diabetes: the hidden pandemic and its impact on Poland

diabetes: the hidden pandemic and its impact on Poland Honorary patronage

Diabetes is a social epidemic, which is on the rise. Globally, every 5 seconds someone is diagnosed with diabetes and every 10 seconds someone dies from diabetes complications. a major disease representing a significant burden across the EU. European Parliament, 2006 285 million people worldwide are suffering from diabetes reaching 438 million by 2030. International Diabetes Federation, 2009 It will not be easy, said Professor Mbanya, but it is a battle that we will all have to fight. Our choice is simple. Either we spend all our time mopping the floor, or we get up and turn off the tap. IDF President Jean Claude Mbanya, Montreal, Canada, 2009 There is still much to do in Poland to fight the pandemic of diabetes. But we can not stop working to minimize the consequences. Prof Krzysztof Strojek MD PhD, Warsaw, Polish Parliament, 2009 Diabetes has spun out of control. If we do not stop the current growth rate of illness, in 2030 the total number of patients will exceed 438 million far more people than all currently residing in North America. Prof Władysław Grzeszczak MD PhD, Warsaw, Polish Parliament, 2009 Diabetes is one of the biggest health problems of modern times, in terms of healthcare, society and economy. Leszek Czupryniak MD PhD, Warsaw, World Diabetes Day, 2009 2

Diabetes: a global problem, a national problem In Poland: About 2.5 million people have diabetes, over 750 000 of them are unaware of their illness and do not receive treatment for this reason. Every second person who has diabetes suffers from a coronary heart disease. Diabetes is the most common reason for kidney failure. Chronic dialises programmes permanently treat over 3 000 diabetes patients. 14 000 amputations are carried out every year amongst patients who have diabetes. It is estimated that in 2010 diabetes will cause over 29 000 deaths. 3

The challenge of a pandemic in 2010, it has been estimated that 285 million people worldwide have diabetes, representing 6.6% of the population aged 20-79. This number is expected to reach 438 million by 2030 1 5

The growth of diabetes, and what s driving it Diabetes is increasing so severely that healthcare systems will soon be struggling to cope. Increasing childhood obesity worldwide is to diabetes and chronic disease what melting glaciers are to climate change, a warning signal of times to come. Diabetes is increasing at alarming rates worldwide. The number of people being diagnosed with diabetes is increasing, and they are living longer, which leads to a rapidly rising prevalence. The International Diabetes Federation (IDF) estimates that in 2010 285 million people worldwide have diabetes, representing 6.6% of the population aged 20-79. This number is expected to reach 438 million by 2030, or 7.3% of the world s adult population 2. Meanwhile a high proportion of people with diabetes remain undiagnosed or are diagnosed too late to be able to manage the disease in a way which avoids the costly complications associated with it. The rapid increase is being fuelled by an ageing population and by increasingly unhealthy lifestyles with poor diet and dropping levels of exercise. The effect of unhealthy lifestyles is increasing obesity (defined as a body mass index (BMI) in excess of 30 kg/m 2 ) and this greatly increases the risk of an individual developing type 2 diabetes. There is no cure for diabetes, despite ongoing efforts, but the burden can be effectively managed, and the risk factors can be reduced. Meeting the challenge of diabetes may not be simple but it is achievable with engagement from a wide range of parties and clear information to show the way. Obesity in Poland 3, 4 Body mass index and risk of type 2 diabetes 5 50% 40% 30% 20% 10% Relative risk 40% 35% 30% 25% 20% 15% 10% 5% 6 0 normal weight overweight General Polish population Type 2 Diabetes population in Poland obese 0 < 23.0 23.0-24.9 25.0-29.9 30.0-34.9 > 35.0 BMI [kg/m 2 ]

Over 2.5 million people suffer from diabetes in Poland (6.54% of the population). However, in 30% the illness remains to be diagnosed. 6 This means that over 750 000 people who have diabetes are not being treated for the disease. By 2030 it is estimated that there will be 3.2 million people with diabetes in Poland. 7 7

Diabetes epidemiology in Poland The prevalence of diabetes increases with age. More than 20% people over the age of 60 suffer from diabetes and as much again live with impaired glucose tolerance (IGT). Prevalence of diabetes (known and unknown) and impaired glucose tolerance in relation to age 8 25% 20% 15% 10% 5% 0 < 39 40-49 50-59 > 60 New diabetes Known diabetes Impaired glucose tolerance age 8 Population of patients Diabetes prevalence, diagnosed, undiagnosed, total 9 0 0.5 1 1.5 2 2.5 3 Undiagnosed Diagnosed millions

The impact of diabetes people with diabetes need medical treatment for life, and have a significantly increased risk of suffering serious complications, including heart attack, stroke, kidney failure, blindness and ulcers leading to foot amputation 10

11

What is diabetes? Diabetes is a chronic, debilitating disease which requires life-long treatment and predisposes to many serious, costly complications. Diabetes is a chronic disease affecting how the body is able to process glucose mainly from sweet or starchy foods. It has two main forms, called type 1 and type 2 diabetes, people with either type need medical treatment for life, and have a significantly increased risk of suffering serious complications, including heart attack, stroke, kidney failure, blindness and ulcers leading to foot amputation. In type 1 diabetes, the pancreas is unable to produce any insulin (insulin being a hormone enabling glucose to be used in the body s cells to release energy). Type 1 diabetes is treated by insulin injections and by careful balance of diet (which provides glucose) and exercise (which uses it up). If the level of blood glucose falls too low (e.g. due to an inappropriately high insulin dose), it can lead to unconsciousness. If the blood glucose level remains too high because of lack of insulin in the bloodstream, the body uses fat reserves instead of glucose as an energy source; giving rise to the release of toxic ketones and acids, which can lead to coma and death. In type 2 diabetes, the pancreas produces only a limited amount of insulin, and what it does produce fails to work properly. Type 2 diabetes can initially be controlled by a healthy diet, weight loss and increased physical activity. Most people who have type 2 diabetes will require pharmacological treatment in order to stimulate the production of an additional amount of insulin, to improve the use of available insulin, or to slow the rate of glucose absorption from the digestive system. People with type 2 diabetes can (and frequently will) also need insulin treatment. Why don t we hear more about it? Despite its rapidly growing prevalence, and the escalating costs of treating the disease, diabetes does not receive the urgent attention that it should. It remains seriously under-reported, partly because many people with type 2 diabetes do not realize they have it and do not seek help for what they see as minor symptoms until they have been established for years. Diabetes often fails to be recorded as a cause of death, where the main reason may have been one of the typical diabetes complications such as heart attack, stroke or kidney failure. What does diabetes mean to the individual? A diagnosis of diabetes means that managing the disease has to become a part of that person s life; as yet it has no cure. The person with diabetes has to manage the balance between diet, medication and exercise on a daily basis. This presents many problems and often leads to depression, so it is important that people with diabetes have access to full and accurate information, training in the practical skills they need, and psychosocial support to help them achieve control and confidence. 12

Complications: Diabetes A chronic disease where blood glucose is too high, either because insulin is not produced or is insufficient. Blindness Risk: Major cause of adult blindness. Diabetes is a leading cause of blindness. Effective treatment: Reduces serious deterioration by more than a third. Symptoms Tiredness, sommnolence weight loss, increased thirst, passing a lot of urine, skin, urinary and genital infections, blurred vision. Stroke Risk: Up to 4 times as likely. Effective treatment: Reduces strokes by more than a third. Complications Serious complications can result from elevated blood glucose levels. However these are largely preventable, and can be delayed with early diagnosis and effective treatment. Heart attack Risk: Increased by 300%, and heart disease is up to 4 times as likely. Effective treatment: Leads to a reduction in heart failure of over 50%. Kidney Failure Risk: 3 times as likely as in the normal population. Effective treatment: Reduces the causes of kidney failure by more than a third. Effective treatment can reduce costly diabetes complications by up to 50% 13 Amputation Risk: A leading cause of non-traumatic lower-limb amputations. Effective treatment: Reduces the number of amputations by up to 80% and effective education reduces the number of foot ulcers.

Impact of diabetes globally 10 Diabetes and its complications are among the 5 most common causes of death in developed countries. According to the World Health Organization (WHO) chronic diseases (e.g. diabetes) are currently the cause of 60% of deaths annually worldwide, of which 80% occur in low- and middle-income countries. The number of diabetes deaths in the world is similar to the number dying from AIDS. The International Diabetes Federation (IDF) estimates that the proportion of patients in the adult population will increase from 9% to about 11% over the next 20 years. Health spending already represents a significant burden on public spending, which will increase as fiscal positions deteriorate and budgets come under pressure. For the second year in a row chronic diseases (diabetes among them) were assessed as one of the key global risks in a World Economic Forum report. 14

15

Impact of diabetes in Poland Diabetes is the most common cause of end stage renal disease among dialized patients in Poland. 11 Chronic dialises programmes permanently treat over 3 000 diabetes patients. 12 14 000 amputations are carried out in patients with diabetes every year. 13 Diabetes caused more than 6 300 deaths in Poland in 2007. 14 It is estimated that in 2010 diabetes will contribute to more than 29 000 deaths in Poland. 15 Our target is for people with diabetes to maintain their blood glucose level expressed as a percentage of hemoglobin bound to glucose (HbA 1c ) below 7% and for some groups of patients below 6.5%. 16 It is estimated that only 26% type 2 DM and less than 6% of type 1 DM patients achieve that targets. 17 Prevalence of diabetes complications among type 2 diabetic patients in Poland 18 retinopathy coronary heart disease nephropathy foot ulcer 0% 10% 20% 30% 40% 50% 16

The aims of diabetes treatment are defined in the Guidelines of the Diabetes Poland (Polish Diabetes Association), 19, 20 however in most patients these aims fail to be met. More than 70% of people suffering from type 2 diabetes in Poland have an HbA 1c level of over 7%, which means that they are at a high risk of developing micro- and macro-vascular complications. 21 77% of diabetic patients in Poland have increased blood pressure. 22 Blood pressure in patients with diabetes in Poland 19 Glycaemic control (HbA 1c ) in patients with type 2 diabetes in Poland 20 Systolic Blood Pressure HbA 1c Diastolic Blood Pressure 20 40 60 80 87 100 120 130 140 148 160 1% 2% 3% 4% 5% 6% 7% 8,07% 9% [mm Hg] 17 Mean blood pressure values23 Blood pressure level that should not be exceeded in patients with diabetes 24 Mean HbA1c level25 HbA level that should not be exceeded in 1c patients with diabetes 26

The costs of diabetes 27 Estimated global healthcare expenditures to treat and prevent diabetes and its complications are expected to total at least 376 billion USD in 2010. By 2030, this number is projected to exceed some 490 billion USD. Expressed in International Dollars (ID), which correct for differences in purchasing power, estimated global expenditures on diabetes will be at least 418 billion ID in 2010, and at least 561 billion ID in 2030. An estimated average of 703 USD (878 ID) per person will be spent on diabetes in 2010 globally. 19

The direct and indirect costs of diabetes As well as the enormous burden of suffering on the people who have it, diabetes places an enormous financial burden on them, their families, and on the economy. Evidence shows that diagnosing diabetes earlier and giving proper care actually reduces healthcare costs, because it reduces the chance or delays the development of costly complications. The costs of diabetes are very significant to both the individual and to the wider economy, and they are growing. Diabetes places an increasing burden on both, in direct costs of providing healthcare, and also in the indirect costs to society of lost productivity and social care, and financial losses to the individual. In many countries healthcare spending has risen faster than the growth in GDP per head of the population, and is taking an increasing share of the budgets of governments, employers and individuals. Treatment and strategies for prevention of diabetes worldwide in 2010 are estimated at 376 billion USD; rising to 490 billion USD by 2030. 28 Because of the growth in prevalence of non-communicable diseases in relation to infectious diseases, the increasing call on governments healthcare spending may cause critical competition for finance within the healthcare budget and between that and other public services. In countries with developed economies, up to three-quarters of the spending on diabetes care goes on treatment of its medical complications (like stroke and kidney failure) in hospitals. But in the developing world costs are distorted by the fact that many people cannot afford treatment and care and therefore do not get it, and that a very large part of economic activity takes place by bartering or unregistered trading. By preventing people with diabetes and their carers from working, the disease hits at the very core of their ability to make a living. Diabetes also results in indirect costs to the economy and the individual which can far exceed the costs of medical care. While people with diabetes are still able to work, it can however impact their ability to function to their full ability. It may involve them taking time off work through illness or because of hospital treatments, and eventually lead to early retirement through disability, and premature death. Those people, with their training and experience, are lost to the workforce. The cost of diabetes to national productivity is great, and proportionately greater for less well-developed economies. At the personal level, people with diabetes suffer lost earnings if they have to give up work. Their care may be provided by family members, who will also lose earnings. Most industrialised countries have organised medical insurance schemes and/or government supported healthcare services, so financial strain is not added to the physical suffering caused by diabetes, but in many developing countries, people with diabetes are obliged to pay for their own medical treatment costs. For example, up to 25% of household income in India is required to cover these costs, and 30% of poor households in China attribute their poverty to healthcare costs. Even in the USA as many as three million people with diabetes may have insufficient cover to provide reasonable healthcare, or none at all. How cost savings are possible In recent years much evidence has shown that enhanced treatment improves the long-term prospects of the person with diabetes, as it can delay the onset of complications. More effective treatment at an earlier stage will marginally increase the early costs, but will reduce costs in the longer term by delaying or preventing the hospital treatment needed for a wide range of complications. In addition, intensive treatment with several anti-diabetic drugs has been shown 20

to reduce diabetes-related mortality by 50% over 13 years. Computer simulation models can throw further light onto this question, allowing greater understanding of how best to influence treatment decisions. One simulation takes as its starting point the UKPDS (UK Prospective Diabetes Study 1998), which showed that there was a significant relationship between better control of blood glucose and reduced or delayed development of diabetes-related complications. The simulation used data from UK patients and the CORE Diabetes Model (CDM), an extensively validated health economics model developed to predict outcomes in patients with type 1 or type 2 diabetes. It has enabled calculations to be made on how the course of diabetes is improved by provision of effective care. The simulations outcomes show, that treatment to target (HbA 1c <7%) results in the delay of occurrence of minor and major complications, what implies a prolonged life expectancy of diabetes patients. The best results give a combination of effective treatment with an early detection, patients treated to target and diagnosed previous to occurrence of complications have a high probability of long life in a good health. Earlier detection and better treatment extends and improve lives Note: Earlier detection & treatment simulated as a patient population with no complication at diagnosis. Better treatment simulated as patient population treated to target of HbA1c =7.0%. 29 Age at diagnosis Minor complications Major complications Baseline (HbA 1c = 9.1%) 52 60-62 66-68 68 Minor complications Major complications Better treatment (HbA 1c = 7.0%) 52 62-64 68-70 70 25-35%* Minor complications 25-60%* Major complications Earlier detection & better treatment 52 65-68 69-71 71 25-40%* 25-65%* * Average risk reducton. 21

Costs of diabetes treatment in Poland Treatment of diabetes in Poland accounts for about 828 million USD* per year. 30 According to IDF projections, in 2010, spending on diabetes in Europe will reach 105.5 billion USD, and by 2025 the average share of health care in the budget may exceed 10%. 31 In 2002, the average annual expenditure on treatment of one patient suffering from type 2 diabetes in Poland amounted to 805 USD and was 32, 33 nearly three times lower than in Western Europe. Poland is in 25th place (among 30 assessed countries) in the ranking of the Euro Consumer Diabetes Index 2008 in terms of quality of diabetes care. 34 Since 2002 there has been no study on the costs of treatment of diabetes and its complications in Poland. * Avarage exchange rate for the first 6 month of 2010 1 USD = 3.02 PLN 22

The cost of treating diabetes complications in Poland Economic analysis based on research results show that ensuring patient efficient therapy will lower the cost of diabetes treatment in Poland. Cost savings are possible in a Polish setting as well. The future effects of current treatment and lifetime treatment cost in Poland were estimated using the CORE Diabetes Model. The simulation contrasts two hypothetical cases: two men, Jan and Piotr, both diagnosed with diabetes when aged 53. Jan s, treatment for diabetes is managed through occasional visits to the doctor and his HbA 1c was lowered to the level of 8% (the average in the Polish population). On the basis of existing evidence on what usually happens to people with diabetes, Jan can expect 8-9 years before he suffers complications (at age 61-62), and his expected life span is 17 years from diagnosis (aged 70). In contrast, Piotr s treatment and further monitoring are given through regular consultations and best fitted treatment options, and his HbA 1c is maintained at the level set in the Polish Diabetic Guidelines. Although diagnosed at the same age as Jan, he can expect 13 years with a good quality of life before experiencing minor complications (at age 65-66), and has a life expectancy of 20 years (to age 73). Piotr will not only have a longer and healthier life but also the cost of his life long treatment will be 25% lower due to the prevention and delay of complications (despite higher treatment costs). As well as the effects on the individual person with diabetes, the costs of their treatment are a real problem for the Polish health care budget. More effective treatment, as received by Piotr, will cost more initially but give tighter control. As the largest part of the costs generated by diabetes is that of treating complications, Piotr s costs will actually be lower overall. Enhanced treatment like that offered to Piotr will cost slightly more at first due to increased medication costs. But because he will remain well for longer, he will not be troubled with the complications of diabetes so soon, or to such an extent as he would be with less effective treatment. Applying the enhanced treatment scenario to the whole Polish population, where the effects of the change take time to filter through, leads to a break-even point after only 6 years, and after that managing diabetes effectively gives an overall reduction in the costs of care. Changing treatment from a Jan s way to a Piotr s way makes it possible not only to prolong the life expectancy of Polish patients but also to generate savings for the Polish health care budget. There is therefore a sound economic basis for investing in managing diabetes well. In other words better treatment reduces costs. Better treatment reduces total healthcare costs in Poland 35 % 100 1,000 750 Return on investment in enhanced treatment (Poland s situation simulation) 36 Jan 50 Piotr Millions $ 500 250 23 0 Complication costs Management cost Implementation of anti diabetic medication 0 2010 2016 2030 Baseline Intervention

Diabetes policy It is necessary to discover the illness and to intervene at an early stage in order to achieve favourable results of treatment. The Global diabetes Policy In the European consumer ranking report concerning the quality of diabetes patient treatment, the European Consumer Diabetes Index 2008 states that early intervention has a favourable influence on the health of the patient and the health protection budget. An obvious correlation has been observed between treatment results, ease of access to basic health care and the quality of information availability for patients. The results of the report clearly indicate that the appropriate control of diabetes does not need to be expensive. The Euro Consumer Diabetes Index 2008 involves 27 EU member countries as well as Norway and Switzerland. The results concerning diabetes patient treatment were obtained from public statistical data and private research. The Diabetes Index assesses 26 indicators in 5 categories: Information, Law and Consumer Choice, Health Care Offers, Prevention, Access to Procedures and Treatment Results. Health Consumer Powerhouse has published recommendations of Diabetes Policy which were issued just after the publishing of the Euro Consumer Diabetes Index report. These are the main European recommendations: An improved prevention programme Countries, which deal with diabetes in the early stage of the illness are highly ranked in the Euro Consumer Diabetes Index. A need for greater transparency The current lack of data concerning diabetes care is limiting the improvement of this care. Only 5 of 29 assessed countries have national diabetes registers. Education improvement The education of diabetes patients is an important element on the road to more efficient diabetes treatment. The education of wide public opinion not to discriminate diabetes patients is equally important. Increasing the number of qualified personnel, especially in Eastern Europe. Qualified medical personnel and diabetology nurses specializing in diabetological care, treatment and complications which affect the foot or eyes, is key in the treatment and prevention of diabetes complications such as diabetes foot or retinopathy. Diabetes Policy in Poland 37 There are strong grounds for diabetology in Poland, however its further development requires a more precise and efficient reflection concerning research, organizational, and financial needs. It also requires complete access of doctor to specializations, creating diabetology specializations for nurses and social care employees, increasing national self-control and independent treatment by means of introducing modern treatment and working out integrated health care systems and diabetology prevention. Diabetes has not been included as a strategic priority of health care in Poland s National Health Programme 2007-2015. On top on this list are cancer, coronary diseases and mental illness. The national Health Programme, whose main aim is to improve the health and quality of life of patients as well as overcoming health care inequalities mentions diabetes in passing, calling for changes in dietary habits as one of the basic ways of fighting illnesses such as diabetes as well as early health care for patients at risk of diabetes complications. In May 2006 Poland accepted the programme for the Prevention and Treatment of Diabetes 2006-2008. In the following years, the Programme came into being as an element of preliminary piloting tasks, whose aims included preparations for the creation of a Patient Register (containing information about diabetes complications), as well as creating a register for children with diabetes. 24

25

Prevention works Up to 90% of cases of type 2 diabetes can be prevented and much of the suffering associated with the complications of diabetes can also be prevented. There is strong evidence that preventative measures have substantial positive effects throughout the type 2 diabetes journey. A range of interventions is needed. Stopping diabetes Primary prevention involves encouraging a healthy lifestyle, with a good, balanced diet and moderate exercise, such that any risk of developing diabetes is minimized and diagnosis of type 2 diabetes is not reached. It is about combating obesity through tackling sedentary western lifestyles. Stopping costly diabetes complications Secondary prevention involves identifying people with diabetes as early as possible and providing education on healthy lifestyle, and enhanced treatment support in order to prevent the development of complications. It needs close monitoring of the progress, and particularly of key indicators of the onset of complications, like retinopathy screening. Stopping diabetes Primary prevention Securing the necessary engagement for the complex web of support required to encourage members of the population at large to live more healthily may be politically and practically challenging, but it can be done and it can be effective. While measures aimed at the whole population may seem too large a challenge, individuals with risk factors or with pre-diabetes can be identified and intervention can prevent or delay the onset of diabetes. Recent studies 38, 39, 40 have concluded that screening for diabetes and pre-diabetes is cost-effective in the part of the population aged over 40, and early intervention as soon as pre-diabetes is detected produces significant savings in healthcare costs in the long term. Pre-diabetes is defined by the WHO as impaired glucose tolerance (IGT) or impaired fasting glucose (IFG) and is a condition in which blood glucose (blood sugar) levels are higher than normal but not high enough for a diagnosis of diabetes. Having pre diabetes puts you at higher risk of developing type 2 diabetes. If you have pre-diabetes, you are also at increased risk of developing cardiovascular disease. Prevention: What s the evidence? The Diabetes Prevention Programme (DPP) study (2002) 41, conducted at 27 sites through the US and involving 3,000 overweight or heavier patients, showed that people with pre-diabetes can prevent the development of type 2 diabetes through lifestyle modification by making changes in their diet and increasing their level of physical activity or medication. They may even be able to return their blood glucose levels to the normal range. Just 30 minutes a day of moderate physical activity, coupled with a 5-10% reduction in body weight, produced a 58% reduction in diabetes incidence while those on metformin (an oral diabetes treatment widely used soon after diagnosis) reduced diabetes incidence by 31% compared with placebo. Those participants aged 60 years and older reduced their risk by 71%. The Da Qing study in China (1997) 42, involving people with diabetes with a mean age of 45, showed that diet intervention alone was associated with a 31% reduction, while the exercise intervention alone showed a 46% reduction in the risk of developing type 2 diabetes during a 6-year follow-up period. The Finnish diabetes prevention study (2003) 43 involved over 500 overweight, middle-aged men at high risk of developing diabetes. After four years, those given an improved diet and increased physical activity showed a 58% reduction in diabetes incidence. In cases where 80% of diet, exercise and weight loss goals were met patients did not develop type 2 diabetes. The Indian Diabetes Prevention Programme (IDPP, 2006) 44 also examined whether the progression to diabetes could be influenced by interventions in lifestyle and with metformin treatment. The relative risk of 26

developing diabetes was reduced by 28.5% with lifestyle modifications and by 26.4% with metformin. Although certain groups are at higher risks of developing diabetes, these studies showed a significant reduction of diabetes incidence through lifestyle modification and medication, regardless of the ethnic background. Stopping costly diabetes complications Secondary prevention The UK Prospective Diabetes Study (UKPDS, 1998) showed conclusively that effective treatment of diabetes can greatly reduce diabetes complications such as heart attack (more than 50%), stroke (by more than a third) and serious deterioration of vision (by up to 33%). Effective treatment involves close monitoring and control of blood glucose levels, blood pressure and lipids (fats, such as cholesterol). The UKPDS established that the effect of managing more than one factor was greater than the combined effect of managing each factor individually. However, diabetes is a progressive disease. Even with effective management the disease progresses from year to year and treatment regimes need to be altered to maintain good control. While work to find a cure for diabetes continues, it is possible to reduce the effects of the disease greatly, which also reduces the cost, as shown above, and with patient and doctor working closely together they can together change diabetes, ensuring the person lives with, rather than suffers from the disease. Prevention an internationally agreed priority The United Nations and the European Union have both recognized the threat that growing diabetes prevalence poses as well as put the emphasis on preventative initiatives. UN Resolution 61/225 of 20 December 2006 encourages Member States to develop national policies for the prevention, treatment and care of diabetes in line with the sustainable development of their health care systems as outlined in internationally agreed development goals including the Millennium Development Goals. The European Parliament, in a written declaration of 2006 said that the Commission and Council should prioritize diabetes in the EU s new health strategy as a major disease representing a significant burden across the EU and a Council conclusion of 2006 said that diabetes is one of the major causes of death and premature death it is possible to prevent or delay the onset of type 2 diabetes [and] that urgent targeted action on diabetes and the underlying health determinants is needed to address the growing incidence and prevalence of disease as well as the rise in the direct and indirect costs thereof. In the face of preventable incidence, and preventable suffering, changing diabetes must be a priority. Risk of heart attack in relation to blood glucose and blood pressure 45 Risk of heart attack 50 40 30 20 10 0 8 150 7-8 140-150 6-7 130-140 <6 <130 Blood glucose (HbA 1c) Systolic blood pressure 27

What needs to change? Measure Collect information on as local a level as possible Share Publish this information and identify the best practices Improve Learn from the differences, exchange the best practices and implement them to improve outcomes for people with diabetes 28

29

The changing diabetes barometer initiative An innovative response to an urgent need Prevention works. This means that the growth in type 2 diabetes incidence can be slowed and the impact of the disease on individuals, healthcare systems and the economy can be reduced. Spreading best practice from primary prevention interventions to treatment regimes, requires measurement, sharing of this information, and improvement based on the adoption of best practices. Launched in November 2007, the Changing Diabetes Barometer initiative aims to improve the lives of people with diabetes and reduce costs caused by this progressive chronic disease. The initiative seeks to achieve these aims by inspiring the collection and sharing of important information on the size of the burden of diabetes, and the effectiveness of interventions to combat it. At its centre is a message to all involved in meeting the challenge of diabetes, a call to measure, share and improve. As illustrated elsewhere in this report, appropriate responses to the growing prevalence of diabetes are known, but ensuring universally high standards remains a challenge. Measuring and sharing will lead to healthy competition between healthcare professionals, between health systems and even between people with diabetes themselves, playing as they do a central role in effective diabetes care, which will in turn lead to improvements. The initiative argues that data must be collected to show the impact of varying efforts and approaches to reduce diabetes incidence, diagnose the disease early, and treat it effectively, reducing the incidence of diabetes related complications and early deaths. For a situation to be managed, it must be measured. At an international level the Changing Diabetes Barometer initiative collects success stories and monitors progress, inspiring the healthy competition which will lead to improved patient outcomes. At a national level the Changing Diabetes Barometer facilitates informed dialogue between stakeholders to bring about the conditions where such an exchange of best practice, based on clear evidence, can occur. Does collecting and sharing information make a difference? Examples in Sweden and Israel show that it does. Measure, share, improve Example cases Diabetes care and the extent to which it is recorded both vary significantly in different parts of the world. But early attempts in some countries to measure and record it are already showing links to significant improvements in diabetes care. The initiatives of two countries show what can be achieved through systematic recording and analysis of data. These examples of best practice are a source of insight on the different ways the problem can be tackled, the attitudes of participants and other interested parties, the difficulties encountered and the various solutions used to overcome them. Sweden The Swedish National Diabetes Register (NDR) was started in 1996 to provide the evidence for continuous quality assessment of diabetes care. Data on 17 aspects of health, lifestyle, biochemical measurements and complications are registered annually and now cover over 40% of the total number of people with diabetes in Sweden. 30

Data covering 1996-2005 gives a clear picture of improvement. For example, the average HbA 1c of people with type 2 diabetes fell from 7.4% in 1996 to 6.9% in 2005. Similar reductions were shown in average blood pressure levels. Such a reduction in HbA 1c would, according to the results of the UKPDS lead to a reduction of 4% in any complication of diabetes and of 8% in micro-vascular complications. Israel In Israel, diabetes treatment is provided by four health maintenance organizations (HMOs), of which the largest is Clalit Health Services. Clalit has operated the Diabetes in the Community Programme since 1995. When it began in 1995, 70 000 people within the Clalit Health Services were known to have diabetes. In 1996 a diabetes register was introduced in each of Clalit s 1,300 clinics; these were computerized by 2000 and all primary care physicians were invited to contribute data on their diabetes patients. The results for each clinic are compared regularly with the others. At the same time Clalit started a multidisciplinary programme of education and training for its medical staff, to show doctors and nurses how to back medical treatment with guidance for patients on lifestyle, diet and exercise. In the 12 years since the Clalit programme began, many more people have been diagnosed with diabetes in Israel. Healthcare professionals are now competing to produce the best outcomes and are seeking more frequent publication. The proportion of patients with HbA 1c over 9% has fallen progressively from 40% in 1995 to 14% in 2007. Meanwhile, Clalit calculates that improved treatment is leading to reduced overall healthcare costs per person with diabetes, and they estimate a payback period to recover initial investment in more effective care of 6-8 years. Improve 3 1 Measure 2 Share 31

Improve Glycaemic Control Programme in Poland The growing epidemic of diabetes and poor glycaemic control, resulting in insufficient prevention of serious complications have necessitated solutions that would effectively improve treatment outcomes while taking into consideration the problem of difficult access to specialist diabetics care and professional education. One indicator of good diabetes control is the level HbA 1c - the gold standard in treatment. In Poland, the regular testing of this parameter is carried out much too infrequently in diabetes treatment, even though specialists emphasize that reducing HbA 1c by just 1% reduces the risk of cerebral stroke by 5%, death by 12% and amputation by as much as 43%. According to international standards, HbA 1c levels in diabetic patients should not exceed 7%. In Poland, that level is exceeded in around 80% of patients. Unfortunately, the challenge here was the insufficient expertise of primary care doctors in intensifying diabetes control, and limited access to HbA 1c measurements. Principles of the Improve Glycaemic Control project In response to those needs, the Diabetes Poland (Polish Diabetes Association) and the College of Family Physicians in Poland in cooperation with Novo Nordisk under the changing diabetes global educational programme launched a training and educational initiative to improve glycaemic control. The Improve Glycaemic Control programme is the result of work of a group of Polish experts working under the patronage of the Diabetes Poland (Polish Diabetes Association), with representatives in the Global Task Force on Improve Glycaemic Control. The project based Dr. Teresa Koblik s shared care programme (Metabolic Diseases Department and Clinic, Collegium Medicum, Jagiellonian University, Cracow). The Improve Glycaemic Control Programme is a nationwide educational project, addressed to specialist doctors, primary care physicians, nurses and patients. The purpose of the programme is to improve the quality of life and treatment outcomes of diabetic patients in Poland. Thanks to a simple system and the involvement of a group of doctors, the programme helps monitor HbA 1c levels and other parameters important for controlling diabetes. The results are uploaded by diabetologists to the internet database www.poprawakontroliglikemii.pl to enable ongoing data reviews and conclusions. 32

The Improving Glycaemic Control Programme addresses one of the main reasons of unsatisfactory treatment outcomes, which is the failure to implement the Polish Diabets Association guidelines regarding the socalled shared care of diabetic patients by a family physician and a specialist. It is also designed to help family physicians who require ongoing support from specialists in carrying out modern diabetes treatment that includes the initiation of insulin therapy. Activities carried out as part of the Improving Glycaemic Control project so far. The Programme is being implemented since 2007 and enjoys strong interest of the medical community and patients. A number of educational activities were carried out on both national and local levels. A nationwide congress for first contact physicians was organized with the participation of diabetology specialists, as well as a number of local training conferences for trainers and workshops for general practitioners. The project involves the cooperation of first contact physicians and specialists, consulting diabetic patients as well as documenting and analyzing (on an ongoing basis) the data of patients covered by the programme. Recommendations This programme is a model example of continuous education in diabetes treatment. It is also a platform for discussing the controversies in diabetology and sharing of best practices. The programme s effects include improved communication with patients, as well as between physicians and diabetology specialists. In particular, the programme has enabled good cooperation between general practitioners and specialists. Teresa Koblik MD PhD, Metabolic Diseases Department and Clinic, Collegium Medicum, Jagiellonian University, Cracow. The knowledge and practical skills of general practitioners have increased in cooperation with the specialists. This expertise pertains to, in particular, the benefits of early intensification of therapy in context of preventing complications. The programme has enabled better access to modern treatment models and has enabled general practitioners to expand their skill set through telephone consultations with specialist colleagues. Wiesława Fabian MD PhD, College of Family Physicians in Poland. By mid 2010, 500 doctors and diabetology specialists had joined, as well as over 2.8 thousand General Practitioners (GP s). During this time over 40 000 HbA 1c denotations had been made. Fact and Figures Trainings for diabetologists of the train-the-trainer type: 70 meetings for almost 3000 participants. Workshops for GP s: 900 meetings throughout Poland. Joint health care for diabetes sufferers (cooperation between GP s and specialist doctors): the health care involved 30 thousand patients. Over 300 diabetology nurses were included in the project in which the education of patients and nurses from GP s outpatients clinics was carried out. 33

What can be done? with appropriate interventions the rapid rise of type 2 diabetes can be stopped, and people with diabetes can be helped to live with, rather than suffer from, their disease 34

35

Polish Diabetologists Declaration in Wisla Giving special status to issues of treatment of diabetes and not dissolving them in other specialties; Increasing the points for diabetes in the National Health Service scoring system and improving procedures for contract values for the treatment of diabetes; Introduction of centrally funded diabetes procedures; Introduction of the minimal number of hours of teaching lectures on the treatment of diabetes (20-30 in the period of medical studies), increasing the number of hours of exercises and strengthening the emphasis on training of diabetologists; Immediate introduction of reimbursement for modern drugs in such proportions as is in other specialties and other countries; More preventive activities, focused on preventing disease and its complications, which may dramatically reduce the cost of treating diabetes and reduce unwarranted expenditures, such as for the treatment of cardio-vascular complications, and improve the effectiveness of this treatment. 36 A fragment of the Wislanski Declaration of Polish Diabetologists, the Polish Diabetes Association, Poland, Vistula, 18th May 2006

We can change diabetes! We can prevent diabetes for most people We can control diabetes in those who are diagnosed We can prevent much of the suffering linked to diabetes We can help people with diabetes to live long, healthy lives But we need to act now 37

Novo Nordisk would like to thank the following experts for their involvement in collecting the professional scientific documents and their counselling: Leszek Czupryniak MD PhD Department of Internal Medicine and Diabetology, Medical University of Lodz Prof Władysław Grzeszczak MD PhD Department of Internal Medicine, Diabetology and Nephrology, Medical University of Silesia Prof Krzysztof Strojek MD PhD Department of Internal Medicine, Diabetology and Nephrology, Medical University of Silesia 38

References 1. IDF Atlas 2009 2. IDF Atlas 2009 3. Biela U. et al. Częstość występowania nadwagi i otyłości u kobiet i mężczyzn w wieku 20 74 lat. Wyniki programu WOBASZ. Kardiologia Polska 2005; 63: 6 (supl. 4) 4. Sieradzki J,Wyniki ogólnopolskie badania DINAMIC 2 (II). Diabet. Prakt. 2003; 2: 103-110 5. Hu F.B. et al. Diet, Lifestyle, and the Risk of Type 2 Diabetes Mellitus in Women. N Engl J Med. 2001; 345:790-797 6. Wittek A. et al. Prevalence of diabetes and Cardiovasular Risk Factors of industrial Area in Southern Poland. Exp. Clin. Endocrinol, Diabetes 2009; 117: 350 353 7. IDF Atlas 2009 8. Wittek A. et al. Prevalence of diabetes and Cardiovasular Risk Factors of industrial Area in Southern Poland. Exp Clin Endocrinol Diabetes 2009; 117: 9. 350 353 10. Wittek A. et al. Prevalence of diabetes and Cardiovasular Risk Factors of industrial Area in Southern Poland. Exp Clin Endocrinol, Diabetes 2009; 117: 350 353 11. A World Economic Forum Report, Global Risks 2009 and Global Risks 2010 Rutkowski B. Postępy w leczeniu nerkozastępczym w Polsce i na świecie. Przew Lek. 2010; 2: 64-69 12. Rutkowski B. Postępy w leczeniu nerkozastępczym w Polsce i na świecie. Przew Lek. 2010; 2: 64-69 13. www.stopacukrzycowa.com 14. Demographic Yearbook of Poland 2009, Central Statistical Office 15. IDF Atlas 2009 16. Diabetes Poland. Clinical Practice Recommendations 2010. Diabet. Prakt. 2010; 11: Sup A 17. Sieradzki J. et al. Badanie Pol-Diab. Część I. Analiza leczenia cukrzycy w Polsce. Diabet. Prakt.2006; 3: 8 15. 18. Kinalska I. et al. Koszty cukrzycy typu 2 w Polsce (badanie CODIP). Diabet. Prakt. 2004; 1: 1-8 19. Diabetes Poland. Clinical Practice Recommendations 2010. Diabet. Prakt. 2010; 11: Sup A 20. Sieradzki J. et al. Badanie Pol-Diab. Część I. Analiza leczenia cukrzycy w Polsce. Diabet. Prakt.2006; 3: 8 15. 21. Sieradzki J. et al. Badanie Pol-Diab. Część I. Analiza leczenia cukrzycy w Polsce. Diabet. Prakt.2006; 3: 8 15. 22. Wittek A. et al. Prevalence of diabetes and Cardiovasular Risk Factors of industrial Area in Southern Poland. Exp Clin EndocrinolDiabetes 2009; 117: 350 353 23. Wittek A. et al. Prevalence of diabetes and Cardiovasular Risk Factors of industrial Area in Southern Poland. Exp Clin Endocrinol, Diabetes 2009; 117: 350 353 24. Diabetes Poland. Clinical Practice Recommendations 2010. Diabet. Prakt. 2010; 11: Sup A 25. Sieradzki J. et al. Badanie Pol-Diab. Część I. Analiza leczenia cukrzycy w Polsce. Diabet. Prakt. 2006; 3: 8 15. 26. Diabetes Poland. Clinical Practice Recommendations 2010. Diabet. Prakt. 2010; 11: Sup A 27. IDF Atlas 2009 28. IDF Atlas 2009 29. Core/IMS based on newly diagnosed UKPDS cohort 30. Kawalec P. et al. Koszty leczenia cukrzycy typu 1 i 2 w Polsce. Diabet. Prakt. 2006; 5:287-294 31. IDF Atlas 2009 32. Kinalska I. et al. Koszty cukrzycy typu 2 w Polsce (badanie CODIP). Diabet. Prakt. 2004; 1: 1-8 33. Głogowski C. et al. Koszty cukrzycy typu 2 na świecie i w Polsce, Farmakoekonomika 4/2004. 34. Euro Consumer Diabetes Index 2008 35. CORE/IMS based on Polish data 36. CORE/IMS based on Polish data 37. Diabetes The Policy Puzzle: Is Europe Making Progress? 2008 IDF 38. Waugh N. et al. Screening for type 2 diabetes: literature review and economic modelling. Health Technology Assessment 2007; 11(17) 39. Colagiuri S. and Walker A.E. Using an economic model of diabetes to evaluate prevention and care strategies in Australia. Health Affairs 2008; 27(1): 256-268 40. Gillies C.L. et al. Different strategies for screening and prevention of type 2 diabetes in adults: cost effectiveness analysis. BMJ 2008; 336: 1180 41. Knowler W.C. et al.(diabetes Prevention Program Research Group) Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393-403. 42. Pan X.R. et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study. Diabetes Care 1997; 20: 537 544 43. Lindström J. et al. The Finnish Diabetes Prevention Study (DPS): lifestyle intervention and 3-year results on diet and physical activity. Diabetes Care 2003;26:3230 3236 44. Ramachandran A. et al. Indian Diabetes Prevention Programme (IDPP): the Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prervent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1). Diabetologia 2006;49:289 297 45. Stratton I.M. et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ 2000; 321 (7258): 405-412 39

Novo Nordisk is a company which is involved in the health care sector and is a global leader in diabetelogical care. Novo Nordisk holds a leading position in such medical fields as hemostatic disorders, growth hormone therapy and hormone replace therapy. Novo Nordisk, with its headquarters in Denmark, employs about 29 800 employees in 76 countries. Novo Nordisk has been in Poland since 1991 and belongs to the Eastern European Region, which embraces 17 countries. The company employs 160 people in Poland. More information can be found on www.novonordisk.pl DIA/78/09-10/12-12 40