The Burden of the Complicated Type 2 Diabetes Patient in China. White Paper

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1 White Paper Catalysts driving successful decisions in life sciences. The Burden of the Complicated Type 2 Diabetes Patient in China by Marco DiBonaventura, Ph.D. Director, Health Economics and Outcomes Research March 2012

2 The Burden of the Complicated Type 2 Diabetes Patient in China 2 The prevalence of diabetes in China is actually expected to surpass that of the United States by 2030 (11.8% in the United States compared with Diabetes Prevalence Table A. Prevalence of Diabetes Among Different Regions of the World in 2011 The Epidemiology of Diabetes Worldwide Type 2 diabetes is considered a worldwide epidemic. According to the International Diabetes Federation, it is estimated that 8.3% of the global adult population between the ages of 20 and 79 currently have diabetes. 1 However, as one might expect, there are substantial variations among regions with respect to the prevalence of diabetes. The lowest prevalence is observed in Africa (3.80%), whereas the highest is observed in North America (11.72%) (see Table A). On a regional level, these rates are expected to rise fairly uniformly in the decades to come. Yet, when looking at individual countries, the rates of change can be quite different. Table B lists the countries that are estimated to have the highest increases in the number of people with diabetes by China, with 39.7 million more adults with diabetes expected in 2030 than in 2011, is second only to India (39.9 million). However, the change in prevalence, from 9.29% to 12.10% (an increase in 2.80%), will actually be greater in China than in India, the latter of which is only expected into increase its prevalence figure by 1.63%. The Prevalence of the Complicated Diabetes Patient Despite such large numbers of patients with diabetes in China, an overwhelming number of them are unaware that they have the condition. Using data from the China 2010 National Health and Wellness Survey (NHWS), an annual self-reported patient survey representative of the urban China population Adults Aged (in 1,000s) Adults with Diabetes Aged (in 1,000s) Africa 3.80% 386,928 14,722 Europe 8.08% 653,233 52,771 Middle East/North Africa 9.15% 356,438 32,603 North America 11.72% 321,968 37,737 South America 8.68% 289,539 25,134 Southeast Asia 8.34% 856,282 71,407 Western Pacific 8.54% 1,544, ,896 Source: International Diabetes Federation, (n=19,954), a mere 3.05% of patients report having been diagnosed with type 2 diabetes, suggesting only a third of patients (even in urban areas of the country) with diabetes are given a diagnosis. This is consistent with other studies, which have also shown only a third of patients with diabetes actually receive a diagnosis. 2-3 Given prevailing stereotypes of the United States and its obesity epidemic, it may be surprising that the diabetes prevalence rates between the two countries are so close (10.9% in the United States and 9.3% in China). In fact, the prevalence of diabetes in China is actually expected to surpass that of the United States by 2030 (11.8% in the United States compared with 12.1% in China). However, despite the general similarities in prevalence and anticipated prevalence changes, the characteristics of patients in the United States and China can be quite distinct. For example, prior research has suggested strong links among hypertension, obesity and diabetes. Indeed, patients with diabetes who have these comorbidities are often referred to as complicated diabetes patients given the additional challenge of their disease management and their increased risk for both microvascular and macrovascular complications. The frequency of diabetes patients being complicated diabetes patients differs dramatically between China and the United States. For the sake of making relevant crosscountry comparisons, the NHWS datasets were used. The NHWS is a patient-reported survey conducted annually in the United States, France, Germany, Italy, Spain, the

3 The Burden of the Complicated Type 2 Diabetes Patient in China 3 Rank Country minus 2011 T2D Population* Prevalence T2D Population* Prevalence Δ in T2D Population* Δ in T2D Prevalence 1 India % % % 2 China % % % 3 Bangladesh % % % 4 Brazil % % % 5 Mexico % % % 6 USA % % % 7 Pakistan % % % 8 Egypt % % % 9 Indonesia % % % 10 Iran % % % *In millions Source: International Diabetes Federation, Table B. Countries with the Greatest Increase in the Number of Patients with Diabetes, UK, urban China, Japan, Brazil and Russia. The survey is predominantly Internet-based, though respondents are also recruited offline in some countries (such as urban China) where the Internet penetration is limited in certain areas and among certain demographic strata. Within each country, recruitment to participate in the NHWS is conducted in such a way as to mimic each country s adult population (through the use of what is called a random stratified sampling framework). This ensures that the final samples of each country are demographically representative in order to generalize to the total adult population. The NHWS in the United States includes 75,000 respondents per year. As presented at The Obesity Society conference, nearly half of all patients with type 2 diabetes concomitantly report being hypertensive and are also obese based on their body mass index levels (see Figure A).4 Only 14% of patients with type 2 diabetes were neither hypertensive nor obese. The pattern is dramatically different in urban China. Analyses of the urban China NHWS revealed that only 8% of patients with type 2 diabetes are both hypertensive and obese (using the lower BMI standard for obesity for Asian populations as recommended by the World Health Organization5). Over half were neither hypertensive nor obese (see Figure B). The Burden of the Complicated Diabetes Patient Figure A. The Prevalence of Diabetes- Related Comorbidities Among Patients in the United States Figure B. The Prevalence of Diabetes- Related Comorbidities Among Patients in China Although the frequency of complicated diabetes patients is much lower in China than in the United States, the effect of concomitant obesity and hypertension on health outcomes can be just as profound. The NHWS assesses health-related quality of life using the Short Form 12 instrument, which provides both a mental component summary (MCS) and a physical component summary (PCS) score; both scores vary from 0 to 100, with higher scores indicating better quality of life and 50 representing the population average.

4 The Burden of the Complicated Type 2 Diabetes Patient in China 4 Although the frequency of complicated diabetes patients is much lower in China than in the United States, the effect of concomitant obesity and hypertension on health outcomes can be just as profound. As shown in Figure C, type 2 diabetes patients tend to have worse MCS and PCS scores than the general population (i.e., means lower than 50) even if they are neither obese nor hypertensive. However, the presence of these comorbidities is associated with a significant drop in health-related quality of life, particularly for PCS. Not surprisingly, being both obese and hypertensive was associated with the largest drop of all. In fact, the PCS decrement for these complicated patients was greater than the sum of its parts. Interestingly, the pattern is less dramatic in China. Certainly the presence of comorbidities was associated with a drop in both MCS and PCS, but not nearly as much as in the United States (see Figure D). However, the pattern from an economic perspective is very different. As presented previously at The Obesity Society conference, there were no differences in resource use events in the United States when comparing across the different comorbidity groups. Even the complicated diabetes patients did not have significantly more physician visits, emergency room visits, or hospitalizations than their non-complicated counterparts. However, in China these comorbidities had a dramatic effect on the number of resource use events. The presence of hypertension and obesity, in isolation, was associated with increased direct economic costs through additional healthcare resource use. However, the complicated diabetes patients were the highest of all. Policy Implications These results provide a sobering picture for China. Over the next 20 years, an additional 40 million adults will have type 2 diabetes, surpassing the overall prevalence rate of the United States. Yet, it may not just be the number of patients but the patient characteristics themselves that is concerning. Nearly half of type 2 diabetes patients in the United States have both hypertension and are obese, and only a small fraction have neither. This pattern is reversed in China. However, given the increasing Westernization and its associated sedentary lifestyle, it is expected that the mix of comorbidities among type 2 diabetes patients in China is not sustainable and will begin to look more like the United States. This shift in the profile of the diabetes patient will have profound economic implications. Patients who are obese and have hypertension have double the number of physician visits and five times the number of hospitalizations and ER visits than patients with type 2 diabetes without these comorbidities. To address these changes in diabetes epidemiology and its associated economic consequences, a more efficient allocation of resources may be necessary. Where possible, Figure C. The Health-Related Quality of Life of Diabetes Patients with Various Comorbidities in the United States Figure D. The Health-Related Quality of Life of Diabetes Patients with Various Comorbidities in China Figure D. The Health-Related Quality of Life of Diabetes Patients with Various Comorbidities in China

5 The Burden of the Complicated Type 2 Diabetes Patient in China 5 Access to current effective treatments will need to be improved, as should the path for innovative future treatments. population-level interventions and healthcare initiatives should be implemented to reduce the precursors to diabetes and comorbidities such as hypertension and obesity that, although damaging in their own right, can further exacerbate the effects of diabetes. However, such changes cannot eliminate diabetes, and improved management of those with the condition is necessary. Access to current effective treatments will need to be improved, as should the path for innovative future treatments. It is also important to emphasize the need for improved patient education. Although the health outcomes discussed here were focused on patients who had been diagnosed, it has been estimated that only a third of patients with type 2 diabetes currently receive a diagnosis. These patients are undoubtedly improperly managed, which could place an additional drain on societal costs, particularly if their lack of glycemic control leads to complications. As healthcare access improves in China, greater emphasis should be placed on developing and refining risk algorithms relevant for the Chinese population to understand those most at risk. These patients should be tested and closely monitored to minimize the number of patients in China with diabetes who go undiagnosed. References 1. International Diabetes Federation. IDF Diabetes Atlas 5th Edition. Accessed February 19, 2012: diabetesatlas/5e/ 2. Dong Y et al. Prevalence of type 2 diabetes in urban and rural Chinese populations in Qingdao, China. Diabet Med 2005; 22: Wong KC, Wang Z. Prevalence of type 2 diabetes mellitus of Chinese populations in Mainland China, Hong Kong, and Taiwan. Diabetes Res Clin Pract 2006; 73: DiBonaventura MD, Krishnarajah G, Pollack M, Wagner J, Balar B, Graham J, Bell K. The combined effects of obesity and hypertension on the quality of life, work productivity and activity impairment of type 2 diabetes patients. The Obesity Society, San Diego, CA. October World Health Organization. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 2004; 363: It also will be particularly important to utilize available data to monitor changes in epidemiology, patient education, and both health-related quality of life and economic outcomes. Through regular analysis of available data sources, interventions can be better designed (such as developing current risk algorithms), and the success of attempted interventions can be quantified. Populationlevel data will be crucial to establish, and change if necessary, healthcare priorities to mitigate the societal burden of diabetes in China.

6 The Burden of the Complicated Type 2 Diabetes Patient in China 6 For more information, please visit About Kantar Health Kantar Health is a global, evidence-based decision support partner to the world s leading pharmaceutical, biotech, device and diagnostic companies. Our 700+ staff act as catalysts, working closely with customers to drive distinctive decision-making that help them prioritize product development and portfolios, differentiate their brands and ensure product profitability after launch. We are unique in that we bring together clinical, medical and methodological expertise, commercial/ marketing know-how and proprietary data. It is this rare combination, together with our unparalleled stakeholder reach, that enables us to mobilize incisive, imaginative and timely ROI-driven solutions, empowering clients to deliver better healthcare options to their customers. About the author Marco DiBonaventure, Ph.D. Marco DiBonaventura, Ph.D., is Vice President, Health Outcomes, within the Health Outcomes Practice at Kantar Health. His role includes overseeing the global operations of the Health Outcomes and Analytical functions, which are responsible for the design, implementation, data management, analysis, report writing, and scientific dissemination of research projects. Dr. DiBonaventura received his Ph.D. in social/ health psychology from Rutgers University where he also taught statistics courses for the Department of Psychology. With staff in over 40 countries, we excel at solving technically or logistically challenging projects around the world and across the product lifecycle, combining on-the-ground know-how and global and national proprietary data to quickly identify value drivers. As part of WPP, we can also incorporate highly innovative thinking from outside the industry into our solutions.

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