2. Section 1: Burden of diabetes The diabetes epidemic Burden of diabetes complications Association with major psychological distress/quality of life The burden of diabetes on healthcare systems

3. The diabetes epidemic Diabetes is an increasing healthcare epidemic throughout the world Global projections for the number of people with diabetes (20–79 age group), 2007–2025 (millions) IDF. Diabetes Atlas 3rd Edition - 2006 28.3 40.5 +43% 16.2 32.7 +102% 24.5 44.5 +81% 10.4 18.7 +80% 53.2 64.1 +21% 67.0 99.4 +48% 46.5 80.3 +73% Worldwide: 246 million people in 2007 380 million projected for 2025 55% increase Africa Eastern Mediterranean and Middle East Europe North America South and Central America South-East Asia Western Pacific World 246 380 +55% 2007: 2025: Increase:

4. China 2007: 4.3% – 39,810 2025: 5.6% – 59,270 The diabetes epidemic Diabetes prevalence in Asia is high and increasing Prevalence rates and numbers of adults with diabetes (1,000s) IDF. Diabetes Atlas 3rd Edition - 2006 Philippines 2007: 6.5% – 3,055 2025: 7.9% – 5,573 Korea 2007: 8.6% – 3,074 2025: 10.8% – 4,163 Thailand 2007: 7.2% – 3,162 2025: 8.9% – 4,660 Bangladesh 2007: 4.8% – 3,848 2025: 6.1% – 7,419 Indonesia 2007: 2% – 2,888 2025: 2.8% – 5,129 Malaysia 2007: 9.9% – 1,531 2025: 12.3% – 2,743 Australia 2007: 6.4% – 926 2025: 7.7% – 1,346 India 2007: 6.2% – 40,851 2025: 7.6% – 69,882

5. The diabetes epidemic Diabetes prevalence in the Middle East and Africa is high and increasing Prevalence rates and numbers of adults with diabetes (1,000s) IDF. Diabetes Atlas 3rd Edition - 2006 Algeria 2007: 7.3% – 1,475 2025: 8.9% – 2,528 Egypt 2007: 10.1% – 4,357 2025: 12.2% – 7,650 Pakistan 2007: 8.3% – 6,929 2025: 8.5% – 11,538 Iran 2007: 6% – 2,565 2025: 8.4% – 5,115 Morocco 2007: 7.1% – 1,360 2025: 9.1% – 2,396 Saudi Arabia 2007: 13.5% – 1,855 2025: 15.7% – 3,610 South Africa 2007: 4.5% – 1,213 2025: 4.4% – 1,279 Lebanon 2007: 7.4% – 167 2025: 9.1% – 267 Israël 2007: 7.8% – 337 2030: 8.5% – 495 Tunisia 2007: 4.8% – 317 2025: 6.2% – 535

6. The diabetes epidemic Diabetes prevalence in Latin America is high and increasing Prevalence rates and numbers of adults with diabetes (1,000s) IDF. Diabetes Atlas 3rd Edition – 2006 Mexico 2007: 9.4% – 6,116 2025: 12.2% – 10,811 Argentina 2007: 6% – 1,488 2025: 6.4% – 1,996 Brazil 2007: 5.8% – 6,913 2025: 11.4% – 17,627 Chile 2007: 5.9% – 645 2025: 6.9% – 945 Colombia 2007: 4.6% – 1,278 2025: 5.9% – 2,251 Peru 2007: 5.4% – 894 2025: 6.6% – 1,544 Venezuela 2007: 4.9% – 795 2025: 6% – 1,388

7. IRAN 3/6 MILLION DIABETIC --- 7/7 MILLION IGT IN 1387 BUSHER 8% DIABETIC----12% PREDIABETIC TEHRAN 7/2% DIABETIC----8/2% PREDIABETIC YAZD 14% DIABETIC- ZANJAN 4/3%DIABETIC----2/3% PREDIABETIC

8. The diabetes epidemic In developing countries, diabetes will affect people aged 45−65 years 1. Wild S et al. Diabetes Care 2004;27(5):1047–1053 Estimated number of people with diabetes (millions) Developed Countries Developing Countries Estimated number of people with diabetes (millions)

9. T2DM: 1 –About 90% of the diabetes population –Dual impairment: insulin deficiency & insulin resistance –No longer a disease of adults only –Obesity –Genetic link –15% of diabetic children aged 10-19 T1DM: 2 –5 to 10% of diabetes cases –Huge geographical variations of incidence rates: A 100-fold higher rate reported in Finland and Sardinia than China –50–60% of cases occur before the age of 16–18 years –Absolute insulin requirement –Autoimmune mediated 1. Stumvoll M. Lancet 2005;365:1333–1346 2. Daneman D. Lancet 2006;367:847–858 The diabetes epidemic T2DM accounts for the vast majority of diabetes mellitus cases

10. Diabetic Retinopathy Leading cause of blindness in adults 1,2 Diabetic Nephropathy Leading cause of end-stage renal disease 3,4 Cardiovascular Disease Stroke 2- to 4-fold increase in CV mortality and stroke 5 Diabetic Neuropathy Leading cause of non-traumatic lower extremity amputations 7,8 8/10 individuals with diabetes die from CV events 6 Burden of diabetes complications Diabetes is a lifelong condition associated with serious complications 1. UKPDS Group. Diabetes Res 1990;13:1–11. 2. Fong DS et al. Diabetes Care 2003;26(Suppl. 1):S99–S102. 3. The Hypertension in Diabetes Study Group. J Hypertens 1993;11:309–317. 4. Molitch ME et al. Diabetes Care 2003;26(Suppl. 1):S94–S98. 5. Kannel WB et al. Am Heart J 1990;120:672–676. 6. Gray RP & Yudkin JS. Cardiovascular disease in diabetes mellitus. In Textbook of Diabetes 2nd Edition, 1997. Blackwell Sciences. 7. King’s Fund. Counting the cost. The real impact of non-insulin dependent diabetes. London: British Diabetic Association, 1996. 8. Mayfield JA et al. Diabetes Care 2003;26(Suppl. 1):S78–S79

11. Burden of diabetes complications Individuals with diabetes are at increased risk of cardiovascular mortality 1. Adapted from: Lotufo P et al. Arch Intern Med 2001;161:242–247 Age-adjusted relative risk of death compared with men with no diabetes or CHD Relative risk of death

12. Burden of diabetes complications Diabetes is a leading cause of death worldwide Diabetes is the fifth leading cause of death after communicable diseases, cardiovascular disease, cancer and injuries 1. Roglic G et al. Diabetes Care 2005;28:2130–2135 All-cause deaths attributable to diabetes (%)

13. Association with major psychological distress/quality of life The physical, psychological and social effects of diabetes are inter-related 1. Polonsky WH. Diabetes Spectrum 2000;13:36–41 Physical Psychological & emotional Social Long-term complications: vision loss, kidney damage, heart disease, amputation Short-term complications: fatigue, sleep disturbance, infections, weight gain Symptoms: glucose control (HbA 1c ), hypo-/hyperglycemia & lifestyle changes Depression Anger Fear Persistent fatigue Exhaustion Helplessness Chronic frustration Changes in daily habits Relationships with family/friends suffer Social life affected

14. The burden of diabetes on healthcare systems In the US, cost of a person with diabetes is 2.4 higher than cost of a person without diabetes* Cost of diabetes in the US in 2002: $132 billion Direct and indirect costs: $91.8 and $39.8 billion, respectively *Compared with a non-diabetic individual: adjusted for age, sex, race/ethnicity 1. Hogan P et al. Diabetes Care 2003;26:917−932 Distribution of total direct healthcare costs

15. The burden of diabetes on healthcare systems High direct and indirect cost of diabetes in Latin America and the Caribbean Estimated costs in 25 countries: –Direct costs: $11 billion (18%) –Indirect costs: $54 billion (82%) 1. Barcelo A et al. Bulletin of the World Health Organization 2003;81:19–27 Distribution of total direct healthcare cost Contributors to the costs of diabetic complications Diabetes medications 44% Complications 24% Consultations 23% Hospitalization 9% Nephropathy 74% Neuropathy 3% Peripheral Vascular Disease 2% Cardiovascular Disease 10% Retinopathy 11% All costs are in year 2000 US$ values

16. The burden of diabetes on healthcare systems High cost of T2DM in Europe: CODE-2 Study Direct medical costs: €29 billion per year 1. Jonsson B. Diabetologia 2002;45:S5–S12 Distribution of overall costs for T2DM patients Ambulatory, 18% Other drugs 21% Hospitalization 54% Cardiovascular and lipid lowering, 42% Anti-infectives 2% OHAs 13% Insulin 11% All others 26% Distribution of overall drug costs for T2DM patients Costs expressed in 1999 values Antidiabetic drugs, 7% Gastrointestinal 6%

17. The burden of diabetes on healthcare systems Complications and hospitalizations substantially increase the cost of diabetes In patients with both micro and macrovascular complications: –The average cost per patient is increased 3.5-fold –Hospitalization costs are increased 5.5-fold 1. Williams R et al. Diabetologia 2002;45:S13–S17 1.7 x 2.0 x 3.5 x 2.1 x 3.1 x 5.5 x Effect of complications on the average cost per patient Effect of complications on hospitalization costs Cost impact factor

18. The burden of diabetes on healthcare systems Cost of diabetes represents a significant share of healthcare resources Medical expenditures for people with diabetes are 2–3 times higher than those without diabetes 1 Costs increase with progression of complications 2 Diabetes costs represent a significant share of total healthcare expenditures per country:* –Italy: 6.6%, Germany: 6.5%, Netherlands: 1.6% 3 –US: 11% 4 –Taiwan: 11.5% 5 –Israel: 6.9% (HMO budget; MHS) 6 *Costs attributable to diabetes – Costs incurred by people with diabetes would represent a higher percentage; e.g. 19% for US MHS: Maccabi Healthcare Services 1. Rubin RJ et al. J Clin Endocrinol Metab 1994;78:809A−809F 2. Brown JB et al. Arch Intern Med 1999;159:1873−1880 3. Jonsson B et al. Diabetologia 2002;45:S5−S12 4. Hogan P et al. Diabetes Care 2003;26:917−932 5. Lin T et al. Diabetes Res Clin Pract 2001;54(Suppl 1):43−46 6. Chodick G et al. Eur J Health Econ 2005;Vol 6(2):166−171

19. Burden of diabetes – summary (1) Diabetes is an increasing epidemic worldwide: 1 –By 2030 the number of people with diabetes globally will exceed 438 million 1 –In developing countries, it will affect people aged 45−65 years 1 Diabetes is a lifelong condition with devastating consequences: –8/10 persons with diabetes die from CV events 4 –The leading cause of blindness in adults 2,3 –The fifth leading cause of death worldwide 5 –A disease associated with major psychological distress 6 –A reduced quality of life 7 1.Wild S et al. Diabetes Care 2004;27(5):1047–1053 2.UKPDS Group. Diabetes Res 1990;13:1–11. 3.Fong DS et al. Diabetes Care 2003;26(Suppl. 1):S99–S102 4.Gray RP & Yudkin JS. Textbook of Diabetes 2nd Edition, 1997. Blackwell Sciences 5.Roglic G et al. Diabetes Care 2005;28:2130–2135 6.Skovlund S et al. Diabetes Spectrum 2005;18:136–142 7.Koopmanschap M. Diabetologia 2002;45:S18–S22

20. Burden of diabetes – summary (2) An increasing burden on healthcare systems: –Medical expenditures for people with diabetes are 2–3 times higher than those without diabetes 1 –Diabetes costs represent a significant share of total healthcare expenditures per country –Costs increase with progression of complications 2 Worsening glycemic control results in substantial cost increases: –For each 1% increase in HbA 1c above 6%, the costs of diabetes increase by approximately 4, 10, 20 and 30% 3 Costs of lost production are at least as high as direct costs 1 1. http://www.eatlas.idf.org/Costs_of_diabetes/ Last accessed 121206 – Diabetes Atlas second edition – IDFhttp://www.eatlas.idf.org/Costs_of_diabetes/ 2. Brown JB et al. Arch Intern Med 1999;159:1873−1880 3. Gilmer et al. Diabetes Care 1997;20(12):1847–1853