic cost of diabetes in 1997 was estimated to
be $98 billion. Of this figure, $44 billion was due to direct
medical and treatment costs and $54 billion was due to
6
indirect costs attributed to disability and death. In 1997, the
per capita costs of health care for people with diabetes
amounted to $10,071, compared to $2,699 for people
3
without diabetes. However, proper treatment can
significantly reduce the costs associated with diabetes-
related illness. One analysis of intensive treatment of type 2
diabetes found that stabilizing blood sugar at normal levels
would raise life expectancy by 1.4 years and reduce the
incidence of blindness by 72 percent, end-stage kidney
disease by 87 percent, and lower extremity amputation by
7
67 percent.
Treatment guidelines for type 1 and type 2 diabetes differ,
although proper nutrition and exercise are a fundamental
part of treating each condition. Because people with type 1
diabetes cannot produce any insulin, they must inject it
daily. First-line treatment of type 2 diabetes usually calls for
adjusting diet and exercise and reducing weight. Often a
short trial of weight reduction and exercise is recommended
6
before the initiation of drug therapy in type 2 diabetes.
In July 1995, the American Diabetes Association convened a
panel of experts to develop a consensus statement on drug
treatment of high blood sugar in type 2 diabetes. The panel
recommended that if progress was not apparent within a
three-month period after initiation of diet and exercise
changes, then the use of a prescription medicine is
6
appropriate.
The array of diabetes drugs available makes a number of
therapy combinations possible. Evidence is mounting that
combinations of drugs often have complementary effects
and can control glucose levels better than a single form of
8,9,10
therapy over time. No single therapy currently available
appears to be superior when used alone, and patients not
responding to a single form of therapy often experience
better outcomes when a second type is added, rather than
11
substituted. One recent study reports that the percentage
of patients who were able to maintain target glucose levels
on a single-therapy regimen dropped to 50 percent after
three years, and to approximately 25 percent after nine
years. Given the lessening effect of single therapies over
time, the majority of patients require multiple therapies to
maintain adequate control of blood sugar levels in the long
10
term. Carefully selected combination therapies may also
have beneficial effects on complications associated with
diabetes or other medical conditions. Eventually, many type
2 diabetes patients require insulin therapy, either alone or
12
with prescription therapies.
THE INCREASING PREVALENCE OF DIABETES
Over the last two decades, the incidence of diagnosed diabetes has increased. Additionally, 5.9 million people are believed to
1
have undiagnosed diabetes. The disease is more common among older people and non-whites. The number of people
diagnosed with diabetes, particularly type 2 diabetes, is increasing for several reasons:

• Improvements in screening and changes in the diagnostic criteria;

2
• Increasing rates of obesity and sedentary lifestyle;
13
• Growth in populations that have high rates of type 2 diabetes; and
14
• Recognition that type 2 diabetes is an increasing problem in children and adolescents.

T
HE TOTAL ANNUAL ECONOMIC
COST OF DIABETES IN 1997 WAS
ESTIMATED TO BE $98 BILLION.

DIABETES AND HEART DISEASE

Heart disease is the leading cause of death in the United States, claiming the lives of nearly 460,000 Americans each
15
year. Patients with diabetes often suffer from heart disease as well, and the presence of diabetes greatly increases the
16
risks associated with heart disease:
4
• Nearly two-thirds of people with diabetes die of heart disease or stroke.
17
• People with diabetes have the same cardiovascular risk as if they have already had a heart attack.
1
• Adults with diabetes have heart disease rates two to four times higher than adults without diabetes.
• Women with diabetes have three to seven times the risk of heart disease and heart attack than women who do not have
18
diabetes.
S
TABILIZING BLOOD SUGAR AT NORMAL LEVELS WOULD RAISE
LIFE EXPECTANCY BY 1.4 YEARS AND REDUCE THE INCIDENCE
OF BLINDNESS BY 72 PERCENT, END-STAGE KIDNEY DISEASE BY
87 PERCENT, AND LOWER EXTREMITY AMPUTATION BY 67 PERCENT.

FACTORS INFLUENCING DRUG SPENDING

METHODOLOGY FOR DIABETES 1994-1997
This study separately analyzed
prescription drug spending
growth for two large national
claims databases, one
representing managed care Spending on pharmaceuticals was analyzed
plan enrollees and the other for individuals who received health benefit
representing those covered by coverage from large employers in 1994 and
large employer-provided 1997. The sample included individuals who
health benefit plans. The study
Price Factors were diagnosed with diabetes. Overall,
defined and assessed several spending on drugs for treating diabetes was
factors affecting the price per 94 percent higher in 1997 than in 1994.
day of therapy and the volume Factors affecting the volume of drugs used
of therapy — the number of Volume Factors outweighed factors affecting the price of
days of therapy received and drugs in influencing spending growth by
the number of patients more than three to one.
receiving drug therapy. The
analysis also examined the
effects of price and volume
changes for established drugs
on the market during the entire
period of analysis and for new
drugs that were first marketed
during this period.

Factors Influencing Growth in Rx Expenditures: % Positive Impact % Negative Impact

Total Growth in Expenditures +94
Growth Due to Volume Factors +73
Changes in the Number of Prescriptions per Person for Established Drugs -36
Changes in the Number of Prescriptions per Person for New Entrants +66
Changes in Days of Therapy for Established Drugs +9
Changes in Days of Therapy for New Entrants +4
Patients per 1000 Health Plan Enrollees +30
Growth Due to Price Factors +21
Inflation +11
Changes in Mix of Established Drugs -13
Price of New Entrants +23

Thirty percent of the overall spending growth could be attributed to an increase in the number of patients treated for diabetes.
Educational outreach and disease management programs that encourage screening and diagnosis of people with unrecognized diabetes
may have influenced such substantial growth. The underlying prevalence of diabetes may also have risen.

Source: MEDSTAT’s Marketscan database

Approximately 5.9 million people are
believed to have undiagnosed
diabetes.

SPENDING PER CAPITA FOR DIABETES MEDICATIONS

The addition of three new drug classes between 1995 and 1997 had a marked effect on diabetes
spending per patient. Per capita spending on all related medications together was 52 percent higher in
1997 than in 1994, representing an increase from $138 in 1994 to $210 in 1997. During this period,
spending on drugs in the sulfonylurea class fell from $90 to $75 per capita, whereas spending on
insulin rose slightly from $91 to $95 per capita. In 1997, per capita spending was $70 and $67 for two of
the new antidiabetic drug classes, biguanides and TZDs.

Source: MEDSTAT’s Marketscan database

DIABETES AND MINORITIES

1
• The prevalence of diabetes among African-Americans is almost twice that of non-Hispanic whites.
• One Native American tribe in Arizona has the highest rate of diabetes in the world. About 50 percent of these adults
3
between the ages of 30 and 64 have diabetes.
1
• The prevalence of type 2 diabetes is twice as high in Hispanics than non-Hispanic whites.
• African-Americans with diabetes are 2.6 to 5.6 times more likely to suffer from kidney disease than other people with
3
diabetes. More than 4,000 new cases of end-stage kidney disease are diagnosed among this group each year. Among
Mexican-Americans, the rate of diabetic end stage kidney disease is four to six times higher than in other diabetes
3
patients.
• Among Native Americans, the rate of diabetic end-stage kidney disease is six times higher than in other diabetes
3
patients. Lower limb amputation rates among Native Americans are three to four times higher than the general
3
population and are 1.5 to 2.5 times higher among African-Americans than the general population.
 ABOUT THIS
PUBLICATION:
"A Closer Look at Diabetes" is a joint
publication of the American Diabetes
Association and the National
Pharmaceutical Council.
The mission of the American Diabetes
Association is to prevent and cure
diabetes, and to improve the lives of all
people affected by diabetes. To fulfill
this mission, the American Diabetes
Association funds research, publishes
scientific findings, provides information
and other services to people with
diabetes, their families, health care
professionals and the public and
advocates for scientific research and for
the rights of people with diabetes.
Since 1953, the National Pharmaceutical
Council (NPC) has sponsored and
conducted scientific, evidence-based
analyses of the appropriate use of
pharmaceuticals and the clinical and
economic value of pharmaceutical
innovation. NPC provides educational
resources to a variety of health care
stakeholders, including patients,
clinicians, payers and policy makers.
More than 20 research-based
pharmaceutical companies are members
of the NPC.
For more information about NPC or for
additional resources, please contact:
The National Pharmaceutical Council
1894 Preston White Drive
Reston, VA 20191-5433
Phone: 703-620-6390
Fax: 703-476-0904
www.npcnow.org
FOR MORE INFORMATION ABOUT DIABETES,
PLEASE CONTACT:
American Diabetes Association
1-800-DIABETES
www.diabetes.org
National Diabetes Education Program (NDEP)/National Institutes of Health (NIH)
1-800-438-5383
www.ndep.nih.gov
American Association of Diabetes Educators
1-800-338-3633
www.aadenet.org
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)/
National Institutes of Health (NIH)
1-800-860-8747
www.niddk.nih.gov
Centers for Disease Control and Prevention (CDC), Division of Diabetes Translation
1-877-CDC-DIAB
www.cdc.gov/diabetes
1 9
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