Download facing the diabetes epidemic

FACING THE DIABETES EPIDEMIC
Introduction
In 1985 it was estimated that diabetes affected 30 million people worldwide. By 2000 this had
increased to 177 million and is expected to top 370 million by 2030 (Wild et al, 2007)1. This
staggering increase means that we are now facing an emerging diabetes epidemic. The
globalisation of ‘fast-food diets’ and sedentary lifestyles have led to an increase in the proportion
of the world’s population that are overweight and obese. As 80-95% of new cases of type 2
diabetes are due to obesity the increasing trend directly impacts on the prevalence of this chronic
illness. Indeed experts estimate that more than a third of those born in the U.S. in 2002 will
develop diabetes.
Diabetes is now increasingly prevalent in children and adolescents accounting for c.50% of new
cases of diabetes in some countries due to the increase in juvenile obesity. Similar increases have
been seen in the prevalence of pre-diabetes, a condition which may progress to diabetes, which
affects 25% of the U.S. population.2
Diabetes places a huge burden on global healthcare resources due in large part to the many
associated complications. Diabetes:3:
 Accounts for more than 50% of all lower limb amputations performed in the U.S each year and
it is estimated that every 30 seconds someone in the world receives a lower limb amputation
due to diabetes
 Leads to neuropathy in nearly 50% of sufferers after 25 years.
 Causes an increased risk of influenza, pneumonia and UTIs due to an altered immune system.
 Causes retinopathy and glaucoma and is the leading cause of blindness in people of working
age (Pasquale, 2006)4
 Increased risk of developing dementia caused by Alzheimer's disease or neurovascular
problems.
 Increased risk of cardiovascular problems including artherosclerosis and CVA (Jeerakathil,
2007)5
 Represents the number one cause for admission to dialysis and kidney transplant programmes
 Doubles the risk for depression (Carnethon, 2007)6
Created by NReade  25/03/2009 DESIGN FOR BETTER HEALTH DECISIONS
These factors contribute to the cost and complexity in managing diabetes for countries worldwide.
Indeed, the NHS estimates that diabetes costs £1m per hour in the UK (NHS, 2006)7. As with
chronic illness healthcare systems and policies must be adapted to cope with the increased burden
and develop approaches to reduce the prevalence of diabetes. The quality of life of those affected
and awareness of the disease are critical particularly as the risk of complications can be minimised
by strict glucose regulation (American Diabetes Association, 2007)8 and lifestyle changes
(including moderate physical activity and healthy diets) can prevent most cases of type 2 diabetes
(Gillies, 2007)9.
The concept of the ‘nudge’
A nudge is “any aspect of choice architecture that alters peoples behaviour in a predictable way
without forbidding any options or significantly changing economic incentive. To count as a nudge,
the incentive must be easy and cheap to avoid”10. Diabetes has been selected for this assignment as
diabetes provides little feedback from poor choices, the consequences are slow to emerge and
come into view infrequently. Individuals also generally lack understanding of the serious nature of
the disease and fail to translate diabetes effectively into their everyday lives. Lifestyle changes can
be challenging and prior experience of choice management ambiguous. People in general make
good choices in contexts, which they have, experience, good information, and prompt feedback.
Given the above, diabetes is an ideal area of health for a nudge and has the potential to be far
reaching. Non-intrusive features with little or no cost are explored for application on a global
scale.
Design for better health decisions
On diagnosis of pre-diabetes (Metabolic X) or diabetes, individuals are encouraged to make better
decisions concerning their health regimes. Influencing behaviour as early as possible is critical.
Individual who adopt good choices consistently can prevent the advancement of the disease. Many
people, once diagnosed, resort to the behavioural tendency of doing nothing, or at first make
changes and then resort back to the path of least resistance. Humans predictably err and are
influenced by the status quo and by the way things are framed. People take shortcuts and make
mistakes when making decisions. Biased behaviour and self-control problems are an underlying
concern in management of diabetes. There often exists a lack of understanding concerning the
severity of the disease, as a result, a poor understanding of the consequences of mismanaging their
personal regimes (such as failure to control blood sugar and regular exercise).
Disease staging
It is proposed that diabetes is described and categorised in ‘disease stages’. For example, Stage one
(Metabolic X), Stage two (insulin resistant) and Stage three (failure to produce insulin). Seemingly
insignificant details (like names) can have a major impact on people’s perception and behaviour.
The use of disease staging is a nudge towards better comprehension of the progressive and
seriousness nature of the disease to the novice. Likewise other well-recognised chronic fatal
diseases such as cancer and hypertension are described in stages. Diabetes is not often associated
with fatality. For the healthcare provider disease staging can be utilised to measure severity of
illness and its impact on hospital costs. It would also be well suited for cost-effectiveness research,
because discharge based systems do not require medical chart review or clinical judgement as part
of the rating methodology. When catagorised in stages the individual is nudged to take corrective
steps relevant to the specific stage, the catagorised information may also be sought more easily, the
amount of accessible information on diabetes can be overwhelming to the individual. Health
providers would also supply targeted health promotion material that encourages goal setting
behaviour to prevent the disease progressing to the next stage. Better transparency encourages
people to make better choices.
Created by NReade  25/03/2009 DESIGN FOR BETTER HEALTH DECISIONS
Universal food labeling symbol for restaurant menus
Food labeling can steer people towards making a better dietary decisions. Indeed vegetarian
options are commonly indicated by the symbol V. A ‘low sugar’ symbol would nudge both
diabetics and none diabetics to make better dietary choices. There is a degree of complexity for the
novice in knowing which food to select. It can be hard to make good decisions when there is
trouble translating the choices faced into experiences had.
Promoting the nudge
To make the health nudge public, a TV commercial is proposed to get people thinking and talking
about diabetes. This would provide an opportunity to highlight the seriousness using a vivid and
memorable medium in a language the novice would understand. TV advertising is far reaching and
captures a wide audience including children and adolescents. Given the prevalence of diabetes the
potential benefit of running an advertisement would be likely a future cost saving.
References
1
Wild S, Roglic G, Green A et al. World Health Organsation: Global Prevalence of Diabetes: Estimates for
the year 2000 and projections for 2030. Diabetes Care 27:1047–1053, 2004
2
American Diabetes Association (ADA). Standards of medical care in diabetes. Diabetes Care. 2007
Jan;30(Suppl 1):S8-15.
3
World Health Organisation, Diabetes Fact Sheet 2008 adopted from http://www.who.int/diabetes/en/
4
Pasquale LR, Kang JH, Manson JE et al. Prospective study of type 2 diabetes mellitus and risk of primary
open-angle glaucoma in women. Ophthalmology. 2006 Jul;113(7):1081-6.
5
Jeerakathil T, Johnson JA, Simpson SH et al. Short-term risk for stroke is doubled in persons with newly
treated type 2 diabetes compared with persons without diabetes: a population-based cohort study. Stroke.
2007 Jun;38(6):1739-43.
6
Carnethon MR, Biggs ML, Barzilay JI et al. Longitudinal association between depressive symptoms and
incident type 2 diabetes mellitus in older adults: the cardiovascular health study. Arch Intern Med. 2007 Apr
23;167(8):802-7.
7
NHS – Key Facts on Diabetes, July 2006: adopted from
http://www.diabetes.nhs.uk/downloads/NW_Pres_Brian_Ferguson_diabetes_key_facts.ppt
8
American Diabetes Association (ADA). Standards of medical care in diabetes. VI. Prevention and
management of diabetes complications. Diabetes Care. 2007 Jan;30(Suppl 1):S15-24.
9
Gillies CL, Abrams KR, Lambert PC et al. Pharmacological and lifestyle interventions to prevent or delay
type 2 diabetes in people with impaired glucose tolerance: systematic review and meta-analysis. BMJ. 2007
Feb 10;334(7588):299.
10 Thaler H, Cass RS Nudge: Improving Decisions About Health, Wealth and Happiness 2009: Publisher:
Yale University Press
11 Sunstein, Cass R. and Thaler, Richard H Libertarian Paternalism is Not an Oxymoron. 2003
Created by NReade  25/03/2009 DESIGN FOR BETTER HEALTH DECISIONS