S U P P L E M E N T

diabetes is that they are based on a

Implications of Population procedure that seems reasonable, given
our current knowledge. The projections
Growth on Prevalence are presented, not because they are

of Diabetes guaranteed, but because they point to

some implications for health policy that
should be considered by leaders in
A Look at the Future health and medical policy, especially
those concerned with the ability of the
ROBERT B. HELMS, PHD profession to care for the elderly with
diabetes.

COMBINING PREVALENCE AND

The purpose of this study was to present projections of the future population of POPULATION DATA—In 1987, a
diabetes patients, to discuss policy implications of these projections, and to suggest study of the cost of diabetes gave the
ways that these projections might be made more useful to medical professionals. prevalence of diabetes as 26.8 patients/
Under the assumption that the incidence of diabetes in four age-groups will 1000 population (1). This study also
remain constant in future years, previous estimates of the incidence of diabetes showed that this overall prevalence was
will be applied to Bureau of the Census population projections to project the strongly related to age, as indicated by
number of new cases of diabetes that can be expected in future years in each of the data in Table 1. The number of
these age-groups. The prevalence of diabetes will remain relatively constant at patients and these population figures for
approximately 1 million patients in younger populations Gess than 45 yr old) 1987 are illustrated in Figure 1, even
through the middle of the next century. As the post-World War II baby boom though the 161,800 patients age <25 yr
ages, the number of older diabetes patients (45 and older) will almost double from are almost unnoticeable on this scale.
6.5 million in 1987 to an estimated 11.6 million in the year 2030. Although there Using the Census Bureau's popu-
is little doubt that the aging of the population will increase the number of diabetes lation projections of these same age-
patients, the assumption of constant incidence rates is a very limiting one. These groups until the year 2050 based on their
projections would be more useful for the planning of research and training if the middle (series 14) mortality assumptions
incidence of diabetes could be estimated for more refined categories of demo- (2), projections of the number of diabe-
graphic and medical characteristics. tes patients by age-group are obtained by
multiplying with the prevalence rates in
Table 1. The results are presented in

T here is a popular adage that, "No one can predict the future." The common Table 2, and in Figs. 2 and 3. Figure 2 is
sense meaning of this statement is that no one knows for certain how future for age-groups <45 yr and Fig. 3 for
events will turn out. But, if no one can predict the future, someone forgot to age-groups >45 yr. These projections
tell everybody else. All of us concerned with the future of science and medicine indicate that the number of diabetes
know that predictions about the future of health care are numerous and made by patients < 25 yr of age will remain almost
nearly everyone. Thus, in a world full of predictions, the real challenge is to constant in the next half century,
narrow the range of uncertainty and select those predictions that have the highest whereas the number between 25 and 45
probability of occurrence. will decline slightly (from a high of
The major justification for these predictions about the future prevalence of 983,000 in 1995 to a low of 870,000 in
2040).
The two older age-groups show
FROM HEALTH POLICY STUDIES, AMERICAN ENTERPRISE INSTITUTE, WASHINGTON, DC. larger rates of growth, as a result of the
ADDRESS CORRESPONDENCE AND REPRINT REQUESTS TO ROBERT B. HELMS, PHD, RESIDENT SCHOLAR, aging of those people born after World
DIRECTOR OF HEALTH POLICY STUDIES, AMERICAN ENTERPRISE INSTITUTE, 1150 SEVENTEENTH STREET, War II. The number of patients in the
NW, WASHINGTON, DC 20036. 45- to 64- age-group is projected to
THIS PAPER WAS PRESENTED AT THE SECOND NATIONAL CONFERENCE ON FINANCING THE CARE OF
almost double between now and the year
DIABETES MELLITUS IN THE 1 9 9 0 S IN WASHINGTON, DC, 3-5 DECEMBER 1989 AND PARTIALLY
2015 (from 2.4 million in 1990 to a high
SPONSORED BY THE UPJOHN COMPANY AND ELI LlLLY AND COMPANY.
of 4.1 million in 2015). This is an aver-
age growth rate of 2.8%, or about 69,000

DIABETES CARE, VOLUME 15, SUPPLEMENT 1, MARCH 1992

 Helms

Table 1—Prevalance of diabetes by age-group influenced primarily by the assumptions

made about fertility and mortality, vari-
PREVALENCE ables that seem to remain relatively sta-
DIABETIC PATIENTS (YR) RATE POPULATION (MILLIONS) ble. However, a study by Schneider and
Guralnik (3) explains that "the rapid
<25 1.8/1000 89.9 pace of biomedical research" may cause
25-44 11.8/1000 76.7 the actual elderly population (85 yr and
45-64 51.8/1000 45.3 over) to exceed even the Census projec-
>65 103.9/1000 29.8 tions, based on the lowest (series 9)
mortality projections. They point out
that the low mortality assumption rather
than the middle mortality assumption
additional patients per year for the next age-group with the highest rate of onset, results in a 50% increase in the number
25 yr. (These are not typically new onset it would be possible to project the effect of those 85 yr and over by the years 2020
cases, because they include those who of the aging of that particular group. Or, and 2040.
age into each age category each year.) For if obesity or smoking in middle-aged
those aged >65 yr, who have the highest African-Americans is expected to de- POLICY IMPLICATIONS FOR
rates of prevalence, the number of pa- crease, separate projections could be DIABETES PROFESSIONALS—Im-
tients is projected to grow at an average made for that population. plications of the aging of the population
of 1.7% per year, adding an average These projections are also based for health policy have been covered ex-
55,000 new patients per year to this on the implicit assumption that no major tensively in other sources (3-6). How-
age-group. For the following 20 yr social or medical events (such as wars or ever, there are some rather obvious im-
(2015-2035), this oldest group of pa- new diseases) will substantially change plications for the diabetes community if
tients is projected to increase by an the Census Bureau's population projec- the population of patients increases by
average of —120,000 patients per year. tions. The census projections are pre- over 1 million in the next decade and by
sumed to be credible because they are over 3.7 million by 2020.
HOW REASONABLE ARE THESE
PROJECTIONS?—These projections
of the prevalence of diabetes in different
age-groups are made under the simpli- Millions Of Persons
90
fying assumption that the current rates of
prevalence will not change in the next
several years. This amounts to what may
be viewed as the overly pessimistic as-
sumption that there will be no scientific
or medical discoveries to reduce the
prevalence of diabetes.
If specific projections of preva-
lence rates are made, they can be easily ^ Population in Millions
combined with the population projec- I Diagnosed Diabetes
tions to produce alternative projections
of affected people. The Census Bureau
makes separate projections for each year
of age from 0 to 85 yr and for 5-yr
groups up to 100. Those people over age
100 are included in a separate group.
The projections are also made by sex and
race, making possible combinations
more refined than the four age-groups
presented herein. For example, if more < 25 25-44 45-64 +
refined estimates of prevalence could be
made for those over 8 5 yr or for the Figure 1—Prevalence of diagnosed diabetes by age in United States, 1987.

DIABETES CARE, VOLUME 15, SUPPLEMENT 1, MARCH 1992

Implications of population growth on diabetes

Table 2—Actual and projected diabetic patients by age-group, 1987-2050 (millions of patients)education. Even if a useful new discovery
is made that could reduce the incidence
AGE-GROUP
of diabetes, it will take a substantial effort
to educate both the medical profession
YR <25 25-44 45-64 >65 TOTAL and the population in time to make an
impact before the bulge in the popula-
1987* 0.162 0.905 2.344 3.100 6.511
tion reaches the age of higher rates of
1990 0.162 0.965 2.419 3.294 6.840
onset. This task will probably be more
1995 0.163 0.983 2.725 3.501 7.372
difficult if the new information requires a
2000 0.164 0.956 3.181 3.626 7.926
change in life-style, such as a change in
2005 0.164 0.909 3.693 3.751 8.517 exercise OT nutrition habits, than if. &
2010 0.162 0.883 4.077 4.104 9.225 drug is developed to bring about the
2015 0.159 0.890 4.139 4.676 9.863 desired physiological change.
2020 0.158 0.905 4.030 5.434 10.527 The pressure to contain health-
2025 0.158 0.909 3.828 6.203 11.097 care costs will intensify in both the pub-
2030 0.158 0.892 3.735 6.816 11.600 lic and private sectors (6). At the same
2035 0.156 0.874 3.771 7.065 11.867 time that the population of diabetic pa-
2040 0.155 0.870 3.844 7.076 11.943 tients can be expected to increase, con-
2045 0.153 0.874 3.854 7.044 11.924 siderable emphasis will be placed on
2050 0.151 0.874 3.787 7.128 11.940 finding more cost-effective ways to treat
*Actual 1987 data from Pracon, Inc./American Diabetes Association (1). the diabetic patient and to reduce com-
plications of other related medical con-
First, the aging of the baby boom Regardless of how optimistic one ditions. Whereas scientific advances may
population means that the next 20-yr may be about the future of scientific contribute to more cost-effective treat-
period (1990-2010) will be somewhat discovery, if these projections serve no ment, there may also be opportunities to
different from the following 20-yr period other purpose they should be to empha- lower the cost of effective treatment by
(2010-2030). Although the number of size the importance of prevention and changing the method or location of treat-
diabetes patients over age 65 will grow
steadily for the next 20 yr, the highest
growth rates will be in the 45- to 64-
age-group. To the extent that this age- Millions Of Persons
1.5 - r
group experiences the highest rates of
onset, the demand for introductory diag-
nosis and treatment programs can be
expected to increase relative to other
types of treatment. For training pro-
grams, this implies that the number of
qualified professionals may have to be
increased and more emphasis directed to
initial diagnosis and treatment. If preven-
I <25
tion-related research can be directed to I 25-44
this age-group, the payoffs in reduced
prevalence may be higher than if directed
to other age-groups.
After the year 2010, the rate of
growth of diabetes patients age 65 and
older can be expected to accelerate rela-
tive to other age-groups. This will in-
crease the demand for treatment and
research into the medical complications
experienced to a greater extent by the 1990 2000 2010 2020 2030 2040 2050
older diabetic patient. Figure 2—Diabetes in young people to remainconstant (projections 1990-2050, aged <45yr).

DIABETES CARE, VOLUME 15, SUPPLEMENT 1, MARCH 1992

 Helms

Millions Of Persons
8 -r
processes of medical training of profes-
sionals, medical research, and the diffu-
sion of information to patients and pro-
fessionals all take several years to become
effective. For planning purposes, the di-
abetes profession still has a short time
period to prepare.

1990 2000 2010
Figure 3—Diabetes in aged to increase (projections 1990-2050, aged >45yr).
merit, or by changing the incentives of
providers and patients.
Although these speculations are
based on what seem to be, at the mo-
ment, reasonable assumptions, diabetes
professionals will be more confident in
projections with greater medical input
@ 45-64
• >/-65
2020 2030 2040 2050
into the future course of the prevalence
of diabetes. Research and careful think-
ing about the future course of prevalence
to replace the simplistic assumption of
constant future rates are highly recom-
mended. In addition, such research
would seem to be timely, because the
References
1. Center for Economic Studies in Medi-
cine, Pracon Inc.: Direct and Indirect
Costs of Diabetes in the United States in
1987. Alexandria, VA, American Diabetes
Association, 1988, p. 9
2. Spencer G: Projections of the Population of
the United States, by Age, Sex, and Race:
1990 to 2080. Washington, DC, U.S. De-
partment of Commerce, Bureau of the
Census, January 1989 (Ser. P-25, no.
1018)
3. Schneider EL, Guralnik JM: The aging of
america: impact on health care costs.
JAMA 263:2335-40, 1990
4. Rivlin AM, Weiner JM: Caring for the
Disabled Elderly. Washington, DC, The
Brookings Institution, 1988
5. Zedlewski SR, Barnes RO, Burt MR, Mc-
Bride TD, Meyer J: The Needs of the El-
derly in the 21st Century. Washington,
DC, The Urban Institute, July 1989
6. Helms RB: Health policy and the econ-
omy: guessing about the future. Am J
Pharmaceut Educ 53:41S-49S, 1989

DIABETES CARE, VOLUME 15, SUPPLEMENT 1, MARCH 1992