The $245 Billion Problem

Why overcoming chronic disease will be our most significant challenge (and opportunity) in the 21st century.

I. The End of the Beginning

If you lived in America in 1906, there were things that were probably true about you:

1. First, it is likely that you worked either on a farm or in a factory, mill, or a mine (or were married to someone who did).
2. Second, you were (statistically) likely to live to the age of 47 and then pass away from tuberculosis, pneumonia, influenza or another infectious disease.

Pre-modern life wasn’t necessarily as bad as Thomas Hobbes made it out to be when he characterized it as “poor, nasty, brutish and short.” But from a purely statistical perspective, he was on-point with respect to longevity. Life was short(er) one hundred and ten years ago, and the most genuinely pressing health-related concern of any man, woman or child was that they might fall prey to an infectious disease. Despite the many scientific and technological advances of the 19th century (breakthroughs in cell theory and germ theory, the emergence of modern surgery and anaesthesia, and the invention or improvement of the microscope, stethoscope and opthalmoscope), life in 1906 could still end abruptly and tragically in the face of swift-acting infections for which there were no vaccines and little in the way disease management best practices.

The story of the 20th century, in the context of the grand arc of humanity, is the story of the triumph of our scientific ingenuity in effectively doubling our average lifespan as a species. Between all the revolutions, upheavals, migrations, and conflicts, we managed to pull off a stunning collective feat in eradicating many of the most deadly threats to our health and welfare.

• In 1923, the first effective immunization for diphtheria was created in the form of vaccine. Vaccines for pertussis, tuberculosis and tetanus followed in 1926 and 1927.
• In 1945, at the end of World War II, the first vaccine for influenza was licensed in the United States. Smallpox was eradicated four years later in 1949.
• In 1964, the year The Beatles played the Ed Sullivan Show, the first vaccine for measles was introduced. By the time they released Sgt. Pepper’s in 1967, there was a vaccine for mumps.
• The reduction of risk of sudden illness and death from disease in childhood and adulthood continued through the 1970s as vaccines for rubella, chicken pox and pneumonia were licensed and introduced.

By the year 2000, with the worst of the AIDS epidemic finally under control in the developed world, the lifespan of the average man and woman were around 75 and 80 respectively in the USA.

II. Affluenza

Unfortunately, as the curve in the graph of infectious rates was trending downward, another global health crisis was emerging. The exponential increases in economic well-being in the second half of the last century fundamentally shifted human behavior patterns and gave rise to new diseases of affluence. The top ten leading causes of death now include such things as cancer, type 2 diabetes, chronic lower respiratory disease and heart disease.

And as the scientific community and society as a whole has conclusively proven but only barely started to grapple with, the onset of these diseases can largely be traced to preventable behavioral choices. A sedentary lifestyle, poor nutition (most egregiously via the consumption of salt-, sugar-, and fat-laden food), smoking cigarettes, overconsuming alcohol and a variety of other behavioral factors are the leading causes of these ‘diseases of affluence’.

Type 2 diabetes is one of these diseases, a condition which causes blood sugar levels to rise higher than normal. Cells cannot use insulin to process blood sugar out of the blood, resulting in high blood sugar levels. Without proper care and treatment, type 2 diabetes can be dangerous or fatal.

Diabetes can often result in significantly impaired quality of life, wreaking havoc on the endocrine, excretory and digestive systems, damaging the central nervous system and leading — in some cases — to amputations and blindness when left unchecked.

It is, by definition, a chronic disease — one which cannot be cured by medications or vaccines and doesn’t really ever just disappear.

III. Pills, Pills, Pills

Every year, type 2 diabetes imposes an incredible cost on the US Health Care System. The anti-diabetic drugs market alone is estimated to be $55.3B in 2017. 1.7 new type 2 diabetes cases are diagnosed every year. Most people who get diagnosed will take a regimen of pharmaceutical drugs to manage their condition:

• Meglitinides like repaglinide and nateglinide increase the secretion of insulin.
• Thiazolidinediones like pioglitazione or rosiglitazone improve the body’s ability to use insulin.
• DPP-4 inhibitors block the production of an enzynme called dipeptidyl peptidase 4, inhibiting glucagon release, increasing insulin secretion, and decreasing blood glucose levels.
• Alpha glucosidase inhibitors like acarbose and miglitol impair the digestion of carbohydrates.
• Insulin sensitizers like metformin, a biguanide derivative, exert an antihyperglycemic effect with minimal risk of hypoglycemia.

Is your head spinning yet?

In a world where we have completely eradicated certain diseases, the market diabetes drugs is anticipated to reach $55.3 billion by 2017 and continue growing beyond that. The cost of these drugs are borne by the payers in the health system, driving up the overall costs of health care.

When we include the overall cost of diabetes on the health care system including procedures, physician visits, hospital inpatient care, anti-diabetic agents, diabetes supplies, and facilities stays, the total cost posed by diabetes on the US health care system annually is $245 billion.

IV. An ounce of prevention

The chronic disease burden in America largely results from a cluster of behaviors and concomitant risk factors which include poor diet, physical inactivity, tobacco use, excessive alcohol consumption and uncontrolled high blood pressure. Varied interrelated chronic diseases share many of the same causes; many of the same strategies and interventions can prevent them or lessen their severity.

Diabetes prevention reached a high point with the publication of the landmark longitudinal study, The National Diabetes Prevention Program Study (NDPP) (2002), which showed that lifestyle interventions were twice as effective at reducing or delaying the onset of type 2 diabetes as a drug regimen. In achieving modest weight loss of 5–7%, participants reduced their chances of developing diabetes by 58%. Taking metformin (the anti-diabetic drug in the other arm of the study) reduced the risk by 31%.

The concept that healthy eating and physical exercise makes people healthier has been a intuitively understood concept since ancient times. What the NDPP did was distill the conclusions and scientific progress that had been happening in earnest since at least the 1970s with direct causal links between behavioral change and chronic disease risk reduction.

V. The Future

Blue Mesa Health is a company founded to provide best-in-class chronic disease prevention programs. The roots of our program infrastructure are the four proven pillars of prevention demonstrated by the NDPP:

• behavioral health coaching
• social support
• healthy diet
• physical activity

Our flagship product, Transform, integrates these four pillars using the science of evidence-based disease prevention programs, the art of design, and the core principle of relationship-building to meaningfully engage participants in a life-changing health journey. Transform is tuned to take into account the myriad factors which ultimately determine health behaviors.

At Blue Mesa Health, we imagine a future where effective preventive health coaching, enabled by best practices in technology, behavioral science and design can make a significant dent not just in the actuarial curve of chronic disease costs, but in the fundamental way that people in the United States and globally live their lives.

Imagine a world where people at the tipping point for various chronic diseases can engage with an effective, relevant, clinically-proven program that can be prescribed like a drug.

In our world, cost-effective coaching is as available as running water, or as easy as tapping for an Uber or a Lyft.

In our world, it’s not just about the health information that is available as a PDF on a web portal or on the other end of a tele-health line: it’s about delivering a complete program that includes engagement, motivation, easy tracking tools and social support, delivered at scale.

Our vision is this: In 100 years, when public health students are sitting in a lecture hall (or experience whatever VR- or AR-enabled version of higher education exists in 2116) they will learn about the great epidemiological transition of the 21st century, where the chronic disease rate started to bend downward after years of skyrocting upward.

Blue Mesa Health, along with other digital health companies and policy-makers, will be credited, as a force that bent the curve.

We can solve the $245 billion problem and improve millions of peoples’ quality of life while doing so.

To learn more about how we are working towards a world with dramatically reduced rates of chronic disease, please visit http://www.bluemesahealth.com/transform.