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Future of Diabetes

Insights from the Diabetes Deep Dive Workshop

Diabetes is already the world’s most costly epidemic. By 2020, in countries such as the US, Malaysia and Indonesia over 10% of the population will be diabetic and there will be over 300m diabetics worldwide. Up to 5% of GDP and over 25% of many public healthcare budgets globally will be typically being spent on dealing with the consequences of diabetes.

Unlike Type 1 diabetes, which is a largely stable closed loop, genetic predisposition and, in the main, controlled by patients and healthcare systems in an effective manner, Type 2 diabetes constitutes over 90% of the diabetic population and is the big growth challenge in the healthcare arena: It is already receiving widespread coverage in mass media and, given the link to obesity, has already been termed “diabesity.” As economic conditions have driven greater concern and visibility of the cost of treating a chronic disease for which there is yet no cure, over the next decade the societal burden of diabesity will become a mainstream political issue: Treatment cost per patient will be a primary concern but, by the end of the decade, the host of initiatives already being launched to decrease the disease will not have started to control the diabetes tsunami in any significant manner.

 

Context of the Challenge:

Over the next ten years there will be a significant shift in the numbers of diabetics and the associated cost burden on society. The total cost of diabetes worldwide was €166 billion in 2007: In the US alone, by 2020, researchers expect there to be around 35 million diabetics with an associated direct healthcare cost of $270 billion a year. By 2030, India will have 60 million diabetics and China 25 million.

In 2010, on average, around 5% of us are diabetic and 1 billion are obese, in Germany the average cost of diabetes per patient is already €2000 per year and in the US, where over 40% of the population is obese, this figure is €3000. The number of diabetic patients has grown by an average of 5% pa over the last decade and, given the prevailing conditions, is expected to continue rising at a rate of between 2 and 6% in varied regions. The strongest growth is forecast to occur in Central and South America – around twice the rates in North America and Europe. In addition, there is a general correlation between income and diabetes – as economies grow and people become more wealthy, so the incidence of diabetes increases; 17% and 20% of the populations of Saudi Arabia and the UAE respectively are already diabetic.

As well as the direct costs of treating diabetes, there are other hidden costs. For the patient, significantly higher insurance premiums are common in developed societies and in countries such as India, 15 to 25% of household income is required to cover treatment. Add on the impacts of increased susceptibility to other conditions as well as more days off work, early retirement and below average productivity and the hidden costs of diabetes are significant.

Globally, by 2025 it is expected that diabetes will directly cost society €300bn, nearly double today. Add on the indirect costs and estimates for the 2020 burden are in the order of €500bn. The majority of this increase will be driven by three key factors:

  • Firstly, as diabetes is largely a condition developed in older people, the increasingly ageing population will swell numbers of individuals developing diabetes. Especially in countries such as the US, India and much of the Middle East, this will be more and more visible issue as a rising share of this increasing ageing population become diabetic.
  • Secondly, as 60% of Type 2 diabetics are obese and develop diabetes as a consequence of poor diet and activity, with obesity already increasing in most markets and the incidence of early onset diabetes in overweight children is rising rapidly, the share of the overall population susceptible to developing diabetes will have grown significantly.
  • Thirdly, given the complexities of the disease, the misinformation in the media and the broader public consciousness about the diabetes condition, its variants and its consequences, compared to the likes of cancer, asthma and HIV, as a disease diabetes in 2020 will be largely as misunderstood in society as it is today.

Picking up on the second of these, diet clearly has a significant impact: A diet containing too many calories due to higher wealth is the biggest risk factor for diabetes. While this has traditionally applied to the US and Western Europe, in the Mediterranean countries fresh fish and fruit diets are now being replaced by more unhealthy meals containing lots of carbohydrates and pork. Moreover, in many emerging economies, Western style food has become more popular and, especially in urban populations, is linked to an increase in diabetes.

Solutions:

New non-invasive technologies, improved low-cost business models and more hard-hitting public health campaigns will have all been deployed around the world in various ways to try to mitigate the impact, manage the consequences and control the rise of Type 2 diabetes globally. Potential technological breakthroughs such as drugs that help you lose weight and inoculations for Type 1 diabetics have yielded initially positive results in animals but it will be 4 to 5 years before clinical trials are complete and humans can start to gain benefit. A main objective of medical developments is now around non-invasive devices which provide alternatives for needles and syringes. So the introduction of implants, to change the dynamics of testing, and patch based systems for blood glucose monitoring are all on the horizon.

However, although more cost effective bariatric surgery, new monitoring systems and insulin delivery devices as well as new drugs are all options, the scale, cost and timing of the introduction of many of these solutions will have little overall impact over the next decade. The primary change will most likely therefore need to occur from a mind-shift in the general public and, arguably, the biggest factor will be in the way new government and regional policies will have been introduced to control food consumption, influence citizen choice and better manage diabetes risk. There are three main areas where action is seen as highly probably and potentially impactful: The introduction of fat taxes, the improved use of patient data and an increase in individual responsibility for healthcare spend.

1.       Fat Tax

Following on from action already taken in Norway and Denmark, Michael Bloomberg, the mayor of New York City, is planning to tackle the American fondness for sugary soft drinks with a so-called ‘soda tax’. U.S. researchers estimate that an 18 percent tax on pizza and soda can push down U.S. adults’ calorie intake enough to lower their average weight by 5 pounds (2 kg) per year. Given that higher taxes on cigarettes proved to be one of the best ways of reducing smoking rates, a parallel approach is on the agenda for obesity. So, whether just a soda tax or a wider fat tax on high calorie foods, momentum is building. With potential regulation at an EU level coming by the middle of the decade, many commentators are now predicting widespread use of financial levies on either key products or their manufacturers as an option that many governments will pursue in an attempt to manage the growth in obesity and associated incidence of diabetes.

Although some countries, such as New Zealand, are experimenting with incentives to encourage people to eat more fresh fruit and vegetables, for many policy makers the option of making unhealthy, high-calorie foods more expensive is a more attractive route – and one that can be easier to implement and manage.

As diet and nutrition is so influential in the development of Type 2 diabetes, many of the larger food companies such as Nestle has been raising investment in functional foods while, at the same time, others are lobbying intensively to prevent the introduction of new legislation aimed at reducing their product portfolios and application of levies on high calorie foods. Drawing lessons from the tobacco industry and in response to mounting pressure from media and government, companies such as Kraft have also begun to voluntarily restrict the marketing of some products to children. Although no major retailers are yet to proactively de-list unhealthy, high calorie foods and remove them from their shelves, as the backlash against obesity builds up momentum over the next decade, the need for retailers to visibly edit the customer’s choice portfolio is seen as a highly probable scenario.

2.       Use of patient data to make the cost and issues visible to patients and the ecosystem:

In terms of making the overall diabetes ecosystem more efficient, few would argue with the potential available from making better use of patient data. While there are already a number of iPhone applications for the engaged diabetic to record and track individual measures, diet and performance as well as an increasing range of mobile and PC based systems that allow sharing of data between patient and doctor etc, there is a big shift on the horizon. By making patient data more visible and more shareable across platforms and systems, as the enabling technology becomes commoditized, several organisations are supporting the notion that peer-to-peer and expert patient groups may have as much influence on individual behaviours as improving the more traditional patient / healthcare professional relationship.

With a more connected ecosystem, more relevant patient data and greater accuracy, the opportunity to mine the data to show new patterns is tangible. Not only will this allow improved relative comparisons from one individual to another, but it will also enable more predictive data analysis. One outcome of this will be more transparency around future patient scenarios and risk so that individuals can both see how their condition is likely to evolve against peer experience and also predict likely risk of side effects such as limb loss, blindness and additional incapacity. As long as we can overcome such issues as who to trust with access to information, supported by the introduction of more virtual, remote diagnosis and access to patient data by the healthcare system, by 2020 we foresee a diabetes ecosystem with heightened visibility of cause and effect for all.

3.       Individual responsibility for healthcare costs

In some markets, the responsibility for the management of the personal cost of healthcare is increasingly being passed on to the individual. In the arena of Type 2 diabetes, this could have significant economic impact over the next decade. Given the lack of a clear story about diabetes in wider culture when compared to other diseases, the need for a major improvement in overall public health literacy and the uncertainty about the true impact of more education, many see that the third component for behaviour change alongside taxation and data use is greater personal responsibility for healthcare costs and hence actions.

Today in Germany some patients are given invoices and receipts to inform them of the costs of their healthcare treatments. In addition many sickness funds already provide rebates against insurance costs back to patients who manage their use of the healthcare system in an effective manner. Across many countries the notion that rewarding the individual financially for reducing the burden on public health ecosystems is gaining momentum and in some, such as the UK, approaches for a widening of the approach are in process. For example, the potential to recoup above average healthcare costs back from patients either through income tax for those in work, or reduction of benefits for those out of work. While these may seem politically contentious, they do signal the level of action that economically pressured governments are proposing in order to contain the mounting healthcare budgets.

As a means of making the cause and true impact of diabetes in society more visible to the wider public, such approaches to individualised patient budgets are gaining political favour and seen, by many, to be a key platform for the future: Greater patient responsibility for their own health and associated costs is an increasingly popular concept that will probably be implemented in varied ways around the world. The average age of impact for Type 2 diabetes has already fallen from 54 to 46 years. Going forward, this is expected to drop further and so, by 2020, the behaviour change needed in society will be in people who are today between 30 and 35. As people see the costs and recognise the personal financial impacts and so make individual choices more readily, especially in the area of diet and exercise behaviours that lead to obesity and Type 2 diabetes, a stick and carrot approach appears preferable and hence probable.

 

Summary

While Type 1 is triggered by certain genetic factors, type 2 diabetes is more related to patients’ lifestyle choices. As such, if governments and public healthcare systems are to manage the associated direct and indirect costs of diabetes, significant behaviour changing actions are seen as critical. Over the next decade, the technology solutions will become multiple but the time to implement and cost of introduction will probably not be able to offset the growth in diabetes from increasing obesity and old age in the global population. As such, as we all on average get wealthier, older and fatter, alongside new medical systems and more and better focused public education, systemic interventions are seen as the way to gain control of the diabetes epidemic. Over the next decade the role of taxation on high calorie foods to influence individual choice, the improved use and sharing of personal data to support this choice, and the increased responsibility for healthcare costs to reward this choice are seen as pivotal in gaining control.

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Comments

2 Responses to “Future of Diabetes”
  1. emt training says:

    My cousin recommended this blog and she was totally right keep up the fantastic work!

  2. Although Type 2 diabetes is a disease associated with aging, it’s now showing up in young children. Since we now know that food is not just energy but information, the only viable, long-term solution is for people to eat whole, unprocessed foods that transmit the right information to their DNA. This will require the cessation of genetic modification contaminating our food supply, and a massive re-education of consumers.

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