Synergies in Prevention for Diabetes and Cardiovascular Disease: Why are we here together? Edward...
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Synergies in Prevention for Diabetes and Cardiovascular Disease: Why are we here together? Edward Gregg, PhD Division of Diabetes Translation Centers for
Synergies in Prevention for Diabetes and Cardiovascular
Disease: Why are we here together? Edward Gregg, PhD Division of
Diabetes Translation Centers for Disease Control and Prevention
Atlanta, GA The findings and conclusions of this presentation are
those of the presenter and do not necessarily represent views of
the Centers for Disease Control and Prevention.
Slide 2
Why are we here together ? (i.e., diabetes and CVD?) What are
the most effective, synergistic public health approaches for
diabetes and cardiovascular disease prevention and control? Why are
we here together ? (i.e., diabetes and CVD?) What are the most
effective, synergistic public health approaches for diabetes and
cardiovascular disease prevention and control?
Slide 3
Slide 4
Crude and Age-Adjusted Incidence of Diagnosed Diabetes per
1,000 Population Aged 1879 Years, United States, 19802010
Slide 5
Projected Prevalence of Diabetes (Diagnosed or Undiagnosed)
Under Scenarios of No further Increase Continued Increased
Incidence Rate Boyle et al., Pop Health Metrics, 2010
Slide 6
www.cdc.gov/diabetes County-Level Estimates of Diagnosed
Diabetes Among County-level County-Level Estimates of Diagnosed
Diabetes Among U.S. Adults Aged 20 Years: 2004 Percent
Slide 7
www.cdc.gov/diabetes County-level Estimates of Diagnosed
Diabetes among Adults aged 20 years: United States 2005 Percent
County-Level Estimates of Diagnosed Diabetes Among County-level
County-Level Estimates of Diagnosed Diabetes Among U.S. Adults Aged
20 Years: 2005
Slide 8
www.cdc.gov/diabetes County-level Estimates of Diagnosed
Diabetes among Adults aged 20 years: United States 2006 Percent
County-Level Estimates of Diagnosed Diabetes Among County-level
County-Level Estimates of Diagnosed Diabetes Among U.S. Adults Aged
20 Years: 2006
Slide 9
www.cdc.gov/diabetes County-level Estimates of Diagnosed
Diabetes among Adults aged 20 years: United States 2007 Percent
County-Level Estimates of Diagnosed Diabetes Among County-level
County-Level Estimates of Diagnosed Diabetes Among U.S. Adults Aged
20 Years: 2007
Slide 10
www.cdc.gov/diabetes County-level Estimates of Diagnosed
Diabetes among Adults aged 20 years: United States 2008 Percent
County-Level Estimates of Diagnosed Diabetes Among County-level
County-Level Estimates of Diagnosed Diabetes Among U.S. Adults Aged
20 Years: 2008
Slide 11
www.cdc.gov/diabetes County-level Estimates of Diagnosed
Diabetes among Adults aged 20 years: United States 2009 Percent
County-Level Estimates of Diagnosed Diabetes Among County-level
County-Level Estimates of Diagnosed Diabetes Among U.S. Adults Aged
20 Years: 2009
Slide 12
Heart Disease and Strokes: Leading Killers in the United States
Cause 1 of every 3 deaths More than 1 of 3 (83 million) U.S. adults
currently lives with one or more types of cardiovascular disease.
Over 2 million heart attacks and strokes each year $444 B in health
care costs and lost productivity Greatest contributor to racial
disparities in life expectancy Roger VL, et al. Circulation
2012;125:e2-e220 Heidenriech PA, et al. Circulation 2011;123:9334
12
Slide 13
Slide 14
Slide 15
The Burden of Diabetes, Heart Disease, and Stroke in Maine
Slide 16
Trends in Incidence of Diagnosed Diabetes among Adults, Maine,
1996 - 2010 The Burden of Diabetes in Maine Diabetes Surveillance
Report, Maine, 2012 National Diabetes Surveillance System,
www.cdc.gov/diabetes
Slide 17
Burden of Heart Disease, Stroke, and Related Risk Factors in
Maine
Slide 18
Dysglycemia Pre-diabetes Undiagnosed Diabetes Diabetes: Heart
Disease And Stroke Untreated and / or Un-detected Risk Factors and
Sub-clinical Disease
Slide 19
Primary Modifiable Risk Factors Diabetes Cardiovascular Disease
Central Obesity Physical Inactivity Sugared Beverages Hypertension
Unhealthy dietary fat Inadequate nuts, grains, fruits, vegetables
Smoking Very low birth weight Poor Sleep Depression Central Obesity
Physical Inactivity Sugared Beverages Hypertension Unhealthy
dietary fat Inadequate nuts, grains, fruits, vegetables Smoking
Very low birth weight Poor Sleep Depression Smoking High LDL
cholesterol Hypertension Physical Inactivity High Blood Glucose
Central Obesity Unhealthy dietary fat Excess salt intake Chronic
kidney disease Psychosocial Stress Very low birth weight Smoking
High LDL cholesterol Hypertension Physical Inactivity High Blood
Glucose Central Obesity Unhealthy dietary fat Excess salt intake
Chronic kidney disease Psychosocial Stress Very low birth
weight
Slide 20
Sources:1900 1978: NCHS Vital Statistics historical tabulated
date; 1979-2005: CDC Wonder. Deaths/100,000 from heart disease and
stroke, United States, 1900-2005. What can we learn from the
epidemiologic trends in chronic diseases and related risk
factors?
Slide 21
Trends in Annual Incidence of Diabetes Related Complications
Over 2 Decades Among U.S. Adults with Diabetes Year Cases per
10,000/year National Diabetes Surveillance System;
www.cdc.gov/diabetes;www.cdc.gov/diabetes
Slide 22
Physical inactivity Secondary preventive therapies Initial
treatments for heart attack or acute angina Treatments for heart
failure Revascularization for chronic angina HTN, statins
Cholesterol reduction Systolic BP reduction Smoking reduction
Clinical interventions = ~50% Risk factor reductions = ~50% BMI
increases Diabetes increases Clinical and Public Health Progress
Each Contributed About Half to the 50% Reduction in Heart Disease
Deaths, US, 19802000 Ford ES, et al. NEJM 2007;356(23):2388-97 HTN,
Hypertension BP, Blood pressure BMI, Body mass index 22
Slide 23
Greatest Improvements in targets for: Lipid Levels: 20.8 %
points Blood pressure: 11.7 % points Glycemic control: 9.4 % points
Remaining Concerns: 33 to 48% did not meet targets. No improvement
in tobacco. Only 14% met targets for all 4.
Slide 24
19901995200020052010 Relative Successes: Secondary Prevention
and Control of Risk Factors 19901995200020052010 Challenges in
Primary Prevention CVD Mortality MI, Stroke Diabetes Complications
Amputations Acute ESRD CVD Risk Factors HTN control Lipids Smoking
Preventive Care Diabetes Incidence Obesity Cardiometabolic risk in
youth General Trends in Secondary and Primary Prevention of
Cardiometabolic Disease Status Unclear: Hypertension Chronic Kidney
Disease Disparities in Vulnerable Groups
Slide 25
Why are we here together? (i.e., diabetes and CVD?) Were both
important. We share a large, common constituency. We share many,
common, highly modifiable risk factors. We both have some important
past successes. Evolving science points us toward some key
synergistic approaches. What are the most effective, synergistic
public health approaches for diabetes and cardiovascular disease
prevention and control? Why are we here together? (i.e., diabetes
and CVD?) Were both important. We share a large, common
constituency. We share many, common, highly modifiable risk
factors. We both have some important past successes. Evolving
science points us toward some key synergistic approaches. What are
the most effective, synergistic public health approaches for
diabetes and cardiovascular disease prevention and control?
Slide 26
Classic Public Health Avenues for Prevention of Cardiovascular
Disease BP control Lipid control Smoking Cessation Glycemic Control
Targeted screening Healthy Diet Physical activity Med Adherence
Smoking Cessation
Slide 27
Where gaps remain, stimulate, support, and facilitate
team-based prevention and care.
Slide 28
Lancet, 2012
Slide 29
Tricco et al., Lancet, 2012
Slide 30
Slide 31
Develop and support effective models of self-management.
Slide 32
Clinical Outcomes Health Status Quality of Life Small group
attention. Knowledge, skills, and ability. Active Collaboration
Problem solving Tailored to individual differences Ongoing Support
Behavioral Goal Setting Elements and Impact of Self-Management
Education for Diabetes and Hypertension Glycemic Control Blood
pressure control Healthy Behaviors Preventive Screening
Slide 33
Slide 34
Building effective networks and clinical-community
partnerships.
Slide 35
Community Clinic Total Population Pre-diabetesDiabetes
Complications Informed Population Strong Community Organizations
Partnership Zone Information Systems Decision Support Proactive
Practice Team Screening for High Risk Diagnosis of Prediabetes
Structured Lifestyle Programs Regular Glucose Monitoring Insurers
Employers Reimbursement Healthy Public Policy Supportive
Environments Informed, Activated Patient s The National Diabetes
Prevention Program A CommunityClinicPayerAgency Partnership
Model
Slide 36
The National Diabetes Prevention Program: A Public-private
partnership to systematically scale the translated model of the
DPP.
Slide 37
Slide 38
Overall Tate-(2005) Kramer-(2009) Aldana-(2005)
Estabrooks-(2008) Amundson-(2009) Whittemore-(2009) Kramer-(2010)
MCBride-(2008) Boltri-(2011) Mau-(2010) Faridi-(2010) Lay Community
Members Parikh-(2010) Vanderwood-(2010) Subtotal Kramer- (2009)
Subtotal Jaber-(2011) Bersoux-(2010) Kramer- (2010) (Year of
Publication) McTigue-(2009) Vadheim-(2010) Medical and Allied
Health Professionals Subtotal First Author- Matvienko-(2009)
Almeida-(2010) Siedel-(2008) Boltri-(2008) Electronic-Media
Assisted Davis-Smith-(2007) Pagoto-(2008) McTigue-(2009)
Ackerman-(2008) Katula-(2011) -4.60 (-19.10, 9.90) -3.99 (-5.16,
-2.83) -5.10 (-12.16, 1.96) -4.50 (-10.77, 1.77) -5.50 (-13.14,
2.14) -2.60 (-8.48, 3.28) -6.70 (-9.64, -3.76) -4.80 (-13.42, 3.82)
-6.60 (-15.81, 2.61) -4.10 (-10.57, 2.37) -0.85 (-3.79, 2.09) -1.50
(-3.34, 0.34) -1.60 (-4.34, 1.14) -4.30 (-10.96, 2.36) -7.90
(-10.06, -5.74) -4.20 (-7.62, -0.77) -2.20 (-6.32, 1.92) -3.15
(-5.46, -0.83) -5.70 (-11.58, 0.18) -2.90 (-7.60, 1.80) -5.60
(-15.20, 4.00) Change (95% CI) -4.80 (-9.90, 0.30) -8.60 (-15.46,
-1.74) -4.27 (-5.85, -2.70) Weight -6.10 (-15.51, 3.31) -1.60
(-2.38, -0.82) -5.10 (-11.18, 0.98) -0.50 (-5.40, 4.40) -4.60
(-8.32, -0.88) -4.70 (-10.97, 1.57) -6.00 (-14.62, 2.62) -7.40
(-11.71, -3.09) Favors InterventionNo intervention effect
0-15-10-5051015 Percentage weight change 26 studies of 3797 high
risk adults: Diverse settings: 12 community (recreation, faith) 11
health care Mean weight change: 4% Every 4 sessions attended: 1%
percentage point added weight loss Aggregate cost: ~ 1000 per
person Ali et al., Health Affairs, 2012
Slide 39
March 19, 2013 Over 1400 lifestyle coaches trained. Over 320
organizations awarded CDC recognition (pending) Five private
insurers and 280 self-funded employers covering program 6 National
CDC grantees Progress To-date for National Diabeters Prevention
Program
Slide 40
Effects of Weight Loss And/or Sodium Restriction on 4-year
Hypertension Incidence Among Overweight Individuals Aged 30-54 With
High-normal Blood Pressure (TOHP II Collaborative Research Group,
Arch Intern Med, 1997)
Slide 41
Frieden, Am J Public Health, 2009 Physical environment Food
environment Social environment Economy and poverty Physical
environment Food environment Social environment Economy and
poverty
Slide 42
Policy Options to Influence Cardiometabolic Risk Tobacco-free
and clean air legislation. Physical education in schools. Physical
activity in worksites. Incentives for healthier food options and
famers markets. Influence access to healthy foods and beverages in
public and educational settings. Sodium Reduction and trans fat
elimination. Food and Menu labeling Regulation of foods in public
areas. Community design for physical activity. Tobacco-free and
clean air legislation. Physical education in schools. Physical
activity in worksites. Incentives for healthier food options and
famers markets. Influence access to healthy foods and beverages in
public and educational settings. Sodium Reduction and trans fat
elimination. Food and Menu labeling Regulation of foods in public
areas. Community design for physical activity.
Slide 43
Promising Targets for Population-Wide Food Policies to
Influence Cardiometabolic Risk
Slide 44
Why are we here together? (i.e., diabetes and CVD?) What are
the most effective, synergistic public health approaches for
diabetes and cardiovascular disease prevention and control? Enhance
and support team-based care. Support effective models of
self-management. Develop and support effective, evidence-based
clinical-community partnerships. Creatively change our environment
to make prevention easier. Why are we here together? (i.e.,
diabetes and CVD?) What are the most effective, synergistic public
health approaches for diabetes and cardiovascular disease
prevention and control? Enhance and support team-based care.
Support effective models of self-management. Develop and support
effective, evidence-based clinical-community partnerships.
Creatively change our environment to make prevention easier.
Slide 45
Our Role in Public Health Population perspective. Link health
systems with communities and policies. Unified measurement and
strong evaluation to drive quality and action. Synergistic
interventions to improve efficiency and outcomes. Population
perspective. Link health systems with communities and policies.
Unified measurement and strong evaluation to drive quality and
action. Synergistic interventions to improve efficiency and
outcomes.
Slide 46
Personalized Risk-based Scores Patient Reported Measures
Clinical Action Measures Measures that include resource use Can we
develop smarter, more useful quality metrics?
Slide 47
What has worked in secondary prevention? Health Services: Acute
care and major medical interventions Acute care and major medical
interventions Diffusion of new science of risk factor management
Diffusion of new science of risk factor management Emphasis on
quality of care Emphasis on quality of care Health system
adaptation and CQI Health system adaptation and CQI Health
Promotion and Health Protection Improved education/awareness of
diabetes control. Improved education/awareness of diabetes control.
Improved CVD risk factor education and awareness. Improved CVD risk
factor education and awareness. Reduced Tobacco / tobacco
legislation Less directly atherogenic food supply Less directly
atherogenic food supply Legislation of diabetes care and supplies.
Health Services: Acute care and major medical interventions Acute
care and major medical interventions Diffusion of new science of
risk factor management Diffusion of new science of risk factor
management Emphasis on quality of care Emphasis on quality of care
Health system adaptation and CQI Health system adaptation and CQI
Health Promotion and Health Protection Improved education/awareness
of diabetes control. Improved education/awareness of diabetes
control. Improved CVD risk factor education and awareness. Improved
CVD risk factor education and awareness. Reduced Tobacco / tobacco
legislation Less directly atherogenic food supply Less directly
atherogenic food supply Legislation of diabetes care and
supplies.