Diabetes is a common but serious and costly disease in Washington State. A complex condition related to harmful blood glucose levels, diabetes is the seventh leading cause of deaths in our state and a contributing factor to serious health outcomes such as amputations or blindness.
About one in eight adults in Washington State have diabetes. In addition, an estimated one in three have prediabetes. Of particular concern: one out of four people with diabetes, and three out of four people with prediabetes, are not aware of their condition. Diabetes is more prevalent among certain groups including racial and ethnic minorities and those with lower income and education levels.
A multifaceted approach to diabetes management and prevention, with special attention to health equity, is vital to improving population health in our state.
Current Health Status
After nearly doubling over the last two decades, the continued growth in the prevalence of diagnosed diabetes (the total percentage of adults with disease at a given time) may have shown signs of slowing beginning in 2011, remaining around nine percent through 2017 in Washington State. Similarly, the rate of newly diagnosed cases has plateaued at eight per 1,000 adults from 2014 to 2017. Although the prevalence and incidence of diagnosed diabetes among adults is not growing dramatically each year, the numbers with diabetes still remains substantial and some high-risk subgroups may experience continued increases over time.
About 19 percent of Washington adults over age 65 have diagnosed diabetes. Age is a factor in diabetes and is of particular concern considering the state’s aging population; the state Office of Financial Management forecasts a doubling of the population over age 65 in Washington State by 2030.
On the other end of the age spectrum, an estimated 2,970 Washington State youth have diagnosed diabetes. National data indicate that both type 1 and type 2 diabetes in youth is increasing, along with childhood obesity rates. Obesity is a risk factor for type 2 diabetes.
Diabetes costs an estimated $6.7 billion a year in Washington State, including direct health care and reduced productivity costs. Interventions to improve management and prevention of diabetes can reduce the economic burden on our state while greatly improving the quality of life for those affected by the condition.
Additionally, nearly two million adults in Washington have prediabetes, of whom 15 to 30 percent will develop type 2 diabetes within five years.
Leadership and local engagement
The Washington State Diabetes Network is a group of public, private, community, tribal and academic partners working together to address and prevent diabetes. Network members and partners who also work with cardiovascular disease can serve on the Cardiovascular Disease and Diabetes Network Leadership Team. To engage with regional coalitions, access webinars, learn about serving on the Cardiovascular Disease and Diabetes Network Leadership Team, and obtain updates, visit the Washington State Diabetes Connection.
Report to the Legislature
The Washington State Legislature directed the Department of Health, Department of Social and Health Services, and Health Care Authority to submit an annual report to the Legislature. The 2019 Diabetes Epidemic and Action Report includes updated data as well as agency action plans, recommended strategies, and considerations for legislation.
Ongoing programs and initiatives: Multiple efforts support diabetes prevention and management. Several worth highlighting:
- Diabetes Prevention Program (DPP) for people with prediabetes or at high risk of developing type 2 diabetes. It is a year-long program that supports lifestyle changes to reverse prediabetes and help prevent or delay type 2 diabetes. In Washington, DPP is offered to members of the Public Employees Benefits Board Program at no cost, to several other employers, and is covered by Medicare. Find DPP classes available in your region or reach out to the Heart Disease, Stroke, and Diabetes Prevention Program to learn about how to offer one.
- Diabetes Self-Management Education and Support (DSMES) focuses on patients with diabetes, and provides one-on-one coaching to support diabetes self-care. In Washington, DSMES providers can seek Medicaid reimbursement and may receive national accreditation or recognition from the American Association of Diabetes Educators or the American Diabetes Association. All insurance programs in Washington that are regulated by the Office of the Insurance Commissioner are required to cover DSMES. For more information on referrals to or payment for DSMES, contact the state Department of Health's Heart Disease, Stroke, and Diabetes Prevention Program.
- Healthy Eating/Active Living works on programs that help people eat healthy and be active where they live, work, and play.
- Community Health Worker Training provides free courses to community health workers, including a section on prediabetes and diabetes.
- Apple Health managed care contracts include incentives for diabetes performance measures for HbA1c control, blood pressure controlled for diabetes patients, and diabetes eye exam.
- Medicaid Health Homes provide care coordination and management to individuals with diabetes and one or more additional chronic conditions, including mental health conditions.
- Community Living Connections services include diabetes support groups, Meals on Wheels, nutrition counseling, and Enhanced Fitness.
Issues you may wish to consider include:
- Diabetes self-management education and support (DSMES) is available as a benefit through nearly all health insurance plans, but few clients use it. Some regions are working on DSMES access to improve referrals and quality of care.
- Short-term outcomes, including cost savings, may be more quickly achieved with interventions that decrease A1c levels in people with diagnosed diabetes. Assessing and addressing cardiovascular risk factors, including blood pressure and high blood cholesterol, are also important in preventing poor outcomes in people with diabetes. Implementing interventions that prevent diabetes, particularly with those experiencing prediabetes, may also help achieve long term cost reduction.
- New interventions, such as group self-management support or engagement of community health workers, may be more effective with some populations than older models of self-management education. However these new models are either not covered by health insurance or not paid for equally.
- Evidence in both clinical trials and studies finds that the onset of type 2 diabetes can be prevented or delayed with lifestyle change support by trained coaches and peer groups over the course of one year. As of April 2018, Medicare began to cover qualified Diabetes Prevention Programs (DPP) for eligible enrollees. Several programs in Washington state have met the criteria to qualify.
- Other insurers in Washington state, including those providing benefits for state and higher-education employees and retirees, cover DPP through specific contracts.
About one in eight adults in Washington has diabetes, across all ethnic and racial groups. While overall adult prevalence appears to be slowing since 2011, it continues to increase in some groups. Groups with higher prevalence include Native Hawaiian/Other Pacific Islanders, Hispanics, non-Hispanic blacks, and American Indians/Alaska Natives.
Type 1 diabetes is more prevalent in white youth than other racial or ethnic groups.
Washington’s Hispanic/Latino population has a significantly higher risk of type 2 diabetes. Services that are culturally and linguistically appropriate and geographically accessible may not be keeping pace with demand in this growing population.
Adults with annual incomes less than $25,000 were twice as likely to have diabetes as those with incomes of $75,000 or more. A similar disparity exists between those with high school education or less and those with a college degree. Access to preventive services and to environments conducive to healthy lifestyle, as well as stress resulting from discrimination and poverty, may contribute to the disparity. Health education and support that accommodates the needs of populations with lower income or education levels are important considerations.
People with both behavioral health issues and diabetes are more likely to experience barriers that impact success of treatment. As a result, many experience more complications and die at younger ages than people without behavioral health issues. Integration of physical and behavioral health, with the patient at the center of care, can be instrumental in addressing this disparity.
In 2017, in Washington State:
- About 682,600 adults (or 1 in 8) have diabetes, of which 41,470 are newly diagnosed.
- About 2,970 youth have diabetes.
- Diabetes is listed as a contributing diagnosis in more than 125,000 hospitalizations.
- Diabetes is the seventh leading cause of death.
- Average medical costs for people with diabetes is about $16,750 per person per year – about twice the cost for people without diabetes.
- About 2 million adults (or 1 in 3) have prediabetes.
- 2018 Washington State Health Assessment - Diabetes and Prediabetes prevalence, including time trends, geographic variation, and disparities.
- Washington State Behavioral Risk Factor Surveillance System (BRFSS) data; self-reported.
- Washington Hospital Discharge Data, Comprehensive Hospitalization Abstract Reporting System (CHARS), and Oregon State Hospital Discharge Data.
- Centers for Disease Control and Prevention, Diabetes Report Card and National Statistics Report: Estimates of Diabetes and its Burden in the United States.
Six strategies identified in the state’s 2017 Diabetes Epidemic and Action Report (DEAR) below are the overarching strategies for action plans:
- Prevent type 2 diabetes
- Support optimal self-management of diabetes
- Use diabetes-specific data and information to guide decisions
- Seek adequate funding for diabetes prevention and care
- Include people affected by diabetes in decisions
Specific actions are identified in Agency Action Plans, page 6 of the 2017 DEAR.
Aligning with these strategies, the report included 13 recommendations for how the state legislature could support reducing the incidence of type 2 diabetes, and improving the lives of people with all forms of diabetes. These recommendations can be applied at state, regional, local, and organizational levels:
- Maintain and further expand access to health care coverage
- Help make out-of-pocket costs more affordable for patients with diabetes
- Support the state’s movement toward value-based purchasing of health care services
- Continue efforts to integrate physical and behavioral health care services
- Encourage Accountable Communities of Heath to implement projects that impact diabetes
- Ensure all health plans provide optimal diabetes benefits
- Support students with chronic health conditions
- Expand staffing and coordination resources for evidence-based, community-based programs
- Increase use of diabetes self-management education
- Raise public awareness of diabetes prevention and management
- Train health care providers to screen for diabetes, and to deliver high-quality diabetes care in culturally and linguistically appropriate ways
- Support using data to drive decisions and improve linkages between health systems and community support services
A Population Health Driver Diagram is a tool to organize strategies around desired change. This example, developed by a multi-sector team of partners, identifies secondary drivers in each of the Three Buckets of Prevention. It may be tailored to the individual needs and resources of your community and populations.
Contact us at P4IPH@doh.wa.gov