Lifestyle Diseases





Taming the growing diabetes epidemic

Why the Middle East must act




The alarmingly high global prevalence of diabetes reflects the grim, devastating realities of this modern epidemic: today, over 380 million adults worldwide are living with diabetes, and about 180 million of these are undiagnosed. The truth is, diabetes has a far larger footprint than other diseases such as cancer (according to WHO, the global cancer incidence rate stands at 14 million): a staggering 8.3% of the world’s adult population currently has diabetes. Unfortunately, future estimates paint an even bleaker picture: based on data from the International Diabetes Federation (IDF), by 2035, the global prevalence rate of diabetes – among people aged 20-79 – will have risen more than 10%.

But here is the silver lining: while Type II diabetes, the most common form of diabetes, is a chronic, incurable and costly disease – it is also preventable.

An unrelenting challenge

In our part of the world, specifically, the number of diabetes cases is soaring at a rapid pace. That’s right: in the Middle East, an estimated 14.2 million people (10% of the adult population – one of the highest prevalence rates in the world) are affected by the disease. The fact is, diabetes rates are skyrocketing in the Middle East and it all boils down to poor nutrition, physical inactivity, and GDP growth. In the last two decades, Middle Eastern countries’ rapid growth in GDP has been matched by a stark increase in obesity and diabetes. In line with this, estimates by the IDF forecast that, between 2013 and 2035, the countries with the fastest-growing diabetes prevalence rate will be the United Arab Emirates, Oman, and Qatar (three out of the six GCC countries).

Type II diabetes is a progressive disease – one that carries a slew of far-reaching health implications. It doubles the risk of coronary heart disease in men, and quadruples it in women. In addition, people with diabetes are three times more likely to have a stroke. Diabetic retinopathy also accounts for 5% of all cases of blindness globally. And someone with diabetes is 25 times more likely to have a limb amputated than someone without diabetes. As a result of such complications, Type II diabetes can reduce a person’s life expectancy by up to 10 years. Remarkably, according to IDF data, in 2014, an estimated 5 million deaths were caused by diabetes and its related diseases.

Unsurprisingly, the economic burden of diabetes can send ripple effects through a country’s healthcare system. Last year, the cost of direct healthcare for diabetes and its complications amounted to around 11% of total healthcare costs worldwide. As stated in the report of the WISH Diabetes Forum 2015, there are also indirect costs of diabetes to consider, such as lost productivity, earlier retirement, and increased requirements for social support. And these are often higher than the direct costs. Interestingly, in the Middle East, a strong link exists between GDP growth, the prevalence of diabetes, and per person spending. On average, the increase in diabetes-related healthcare costs per person amounts to approximately $110 – for every $1,000 increase in GDP per capita. Given the current treatment paradigm, and as the Middle East’s GDP continues to grow, it is only a matter of time before the region faces a hefty bill for diabetes.

Looking to the future

Of course, if a diabetes cure were on the horizon, the dynamics would be drastically different and many of these pressing issues would eventually be addressed, and maybe even resolved. At the Boston Consulting Group (BCG), however, we have conducted substantial research that confirms that this is not the case. A cure for diabetes will likely not be discovered or formulated until at least 2030. This is primarily due to the fact that, currently, the medical and pharmaceutical community is focusing on symptomatic treatments and so, these will remain a priority in the diabetes drug pipeline.

It is no surprise that enhancing preventive care for most-at-risk populations could have a huge impact on both quality of life and healthcare costs. At present, approximately 7% of the Middle East population has Impaired Glucose Tolerance (IGT), which means they are at high risk of developing Type II diabetes.

Prevention is therefore an imperative, vital and urgent need.

To gain further insight into the current diabetes landscape, BCG conducted a yearlong study on the disease. As part of our research, we assessed the global impact of diabetes and identified four strategic priorities that can help reduce the disease’s prevalence rates. Here they are:

1. Increasing government-led population- level health programs

Across the Middle East, there should be a more concerted effort to launch government-led population-level programs to promote preventive measures. While population-level programs have been limited in the GCC, there are examples such as the Weqaya health initiative in Abu Dhabi, and the Beat Diabetes Walk in Dubai that have been implemented. It is critical for governments in the region to significantly expand these initiatives to target schools. Furthermore, greater regulation of unhealthy food can make a huge difference. For example, in 2011, Hungary introduced a tax on unhealthy food; a year later, France followed suit and slapped a ‘health tax’ on soft drinks.

Governments – in cooperation with FMCGs – across the Middle East should implement stricter regulations when it comes to packaging sizes and unhealthy ingredients. Likewise, foodservice players need to include the caloric value of their food product and its nutritional information on the label. In parallel, to help improve students’ health and slash obesity rates, collaboration between the education and healthcare sectors is crucial. For example, schools could ban fizzy and sugary drinks.

2. Driving the ‘consumerization’ of basic diabetes care

In the coming years, we, at BCG, expect to see a ‘consumerization’ of diabetes care, especially when it comes to patients in the early phases. This entails making diagnosis and care as convenient as possible, guaranteeing access to suitably-located clinics, providing patients with low-cost drugs and screenings, and making diabetes education readily available. In the US, for instance, there are 140 walk-in clinics in Walmart stores across the country. And these clinics offer screening for diabetes, making early detection possible. In that same vein, Chilean start-up RetiDiag uses retinal photographs and telemedicine evaluation to screen people with diabetes and detect diabetic retinopathy at a very low cost.

To conclude, ‘consumerization’ can generate positive outcomes by driving treatment compliance, slowing down the progression of diabetes, and more importantly, prompting governmental intervention to encourage the private sector to diagnose and treat basic forms of diabetes. Working with private and quasigovernment entities can enhance access to consumer data, promote early diagnosis, and enable early treatment for patients.

3. Pushing targeted new treatments

For the Middle East, halting the spread of diabetes also means advocating new forms of targeted treatment and drugs that treat complex cases (without engendering adverse side effects) and prevent complications. Additionally, a shift to integrated care is necessary. Integrated care offers the possibility to cut costs and offer care along the whole value chain; it relies on the concept that one entity is fully responsible for the care of the diabetic patient, from coordinating treatment and seeing specialists to following up on compliance and the way care is delivered. An early attempt at this model can be found in Abu Dhabi, at the Imperial College London Diabetes Center. For GCC governments, this is a particularly critical lever to push as government entities often control upwards of 50% of the provision.

At BCG, we have benchmarked several examples of integrated care models globally that have made a positive impact. In the US, for instance, Geisinger Diabetes Care is an accountable care model that aligns the goals and incentives of payers, providers and patients. The new system has reaped significant results in diabetic care; these include a reduced risk of retinopathy, stroke, and myocardial infarction (in a span of three years). For every 82 patients treated, one myocardial infarction was prevented. For every 178 patients treated, one stroke was prevented. Lastly, for every 151 patients treated, one case of retinopathy was prevented.

4. Revamping payment models

In healthcare, payment models set up the incentives and hence drive the behaviours of all stakeholders. Addressing diabetes effectively requires a change in the behaviour of these players. Current payment models are designed to support episodic care and have few elements, if any, tied to outcomes. It is critical that providers deliver integrated care – as opposed to episodic care. It is equally important for patients to comply with treatment and make the necessary lifestyle changes.

Payment models have the power to align incentives and inspire such behaviours. There are already various examples in advanced economies of insurers using payments to incentivize desired behaviours in both providers and patients. Given the Middle East’s high rate of insurance penetration, we believe that payment models can serve as an essential tool for addressing the diabetes epidemic. Through regulation or national insurance schemes, governments can shift to more outcomebased integrated care payment models.

Taking action

Ultimately, the goal is to inform and equip policymakers, providers with the right information and tools needed to make things happen. Here is how:

• First, Middle East policymakers need to invest in multiple population-led programs to help create an environment focused on prevention. People need to receive the right education and skills training for them to be able to selfmanage. Moreover, they need to have the right incentives for them to want to manage their condition. This means investing sufficient resources and using new technologies, which, based on our work with policymakers across the region, are presently relatively scarce. There needs to be a coordinated approach adopted by all stakeholders both inside and outside the healthcare system – at the municipal, national, and regional level. Most importantly, the range of interventions (from education to non-fiscal incentives, fiscal incentives and legislation) must befit the Middle East’s culture and help shape the population’s behaviour.

• Middle East policymakers should also look to incentivize and drive healthcare providers to deliver more integrated, outcome-focused care for people with diabetes. The current, fragmented, feefor service approach does not encourage the type of care that is truly required. As outlined earlier, the effective management of diabetes entails a healthcare system that considers the totality of patients’ health needs. It is about acting proactively and in a coordinated way to ensure that patients receive the right care at the right time –and reap the best possible outcomes. Currently, no healthcare system in the Middle East meets these requirements.

• Policymakers should establish effective surveillance to identify and support those at risk of Type II diabetes. The majority of these cases can be prevented by lifestyle changes or adequate drug treatments. Screening for diabetes has proven to be cost-effective. The role of policymakers is to make screening cheaper as well as more accessible and appealing for more people.

As the prevalence of diabetes in the Middle East continues to rise – and with no cure in sight – now is the time for the region’s policymakers to act. While there is no silver bullet for diabetes, action on the above can help stymie the impact of the disease and make the future of diabetes management a lot less daunting.

 Date of upload: 16th Nov 2015

 

                                  
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