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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 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.

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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?

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Crude and Age-Adjusted Incidence of Diagnosed Diabetes per 1,000 Population Aged 1879 Years, United States, 19802010

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Projected Prevalence of Diabetes (Diagnosed or Undiagnosed) Under Scenarios of No further Increase Continued Increased Incidence Rate Boyle et al., Pop Health Metrics, 2010

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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

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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

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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

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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

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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

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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

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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

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The Burden of Diabetes, Heart Disease, and Stroke in Maine

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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

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Burden of Heart Disease, Stroke, and Related Risk Factors in Maine

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Dysglycemia Pre-diabetes Undiagnosed Diabetes Diabetes: Heart Disease And Stroke Untreated and / or Un-detected Risk Factors and Sub-clinical Disease

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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

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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?

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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

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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

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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.

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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

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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?

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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

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Where gaps remain, stimulate, support, and facilitate team-based prevention and care.

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Lancet, 2012

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Tricco et al., Lancet, 2012

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Develop and support effective models of self-management.

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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

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Building effective networks and clinical-community partnerships.

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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

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The National Diabetes Prevention Program: A Public-private partnership to systematically scale the translated model of the DPP.

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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

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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

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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)

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Frieden, Am J Public Health, 2009 Physical environment Food environment Social environment Economy and poverty Physical environment Food environment Social environment Economy and poverty

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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.

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Promising Targets for Population-Wide Food Policies to Influence Cardiometabolic Risk

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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.

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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.

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Personalized Risk-based Scores Patient Reported Measures Clinical Action Measures Measures that include resource use Can we develop smarter, more useful quality metrics?

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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.