Diabetes Care Will Cost $336B by 2034

By John Gever, Senior Editor, MedPage Today
Published: November 27, 2009
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

More than 44 million Americans will have diabetes within 25 years under current trends, and the annual cost of caring for them will triple to $336 billion in constant 2007 dollars, researchers said.

The obesity epidemic, ever-earlier ages of diabetes onset, and increasing longevity of people with established diabetes are combining to enlarge the diabetic population far beyond anything envisioned in earlier projections, Elbert S. Huang, MD, MPH, of the University of Chicago, and colleagues reported the December issue of Diabetes Care.

"Without significant changes in public or private strategies, this population and cost growth are expected to add a significant strain to an overburdened healthcare system," the researchers warned.

Currently, some 24 million Americans are living with diabetes, Huang said in a briefing for reporters. "Already this represents a great economic burden for the country and for government programs like Medicare," he said.

Huang and colleagues estimated that costs to Medicare would rise nearly fourfold, from about $45 billion currently to $171 billion in 2034, in constant dollars.
Previous forecasts had projected slower growth in the number of diabetic patients. For example, a 2001 study by CDC researchers estimated that about 29 million Americans would be diagnosed with the disease in 2050.
Unlike earlier efforts, Huang and colleagues included trends related to obesity in their model for projecting future cases of diabetes, as well as data from the 2004 United Kingdom Prospective Diabetes Study (UKPDS) on the natural history of the disease.
The UKPDS data allowed the researchers to develop a model by which individuals with certain disease durations and ages were expected to have developed corresponding levels of cardiovascular, renal, ocular, and other complications.
"We know that the average cost of treating diabetes in newly diagnosed people is substantially different from the costs of treating someone who has lived with diabetes for 20 or 30 or 40 years and is suffering from microvascular or cardiovascular complications," Huang explained.
Data from the U.S. government's Medical Expenditure Panel Survey were used to attach treatment costs to care of diabetes and the associated complications at different patient ages and disease durations.
"Our model accounts for that natural history and the change in the life of a patient," he said. That is why the study forecast more rapid increases in costs than in the diabetic population -- because patients are living longer with these expensive complications.
The study also took account of trends in body mass index distribution. According to the group's projections, "overall obesity distribution in the nondiabetes population remains fairly stable over time, with [about] 65% of the population being overweight or obese."
Some 35% of the population will be overweight throughout the period, while the percentage classed as obese will decline from 30% currently to 27% by 2034, the researchers said.
The obesity projections were based on UKPDS and U.S. data on how body mass index changes with age. Actual obesity prevalences could be higher or lower if eating and exercise habits or anti-obesity medical treatments change significantly.
The current study did not analyze the potential effects of interventions aimed at reducing the incidence and severity of diabetes. But Huang said small-scale programs promoting healthy eating and exercise have shown the ability to affect the natural history of diabetes.
Matt Petersen, a spokesman for the American Diabetes Association, said "realistic and achievable amounts of changes in diet and physical activity do have a clinically significant effect on primary prevention."
But Huang acknowledged that, outside of formal clinical studies, "it's not clear that... community efforts are collectively making a big impact in terms of diabetes prevention."
On the other hand, he said data from the CDC's National Health and Nutrition Examination Survey indicate that blood glucose, cholesterol, and blood pressure control may be improving. (See 'Bad' Cholesterol Rates Plummet)
"I don't know if that's attributable to community efforts as much as to physician and patients becoming more aware of targets for diabetes care and slightly better delivery of drugs," Huang said. "I would say that the story is mixed in terms of diabetes prevention and diabetes care.
The researchers noted several limitations to their analysis:

• It did not account for possible future changes in diabetes screening rates, which could raise or lower the numbers of people receiving treatment.
• It did not account for immigration by people younger than 24.
• All individuals with body mass index values of 30 and higher were grouped together, leading to potential underestimation of the future diabetic population and costs.
• The model assumed no change in baseline age-specific rates of obesity.

Moderate-to-High Alcohol Intake Linked to Reduced CHD Risk in Men

Men who drink moderate to very high amounts of alcohol may have a reduced risk for coronary heart disease, according to an observational study in Heart.

Over 40,000 Spanish men and women completed questionnaires about their lifestyles, including alcohol intake, and were followed for a median of 10 years. During that time, 1.5% developed CHD.

After adjustment for lifestyle factors and comorbid conditions, men who regularly consumed moderate to very high amounts of alcohol (range: 5 to at least 90 g/day — the equivalent of roughly one to six standard drinks) had about half the risk for CHD as those who never drank. Findings were similar for all kinds of beverages consumed.

Among women, alcohol intake was not significantly associated with CHD.

Heart article (Free abstract; full text requires subscription)

FDA: Clopidogrel's (Plavix) Antiplatelet Effect Can Be Halved by Omeprazole (Prilosec)

The FDA is updating clopidogrel's label to warn against its concomitant use with the proton-pump inhibitor (PPI) omeprazole. The agency says omeprazole can reduce clopidogrel's antiplatelet effect.
New manufacturer-conducted studies indicate that clopidogrel's antiplatelet effect was reduced by nearly 50% in people receiving both drugs. Administering the drugs at different times does not diminish this drug interaction, the FDA warns.
Omeprazole blocks the enzyme CYP2C19, which converts clopidogrel into an active metabolite. Other drugs that should also be avoided in tandem with clopidogrel include cimetidine, fluconazole, ketoconazole, voriconazole, etravirine, felbamate, fluoxetine, fluvoxamine, and ticlopidine. (The agency says it does not yet have enough information to make recommendations about PPIs other than omeprazole, although esomeprazole — a component of omeprazole — should also be avoided with clopidogrel.)
The FDA notes that providers should also make sure that their patients on clopidogrel are not taking over-the-counter versions of omeprazole or cimetidine.

USPSTF Recommends Against Routine Mammography for Women in Their 40s

The U.S. Preventive Services Task Force now recommends against routine screening mammography for average-risk women aged 40 to 49. This represents a change from the USPSTF's 2002 recommendation statement, which advocated for routine screening starting at age 40.
Among the task force's other updates, published in Annals of Internal Medicine:

• Screening mammography should be performed every 2 years for average-risk women aged 50 to 74.
• Evidence is insufficient to recommend for or against screening in women 75 or older.
• Clinicians should not teach women how to perform breast self-exams.
• Evidence is insufficient to make recommendations on using clinical breast exams in addition to mammography.
• Evidence is insufficient to recommend for or against using digital mammography or MRI instead of film mammography.

In Journal Watch Women's Health, Dr. Andrew Kaunitz says that because the updated guidelines recommend less screening, women may be confused or even outraged. He calls for consistent "frank discussions" with patients about the benefits and risks of screening mammography.

(The American College of Radiology has spoken out against these guideline changes.)

Chocolate Is Associated with Lower Mortality Following First Heart Attack

Amount of chocolate consumption was related inversely to cardiac-related mortality during an 8-year follow-up

Several studies have suggested that chocolate, perhaps in a process mediated by its antioxidant content, protects the heart (JW Gen Med Jul 10 2007 and JW Gen Med Sep 23 2003). A Swedish team identified 1169 nondiabetic patients who were hospitalized with initial nonfatal myocardial infarctions. Detailed food histories for the preceding 12 months were completed by 86% of patients; participants were followed for an additional 8 years.

Compared with patients who never ate chocolate, those who ate chocolate less than once monthly suffered 27% less cardiac-related mortality (after multivariate adjustments); risk was 44% lower for weekly chocolate eaters and 66% lower for those who ate chocolate two or more times weekly. Nonfatal adverse cardiac events, strokes, and total mortality, however, were not related clearly to chocolate consumption. Consuming other sweets (e.g., cookies, cakes, ice cream) had no relation to cardiac mortality.

Comment: The strengths of this study are its size and long-term follow-up. The main weakness is that chocolate consumption was assessed only once, during hospitalization for initial MIs, and not during follow-up. To me, the most interesting result of the study is that chocolate strongly protected against cardiac mortality but not against adverse cardiac events. The same finding has been reported for ω-3 fatty acid supplements, which suggests that the primary beneficial effect of both chocolate and ω-3 fatty acid supplements is in suppressing arrhythmias.

— Anthony L. Komaroff, MD

Published in Journal Watch General Medicine September 3, 2009