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July 13, 2016

Diabetes: Defining Moment of a Crisis

Summary:

Unless a widespread education and intervention campaign on diabetes takes place, we are looking at a disaster.

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We are in the midst of a global public health crisis. The prevalence, growth and wide-scale complications as a result of diabetes have been called the defining moment in the field of public health. Unless a widespread education and intervention campaign takes place, we are looking at a disaster.

Currently, 30 million Americans, or roughly 10% of the U.S. population, have diabetes. It gets worse; more than 8 million of these people don’t even know they have it. In 2012, another 86 million Americans had what is referred to as “pre-diabetes,” up from 79 million in 2010. Without a major education and intervention effort, 33% of all Americans will have full-blown diabetes by 2030.

In the year 2000, the World Health Organization (WHO) estimated that 2.8% of the world population in all age groups would have diabetes — that was 171 million people. By 2030, WHO projects that 4.4% of the world population, or 366 million people, will have diabetes. What is also scary is that these estimates are most likely conservative because they assume that the obesity rate of the world population will remain constant. Excuse the pun, but fat chance of that. Obesity is a growing problem both in the U.S and worldwide, including third-world countries, and is a major risk factor for diabetes.

Jeff Dachis, CEO of One Drop, a diabetes self-care and technology company based in New York, recently stated at a HITLAB seminar held at Columbia University/Mailman School of Public Health, “Diabetes is hard, but it doesn’t have to be.” Although diabetes is a very serious health condition with a wide array of potential life threatening complications, Dachis says, “there is no reason a diabetic can’t live a perfectly normal, healthy life with proper diagnosis, treatment and enlightened self-care. Diabetes can be completely diagnosed and managed. ” He ought to know; he was diagnosed with Type 1, or juvenile, diabetes a few years ago in his late 40s but now is “really good at keeping my blood sugar within normal range 24/7.”That is the basic problem: A person with diabetes has too much glucose, or blood sugar.

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Diabetes is a group of diseases that affects how your body uses glucose, or blood sugar. Type 1 diabetes occurs when your immune system attacks and destroys insulin-producing cells in your pancreas. As a result, glucose builds up in the blood stream instead of being transported for energy to cells that make up muscles and tissues. Type 1 patients must rely on regular insulin shots to survive and avoid long-term complications. Insulin is vital to cell growth and lowers the amount of glucose needed by helping cells use it for energy. The exact cause is still unknown, but diabetes is thought to be a genetic susceptibility to unknown environmental factors. Type 1 can occur at any age but typically occurs in children and adolescents under age 19.

Type 2 occurs when your cells become resistant to the action of insulin and the body doesn’t use it well. The pancreas itself is not under attack, but it can’t make enough insulin to overcome the cells’ resistance. With Type 1 or 2, the result is the same: Glucose builds up in the blood stream. Type 1 tends to have more severe symptoms and acts more quickly.

Gestational diabetes occurs when pregnant women who never had diabetes end up with high glucose levels due to insulin resistance that develops during late pregnancy. If untreated, or poorly controlled, it can affect the health of the mother and the baby. In these cases, the baby is getting too much glucose and energy and can become what is known as a “fat” baby. This can cause health problems for the baby and a higher risk for obesity and Type 2 diabetes developing later in life. The CDC estimated in 2014 that 9.2% of all pregnancies in the U.S. involved gestational diabetes.

The direct health dangers of patients with diabetes include hyperglycemia (high blood sugar), diabetic ketoacidosis (when cells starving for energy break down fat in the body and cause significant weight loss) and hypoglycemia (or low blood sugar). Severe hypoglycemia can be fatal and is often referred to as “diabetic shock.” Extreme hyperglycemia can also occur with sky-high glucose levels, when the blood actually turns thick and syrupy — it is also extremely life-threatening. These cases are typically preceded by an illness of a patient with Type 2 diabetes.

Someone dies every six seconds in the world because of diabetes, and it is by far the most expensive disease to treat due to the enormous complications that may result. The American Diabetes Association (ADA) estimated that, in 2012 alone, $176 billion was spent on direct medical care and another $69 billion was spent on reduced workplace productivity, for an annual total of nearly $250 billion. The complications and co-morbidities because of the increased risk of health problems that result  can add another $500 billion per year to the U.S. healthcare system and lost productivity.

The increased risk of gradual long-term health complications because of diabetes is profound. There is an increased risk for cardiovascular disease (1.7x higher), heart attack (1.8x higher), stroke (1.5x higher), nerve damage or neuropathy to the lower limbs, serious foot infections that lead to amputations, kidney damage, eye damage from diabetic retinopathy (damage to blood vessels in the retina), cataracts and glaucoma (increased eye pressure) that may lead to blindness, various skin conditions and infections and erectile dysfunction in men. Overall, a person with diabetes (adjusted for age) has a 2.3x higher annual healthcare cost than someone without diabetes.

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Here are other alarming statistics from the 2014 National Diabetes Statistical Report prepared jointly by the ADA and CDC:

  • Diabetes was listed as the primary cause of kidney failure in 44% of all new cases in 2011.
  • 80% of patients who have diabetes for 20 years or more develop diabetic neuropathy.
  • 71% of patients with diabetes over age 18 have high blood pressure or are taking high BP medication.
  • 65% of patients over age 18 with diabetes have high cholesterol.
  • 60% of the 73,000 non-traumatic lower limb amputations in 2010 were patients with diabetes.
  • 29% of all patients with diabetes over age 40 develop diabetic retinopathy.
  • 26% of senior citizens 65 years or older have diabetes or 12 million people (both diagnosed and undiagnosed).
  • There are 1.3 million children, adolescents and adults in the U.S. with Type 1 diabetes.
  • Diabetes is the 7th leading cause of death (*underestimated because of co-morbidities caused by diabetes listed as cause of death. The ADA reports that only 35% to 40% of people who died with diabetes have it reported as the cause of death.)
  • 1.4 million new cases occur every year in U.S.
  • 282,000 ER visits for people 18 and over occurred in 2012 because of hypoglycemia.
  • In 2011, more than 228,000 people with kidney failure because of diabetes were living with kidney dialysis or a kidney transplant.

All these alarming facts and statistics can be mitigated with proper diagnosis, treatment, medications, correct use of insulin and self-care, such as diet and exercise. For example, it is estimated that 90% of all the blindness caused by diabetes could be prevented by proper self-care. But this is also the crux of the problem. Jeff Dachis and others in the field of public health are outspoken critics of the current state of diabetes disease management and our healthcare system in general, which is based on treating chronic conditions on a fee-for-service basis and not preventing them in the first place. “Chronic care is expensive, fragmented and inefficient; we need to transform the model to outcomes driven self- care,” Dachis stated at the HITLAB seminar series.

An alarming observation by Dachis is that “most diabetics are over-dosing on insulin.” The dangers of an insulin overdose are real and may be the result of misreading syringes or vials, taking the wrong type of insulin (rapid-acting, short-acting or long-term-acting) and taking insulin without eating — all of which can lead to lowering blood sugar to dangerous levels.

In a follow-up interview, I pressed Dachis for the root cause of so many problems in diabetes treatment today. What I learned is that the “one-size-fits-all” approach not only doesn’t work, it can be very dangerous. Dachis stated that the standard treatment is for the treating physician to prescribe a fixed dose of insulin, typically twice a day (morning and evening) to the patient and give her an “I will see you in three months. This approach is dumb, since patients should be checking their glucose levels every three hours and not every three months, and can result in a dangerous insulin overdose.”

Each diabetic must manage his own blood glucose levels 24/7 through use of emerging technologies developed by new entrepreneurs in the field, such as One Drop. One Drop provides a whole package of self-care tools and real-time coaching to patients to transform diabetes care. When daily insulin injections are set with a standard dose, it does not reflect the needs of that patient at any given time.

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The dose and type of insulin taken should be directly related to what the person just ate, her current glucose levels, how much exercise she did that day, medications she is taking, etc. This way, the patient is maintaining a safe level of blood glucose at all times to prevent both hyperglycemia (too much glucose), which results in gradual long-term chronic conditions, and hypoglycemia (too little glucose), which can be immediately life-threatening. An injection of too much insulin, based on a daily fixed amount, can send a person into a state of hypoglycemia and result in many diabetes patients overdosing on insulin.

The One Drop diabetes self-care disease management model includes a free app for the patient (http://apple.co/1lWTvGk), a glucose testing kit, unlimited test strips, an adjustable daily carb ratio to insulin dose capability and customized individual coaching by certified diabetes counselors in a 24/7 chat room. This is part of the revolution that is taking place in healthcare in regard to self-care-utilizing emerging technologies, the internet and mobile apps. Patients can learn how to best control their glucose levels from their own data and from 40 million data points, to learn what others with similar conditions are doing successfully. The One Drop App is free to use. The entire kit and self-care program with 24/7 coaching comes with a monthly subscription fee that can be paid by the health insurer, the employer or the individual patient. The entire goal is to provide these technologies and self-care model at no cost to the patient.

One major health insurer has now enrolled and is co-branding the One Drop self-care program. The insurer has put its own medical nurse case managers on the system as part of the diabetes disease management program. For more information, contact One Drop at http://onedrop.today.

It is all about the math. People with diabetes “must count the carbs.” Glucose levels need to be monitored in real time, 24/7. Dachis noted that people with diabetes should “think of themselves as a regulator, just like setting the thermostat at 70 at home year-round.”  Insulin is a deadly drug. It can kill you. It can’t be taken orally because the stomach’s enzymes would interfere, so it must be injected with a fine needle or insulin pump. That is why we need to empower people to use the internet, mobile apps and technologies, as well as use a preventive self-care model and steer them away from “the sick system” of chronic care.

For people with diabetes who don’t think they have the time to monitor their glucose levels, think again. Waiting for the complications is a very bad idea. For the eight million people with clinical diabetes who don’t know it, it is time to get diagnosed and treated now.

For the 86-plus million Americans with pre-diabetes who are a high risk of Type 2 diabetes, you need to get tested and learn how to prevent the onset of the disease. People at high risk of diabetes include those with a family history, who are overweight, who have sedentary lifestyles, who have high cholesterol and who have high blood pressure or cardiovascular disease.

The good news is that diabetes can be diagnosed, treated and controlled with proper diet, exercise and medications. People with diabetes can live normal, healthy, long lives with a proper self-care regiment. The bad news is that this global public health crisis is going to get a lot worse, affecting tens of millions of people in the U.S and around the world before it gets better, unless an extensive call to action takes place.

A revolution is coming — just like after the Boston Tea party — in the form of day-to-day acknowledgment and empowering people to use apps, wear sensors and receive real-time telemetrics as part of a power shift from doctor to patient.

One Drop is in the process of conducting clinical outcomes studies and hopes to have its study published later this year.

This article is dedicated to my dear friend Scott Sandor, who we lost to a diabetic coma at the tragic young age of 40.

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About the Author

Dan Miller is president of Daniel R. Miller, MPH Consulting. He specializes in healthcare-cost containment, absence-management best practices (STD, LTD, FMLA and workers’ comp), integrated disability management and workers’ compensation managed care.

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